EXERCISE AFTER STROKE Specialist Instructor Training Course L3 Stroke: the first few days Prof. Gillian Mead Reader and Consultant The University of Edinburgh

Stroke is a Medical Emergency

Face Arm Speech Test (Time..) Helps public recognise symptoms of stroke; Can they smile? Does one side droop? Can they lift both arms? Does one drop? Is their speech slurred or muddled? Test all three symptoms Of course, there can be other focal neurological symptoms too (and not all of the above symptoms are due to a stroke)

Acute Management (1) Ischaemic stroke –Aspirin (within 48 hours of onset) –Clot busting drugs given within 6 hours of onset reduced risk of death dependency Benefits greater if given as soon as possible after symptom onset Associated with a risk of bleeding into the brain Lancet 2012; 379: 2364–72RCP guidance recommends treatment wthin 3 hours, consider treatment 3-6 hours –Decompressive craniectomy (lifting a flap of the skull to relieve pressure) in a tiny proportion of younger patients who develop potentially fatal brain swelling Haemorrhagic stroke –Neurosurgery (only occasionally) to remove blood –Reverse blood clotting defects –Early Blood pressure lowering-one trial (N Eng J Med Craig Anderson 2013) showed benefit; some centres now implementing this, whilst others believe more evidence is needed

Acute management (2) Intermittent pneumatic compression of legs –reduces risk of clots in legs and reduces risk of death at 6 months (clots collaboration May Lancet 2013) General supportive –Intravenous fluids (for patients who can’t swallow) –Nutrition (nasogastric tube, modified diet, normal diet) –Oxygen (if oxygen levels low) –Bowel and bladder care –Prevention of pressure sores (? Pressure relieving mattress, regular turns) –Control blood glucose Best outcomes if patient is admitted to a stroke unit

What is a stroke unit? Organised inpatient (stroke unit) care can be considered a complex organisational intervention comprising multidisciplinary staffing providing a complex package of care to stroke patients in hospital Care can be provided in a dedicated ward (stroke, acute, rehabilitation, comprehensive), by a mobile stroke team or in a mixed rehabilitation ward. Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke Cochrane Database of Systematic Reviews

Cochrane Systematic Review of Stroke Units 28 randomised controlled trials with 5855 participants. Stroke unit care reduced the odds of –Death –Death or institutionalisation –Death of dependency Any patients characteristics associated with better outcomes? –The magnitude of benefit seemed greater for participants with more-severe stroke. –Stroke unit benefits are apparent across a range of participant subgroups (age, sex, initial stroke severity and stroke type). –Mild strokes-no significant effect on death but had a reduced risk of dependency Outcomes better when stroke unit based in a discrete ward

Why do stroke units improve outcomes? Care co-ordinated by a multidisciplinary team Team meets to discuss patients at least weekly Nurses have expertise in rehabilitation Team consists of professionals interested or specialising in stroke Regular in-service training for staff and involvement of carers in patient care ? Early mobilisation, rapid treatment of complications of stroke Langhorne1995.

Rehabilitation Aims to Minimise Functional Effects of Stroke Core team –Physician –Nurses –Physiotherapist –Occupational therapist –Speech and language therapist –Social worker –Dietician Others who may be consulted –Psychologist –Psychiatrist –Vascular surgeon –Radiologist –Rheumatologist –Optometrist –Orthotist

Scottish Stroke Care Audit National Audit allows each health board to evaluate care against published standards –Brain imaging –Aspirin –Stroke Unit access –Swallowing assessments –Neurovascular clinic access

Complications from stroke during hospital admission

Patterns of Recovery Rate of recovery generally most rapid in the first few weeks If a patient deteriorates, consider medical complications, recurrent stroke There is no absolute end to recovery, but most rapid improvement is within the first 6 Months (RCP guidelines 2012) Some patients continue to recover for several years Mechanisms underlying recovery are complex and include –Restoration of blood flow (and so neurones not irreversibly damaged may recovery) –Neuroplasticity –Functional adaptations

Summary Stroke is a medical emergency: Act FAST! Acute treatments can improve outcome Stroke Unit care improves outcomes Medical complications are common after stroke Pattern and rate of recovery is highly variable

Essential Reading Further detail about the topics discussed in this session can be found in section L3 and L4 of the course syllabus.