1. EXERCISE AFTER STROKE Specialist Instructor Training Course L4 Stroke: the longer term Dr. Gillian Mead Reader and Consultant
INTRODUCTION
Thanking organisers
Remit: title potentially holds a LOT -> continuous decision-making as to what to exclude; hoping I have made the right decisions!
Selection criteria:
Focus on relearning (not compensation) ->
Strategies used or useable by therapists ->
Focus on stroke: largest population of people with a neurodisability, most research done with this group->
Focus on UL: poor recovery compared to LL in stroke, important for many people in their ADL and participation.
The University of Edinburgh

2. Overview of talk Stroke prevention (lifestyle and drugs)
Longer term post-stroke problems
Co-morbidities (and drugs for comorbidities)
Services for people after stroke

3. Learning Outcomes At the end of this session, you should be able to:
Describe the measures for stroke prevention
Describe the impact of stroke in the longer term
Demonstrate knowledge and understanding of the most common co-morbidities of stroke, their medications, and how these may impact on a person’s capacity to exercise.
Explain the role of exercise in the context of stroke prevention
Outline the various services for people with stroke
Identify relevant government policy and published national guidelines on stroke
The University of Edinburgh

4. Secondary prevention (general)
Healthy diet
Exercise
Alcohol
Weight reduction
Stop smoking
Advice given at time of stroke, advice reinforced after hospital discharge by GP, practice nurse
(see CHSS, SA, Different Strokes information leaflets)

5. Secondary prevention: general

6. Secondary prevention Ischaemic Haemorrhagic
Antiplatelets (aspirin and dipyridamole, or sometimes clopidogrel)
Blood pressure lowering medication
Cholesterol reduction
Warfarin for atrial fibrillation
Carotid endarterectomy for severe carotid stenosis
Haemorrhagic
Treat underlying cause (e.g. arteriovenous malformation)

8. Drugs for secondary stroke prevention (STARTER n=66)

9. Longer term problems after stroke (relevant to exercise delivery)
Pain
Fatigue
Mood disorders (anxiety, depression, emotionalism)
Falls and fractures
Cognitive impairment
Seizures
Infections (urine, chest most common)
Bladder and bowel problems
Contractures

10. Pain is common Stroke related pain Non-stroke related
Complications e.g. DVT
Central post stroke pain (typically burning, shooting)
Shoulder pain (hemiparetic side) in 25%
Pressure sores
Limb spasticity
Non-stroke related
e.g. arthritis

11. Shoulder pain Affects 25% of patients More common in severe strokes
Causes are multifactorial
Optimum treatment uncertain
Advice from physiotherapist

12. Central post-stroke pain
Burning, icy, lancinating, lacerating, shooting, stabbing, clawing
May respond to antidepressants (amitryptiline), anticonvulsants (gabepentin)

13. Falls
In the first six months after discharge, half to three-quarters of patients fall
Causes
Patient related factors e.g. muscle weakness and wasting, incoordination, loss of awareness of midline
Environment e.g. uneven floors, footwear
Drugs e.g. sedatives, antihypertensives

14. Prevalence of fatigue after stroke
The prevalence of fatigue depends on how fatigue is defined,
Tools for measuring fatigue
Methods of applying tools e.g. postal questionnaires, telephone questionnaires, face-to-face interviews
Inclusion or exclusion of depression
Patient groups
Time after stroke,

15. Potential mechanisms of post-stroke fatigue
Pain Depression Direct physical mechanisms Treatment
Sleep disturbance Reduced mobility
FATIGUE
Behavioural avoidance and de-conditioning therapy
Adapted from Wessely, Hotopf and Sharpe 1998
Several mechanisms may underlie fatigue, including depression, treatment, behavioural avoidance of exercise and deconditioning.
What is the evidence for these mechanisms?

16. Mood disorders Depression in around 25% Anxiety in around 20%
Emotionalism (20%) sudden outbursts of laughing or crying

17. Cognitive impairment Memory and thinking problems
May precede stroke or occur as a result of stroke
Affects around 20% of patients at 6 months (MMSE of 23 or less)
Can get worsening of cognitive impairment as a result of other medical problems e.g. infection

18. Co-morbidities
Diagnosable condition which exist in addition to main condition
May have caused stroke (e.g. atrial fibrillation)
Co-morbidity e.g. angina may be caused by a common risk factor (e.g. high blood pressure)
May be unrelated to stroke e.g. gout

19. Co-morbidities in STARTER

20. Drugs for co-morbidities in STARTER n=66

21. Relevance of co-morbidities to exercise delivery
Hypertension: drugs may cause postural hypotention and dizziness, beta-blockers: measurement of pulse rate to measure intensity of exercise
Ischaemic heart disease: exercise can carry risks.
Avoid if unstable angina
Exercise within limitations of stable angina.
Congestive cardiac failure: tailor to breathlessness and fatigue
Diabetes mellitus: exercise may precipitate hypoglycaemia. Seek medical advice prior to taking up classes. Strategies may include
Reduction of insulin dose prior to exercise
Take additional carbohydrate prior to exercise.
Avoid injecting insulin into exercising muscle as absorption increases and so risk of ‘hypos’

22. Services for people after a stroke
In-patient care (rehabilitation, terminal care, long-term NHS care)
Out-patient care (e.g. neurovascular clinics)
Early supported discharge services
Primary care team
GP (quality outcomes framework)
District nurse
Practice nurse
Respite care, day hospital
Domiciliary physiotherapy
Long-term nursing home care
Charities (e.g. advice lines, CHSS stroke nurses)

23. Younger stroke patients
25% of patients are under 65
Similar neurological effects as older patients
Need to consider impact on employment, finances and relationships
All age stroke units, young stroke units
In Lanarkshire: young stroke worker
Different Strokes: charity set up by younger stroke patients for younger patients

24. Department of Health: National Stroke Strategy
10 point action plan
Awareness (recognition of symptoms)
Preventing stroke
Involvement
Acting on warnings
Stroke as a medical emergency
Stroke unit quality
Rehabilitation and community support
Participation (planning housing, transport)
Workforce (skill mix)
Service improvement

25. Summary Early management of stroke
Acute treatment (aspirin and clot busting drugs for ischaemic stroke)
Secondary prevention (aspirin, antihpertensive drugs, statin, warfarin, carotid endarterectomy)
Rehabilitation (on a stroke unit by a multidisciplinary team)
Long-term problems (pain, fatigue, cognitive impairment, mood disorders, falls, infections)
Co-morbidities (ischaemic heart disease, diabetes have important implications for exercise delivery)
Stroke in a national context: stroke strategies exist for UK

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