EXERCISE AFTER STROKESpecialist Instructor Training Course

L4Stroke: the longer term

Dr. Gillian Mead Reader and Consultant

The University of Edinburgh

Overview of talk

• Stroke prevention (lifestyle and drugs)

• Longer term post-stroke problems

• Co-morbidities (and drugs for comorbidities)

• Services for people after stroke

Learning OutcomesAt 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

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)

Secondary prevention: general

Secondary prevention

• Ischaemic– 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)– Blood pressure lowering medication

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antiplatelets anticoagulants ACE- thiazide beta-blockers calcium antag alph blockers

%

Drugs for secondary stroke prevention (STARTER n=66)

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

Pain is common

• Stroke related pain– 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

Shoulder pain

• Affects 25% of patients

• More common in severe strokes

• Causes are multifactorial

• Optimum treatment uncertain

• Advice from physiotherapist

Central post-stroke pain

• Burning, icy, lancinating, lacerating, shooting, stabbing, clawing

• May respond to antidepressants (amitryptiline), anticonvulsants (gabepentin)

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

Prevalence of fatigue after stroke

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Potential mechanisms of post-stroke fatigue

Stroke

Pain Depression Direct physical mechanisms Treatment

Sleep disturbance Reduced mobility

FATIGUE

Behavioural avoidance and de-conditioning therapy

Adapted from Wessely, Hotopf and Sharpe 1998

Mood disorders

• Depression in around 25%

• Anxiety in around 20%

• Emotionalism (20%) sudden outbursts of laughing or crying

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

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

Co-morbidities in STARTER

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hypertension IHD Cancer Diabetes LVF arthritis other

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Drugs for co-morbidities in STARTER n=66

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analgesics ulcer drugs inhalers steroids thyroxine diuretics digoxin antidepress

%

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’

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)

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

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

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

Essential ReadingFurther detail about the topics discussed in this

session can be found in section L3 and L4 of the course syllabus.

The University of Edinburgh