exercise after stroke specialist instructor training course l4 stroke: the longer term dr. gillian...
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EXERCISE AFTER STROKESpecialist Instructor Training Course
L4Stroke: the longer term
Dr. Gillian Mead Reader and Consultant
The University of Edinburgh
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Overview of talk
• Stroke prevention (lifestyle and drugs)
• Longer term post-stroke problems
• Co-morbidities (and drugs for comorbidities)
• Services for people after stroke
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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
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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)
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Secondary prevention: general
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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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0
10
20
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70
80
antiplatelets anticoagulants ACE- thiazide beta-blockers calcium antag alph blockers
%
Drugs for secondary stroke prevention (STARTER n=66)
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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
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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
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Shoulder pain
• Affects 25% of patients
• More common in severe strokes
• Causes are multifactorial
• Optimum treatment uncertain
• Advice from physiotherapist
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Central post-stroke pain
• Burning, icy, lancinating, lacerating, shooting, stabbing, clawing
• May respond to antidepressants (amitryptiline), anticonvulsants (gabepentin)
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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
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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
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Mood disorders
• Depression in around 25%
• Anxiety in around 20%
• Emotionalism (20%) sudden outbursts of laughing or crying
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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
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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
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Co-morbidities in STARTER
0
5
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25
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40
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hypertension IHD Cancer Diabetes LVF arthritis other
%
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Drugs for co-morbidities in STARTER n=66
0
5
10
15
20
25
analgesics ulcer drugs inhalers steroids thyroxine diuretics digoxin antidepress
%
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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’
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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)
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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
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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
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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
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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