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Cerebrovascular Accident or Stroke

by: - September 5, 2016
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By: Dr Lucia Corriette

Overview
According to the World Health Organization (WHO), “A stroke is caused by the interruption of the blood supply to the brain, usually because a blood vessel bursts or is blocked by a clot.” There are two types of stroke. Hemorrhagic stroke occurs when a blood vessel ruptures and ischemic stroke is the result of a blood clot. They both lead to the absence of blood travelling to the brain and both result in the death of brain tissue.
Stroke is one of the four leading causes of death in the Caribbean. In the United States it is the third leading cause of death and the leading cause of major long-term disability. Globally, stroke is the second leading cause of death above the age of 60, and the fifth leading cause of death in people aged 15 to 59.

Typical symptoms of a stroke include sudden weakness or numbness of the face, arm or leg, most often on one side of the body; confusion, difficulty speaking or understanding speech; difficulty seeing with one or both eyes; difficulty walking, dizziness, loss of balance or coordination; severe headache with no known cause; fainting or unconsciousness. In some cases, stroke can result in coma and/or death.

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Causes of stroke

High sodium/salt consumption
• High sodium consumption (>2 grams/day, equivalent to 5 g salt/day) and insufficient potassium intake (less than 3.5 grams/day) contribute to high blood pressure and increase the risk of heart disease and stroke.
• Most people consume too much salt—on average 9–12 grams per day, or around twice the recommended maximum level of intake.
• WHO Member States have agreed to reduce the global population’s intake of salt by a relative 30% by 2025.

Uncontrolled hypertension
• When diagnosed with high blood pressure it is extremely important that patients take their medication as prescribed. Not doing so can result in extremely high blood pressure levels and stroke. Stroke is also known as the “silent killer” because it happens without warning. Many people diagnosed with stroke did not take their blood pressure medication as prescribed.

Lack of physical activity
• WHO defines physical activity as any bodily movement produced by skeletal muscles that requires you to use energy – including movement undertaken while working, playing, carrying out household chores, travelling, and engaging in hobbies or other leisure activities.
• Insufficient physical activity is 1 of the 10 leading risk factors for death worldwide. People who are insufficiently active have a 20% to 30% increased risk of death compared to people who are sufficiently active.
• Insufficient physical activity is a key risk factor for noncommunicable diseases (NCDs) such as cardiovascular diseases (including stroke), cancer and diabetes.
• Physical activity has significant health benefits and contributes to prevent NCDs.
• Globally, 1 in 4 adults is not active enough.
• More than 80% of the world’s adolescent population does not engage in sufficient physical activity.

Poor diet
Consuming a healthy diet helps prevent malnutrition in all its forms as well as a range of noncommunicable diseases and conditions. The increased production of processed food, rapid urbanization and changing lifestyles have led to a shift in dietary patterns. People are now consuming more foods high in energy, fats, free sugars or salt/sodium, and many do not eat enough fruit, vegetables and dietary fibre such as whole grains.

• Reducing the amount of total fat intake helps prevent unhealthy weight gain in the adult population
• Excess calories from foods and drinks high in free sugars contribute to unhealthy weight gain, which can lead to overweight and obesity
• 1.7 million deaths could be prevented each year if people’s salt consumption were reduced to the recommended level of less than 5 g per day
• Eating at least 400 g, or 5 portions, of fruits and vegetables per day reduces the risk of NCDs and helps ensure an adequate daily intake of dietary fibre.

Other causes
• Atherosclerosis. This results in the development of plaques in the arteries which can lead to clot formation
• Blood vessel damage due to long-term diabetes or hypertension which can lead to clot formation
• Heart conditions which can produce blood clots
• A ruptured aneurysm which results in bleeding in the brain

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Medical management

At some medical facilities, selected patients diagnosed with ischemic stroke are treated with intravenous recombinant tissue-type plasminogen activator (r-tPA). This has to be given within three hours of stroke onset and works to break up the clot and cause the return of blood flow to the brain a lot faster than regular treatment. While expensive, it is considered a cost effective measure and one that should be more widely used because of the improved outcomes.

Stroke is considered a medical emergency and usually requires admission to hospital. Diagnostic imaging tests such as computed tomography (CT) can be used to determine the extent of the damage to the brain. The goal of treatment is to stabilize the patient; reduce the high blood pressure to acceptable levels; or stop the bleeding in the brain. When the blood pressure is at a safe level or the bleeding in the brain has stopped, the patient can be referred to physiotherapy. Some patients may have difficulty speaking, in which case a speech therapist would be needed.

Physiotherapy management

Physiotherapy management of stroke patients begins in the acute stage, usually a few days after admission to the hospital. After discharge from the hospital physiotherapy should continue at a rehabilitation unit, in an out-patient unit or through home visits.

Patients who have suffered a stroke tend to have weakness of one side of the body. This weakness affects their ability to function which may include some or all of the following: An inability to hold objects, move the arm, move in bed, sit up, move the legs, stand and walk.

Physiotherapy treatment of stroke patients involves the use of exercises that are aimed at restoring movement. The lack of movement is due to damage to specific areas of the brain. Therefore, the exercises are also specific and include a lot of repetition. This is meant to encourage neuroplasticity of the brain where repeated actions result in the development of new pathways which can then produce return of movement. This means that the brain is able to rewire or reorganize itself after injury through repeated exercises.

Stroke patients may also have abnormalities in tone. Increased tone or spasticity means that the limb may feel stiff, while decreased tone or flaccidity results in a “floppy” arm or leg.

The presence of decreased movement may cause the therapist to refer the patient for orthotic devices. One example of this is an ankle foot orthosis for patients who have difficulty lifting their foot off the floor. Assistive devices such as quad canes or walkers may also be suggested for use by the physiotherapist. These provide support during ambulation/walking.

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Exercises to improve balance and ambulation are also a big part of stroke rehabilitation.

Stroke exervise

According to the American Physical Therapy Association, studies have shown that patients with stroke obtain better return of function when early, aggressive physiotherapy treatment is commenced. Therapists tend to select an approach to treatment that includes contributions from a broad and varied list of techniques. The approach to patients’ care includes treatment aimed at decreasing impairments and helping the patient compensate for their inability to perform tasks such as bathing, getting dressed, eating and moving around. It is important to recognize that full recovery is not always possible. However, the long-term goal of rehabilitation is to improve function so that the patient becomes as independent as possible.

References
1. American Physical Therapy Association. Changing Landscapes: Emerging Technologies to Treat Stroke. http://www.apta.org/Media/Releases/Consumer/2010/6/3/ Accessed August 30, 2016
2. Boudreau, D.M., Guzauskas, G.F., Chen, E., Lalla, D., Tayama, D., Fagan, S.C. & Veenstra, D.L. Cost-Effectiveness of Recombinant Tissue-Type Plasminogen Activator Within 3 Hours of Acute Ischemic Stroke. Current Evidence. Stroke. 2014;45:3032-3039
3. Jette, D. U., Latham, N. K., Smout, R. J., Gassaway, J., Slavin, M. D., & Horn, S. D. Physical Therapy Interventions for Patients with Stroke in Inpatient Rehabilitation Facilities. Physical Therapy. 2005;85(3): 238-248.
4. My Healthy Feeling. http://www.myhealthyfeeling.com/hemorrhagic-stroke-treatment-symptoms-prognosis-recovery/ Accessed September 2, 2016
5. Pathophysiology-Neurology Objectives. https://quizlet.com/19918050/pathophysiology-14-15-neurology-objectives-679-flash-cards/ Accessed September 4, 2016
6. Therapydia. Balance exercises. http://therapydiatampa.com/tag/balance-exercises/ Accessed August 30, 2016
7. World Health Organization. Healthy diet Fact Sheet. http://www.who.int/mediacentre/factsheets/fs394/en/ Accessed August 30, 2016
8. World Health Organization. Physical Activity Fact Sheet.
http://www.who.int/mediacentre/factsheets/fs385/en/ Accessed August 30, 2016
9. World Health Organization. Salt Reduction Fact Sheet.
http://www.who.int/mediacentre/factsheets/fs393/en/ Accessed August 30, 2016
10. World Health Organization. Stroke, Cardiovascular Accident. http://www.who.int/topics/cerebrovascular_accident/en/ Accessed August 30, 2016
11. World Heart Federation. Stroke.
http://www.who.int/mediacentre/factsheets/fs394/en/ Accessed August 30, 2016