Physiotherapeutic Management of Stroke

Introduction

Cerebrovascular disease or the term stroke is used to describe the effects of an interruption of the blood supply to a localised area of the brain. It is characterized by rapid focal or global impairment of cerebral function lasting more than 24 hours or leading to death (Hatano, 1976). As such it is a clinically defined syndrome and should not be regarded as a single disease. Stroke affects 174-216 people per 10,000 population in the UK per year and accounts for 11% of all deaths in England and Wales (Mant et al, 2004). The risk of recurrent stroke within 5 years is between 30-43%. One problem is that the incidence of stroke rises steeply with age and the number of elderly people in the UK is on the increase. To date people who experience a stroke occupy around 20 per cent of all acute hospital beds and 25 per cent of long term beds (Stroke Association, 2004). The British Government now identifies stroke as a major economic burden on the National Health Service (DoH, 2002).

Fifty percent of stroke survivors will experience some residual impairment (physical and cognitive), which is devastating to the individual and their families (Rudd et al, 2002). It is therefore vital for patients and resources that maximum functional recovery is achieved as fast as possible. The physiotherapist has a key role to play in the management of stroke patients, through assessment, prevention strategies, acute management and recovery. This essay aims to critically discuss physiotherapeutic management and examine how it has and may be influenced by a number of factors (e.g. type of organized system for the delivery of post stroke care, setting of therapy, evidence based practice from which National Guidelines are produced etc). The first stage is to outline stroke pathology, of which forms the basis of appropriate management.

Pathology

There are two major stroke sub groups, those resulting from infarction (ischemic stroke) and those resulting from haemorrhage (intracerebral and subarachnoid). Each of the types can produce clinical symptoms that fulfil the definition of stroke. The types often differ with respect to survival and long-term disability, from recovery in a day to incomplete recovery, severe disability and death (Warlow et al, 2001).

Ischemic stroke is the most common type of stroke, which accounts for approximately 85% of all cases (Rudd et al, 2002). It affects 35 people per 100,000 of the population per year (Coull et al, 2004). Ischemic stroke can be caused by a sudden occlusion of arteries supplying the brain, as a result of thrombosis formed directly at the site of occlusion (i.e. thrombotic ischemic stroke), or in another part of the circulation, which eventually obstructs arteries in the brain (i.e. embolic ischemic stroke). Diagnosis is usually based on neuro-imaging recordings, however, it may not be possible to decide clinically or radiological whether it is a thrombotic or embolic ischemic stroke (Rudd & Wolf, 2002).

Intracerebral haemorrhage is a bleeding from one of the brain's arteries into the brain tissue. The lesion causes symptoms that mimic those seen for ischemic stroke. Diagnosis is based on neuro-imaging, which can differentiate it from ischemic stroke. Hypertension is the single most underlying cause of intracerebral haemorrhage (Poungvarin, 1998).

Subarachnoid haemorrhage is characterised by arterial bleeding in the space between the two meninges pia mater and arachnoidea (The university of Virginia, 2004). Typical symptoms are sudden onset of very severe headache, vomiting and usually impaired consciousness.

To date there appears to be no single, specific cause of stroke but rather several factors that may increase the risk of an individual having a stroke. The causes of the first stroke are generally identical to those that result in subsequent stroke. It is therefore important to identify risk factors in order to provide appropriate management.

Risk Factors

People with more than one risk factor have an "amplification of risk", in which multiple risk factors compound their destructive effects creating an overall risk greater than the simple cumulative effect. Generally, risk factors for stroke can be classified as non-modifiable, potentially modifiable and modifiable (Sacco et al., 1997).

Non-modifiable risk factors for stroke include age, gender, family history and ethnicity. For example, age is the single most important risk factor for stroke (National Institute of Neurological Disorders and Stroke -NINDS, 2004). Indeed, for each 10 years after age 55, the stroke rate more than doubles for both men and women (The Stroke Association, 2004). Men have a higher risk for stroke; with the stroke risk for men at 1.25 times that as for women (Sacco, et al, 1997).

Potentially modifiable risk factors include diabetes and heart disease (and some controversial factors such as alcohol and drugs)(Goldstein, 2001). Diabetes is associated with stroke, independently of the various cardiovascular risk factors that usually accompany this disease (hypertension, dyslipidemia and obesity) (American Stroke Association (ASA), 2004).

Modifiable risk factors include hypertension, smoking, physical inactivity and obesity (Rudd & Wolf, 2002). In middle and late adult life, hypertension is undoubtedly the strongest modifiable risk factor for both ischemic and hemorrhagic stroke (Rothwell, 2004) and is present in 70% of stroke cases. Another powerful modifiable stroke risk factor is smoking, (which amongst other things promotes atherosclerosis) and which almost doubles a person's risk for ischemic stroke (ASA, 2004). As part of therapeutic management a physiotherapist would refer the patient to a smoking cessation program. Ideally, health care providers (including physiotherapists) should screen individuals for risk factors that could lead to cerebrovascular disease and use this opportunity for education.

Given the pathology of stroke and the number of risk factors, it is not surprising that the spectrum of clinical presentations is also extensive (Warlow et al, 2001). It is important to recognise that each person should be considered on an individual basis, as no two cases will present the same (Moser & Ward, 2000). The following section therefore provides an overview.

Clinical Presentation

The types of disability that follow a stroke depend upon which area of the brain is damaged and may correlate to the patient's neurological deficits with the expected sites of arterial compromise (Warlow et al, 2001). The effects of the stroke will also