1. What is a stroke?
Stroke – a serious condition
Stroke, one of the most common neurological disabilities in South Africa, can have a devastating impact on a person’s life. As any area of the brain can possibly be affected by a stroke, virtually any function of the brain can be involved. Fortunately, however, the knowledge regarding the management and prevention of strokes has improved greatly over recent times, making it possible to reduce the likelihood, or effect, of a stroke.
There are many differing definitions of a stroke. A simple description of a stroke is that it could be considered a “brain attack”, which is in many ways similar to a “heart attack”. The brain, like the heart, is supplied with numerous blood vessels, which, among other things, provide the essential nutrients and oxygen that brain cells require. Any disease process that interferes with the blood supply to the brain, thereby damaging or destroying brain cells can lead to a stroke.
A stroke or brain attack (also known as a cerebro vascular accident or CVA) occurs when an interruption to the blood supply of an area of brain occurs. This can either be due to a clot becoming lodged in a blood vessel or the rupture of a weakness in the vessel wall, resulting in a haemorrhage.
Without the oxygen and nutrients supplied by the blood, brain cells will die very quickly and a chain reaction at a cellular level is set in motion, which can result in continuing damage over the next few hours. It is during this window period that prompt medical treatment can make a difference to the degree of damage and therefore to the patient’s level of function later.
What happens when the blood supply to the brain is affected?
The brain cells are extremely sensitive to any changes in their blood supply and can only survive a short time without oxygen and adequate nutrients. After this time, the cells may be damaged and may die. There are two types of injury to the brain cells, known as primary and secondary injury.
2. Risk factors for stroke and symptoms:
- Atrial fibrillation (irregular heart rate) is the most common cause of ischaemic stroke
- Advanced age
- Family history
- Hypertension (high blood pressure)
Reduce the risk of stroke by maintaining a healthy lifestyle:
- Eat a balanced diet, rich in fruit and vegetables
- Quit smoking
- If you’re over 40, have your blood pressure checked every 6 months
Who suffers from strokes?
While strokes occur mostly in older people, people of all ages can have strokes. A significant percentage of strokes occur in people under the age of 50, and women are not exempt.
What to do if you think you’re having a stroke
- Get to an emergency centre immediately – preferably one that has a Stroke Unit.
- Do not wait for your symptoms to subside - take action immediately. Do not drive yourself.
Why do people develop stroke?
A stroke may occur when the blood vessels supplying the brain either become blocked or (occasionally) rupture, causing a small bleed in the brain. There are other causes of a stroke, including clots originating from other parts of the body that travel to the brain and block the blood vessels, or there may be a structural problem or weakness in a blood vessel in the brain.
Many conditions or habits may increase the likelihood of developing stroke, including hypertension, diabetes, high levels of fat in the blood (hyperlipidaemia), obesity, drug and alcohol use and others.
What are the symptoms of a stroke?
The brain is an incredibly complex organ, which contains various centres and pathways that control our movement and sensory functions, our hearing and sight and our language and speaking ability, to mention but a few.
A stroke can affect virtually any area of the brain and the symptoms of a stroke depend on the area(s) and function(s) affected. Additionally, a stroke may be limited in its area or be widespread, so the spectrum of possible symptoms is wide.
As an example, a person with a stroke may experience one or a combination of the following symptoms:
- Sudden onset of severe headaches with unknown cause
- Sudden weakness, numbness or paralysis of the face or limbs, particularly on one side of the body
- Sudden visual loss or double vision
- Sudden difficulty walking, dizziness or loss of coordination
- Sudden difficulty with speech or understanding basic speech (aphasia)
However, strokes do not always present with the above symptoms and a patient may present with confusion, convulsions, dementia or coma. Occasionally other medical problems can cause symptoms that are similar to those caused by a stroke and these include epilepsy, brain tumour, migraine headache and others.
2. Diagnosis and treatment of stroke
What should be done if someone may have experienced a stroke?
A stroke, like a heart attack, is a medical emergency and should be treated as such. Therefore, if you suspect that you may have had a stroke or have any other concerns, please consult your doctor or hospital as a matter of extreme urgency. The period (especially the first few hours) immediately after a stroke is enormously important in minimising the damage to brain cells.
Strokes can be anything from mild to fatal, but they are always a medical emergency which requires immediate treatment. Every second counts. Brain cells start to die within four minutes of the onset of a stroke, therefore the sooner the signs are recognised and the symptoms treated, the better your chance of survival and recovery. The average delay before the patient reports their stroke is 30 minutes and further delays in reaching an emergency centre normally occur.
The outcomes of early treatment for stroke are much improved nowadays, where the awareness of stroke symptoms leads to faster diagnosis.
A patient who has had a stroke needs to have a CT scan within 20 minutes, and medication administered within 3 hours of onset, for best results. However, interim data shows that patients wait between 3 and 4 hours from the time of onset before reporting to the hospital for treatment.
Encouraging outcomes, due to the effective use of thrombolytic drugs, have prompted the medical profession to become more organised in the management of acute stroke. Stroke units have sprung up around the world where dedicated multi-disciplinary teams include clinicians, haematologists, clinical psychologists, occupational therapists, physiotherapists and speech therapists. The availability of advanced round-the-clock radiology enables quick and accurate diagnosis.
TIA’s (Transient Ischaemic Attacks), commonly called “mini-strokes”, occur when the cerebral arteries are narrowed. Typically a patient would experience short episodes of confusion, weakness or even loss of consciousness. Early management of TIA’s is essential to reduce the risk of a stroke in the future, however this warning sign is often ignored once the patient has recovered. Patients who have had a TIA could benefit from a visit to a vascular surgeon for screening of the carotid arteries to detect any blockages.
3. Rehabilitation after Stroke
Depending on the severity of the stroke, a patient may need to receive care by one or even all of these practitioners during hospitalisation and as part of the rehabilitation programme.
Emotional support: Clinical Psychology and Support Group
Rehabilitation can be arduous, both for patients and their families, and they may benefit from joining a support group. The coping skills of each individual vary, and the use of coping strategies is adjusted accordingly in managing the patient’s recovery. A clinical psychologist can work with the family to guide the patient towards health and feeling “alive”. This approach especially comes into play where occupational, speech or neuro-physiotherapy is required in the event of weakness or paralysis on one side of the body.
Simple aspects of practising to walk, eat and write go a long way to expediting recovery as well as preserve and improve the quality of life of stroke patients. It is recommended that the patient resume therapy as soon as he or she is ready and motivated. The therapist will assist and guide the patient and relatives throughout the rehabilitation process to ensure the patient reaches his full potential and maximise his recovery.
A stroke may also affect a person’s ability to communicate in a number of ways. A patient might have a specific isolated speech problem or there could be a combination depending on the area of the brain affected by the stroke.
Various treatment methods are used to enable communication, including alternative communication strategies such as teaching gestures or using a communication board- or device. Speech-Language Therapists are uniquely trained to manage communication difficulties as well as swallowing disorders. After doing a full evaluation, a Speech-Language Therapist will make a diagnosis and plan therapy according to the results for each individual.
The following may be present:
Aphasia: a language deficiency that results in an inability to express oneself by speaking or writing and/or an inability to understand written or spoken language. Communication difficulties may range from mild (occasional difficulty finding the right word) to severe (complete loss of speech).
Apraxia: a motor planning problem. The person will have difficulty planning and performing the sequences of speech movements necessary to say a word.
Dysarthria: motor speech disorders that occur because the muscles needed to produce words have been weakened or paralyzed by the stroke. The person may have slurred speech and/or changes to their voice.
Dysphagia: a swallowing problem that involves difficulty in moving food from the mouth to the stomach. Dysphagia can be serious. Someone who cannot swallow well may not be able to eat enough food to maintain their ideal weight and there is a risk that food may enter the lungs, which can lead to infections (aspiration pneumonia).
Physiotherapy and Occupational therapy
The location of the damaged area within the brain and the size of the area involved will determine the degree and type of deficit that the patient has to try to overcome. There could be problems with movement, sensation, perception of space or position sense, balance, speech, swallowing, vision, concentration, memory, or the ability to process instructions. Generally there are combinations of several of these disabilities.
In order to address these problems one needs the assistance of different professionals and therefore a rehabilitation team comprising doctors, nursing staff, physiotherapists, occupational therapists, speech therapists, psychologists and social workers will all become involved in the person’s return to function.
A physiotherapist in the field of neuro-rehabilitation is in the unique and privileged position of really getting to know her patients, their own specific problems and needs and how these fit into the context of their lives. Once the medical crisis has been dealt with and the stroke patient is stable in hospital, the physiotherapist is often the first member of the paramedic team to come into contact with the patient. Patients and their families are often bewildered, afraid and terribly uncertain of how they will cope in the future. The physiotherapist can become a lifeline at this stage as she spends time with the patient and can provide enormous reassurance to both patient and family.
While it is true that brain cells that have died do not re-generate, it is now known that the brain nevertheless has a degree of “plasticity”, enabling neighbouring cells to grow new connections and take over the function of those destroyed. It is this ability that physiotherapists try and stimulate with therapy and the degree of success is dependant on many factors, chief of which is probably the ability of the patient to learn and put into practice what he has achieved during his therapy sessions.
Physiotherapists are primarily concerned with encouraging the return of normal movement, but in neuro-rehabilitation it is seldom possible to treat this problem in isolation as so many other facets of the patient’s difficulties will impact on how he is able to respond to the therapy. Therefore, a close association with other members of the team is very beneficial.
Therapy begins in hospital, initially focusing on preventing complications such as respiratory infections or pressure sores, as well as facilitating correct movement patterns and teaching good positioning to reduce the negative impact that spasticity and reflex patterns of movement can have. Emphasis is placed on postural alignment and symmetry, and at the same time teaching patients how to regain some of their lost independence.
Patients are helped to set small attainable goals at a time, thereby giving them a feeling of success which then provides further motivation. Therapy continues after discharge from hospital, perhaps in a rehabilitation unit for a few weeks, but ultimately with the goal of returning the person to their own home, at which stage therapy can continue as an out patient or as home based therapy, depending on the individual’s circumstances.
Not all stories have a perfect ending and recovery from stroke is no exception. Compromises generally have to be made, adjustments to lifestyle are inevitable with most people, but improvement is possible and the return to a meaningful life for her patient is the goal of every therapist.
(Constantiaberg Stroke Service, July 2009)