Stroke: from physiopathology to rehabilitation

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Dr. med. Yannis Dionyssiotis

Introduction to Stroke 

 Stroke was recognized as a pathologic entity since the days of ancient Greece. Hippocrates used the term “apoplexy“ to describe the sudden loss of consciousness and paralysis. The word stroke is used to describe the event of a sudden and dramatic development of a neurological deficit as a result of pathological obstruction or bleeding of one or more blood vessels in the brain leading to necrosis of the brain regions that are supplied with blood from these vessels. We now know that stroke is a serious condition that often leads to death or permanent disability resulting in functional and neurological deficits; is the third leading cause of mortality in developed countries and the first cause of disability in humans and responsible for 25,000 cases annually in our country Greece, according to the World Health Organization (WHO).

Is it possible to reduce the risk of stroke?

The table shows risk factors which do not change, and others which can be changed or modified. Some people are at higher risk to suffer from stroke: older people, men more frequently than women and individuals with a history of stroke.

Table: Risk factors for Stroke

Which do not change               can be modified                        can be changed

Age                                                         Hypertension                                       Obesity

Gender                                              Atrial fibrillation                             Physical activity      

Genes                                                          Diabetes                                           Alcohol

Race                                                            Lipids                                                      HRT

Ethnicity                                          Carotid Stenosis                                  Contraceptives

Other factors that increase the possibility of a stroke but can be treated or changed are:

  • Hypertension

The most important factor in preventing stroke is the proper treatment of arterial hypertension. It is the strongest single risk factor for both ischemic and hemorrhagic strokes. A 50 years man with hypertension has quadruple stroke risk in the coming years than a healthy one. It has been shown that treatment of hypertension reduces stroke by 38% at least. The antihypertensive therapy should be recommended by a specialized physician who will decide what drug and in what dosing is appropriate for this patient. The most common classes of drugs are diuretics, inhibitors of beta-adrenergic receptor, the calcium antagonists, competitors of angiotensin II and angiotensin-converting enzyme. In 2003 a published study of 6105 patients from 10 countries in the American journal STROKE has showed among other, benefits in patients who had suffered a stroke when treated with antihypertensive therapy based on the ACE inhibitor perindopril or the combination of the diuretic indapamide.

  • Cardio-vascular disease

The most common heart condition that causes ischemic stroke is an arrhythmia called atrial fibrillation. This is the second in a row risk factor for stroke after hypertension. Approximately 0.4% of the general population have atrial fibrillation; its frequency increases with aging. Half of thromboembolic stroke is due to this arrhythmia. Moreover, asymptomatic carotid stenosis (narrowing of over 50% of carotid without clear symptoms), occurs in about 5 to 9% of people aged over 65 years. These people are at risk of suffering an ischemic stroke with a frequency of 1-2% annually. Endarterectomises surgery by an experienced vascular surgeon is recommended usually in patients with a stenosis over 60%. Other heart diseases such as myocardial infarction, valve disease, cardiomyopathy, etc., are also important risk factors for stroke. The contribution of the cardiologist is necessary to treat these diseases.

  • History of transient ischemic attack (TIA)

TIA is called the temporary interruption of blood flow to a part of the brain. It lasts for a few seconds or a few hours, but usually less than 24 hours. It is an important warning sign of a future stroke. It is a sign that the blood flow to the brain is disturbed.

  • Diabetes

The presence of diabetes increases the risk of ischemic stroke up to 6 times. The risk is higher when diabetes coexists with hypertension.

  • Cholesterol

High cholesterol values are a major risk factor of coronary heart disease but until recently there were a debate for the event in general strokes. In patients with ischemic heart disease who have high cholesterol, administration of anti-cholesterol drugs (statins) reduced stroke in an average of 23%.

  • Lifestyle Habits: Smoking, alcohol, obesity, physical activity

Smoking is considered a major risk factor of stroke, as it doubles the risk of disease. The decrease in consumption of excessive amounts of alcohol and the treatment of obesity reduces the possibility of a stroke. Daily, moderate physical activity with duration more than a half hour helps indirectly to reduce other factors that increase stroke risks.

Other minor risk factors for stroke found in several studies are the following: drugs such as amphetamine, cocaine and heroin, and people with elevated homocysteine ​​levels have a serious risk of suffering a stroke; prethrombotic conditions caused by or acquired gene diseases (anti-cardiolipin syndrome, Leiden factor V, etc) are also associated with increased risk of stroke.

The use of hormone replacement therapy for over three years in women after menopause increases the risk of having a stroke. The probability of a woman to express a stroke after use of oral contraceptives is very small. The risk is higher in women who smoke, have hypertension or a thrombotic event in their history.

Classification

Strokes can be classified in ischemic infracts and brain haemorrhages. The ischemic cerebral infracts are more frequent (80%) and caused by blockage of a vessel usually because of a blood clot. As a result of the blockage, the region of the brain irrigated by this vessel is deadened. The main causes of ischemic strokes are atherosclerosis of the arteries (carotid and vertebral) and heart diseases such as myocardial infarction and particularly atrial fibrillation. Brain haemorrhages account for 20% of the strokes and are usually due to hypertension or brain aneurysm. In this case the blood vessels break and blood poured into the brain resulting in its destruction.

Differential diagnosis whether it is an ischemic or hemorrhagic stroke or a disease with a similar clinical picture should be initially done by the specialized physician. The clinical picture of stroke includes a variety of symptoms. There may be motor deficits (paralysis of one side of the body, loss of voluntary control of movement, decrease of the angle of the mouth or facial deformity), altered reflexes and spasticity in specific muscles, sensory disturbances, abnormal control of urination and defecation, weakness communication, speech disorders and visual deficits in memory, perception and action. The diagnosis is assisted by imaging particularly CT, MRI, MRA, etc.

Walking of a patient with right Hemiplegia because of a Stroke

Diagnosis and clinical picture

Medical complications of the patient who suffered a stroke

1) Cardiovascular (because of possible correlation between thrombotic stroke and pre-existing atherosclerotic heart disease)

2) The generalized reduction in functional capacity of systems because of the disease and immobilization in bed (i.e., orthostatic hypotension, pulmonary atelectasias, depression, decreased muscle strength, contractures, osteoporosis, metabolic changes, ulcers, sleeping, constipation, gastroesophageal reflux etc.

3) Deep vein thrombosis occurs in 42% of patients not taking prophylactic medication.

4) Pneumonological: pneumonia (30% of patients) but serious problems such as pulmonary embolism happen rarely.

5) Neurological problems such as paralysis, displaying spasticity, painful muscle spasms, neglect (ignorance of the existence of the other half of his body), seizures, hydrocephalus.

Spasticity in paralyzed limbs is common after a stroke

6) Gastrointestinal (neurogenic bowel, dysphagia, swallowing difficulties, malnutrition).

7) Communication problems or inability to articulate speech, problems with speech and understanding of written and spoken language, etc. (30% of patients).

8) Cognitive problems: deficits in memory, orientation, language, perception, thought, attention and learning (15-25% of patients).

9) Urinary Problems (urinary incontinence 50% of patients).

10) Dermatological sprawling ulcers (15% of patients).

11) Depression: difficulty in controlling emotions is present in 25-79% of patients.

12) Pain not due to damage (2%), but mostly in the paralyzed shoulder.

13) Falls are happening in 30% of these patients during transfers in and from a wheelchair; impairments in balance and neuromuscular coordination are the most common causes.

Management of Stroke

• Prevention

Prevention of stroke now-days is based on identification of individuals at high risk of stroke. These people have one or more risk factors reported and are likely to develop stroke more than those without risk factors.

The patients after the acute phase have various grades of automatic restoration of deficits and improving in functional capabilities. The timing of the rehabilitation program varies from patient to patient and in some cases is unfortunately absent. Moreover, each patient with stroke shows significant and unexpected differences. One patient can walk in three weeks while another one is wheelchair-bound or bedridden. These differences are due to various factors such as the region of lesion in the brain, concomitant diseases, age, etc.

Rehabilitation of patients who survived after the stroke.

Objectives of the rehabilitation program include the following:

• each patient after proper evaluation of the functional and neurological deficits should follow individualized program designed according to the severity of deficits
• goal of treatment is to upgrade the functional level of the patient
• education of the patient and his family about the disease and its complications
• assessing the patient for a suitable device – orthosis for the movement and activities of daily living
• prevention of a new stroke
• improvement of physical performance
• prevention and treatment of accompanying diseases
• psychological support
• social rehabilitation
• training in self-help and independence of the patient

Treatment in the acute phase and early rehabilitation

Treatment in the acute phase is happening initially in an intensive care unit or in a neurological department or medical clinic and includes general supportive treatment measures (improvement of blood oxygen, blood pressure regulation, sugar levels, responding to a possible fever, treatment of possible seizures, electrolyte regulation) and the primary medication of anticoagulant therapy (if cerebral haemorrhage is excluded and no other contraindications exist), prophylaxis of deep vein thrombosis, intracranial pressure measurement (in bleeding), specialized medical interventions, etc. After the first week, hypertension should be treated in a stroke. This treatment benefits all types of stroke (ischemic or hemorrhagic). The best therapeutic effect of medication is achieved by using a combination of angiotensin converting enzyme inhibitors and diuretics.

Rehabilitation should begin immediately upon entry of a patient in an intensive care unit. Under the guidance of Rehabilitation physician the therapist begins: 1) respiratory physiotherapy on the patient in order to remove the bronchial secretions to avoid complications, 2) positioning that means the correct position and posture in bed to prevent aspiration and pressure sores (in collaboration with nurses), 3) application of splints and special pillows that help to prevent contractures, 3) range of motion exercises in the upper and lower extremities of the patient in bed.

During his stay in Neurologic/Internal Medicine Department and while in bed the patient continues physiotherapy and respiratory exercises, range of motion exercises in the upper and lower extremities to prevent deformities and pressure sores. Emphasis is given to the region of hemiplegic shoulder and leg (ankle) to prevent complications which are common after a stroke. In patients with neglect all stimuli should be given from the affected side (feeding, speaking, bedside table etc.)

Rehabilitation (sub-acute and chronic phase)

  • Rehabilitation Centre / Department of Physical Medicine and Rehabilitation / Home

In the rehabilitation centres or units of Physical Medicine and Rehabilitation the physician works together with rehabilitation therapists (physical therapists, occupational therapists, and speech therapists), social workers, and psychologists etc. to reintegrate the patient’s life. The rehabilitation is a remedial learning process that accelerates and maximizes recovery.

Physiotherapy: early attention is given to breathing exercises and retraining in the seating position (if necessary) and then to strengthen the healthy part of the body and trunk, while at the same time the therapist exercises the hemiplegic part of the body in order to put the patient in the sitting position without any assistance. The program is focusing on leg exercises to prepare hemiplegic leg to accept weight during the phase of walking retraining. At the upper limb the aim is to raise the arm without pain. Balance exercises in an upright position are following. Then patient is starting to be trained in gait (with the help of the therapist and walking aids) and gradually in climbing and descending steps. Climbing the steps is done with the good foot and descending with the hemiplegic. At the beginning the patient usually needs help of another person or crutches. The railing can be used for balance. The approach usually applied to strokes is Bobath method based on the interception of pathological patterns of movement a patient because of the incident, to facilitate normal movement patterns. The improvement of aerobic capacity is done using special electronic bicycle of passive-active mobilization. The physician and the therapist should take into account the element of fatigue and not to deplete the patient in a very intensive physical therapy program.

Cognitive disorders: the treatment of cognitive disorders (deficits in memory, orientation, language, perception, thought, attention and learning) is of major importance and should be an objective of the rehabilitation program.

Impaired sensation and proprioception: despite their importance in stroke are usually neglected because physicians, patients and relatives are more concerned to functionality associated with motor skills. The proprioception gives us information on the location of the body during our move. Their importance is crucial to recovery.

Occupational Therapy: helps restoring upper extremity impairments and focuses on functional restoration. The case concerns the kinetics and emphasizes education and other functions (mental, cognitive, perceptual, emotional) and in all areas of everyday life (work, home and family, social contacts and leisure activities).

Speech Therapy: helps in communication and swallowing disorders after stroke. Diagnosis and rehabilitation programs for these disorders are an essential component of treatment and also minimize the likelihood of aspiration pneumonia.

The application of splints helps prevent contracture (i.e., extensive type fingers and wrist splints, splints and knee angle adjustable ankle) and the implementation orthotic equipment is needed to stand and walk in some patients.

An important element of rehabilitation is the prevention and treatment of ulcers and pressure sores, because in case of delayed healing are a portal of microbes and increase the energy needs of the organization.

Spasticity after stroke: Spasticity is a movement disorder. It causes muscle spasms (flexor muscles of the upper limb, extensors of the lower limbs), abnormal control of posture and prevents the harmony of movements complicating the functionality of the body. Spasticity can occur from the initial stage with a low or high degree (according to spasticity measure scales i.e. Ashworth scale). Treatment of spasticity targeted and extended at various levels. Physical therapy and modalities, special splints and cryotherapy, have supplementary role as their effectiveness in terms of spasticity is temporary and lasts few hours. Key elements in the treatment of spasticity are medication and chemical neurolysis (botulinum toxin A injections), while in permanent deformations orthopedic surgery is needed. The treatment of spasticity with oral medication and botulinum toxin A must be followed by an appropriate physical therapy program, occupational therapy and retraining of movement and maximum functional results. The intervention in spasticity is always based on patient’s needs and the importance of self-functioning.

Complex regional pain syndrome: this is a clinical entity that occurs quite frequently (12-70%) in subjects suffered a stroke, and relates mostly to the upper end. It usually occurs with heartburn, restriction of movement of the shoulder (particularly), wrist and hand, swelling, increase in muscle tone and temperature, hyperhidrosis, etc. Early diagnosis is the key to prevention and treatment.

Biofeedback (BFB) is a clinically effective therapeutic method of retraining to rehabilitate patients with stroke focusing in retraining weak muscles. The device gives an audible or visual signal. In this way the patient is trained to sense the increased muscle activity, and monitor the enhanced reactions while monitoring the biofeedback device. Thus it can focus its attention on the recognition of this feeling, and manage movement in a better way. Intact proprioceptive sense has an important role to have the benefits of biofeedback technique. Rehabilitation Physicians are expertise to distinguish which patients need the biofeedback.

Psychogenic disorders: stroke can cause depression and other mental disorders. Early recognition and treatment can improve both the mental condition of the patient, and cooperation in rehabilitation. Drugs are the first line therapy, especially the newer antidepressants. Great importance is 1) to encourage and reward the patient for everything he is trying during treatment because there is always a risk to be disappointed and to deny to participate in treatment and 2) to support psychologically the related persons.

Surgery in hemiplegic: the purpose of the surgery is mobilization and easy care giving of patients as well as walking, where there is this possibility. Cross-section tendons or muscles or extensions of Achilles tendon in the legs are interventions that can assist in functional rehabilitation of patients with stroke.

Conclusion

The majority of patients with stroke have accompanying medical problems that require monitoring and therapeutic interventions (hypertension, heart disease, diabetes, etc.). The proper treatment reduces the risk of new stroke and increases survival. The rehabilitation does not end when the patient is leaving the hospital and patients benefit from continued treatment. The depression, decreased sexuality, difficulties in movement, driving and spasticity necessitate chronic patient evaluation and rehabilitation.

  • Dr. med. Yannis Dionyssiotis studied Medicine at the University of Athens. After finishing his specialization in National Rehabilitation Center “EIAA” and completing his thesis in the University of Athens he worked as Physiatrist in the Rehabilitation department of KAT Hospital in Kifissia and as the head of Physical Medicine and Rehabilitation Department in Rhodes General Hospital in Greece. Currently is the Director of Physical and Social Rehabilitation Centre Amyntaeo in Florina Greece.
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Yannis Dionyssiotis, MD, PhD, Director of Physical & Social Rehabilitation Center Amyntaeo, Florina, Greece, e-mail:yannis_dionyssiotis@hotmail.com
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