Stroke and the Guidelines – What we All Should Know

How Common is Stroke?
In Australia, stroke is the third leading cause of death, with 10,869 fatalities due to stroke in 2015 (ABS). In the western world it is one of the largest causes of disability, and its healthcare burden is projected to triple by 2030 (Rajsic et al., 2019). Over the past two decades, rates of stroke events have reduced by 27%, and disability resulting from stroke has reduced from 45% - 39%. However in 2013, stroke rates were almost 100 per day (Australia’s health: Stroke, 2016).

What Does the Latest Evidence Tell Us?

In 2017, the most recent Clinical Practice Guidelines for stroke were published in order to guide best clinical practice throughout the acute, subacute and community care and rehabilitation process.

Regarding acute presentations, all suspected stroke patients should be immediately admitted to a stroke unit, cared for by a specialised multidisciplinary stroke team, and their rehabilitation needs and goals assessed for follow-up care.

Stroke survivors in the community require appropriate education, information and supports. As a history of stroke greatly increases the risk of further stroke, patients must be aware of how to identify a stroke with the F.A.S.T acronym. It is then strongly recommended that patients receive education and strategies for the management of modifiable risk factors for stroke, such as

• smoking
• diet
• obesity
• alcohol
• physical activity

Other important health and quality-of-life changes which need to be addressed in the community include

• social isolation,
• fatigue,
• patient follow-up options,
• self-management of things such as
  • Pharmacotherapy (medications)
  • carer training and support

The overall aim is to achieve ongoing sustainability in the long term holistic health and wellbeing of this population. It is important that education be provided with the patient’s family and/or carer, in order to achieve best outcomes.

A multidisciplinary rehabilitation program is important for any stroke survivor with goals to improve their health, quality of life or function, and should be based around specific, challenging, and continually updated multidisciplinary patient-centred goals. Development of a patient centred evidence-based rehabilitation program requires a thorough multidisciplinary assessment, which aims to address presenting deficits and dysfunctions.

The evidence recommends deficits, such as strength, balance, function, speech and language, and any home or community based activities and mobility, must be targeted with specific interventions provided by trained clinicians. This includes all stroke survivors needing to be screened regarding dietary or cognitive dysfunction.

Return to work should also be discussed with all stroke survivors, with assessment, management planning and strategies implemented by a trained healthcare professional.

What the Evidence Doesn’t Support

Certain interventions or management strategies are not recommended by the research.

These include

1. Shoulder taping: while it is appropriate in improving shoulder pain, is not recommended for management of subluxation (a partial dislocation). Instead, education and functional training, and the use of supports and slings, should be used.

2. Spasticity (muscle shortening): stretching is not recommended. Similarly, use of splints or prolonged positioning is not recommended in the management of contracture. Botulinum Toxin A can be used to effectively reduce spasticity and subsequently improve other factors such as personal hygiene, however does not improve functional outcomes.

3. Contracture (tight muscles) management: the evidence is currently unclear, however motor retraining, electrical stimulation or serial casting may be considered.

Fatigue and Mood Changes

Fatigue and mood changes are very common with stroke survivors, and should be screened for. Fatigue management should include education, addressing modifiable risk factors such as certain drugs and alcohol, depression and sleep disturbances. Evidence is limited, but sleep hygiene and exercise are currently recommended. Where changes in mood are suspected, such as depression, anxiety or emotional lability (rapid changes in mood), a trained clinician should provide evidence-based assessment and management.

Falls Risk Screening

All stroke patients should have a falls risk assessment completed. Where appropriate, falls risk management strategies and comprehensive home assessments should be undertaken by a qualified health professional.

Driving

Return to driving should be discussed with all stroke survivors, and education about the effects of stroke and the return to driving process should be provided. Generally, stroke survivors should not return to driving for 4 weeks, and 2 weeks post TIA. For commercial licences, 3 months post stroke and 1 month post TIA is required. An appropriate specialist should determine medical fitness for return to driving, and an occupational therapy driving assessment is required where post-stroke deficits remain which may impact driving.

Education and Carer Supports

Stroke survivors and their families and/or carers should receive tailored education and information regarding all stages and elements of stroke recovery and rehabilitation. This includes opportunities to talk with the healthcare team members, discuss test results, treatment plans, discharge and follow-up, community and support planning.

Carers themselves should be involved in the rehabilitation process, and be provided with their own specific support regarding wellbeing, psychosocial supports, problem solving, coping strategies and stress management.

Donvale Rehabilitation Hospital Day Program

Donvale Rehabilitation Hospital offers individualised, multidisciplinary rehabilitation programs. Donvale Rehabilitation Hospital’s progressive and passionate team of multidisciplinary healthcare professionals manages a variety of neurological conditions in adults of all ages, employing evidence-based practice and high-quality equipment.

Our agreements with most health funds means out-of-pocket expenses are kept to a minimum.

To ensure your patients achieve best possible outcomes and quality of life, please contact us.

A referral form can be downloaded from our website, please visit Day Rehabilitation webpage.

Referrals should be addressed to:

References

ABS - www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0~2015~Main%20Features~Stroke~10003

Australia’s health: Stroke. (2016). Retrieved from the Australian Government’s Australian Institute of Health and Welfare website on 23/04/2019. URL: www.aihw.gov.au/getmedia/c420f6f1-0464-4f43-b55a-62f995a0f8f3/ah16-3-6-stroke.pdf.aspx

Nelson, M., McKellar, K., Yi, J., Kelloway, L., Munce, S., & Cott, C. et al. (2017). Stroke rehabilitation evidence and comorbidity: a systematic scoping review of randomized controlled trials. Topics In Stroke Rehabilitation, 24(5), 374-380. doi: 10.1080/10749357.2017.1282412

Rajsic, S., Gothe, H., Borba, H., Sroczynski, G., Vujicic, J., Toell, T., & Siebert, U. (2019). Economic burden of stroke: a systematic review on post-stroke care. The European Journal Of Health Economics, 20(1), 107-134. doi: 10.1007/s10198-018-0984-0