Stroke outcome: every second counts

A stroke is a serious, life-threatening medical condition that occurs when the blood supply to part of the brain is cut off by either a blood clot or due to a bleed from a burst blood vessel. In the UK, strokes are a major health problem with around 110,000 strokes occurring every year in England (1). It is the third largest cause of death, after heart disease and cancer; and brain injuries caused by strokes are a major cause of adult disability in the UK.

Reducing patient mortality is vital, and stroke mortality rates have decreased worldwide in the past two decades, however severe disability is a common result of stroke. Of the patients who were admitted to hospital following a stroke in England in 2012-2013, 83.6% of them spend 90% or more of their time at a stroke unit (2). The major global burden of stroke is disability: caring for severely disabled individuals is a huge undertaking and also puts enormous pressure on the NHS. The present objective must minimise the disability after stroke.

Timing for stroke interventions is absolutely critical and there is robust evidence showing that rapid treatment improves outcome after stroke. The NICE guidelines on diagnosis and initial management of acute stroke has a keen emphasis on identifying key features of stroke so that healthcare providers can stratify patients by risk factors and treat them accordingly. Anyone with a suspected transient ischaemic event or stroke should be seen within 24 hours (3).

Tissue plasminogen activator (tPA) is a protein involved in the breakdown of blood clots. Because it works on the clotting system, tPA is used clinically to treat strokes but is only effective when administered as early as possible after the onset of stroke symptoms. tPA was shown to improve outcome (mortality and physical dependence) significantly when administered within six hours after a stroke, and to a greater degree in patients treated within three hours (2, 3). However, rTPA is contraindicated in haemorrhagic stroke and when given outside its optimal time-window its detriments may outweigh its benefits and may actually increase mortality.

Over the last decade there has been increased interest in applying these early interventions to mobilisation after stroke, whereby patients are out of bed and on their feet within 24 hours after stroke onset. It has been estimated that complications of immobility account for 51% of deaths in month preceding an ischemic stroke (4). A study carried out in 2004 by Bernhardt et al observed that acute stroke patients were relatively immobile, spending more than half the day resting in bed (3) prompting further studies where early mobilisation was recommended. These data showed that mobilisation within 24 hours of stroke is associated with prompt discharge home and contributes to improved outcomes in patients managed in a stroke unit

Evidence shows that patients managed in a stroke unit promoting early mobilisation had lower mortality rates and better outcome than those managed in general medical wards without early mobilization (5). Although the exact contribution of immobility to death and complications is unclear, the benefits include reduced blood pressure, preventing lung infections and deep venous thrombosis, and improving functional outcome (4, 6)

Early mobilisation has been shown to improve mood disorders such as depression, anxiety and irritability (7), which are common in stroke patients. Furthermore, earlier more intensive mobilization after stroke may fast-track return to unassisted walking and improve functional recovery. These aspects of recovery, although less direct indices of stroke outcome, are essential for regaining functional independence.

Accumulative data (8) suggests that at minimum dose of 1000 minutes (ie, 16 hours) of exercise therapy is required to produce 5% change in basic activities in day-to-day skills and also for long-term outcome after stroke. Although trials on early mobilisation are ongoing, early stroke rehabilitation is strongly recommend by clinical practice guidelines for patients with stroke (8).

Although early mobilisation is only one of many components of stroke unit care, it may be an important factor for improving outcomes (6). In order to establish the most beneficial time window for early mobilisation, more research into the molecular mechanisms underpinning the recovery of ischaemic tissue is needed.

Older people are most at risk of having strokes, although they can happen at any age – including in children. Although actual incidence of stroke has dropped in recent years, there has been a worrying demographical shift, with a 25% increase in stroke incidence in the 25-64 age-group; it is no longer a disease of the elderly. This fact itself highlights the need for education in preventing strokes: while a genetic predisposition may confer a degree of susceptibility to strokes, lifestyle choices such as smoking, obesity, poor diet and lack of exercise are huge contributing factors.

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

1. http://www.nhs.uk/conditions/Stroke/Pages/Introduction.aspx
2. http://www.england.nhs.uk/statistics/statistical-work-areas/integrated-performance-measures-monitoring/stroke-data/
3. https://http://www.nice.org.uk/guidance/cg68/chapter/guidance
4. Bernhardt J, Dewey H, Thrift A, Donnan G (2004): Inactive and alone: physical activity within the first 14 days of acute stroke unit care. Stroke; a journal of cerebral circulation.35:1005-1009.
5. Indredavik B, Bakke F, Solberg R, Rokseth R, Haaheim LL, Holme I (1991): Benefit of a stroke unit: a randomized controlled trial. Stroke; a journal of cerebral circulation.22:1026-1031.
6. Indredavik B, Bakke F, Slordahl SA, Rokseth R, Haheim LL (1999): Treatment in a combined acute and rehabilitation stroke unit: which aspects are most important? Stroke; a journal of cerebral circulation.30:917-923.
7. Cumming TB, Collier J, Thrift AG, Bernhardt J (2008): The effect of very early mobilisation after stroke on psychological well-being. Journal of rehabilitation medicine.40:609-614.
8. Galvin R, Murphy B, Cusack T, Stokes E (2008): The impact of increased duration of exercise therapy on functional recovery following stroke–what is the evidence? Topics in stroke rehabilitation.15:365-377.