A Revolution in Stroke Care
By: Dr. J. Bernard Walsh
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A Revolution in Stroke Care By: Dr. J. Bernard Walsh |
One often hears of the dramatic changes in treatment of different forms of cancers, leukaemias and cardiac conditions, but one doesn't hear as often about the development of significant changes in the management of stroke care over the last decade. This improvement has taken place at all levels in the management of the disease.
1. Diagnosis
The wide availability of CT scanning has meant that we have a much more comprehensive and accurate diagnosis of the cause of the CVA so that patients with haemorrhage are separated from those who have cerebral infarcts, thus avoiding anti-coagulant and anti-platelet therapy for patients who would be harmed by this therapeutic approach. CT scanning also permits the exclusion of other pathologies such as cerebral tumours and sub-durals which, though relatively speaking are less common, can still present quite frequently in a busy general hospital.
2. Airway Protection
The protection of the airway by comprehensive assessment of swallowing by the admitting staff and by the speech therapists, together with the use of video-fluoroscopy, has enabled a very rational and organised approach to the management of feeding in patients with impaired swallowing reflexes.
I remember in the 1970's any person with a reasonable gag reflex would be perceived by all care staff as being fit to begin feeding, but the realisation that a gag reflex can still be present in a person with a severely-impaired swallowing reflex is something that has become increasingly clear to all clinical practitioners over the past decade. This, together with staff awareness of the need to gradually introduce feeding on a phased basis, with greater emphasis on set diets and semi-solids, has significantly lessened the development of pneumonia in stroke patients.
The advent of videofluroscopy has also enabled an objective record to be made on the swallowing reflexes of different patients so that side by side with clinical assessment, a comprehensive structured approach is made in the individual management of each case.
The use of fine bone tube feeds and PEG (per endoscopic gastrostomy) tubes has permitted the maintenance of nutrition in patients who are unable to tolerate any oral feeds.
Both of these have made a tremendous difference in maintaining a patient's strength and lessening the incidence of chest infections.
3. Intensive treatment of respiratory tract infections
In addition to protecting the airway, patients developing RTI's are now treated intensively with IV antibodies and intensive physiotherapy so that pneumonia is not permitted to take a hold.
4. Skin Care
Modern continence wear and the advent of computerised controlled air cell mattresses have made the nursing of the more dependent stroke much easier, especially during the early phases when the skin is potentially very liable to injury and breakdown.
5. Physiotherapy and Rehabilitation
The advent of Bobath techniques and the greater emphasis on treating a stroke from the ground up, making sure that 'a patient doesn't run before he or she can sit' has ensured that there is a much lesser incidence of pulled muscles and strained ligaments.
While it may take longer for a patient to stand and walk, in the long-term, the greater improvement in mobility of patients together with the absence of fixed flexion contractures and the virtual disappearance of shoulder/hand syndromes has made a major contribution towards the long-term rehabilitation prospects of many stroke victims.
6. Comprehensive assessments of activities of daily living and of perceptual deficits
The increasing awareness that many patients who have significant perceptual deficits - though the motor and speech deficits may be mild - has helped greatly in ensuring that support networks are properly targeted when a patient goes home.
Patients may have problems in orientation in space and have practical problems in dressing and cooking, though they may be still intellectually extremely bright and may have no physical weakness. Perceptual assessment helps to identify these deficits. This is the area where the occupational therapists in this country and where the neuro-psychologists in other countries have had a major role to play.
The role of the occupational therapist in the assessment of activities of daily living and in ensuring that the house is properly adapted to meet the needs of the individual patient is also a guarantee that more patients who in previous times ended up in institutional care are now returning home.
The increasing sophistication of the approach of speech therapists not only in the assessment of swallowing but also in language re-learning skills, plus their use of mini-computers and electronic communication aids, has also helped many patients with significant dysphasia and anarthrias to have a new lease of life.
7. Prevention of further cerebrovascular events
The increasing awareness that any patients with a stroke must have their blood pressure adequately controlled, while avoiding at all costs any postural hypertension, has meant that all doctors must pay particular attention to the level of blood pressure in patients who are at risk of developing a cerebrovascular accident. The use of anti-platelet agents and warfarin, plus the availability of carotid endarterectomy, in selected cases, has also helped to further reduce the incidence of cerebrovascular events.
8. Day Hospital Care
Day hospital treatment has meant that a patient who would otherwise remain in hospital for an extended period with a stroke can now go home earlier to the more therapeutic home environment, but at the same time, coming back to the day hospital for periods of intensive therapy, rehabilitation and medical review.
Those of us who have been looking at strokes over the last 20 years have seen a dramatic revolution in the approach to the early treatment of these patients. The more ready intensive treatment of the early phases of a stroke, coupled with developments in medicine, nursing, physiotherapy, occupational therapy and speech therapy, have all meant that many patients who 20 years ago would have had no significant chance of getting back to any quality of independent life can now look forward to going out to a good quality life and care in the home environment.
In these times of high technology and of rapid developments in all specialities, let us not forget that stroke care is one of the areas that has seen the greatest revolution of all.
Dr. J. Bernard Walsh is a Consultant Physician and Senior Lecturer, Department of Medicine for the Elderly, St. Jame's Hospital And Trinity College, Dublin.
This article was first printed in the Irish Medical News.