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Stroke prevention and rehabilitation

Bernard Gibbon
PhD RN RNT
Head of Department Primary and Community Nursing University of Central Lancashire
Preston

According to the World Health Organisation, a stroke is characterised by: "a focal neurological deficit due to local disturbance in the blood supply to the brain. It persists for more than 24 hours."(1) Its onset is usually abrupt, but it may extend over a few hours or longer. Stroke is the third most common cause of death and the most frequent cause of disability in adults.(2) The incidence of stroke remains high, with about 100,000- 120,000 first strokes per annum in the UK, and about 30,000 recurrent strokes. A significant proportion of these people, about one-third, will die. Expressed at a local level, a health district serving around 250,000 people can expect some 500-600 people to have a stroke each year. In a typical health district there will be around 1,000 people with some degree of disability following stroke. Many of these will be elderly as the risk of stroke increases with ageing. Stroke affects men and women equally.(4) 
The causes of stroke are often cited as embolic, thrombotic or haemorrhagic depending on the pathophysiological changes occurring, and the ­­­prognosis varies from very severe in haemorrhagic to variable in embolic and ­thrombotic strokes. There is no cure for stroke in terms of surgery or medication, which serves to emphasise the importance of prevention. A number of predisposing factors influencing risk of stroke disease have been ­identified, providing scope for prevention (see Table 1).

[[NIP01_table1_45]]

Stroke should be treated as a medical emergency. Increasingly, hospitals provide a stroke service that includes a rapid assessment clinic, an acute stroke unit (which may have beds for highly-dependent patients) and a stroke rehabilitation unit, as systematic review and meta-analysis have demonstrated that organised stroke services help reduce morbidity and mortality.(5) While most people suffering a stroke are referred to and admitted to hospital, a number of patients are managed in the home throughout the entire episode. Reasons for this are usually family and GP choice. Inpatient stay is variable in terms of ­duration and is dependent upon progress towards independence. However, rehabilitation is not complete at the time of discharge home, and further rehabilitation gains can be achieved up to two years following the stroke.(6)
Discharge home ­follow-ing inpatient care and ­rehabilitation carries mixed emotion for patients. They are pleased to be going home, surrounded by familiar people and things, but are often anxious about their ability to cope physically, psychologically and socially. In this phase, primary care services can play an important role.

Stroke prevention
Many of the actions that can be taken to reduce the risk of stroke can be determined through screening programmes that are routinely undertaken in primary care. A brief review of the pathology giving rise to stroke can illuminate the reasons for screening. The most common forms of stroke are following thrombus formation in the arteries supplying blood to the brain. Arteries are prone to arteriosclerosis and atherosclerosis, which as the names imply cause "hardening" of the arteries. Arteries damaged in this way can lead to plaque formation that can impede blood flow and give rise to clot formation. Conditions such as hypertension, diabetes and hyperlipidaemia are known to cause arterial damage. Cigarette ­smoking is also a known cause of arterial damage.
Emboli, clots forming at a distance from the site of occlusion, are associated with a range of heart disorders such as atrial fibrillation and valvular disease. These conditions can be detected during routine screening.
The aims of healthcare are prevention. This includes discouraging smoking and ensuring that high-risk groups, such as the elderly and those with a family history of stroke, are screened for high blood pressure and treated appropriately. Similarly, patients should be screened for lipids. Interventions should be monitored and evaluated at regular intervals. Patients with diabetes should be monitored regularly to ensure optimal control of diabetes as this reduces the risk of arterial changes that predispose to stroke. Dietary advice should also be given to reduce the risk of obesity and high blood ­pressure worsened by a high-salt diet.
Preventive measures are not always valued by patients, as conditions such as hypertension are hidden disorders - the patient does not experience symptoms, and medication taken often produces unwanted or unpleasant side-effects. This underlines the importance of monitoring and evaluating interventions.

Rehabilitation in primary care
Despite measures designed to reduce the risk, many people will still suffer a stroke. Immobility can lead to complications, such as deep vein thrombosis, which can lead to pulmonary embolism, pneumonia and pressure sores. In addition, immobility can lead to ­urinary tract infection, which in turn can lead to renal damage. The neurological damage results in ­hemiplegia, paralysis of one side of the body, and ­contractures can occur worsening the patient's ­mobility. Shoulder pain is common as the weight of the arm pulls on the shoulder joint and causes subluxation. This can be made worse by poor handling technique. In addition to these physical complications, many stroke patients become depressed, which also ­decreases the likelihood of regaining independence.
Rehabilitation is concerned with preventing deformities such as contractures and retraining the affected arm and leg so that the patient can mobilise and gain independence in activities of daily living. It is also ­important to help the patient regain social integration.
Patients will have gained some independence following inpatient rehabilitation, and the role of the nurse in primary care is to ensure that these gains are maintained and improved upon once the patient is home. This includes supporting the family while ensuring that they do not inadvertently increase the patient's dependence by doing too much for the patient.

Conclusion
Nurses working in primary care can do much to reduce the risk of stroke through screening and ensuring appropriate interventions are implemented and ­evaluated. In the rehabilitation phase, supporting the patient and family to ensure independence is ­maintained and complications avoided will do much to facilitate social reintegration.

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References

  1. World Health Organisation. Technical Report Service No. 469. Cerebrovascular diseases, prevention, treatment and ­rehabilitation. Geneva: WHO; 1971.
  2. Rudd A, Irwin P, Penhale B. Stroke at your fingertips. London: Class Publishing; 2000.
  3. Marmot MG, Poulter NR. Primary prevention in stroke. Lancet 1992;339:344-7.
  4. Bonita R. Epidemiology of stroke. Lancet 1992;339:342-7.
  5. Stroke Unit Trialists' Collaboration. Collaborative systematic review of the randomised trials of organised ­inpatient (stroke unit) care after stroke. BMJ 1997;317:1151-9.
  6. Barer DH. Stroke rehabilitation; panacea or placebo. Geriatr Med 1990;20(9):45-9.

Resources
Stroke Association
W:www.stroke.org.uk
Mobility Advice and Vehicle Information Service (MAVIS) Advice on car ­adaptations and ­transport for disabled people
W:www.mobility-unit.detr.gov.uk
Action on Smoking and Health
W:www.ash.org.uk

Further reading
Anderson R.The aftermath of stroke. Cambridge: University Press; 1992.
Gibbon B. Stroke nursing care and management in the community:a survey of district nurses' perceived contribution in one health district in England. J Adv Nurs 1994;20:469-76.
Laidler P. Stroke rehabilitation: structure and strategy. London: Chapman Hall; 1994.
O'Connor SE. Nursing and ­rehabilitation, the interventions of nurses in stroke patient care. J Clin Nurs 1993;2:29-34.