Summary
Although stroke mortality has declined, the annual incidence rate in the general population continues to increase. For many stroke survivors and their families, an acute stroke is the beginning of an ongoing struggle with physical impairment and subsequent disability. Over time, the immediate clinical consequences of stroke are complicated by a variety of poorly understood medical, musculoskeletal, and psychosocial difficulties. Primary care physicians are best suited to optimize chronic disease control, reduce risk, and manage stroke complications. Early screening and appropriate treatment are key. Secondary prevention and attention to bowel and bladder problems can help reduce medical complications and readmissions, while adequate analgesia, extremity positioning/splinting, and physical therapy can reduce discomfort and preventable pain. Primary care physicians can identify and treat emotional issues after stroke and provide psychological counseling to patients and caregivers. Adequate education and support can restore a stroke patient's independence or minimize the resulting dependence.
The functional impairment caused by diseases such as stroke can seriously affect the quality of life of patients. The application of assistive devices in rehabilitation services has a very good auxiliary value in the recovery of many functional impairments. The government and rehabilitation institutions at all levels are also actively promoting the development and application of assistive devices. Rehabilitation robots are a type of rehabilitation assistive devices. Robot-mediated rehabilitation is a rapidly developing application field. Robot-assisted technology is integrated with neuroscience, rehabilitation therapy, etc. to provide more options for the rehabilitation of functional impairments in stroke patients. Rehabilitation robot-assisted technology has a lower cost advantage than traditional rehabilitation treatment, and also has better repeatability and digital, standardized treatment procedures and data advantages. Clinical application of rehabilitation robots can better help patients recover their functions and maximize their return to family and society.
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Late medical complications of stroke
Little attention has been paid to the long-term consequences and complications of stroke (i.e., physical, musculoskeletal, and psychosocial complications). Based below summarizes these. Late physical complications of stroke occur weeks to months after hospital discharge. Some stroke survivors continue to experience these complications years after their acute stroke. Primary care physicians are often called upon to address these issues but are often hampered by a lack of resources.
Post-stroke seizures Seizures occur in 5%–9% of all stroke survivors.Most seizures occur within the first year of stroke. It is unusual to develop seizures more than two years after stroke onset. Seizures are more common in haemorrhagic stroke, total anterior circulation stroke and stroke involving the cortex. They should be treated with conventional anticonvulsants. Prophylactic anticonvulsant medications are unnecessary in patients with uncomplicated strokes and no previous history of seizures.
Urinary incontinence Following stroke, patients often experience varying degrees of urinary frequency, urgency, or urinary incontinence due to neurogenic bladder, resulting in incomplete bladder emptying. The exact mechanism of urinary incontinence after stroke is unknown. 25% of stroke patients are incontinent at discharge, and 15% remain incontinent one year later. Urinary incontinence 30 days after stroke is associated with nearly four times the one-year mortality rate among mainland stroke survivors. Treatment includes exclusion of exacerbating/causing features, particularly urinary tract infection, medications (e.g., diuretics), and fecal impaction. Anticholinergic drugs, such as oxybutynin chloride, may be used to reduce urinary urgency and frequency. The use of an external catheter (urinary sheath) in men or a diaper in women is an acceptable method of treating patients with incontinence. Intermittent catheterization is also an option for patients with urinary retention. Indwelling urinary catheters should only be used as a last resort to treat persistent urinary incontinence due to their associated complications. If a regular, socially acceptable voiding pattern cannot be established, consultation with a urologist may be necessary.
Bowel Incontinence New-onset fecal incontinence is very common after stroke, occurring in 56% of patients acutely, 30% at 7-10 days, and 11% at three months. Older patients, women and people with severe strokes are most at risk. The effects of fecal incontinence are always devastating. It is viewed as a social taboo and may lead to poor self-image, depression, caregiver stress, and reduced participation in recovery. Comprehensive evaluation requires bowel history, medication review, diet/fluid intake, mobility, current bowel status, abdominal examination, and rectal examination (performed by trained person). Management aids include skin care, pads, faecal collectors and anal plugs.
Cognitive impairment Cerebrovascular disease is increasingly recognised as a common cause of cognitive impairment and dementia in later life. Vascular dementia is the second most common cause of dementia after Alzheimer’s disease. About 10% of patients develop cognitive impairment after the initial stroke and about 30% at the end of one year. Risk factors for developing dementia include advanced age, previous stroke, lacunar infarction, diabetes mellitus and left hemisphere stroke. By preventing stroke, we can help to reduce the risk of vascular dementia in our patients.
Musculoskeletal complications of stroke
Musculoskeletal problems following a stroke invariably involve the hemiplegic side and may not become apparent until weeks to months have passed. Stroke patients often complain bitterly about the pain associated with these complications.
Wrist and Hand Flexion Waist and hand flexion contractures of the wrist and hand occur in hemiparetic wrists and hands. Fixed flexion contractures of the hand can interfere with recovery of hand function. It can be painful and often ugly. Prevention through regular movement exercises and positional splinting is key to management. The splint should maintain gentle stretch on the flexor muscles, maintaining a 20°–30° extension of the wrist, and should not increase spasticity.
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Spasticity and hypertonicity Up to 60% of stroke patients have symptoms related to spasticity. Spasticity is excessive, inappropriate, and involuntary muscle activity that results in stiffness, loss of movement, and pain. In the worst cases, it can create a fixed deformity called a contracture and can lead to the development of pressure ulcers. Conservative treatment of contractures includes physical therapy (passive range of motion exercises), splinting, and correct limb positioning. Pharmacological treatment of spasticity in stroke patients includes systemic and local treatments. Medication should generally not be used alone but should be used in conjunction with physical therapy and positioning/active splinting. Systemic medications used to treat spasticity include baclofen, tizanidine, dantrolene, and diazepam. Topical treatment of spasticity with botulinum toxin is effective in a selected group of patients. Unlike systemic antispasmodics, which are nonselective and often associated with general weakness and loss of function, botulinum toxin is a targeted therapy. Surgical treatment is rarely used but may be a last resort to ensure proper seating and orthotics or to maintain proper hygiene. Examples include adductor tenotomy or obturator neurectomy.
Hemiplegic Shoulder Pain Hemiplegic shoulder pain (HSP) is common (accounting for 9%–40% of hemiplegic stroke cases) and usually occurs 2–3 months after stroke onset. HSP can be divided into four types: (a) joint pain caused by joint misalignment that produces severe pain during movement (active or passive); (b) hyperactive or spastic muscle pain (i.e., deep pulling pain during movement); c) diffuse pain (i.e., persistent pain around the shoulder) due to altered sensation due to stroke; and (d) reflex sympathetic dystrophy, diffuse involvement of the entire limb and shoulder. HSP can be prevented by attention to handling and posture , especially in patients with arm laxity early in recovery from stroke. Medical treatment may require only simple analgesics or a specific antispasmodic drug such as baclofen. Local steroid joint injections may be helpful in treating adhesive capsulitis (28) Transcutaneous electrical nerve stimulation, or TENS, can relieve pain, allow for passive movement around the joint, and improve functional range for dressing and hygiene. Referral to a physical therapist for shoulder mobilization, followed by a home program, by Physical therapist administration is the preferred treatment method for patients or families.
Psychosocial complications of stroke
The psychosocial complications of debilitating stroke are very common and almost inevitably have a profound impact on the patient and their family and friends.
Poststroke Depression Poststroke depression is extremely common and often underdiagnosed. Treatment can have a huge impact on recovery and quality of life. Up to 70% of stroke patients experience depressed mood after stroke, and 25%–30% exhibit significant poststroke depression. Depression was not predicted by stroke subtype or lesion location but was particularly common in patients with aphasia. There are many different assessment tools and scales, including the Geriatric Depression Scale, Hamilton Depression Rating Scale, and Patient Health Questionnaire. The Visual Analog Self-Esteem Scale is helpful in assessing the emotions of some people with aphasia. Prompt recognition and treatment can improve outcomes. Nonpharmacological treatments, including counseling, are helpful but often underutilized.
Most classes of antidepressants appear to be safe in post-stroke patients. Commonly used are selective serotonin reuptake inhibitors (SSRIs). If possible, medication should be combined with psychotherapy or counseling. In resistant cases, referral to a psychiatrist may be considered.
Mood/Emotion Changes Emotions such as depression, anxiety, anger, apathy, and lack of motivation can be difficult to manage, especially after a stroke. Some changes are the result of actual damage and chemical changes in the brain caused by a stroke. Others are normal responses to the challenges, fears, and frustrations people may feel when dealing with the effects of a stroke. Often, acknowledging these feelings when talking about the effects of stroke helps stroke survivors cope with these emotions.
Conclusion
In summary, many stroke patients develop a variety of medical, musculoskeletal, and psychosocial complications months to years after stroke. These complications can add to the pre-existing disability caused by a stroke. Primary care physicians are ideally positioned to manage these complications and are often called upon to do so. Because stroke is a common condition, primary care physicians can help stroke patients by understanding the potential complications that may arise after a cerebrovascular event.
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