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Post-Hospital Stroke Care- a neglected entity

Dr. Sreenivas U.M., Consultant Neurologist, Arunai Neuro Centre and Research Foundation

The care of patients with stroke does not end with being discharged from the hospital. Many patients have faced this conundrum on what to do once they have been discharged home, often with significant residual problems.

In stroke, the long term care has two components- prevention of another stroke and recovery from this stroke. While prevention of the next stroke is usually focussed upon by most doctors, since it can add to the morbidity and mortality, aiding recovery is often neglected.

Prevention of another stroke depends on the cause of the first stroke. In ischemic strokes, blood thinners are used to prevent another clot forming. These can be “milder” drugs such as aspirin or clopidogrel, or more “stronger” drugs such as warfarin, apixaban, edoxaban, etc. The choice of drug depends on the underlying cause. People with heart problems leading to the stroke usually end up on the stronger medications.

For hemorrhagic strokes, blood pressure control is the first line of defence. An underlying abnormal blood vessel may also need to be ruled out.

In both ischemic and hemorrhagic strokes, along with cause specific prevention, optimisation of blood pressure and diabetic control, as well as abnormal lipids, is also extremely important to prevent recurrence.

For recovery from the current stroke, the rehabilitation depends on both the patient and the rehabilitation professional. This can be physiotherapist, speech therapist and/or occupational therapist, depending on the specific needs of each patient. Many patients do not need inpatient rehab and can be managed as outpatients. However, in severe strokes, the disability might be too high to be able to managed at home. This would require specialised therapy input, on an almost daily basis, till the patient gains a level of independence. The recovery also depends on the patient’s belief and commitment to the rehabilitation process.

Recovery can be rapid initially but tends to slow down with time elapsed since the stroke. The maximum recovery happens within the first 3 months, with considerable recovery possible upto 6 months. Beyond this, the rate of recovery slows, but does not stop. The goal of rehabilitation is always to create independence in activities of daily living and not to improve the patient completely back to their pre-stroke self. This might not be possible in a majority of patients, with many having at least minimal residual problems.

Limb and face weakness are usually the first to recover, with unsteadiness being the next symptom to recover. Sensory loss and visual loss are usually the last to recover and may take years. In many individuals, the sensory loss may end up permanent, but patients are able to adapt to living with it.

With time, many patients can develop stiffness in the arms and legs, a condition called spasticity. This can be treated with an injection called botulinum toxin, which relieves the stiffness and helps to improve the function of the limb.

A combination of the above strategies will lead to optimal post hospital care and enhance recovery and reduce the risk of recurrence of strokes.

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