In order to keep my designation as a clinical specialist in neurologic physical therapy (NCS), I am required to complete a series of activities which all together are called the Maintenance of Specialty Certification or MOSC. One of the activities is writing a reflective case report every three years. For this activity, I take a case I’ve worked on recently and write a paper discussing how I treated the patient, why I chose the treatment strategies I chose and what I would change if I were to treat that case again today.
In preparation to write my paper, I’m currently combing through the available research on my case (this is called a literature review), so I can back up the treatment strategies I chose with research and maybe find some new strategies as well! Y’all are going to come along and be my shadow as I sift through what’s out there. Doing a little pre-writing here with you guys will also help me to organize my thoughts, so you may see some of my clinical reasoning as well.
The case I’ve chosen was a middle aged Mexican American female who had experienced a bilateral lacunar ischemic cerebellar stroke. Her main complaints were vestibular in nature– complaints of severe dizziness, light sensitivity– and also some co-occurring ataxia (coordination problems) and apraxia (problems with planning and executing movement). Very complicated case, but very interesting to work with and one of my favorite cases, which is why I chose to write about her.
So today we’re starting at the basics from the very lengthy report above: stroke statistics, in blurbs (commentary in italics.)
— Each year, about 795,000 people have a stroke.
— This number has decreased from 1987-2011.
— Rates of stroke in those aged 40-54 has been increasing.
— The BASIC projects (NINDS) demonstrated a higher incidence of stroke among Mexican Americans compared to non-Hispanic whites in a community in southeast Texas. They specifically had more ischemic strokes.
— Stroke is the 5th largest killer of Americans, behind heart disease, cancer, chronic lower respiratory disease and unintentional injuries/accidents.
— Stroke risk factors (things that make you more likely to have a stroke) include: high blood pressure, diabetes, disorders of heart rhythm, high cholesterol, smoking/using tobacco, physical inactivity, poor nutrition, family history of stroke, and kidney disease.
— Intensive blood pressure lowering appears to be the most beneficial for the reduction in risk of stroke.
—Ischemic stroke is a disease which can be inherited.
— Vascular risk factors (high blood pressure, diabetes, high cholesterol, diabetes, heart diseases and smoking) are higher in the middle aged population than you would think– 12-52%.
— Females with natural menopause before 42 years of age had twice the ischemic stroke risk as those who experienced menopause after 42.
— Estrogen replacement therapy after menopause increases a woman’s risk for a stroke.
— Estrogen based oral contraceptives almost double the risk of an ischemic stroke, but the absolute increased risk is small (4.1 ischemic strokes per 100,000 non-smoking, normotensive women.)
— Migraine with aura is associated with ischemic stroke in younger women, particularly if they smoke or use those estrogen based oral contraceptives. Combining migraine with smoking and oral contraceptives increase a woman’s chance of having an ischemic stroke 9 fold.
— Pre-eclampsia is a risk factor for ischemic stroke later on after pregnancy.
— In the BASIC project, Mexican Americans had a higher prevalence of post stroke sleep disordered breathing. Acute brainstem stroke has a higher incidence of post stroke sleep disordered breathing, although ischemic stroke was not found to be associated with breathing problems or the severity of problems if present.
— One third of stroke survivors develop post stroke depression. Twelve randomized control trials (RCTs) suggest that antidepressant meds might be effective in treating it. Eight other RCTs suggested that preventative antidepressant meds may prevent non-depressed stroke survivors from developing depression.
— In a single-center study of 144 stroke survivors, Hispanics scored lower on a test of stroke symptoms and what to do about those symptoms than non-Hispanic whites (72.5% vs 79.1% correct) and were less aware of tPA as a treatment for stroke. (tPA is a clot busting drug used to treat ischemic strokes which can be a miracle drug. BUT in order to qualify to be treated with this drug, you have a recognize you are having a stroke and present to a stroke certified hospital with an emergency department that can confirm you are having an ischemic stroke in 4 hours or less.)
— Dizziness was one symptom that seemed to increase the likelihood that 911 would be called.
— A systematic review of 18 studies from 8 countries concluded that knowledge of stroke symptoms were limited in stroke survivors.
— Stroke was among the top 18 diseases contributing to years lived with disability in 2010. Women often have greater disability than men. One study found that women were half as likely to be independent with activities of daily living (ADL) than men.
— In a study looking at outcomes 90 days post stroke, Mexican Americans scored worse of neurological, functional and cognitive outcomes than non-Hispanic whites.
— 44.7% of younger stroke survivors have poor functional outcomes.
— A Cochrane review including 5855 people concluded that stroke patients who receive organized inpatient care in a stroke unit had better outcomes including decreased odds of death, institutionalized care and dependency than when treated in an alternative form of inpatient care.
— The average length of stay in inpatient rehabilitation was 14.6 days.
— About 70% of Medicare beneficiaries receive care from more than 1 setting, most going to skilled nursing (32%), then inpatient rehab (22%) and home health care (15%).
— The average annual direct and indirect costs of stroke in 2013-2014 $40.1 billion US dollars. That is predicted to rise of $94.3 billion US dollars by 2035. However, only $16.0 billion US dollars is projected to go Hispanics. (What the…?! The population is moving to where there will be more Hispanics than non-Hispanic white people at that point in the US. According to the above, Hispanics tend to have more and worse strokes and yet they’re projected to get 17% of the money spent. Something does not compute.)