Stroke Part 3

Long-term physical training

Last week I explained the great importance of physiotherapy in working and strengthening the affected muscles immediately after a stroke.The improvement starts soon but the pace of change slows with time.  After a few months the performance of specific muscle groups is about as good as it is going to get.

Another enormously important role of physical activity for the post-stroke patient is fitness training. Sadly this is seldom applied. A low level of physical fitness is one of the risk factors for stroke. Regular exercise reduces blood pressure, improves blood lipids, gives better diabetic control and helps with weight loss – and thereby reduces the very real threat of further strokes. The increase in performance can be very significant and is particularly so for those left significantly impaired by the long-term effects of the stroke.

Some of the benefits

Post-stroke physical training has also been shown to reinforce the gains of early rehabilitation by further increasing cardio-respiratory fitness and muscle strength and improving walking capacity. Immobility, unilateral limb weakness, poor balance, cognitive impairment, reduced activities of daily living and quality of life, plus the risk of stroke recurrence all benefit. Greater self-confidence and independence are additional rewards, as are the amelioration of boredom and frustration.

It is hard to overstate the multiple benefits of fitness training for stroke patients. It is just as effective as standard drug treatments, and maybe more effective in reducing the risk of recurrence and subsequent stroke-related death. The rationale for this is that decreased fitness is one of the risk factors for stroke and that, like other results of arterial disease, further episodes must be increased by failing to try to remedy this.

A Cochrane Review has examined many of the problems faced by recovering stroke patients in a meta-analysis of 45 trials involving 2,188 subjects. The report concluded that cardiorespiratory training reduces disability after a stroke, improves the speed and tolerance of walking and probably improves balance. Other benefits from exercise training for stroke victims include improved cognitive function, self-confidence and independence.

 Atrial Fibrillation and Embolic stroke

Emboli are blood clots which end up a long way from where they are formed. In the case of embolic strokes the clots are almost always formed in the atria (ante-chambers) of the heart and develop there as a complication of atrial fibrillation. The clot gets thrown out from the heart  into the arteries supplying the brain. The resulting arterial blockage causes the stroke.  This form of stroke makes up about 10% of all ischemic strokes.

Atrial fibrillation (AF) is a very common condition of later life. The illustration above shows two ECG strips – the upper shows normal heart rhythm while the lower shows the fast heart rate and irregularity characteristic of AF.  Since the atria are not necessary for the heart to pump out blood, AF is not fatal but it does reduce the heart’s efficiency. The heart beats more rapidly and irregularly. The main complication is the development of blood clots in the atria. These can be dislodged and end up in the brain, causing a stroke. It is important that people with AF take blood thinners to prevent this.

Causes of AF

The frequency of AF increases with increasing age and for most AF sufferers the cause is unknown. AF is commoner in those with obesity or hypertension and is sometimes caused by an over-active thyroid. Otherwise its cause is a mystery.

High levels of physical fitness are protective – the fitter the individual, the lower the risk  Increasing physical fitness also lessens the risk associated with other factors, particularly obesity and hypertension. The risk reduction resulting from increased physical fitness is more pronounced in women than men. In men very high levels of physical activity may actually increase the risk of AF, particularly at levels above 5000 MET minutes per week – equivalent to brisk walking for about 15 hours a week.

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