Episode 89: Stroke neurorehabilitation

[MUSIC] The RCP Medicine podcast, advancing medical knowledge, one episode at a time. Welcome to the RCP Medicine podcast. My name's Dr Helen Banks. I'm a consultant in rehabilitation medicine and I work at the Walton Centre in Liverpool. I'm joined by my colleague, Dr Ganesh Bhavakatti, who's also a consultant in rehabilitation medicine and the lead for the new rehabilitation department at the Walton Centre in Liverpool. Today we're going to be talking about managing complex disability after stroke. Welcome Ganesh. Thank you. So Ganesh, let's start. Can you tell me what a stroke actually is? Stroke is an acute vascular event causing a focal or diffuse brain damage. There are many events which can cause that. For example, an ischemic, which is a block in the vasculature or a hemorrhagic, which is a bleed in the brain, which could be a diffuse or a focal bleed or an hypoxic ischemic brain damage, i.e. after a cardiac arrest also. So all these are come to us. Cloud can be classified as a different types of stroke. Okay. And how common is stroke? Stroke is a very important cause in morbidity and mortality. If you look into the UK figures, about 100,000 strokes per year can be happening in UK. And we know that with the advancing medicine, 60% of the patients survive longer than five years following stroke. But the sad thing is, at least 50% of them will remain with the long term disability and a smaller subset of them with the severe disability lasting long, long time. So if we consider all these in a perspective, there's about 1.3 million people in the UK living with after effects with a long term disability following a stroke. If you consider that 1.3 million people with disability, think about the people suffering with that, think about their loved ones, think about the society in and large. So there are a significant impact on the society due to a long term effect of a stroke. So understanding that and management in appropriate way is essential part to manage this. So as you mentioned, there's a smaller subset of people who have a stroke who end up with a severe disability. And I'm that's the sort of subset that we as rehabilitation doctors generally get involved with. Can you tell me a bit more about when you get involved with patients with stroke as a rehabilitation doctor? It varies. As we know Helen, it varies from region to region and the way it's commissioned in a local ways. I can talk more about our area. There's a chasharan mercy area. And we know that there is a stroke acute stroke pathway, acute stroke, thrombolysis pathways, acute stroke, thrombectomy and services pathway. When we talk about the specialist rehabilitation pathway, as we know in a chasharan mercy region, we have 103 beds, specifically designated with the specialist rehabilitation, managing patients after varied etiology including stroke. So we have hyperacute rehabilitation, acute rehabilitation, post-acute rehabilitation and extended rehabilitation in the community and community specialist therapy team and outpatient services to cater patients with a disability, following incidences such as stroke. For example, we looked into last 12 or 13 years of our data and that shows about at least every every any point of time we have about 20 to 30 percent of our patients are related with the stroke. And what kind of what kind of diagnoses or stroke diagnoses do you tend to say? Say for example patients are coming after a very severe end of the spectrum of the stroke. For example, subalachnoid hemorrhage following a coiling or a clipping, they're needing severe bleeds of the patient with the intracerebral hemorrhage or aneurysmal bleeds or the patients with the AV malformation bleed, MCA infarction, that's a middle cerebral artery infarction. That's a severe, the tax total anterior circulation syndrome, types of strokes, requiring neurosurgery, that's part of their skull removed, that's called a hemicrenioplasty, craniectomy sorry, and also patients with the brain stem strokes which is leading to a severe physical disability. For example, if you I think if our listeners heard about the lockdown syndrome or the patients with a pedoc, what is prolonged disorder of consciousness, which is a problem with the awareness, which is another podcast by itself, there's a Royal College of Physician guidelines on that, our hypoxic brain injury people are a stroke with a severe impairment, but if I need to summarize that, patients after a stroke with a severe impairment, with a severe disability, but with the realistic expectation of gaining level of independence is a possibility in such patients, they come to our set of settings. They come from various sources, for example, from the neuroscience colleagues, neurosurgeons or neurologists, or acute stroke services in the region, or from the other therapy team, if they are considering from the outpatient services, it might be referred from a primary care physicians or the other community therapy team. So these are the various places where the patients been referred to our services here. Should we move on to a case to give a bit of an example of the kind of patient we might see after a stroke within neuro rehabilitation. So we've got Amy, she's a 35-year-old woman, she lives with her husband and her three-year-old son and she works as an accountant. She was previously well, the only pass medical history is that she was high intensive during her pregnancy, she keeps active and enjoys walking their dog. She was admitted to her local stroke centre three weeks ago after developing a severe headache and severe right-sided weakness. She had slurred incomprehensible speech and a reduced conscious level. She was investigated and obviously seen immediately and found to have a large left-sided intracurable hemorrhage with midline shift. She was transferred to a neurosciences centre where she underwent a decompressive craniectomy. And as you alluded to before, that's where a portion of the skull is removed to allow for swelling of the brain and to prevent further harm and the potential for for conning and death. She was managed post-operatively on the intensive care unit and as part of her wean attracuostomy was placed. They managed to get Amy off the ventilator but were having some difficulty weaning from the tracheostomy. The team on ITU discussed her case with her parent stroke team and they suggested referral to hyperacute rehabilitation where hopefully she could be weaned from the tracheostomy whilst also receiving rehabilitation. This referral comes through to your team what more would you want to know? This is I want to reiterate that this is a typical type of patients who come to our hyperacute rehabilitation settings and there are a few things we would like to consider first. First thing is medical situation. What is her neurological status and how is medical stability she is having? What is her impairment disability and participation? These are the three concepts very important to understand. I'm sure we'll discuss this as we go. And what has been input been provided so far and how the patient been progressed and what is the likely progress in the coming weeks? Are we anticipating? Considering the brain injury, considering her pre-existing functionality which appears to be very well and she is working and a mum and a wife and we need to look into her progress and her likely progress in the future. That will determine where she is going and how she will go. So you mentioned impairments, disability and participation. These are terms that we use all of the time in rehabilitation medicine but our audience may not be so familiar with them. Can you explain what you mean? And then I'll tell you a little bit more about Amy after that. When you're looking into impairment disability participation, we're looking to say, for example, Amy had bleeding affecting her left inter-cerbable hemorrhage. So if we go as a medic and explain them saying that we have a right-sided weakness and their power is 2/5 and the right lower limb power is 2/5 and the speech difficulties, difficulty with the breathing. All they see are explaining about the impairments. What are the bodily neurological examination is? Then we are looking into because of that weakness, what they cannot do. They are difficulty in using their hand to feed themselves. They are difficulty to breathe themselves. They are finding difficulty with the speech. They are finding difficulty with standing, transferring and taking steps. Now you're describing a disability. What they are unable to do and that's a description of disability. And there are ways to improve the disability by various other other methodologies. Then you're looking for she's an accountant and she is a mum. She is a wife. Now this is participating in social activities and her vocational activities. Now we are describing a person in their environment to say that what is their participation goals are. And her goals may not be completely recovering to normal neurological function, but her goals may be to return to being mum, being wife, being accountant could be her participation goals. So these are, in just simple ways to put it in, a person may not achieve a full recovery of the impairment. They may not completely go away with their disability, but they can still participate in their social activities in spite of their difficulties. That's great. That's really helpful. I suppose I just wanted to add a little bit there in that. Whilst we talk about disability and what people can't do, actually we do try and take a positive kind of approach. So rather than saying somebody can't walk, we would say they mobilize via an attendant health wheelchair and try and take that kind of positive slant. They are they are fed or they're able to feed themselves with support from one person rather than they can't feed themselves. That's generally the way that we try and describe things actually within a rehab setting. Is that a fair comment? Absolutely. Thank you. Hello. I'll tell you a little bit more about Amy then. So from a medical perspective, she's been treated for a hospital acquired pneumonia, now all phantomiotics. She's got significant secretions from her tracheostomy, and he's a managed with suction and also a CTAL system. Her blood pressure is under control with two agents, and it's felt that this was likely to have been a hypotensive hemorrhage, although the stroke team plan to investigate this further. So in terms of her impairment, she has a right hemiparesis with flickers of activity only in her thigh. Tone is low. She's got a probable expressive and receptive dysphazier, so problems communicating both understanding and expressing communication. This is difficult to assess fully because she's currently got the tracheostomy in. Her swallow is deemed to be unsafe. She's got bladder and bowel incontinence. She's distressed, tearful, fatigued and drowsy. From a disability perspective, she's currently transferring it from bed to chair with a hoist and assistance of two to use that equipment. She's sat out of bed briefly in a very supportive chair, but she needs assistance of two to roll in her bed and for all care needs. She has no verbal output because of the tracheostomy, and she hasn't been able to use a spell chart. She's following simple one stage commands only. She's fed via a nasogastric tube. She has a urinary catheterine situ and is incontinence of bals. She's also been quite constipated. From a participation perspective at this point, she's on sick leave from work and her husband is caring for their daughter at home. Rehabilitation input so far, so we have to start immediately and the intensive care therapists will be doing this. She's been receiving daily physiotherapy. They've provided her with resting splints for her hand and feet and they've been giving her passive stretches and chest physio. Occupational therapy have supported her seating and speech and language therapy have predominantly been supporting her tracheostomy ween, but they have started to assess communication. And just to go back, a spell chart is simply as it sounds, it's letters and patients who are unable to vocalise can point to the letters to spell out the words they want to say. So, would you admit this lady to rehabilitation and what would your management be if you do? She definitely need admission, isn't she? She definitely need admission to hyperacute rehabilitation, requiring an inpatient, a multidisciplinary team, rehabilitation, probably of a longer duration, probably that is the definite smart goals. Smart for the listener, it's a specific measurable, achievable realistic and timed and such goals should be in collaboration with the team and the family and the patient, which should be a realistic one. Poor girl, she must be going through a lot here, isn't it? So there's definitely a lot of goals we can do and change. There are her participation as you rightly mentioned and there are a lot of goals to be achieved. So this is the holistic approach. This is rather than seeing that patient with the bleed, with the right side weakness and speech, we are talking about Amy who has an accountant who has a who has a full fill life before and looking into how holistically we can try to reach her functionally as close as possible to her pre-morbid functionality rather than just looking into what are her impairments and what is our disabilities. We want to look at enhancer recovery and trying to improve the participation. So there are two things to consider. One thing and the most important is how will I support the patient and how will I or my team, we can lead the team to ensure the patient recovers on the pathway and how will I support her psychologically, her family socially as well. So we will look, it is a long, tortuous road just to remind ourselves that there will be a lot of bumpy road ahead as well. So that is something to acknowledge and ensure the patient are set the right goals in the beginning. We have to assess the pre-morbid conditions in general but it appears that Amy is a relatively stable girl before and stable medical conditions before. When the patient been assessed when I do an initial admission, I look into patients' impairment disability participation, I also look into what are the brain damage we are talking about and how much the how much the switches so-called the brain cells at which part of the switches damage and what are the likely impact on those patients and what we can help and what are the potential complications we are looking for in such damage. We are proactively think so that we can think about it and plan for it. For example, we know in a interseparal hemorrhage there is a risk of another reblet, there is a risk for example not may not be exactly with Amy but maybe with other subparachnone patients they can come with the risk of infarction, secondary infarction or they can have a risk of hydrocephalus. So we will be looking for these type of neurological decline. So once they get better and they start decline, you know that something wrong is happening. So you proactively look for it and anticipate it and manage it proactively to ensure that there is no further brain damage happen. So this is a tertiary or quaternary brain damage avoiding that so primary prevention from that point of view. Then we're looking into impact of general medical stability. So when Amy is not her functionality anymore, she's in her bedbound, she's on a trackie, there are multiple tubes in her body, she's at risk of infections, multiple infection. It may be just infection, urine infection or a trackie from the source of track, she will be even more risk of those of the infections as well. So we have to make sure that that's been addressed proactively and managed it. So the role of doctor as for example me here, I'll be providing a bird's eye view of the whole team or a helicopter view, you can say that way on the issues, their prognosis and in certain families want to know what is tomorrow, what is three months down the line, what is six months down the line, what's a year down the line, how I should be prepared. So sitting with them and understanding and taking the family with you to plan for the future is also essential. My team will be the multi-disciplinary team which includes physiotherapy, occupational therapy, speech therapy, dietician, psychology, neuropsychiatry, and the specialist nurses will be assessed in their own assessments in each domains and they will be feeding back on a weekly basis. So understand how the patient is progressing, what are their smarter goals and how they are whether they are achieving or not achieving, if they're not achieving, why they're not achieving, if they're achieving, can we increase and improve or give the higher task so that there can be done. For Amy can you just talk a little bit, I suppose a bit more about the interdisciplinary team and what kind of work each of those members you've mentioned might be doing for her or with her. So if you're looking into physiotherapy, they will be looking in upper limb, lower limb power, managing the tone, looking in different sets of exercises. In general for a medical team, we look into exercise into three groups, the stretching exercises, strengthening exercises and task specific exercises. In short, what it means is stretching the muscles to allow it to full length of the journey, looking into strengthening those muscles, agonist and antimonistic muscles and allowing them to do a certain activities for a upper limb and lower limb, i.e. looking after their own body, looking after their ability to sit, stand and walk if that is possible. And stretching just to our device by stretching is really, really important isn't it and maintaining range of movement in all joints because without that there is a significant risk of patients developing contractures and that can really complicate future rehab and return to mobility or activity. So very early on, there are a piece need to be involved to support patients to maintain that range. That's very correct because she is a red category, the higher risk for developing spasticity. There's a plenty of publication in that, Royal College of Physicians guidelines on a spasticity there and the early management of spasticity may improve the outcome drastically different than not managing them proper. Then going on from the other disciplines, my occupational therapist will look into their cognitive ability, they are also looking into their functionality, activities of daily leaving and upper limb function, speech and language therapy will have both roles of, as you mentioned, she's using the board and communicating. So how her communication can be improved, both in reception and expression part of it, how her swallowing can be improved, how her trackie can be looked into, trackie probably need a combination of a doctor, speech therapy and also just physiotherapy to about decanulation. By looking into the diagnosis here, I feel that she is extremely likely to be decanulated, albeit slowly maybe, but she will be coming out of her goals of taking a decanulation of the, she is very likely. Just by decanulation, you may remove the trackiest male or trackies as it's generally called on her on a rehab unit. That's correct, thank you. Thank you for correcting. That is trackie, meaning of the trackie and coming in, the trackie can be coming out, which will be a great for her, for all aspects, whether it's a infection, medical stability or movement and social movement, and other things. Then my dietician colleagues will be looking there, her nutritional needs are met, understanding her pre-morbid BMI, body mass index, and also supporting the move from nasogastric feeding to parental or oral feeding. Then the psychological support will be essential, isn't it? She's already feeling down and that can be too as an aspect of it. One is due to the type of the end damage what she had and the impact on the cognition. Why the second thing is the impact of why me and how my life I've been shattered because of this stroke. So the psychological impact, so supporting the patient and the family through this journey is going to be very hard, but my psychological psychology team will be supporting the family through that. So Ganesh, you just mentioned spasticity, just to clarify, patients at risk of contracture regardless of whether they have spasticity and they need to have their joints and their muscles moved to maintain range of movement, but am I right in saying spasticity would further increase that risk and complicate it? Absolutely right, Helen. There are two elements. One thing is the tone of the muscles and second thing is immobility. So biomechanical element of the muscles and the joints. So if Amy, she has a low tone and she's not moving her hands and legs, so if she doesn't, if we do not move our hands and legs, then we are at risk of losing that muscles and losing the range of motions, developing into contractures. And if she developed that she is at high risk of developing high tone in the coming weeks as well, which can even further her risk of developing contracture. So regular moving joints and maintaining the range of movement is extremely essential to manage the tone and manage the preventing the risk of contractures. And what is spasticity? In general, in the simplest form, it's a increased tightness of the muscle. It's a tone. The tone of the muscles being increased and that causes tightness. And spasticity, if it has not been managed and obviously the contracture is a straightforward and understandable risk of complications of the spasticity. However, there is multiple complications it can lead into the impact on the patient's both on the symptomatic way, causing pain and spasms and it can impact them on the psychologically with the low mood and inability to carry out tasks that can impact on the patient's unable to do a task on active goals like moving hands and picking subjects and other things. Or it can impact on their passive case. For example, some it can impact on their ability to dress undress or ability to sit comfortably so on and so forth. So managing them includes the physical therapy that is a physiotherapy, occupational therapy, splinting, stretching and also the pharmacological methodology. That is the medications whether it's a oral medications or a bottle of toxin. It's a whole load of one new podcast itself. That's a Royal College of Physicians guidelines on the spasticity which was published in 2018 and which is a very good read for all the stroke doctors. So essentially we have a responsibility to prevent or manage spasticity as best we can to actually an other patient to recover and be able to regain as much activity and function as possible. Absolutely. You've described sort of the MDT role or what kind of things the MDT might be looking at for Amy and that there would be updates sort of every week from an MDT and within MDT meetings. I'm presuming you also have meetings like we do with patients and their families as well. How often would you do the eyes? The management of the family meetings will be a goal setting meeting happens every four weeks and a smart goal need to be identified and progressed with that. The meeting with the family will be even more closely than that. For example when we do the ward round we tend to do it to the time when the family are around so that they can ask questions. For everybody may not be ready to accept all the neurological conditions straight away so we need to assess and understand their psychological makeup and when they're ready and deal with the questions because they will be not only going through medical questions but a social questions and difficulties in the house and their finance and their work and so on so forth. So looking after that is also essential. From experience one of the things family will really want to know from you is how much is she going to recover and how long will that take? How do you sort of manage your answer that kind of question? There is an approximate of approximate ways. There are a lot of studies coming in last one decade about the prognostifications and how the brain injury and the impairment at the time of admission can tell you whether the patient able to use their arm functionally or leg functionally. So it is about understanding of the patient's functionality. For example Amy was a very high active function before. So that's the positive factors. So you're looking to all the positive factors and negative factors in a patient. She had a massive bleed which is a negative factor. Then you'll be looking for the neurological damage and the impairment time. So if the power is zero by fire at the time of admission it is then you need to be very skeptical about what is a likely prognosis is but you have an approximate or many years of experience to understand what is a likely functionally. What's a likely that they'll be able to sit, stand and work with and help of an aid. So it looks like Amy is very likely, for example, likely to be decanulated, likely to be able to communicate better than what she is now. She'll be able to sit independently. She's likely to be standing and probably walking with the help of an aid. So that might be a goal which could be achieved in next three to six months. So this type of a direction will be showing and obviously will be guided by her engagement and her progress and which will indicate or fine tune even better at the time. Thank you. As a rehabilitation doctor you've mentioned before some of the medical complications that you may see for example further brain injury from bleeding or hydrocapillus and infections. What other kind of things as a rehab doctor at this stage in Amy's journey, will you be thinking about what we're looking at? Obviously co-existing medical condition and management of its essential and Amy is relatively well but usually the group of patients come to us, we'll have a co-existing diabetes, blood sugar so on and so forth. So not to forget that, that will have an impact on their recovery and their possibly the secondary complications of that. So a very close eye is required for it. And her meaning of the tracheostomy needs a very close making sure that her swallowing has been managed. For example, Helen, we produce about one and a half liters of saliva a day which we don't see it. We swallow it well. Her swallowing is impacted. So if she starts to having an anterior drooling that will come with its own complication. An anterior drooling has been coming out of the mouth. Coming out of the mouth or it can go back of the mouth and cause choking and just infection. So management of the her saliva, it's not an excessive saliva, it's a normal saliva amount, but that's going in a wrong direction rather than going in a swallowing way. So that need to be maybe reduced or maybe managed with the help of a medication. For example, oral or a patch, I was in a patch like a pyronyne or a bottle of toxin which is a licensed medication now. Where would you inject the botulinum toxin to manage saliva? To the saliva reglands, there's a parotid sense of mandible glands and simple injections every three to four months might suffice and they may not need a repetition if it's her swallowing repeats because if she doesn't have an excessive saliva, so this could be managed with one of injections too. Then moving on with other complications, for example, apart from we already mentioned about the secondary neurological or medical complication, but there is a function. When we look into patient's body, we mention about statutory management of the medications. For example, we use a lot of medications in this group of patients. Yami could be started on antidepressants, she might be started on the spasticity medication. So you need to tailor what other medication which could help patients neurological recovery while what other medications which can hinder neurological recovery. I brain's a present medication. I would like to avoid them or we know of them. For example, for rehabilitation doctor Haloparidol, which might be used in intensive care for rightly so, to manage the agitation, which is a big no-no for us because it's causes severe depressive actions and they can hinder the recovery of the brain cells. So we want to avoid such medications and we need to closely manage her mood because if Amy is not willing to engage in the rehab, she's not going to progress essentially and there are plenty of reasons why she her mood can be low and down. So that proactive management of the mood, which might be a behavioral management, a supportive management or a medication management, we can be helpful with her motor recovery, her engagement in rehabilitation. Moreso, her capacity need to be assessed. She need to understand the cognition and understanding all these things, what are we doing? Are we doing with her consent? Or are we doing in her best interest? For example, we apply dolls, there's a deprivation of liberty safeguarding if she do not have a mental capacity of her own. She has speech problem, she's on a tracheostomy, she can obviously we look into, she has a brain injury, is she able to understand, is she able to retain the information, she's able to weigh the benefits of risk and she's able to communicate her decision. If she fails to do certain things like that, she might need dolls and might need to be managed under best interest of her ongoing care and therapy. Going back to what you just said actually about sort of medication management and trying to make sure you're not using too many medications that could potentially cause harm rather than good. One of the things I'll often do is use a medication that will do more than one function. So for example, if somebody's got a low mood but they've also gotten your apathic pain, I might use deloxity or amitriptoline. If they've got a low mood in their sleep is really poor, rather than adding in a sedative at night, I might use metasopene or if they've got spasticity and pain, pre-gablin or gabapentin, overbacklefen, which is just an antispasmodic, and I find that that helps keep your list of medications down just a little bit. That's good. Thank you. So Amy's on the rehabilitation unit. She's receiving multi-disciplinary team input and actually the team are working in an inter-disciplinary way. So and by that I mean that rather than physiotherapist just looking at the legs and mobility, they may also be looking at swallowing. They're working with speech and language therapy to achieve similar goals. So the team are working together to achieve goals in an inter-disciplinary way rather than in parallel. So the track yesterday comes out. Amy starts to get some recovery in her leg. She's beginning to transfer using a turner, which is a piece of equipment where she stands up on a stand that rotates and is supported by nursing staff to twist that so that she can move from bed to chair. Her arm unfortunately remains densely weak. Trials of oral fluids are commenced to see if her swallow can be progressed. She's less drowsy so she's much more engaged in the therapy sessions that she's had. Her mood is low but antidepressants have been started and she's got daily family visits and her daughter's been visiting a few times a week as well. So that started to boost things up. So what would be the next steps for her? I'm pleased to note that Amy is progressing in the right direction and right trajectory. And with the support of the team, she is moving in the right trajectory and without which she might not have. So she's ready. She's ready for the next step. A closer home. So that means she's ready from hyperacute or acute rehabilitation unit into a post-acute rehabilitation unit, which is we have in our area closer to the home in each. There are three different four different places we have. So she will be ready to engage in her rehabilitation much more intensively, and so she will be she I think very likely to be moved from to a post-acute unit and engage in her rehabilitation there. Okay and that's exactly exactly what happens. So along the way, Amy's made progress so that the team of reset girls looking at the kind of progress they expect to be making and she's moved on to a post-acute rehabilitation unit. Within that setting, she progresses. She's now eating a modified diet. Her dysphasia, so communication problems are improving. So she's following more complex instructions now. She's able to make her needs no verbally, but doesn't always get the words right, but she's using gesture and pointing to support this what we call a total communication approach. She's now transferring with a Zimmer frame. So she's moving from for May to be standing, holding on to a frame and moving that. The therapy team are beginning to look at taking steps with her. She's got some flickers proximally, so around the shoulder and upper arm, but there's no functional activity yet, and she's developed some spasticity and cloness in her leg and arm. So what kind of input would you envisage her having at this stage of rehabilitation? I think there are certain things we can be happy about. For example, her early neurological complications, she come across. I think she's just out of the window for thankfully. And now next is is still our we are not can't take our legs out of the accelerator so to say. I think her spasticity need to be looked. She is at high risk of developing into severe spasticity if it's not being managed promptly. So she will require very likely a botanum toxin injections or other antispasticity medications along with the physical therapy. She will be, how I need to look into my drug chart to make sure that she's not on any unnecessary medication here. And one of the common complications it might sound as very simple and very silly, but one of the common things, Helen, you and me, when we're going wardrobe, a bowel and bladder problems, because all these patients, because of their reduced mobility, change of medications, change of neurological impact on the bowel, they will be either constipated or been over prescribed with laxatives and causing diarrhea. So this means our routine on the weekly occurrence to have changing of their laxatives and regularize them, make sure that they open in an appropriate way and not been suffering without with a constipation or diarrhea. I absolutely agree with you and I think that one of one of the easiest things to do for a patient is to support their bowel management and actually the impact that can have both on how they feel, but also how they can participate in rehabilitation can be absolutely massive. So yeah, I agree that connection. And I also need to linking with now, I've become a lot of link work or role as well, apart from my being a doctor and a medic, I need to be looking into their patient's case manager, looking into what are the support I can do referring back to their earlier first physician involved. For example, it might be neurosurgeon or a neurologist who might be involved in acute management. So linked with them, do we need another re-imaging or looking in any further intervention? Looking, making sure that the goal set by the MDT is a holistic goal and also this is looking into the patient, but there is a lot more happening by this time. Amy probably will be two or three months down the line. And now the, obviously the sun is on high so there with this dad and the dad and the sister and the worker may be thinking whether Amy is going to come back to work or not. So her employment might be in a risk. So I might need to lease when they have employer, maybe they need a letter supporting letters. They might need some social worker support. My might want to need a support for a family there looking into psychological support or the long term planning. So they might need a lot more than earlier period now. So that might be my role. So my role as a holistic view even gets more complicated. And I think you're absolutely right so the team, as they have throughout her rehabilitation, but now really are able to work with Amy to look at goals and actually to incorporate her wants wishes and what she enjoys into the goals that they create. So for example, she's progressing with her swallow. Her ultimate goal is pizza. She loves pizza and she loves eating pizza with her son. So that's a food goal for her to work towards with speech and language therapy. But also she plans to cook this herself in the therapy kitchen with the occupational therapist and then eat it with her son. That's a really lovely goal for her. Likewise communication wise, she's, she's practicing reading. She wants to read her son a bedtime story and setting goals like this make it help I think in terms of patient's motivation doesn't it? She, she's also gaining continents which is brilliant and that's a high priority for her. The therapists are helping her to progress now with walking. Stairs are felt to be a target and that's a big deal because that that's the difference between being able to return to your bedroom at home versus having to sleep downstairs sometimes in the living room. She's doing some active upper limb work. Those flickers have been seen so that the occupational therapist is working really hard now to see if they can promote that recovery and any recovery that she is having they can optimize what she's able to to do with that. She's also learned some compensatory single arm techniques for her own personal care activities, domestic tasks, things in the kitchen, but also for childcare helping her son, they've get washed and dressed with with family support is really important to her. And the occupational therapist and physios have been out to her home. They've assessed the environment and actually arranged provided equipment so that she can spend weekends at home with with her family so that she can firstly have the the experience of being back at home and obviously the the emotional benefit of that, but also so she can identify any any areas of difficulty that that further workers and inpatient could focus on things are going well for her. However she then has a seizure and ends up transferred over to the acute hospital because it was a fairly prolonged seizure returning back to the ward about three or four days later. Fortunately no worse off than she had been before. Is that something that you see commonly? After patients with a brain injury are extreme high risk of seizure, there are two elements to look into. We do not start on anti seizure medication proactively. We know that risk is already increased, but if they develop a seizure about for for example seven days later they're likely to require anti seizure medication longer time. So, so you mean you wouldn't start a prophylactic anti epileptic and spend somebody just because they've had a stroke but somebody that has had a seizure you would start medication on or you'd certainly discuss medication with them. We will start on a medication and they probably require a medication for a long time to come. Okay, there are two elements again. One thing is the what are the seizure medication you could consider and what is that anti epileptic medication can cause on a neurological function because there are certain medication can have a neural depressive action, certain medication can have impact on their cognition. So we need to be very closely monitoring in such situation, but extremely likely that Amy is going to be controlled or epilepsy can be controlled with one medication rather than multiple medication. This might have an impact on her driving. This is something we need to consider on a long term and they need to be sincere free for certain duration before they can get back to driving. And if she comes back in outpatient and discuss with me about weening of the anti epileptic that can have an impact on her driving as well. So this need to be very carefully considered and on a long term impact on the patient and their potential problems as well. So Amy ends up being discharged. This is eight months after her admission with a stroke. At this point she's walking with a stick indoors. She's using a wheelchair outdoors that's pushed by somebody else. She's able to climb a single flight of stairs holding onto a rail with somebody stood behind her for support. She's washing and dressing, doing most of this independently but needs help with some items. She's now eating a normal diet and drinking normal fluids. She's got a mild residual expressive dysphasia where her understanding is very good and she's actually doesn't seem to have any underlying cognitive difficulties either. She's continent of bladder and bails and there has been some further recovery of movement in her right arm in that she's able to grasp but she struggles to release things. She's now able to access her property. She's spent weekends at home and she's been supported by her husband and her mum to help her son bathe and dress and to prepare family meals. At this point she's discharged and she's passed on to community rehab services and that's sort of where she is at this point. Is Amy's admission and journey a fairly standard one? I feel that she is very well within our trajectory what we expect from patients with severe disability like that. Some may say that eight months of rehabilitation this depends on the commissioning arrangements on a locally and also if you look into the value of the very well studied and very well published about the cost of rehabilitation was as the outcome. Remember she's a 35 year lady with the active life and plenty of life expectancy expected for her to leave a full fill life and that is outcome reduction of the care element, reduction of roles she could participate in a society. She's immense and she could contribute back to society as well. So this is an immense change in her life and without this support she would not have reached where she reached now. The role is not done yet because we still have some goals to continue with and a community reintegration back to society and community rehabilitation is an ongoing task here. Yeah and is is Amy somebody that you would be following up? That's correct. She will be forwarded up into one is a therapeutic team with the community rehabilitation team and with me and our patients where I'll be looking for their sugar physical well-being, her progress, potential problems that worsening off her tone and spasticity which might need a regular injection of work limb toxin so maybe her advice and support for example in the driving, returning to work and what are the adaptations she might require whether it's working for home or other supports. What are the other support structures and pointing to those for example stroke association and some regionally there are some other charities for example in our region we know there is a brain charity and similar similar different services such as like that in each area and there might be some in some occasions I I can't see with Amy but there are medical legal issues can make them across and we might need to support them with that as well. Yeah and I agree from a rehab perspective she's somebody I'd probably be following up for a while yet if she has spasticity management and needs ongoing sort of medication or botulinum toxin spasticity it could be that she's actually followed up lifelong but for me I'd sort of certainly be looking at her to have completed her recovery to have optimized her activity and her participation and actually to have no further issues that she needs my help with before I think about discharging her. That's correct but only to use a couple of of what I wanted to address even in our patient Amy maybe Amy and with her family and I may be the same clinician but like anyone of us our life's circumstances changes we change with the time and so is our patients so addressing those changes and the potential difficulties during those change is essential and the so some support in a in a medium term is required for her to go through that. I think that's that's the end of my questions for you about Amy I think we've talked through her case is there anything that I haven't asked you that you think I should have done or anything you want to add. Thank you Helen this is a very thorough discussion of our rehabilitation pathway of the standard patients but not to forget there are a lot of some patients might have a faster progress and a better recovery some patients may not pass through the same trajectory they might have a slower progress and they might have a delayed and along and the pathways of recovery when we if we look into the data over time we know that some patients progress very fast in the first six months and then slows down not reach plateau that's the wrong word and they slow down or some may not progress initially for six months and then progress suddenly some might have a baby patterns in their recovery pathway so never write off and say that they will never recover and also the just a returning of the impairment managing the impairment is not the only thing and about of participation in my head Helen when I become starting become a doctor Stephen Hawkins was my my guru in my head my model role model so in spite of severe impairment severe disability he is known around the world every single human know about Stephen Hawkins so I would say that our aim is to not focus on disability only it's about the participation and how that can improve the patient's functionality in and the return back to society as a in general fantastic thanks Ganesh so in terms of sort of take home points for our listeners can you sort of tell me what you particularly like them to have taken away from today or to think about a little bit more on the rhyme if you come across a patient with the stroke in this case look after the management of the acute stroke and the preventative part of the stroke but don't forget the patient as a whole look after their because these patients will likely to have a disability and a long run rehabilitation rehabilitation back to their own functional status is are close by to it is a very essential part because they this not only the patient they are loved ones and wider society suffers without which and we know the impact on the wider society with one over 1.3 million and the associated around their near society is suffering with those disability with our support with the right support this disability can be minimized the patient can lead a fruitful life for many years to come so not to forget that one thank you thank you very much so thank you to everyone for listening if you're interested in finding out a little bit more or referring back to some of the guidelines or documents that Ganesh has mentioned they'll be included in the links below that's it for today's episode of the RCP medicine podcast don't forget to like and subscribe and join the conversation by following us on Instagram Twitter and LinkedIn together let's continue shaping the future of health care (soft music)