Stroke Team in Action

Overview
This guide will be an interactive online platform that allows individuals at risk of stroke, and those who have suffered from stroke, and their families and friends to access information about stroke, a speech pathologist’s specific role within treatment and other supports that are available. This resource is targeted towards both the individual and their friends and family because the family was found to be the second most common source of information, after information they received from a doctor or other medical staff, for people who had experienced stroke in a Spanish study. This is also important as the same study found that only 65% of people felt that they were well-informed by medical staff and only 25% completely understood what was being explained to them, which was often noted by doctors as being due to a lack of previous medical knowledge and understanding.

This resource will be provided through an interactive online platform because internet-based research was the third most common way of finding information among people who had experienced stroke. Therefore, this guide may provide accurate and engaging information for people who have experienced or are at risk of stroke in an engaging and accessible way.

Stroke is the third leading cause of death in Australia and one of ten leading causes of death in those over 45, with over 10,869 stroke fatalities in 2015. However, a study of patients in Spain, 3-12 months post stroke, found that only 16% of people who had experienced a stroke knew what a stroke was and 43% of people either made an appointment with their general practitioner (GP) or stayed home and rested when they experienced the symptoms of their stroke rather than going to the emergency room. This suggests a lack of knowledge of both the symptoms of stroke, but also of how to respond to these symptoms and the appropriate services to access, which our guide will address.

Speech pathologists in Australia are qualified specialists in areas such as language, communication and swallowing and may be able to assist a person who has experienced a stroke to recover through specialised rehabilitation therapies. Speech pathologists are an important part of the stroke recovery process as up to 60% of people who experience a stroke may experience a swallowing difficulty, 20% may experience trouble using their speech and up to 30% may have difficulty expressing ideas or with the comprehension of language. Therefore, our guide will also be addressing the specific role that speech pathologists play in stroke intervention and rehabilitation. We believe that this guide is an important contribution to stroke education as it has been shown throughout research that education about what stroke is, its symptoms and risk factors can improve health outcomes by improving health behaviours and reducing the risk of further stroke in those who have previously experienced stroke or were at increased risk of stroke after a Transient Ischaemic Attack (TIA).

In a typical human being:
Blood vessels, also known as arteries carry blood from the heart to the brain. The blood contains oxygen and essential nutrients for brain cells  in order for the brain to function optimally. The arteries are specific to certain areas of the brain.

“A clinical syndrome characterised by prolonged altered cerebral function, caused by vascular dysfunction”.

Some people think a stroke affects the heart while some others think stroke only happens to older people. Well, the fact is that stroke can happen to anyone. To put it simply, a stroke occurs when one of the arteries leading to or within the brain is suddenly interrupted. The blood that flows in the artery is occluded, either by a blood clot or a broken vessel in the brain. It is deemed a medical emergency because the lack of oxygen supply damages the brain cells and as a result, 1.9 million brain cells start to die every minute.

The effect of stroke varies depending on the location of the brain the stroke attacks and the extent of brain tissue affected. For instance, if a stroke obstructs the back part of the brain, the sensations involving vision will be compromised. Stroke leads to a wide range of impairments such as in speech, understanding and emotions, sensations and ability to move body parts as well as affecting vital functions like breathing, controlling heart rate and swallowing. Transient Ischemic Attack (TIA):
 * A TIA occurs when an insufficient systemic circulatory supply causes a temporary blockage of blood flow to the brain. An artery in the brain is blocked for a short period of time, slowing down or possibly stopping the flow of blood in the affected brain area.
 * A TIA is also referred to as a "Warning Sign" for future stroke because the symptoms are similar to that of a major stroke. The differences between a TIA and a stroke is the duration of the presenting signs and symptoms. Unlike stroke, TIA occurs rapidly and resolves withing 24 hours. [8]
 * This temporary status should not be taken lightly or ignored . There are approximately 46,000 people each year with TIA who are more likely to suffer form a major stroke compared to a stroke survivor having a recurrent stroke. [9]

Face
Dropping: one side of the face will droop or may be numb. A smile may be uneven or lopsided.

Arm
Weakness: one arm may be weak or numb. The person may lift their arms and one may drift downwards.

Speech
Difficulty: speech may be slurred. When the person is speaking it may be hard to understand.

Time
To call 000: if the person shows any of these symptoms, even if the symptoms go away, call 000 and get them to the hospital immediately.

Other symptoms of note

 * Numbness - sudden weakness of face, arm or leg, especially if only one side of the body.


 * Confusion - trouble speaking or understanding speech


 * Trouble seeing - blurred vision in one or both eyes


 * Trouble walking - dizziness, loss of balance or coordination


 * Sudden sever headache

Risk factors
Non-modifiable 1. Age

Age is one of the most important risk factors for stroke. It can affect people of all ages but the risk increases with age. The chances of acquiring stroke doubles every 10 years after the age of 45.[9] However, this does not rule out the possibility of disease in younger people. 1 in 7 strokes is found to occur between the ages 15-49 due to obesity, diabetes or high blood pressure.

2. Sex

More common in women, due to pregnancy and the use of birth control pills increases the risk.[10]

3. SES

Socioeconomic status can also have an effect on stroke risk, with those living in deprived areas being twice as likely to have a stroke compared to those living in more affluent areas.

4. Ethnic background

Ethnicity can also play a part in doubling the risk of stroke.[9] People from Afro - Caribbean and Asian ethnic origins have a higher incidence of hypertension and diabetes and this has a knock on effect on the prevalence of stroke.

5. Family history

Stroke risks can be higher in some families than others. Genetic factors play some role in related conditions like high blood pressure and stroke. People with a family history of stroke also share common environmental factors that increases their risk. Modifiable 1. Conditions
 * Previous stroke or a Transient Ischemic Attack - These are significant risk factors for the occurrence of a major stroke.
 * High Blood Pressure (hypertension) - High blood pressure is one of the most important risk factors for stroke. It is termed a silent condition because people who are affected are unaware of its presence. The normal blood pressure range falls on 120/80 while high blood pressure is over 140/90. High blood pressure puts a strain on blood vessels all over the body, including the arteries that lead to the brain. In order to keep blood circulation going, the heart has to work much harder. This can lead to stroke through weakened and damaged blood vessel walls, blood clots or plaques breaking off artery walls and blocking a brain artery as well as speeding up common forms of heart diseases.[11]
 * High Cholesterol (hyperlipidemia/dyslipidemia) - Lipids are essential for digestion and hormone synthesis but as with everything, moderation is key. The abnormal levels of lipids in the body, found in diet high in saturated fats, contribute to cardiovascular disease and stroke. There are two types of lipids; low-density lipoprotein (LDL) and high-density lipoprotein (HDL). The LDL is known as the bad cholesterol that builds up on the walls of an artery and increases your risk of ischemic stroke. On the other hand, HDL is the good cholesterol as it functions to remove excess cholesterol from the bloodstream through the liver for breakdown and removal. This process reduces the risk for stroke.[11]
 * Atrial Fibrillation (AF) - AF is now widely recognised as a major cause of stroke, in fact, it is the leading factor of stroke in older patients. AF disrupts the normal synchrony of heart pulses by causing irregular heartbeats and affects the smooth flow of blood through the heart. In some instances, the blood completely stops flowing through the heart and leads to ‘blood pooling’ in the chambers of the heart. Subsequently, blood clots are formed in the heart which then breaks off and travels towards the brain, where it can cause an embolic, ishaemic stroke.[9] AF is also associated with other conditions such as lung cancer, high blood pressure and diabetes.
 * Type II Diabetes - Diabetes, specifically type II doubles an individuals’ risk of ishaemic stroke.[9] When the body does not produce sufficient insulin to turn sugar into energy, extra fatty deposits clot the walls of blood vessels. If this goes unnoticed, the clots can grow in size and cut off blood supply to the brain, resulting in a stroke.  People at risk of Type II Diabetes are those older than 55, over 45 with high blood pressure or overweight and with a family history of diabetes.

2. Behaviour
 * Unhealthy diet and Obesity - The number of Australians who are obese has consistently increased in recent decades, to nearly 2 in 3 adults (63%) and 1 in 4 children (27%) aged 15-17 years.[12] Being overweight or having too much fat increases the chance of high blood pressure, high cholesterol, kidney disease, heart diseases and more. Some of these conditions are potential risks for stroke.
 * Physical Inactivity - More than half of Australian adults (more than 9.5 million people) do not attempt the required amount of physical activity, that is a total of 2.5 hours weekly. While 15% of adults do no exercise at all.[2]
 * Excessive alcohol consumption - When there is too much alcohol in the blood system, blood pressure rises to consistently high levels. As previously mentioned, high pressure increases risk of stroke. Excessive amounts of alcohol is linked to type II diabetes, extra kilojoules in your diet and atrial fibrillation, which are all risk factors of stroke. Alcohol also levels of triglycerides, a form of fat in your blood that can harden your arteries.[13]
 * Tobacco use - Tobacco contains 4,000 toxic chemicals that are absorbed into the bloodstream. Cigarette smoking thickens the blood, which then increases the risk of blood clots forming. We are now well aware that blood clots in the arteries of the brain lead to stroke. Even secondary smoking can make you more likely to have a stroke.[13]



Quiz
Choose the correct answers and click "Submit": {What causes a stroke? - Blocked blood vessel in the brain - Bleeding in the brain from a blood vessel - Loss of oxygen to part of the brain + All of the above
 * type=""}

{What is the major risk factor for stroke? - Obesity - Diabetes + High blood pressure - Family history of stroke
 * type=""}

How a stroke may affect you
Each side of the brain controls the contralateral (opposite) side of the body. Because of this nature, a stroke that affects one side of the brain will result in neurological complication on the opposite side it affects.

Strokes account for 40,000 deaths every year 50% of stroke survivors have a disability and an increased risk of recurrent stroke.

Prevention
Stroke negatively affects the patients’ quality of life as well as that of their family and informal carers. However, with control of risk factors it is a preventable and treatable disease. Lifestyle modifications such as improved diet, increased physical activity, management of blood pressure and cholesterol and to stop smoking greatly lowers risk of stroke. 1. Management of Blood pressure, Type II Diabetes and Cholesterol

These conditions can be improved with medications and lifestyle changes. Keeping the levels within a recommended range, limiting foods high in added sugar and fats as well as regular exercise and maintaining a healthy diet are some precautionary steps that can be taken to lower your chances of getting a stroke.

2. Physical Activity

Any form of moderate physical activity that increases your heart rate, makes you feel warm and a little out of breath can help avoid conditions that are related to stroke. For instance, a 30 minute bike-ride or fast paced walks is recommended on most days of the week, if not all.

3. Healthy Diet

To maintain a balanced diet, follow the Australian Dietary Guidelines.

4. Drink Alcohol in Moderation

Limit your alcohol consumption to two or less standard alcoholic drinks per day, as recommended by the Australian Alcohol Guidelines.

5. Quit Smoking

It has been proven that blood pressure level returns to normal within a month of quitting smoking. On top of that, the risk of heart attack and stroke drops as much as half after one year a person quits tobacco products.

Quiz
Choose the correct answers and click "Submit": {Does stroke rarely occur in people under 65? - True + False
 * type=""}

{A stroke is a medical emergency. + True - False
 * type=""}

Stroke in the speech pathologist practice
It is recommended that all post-stroke patients be screened for communication deficits, and receive formal and comprehensive assessment by specialists to determine the nature of the communication impairment. Impairments arising post stroke may include: Aphasia, Dysarthria, Apraxia or Dyspraxia of speech, voice problems and cognitive-communication disorder. For this reason, it is recommended that post-stroke patients see a speech pathologist in order to have treatment of any complications; seen in around one thirds of stroke survivors; with speech and language.

Aphasia: A condition in which damage to the brain results in difficulty understanding and recognizing words and sounds. This may affect the words the individual tries to express to others or that the individual’s understanding of others.[3]

Dyspraxia: The difficulty coordinating and/or planning muscle movements involved in the production of speech and swallowing. This may affect the ability to make correct mouth movements for speech or muscle movements for chewing and swallowing.[3]

Dysarthria: A type of weakness, paralysis or lack of coordination in the muscles involved in speech and breathing that result in slurred speech or a decrease in speech volume.[3]

Treatment for stroke may therefore vary in that post-stroke can lead to differing outcomes. A speech pathologist may treat aphasia in that they will ask patients to practice talking, listening, reading and writing. For Apraxia, they may work on re-coordinating the muscles involved in speech, while for dysarthria, due to weakened or paralysed muscles, they may work on speech articulation and strength exercises for speech muscle. The Clinical guidelines for Stroke Management, (2019) states that speech and language therapy for post-stroke patients with aphasia, dysarthria, and apraxia of speech is highly recommended.

The Department of Health and Human Services (2015) Australia, states that the purpose of rehabilitation after stroke is to re-learn skills that were lost from the damaged brain, and to learn new ways of performing tasks to get around any barriers faced. It is stated that rehabilitation will start as soon as the patient is stable in a hospital, then moving to a rehabilitation facility or outpatient care. Rehabilitation aims to improve muscle strength and coordination, mobility and the use of affected limbs, the range of motion and tension of joints, communication in speech, reading and writing, thinking and memory, and general mental health.

The speech pathologists role in treatment of post-stroke patients should include the evaluation and treatment as a part of the collaborative team of rehabilitation professionals. A multi discipline professional stroke team may look like the following: doctors such as a neurologist or general physician, nurses, social worker, a physiotherapist, a speech therapist, a neuropsychologist, and an occupational therapist.


 * Physicians and general practitioners are responsible for managing and coordinating the long-term care of the patient while incorporating different rehabilitation programs to fit individual needs. The general health of the patient is also a concern, where the prevention of stroke is focused on controlling blood pressure or diabetes through examination of risk factors.
 * Neurologists in the stroke team direct the stroke team while the patient is in the hospital setting, taking on specialised roles after the acute stage of the stroke has passed.
 * Rehabilitation Nurses are to help survivors to learn how to manage their own personal care and perform basic daily living activities, while working to reduce risk factors on a follow-up stroke by training family and caregivers.
 * Physical Therapists are there to evaluate the patient to provide an individualised rehabilitation plan to recover anatomical function. This may be the use of their legs and arms, where some may even teach how to use assistive devices (i.e., canes, walkers or wheelchairs) to help retain lost skills post-stroke.
 * An Occupational Therapist work to help post-stroke patients to relearn the motor skills to engage in occupational activities (i.e., basic activities of daily living), while teaching adaptive skills to match environments by making changes at the home to increase safety, remove barriers, and facilitate physical functioning.

The speech therapist job in this team is they assist with speech and language understanding, reading and writing, where they will determine the extent of the presented problems, and create a specific and individualise treatment plan. In the realms of cognition a speech pathologist role is to conduct tests to determine where functioning may be affected both informally and formally, allowing for individualised treatment plans involving exercise to improve attention, memory, problem solving and so on. When working with Aphasia, a speech pathologists role includes the treatment of word retrieval exercises, sentence formulation, and following auditory or written directions all dependent on the type of stroke induced aphasia. Lastly, a speech pathologist role in dysphagia may be to work on oral, pharyngeal, or esophageal phases of swallowing to minimise risks of aspiration and associated complications.

Quiz
Choose the correct answers and click "Submit": {What are the impairments that can arise post stroke? - Aphasia - Dysarthria - Cognitive-communication Disorder + all of the above
 * type=""}

{What does a Speech Pathologist do for a stroke victim? - Teach them English - Improve sensory and motor abilities that have been damaged + Regain and strengthen their ability to communicate - Assess patients to determine their nutritional requirements to develop individual treatment plans
 * type=""}

Some aspects of life after stroke include:

 * Resuming work: Some people experience fatigue and tiredness after a stroke and have difficulty carrying out any kind of physical activity for any length of time. Part-time work at least in the early stages may be a good idea. Unless the stroke has reduced awareness of impairment, it is probable that the person who had the stroke is the best judge of when to return to work.
 * Driving: someone who appears to have made a full recovery after stroke should not drive a car for at least a month as the risk of another stroke is greatest at this time. To drive again involves being cleared by the doctor.
 * Sports and exercise: Resumption of physical activity and hobbies is an important part of rehabilitation- normal activity should be resumed as soon as physically possible.

Help and treatment from family, partners and friends
People with stroke may have trouble with many activities that were easy before such as walking, talking, and taking care of daily activities such as bathing, dressing, eating and using the toilet. This is a very frightening and confusing time for the post-stroke patient, their partner, their family, and friends.

Family/caregivers:

 * Family members play an important role for people who had a stroke that can help keep the patient well informed about their treatment and help to communicate their needs and ideas. A stroke is always stressful for the family. Much time may be required to meet the needs of a stroke survivor. Therefore, caregivers need as much support as possible from others. Working together eases the stress on everyone.

As a family member, you can help by:

 * Support the stroke survivor efforts to participate in rehabilitation decisions or to visit allied health professionals such as a physical therapist, occupational therapist, psychologist or a speech pathologist.
 * Be informed. Participate in education offered for stroke survivors and their families. Attend some of the rehabilitation sessions. This allows the family to learn how rehabilitation works and how to help.
 * Find out the stroke survivors strengths and limitations. This allows family members to adjust on doing things for them as it allows a stroke survivor to do the things they can do without help, letting their ability and confidence to grow.
 * Visit and talk with the stroke survivor in their home or rehabilitation facility.

StrokeLine’s health professionals provide information, advice, support and referral.
StrokeLine’s practical and confidential advice will help you manage your health better and live well.

National Stroke Foundation
The National Stroke Foundation is a not-for-profit organization that works with the public, government, health professionals, patients, carers and stroke survivors to reduce the impact of stroke on the Australian community. Information about stroke is available on the web site, and information kits about stroke can be ordered by telephone.

Join Australia’s largest stroke community for information and support.
EnableMe: stronger after stroke

To find a speech pathologist
Speech Pathology Australia

Australian Aphasia Association

ACT - Stroke Association of ACT

NSW - Stroke Recovery Association of NSW