by Dr Elwood I L Fox, DO
According to the Centres for Disease Control, in 2020, stroke was the fifth leading cause of death in the US. Worldwide, World Health Organisation data from 2019 showed stroke as the second leading cause of death behind ischemic heart disease.
Based on my involvement as consultant physiatrist at BHB for over ten years, there is anecdotal evidence of five to 10 stroke patients per week treated through BHB. Not all are being admitted for acute care. Some receive outpatient services through the Rehab Day Hospital.
Furthermore, it is estimated that there are 250 to 300 strokes per year on island with about five percent never receiving medical or rehabilitation treatment during the acute phase. Data collection is required for recording of stroke deaths annually, and would probably reveal greater than 1,000 stroke survivors on island at present.
Some of the main impairments caused by stroke involve cognition, speech and communication, ability to swallow, movement, activities of daily living (ADLs), bowel and bladder dysfunction, and mood and behaviour.
Secondary diagnoses related to stroke are seizures, dementia, hemiparesis, spasticity, chronic pain and depression. These conditions may be permanent and impact discharge disposition with approximately 25 percent of stroke patients requiring assistance at home or in a long-term care environment.
Based on this critical need to evolve and improve stroke treatment in Bermuda, BHB, as part of a clinical affiliation with Johns Hopkins, started the Primary Stroke Centre in 2019. This April, we received the Stroke Distinction Award from Accreditation Canada.
A stroke happens when an individual develops clinical signs of focal or global disturbances of cerebral function with signs lasting 24 hours or longer, with no apparent cause other than vascular origin. It could lead to death, and therefore must be taken seriously, making evaluation in the emergency room essential.
The goal on presentation is rapid diagnosis to see if the patient is a candidate for thrombolytic treatment. After medical stabilisation, secondary stroke prevention strategy is the priority of medical management along with mitigation against potential post-stroke complications.
Collaboration of care involves the established clinical pathway with coordination between all physicians.
Nursing provides 24-hour care while hospitalised. Usually within 72 hours of admission, a depression screen is carried out, and rehab interventions begin with an initial assessment from allied health services, speech language pathologists, a physical therapist and an occupational therapist.
A dietician also assesses nutritional status, the medical social worker coordinates discharge, and when available, psychology offers counselling. All physicians, nurses, allied health staff and others form part of this multidisciplinary team. Team stroke rounds are held weekly during the first 30 days of admission, with open communication channels amongst all stakeholders being the primary aim to outline both medical and rehabilitation plans of care towards discharge goals. The patient, significant others, and family are integral members of this team approach in rehabilitation. Recreational therapy is limited, being offered on long-term care ward only. There is no vocational rehabilitation on island.
Outpatient therapy programmes such as the Rehab Day Hospital, private therapists or Government community therapists are involved in continued rehab once discharged from the hospital, through referral.
For those discharged from BHB, medical follow-up care is with a GP or through BHB’s Patient Centred Medical Home, with both being vital for continuity of care.
Neurology and physiatry have outpatient clinics, and cardiology may need to follow in setting of documented or suspected cardioembolic etiology for stroke. Other specialists that may be involved post discharge are ophthalmology, optometry, audiology and neuropsychology.
Unfortunately, not all patients survive stroke, and some require palliative care. The clinical support network also includes insurance carriers, overseas acute care hospitals for neurosurgical interventions, and acute rehab hospitals where patients undergo intense stroke rehabilitation overseen by physiatrists in the US Government agencies, charities, church affiliations and community advocates are part of the social support network on island.
The primary goal of stroke rehabilitation is functional restoration by maximizing the independence, lifestyle and dignity of the patient. This approach implies rehabilitative efforts from a physical, behavioural, cognitive, social, vocational, adaptive and educational point of view.
The multidimensional nature of stroke and its consequences make coordinated and combined interdisciplinary team care the most appropriate strategy to treat the stroke patient. It is now well established around the world that stroke rehabilitation is recommended for all stroke patients and should follow the mandate of ‘the sooner, the better potential outcome’, and ‘the longer the maintenance programme, the higher potential to maintain gains achieved’.
Although most recovery occurs within the first three months after stroke, functional gains could still be seen even years later. Neuroplasticity is the ability of the brain to reorganise at any age with the right stimulation in a learning and supportive environment.
Finally, the contribution of social determinants of health on disparities in care are presently being studied to gain insight into better population health strategic planning.
We plan to broaden the use of functional electrical stimulation during stroke rehabilitation, and the new electronic medical record, PEARL, coming on board this October should enhance documentation and ability to do further quality reporting. Future planning may include creation of a formal stroke rehabilitation unit, inclusion of robotic and wireless technology, and virtual reality in both the acute inpatient and outpatient setting.
In physical medicine and rehabilitation research there is some promise in present investigations regarding the use of transcranial magnetic stimulation, biological therapies such as stem cells, and the value of alternative or complementary techniques such as acupuncture.
National awareness of stroke signs and symptoms continues to be an emphasis along with education on medical co-morbidities, age, risk factors and lifestyle modifications that impact stroke recovery and outcome. BHB strives to provide safe, effective, patient-centred, timely, efficient, and equitable care for stroke patients on island. To achieve this objective will require ‘all hands on deck!’
Dr Fox is Bermuda Hospital Board’s Director of Physiatry and Rehabilitative Services. He is Bermuda’s only specialist physician in Physical Medicine and Rehabilitation. He practiced in the US for over 20 years before retiring at the start of the Covid-19 pandemic to pursue an Executive Healthcare MBA, and focus on healthcare reform on island. His areas of expertise are patients with stroke, traumatic brain injury, spinal cord injury, amputation, motor vehicle and work injury recovery, as well as cardiopulmonary and cancer rehabilitation.