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Prompt stroke therapy will cut disease burden

Urgent initiation of preventive treatment after stroke would reduce recurrence

Louise Prime

Friday, 13 May 2011

The huge burden of stroke will continue to rise over the next two decades as populations age, unless greater improvements are made in prevention, warn researchers today in The Lancet. They say that direct costs of treating stroke in the UK alone are about £9m, with “immense” indirect costs resulting from stroke-related dementia, depression, falls fractures and epilepsy.

A second paper in The Lancet points out the large evidence gaps that remain regarding stroke rehabilitation, even though improvements have occurred over the past 20 years.

Professor Peter M. Rothwell from the John Radcliffe Hospital in Oxford and his colleagues say in the first paper that primary prevention of stroke is the most important element of reducing stroke burden. But they stress the importance of secondary prevention, because effective intervention can more than halve the risk of recurrent strokes – which represent about a third of all strokes, and are usually more severe and more likely to result in dementia than the first stroke or transient ischaemic attack (TIA).

They write: “Secondary prevention with antiplatelet agents, antihypertensives, statins and anticoagulation, and carotid endarterectomy as appropriate should be initiated urgently after TIA or minor stroke because of the high risks of early stroke recurrence.”

They say that aspirin plus dipyridamole or clopidogrel are usually recommended as the first-line approach after cerebral ischaemia of arterial origin, which make up about 80% of ischaemic strokes. The other 20% are caused by embolism from atrial fibrillation, for which new treatments such as factor Xa and thrombin inhibitors may take over from vitamin K antagonists as the current standard.

They add that patients who have had either type of ischaemic stroke can lower their risk of recurrence by about 20% by taking drugs to lower lipids and blood pressure.

Professor Peter Langhorne from the Royal Infirmary in Glasgow and colleagues say in the second paper that there is good evidence for the benefits of stroke rehabilitation in well coordinated multi-disciplinary stroke units, which include physiotherapy, and for similar interventions in the patient’s home. They add that occupational therapy can help with activities of daily living.

They point to potential benefits to recovery of the arm’s motor function from constraint-induced movement therapy (which emphasises repeated practice with the affected limb) and robotics; and to improvement in gait with fitness training, high-intensity therapy and task-training. But they say that little good evidence exists on interventions to improve speech.

They say: “Evidence of impairment-focused therapies enhancing true neurological repair in the human brain is still scarce.

“By contrast, strong evidence shows that task-oriented training can assist the natural pattern of functional recovery, which supports the view that functional recovery is driven mainly by adaptive strategies that compensate for impaired body functions.”

They conclude: “Several ongoing trials of repetitive task training, early mobilisation, treadmill training, physical fitness training, and speech and language training for aphasia and dysarthria are high-quality, multicentre, multidisciplinary studies of complex interventions … The results of these trials will hopefully provide better information to guide future practice.”

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