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STROKES

STROKES A Discussion and Analysis Of Motor Development Skills and Stroke Patients When assessing the relative literature as well as the plight of stroke patients, one finds that there are many causes or reasons why people fall victim to strokes. Accidents, diet, and old age-related factors are most often identified. Similarly, there exists some consensus as to appropriate treatment or therapy, which of course is dependent upon the individual and actual condition. The risk of stroke in all Americans increases after the age of 45. More often that not, clinicians are predisposed to prevention over treatment. Arteriosclerosis has been identified as a frequent cause of strokes, and certain factors have similarly been identified as exacerbating individual's medication conditions. Diet as well a related factors including smoking tobacco and drinking alcohol are considered culprits in this assessment. Hypertension is a manifestation of systemic disease, and is largely treatable. Stroke risk increases directly with elevation in systolic and diastolic blood pressure in women and men regardless of age. Control of hypertension has convincingly been shown to reduce stroke incidence and mortality, and the effect of blood pressure reduction is at least as great in elderly patients as in younger ones. Recently, a prospective study involving more than 400,000 patients in many countries confirmed that the lower the diastolic blood pressure, the lower the stroke and CAD, even in the normotensive range of 70-80 mm Hg. The hypertension connection is most pronounced in black Americans and in those of Chinese and Japanese origin, but it applied universally. At some point it is wise to evaluate high-risk patients for target organ damage, including hypertensive renal changes and LVH. When implementing risk modification strategy with the stroke patient or the person with long-standing hypertension, however, blood pressure reduction should not be sudden or anti-hypertensive therapy aggressive (Adams, Caplan, Russell, 1990). As indicated, recognition is regarded as the most important area regarding strokes. To a large extent, this emphasis has served to reduce strokes in America. Part of this reason may be due to the aggregate decline of cigarette smoking. At least this was concluded by the Framingham Heart Study, which concluded that risk of stroke was proportionate to the number of cigarettes smokes, and those who smoked more than 40 cigarettes per day was approximately twice that of those smoking fewer than 10 per day. As indicated, stroke may be related to a number of causal factors. Many individuals who have suffered strokes can trace this disorder to brain injury. To this extent, researchers have also emphasized appropriate medical care which assumes this vantage. Example: The transmission of electrical impulses in the brain can be impaired either by damage to blood vessels that supply the nerve cells or by direct damage from injury or disease to the nerve pathways themselves. Restoration of blood flow or of transmission of nerve signals does not always result in restoration of function, however, because brain cells may continue to die due to damage from oxygen-free radicals, substances the body produces in response to trauma. No one knows why these substances are produced, but much research is being devoted to developing drugs that will limit the damage they cause to brain cells following brain injury as a result of external trauma or disease. Upjohn Company of Kalamazoo, MI is testing a class of drugs its calls lazeroids, names after Lazarus, the man raised from the dead in the Biblical story. By blocking the action of oxygen-free radicals, these drugs have already shown promise in restoring muscle function in laboratory animals after nerves are severed. It is hoped they will eventually prove useful in treating brain damaged stroke and accident victims as well as slowing the brain cell damage that occurs in patients with Parkinsonism and Alzheimer's (Medical Update, 1990). This breakthrough represents one of the many innovations or leading edge areas of medical pursuit in the 1990's. As always, a good degree of testing is required, as well as consideration of expense or cost before such application would be widely available. The aforementioned represents one type of potential therapy. Currently, physical therapy is actuated on a wide basis with stroke patients. Inevitably, it is the motor cortex which will be seriously impacted at the time of a stroke. Apraxia is the characterization of such event, that is when one incurs a stroke and the motor cortex is impacted, the result is apraxia or an inability to make purposeful movements. In ideomotor apraxia, simple tasks may be performed, but complicated acts cannot be, because the idea cannot circulate throughout the area of damage, or because the command cannot be remembered long enough (amnestic). In functional apraxia, a patient may recognize an object such as a shoe, but then no longer remember what it is used for. Consequently, the stroke patient's memory is impacted as well as his/her ability to perform basic functions or simple necessities. To a large extent, physical therapy may aid and decrease this deficiency. In fact, I believe it would be fair to state that in the case of most individuals who have received this kind of trauma to their motor cortex, they find the greatest benefit within physical therapy Ñ particularly after the stroke has occurred. Of course, physical therapy is not the only type of therapy, and drugs are ubiquitous in its treatment. At the same time, and as indicated earlier, there are different types of strokes as well as causes. Atrial fibrillation, rapid and disorganized heart beats originating in the upper chambers of the heart, may produce blood clots that cause stroke. There is general agreement that patients with atrial fibrillation and rheumatic valvular disease (obstruction of the mitral valve, which controls blood flow from the left atrium to the left ventricle) should be treated with long-term warfarin (Coumadin) anti-coagulant therapy to prevent stroke. However, treatment of non-rheumatic atrial fibrillation (without accompanying mitral valve stenosis or obstruction) is still controversial. These patients have a risk of stroke five times greater than normal. One report from the Boston Area Anti-coagulation Trial for Atrial Fibrillation (BAATAF) on the efficacy of low-dose warfarin in preventing strokes summarized its results. A total of 420 patients with non-rheumatic atrial fibrillation were divided almost equally into warfarin and control groups. The average age of the participants was 68 years and 72% were men. The controls were allowed to take aspirin, also an anti-coagulant. The results suggest that low-dose warfarin was effective in preventing stroke among these patients during a follow-up period of over two years, and that side-effects, including hemorrhage, were few. There was one death from stroke and one from hemorrhage in each group. Two non-fatal strokes occurred in the warfarin group, compared with thirteen in the control group. Eight of the thirteen controls who suffered non-fatal strokes were taking aspirin, most at a dosage of at least 325 mg per day, supporting the view that aspirin is not useful in preventing stroke in this patient population. Advanced age also increased the risk of stroke. Some of the 19 deaths from cardiac causes may have been due to undiagnosed stroke or hemorrhage, but there were also fewer of these events in the warfarin group (N.E. Journal of Medicine, 1990). In my view, this study as well as related conclusions underscore a number of factors. These factors have to do with the efficacy of some treatment based upon the type of stroke patient as well as the type of risk. Advanced age was cited as one causal factor of stroke risk, and non-rheumatic atrial fibrillation was a primary identifier within this study. It also showed that aspirin is not useful within this patient population. At the same time, the success which aspirin-aided therapy has achieved is thoroughly documented. Indicatively, blood clots exist as an important causal factor within the understanding of the relationship between stroke and the motor cortex of the brain. To this extent, it has even been suggested that aspirin be added to the water supply. As news accounts have stated, one preliminary report applies only to people with atrial fibrillation, an abnormality of the heart's rhythm. In this condition, the atria (the two small chambers of the heart) lose their ability to coordinate their contractions. Instead of squeezing rhythmically to help fill the ventricles, they quiver. Blood clots can form whenever blood flow stagnates. If a bit of clot gets broken off, it will then be carried like a projectile to the brain, where it can cause a stroke. Although atrial fibrillation can develop in young people, it is most commonly a result of arteriosclerosis in the elderly, and becomes an important cause of strokes as people reach their late 70's and 80's. To see whether anti-clotting agents can help this problem, five major studies have been started in the past few years. The focus of the research has been on warfarin which prevents clots from forming when blood stagnates inside a vein. Two studies have also included aspirin, although past experience has suggested that aspirin would not be particularly useful. The first to be reported, in Denmark, found that warfarin was protective, but that a baby aspirin a day had no effect on risk of stroke. Three others involving warfarin are still underway. Until they are completed, the jury remains out on this drug. The case for aspirin is so-far based only on a preliminary report from the "Stroke Prevention in Atrial Fibrillation Study," published in the New England Journal of Medicine on March 22, 1989, pages 861-68. As Daniel Singer, M.D., Director of Clinical Epidemiology in the General Medicine Unit with the Massachusetts General Hospital, and the epidemiologist on one of the ongoing warfarin trials says, "It is a premature extension of these findings to go ahead and recommend aspirin for everyone with atrial fibrillation, let alone for people with normal rhythm. The finding is surprising and so far is an isolated one." (Harvard Medical School Health Letter, 1990). As indicated, according to this study, the jury is still out on the usefulness of aspirin. However, this author is aware of the extent to which aspirin is regarded as not only a useful drug, but an important one and one that is utilized for stroke patients. At the same time, warfarin is also a subject of some debate and, as indicated, this usually rests with the study one refers to as well as the type of stroke and the population involved. There is one area where there remains little controversy or disagreement, however, and this has to do with prevention and early care Ñ particularly with acute stroke victims. Acute stroke can emanate from a wide variety of causes. The results of these may similarly run the gamut from arteriosclerosis and cardiac emboli to inflammatory conditions such as vasculitis, hemoglobinopathies such as Sickle Cell Anemia. For purposes of maximizing the extent of recovery and minimizing the likelihood of repeated stroke, the differential diagnosis must be accurate and the etiologic diagnosis as precise as possible. Current thinking among stroke experts holds that treatment should be directed at a patient's specific pathologic and pathophysiologic problems, not based only a time course or apparent extent of brain damage at early evaluation. Treatment based on time course Ñ when diagnosis is defined in such terms as partial stroke, stroke-in-progress, completed stroke, reversible ischemic neurologic deficit (RIND), and transient ischemic attack (TIA) may be ineffectual or harmful and delay appropriate therapy (Adams, Caplan and Russell, p. 121). As the pervasiveness of drug therapy is so common, there exists an inordinate number of studies on drug and drug-type therapies. It has been found that certain neurotransmitters such as catecholemines and gamma-aminobutyric acids may have a profound effect upon recovery. Additionally, other studies involved animals and have implicated certain anti-hypertensive agents including clonidine and pazosin, benzodiazepines, neuroelectic agents and anti-seizure drugs. One study, the Durham County Stroke Study, is an ongoing prospective study run by Duke Researchers (Duke Univ.). Residents are assessed at admission and at regular intervals thereafter, using the Fugal-Meyer Scale, a standard neurology protocol for measuring sensorimotor function. Dr. Goldstein and his co-workers reviewed the records of the study's 58 participants with "carotid distribution ischemic strokes in at least 30 days of follow-up." (Medical World News, 1990) In the end, some drug therapy has been banned in some places, including Haloperidol. Nevertheless, drug treatment remains an ongoing as well as controversial exercise and no doubt will continue for some time to come. Ultimately, this is a fertile area of research which will most certainly require further research. The primary concern of this research paper is with the relationship between stroke patients and motor development skills. One study which addressed this issue indicated that the functional anatomy of motor recovery was studied by assessing motor function quantitatively in 23 patients following capsular or striatocapsular stroke. While selective basal lesions did not effect voluntary movements of the extremities, lesions of the anterior or posterior limb of the internal capsule lead to an initially severe motor impairment followed by excellent recovery, hand function included. In contrast, lesions of the posterior limb of the internal capsule in combination with damage to lateral thalamus compromised motor outcome. In experimental tracing of the topography of the internal capsule in Macaque monkeys, we found axons of primary motor cortex passing through the middle third of the posterior limb of the internal capsule. Axons of premotor cortex passed through the capsular genu, and those of supplementary motor area through the anterior limb (Wolfgang, et al, 1992). This was an experimental study, replete with experimental and control groups. The authors prefaced their work with the assumption that the central motor system is, in clinical practice, commonly considered to be hierarchically organized, with the primary motor cortex in control of motor limbs, executing its influence via the pyramidal tract. The authors referred to studies which have been performed with monkeys (i.e. Macaque monkeys), upon which the primary conclusions were based. It should be stated that the type of stroke involved within this study concerns itself with capsular. Several mechanisms have been proposed to account for the clinical recovery of neurological function after acute ischemic brain injury. The potential role of ipsilateral cortical efferent pathways in recovery has been most dramatically suggested by the recovery observed in children following surgical hemispherectomy. The authors previously adduced evidence to support this notion. There are further clinical observations that the process of recovery from ischemic injury is associated with profound changes in the functional organization of the brain (Weiller, et al, 1992). The authors identified quantitative changes in regional cerebral blood flow and concluded that recovery from motor stroke due to comparatively small striatocapsular lesions is associated with a complex pattern of functional reorganization of the brain. This portion of the brain is, for the most part, at rest and occurs during performance of a simple motor task. The authors also concluded that it appears that a remarkable reorganization as well as plastic functional changes occur in the human brain after injury. The relationship between patients' stroke and motor development occurs within other and varied contexts. Most commonly, as the layman may relate to, participation in physical activity may serve as precursors of strokes. For example, there exists a number of cross-sectional surveys as well as cohort and case-controlled studies which have pointed to a peripheral interest, but not directly applicable to the relationship between participation in physical activity and stroke patients. According to Powell and Dysinger, there exists a relationship between physical activity and stroke (1992). In the final analysis, there exists specific patterns of activity which underline the relationship between stroke patients and motor development. These include the authors' analysis of data to be considered with any variables that are likely to reflect an association between childhood and adult activity patterns. ReferencesAdams, Harold P. Jr., Louis R. Caplan, and Eric J. Russell. Patient Care. "Early Care in Acute Stroke." Oct. 15, 1990, Vol. 24, p. 121.Adams, Harold P. Jr., Louis R. Caplan, and Eric J. Russell. Patient Care, "Stroke: Recognition and Risk Factors." Aug. 15, 1990, Vol. 24, p. 144.______________. Harvard Medical School Health Letter, "Aspirin and Stroke." May 1990, Vol. 15, p. 1.______________. Medical Update, "New Hope for Stroke and Brain Injury Victims." Dec. 1990, Vol. 13, p. 6.______________. "Helpful Drugs May Hurt in Stroke," Medical World News, March 30, 1990, Vol. 31, p. 11.______________. New England Journal of Medicine, "The Effect of Low-Dose Warfarin on the Risk of Stroke in Patients with Non-Rheumatic Atrial Fibrillation." Nov. 29, 1990, Vol. 323, p. 1505.Powell and Dysinger. American Journal of Preventive Medicine, "Childhood Participation in Organized School Sports and Physical Education and Precursors of Adult Physical Activity," (1992) 3, No. 5.Weiller, Cornelius, M.D., Francois Chollet, M.D., Karl J. Friston, MRC, Psych., Richard J.S. Wise, M.D., and Richard J.F. Frackowyak, M.D. Annals of Neurology, "Functional Reorganization of the Brain in Recovery from Striatocapsular Infarction in Man," 31, No. 5, May 1992, p. 466.Wolfgang, Fries, Adrian Danek, Klaus Scheidtmann, and Christoph Hamburger. American Journal of Physical Medicine, 1992, 48, p. 369. Bibliography: ReferencesAdams, Harold P. Jr., Louis R. Caplan, and Eric J. Russell. Patient Care. "Early Care in Acute Stroke." Oct. 15, 1990, Vol. 24, p. 121.Adams, Harold P. Jr., Louis R. Caplan, and Eric J. Russell. Patient Care, "Stroke: Recognition and Risk Factors." Aug. 15, 1990, Vol. 24, p. 144.______________. Harvard Medical School Health Letter, "Aspirin and Stroke." May 1990, Vol. 15, p. 1.______________. Medical Update, "New Hope for Stroke and Brain Injury Victims." Dec. 1990, Vol. 13, p. 6.______________. "Helpful Drugs May Hurt in Stroke," Medical World News, March 30, 1990, Vol. 31, p. 11.______________. New England Journal of Medicine, "The Effect of Low-Dose Warfarin on the Risk of Stroke in Patients with Non-Rheumatic Atrial Fibrillation." Nov. 29, 1990, Vol. 323, p. 1505.Powell and Dysinger. American Journal of Preventive Medicine, "Childhood Participation in Organized School Sports and Physical Education and Precursors of Adult Physical Activity," (1992) 3, No. 5.Weiller, Cornelius, M.D., Francois Chollet, M.D., Karl J. Friston, MRC, Psych., Richard J.S. Wise, M.D., and Richard J.F. Frackowyak, M.D. Annals of Neurology, "Functional Reorganization of the Brain in Recovery from Striatocapsular Infarction in Man," 31, No. 5, May 1992, p. 466.Wolfgang, Fries, Adrian Danek, Klaus Scheidtmann, and Christoph Hamburger. American Journal of Physical Medicine, 1992, 48, p. 369.

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