Stroke Prevention, Management, And Rehabilitation In India: A Critical Study

Understanding Stroke: Symptoms, Causes, and Classification

Stroke is a chronic medical condition that is developed due to an interruption r reduction of flow of blood into the brain. This term can simply explained as a brain attack, where brain tissues are deprived of oxygen and nutrition and starts to dysfunction or die. With the death of brain cells the controls of mechanism related to that parts stops completely resulting severe conditions to the patient. This is a chronic medical emergency and should be treated immediately. Nearly 800,000 people all over the world are the victim of this chronic medical conditions (Teasell et al., 2012). However, with advances of medical treatment almost 80 percent of the strokes can be prevented now-a-days.

The incidents of strokes, a chronic medical condition, in India is a developing problem and it is much higher that the western countries. It is the major cause of life losses, losses of speech and limbs of human body in India. According the data of Indian Council of Medical Research approximately 930,000 cases of strokes happen each year and among them almost 640,000 people dies. To prevent this condition, national guidelines for stroke conditions have been published in accordance with top medical organisations and doctors.

Purpose of the study is to understand the condition of the chronic disease and prepare an action plan for prevention, management and rehabilitation by drawing S.M.A.R.T. objectives. The aims and objectives are to be critically examined to develop the action plan.

Practically the aim of this discussion is to develop a plan for prevention, management and rehabilitation of strokes in India. To do that firstly it is required to understand the chronic condition of stroke and its effects on the population of India.

The clinical definition World Health Organisation of stoke is the rapid growth of the symptoms of focal neurological disturbance that lasts for more than 24 hours or lead a patient to death with only reasons associated with vascular origin. It is the medical condition, which cuts of the supply of blood to the brain or creates an interruption. Without the proper supply of oxygen and nutrients brain cells start to die almost immediately. This cause the end of body mechanisms those are being controlled by the brain (Baumann & Dang, 2012). There are some signs or symptoms those are able to help to predict of stroke condition of human. These signs are trouble in sudden trouble in speaking and understanding, paralysis of limbs or face, troubles in seeing or walking, headaches and some other. According to its pathophysiology the syndrome can be divided into two broad categories which are discussed below.

Stroke in India: An Overview

Ischaemic stroke is the first kind of stroke where sudden occlusions are happened to the arteries those supply blood to the brain. The cause behind it is the development of a thrombus at the occlusion site or somewhere in the path of the circulation (Vestbo et al., 2013). Almost 50% to 85% of the strokes occur due to this reason. Death rates due to this stroke is relatively low.

Haemorrhagic strokes are the second category of strokes. Here the major reason behind the stroke is the bleeding that occurs in an artery of the brain into the brain tissue, which is medically termed as subarachnoid haemorrhage or the bleeding of arteries in the special gaps of meninges, which is medically termed as intra-cerebral haemorrhage (McAllister et al., 2012). Death rate in this case is relatively high.

Reliable estimation or quantification of mortality and morbidity in India due to stroke cases are limited. The reasons behind this are the incompleteness in death certification, lack of public awareness, unpredictability in etiologic in unexpected death cases and wrong classification of death causes. Although in 1998, a system had been introduce in India for keeping the records of proper causes of death, approximately 14% of the total deaths in the country are being classified (Gourie-Devi, 2014).

According to the researches of Indian Council of Medical Research41% of deaths and approximately 72% of disabilities among the non-communicable diseases are occurred due to strokes (Prabhakaran & Chong, 2014). An estimation of Indian National Commission of Macro-Economics has suggested the increase of number of strokes will be 1,667,372 in the year of 2015 form 1,081,480 in the year of 2000.

Specific- The goal is to reduce the risk of stroke as a chronic disease in India. This can be done by recognising the symptoms of stroke such as temporary weakness or permanent paralysis of one part of the body.

Measurable- To evaluate if the goal of reducing the stroke factor can is met or not will be possible by conducting a survey in the clinics and hospitals and collecting quantitative data.

Achievable- The goal will be achievable only if proper awareness is created among the people about the terrible consequences of stroke.

Relevant- The goal should tally with the measures taken to reduce stroke condition.

Timely- It should be ensured that the targeted goal is attained in the specific time period.  

Primary prevention objectives are associated behaviour modification. Generally treatment is started after an attack off stroke. However, much behavioural modification can prevent this condition from happening. These modifications are reduction in alcohol drinking and smoking, different pattern of salt consumption, enhanced physical activity and some others (Lennon, McKenna & Jones, 2013). Even after attacks these modifications can help a person to regain his or her natural lifestyle. Modifications like increased consumption for vegetables and fruits help a patient to recover from his or her condition. According to the researches this practices in each day reduce the probability of strokes by 6%.

SMART Objectives for Stroke Prevention, Management, and Rehabilitation in India

The objective is associated with educating and mobilizing the management teams for a follow- up of medical care after the patients leave the hospital. The stroke recovery resources are related to the reduction in blood pressure for preventing another stroke attack. Blood pressure can be controlled by putting restriction on salt and fatty foods which will reduce weight. It is recommended for the patients to eat more fruits and vegetables. Along with the control on diet the patients should be involved in regular physical activity such as riding bicycle and light walking which should be done for a minimum of 30 minutes five times a week. With the modification in lifestyle such as cigarette smoking or taking oral contraceptives should be avoided for reducing the stroke factor.

Third SMART objective is associated with rehabilitation. Tertiary prevention objective is majorly helpful for the persons who have faced recent strokes. The major goal of this plan is to maintain the daily necessary activities for the patients so they can become physically fit to live daily life after suffering a stroke attack. The rehabilitation process must be started as soon as the patient is seemed to be fit for the activities and should be continued as long as it takes for the patient to be clinically fit (Rohde, Worrall & Le Dorze, 2013). This rehabilitation process can be processed by specific treatment settings provided at appropriate healthcare centres or at home, along with the expertise of an experienced medical practitioner (Janssen et al., 2014). According to many surveys, this rehabilitation process has been proved to be the best possible recovery process for a patient. A rehabilitation therapy makes a person able to live his or her life normally and makes him or her more comfortable and independent in daily activities.

This particular portion examines the SMART objectives in accordance with the required perspectives. For prevention, management and rehabilitation of strokes 3 SMART objectives have been planned so far. These objectives are associated with Specific behaviour modifications, Measurable medical treatments and Time- based risk modifications appropriate rehabilitation process.

Primary prevention objective is based on behavioural modifications. In this case, the effectiveness of change in human behaviour, daily activities and habits in case of reducing the chances of strokes in both patients and healthy people (Zaidat et al., 2012). Daily exercise keeps one healthy and maintains proper body weight by balancing the calories absorbed in a day. Reducing alcohol and smoking substantially reduces the harmful effects of alcohol and tobacco on health. High among salt consumption increases the blood pressure among people and that is a probable cause for strokes (Menon et al., 2014). Therefore salt consumption has to be controlled. In order to maintain a healthy diet, fruits and vegetables needs to be eaten regularly as they provide sufficient amount of fibre, minerals and vitamins. They also deliver low amount of calories. Eating of grain foods helps in control of blood cholesterol and eating of fish reduces the probability of arterial diseases. Factors like relevance, availability and measurement can be clearly understood from this discussion and the time limit for this objective is lifelong (Schulman?Green et al., 2012).

Primary Prevention Objective: Behavioural Modifications

Secondary prevention objective is related with medical treatment and risk modification factors oriented with strokes. For management and prevention, this is the most important objective. For proper medical treatment, early recognition of stroke is very important. A major reason of increasing number of deaths due to this chronic syndrome is the unawareness of patients and their families. Constantly neglecting the risk factors, involvement of organs and sigs of strokes provides the time for the syndrome to reach to a critical position. To recognise stroke symptoms different diagnostics have been done according to the direction of a qualified medical practitioner. These diagnostics include blood tests, CT scan, cerebral angiogram, Echocardiogram, Magnetic resonance imaging and Carotid Ultrasound (Liebeskind et al., 2014). These are specific diagnostics to reveal the condition of the patient. These determine blood clotting, current condition of blood flow into the brain, functionality of arteries, images of heart and others.

Following the diagnostics, category of the strokes has been identified and treatment begins. For Ischemic strokes, to quickly restore the blood flow medicines like Aspirins and TPA are given instantly. For emergency conditions Carotid endarterectomy and Angioplasty and stents are applied by a surgeon (Nuño et al., 2012). In India, due to the factors like high cost of the treatment and time delay in hospital formalities, a very few cases have been accounted to have thrombolytic therapy, that is rTPA applied to acute Ischemic stroke cases. Most of the time it has been done before checking the coagulation profile of the patient. In case of Haemorrhagic strokes, control of internal bleeding and reduction of the pressure on brain have been given priority. As an emergency measure transfusion of blood products is provided with warfarin or anti-platelet drugs (Bonner et al., 2016). After the stop of bleeding, different surgical processes are recommended like surgical clipping, Surgical AVM removal, Stereotactic radio surgery and intracranial bypass. These procedures are the part of surgical blood vessel repair that is to repair the abnormalities present in the blood vessels that leads to haemorrhagic strokes. This is also a part of SMART objective, as treatment has a time boundary and condition specific. The availability at reasonable cost can be a matter of question for some cases.

Tertiary prevention objective represents the rehabilitation process for the stroke affected patients. After the completion of medical treatment, to get back to the normal life as good as possible, a person needs to recover ad regain the strength. Depending on the sectors of brain which have been affected by strokes the damages occur in the body parts. Depending on those, a medical practitioner recommends therapy for recovery and rehabilitation. The severity of the stroke decides the options for rehabilitations. There are several options like inpatient therapy in rehabilitation unit in a healthcare centre, a therapy in sub acute care unit, home therapy, outpatient therapy and a long term skilled nursing care. Long term rehabilitation brings back the impendence of activities for any patient as good as possible. A patient regains some or most of his or her basic skills during this rehabilitation (Mendis, 2013). Several professionals can be included in this rehabilitation process. They are Neurologists, Physiatrists, Physical Therapists, Rehabilitation Nurse, Occupational Therapists, Dietician, Neuropsychologists, Recreation Therapists and some others (Oldenburg et al., 2015). However, in India this rehabilitation process is not easily available to most of the people. From various surveys it has been noticed that only 50% of the population receive immediate recovery treatments and the case is worse in the rural areas. Women do not receive the treatment as men do in some places. 31% of daily support and 47% of speech recovery processes have been recorded in the rural areas. This is the last SMART objective and all the categories of a SMART objective is present here, though according to the current situation this objective is a tough one to implement worldwide.

Secondary Prevention Objective: Medical Treatment and Risk Modification

Aim: To reduce the effect of chronic medical condition of strokes in India
Objective	Strategy	Actions	Outcome Measures	Outcome Indicators	By Who?	Timeline
1.Reducing alcohol drinking and smoking.	Communicating with experts to understand the harmful effects of tobacco and alcohol (Ong et al., 2014).	Termination of smoking and reducing drinking of alcohol to a minimum limit.	Improvement of individual health and reduction of effects of tobacco and alcohol.	Reduction in cases of strokes where smoking and drinking are the major problems.	Each and every individuals.	Lifelong
2.Maintaining a healthy diet.	Consulting with a good dietician to develop a balanced diet.	Maintaining the diet with balanced nutrients like substantial food and vegetables, grains and fishes.	Development of health. Maintenance of supply of nutrition in human body and reduction of excessive undesired elements.	Reduction in stroke attacks, even in the rural part of the country.	Dieticians and patients.	Lifelong
3. Follow up of any unnatural symptoms associated with stroke.	Individual and social awareness regarding strokes and its effects.	Regular news reading, following up the articles of doctors and regular check-up (Jauch et al., 2013).	Increase in public awareness.	Increase in regular check-ups, especially in case aged people.	Individual and their families.	Lifelong, specifically at the time of any abnormalities.
4. Immediate medical treatment.	Communicating with professional medical practitioners.	In case of emergency, immediately contacting the doctor who was maintain the check-up. Depending upon the severity of conditions necessary drugs and surgical methods need to be applied.		Proper handling of emergency cases, Reduction in death due to lack of immediate medical treatments.	Doctors and surgeons.	In case of emergency.
5. Presence of appropriate surgical technologies.	Presence and maintenance of different medical instruments those can perform the required surgeries. Also the proper training of the medical staffs assisting in a surgery.	Depending upon the category of stroke, proper surgery has to be applied immediately. In hospitals systems for Echocardiogram, Magnetic resonance imaging, surgical clipping, Surgical AVM removal, Stereotactic radiosurgery needs to be ready all the time.	Increase in surgical efficiency. Staffs are highly qualified insurgery assistance.	Successful treatment of strokes. Effective handling of emergency cases.	Medical practitioners and medical staffs.	In case of emergency.
6. Effective rehabilitation procedure.	Measuring the severity of the case the place of rehabilitation must be chosen. The professionals associated with rehabilitation should also be chosen in accordance with the case.	Therapies like inpatient therapy, home therapy and outpatient therapies must be provided to the patient immediately after primary stage of recovery. Other professionals like , Physical Therapists, Rehabilitation Nurse, Occupational Therapists, Dietician, Neuropsychologists and others needs to be arranged as per requirements.	Quick recovery of the patients who have suffered strokes.	Small time intervals for a patient to recover and get back to normal life.	Neurologists, Physiatrists, Physical Therapists, Rehabilitation Nurse, Occupational Therapists, Dietician, Neuropsychologists, Recreation Therapists and others. Patients are also involved in this.	After the preliminary medical treatment. It will go on as long as the patient gets back to his or her regular life.

Conclusion:

Therefore, the report concludes the severity of the chronic syndrome of strokes, especially in India along with an action plan for prevention, management and rehabilitation. Stroke is becoming one of the fundamental epidemics all around the world especially in India. Like a chronic disease, stroke can be treated with various style of reasonable generic drugs and some necessary modification in lifestyle. Different organised healthcare models for stroke are present in the developed countries. However, the preliminary systems of health care and acute services of stroke cares are the fundamental procedures that prevent or treat the stroke.

The innovative care initiative of WHO for India focuses on the mobility of resources through local communities. In recent years India has developed a good number of national policies for several chronic diseases including strokes which are effective. However, still some barriers remain in the path of development and implementation of the policies. The main challenge is to develop the public awareness and thus the objective of prevention, management and rehabilitation of stoke can be successful.

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