A long yet important journey
A STROKE can happen to anyone regardless of age and ethnic background, but people are especially vulnerable once they hit the age of 55. Rather alarmingly, there is a high prevalence of stroke in Malaysia. The National Stroke Registry stated that a total of 11,284 stroke cases were reported from 2009 to 2016.
The public needs to be better aware of the effects of stroke as more often than not, a stroke can leave an individual with longterm disability. It can bring about serious impairment to a person’s language, cognition, motor and sensory skills. It is for this reason that continuous rehabilitation is the only way forward for many stroke survivors.
Recovery should start early
Andrew Reggie, head of Rehabilitative Services at ParkCity Medical Centre, says it is crucial to start the stroke rehabilitation process as early as possible because it can increase the survivors’ chances of regaining brain and body functions affected by stroke. He says, “Rehabilitation often starts while the patient is still in the intensive care unit. The therapist usually starts rehabilitation with chest physiotherapy (for airway clearance), positioning, as well as passive range of motion exercises. During this time, the patient may still be unconscious and receiving oxygen support.”
It is a known fact that no two cases of stroke are exactly the same. As such, the rehabilitation programme would have to be tailored accordingly to suit the stroke survivor. Andrew says patients will go through numerous assessments to determine the type of rehabilitation they would need to undergo. He explains, “There are so many aspects to look at before a complete plan can be finalised. First, we need to look at their respiratory function and see if they require oxygen support before they start the exercises. Apart from that, we also look at the muscle power, as well as the muscle tone of the limbs and trunk. Assessments are based on outcome measures that are widely used globally.”
He adds that a sensory assessment will be done on stroke survivors to look at whether they are able to feel touch, pressure and pain. Patients’ mobility functions will also be examined along with other checks, such as seeing if patients can turn on their side while lying down, sit down and stand unassisted, and how well they can balance themselves. The patients’ road to recovery goes beyond the hospital walls. A home environment assessment is performed to identify possible physical barriers, and recommendations are then made to support their independence.
According to Andrew, the goal of rehabilitation is to improve or restore survivors’ affected skills so that they can be as independent as possible. So, when formulating a rehabilitation plan for stroke survivors, a combination of several disciplines – such as physiotherapy, occupational therapy, speech therapy, as well as psychological support – is important in order to make sure that the survivors are able to return to the same routines they used to do before the stroke.
A balanced diet is essential
While rehabilitation is a key factor in the recovery of stroke survivors, their diet also plays an important role. Having a wellbalanced diet can help to reduce the risk of another stroke. ParkCity Medical Centre chief dietitian Bee See Wei says the most common challenge a stroke survivor would face is a poor appetite. “Patients usually have difficulty in moving their jaw muscles as they are sensitive to pain, hence the poor appetite.”
Bee adds that many stroke survivors would suffer from malnutrition because of this. It has been reported that stroke patients have an increased malnutrition rate from 16% at admission, to 22%-35% after two weeks in the ward. This condition worsens once patients are discharged and return home – mainly due to sup-optimal nutrition care and, usually, a diet plan that is not tailored to individual needs.
It has been estimated about 29% to 64% of stroke patients would experience dysphagia. Dysphagia is the medical term for the symptom of difficulty in swallowing drinks and food. There are two most common dietary interventions for stroke patients with dysphagia: 1) A texture modified diet where a swallowing test would be done by a speech therapist to determine the types of drinks and consistency of food that are suitable to be taken orally by stroke patients; 2) Feeding via an enteral feeding tube for patients who are unable to eat and drink orally, and are of high risk for aspiration. They need to be fed using an enteral feeding tube until they are able to swallow normally – some severe stroke patients might need enteral nutrition support via tubes permanently. A dietitian will devise a special meal plan that consists of more food items that are easy to consume based on their texture. The food amount and nutritional value are among the other considerations too.
Alternative meals
Bee shares that in order to encourage stroke survivors to eat, a dietitian may have to come up with various strategies to make dining a more enjoyable experience. The most common strategy would be to make the food as colourful as possible. “This can actually help the patient to feel like they are eating just like a non-stroke patient. Other than that, dietitians will also design a meal plan that is closest to the patient’s preferences,” she explains. Other strategies include introducing patients to the idea of consuming smaller and more frequent meals instead of one big meal.
While a balanced diet is always advised, Bee notes that the biggest difference in a stroke survivor’s dietary plan depends on any pre-existing health conditions the patient is living with such as diabetes, hypertension or high cholesterol. In such cases, there are obviously varying ingredients that have to either be reduced, or avoided. She says, “If stroke survivors are diabetic, we would suggest them to reduce the intake of refined sugars, choose more complex carbohydrates and consume fruits in correct portions. If they have high cholesterol, then perhaps they can look into reducing foods that are high in saturated fats and replace them with foods that are high in polyunsaturated or monounsaturated fatty acids. They could also consume low-fat dairy products, besides replacing butter, ghee and lard with products based on vegetable and plant oils. Moreover, it is good to limit red meat intake, especially fatty cuts and processed forms.”
She acknowledges, “There will always be patients who feel hesitant or reluctant whenever a dietitian suggests alternative meals. However, it is the dietitian’s duty to provide these patients with a wide variety of options until they accept one.”
From limitations in executing daily tasks, to having to eat an entirely new diet, the road to recovery can become very stressful for stroke survivors. It is a change of lifestyle for them, as well as their caregivers. Dietitians offer a personalised diet consultation for both inpatients and outpatients in accordance to the latest evidence-based medical nutrition therapy in providing dietary interventions to stroke patients and survivors, together with other lifestyle modifications such as smoking cessation, increased physical activity and reduced alcohol intake. People have to understand that due to such challenges, perseverance and patience is key when it comes to recovery.