Editorial

Introduction

A stroke can have a major impact on many aspects of a person's life. Last month we talked about stroke patients returning home after the hospital, this month we will follow-up on this with an article on returning to work after stroke

Back to work after a Stroke

Although strokes normally affect older people, up to a quarter of all strokes actually occur in people of working age - a time when careers and families are being established. Depending on the severity of the stroke, not all stroke survivors are able to return to full-time employment. There can be many reasons for this:

• Forced to retire by employer
• Unable to meet expectations
• Unable to drive or use public transport
• Fear of losing benefits
• Not fit enough to work
• No longer able to do previous job, face demotion

However, for most of the younger stroke survivors their main objective is getting back to work - not only for financial reasons but also to help to rebuild their confidence, regain their independence and even enhance their recovery. Yet not all of those stroke survivors are able to make the return. Among the ones that don't make it back to work, many might have been able to re insert themselves, if they had been given better support and followed an adequate rehabilitation program.

Rehabilitation helps

Depending largely on the level of the impediments at the acute phase, a stroke can often lead to long disability periods for the stroke survivors, making the possibility of returning to work fade away. Yet, for many, taking the right action can make all the difference. Long term support and appropriate rehabilitation tailored to the needs of the patient, is crucial for stroke survivors aiming to return to work. The patient’s firm will to return to work, can also serve as the motivational factor needed to initiate an intensive rehabilitation process. Physiotherapy, speech and language therapy, and psychological support all work help achieve faster and more complete recovery.

Continuing disability and the patients' ability or not, to independently care for him or herself, is obviously an important determinant of whether it is possible to get back to work. Following and intensive and well tailored rehabilitation program will minimize the likelihood of needing to cope with such a situation. On the other hand, depression is one of the major causes of work failure, and has a significant impact of its own, on work status after a stroke. However – as discussed last month – depression is a separate illness that can be treated successfully if appropriately approached.

Make your employer prepared

The attitude and willingness to help shown by the employer is of major importance and can have direct impact on whether or not a stroke survivor returns to work. It is thus very important to contact the employer as soon as possible following the stroke, to agree on reasonable and necessary adoptions to the working arrangements and conditions to make the return to work as smooth as possible. Too many stroke survivors who go back to work leave soon afterwards because their employers have not made the necessary adaptations, making it impossible for them to fit in and perform at their capacity. There are several measures that you might ask the employers to take so as to help you continue your work:

• Allowing a phased return to work
• Changing working hours
• Part-time work
• Redeployment
• Job sharing
• Providing help with transport to and from work
• Arranging home working

Adaptations to a job or work environment must also be backed with appropriate training and guidance. For example, if a new tool is provided, the stroke survivor will need to receive training on how to use it.

Finally, negative employers – unwilling to make the necessary adoptions – exist, but mustn’t stop the patient. The sufferer should allow him or herself some time and look for new opportunities with employers that understand their situation and show the required flexibility. To consider a career change could also be an option, not forgetting that there is always life after work.

Sources:
Web MD Stroke News
Stroke Organization UK

Pain after Stroke

Pain is a frequent but still poorly studied long term consequence of stroke. Sometimes it can even be a "good" sign, telling that sensation is returning to a previously numb part of the body. In a recent paper, the prevalence and intensity of pain was evaluated. It was found that 4 months after stroke onset, one third of patients were complaining of moderate to severe pain, and that 1 year later, one fifth were still experiencing moderate to severe pain and that the intensity of the severe pain had increased.

The precise cause of post-stroke pain is unknown, although it may be due to a hyperactivity of the autonomic nervous system. Because the brain has been damaged, it feels pain when it should be feeling a sensation that is not painful. One major problem is that painkillers have no effect on this type of pain.

Patients may experience one type of pain or several kinds. The key is to figure out what is causing the pain so that the patient can treat it. There are basically two kinds of pain after stroke:

Central pain is constant, moderate or severe. It tends to be felt in one part of the body, usually an arm or a leg. It is always on the side of the body affected by the stroke. Central pain is produced within the brain as a result of the stroke. It does not stem from damaged nerve endings. Rather, the body sends normal messages to the brain in response to touch, warmth, cold and other stimuli. But the brain does not understand these signals correctly. Instead, it will register even slight sensations on the skin as painful.

To find a way of relief, patients should explain their symptoms to the doctor. Together, they can determine the best treatment. Patients could already try some solutions when at home. A start is to avoid things that can cause pain, such as hot baths, tight or easily bunched clothing, and pressure on the side of the body affected by the stroke. While sitting or lying down, support the paralyzed arm on an armrest or pillow to relieve shoulder pain from the arm’s weight; the same should be done with a sling while walking. At last, patients could use heart packs or simple exercises prescribed by their physical therapist.

What else can help besides asking the doctor? First of all, focus on thoughts or activities that are enjoyable. Patients can and should still be active, productive and have a good quality of life. Relaxation, meditation or hypnosis can also help to manage the pain. Secondly, finding and joining an adequate stroke support group. Other survivors will understand and validate the issues and offer encouragement and ideas for pain relief. At last, speaking honestly and openly with the care giver about the pain issues, who will be glad the patient did so, and together work out the best solution.

Further research will hopefully precisely evaluate the various mechanisms of pain and the impact of medications and non pharmacological treatments. So that pain after stroke will be no longer neglected because of its high prevalence.

Sources:
National Stroke Association
Journal of Neurology, Neurosurgery & Psychiatry