The Indirect Effects of COVID-19 on Stroke Care
Brian Harris, Owen McCarthy, Jennifer Lavanture, and Lauren Steidl
The unfolding COVID-19 pandemic has profoundly affected our way of life by limiting our ability to move, to work, and to interact with others. We are increasingly aware of the toll this takes on mental health and morale at the individual and societal levels. However, largely absent from media coverage and our collective consciousness are the indirect health impacts of COVID-19 on one of our most vulnerable populations: stroke survivors.
There have been significant reductions in stroke mortality in the last 50 years, however, stroke remains a leading cause of disability in the United States and the COVID-19 pandemic is interrupting progress in management of acute stroke recovery (CDC Stroke Facts). Fewer patients are reporting to hospitals with acute strokes, as evidenced by a 39% decrease in stroke imaging since the beginning of the pandemic (Kansagra et al., 2020). An article published in The Neurohospitalist Society last month postulated that “the etiology of this phenomenon is either strict ‘social distancing’ that some people may misperceive to exclude even emergent situations, or fears of contracting the virus while hospitalized” (Rose et al., 2020). While these are legitimate concerns during a pandemic, seeking medical attention immediately during or after a stroke has shown to significantly improve outcomes and save lives. Without early intervention during the acute phase of stroke, stroke survivors are at greater risk of having more severe chronic stroke deficits in the future. These ramifications gave rise to the aphorism “time is brain,” a concept that remains true even as the needs of stroke victims are eclipsed by those suffering from COVID-19. It’s critical that we stay vigilant in our identification and treatment of strokes, as “vast numbers of neurons, synapses, and nerve fibers are irretrievably lost every moment in which treatment does not occur” (Jeffrey L. Saver, 2005).
COVID-19 has also affected the subacute stroke populations by limiting access to facilities and non-emergent care, including rehabilitation. Even when outpatient centers are open, stroke survivors’ access to rehabilitation may remain limited in a practical sense, given that the majority of stroke survivors are also at a higher risk of developing severe COVID-19 illness (CDC). As such, patients may be advised or may choose to avoid clinic-based appointments. Stroke survivors may also forgo treatment due to reliance on caregivers or public transportation to attend visits. Moreover, in-person therapy may be less effective during these times, given that traditional physical therapy interventions often rely on hands-on protocols and therapists are currently attempting to remain at a safe distance as much as possible during their sessions.
Due to the impacts of COVID-19 on acute and subacute stroke care, this pandemic will invariably have downstream effects on the chronic stroke population, both in terms of the size of the population and severity of deficits. In the U.S. alone, 3.3 million, or 47%, of the 7 million stroke survivors suffer from post-stroke walking impairments. The total number of stroke survivors with walking deficits increases each year, as 374 thousand of the 795 thousand new stroke cases involve mobility impairments (American Heart and Stroke Association; CDC Stroke Facts). Chronic stroke walking deficits increase fall risk, reduce quality of life, and significantly lower levels of independence (Batchelor et al., 2012). It is critical, beginning in the subacute phase of recovery, for stroke survivors with mobility deficits to improve their walking function through structured rehabilitation.
Even during normal times, there is no standard of care for treating chronic stroke walking deficits. Those who are more fortunate may be able to afford physical therapy or have the ability to go on walks to improve their walking function, but many chronic stroke survivors with walking deficits are confined to their homes and live sedentary lives. This problem has been exacerbated as a result of orders to quarantine in homes where practicing walking is likely to feel tedious. This sentiment was perfectly captured in the following statement by a stroke survivor named Ken: “Especially during this pandemic, getting outside to breathe some fresh air and feel less isolated is essential to preserving your sense of wellbeing and physical health. However, as a right hemisphere stroke survivor, I often experience motivational challenges in doing so and am looking for solutions to facilitate this and improve my function.”
While it’s important for healthcare systems to implement protocols that mitigate risk of virus transmission and to devote the time, attention, and resources necessary to fighting the pandemic, we can’t overlook the impact of the pandemic on patients without COVID-19. Combatting this pandemic is vital to the state of public health, but doing so should not come at the expense of those who already occupy a vulnerable place in our society. It is incumbent on us as a society to revisit the usual standards of care, to protect caregivers and preserve critical care capacity, and to embrace radical transformation of healthcare systems to maintain delivery of high-quality care. This revolution will necessitate further investment in and adoption of disruptive technologies and systems, including telehealth, remote monitoring, and digital therapeutics.
While we are being asked to quarantine to avoid contracting COVID-19, stroke survivors are unable to quarantine from impairments that are a source of constant struggle. In addition to showing us the importance of encouraging stroke survivors in the acute phase to seek treatment regardless of the state of public health, this pandemic has reminded us that our system for treating chronic stroke survivors is fundamentally flawed. Even after this pandemic, our approach to chronic stroke care will continue to leave this population hung out to dry and forced to come up with their own solutions. This is why we are building MedRhythms and our suite of evidence-based digital therapeutics for gait rehabilitation following neurologic injury and disease, starting with chronic stroke walking impairments. In all times, extraordinary and ordinary alike, stroke survivors at every phase of the recovery process will need and deserve care.