Tuesday 16 April 2013

Andrew Marr's "exercise induced stroke" ...What have we to learn?

Andrew Marr; a case of exercise induced stroke?

Well-known political commentator Andrew Marr, recently told the story of his sudden stroke. It seems that Marr was of the belief that his stroke was ‘exercise induced’ … alarming news indeed, so alarming that the topic made the Jeremy Vine show on Radio 2! So how did he come to that conclusion I hear you ask? Marr explained that he had suffered two 'mini-strokes' – or transient ischaemic attacks – the year before, but that he "hadn't noticed" (presumably revealed by subsequent scans). He went on to make the suggestion that his stroke was triggered by a vigorous rowing machine exercise bout, that he was undergoing in response to newspaper reports relating to the benefit of high intensity training (HIT).........

Carotid artery dissection

So what happened? Well all we can say, is that Marr reported how he felt the symptoms of his stroke (“blinding head ache and flashes of light”) following the exercise where he said he "gave it everything I had" in the belief that this would benefit his health. He described how he had “torn the carotid artery, which takes the blood supply to the brain”. In other words he had suffered an arterial dissection with embolisation. He woke the next morning with what was essentially an ischaemic stroke........

NHS response

There has been much commentary since the interview and the NHS have been quick to respond and reassure patients in a factual way. Is-exercise-to-blame-for-Andrew-Marrs-stroke?

.......... Indeed, some ‘experts’ have made the suggestion that there may not have been a link between the two events. Marr had explained some of his life style risk factors such as his high-pressure job, previous smoking and a history of being overweight. So it is of course plausible that his carotid arteries were already showing signs of atherosclerotic pathology. Was there a link? Well it is impossible to say for sure, but stroke sufferers commonly report headache, neck pain and visual disturbances as their primary symptoms and this is well documented in the literature........

IFOMPT guidance on risk

The significance of this event to physiotherapists is multifactorial. As prescribers of exercise we have to have an understanding of what happened and be able to risk assess and advise patients accordingly. It illustrates also that we must consider the holistic health of patients too as part of a risk assessment strategy and this is supported by the recent IFOMPT cervical spine document. 

Cranial nerve examination?

Indeed it is feasible for such a patient (pre-ischaemia) to walk into a physiotherapy out patient department seeking treatment for their “head ache” (Marr had a window between the onset of his symptoms and his eventual stroke).  Only careful consideration of their symptoms and physical examination, to include blood pressure and cranial nerve testing, may reveal the true nature of the underlying pathology. 

Remember the acronym FAST (face, arms, speech, time – full details on the NHS website) and don’t forget to include the cranial nerves in your examination.

So, is HIT harmful?

Well the jury remains out on that one, though the balance of evidence suggests not. Whilst it would be bad science to use a single case study to promote a knee jerk reaction, Marr’s experience certainly raises the debate and once again raises the spectre of heterogeneity. 

The key message

If those commentators are right; and this was simply a stroke that was 'waiting to happen'. Then you truly never know, quite who or what might be lying on your treatment table ... Happy risk assessment! 

The author  

..... has written over 20 peer reviewed papers relating to blood flow issues related to manual therapy, his work has been cited in the IFOMPT International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention

Altered haemodynamics

Follow on twitter@TaylorAlanJ

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