Stroke rehabilitation: long-term rehabilitation after stroke

Stroke units

1. People with disability after stroke should receive rehabilitation in a dedicated stroke inpatient unit and subsequently from a specialist stroke team within the community.

The core multidisciplinary stroke team

1. A core multidisciplinary stroke rehabilitation team should comprise the following professionals with expertise in stroke rehabilitation: consultant physicians; nurses, physiotherapists, occupational therapists, speech and language therapists, clinical psychologists, rehabilitation assistants and social workers.

Health and social care interface

1. Health and social care professionals should work collaboratively to ensure a social care assessment is carried out promptly, where needed, before transfer from hospital to the community. The assessment should:

   • identify any ongoing needs of the person and their family or carer, for example, access to benefits, care needs, housing, community participation, return to work, transport and access to voluntary services

   • be documented and all needs recorded in the person's health and social care plan, with a copy provided to the person with stroke.

Transfer of care from hospital to community

Rehabilitation can take place either in hospital or at home. There are potential advantages to rehabilitation at home, including interventions targeted more accurately at need within that environment, enhanced wellbeing and mood for patients and carers, and greater cost-effectiveness. ³ There are also potential disadvantages. High intensity therapy may be more difficult to organise in a community setting.

Free and effective communication and clear lines of accountability between hospital- and community-based services are therefore essential. Standard operating procedures and local protocols are required.

1. Before transfer of care from hospital to home for people with stroke, establish that they have a safe and enabling home environment:

   • check that appropriate equipment and adaptations have been provided and that carers are supported to facilitate independence

   • undertake a home visit with them unless their abilities and needs can be identified in other ways, for example, by demonstrating independence in all self-care activities, including meal preparation, while in the rehabilitation unit.

Early supported discharge is a service which allows transfer of continued rehabilitation at the same level of intensity and expertise from an inpatient to a primary care setting.

1. Offer early supported discharge to those who are able to transfer from bed to chair independently or with assistance, as long as a safe and secure environment can be provided.

2. Hospitals should have systems in place to ensure that:

   • people after stroke and their families and carers (as appropriate): (1) are involved in planning for transfer of care, and carers receive training in care (for example, in moving and handling and helping with dressing) and (2) feel adequately informed, prepared and supported

   • GPs and other appropriate people are informed before transfer of care

   • an agreed health and social care plan is in place, and the person knows who to contact if difficulties arise

   • appropriate equipment (including specialist seating and a wheelchair if needed) is in place at the person's residence, regardless of setting.

3. Documentation should be individualised, and should include the following information as a minimum:

   • basic demographics, including contact details and next of kin

   • diagnosis and relevant medical information

   • list of current medications, including allergies

   • standard screening assessments

   • the person's rehabilitation goals

   • multidisciplinary progress notes

   • a key contact from the stroke rehabilitation team (including their contact details) to coordinate the person's health and social care needs

   • discharge planning information (including accommodation needs, aids and adaptations)

   • joint health and social care plans, if developed

   • follow-up appointments.

Screening and assessment

The generalist should be particularly aware of the following aspects of stroke-related need and ensure they are systematically addressed in tandem with care planning and liaison with the stroke team.

1. On admission to hospital, to ensure the immediate safety and comfort of the person with stroke, screen them for the following and, if problems are identified, start management as soon as possible:

   • orientation

   • positioning, moving and handling

   • swallowing

   • transfers (for example, from bed to chair)

   • pressure area risk

   • continence

   • communication, including the ability to understand and follow instructions and to convey needs and wishes

   • nutritional status and hydration (follow the recommendations in stroke (CG68)⁴ and nutrition support in adults (CG32).⁶

Cognitive functioning

1. Screen people after stroke for cognitive deficits. Where a cognitive deficit is identified, carry out a detailed assessment using valid, reliable and responsive tools before designing a treatment programme.

Emotional functioning

1. Assess emotional functioning in the context of cognitive difficulties in people after stroke. Any intervention chosen should take into consideration the type or complexity of the person's neuropsychological presentation and relevant personal history.

Setting goals for rehabilitation

Consensus, localised effective interdisciplinary communication, involvement of family or carer, and continuity, are all essential to efficient planning and delivery of a tailored rehabilitation programme. Sporadic cross-referral alone is inadequate. The overarching objective is restoration of the fullest possible lifestyle and range of activity, irrespective of age.

1. Ensure that goal setting meetings during stroke rehabilitation are timetabled into the working week

2. Involve the person with stroke and, where appropriate, their family or carer in the discussion.

For younger people with stroke, crucial consideration of employment and career – sometimes inappropriately deferred – should be built into the planning process from the outset.

Return to work

1. Return to work issues should be identified as soon as possible after the person's stroke, reviewed regularly and managed actively. Active management should include:

   • identifying the physical, cognitive, communication and psychological demands of the job (for example, multitasking by answering emails and telephone calls in a busy office)

   • identifying the impacts of any impairments on work performance (for example, physical limitations, anxiety, fatigue preventing attendance for a full day at work, cognitive impairments preventing multitasking and communication deficits)

   • tailoring an intervention (for example, teaching strategies to support multitasking or memory difficulties, teaching the use of voice activated software for people with difficulty typing, and delivery of work simulations)

   • educating about the Equality Act 2010 and support available (for example, an access to work scheme)

   • workplace visits and liaison with employers to establish reasonable accommodations, such as provision of equipment and graded return to work.

Intensity of stroke rehabilitation

1. Offer initially at least 45 minutes of each relevant stroke rehabilitation therapy for a minimum of 5 days per week to those with the ability to participate, and where functional goals can be achieved. If more rehabilitation is needed at a later stage, tailor the intensity to the person's needs at that time.

Swallowing

1. Offer swallowing therapy at least 3 times a week to those with dysphagia able to participate, for as long as they continue to make functional gains. Swallowing therapy could include compensatory strategies, exercises and postural advice.