Cerebrovascular event rehabilitation

See also the separate Cerebrovascular Events, Transient Ischaemic Attacks and (Secondary) Stroke Prevention articles.

All people with suspected stroke should be admitted directly to a specialist acute stroke unit. People who have had a suspected transient ischaemic attack (TIA) should be referred immediately for specialist assessment and investigation and should be seen within 24 hours of the onset of symptoms. Scoring systems should not be used to inform urgency of referral - all patients should be referred within this timeframe.¹

While stroke survival is improving, the main burden of stroke is disability - almost 2 in 3 stroke survivors leave hospital with some degree of functional impairment.² Reducing this burden requires optimising stroke prevention and improving acute care but rehabilitation is equally essential.

People with acute stroke should be helped to sit out of bed, stand or walk as soon as their clinical condition permits as part of an active management programme in a specialist stroke unit. However, if they need help to perform these activities, they should not be offered high-intensity mobilisation within the first 24 hours after onset of symptoms.¹

High-intensity mobilisation:¹

• Begins within 24 hours of onset of symptoms.

• Includes at least three more out-of-bed sessions than usual care.

• Focuses on sitting, standing and walking.

Much of the evidence supporting exercise-based programs for stroke secondary prevention is based on participants with ambulatory stroke or TIA. However, many stroke survivors encounter physical and environmental barriers to engaging in regular physical activity for health. For example, neurological weakness, altered perception or balance, or impaired cognition may negate participation in conventional exercises programs. Adaptive equipment and skilled personnel can help to overcome many of these barriers to participation.³

The use of technology promotes repetitive, task-specific training, active engagement of patients, integrating constructive and concurrent feedback, and accurately measuring functional improvement. Technological advances in stroke rehabilitation include exergames, tele-rehabilitation, robotic-assisted systems, virtual and augmented reality, wearable sensors, and smartphone applications.⁴

What is rehabilitation?

Rehabilitation is a complex set of processes, usually involving several professional disciplines and aimed at improving quality of life for people facing daily living difficulties caused by chronic disease.

Rehabilitation starts in hospital but continues after the individual has returned to the community. It is extremely important in terms of making the patient as independent as possible, with enormous implications for the physical and psychological well-being of the person and cost to the community.

Rehabilitation after a cerebrovascular event (CVE) is a multidisciplinary function. It is also important to remember that the disease affects not just the individual but the whole family. Secondary prevention of stroke must not be overlooked.⁵

Cerebrovascular event rehabilitation (epidemiology)⁶

• In the UK, 100,000 people have strokes each year and there are 1.3 million stroke survivors.

• 9 in 10 of these are living at home six months after their stroke and 1 in 4 stroke survivors who return home live alone.

• Stroke patients cared for in specialist units (77% of all people who have a stroke) are more likely to be alive and living independently after one year than those cared for on general wards.

National Institute for Health and Care Excellence guidelines⁷

• A full medical assessment should be undertaken on all people with stroke, including cognition (attention, memory, spatial awareness, apraxia, perception), vision, hearing, tone, strength, sensation and balance. This assessment should take into account:

  • Previous functional abilities.

  • Impairment of psychological functioning: cognition (attention, memory, spatial awareness, apraxia, perception), memory, attention, emotional state and communication (including the ability to understand and follow instructions and to convey needs and wishes).

  • Impairment of physical functioning, including vision and hearing, muscle tone, strength, sensation and balance.

  • Pain.

  • Activity limitations.

  • Social and cultural factors.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. A core multidisciplinary stroke rehabilitation team should include consultant physicians, nurses, physiotherapists, occupational therapists, speech and language therapists, clinical psychologists and social workers.

• Other services that may be needed include continence advice, dietetics, electronic aids (eg, remote controls for doors, lights and heating and communication aids), liaison psychiatry, orthoptics, orthotics, podiatry and wheelchair services.

• On admission to hospital, any person with stroke should be screened and, if problems are identified, management started as soon as possible for the following: orientation, positioning, moving and handling, swallowing, transfers (eg, from bed to chair), pressure area risk, continence, communication, nutritional status and hydration.

• Provide education and support for people with stroke and their families and carers to help them understand the extent and impact of cognitive deficits after stroke, recognising that these may vary over time and in different settings.

Vision

• Use interventions for visual neglect after stroke that focus on the relevant functional tasks, taking into account the underlying impairment:
  

  • Examples include interventions to help people scan to the neglected side (eg, brightly coloured lines or highlighter on the edge of the page), alerting techniques (eg, auditory cues), repetitive task performance (eg, dressing) and altering the perceptual input using prism glasses.

• Refer people with persisting double vision after stroke for a formal orthoptic assessment.

• Offer eye movement therapy to people who have persisting hemianopia after a stroke.

• When advising people with visual problems after stroke about driving, consult the Driver and Vehicle Licensing Agency (DVLA) regulations.⁸

Memory function

Use interventions for memory and cognitive functions after stroke that focus on the relevant functional tasks, taking into account the underlying impairment - eg, external aids (such as diaries, lists, calendars and alarms) and environmental strategies (routines and environmental prompts).

Emotional functioning

• Crying and emotional lability are very common. Patients should be given the opportunity to talk and the social situation should be examined.

• Support and educate people after stroke, and their families and carers, in relation to emotional adjustment to stroke, recognising that psychological needs may change over time and in different settings.

• When new or persisting emotional difficulties are identified at the person's six-month or annual stroke reviews, refer them to appropriate services for detailed assessment and treatment.

• Manage depression or generalised anxiety as indicated. See the separate Depression and Generalised Anxiety Disorder articles.

Swallowing

• All stroke patients should be screened for dysphagia before being given food or drink.

• Offer swallowing therapy at least three times a week to people with dysphagia after stroke who are able to participate, for as long as they continue to make functional gains.

• Ensure that effective mouth care is given in order to decrease the risk of aspiration pneumonia.

• Provide nutrition support to people with dysphagia.

Communication

• See also the separate Dysarthria and Dysphasia article.

• Refer people with suspected communication difficulties after stroke to speech and language therapy, for detailed analysis of speech and language impairments and assessment of their impact.

• Provide opportunities for people with communication difficulties after stroke to have conversation and social enrichment with people who have the training, knowledge, skills and behaviours to support communication. This should be in addition to the opportunities provided by families, carers and friends.

• Speech and language therapists should assess people who have limited functional communication after stroke for their potential to benefit from using a communication aid or other technologies - eg, home-based computer therapies or smartphone applications.

• When persisting communication difficulties are identified at the person's six-month or annual stroke reviews, refer them back to a speech and language therapist.

• Ensure that environmental barriers to communication are minimised for people after stroke - eg, make sure signage is clear and background noise is minimised.

• Make sure that all written information (including that relating to medical conditions and treatment) is adapted for people with aphasia after stroke.

• Offer training in communication skills (eg, slowing down, not interrupting, using communication props, gestures, drawing) to the carers and family of people with aphasia after stroke.

Motor function

• Provide physiotherapy for people who have weakness, sensory disturbance or balance difficulties after stroke that have an effect on function.

• Consider strength training for people with muscle weakness after stroke. This could include progressive strength building through increasing repetitions of body weight activities (eg, sit-to-stand repetitions), weights (eg, progressive resistance exercise), or resistance exercise on machines such as stationary cycles.

• Fitness training: encourage people to participate in physical activity after stroke.

• Cardiorespiratory and resistance training for people with stroke should be started by a physiotherapist with the aim that the person should continue the programme independently, based on the physiotherapist's instructions.

• Offer walking training (treadmill with or without body weight support) to people after stroke who are able to walk, with or without assistance, to help them build endurance and move more quickly.

• Tell people who are participating in fitness activities after stroke about common potential problems, such as shoulder pain, and advise them to seek advice from their GP or therapist if these occur.

• Therapy aids:
  

  • Consider wrist and hand splints in people at risk after stroke - eg, people who have immobile hands due to weakness, and people with high tone.

  • Consider a trial of electrical stimulation in people who have evidence of muscle contraction after stroke but cannot move their arm against resistance.

  • Consider constraint-induced movement therapy for people with stroke who have movement of 20° of wrist extension and 10° of finger extension. Be aware of potential adverse events (such as falls, low mood and fatigue).

  • Offer people repetitive task training after stroke, on a range of tasks for upper limb weakness (eg, reaching, grasping, pointing, moving and manipulating objects in functional tasks) and lower limb weakness (eg, sit-to-stand transfers, walking and using stairs).

  • Consider ankle-foot orthoses for people who have difficulty with swing-phase foot clearance after stroke (eg, tripping and falling) and/or stance-phase control (eg, knee and ankle collapse or knee hyperextension) that affects walking.

  • Functional electrical stimulation may be used to produce muscle contractions that mimic normal voluntary gait movement (lifting the foot and achieving correct placement on the ground) by applying electrical pulses to the common peroneal nerve, either through the skin surface or implanted electrodes.⁹

Pain management

• Provide information for people with stroke and their families and carers on how to prevent pain or trauma to the shoulder if they are at risk of developing shoulder pain - eg, if they have upper limb weakness and spasticity.

• Manage shoulder pain after stroke, using appropriate positioning and other treatments according to each person's need.

• Management of neuropathic pain as indicated.

Self-care

• Provide occupational therapy for people after stroke who are likely to benefit, to address difficulties with personal activities of daily living. Therapy may consist of restorative or compensatory strategies.

• Ensure that appropriate equipment is provided and available for use by people after stroke when they are transferred from hospital, whatever the setting (including care homes).

Return to work

Return-to-work issues should be identified as soon as possible after the person's stroke, reviewed regularly and managed actively.

For management of long-term sickness and incapacity for work, see the separate Long-term Sickness and Incapacity article.

Long-term health and social support

• Inform people after stroke that they can self-refer, usually with the support of a GP or named contact, if they need further stroke rehabilitation services.

• Provide information so that people after stroke are able to recognise the development of complications of stroke, including frequent falls, spasticity, shoulder pain and incontinence.

• Provide information about transport and driving (including DVLA requirements).⁸

• See the separate Urinary Incontinence and Faecal Incontinence articles.

• Review the health and social care needs of people after stroke and the needs of their carers at six months and annually thereafter.

• For guidance on secondary prevention of stroke, see the separate Stroke Prevention article.