Rehabilitation for patients after stroke
NICE has issued guidance on how to support the long-term rehabilitation and care of people living with stroke
In this article…
- What makes an effective inpatient stroke rehabilitation service
- Assessment and management on admission to hospital
- Collaboration between health and social care professionals
Stroke is a major health problem in the UK with approximately 125,000 people each year in England, Wales and Northern Ireland having a first or recurrent stroke. Most people survive a first stroke but often have significant morbidity. There are currently more than 900,000 people in England living with the effects of stroke.
Since the 1960s, the number of people who survive a stroke has been increasing steadily. This has largely been due to the development of stroke units, thrombolytic “clot-busting” drugs and the reorganisation of stroke services. Despite these improvements, over 30% of stroke survivors will have persisting disability and need effective rehabilitation services.
The National Institute for Health and Care Excellence has developed a clinical guideline on long-term rehabilitation for people who have had a stroke (NICE, 2013). While it does not cover every aspect of rehabilitation in detail, the guideline reviews some of the available interventions that can be used in stroke rehabilitation.
The guideline states that people with disability after stroke should receive rehabilitation in a dedicated stroke inpatient unit. They should also receive follow-up care from a specialist stroke team in the community. An inpatient stroke rehabilitation service should provide access to other services that may be needed, such as continence advice, dietetics, electronic aids (remote controls for doors, lights and heating, and communication aids), liaison psychiatry, orthoptics, podiatry, wheelchair services and a multidisciplinary education programme.
The guideline recommends that inpatient stroke rehabilitation services should be provided by a core multidisciplinary team who have the knowledge, skills and behaviours to work with stroke survivors and their families and carers to manage the changes experienced as a result of a stroke. The team should include nurses, physiotherapists, occupational therapists and speech and language therapists, as well as consultant physicians, clinical psychologists, rehabilitation assistants and social workers.
In order to ensure the immediate safety and comfort of patient with acute stroke, the guideline recommends that the following should be assessed and managed on admission to hospital as quickly as possible:
- Positioning, moving and handling;
- Transfers (for example, from bed to chair);
- Pressure area risk;
- Communication, including the ability to understand and follow instructions and to convey needs and wishes;
- Nutritional status and hydration.
A full medical assessment of the patient should be performed; this should include assessment of cognition (attention, memory, spatial awareness, apraxia, perception), vision, hearing, tone, strength, sensation and balance.
Early supported discharge is highlighted as a key part of a skilled stroke rehabilitation service. The guideline recommends that it should be offered to patients who are able to transfer from bed to chair independently or with assistance, as long as they are being discharged to a safe and secure environment. To that end, the guideline recognises the importance of health and social care professionals working collaboratively to ensure a social care assessment is carried out promptly, where needed, before stroke survivors are transferred from hospital to the community.
NICE also recommends that before transfer from hospital, a health and social care plan is discussed and agreed with the patient and family or carer, and provided to all relevant health and social care professionals.
In addition, the guideline recognises the importance of providing comprehensive information, including a summary of rehabilitation progress and current goals, functional abilities (including communication needs), cognitive and emotional needs and medication needs.
The guideline emphasises the importance of careful multidisciplinary assessment and treatment in stroke rehabilitation, and provides guidance to support the long- term rehabilitation and care of people living with the effects of stroke.
As well as recognising the benefits of a range of stroke rehabilitation interventions that are targeted and relevant to the individual, the guideline also highlights where there are gaps in the evidence to support best practice, and signposts the way for appropriate research projects to address these.
● The guideline is available from the NICE website
Sue Thelwell is stroke services coordinator, University Hospitals Coventry and Warwickshire Trust
National Institute for Health and Care Excellence (2013) Stroke Rehabilitation: Long-term Rehabilitation After Stroke. London: NICE.