Physical Rehabilitation and the National Stroke Guidelines, 2017, EXPLAINED!
May 6, 2018 Matt Smith
The latest edition of the National Stroke Guidelines were released last year and I would like to take the time to provide some interesting information that may help stroke survivors and their families to make informed choices with regards to how a physiotherapist may be able to assist you to optimise your function, particularly after leaving hospital. The full guidelines are available here if you would like more information.
Early Supported Discharge
The Guidelines state the following: there is a strong recommendation that patients with mild to moderate disability should be offered early supported discharges services to assist them in returning home as soon as possible after stroke. Stroke survivors in the early supported discharge programs generally stay in hospital for a significantly shorter period than those patients not in an early supported discharge program. The length of the hospital stay for those in the early supported discharge program was approximately seven days. People who undergo early supported discharge ware less likely to be admitted to a nursing home or to have passed away within 5 years post-stroke. However, we must remember that only patients with a mild to moderate stroke should be considered for early supported discharge, so they are less likely to end up in nursing home care or to pass away within the first five years post stroke compared to patients who have suffered from a more disabling stroke.
Home-Based Rehabilitation
The Guidelines state that there is a weak recommendation that home-based rehabilitation should be the preferred model for stroke patients to rehabilitate in the community. If patients are unable to undergo home-based rehabilitation, then centre-based rehabilitation care is preferred.
Goal setting is a very important part of stroke recovery, and the Guidelines strongly recommend that this occurs in conjunction with the health professionals involved in the patient’s care, the patient and their family. The goals should be specific to the patient and their needs and lifestyle, and should be clearly communicated and documented so that everyone knows the aim of treatment. We often use SMART goals when planning the treatment approach with our patients. This stands for Specific, Measurable, Attainable, Relevant and Timely. This will be discussed in more detail with your physiotherapist at your first (and subsequent) appointment/s.
Stroke patients with weakness in their arms and/or legs should undergo a strength training program. In addition to this, some patients with severe weakness may benefit from electrical stimulation to help some of the very weak muscles to start working again. Physiotherapists can assess the stroke patient and provide a safe and appropriate strength training program to encourage optimal muscle strength return after stroke. This program should be updated regularly to ensure that the muscles continue to work correctly and adequately for a strength gain to be seen and to allow the patient to use such gains in a practical way, i.e. in conjunction with a functional training program where specifically difficult tasks are practiced around the home.
Amount of Rehabilitation
Stroke patients need to do as much scheduled therapy as possible in order to improve their physical and mental functioning as much as possible. The Guidelines recommend a minimum of three hours of therapy per day. Group circuit classes are another great way to increase the amount of therapy time that a stroke patient can participate in. Individual exercise programs should also be practiced by the patient in their own time, and guided and updated by the treating physiotherapist. Sometimes, this may include the help and/or supervision of family and friends, or it may involve the patient working on specific tasks and movements independently. This can be discussed with your physiotherapist and will depend on your specific presentation and what you can safely do as you recover.
All stroke survivors should begin cardiorespiratory training while they are an inpatient at the hospital, and this should continue over the long term after discharge. The type of activity will depend on the severity of the stroke and appropriate fitness training can be discussed with your physiotherapist. Task-specific training is very important and includes such things as sitting balance, moving around in bed, getting in and out of bed, standing balance, stepping, walking, moving between a bed and chair (transfers), getting in and out of a car or on and off a bus. These daily tasks can all be assessed and (often) retrained with an experienced physiotherapist.
Arm Therapy
There is a strong recommendation that stroke survivors with some ability to straighten their fingers and wrist should undergo intensive constraint-induced movement therapy. This involves the good hand being restrained and not used to force the bad side to do the work. Scheduled constraint-induced movement therapy should occur for a minimum of 2 hours per day for 2 weeks, with the good hand being restrained for a total of at least 6 hours per day. This forces the patient to practice functional tasks and movements with the weak hand and further reactivates the damaged pathways in the brain that can only be fired up again by lots of practice. Other modalities for which there is a weak recommendation include robotics, electrical stimulation, mental practice and mirror therapy and these can all be discussed with your physiotherapist if you would like more information.
People who are living in the community post-stroke and are having trouble with everyday tasks should be assessed by a physiotherapist and provided with a rehabilitation program that includes practice of the difficult tasks. This may require some of the difficult tasks to be problem-solved and modified, so please talk to your physiotherapist to help you find the solutions you need to make your life a little easier.