In general, successful stroke rehabilitation depends on:.
The rate of recovery is generally greatest in the weeks and months after a stroke. However, there is evidence that performance can improve even 12 to 18 months after a stroke. Recovering from a stroke can be a long and frustrating experience. It's normal to face difficulties along the way.
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This content does not have an English version. This content does not have an Arabic version. What to expect as you recover. Free E-newsletter Subscribe to Housecall Our general interest e-newsletter keeps you up to date on a wide variety of health topics. What to expect as you recover Stroke rehabilitation is an important part of recovery after stroke.
By Mayo Clinic Staff. References Daroff RB, et al. Bradley's Neurology in Clinical Practice. Accessed March 28, Bope ET, et al. Conn's Current Therapy Mayo Foundation for Medical Education and Research; Fu MJ, et al. Stroke rehabilitation using virtual environments. Cunningham DA, et al. Tailoring brain stimulation to the nature of rehabilitative therapies in stroke. Accessed April 24, National Institute of Neurological Disorders and Stroke.
Life After Stroke
Overview of geriatric rehabilitation: Program components and settings for rehabilitation. Patient assessment and common indications for rehabilitation. Schultz BA expert opinion. Stroke is a leading cause of serious, long-term disability, the effects of which may be prolonged with physical, emotional, social, and financial consequences not only for those affected but also for their family and friends.
Evidence for the effectiveness of stroke unit care and the benefits of thrombolysis have transformed treatment for people after stroke. Previously viewed nihilistically, stroke is now seen as a medical emergency with clear evidence-based care pathways from hospital admission to discharge. However, stroke remains a complex clinical condition that requires health professionals to work together to bring to bear their collective knowledge and specialist skills for the benefit of stroke survivors. Multidisciplinary team working is regarded as fundamental to delivering effective care across the stroke pathway.
This paper discusses the contribution of team working in improving recovery at key points in the post-stroke pathway.
Recovery and support
Despite advances in identification and reduction of risk, stroke remains a major illness. Annually, 17 million people worldwide suffer a stroke. Of these, 5 million die and another 5 million are left permanently disabled, placing a burden on family and community. The burden of stroke is considerable at a population, societal, and individual level.
Post-stroke hospitalization rates are significantly higher than for a matched non-stroke cohort. However, despite these advances, longer term outcome remains poor for many, 11 — 13 with unmet needs common. Many stroke survivors require assistance from informal caregivers, often family members, for activities of daily living, including bathing, dressing, and toileting. The evidence on which this paper draws is primarily of that presented in Cochrane and other systematic reviews published since and, where appropriate, evidence from quantitative and qualitative studies relevant to improving post-stroke recovery.
The paper comments on contributions made by multidisciplinary teams MDTs in providing evidence-based care to improve post-stroke recovery. Individual responses to and recovery from neurological injury following stroke are complex and variable. This requires health professionals to work collaboratively to bring to bear their collective knowledge and specialist skills for the benefit of stroke survivors. In the discussion that follows, we first outline differences between multidisciplinary and interdisciplinary working to underline their contribution and use in stroke care.
The paper is then divided into three sections to reflect the contribution of stroke teams at key points in the stroke pathway Figure 1.
These are first, the prehospital and emergency department ED period; second, the inpatient period; and third, the period after hospital discharge, including the related area of longer term support for stroke survivors. TIA, transient ischemic attack; ED, emergency department. MDT working is linked by policy makers and clinical guideline developers with improvements in the quality of stroke care. This confidence in the benefits accruing from MDT working stems partly from a Cochrane systematic review of trials of inpatient stroke care which found unequivocal evidence that organized inpatient care provided in stroke units by MDTs improved outcomes.
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- Improving post-stroke recovery: the role of the multidisciplinary health care team;
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Advantages gained are persistent and applicable regardless of age, sex, disability, and level or type of stroke. Multidisciplinary rehabilitation is therefore now a central tenet of high-quality stroke care. A comment on team types is important before progressing to the discussion of the contribution made by stroke teams in improving post-stroke recovery. An MDT is a collection of professionals from different disciplines who share a common area of working practice. Stroke teams are larger than many health care teams, so coordination and effective collaboration are important.
Interdisciplinary teamwork IDT implies that not only do team members perform activities toward a common goal, they also accept the added responsibility of group effort on behalf of patients. In stroke services, this collaboration can occur in weekly, or more frequent, IDT meetings, 19 , 32 , 34 and through ongoing patient-focused dialog. However, there is evidence in stroke services and in health care more generally that this is easier to proclaim than to achieve. One of the most significant changes in stroke care in the last 15 years has been the recognition that stroke-specific assessment and rapid transfer of people with stroke and transient ischemic attack TIA symptoms to ED saves lives and improves outcomes.
First Steps for Caregivers
Time to specialist assessment is critical in reducing mortality and improving outcomes after stroke and TIA. In the Emergency Stroke Calls: Jones et al 40 found that calls categorized as stroke by EMS dispatchers were commonly confirmed as stroke in the ED; they argued that further development and training of EMS and ED staff were needed to improve prehospital stroke recognition and expedite effective hyperacute stroke care.
A coordinated and streamlined process that involves public education, education of EMS dispatchers, and collaboration between paramedic teams and stroke teams in EDs is essential. Written protocols delineating key stages in care increase the likelihood that stroke teams will provide effective hyperacute stroke management. It is common for hyperacute stroke teams to be based on inpatient stroke units.
Stroke physicians and stroke specialist nurses attend the ED when alerted by a Code: Following rapid assessment by a stroke team in ED, the decision to provide thrombolysis normally requires CT or magnetic resonance imaging MRI of the brain, ideally completed immediately on arrival in ED and in all cases within 1 hour of arrival.
Following arterial occlusion, two zones of local injury occur, the core and the ischemic penumbra. This severe reduction in oxygen and glucose results in death of neurons and glial cells. However, cells within the ischemic penumbra remain viable for a short period of time as some oxygen and glucose are provided by collateral circulation. Intervening effectively in this time-sensitive period requires a high level of collaboration and shared understanding of progression in brain injury in hyperacute stroke teams; unless reperfusion is achieved, a wider area of infarction will develop and more severe disability and death is likely.
Thrombolysis is maximally effective within a narrow therapeutic window. Provided there are no contraindications, clinicians should consider administration of thrombolysis within 3 hours of known symptom onset for people of all ages. The Third International Stroke Trial 48 indicated no increased risk to patients aged over 80 years during that time period, but that treatment efficacy reduced significantly after 3 hours.
National Clinical Guidelines for Stroke 19 recommend clinicians consider administration of intravenous thrombolysis between 3 hours and 4. Collaborative, interdisciplinary team work, and a patient-focused organizational culture were found to be prominent features of hospitals achieving marked improvement and outstanding performance in door-to-balloon times for ST-segment myocardial infarction. The approach, known as the Helsinki model, 51 is based on 12 linked components and takes a systems analysis and patient-focused approach to removing unnecessary barriers to rapid specialist assessment, brain imaging, and, where appropriate, thrombolysis.
Further changes required collaboration between imaging and stroke team members and included direct patient transfer to CT instead of an ED stretcher and immediate on-table CT interpretation by the stroke team. Such changes challenge existing organizational processes and also staff who are accustomed to working in particular ways, especially where out-of-hours services require revision to provide hour CT and stroke team services rather than on-call services. While the Helsinki model has not yet achieved widespread adoption, Meretoja et al 51 , 52 demonstrate that skilled leadership and an approach based on integrated IDT principles can achieve substantive change in short periods of time.
Recent research has demonstrated that mechanical clot retrieval can improve outcomes for those who have experienced an ischemic stroke caused by occlusions in the proximal anterior cerebral circulation. This intervention may become a mainstream therapeutic technique in the near future and therefore will require close collaboration between stroke teams and interventional radiologists. The aforementioned developments have led to improvements in prehospital and hyperacute stroke care. However, a relatively small proportion of the total stroke population will benefit from intravenous thrombolysis or mechanical clot retrieval.
In some hospitals, stroke coordinators nurses or therapists are core team members and work with stroke survivors, their families, and the wider stroke team from admission to discharge. Along with physicians and other stroke team members, stroke coordinators provide secondary stroke prevention and behavior change advice aimed at helping stroke survivors reduce the risk of recurrent events.
Stroke Recovery: Tips for the Caregiver
Stroke physicians focus on medical management and oversee patient care from admission through to follow-up at 6 weeks; most advocate for and contribute fully to MDT or IDT working. In the UK, postdischarge patient follow-up is expected at 6 weeks and 6 months. Early assessment of patients, normally within 24 hours, and appropriate referral prompted by National Clinical Guidelines 19 and Sentinel Stroke National Audit Programme 34 standards ensure that these professionals contribute to rehabilitation where specific needs are identified.
Stroke units include hyperacute units where stroke survivors undergo intensive physiological monitoring and medical stabilization during the first 72 hours post-stroke, and acute and rehabilitation units often combined where the remainder of the inpatient stay is experienced. To achieve reductions in mortality and increased independence associated with organized inpatient stroke care, stroke survivors should be admitted directly to stroke units from the ED and remain there for the duration of the inpatient stay.
In most countries, inpatient stroke rehabilitation is underpinned by evidence-based National Clinical Guidelines 19 , 57 — 59 and relies on a coordinated team approach to planning, delivering, and evaluating care. High-quality Cochrane systematic review evidence is available in relation to the types and effectiveness of some, but not all, rehabilitation interventions used by PTs, OTs, and SALTs working with stroke survivors. These interventions, although primarily managed by single disciplines, rely upon all members of stroke unit having an understanding of the principles underpinning the intervention and providing a rehabilitation-focused environment in which stroke survivors are encouraged or supported to continue therapeutic activity.
Cochrane reviews report that physiotherapy, occupational therapy, and speech and language therapy interventions can improve outcomes for stroke survivors, but the active ingredient and the form of intervention that is most effective have not been identified. Legg et al, 61 in a review of nine RCTs 1, participants found that OT increased personal activity of daily living ADL scores and reduced the odds of a poor outcome. For every eleven patients receiving an OT intervention to facilitate personal ADLs, one was spared a poor outcome. Brady et al 62 in a review examining speech and language therapy for aphasia after stroke included 39 RCTs 2, participants.
The review identified some evidence of the effectiveness of SALT in improving functional communication and receptive and expressive language for people experiencing aphasia after stroke. However, Brady et al 62 concluded that the evidence was not sufficient to conclude one specific SALT intervention was more effective than another. Similarly, in a larger review of approaches to physical rehabilitation after stroke, Pollock et al 63 included 96 studies 10, participants.
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They concluded that physical rehabilitation, comprising a selection of components from different approaches, is effective for recovery of function and mobility after stroke. No single approach was found to be any more or less effective in promoting recovery of function and mobility. Given these findings, it is important that stroke team members adopt a consistent and evidence-based approach to rehabilitation practices.
All stroke team members can support stroke survivors in practices related to improving independence in ADLs, in increased function and mobility, and in communication. Intercollegiate Stroke Working Party 19 p: There is some evidence that stroke teams who have adopted an interdisciplinary approach are more likely to work in this way.
In addition to the presence of mobilization protocols in Trondheim, observations indicated that while Trondheim patients had on average twice as many therapy sessions as those in Melbourne, there was no significant difference in the average number of minutes per session.
A notable difference between the two units was the involvement of registered nurses with a high level of education and training in stroke rehabilitation. The mobilization intervention occurred 24 hours per day led primarily by a nursing team that were highly involved with mobilization. In Trondheim, nurses spent A small follow-up study explored interdisciplinary interactions in interviews with staff in both units, concluding that greater integration and sharing of knowledge, skills, and roles within the Trondheim team was instrumental in improving patient outcomes. One of the CERISE studies, examining use of time by PTs and OTs, reported a higher level of nursing involvement in rehabilitation activity in the UK unit, but this did not demonstrate any improvement in motor and functional recovery.
No comparisons were made, but it appears likely that the interdisciplinary approach evident in Trondheim was not a feature of the UK unit. The CERISE group, while drawing attention to variation in the organization of rehabilitation work between the four centers, for example, discrete disciplinary working practices between PTs and OTs, did not attribute these to differences in team working per se, but rather focused on the efficiency of the organization of rehabilitation services.
Regular problem-oriented and opportunistic dialog between team members led to stroke-and therapy-specific language being increasingly shared. The impact on rehabilitation-related activity was similar to that observed in Trondheim, 64 , 65 with registered nurses consistently applying rehabilitation principles agreed with therapists across 24 hours each day.
In an action research study, 70 development of a community of practice in a large stroke unit in London was reported to be instrumental in building a committed team of stroke clinicians, which displayed all the characteristics of interdisciplinary working. This team was recognized nationally for their success in developing an evidence-based stroke service in which nurses as well as therapists were central to providing rehabilitation.
However, not all stroke teams adopt an interdisciplinary approach to their work. The authors found that the larger the team, the more the likelihood of uniprofessional groupings occurring 21 and that nationally audited performance targets 34 were a disincentive to interdisciplinary working. In contrast to the studies outlined earlier, Harris et al 21 found that despite having most contact with patients and carers, nurses had least involvement in the stroke teams as a whole and integrated working was uncommon in these teams. Similarly, in a process evaluation of a pragmatic cluster RCT of a caregiver training intervention, marked variability in team working approach was observed in six of ten stroke units observed.
In a secondary analysis comparing compliance with the compulsory elements of the caregiver training intervention with team type, it was noted that teams with a loose MDT affiliation were less compliant with intervention delivery than those with an IDT approach. While treatment in a stroke unit is enshrined in the stroke care pathway, pressures on in patient services are such that the length of stay in such units is reducing. A form of postdischarge MDT rehabilitation was developed to reduce the length of stay in hospital and evaluated under the umbrella term of early supported discharge.
A Cochrane review of stroke specialist ESD teams 71 14 trials with 1, participants reported that ESD increased the likelihood that patients will regain independence in activities that support daily living and resulted in fewer patients requiring long-term institutional care, for mild to moderately disabled stroke survivors. This reinforces findings from previous research that rehabilitation in the home is beneficial, 72 , 73 as it facilitates greater emphasis on daily activities. These included the recommendation that ESD teams should be multidisciplinary, led by a co-coordinator who facilitates weekly meetings, have key workers assigned to each patient, and be based in hospitals in order to play an active role in discharge planning.
The focus in the identified key features of ESD services is primarily on the patient, with strategies of how to address or measure carer health status or quality of life not identified. In qualitative interviews, carers expressed the view that appropriate levels of training, both practical and emotional, and information had not been provided in an appropriate format. Focus on patient needs alone can inadvertently lead to the neglect of carers, who may experience considerable and sustained burden and anxiety.
It is important that stroke teams have an information strategy, ensuring that messages to patients and their families are consistent and that not only basic information is provided but also that they have the knowledge of where and how to access further information if required. Many stroke survivors experience a poor transition of care from hospital to home; the memory of this transition can influence their recovery. Patients and carers should also be made aware of services eg, stroke clubs and respite care and benefits that are available to them.
It has to be recognized that input from specialist stroke teams cannot continue indefinitely. There is little current information on how best to provide longer term support for stroke survivors and their carers, although their needs have been identified. This reflects a view that the stroke team contribution will vary according to patient need, and that later in the stroke recovery pathway, teams require knowledge and understanding of community-based services rather than specialist stroke knowledge.