Stroke Rehabilitation

Sami Abdulhakim
 Stroke services
• Organizing health and social care for people needing rehabilitation after
stroke .
• in a stroke unit and subsequently from a specialist stroke team in the
community or
• directly from a specialist stroke team in the community if they have left
hospital through early supported discharge (where people in an
inpatient setting are offered early discharge to continue rehabilitation at
home) or
• in a level 1 or 2 specialist inpatient neurorehabilitation unit and
subsequently from a specialist stroke team in the community. [2013,
amended 2023]
Stroke services…………..
 Multidisciplinary Stroke Rehabilitation Team

This guideline covers rehabilitation after stroke for over 16s. It

aims to ensure people are assessed for common problems and
conditions linked to stroke, and get the care and therapy they
need.

It includes recommendations on the organisation and delivery of

rehabilitation in hospital and the community.
Stroke services…………..
provide access to other services that may be needed, for example: －

 audiology －
 continence advice －
 liaison psychiatry －
 orthotics －
 pharmacy －
 podiatry －
 wheelchair services –
 electronic aids (for example remote controls for doors, lights and heating,
and communication aids) －
The core multidisciplinary stroke rehabilitation team

The team should comprise the following professionals with

expertise in stroke rehabilitation:
• Consultant Physicians Specializing In Stroke, Or
• Neuro-Rehabilitation Medicine
• Nurses
• Physiotherapists
• Occupational Therapists
• Speech And Language Therapists
• Dietitians
• clinical psychologists or clinical neuropsychologists
• orthoptists
• rehabilitation assistants
• social workers.
Throughout the care pathway, document the roles
and responsibilities of the multidisciplinary team clearly
and communicate these to the person and their family
members and carers.

Health and social care professionals should collaborate to

ensure a social care assessment is carried out promptly,
where needed, before the person who has had a stroke is
transferred from hospital to the community.

Identify any ongoing needs of the person, and their

family members and carers, should be documented
 On transfer of care from hospital to the community, This should
include a summary of the person's rehabilitation progress and
current goals and details of their:

• Diagnosis and health status

• Functional abilities (including communication needs)
• Care needs, including washing, dressing, help with going to the toilet and eating
• Psychological (cognitive and emotional) needs
• Medication needs (including the person's ability to manage prescribed medicines etc….
• Social circumstances, including carers' needs
• Mental capacity regarding the transfer decision
• Management of risk, including the needs of vulnerable adults
• Plans for follow-up, rehabilitation and access to health and social care and voluntary
sector services.
 Planning and delivering stroke rehabilitation
Screening and assessment (if problems are identified, take action as soon as possible to ensure their
safety and -comfort: )
• pressure area risk
• signs of disorientation • their continence
• how they should be positioned • their communication, including their ability to understand and
• swallowing function follow instructions and to convey their needs and wishes
• how they move (for example, from a bed to a chair) • their nutritional status and hydration

Perform a full medical assessment of the person after stroke,

including cognition (attention, memory, spatial awareness,
apraxia of speech, perception), vision, hearing, muscle tone,
strength, sensation and balance.
Carry out a comprehensive assessment of a person after stroke
that both identifies and takes into account:

• their previous functional abilities

• changes to, or impairment of, psychological and neuropsychological functioning
(cognitive, emotional or behavioural functioning, such as new signs of emotionalism)
• mental health (for example, the onset of depression, anxiety or posttraumatic stress disorder), including signs
indicating an increased risk of suicide (suicidality) such as suicidal thoughts, plans, actions and suicide attempts
• impairment of body functions, including pain
• activity limitations and participation restriction
• environmental factors (social, physical and cultural).
Feeding Bathing
Score
Sco
0 Unable re

Needs help cutting or spreading butter, etc, or 0 Dependent

5
requires modified diet
5 Independent (or in shower)
10 Independent Dressing
Grooming Score

Score 0 Dependent

0 Needs help with personal care 5 Needs help but can do about half unaided

Independent face/hair/teeth/shaving (implements 10 Independent (including buttons, zips, laces, etc)

5
provided)

Bladder Bowels
Score Score

Incontinent or catheterized and unable to manage 0 Incontinent (or needs to be given enemas)
0
alone
5 Occasional accident
5 Occasional accident
10 Continent
10 Continent
Toilet Use stairs
Score Score

0 Dependent 0 Unable

5 Needs some help, but can do something alone 5 Needs help (verbal, physical, carrying aid)

10 Independent (on and off, dressing, wiping) 10 Independent

Transfers (Bed to Chair and Back) Mobility (On level Surfaces)

Score Score

0 Unable, no sitting balance 0 Immobile or < 50 yards

5 5 sit
Needs major help (one or two people, physical), can Wheelchair independent, including corners, >50 yards

10 Minor help (verbal or physical) 10 Walks with help of one person (verbal or physical) >50 yards

15 Independent 15 Independent (but may use any aid, e.g., stick) >50 yards
The Barthel Index for Activities of Daily Living
(ADL)
it helps clinicians understand a patient’s ability to perform essential daily tasks. As
the patient get score out of 100 indicates a high level of independence, and vice
versa ……….but …in between 0-95…….. he/she may still benefit from targeted
interventions to improve specific areas.

1.Feeding:
1. If a patient scores low in feeding independence, interventions may include:
1. Providing adaptive utensils or assistive devices.
2. Teaching compensatory techniques for self-feeding.
2.Bathing:
1. For patients who need assistance with bathing:
1. Occupational therapists may recommend adaptive equipment (e.g., shower chairs, grab bars).
2. Teaching safe techniques for bathing.
3.Dressing:
1. Interventions for dressing difficulties:
1. Adaptive clothing (e.g., front-closing garments).
2. Teaching patients how to dress independently using modified techniques.
4. Toileting:
4. For patients with toileting challenges:
4. Installing raised toilet seats or grab bars.
5. Educating patients on proper toileting techniques.
5.Transfers (Bed to Chair and Back):
1. Interventions for transfer difficulties:
1. Physical therapists may work on strength, balance, and transfer techniques.
2. Providing assistive devices (e.g., transfer boards, sliding sheets).
6.Mobility on Level Surfaces:
1. Patients with mobility limitations may benefit from:
1. Gait training.
2. Assistive devices (canes, walkers) to improve walking distance.
7.Stair Negotiation:
1. For patients who struggle with stairs:
1. Occupational therapists can teach safe stair-climbing techniques.
2. Home modifications (handrails, stairlifts) may be recommended.
The Modified Rankin Scale (MRS) is a commonly used scale for measuring the
degree of disability or dependence in the daily activities of people who have suffered a
stroke or other causes of neurological disability.
It has become the most widely used clinical outcome measure for stroke clinical trials 1.
Let’s delve into the details:
1.Purpose:
1. The MRS is a single-item, global outcomes rating scale specifically designed
for patients post-stroke.
2. Unlike assessing performance on a specific task, the MRS categorizes functional
independence based on pre-stroke activities.
3. It provides a holistic view of a patient’s overall disability level.
2.Scoring and Categories:
1. The MRS assigns a grade from 0 to 6, representing different levels of disability:
1.Grade 0: No symptoms at all.
2.Grade 1: No significant disability despite symptoms; able to carry out all
usual duties and activities.
3.Grade 2: Slight disability; able to look after own affairs without assistance.
4.Grade 3: Moderate disability; requires some help but can walk unassisted.
5.Grade 4: Moderately severe disability; unable to attend to bodily needs
without assistance and cannot walk unassisted.
6.Grade 5: Severe disability; bedridden, incontinent, and requires constant
nursing care and attention.
7.Grade 6: Dead.
3. Administration:
1. The conventional method involves a guided interview process with the patient.
2. The assessment considers the patient’s activities of daily living, including
outdoor activities.
3. Information about neurological deficits (e.g., aphasia, intellectual deficits) should be
obtained.
4. All aspects of physical, mental performance, and speech contribute to choosing a
single MRS grade.
4.Critique and Structured Interview:
1. Some critics find the MRS categories broad and poorly defined.
2. A structured interview format is available to enhance consistency in administration 2.
Remember that the MRS helps clinicians understand a patient’s functional status and
guides rehabilitation planning
 Setting goals for Rehabilitation

Ensure that people after stroke have goals for their rehabilitation that:
• are meaningful and relevant to them
• focus on activity and participation
• are challenging but achievable
• include both short- and long-term elements.
• timetabled and held regularly, involve the person after stroke and, where
appropriate, their family members and carers, in discussions.
 Planning Rehabilitation
Family members and carers (as appropriate) to actively take
part in developing their stroke rehabilitation plan.

Review stroke rehabilitation plans regularly in multidisciplinary

team meetings. Ensure any documentation is tailored to the person after stroke
high-intensity mobilization during the first 24 hours after the
onset of stroke symptoms,
Offer needs-based rehabilitation to people after stroke. This should be for
at least 3 hours a day, on at least 5 days of the week
Ensure all rehabilitation sessions:

• Include activities linked to the person's goals

• Are tailored to any ongoing medical needs, including post-stroke fatigue
• Take into account any psychological factors

Make special arrangements for people after stroke who have

communication or cognitive needs (for example, by holding
joint speech and language therapy and physiotherapy sessions
for those with communication difficulties) or any specific
impairments problem such as aphasia or cognitive impairment?
Memory function
• increasing the person's own awareness of the memory impairment
• enhancing learning using errorless learning (internal strategies related to
encoding information such as 'preview, question, read, state, test’)
• external aids (for example, diaries, lists, calendars and alarms)
• environmental strategies (using routines and environmental prompts).

Attention function

• Use behavioural observation to evaluate the impact of any impairment on functional tasks.
• focus on the relevant functional tasks.
Psychological functioning

Assess the person after stroke for changes to: • their emotional functioning, such as the onset of emotionalism
• their behavior.
• any signs that could indicate an increased risk of suicide
• When new or persisting changes to mood or emotional difficulties are identified at the person's 6-month or
annual stroke review, refer them to appropriate services for detailed assessment and treatment.
Fatigue

Consider a standardized assessment for fatigue in people after stroke in the early stage of their
rehabilitation programme and at their 6-month stroke review.

• the Fatigue Severity Scale

• the Fatigue Assessment Scale
• the Modified Fatigue Impact Scale.

Vision
Offer people who are in hospital after stroke with persisting hemianopia a ophthalmology
specialist assessment as soon as possible.
Hearing

Screen people for hearing problems within the first 6 weeks after stroke. [2023] 1.9.2 Consider the
Handicap Hearing Inventory in the Elderly or Amsterdam Inventory Auditory of Disability questionnaires
for screening. [2023] 1.9.3 During screening, ask the person, and their family members and carers,
Mouth care
Assess oral hygiene in people after stroke using national or local protocols:.

Encourage people after stroke to do the following at least twice a day:

 • brush their teeth and gums, using an electric or battery-powered toothbrush if needed
 • use mouthwash and oral gels with antibacterial and antifungal properties, if needed.
 •Ensure that a suitably trained healthcare professional, family member or carer delivers or supervises
mouth care for people after stroke who cannot, or find it difficult to, follow a mouth care regimen.
 Swallowing N.B. effective mouth care regimen, because this decreases the risk of aspiration pneumonia
Assess and Provide information to people with dysphagia (difficulty in swallowing) after stroke, and their
families and carers, on what the condition is and its risks.

Give families and carers information on how they can help someone who is coughing or choking while eating
or drinking.

If the person has dysphagia and is unable to take tablets, review the need for the medication and, if it is still
needed, change either its formulation or the route of administration.
Support people who have oropharyngeal dysphagia (OPD) to eat and drink as safely as possible, using 1 or more of the
following methods (as advised by a dysphagia-trained healthcare professional):

• adaptions to their physical position

• modifying fluid intake (for example, taking small sips or drinking thickened fluids)
• modifying their diet (for example, changing the texture of the food)
• adapting the way food and drink is served (for example, serving food with different cutlery)
• using compensatory strategies and maneuvers appropriate for the person (for example, the Mendelsohn manoeuvre)

If the person with dysphagia is at risk of aspiration but wishes to eat and drink without the
assistance of aids and interventions respect their choice follow the recommendations on
putting shared decision making into practice and communicating risks, benefits and
consequences
Communication

Screen people for communication difficulties within 72 hours of onset of stroke symptoms.
Each stroke rehabilitation service should devise a standardized protocol to screen for communication difficulties
in people after stroke.

speech and language therapist for detailed analysis of any

impairments and assessment of their impact.

Provide appropriate information, education and training to the

multidisciplinary team to enable them to support and
communicate effectively with people who have communication
difficulties and their families and carers

using a communication aid or other technologies (for example,

home-based computer therapies or mobile apps

Consider a computer-based programme (or apps) tailored to

individual goals and circumstances in relation to word finding,
alongside face-to face speech and language therapy.
community-based communication and support groups
Movement :

Provide physiotherapy for people after stroke who have weakness in their trunk or upper or lower limbs, sensory
disturbance or balance difficulties that affect their movement.

People with movement difficulties after stroke should be treated by physiotherapists with the relevant skills and training in
diagnosis, assessment and management.

Continue to treat people with movement difficulties until they are able to maintain or progress function either
independently or with assistance from others (for example, rehabilitation assistants, family members, carers or fitness
instructors).

Strength training
progressive strength increasing repetitions of body weight activities weights (for example,
progressive resistance exercise), or resistance exercise on machines such as stationary cycles.

Fitness training
Fitness training
For patient who able to walk and are medically stable after stroke for cardiorespiratory and resistance
training that is appropriate to their individual goals. ensure physiotherapists supply any necessary
information about interventions , safe for the person and tailored to their needs and goals and
possible complication such as shoulder pain or stiffness ,RDS etc…….

Wrist and hand splints

For people who have hands that are immobile due to weakness or spasticity (high tone) to :
 • maintain joint range, soft tissue length and alignment
 • increase soft tissue length and passive range of movement
 • facilitate function (for example, a hand splint to assist grip or function)
 • aid care or hygiene (for example, by enabling access to the palm)
 • increase comfort (for example, using a sheepskin palm protector to keep fingernails away from the
palm of the hand).
 Splinted should be fitted by appropriately trained healthcare professionals,
 Electrical stimulation therapy for the upper limb

Do not routinely offer people after stroke electrical stimulation for their hand or arm.
Consider a trial of electrical stimulation therapy as part of a comprehensive rehabilitation programme for
people who have evidence of muscle contraction after stroke but cannot move their arm against resistance.

Continue electrical stimulation therapy if the person's strength and their ability to practise functional tasks (for
example, maintaining range of movement, or improving grasp and release) is found to be improving.

If a trial of electrical stimulation therapy is appropriate, ensure the treatment is guided by a qualified
rehabilitation professional.

Constraint-induced movement therapy

Repetitive task training sit-to-stand transfers, walking and using stairs
Walking therapies and group circuit training