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Rehabilitation

Physiotherapy

 

The damage done after a stroke can range from mild symptoms and difficulties to severe problems that leave patients dependent on others. In addition, there is a risk of dying from the stroke which is about 12% at seven days, 19% at one month and 30% at one year for first ever strokes.

However, people who survive the stroke usually show some degree of recovery. The extent of recovery, unfortunately can be very disappointing with up to 30% of patients remaining dependent on others for help with everyday activities at the end of one year.

Recovery begins with natural improvement and through rehabilitation.

What is rehabilitaion?

Rehabilitation is the process by which the patient regains lost abilities or learns to compensate for disabilities to become more independent.

It is formally defined as "an active process by which those disabled by injury/disease achieve a full recovery, or if full recovery is not possible, realise their optimal physical, mental and social potential and are integrated into their most appropriate environment."

The patient works with a team of health professionals called the multidisciplinary team. The core team consists of doctors, nurses, physiotherapists, occupational therapists, speech and language therapists, dieticians, therapy assistants, psychologists, social workers and pharmacist.

The aim is to enable the patient to:

  • Relearn lost skills
  • Learn new skills
  • Adapt to the limitations caused by the stroke
  • Find practical support for life after the stroke

 

Physiotherapy

Physiotherapists are concerned with human function and movement and maximising potential. The most common perception of the profession is that of fixing musculoskeletal sports injuries, however Physiotherapists work in a wide variety of health settings such as intensive care, stroke recovery, and care of the elderly. Read more about Physiotherapy

How does a physiotherapist help someone who has had a stroke?

Physiotherapy works alongside the natural healing process following a stroke to assist recovery. Following the assessment process, each patient receives a tailor-made therapy programme based on the individuals needs. Where appropriate, the individual is involved in setting realistic functional goals to direct the therapy sessions.

Therapy may involve some of the following activities:

  • Positioning in bed or in a chair
  • Sitting out of bed in specialist chairs
  • Re-education of movement to assist function, in sitting or standing positions

Therapy is an ongoing process which continues throughout the day with all members of the ward team.

How can friends and family help?

Family and friends can help us by:

  • Bringing in comfortable unrestricted clothing and comfortable footwear. If possible shorts and vests are ideal to assist the assessment process.
  • Attend goal planning sessions with your relative/friend. This will allow you to meet members of the ward team and discuss progress. This is also a good opportunity to ask the therapy team any questions you may have.
  • Arrange an observational session to watch your relative/friends therapy (optional). During these sessions, it may be that the therapist can teach you some useful exercised to assist therapy.

 

Occupational Therapy

Occupational Therapists (OTs) work with people of all ages, helping them to carry out the activities they need, or want to do in order to achieve their daily routines. They assist a person to manage challenges based on their individual needs and lifestyle. Read more about Occupational Therapy
 

How does an OT help someone who has had a stroke?

People who have had a stroke can be affected in different ways and may experience difficulties in the following areas:

  • Physical – Weakness on one side, reduced sitting balance or mobility
  • Cognition – Difficulty with memory, problem solving, planning and organising self
  • Speech – Difficulties understanding language, finding the correct words and slurred speech

OT’s consider the impact of such difficulties on a person’s daily living and how that change in circumstances can affect their independence and confidence. They work closely with the individual to identify areas of their daily routine that they are finding more difficult following their stroke. These can include:

  • Getting dressed
  • Having a shower/bath
  • Going to work
  • Socialising
  • Undertaking a favourite hobby

They then work with the individual to set rehabilitation goals to help maximise their independence.

In hospital

OTs will work with a person and the rest of the stroke team to design a programme of treatment based on individuals abilities, needs and preferences. In the initial stages this may involve looking at safe ways for a person to be able to get out of bed and sit in a chair. As rehabilitation progresses the OT may look at how a person manages to get washed and dressed, prepare a hot drink or meal.

Later stages of rehabilitation may involve looking at returning to work, driving or leisure/hobbies. In situations where an individual has been unable to re-gain their previous level of ability the OT will help them to adapt to their change in circumstances by teaching them to manage their everyday activities in a different way. 

Discharge

Towards the end of an individuals stay in hospital the stroke team will work closely with the patient and their family/carer to establish a plan for discharge. The OT may conduct a visit to the person’s home to establish any safety concerns, needs for equipment and ways of modifying the environment. If it is felt that an individual is likely to require ongoing support or further rehabilitation at home the OT will liaise with community colleagues and agencies to ensure that this is addressed prior to discharge.

How can friends and family help?

We welcome the participation of family, friends and carers in the rehabilitation process.
Family and friends can help by:

  • Bringing in comfortable and unrestricted clothing such as T-shirts, polo shirts, jogging bottoms, comfy slacks and elasticated waist skirts
  • Bringing in familiar toiletries
  • Attending family meetings with your relative, friend, carer and ward team
  • Attending joint therapy sessions with your relative or friend and their therapist (where appropriate)
  • Providing information about the individuals previous abilities and likes/dislikes

 

Speech and Language Therapy 

Speech and Language Therapists are health professionals that work with individuals who have difficulties with communication and/or swallowing. They work across a variety of different settings including hospital wards, outpatient departments, day centres and in individuals' own homes. Read more about Speech and Language Therapy.

 

How does Speech and Language Therapy help someone who has had a stroke?

Communication and swallowing difficulties are common following stroke. Approximately one third of people will experience communication difficulties after a stroke and approximately one half of all people will demonstrate difficulty swallowing post stroke, though many will regain their swallow quite quickly.

All people who exhibit communication and swallowing difficulties should be referred to Speech and Language Therapy as soon as individuals are well enough to take part in assessment.

A Speech and Language Therapist will assess people with communication difficulties and will help individuals to overcome or adapt to a range of communication problems. Assessment will vary depending on the individual’s presentation and once it is complete a therapy plan will be developed and the Speech and Language Therapist will work closely with the individual's family and other health professionals. The overall aim is to help the individual to recover their communication skills as much as possible or to find alternative ways to communicate, for example, using a communication aids, such as, picture charts or electronic aids.

A Speech and Language Therapist will assess people with swallowing difficulties and will advise on, if possible, safe ways to eat and drink, this might include altered food or drink consistencies.

If a person is not safe to swallow a recommendation for non-oral feeding may be made. This might be temporary measure (nasogastric feeding) or if swallowing difficulties persist it may be more long term (PEG feeding).

Guide to terminology

Dysphagia – this word is used to describe difficulty in swallowing.

Dysphasia or Aphasia – these words are used to describe language difficulties. It might be problems understanding language (receptive dysphasia) or with finding the words to express themselves (expressive dysphasia).

Dysarthria – this word is used to describe difficulty in speaking due to weakness in the muscles used for speaking.

Dyspraxia – this word is used to describe difficulty in speaking due to incoordination of the muscles used in speaking.

Clinical Psychology

The effects of a stroke can encompass physical and psychological aspects that can affect not only the individual but also the people around him or her, such as family, friends and colleagues. The role of a Clinical Psychologist is to provide information and support to the patient, his/her family and the team of rehabilitation therapists on the psychological aspects of stroke. In broad terms a stroke can affect cognitive skills and emotions. The impact of these two factors is often inseparable but for the purposes of explaining the role of a Clinical Psychologist it is useful to consider each in turn.

Cognitive skills

‘Cognitive skills’ is a term used to describe a collection of skills for which the brain is responsible and includes memory, language, perception, attention, controlling movement, reasoning, planning and judgement.

Just as it can be harder to move an arm or a leg after a stroke, it can also be more difficult to use some of these cognitive skills. Some of these changes can make it seem as if a person’s personality has changed. Below are a few examples of the ways in which a stroke can make some of these skills more difficult, how it can affect a person’s behaviour and the impact they may have on their interactions with others:

  • It can be harder to remember new information leading to confusion about where you are and what day it is. People may also forget that friends and family have visited.
  • Being less tactful than is usual for the affected person.
  • Being less able to act on intentions e.g., expressing an intention to wash but being unable to start.
  • Becoming stuck on a topic of conversation despite a change in subject.
  • Talking about seemingly unconnected subjects and not paying attention when someone else is talking.
  • Reduced or complete lack of awareness of the physical effects of the stroke e.g, some people may say they can walk when in fact they cannot.

It is quite common for people to be aware of ‘feeling muddled’ after a stroke and for family members to notice such changes. It can be confusing to understand why this is, making it important to provide information to help make sense of these changes.

Cognitive difficulties can also have an impact on a person’s rehabilitation after stroke. The team of rehabilitation therapists are sensitive to signs that this may be happening.

They might refer to a Clinical Psychologist who can conduct a more formal assessment of these skills, which can be used to make recommendations to help reduce their impact on future rehabilitation sessions.

Emotion

The effects of the stroke on a person’s cognitive skills can also make it more difficult for him/her to regulate his/her own emotions. It can be harder to manage feelings of anger, frustration, fear and sadness.

All of these feelings are to be expected after a stroke, not least because people are often trying to understand what has happened. It is commonly a very distressing time.

For some people the level and duration of distress can make it harder for them to engage with their rehabilitation. There can be a variety of reasons for a person’s distress partly because the effects of a stroke can mean very different things to different people.

A Clinical Psychologist may be asked to assess these reasons. The information from this assessment can either be used to inform further therapy with the Psychologist, or can be used to advise the rehabilitation team about approaches to working with the patient to help reduce or manage the impact of this distress on the rehabilitation sessions.

A stroke affects more than the patient. It also affects his/her family and close friends. Family and friends commonly have their own distress and questions about what has happened to loved ones and what it might mean for the future.

Part of the role of a Clinical Psychologist is to provide emotional support to family members who may feel they too are finding it difficult to understand and cope with what has happened.

 

Dietetics

On admission to the stroke ward all patients are assessed to establish their nutritional state. This is done using a screening tool called MUST (Malnutrition Universal Screening Tool).

This involves checking the patients previous and current weight, height, general medical condition and any recent weight loss. If this results in a score of 2 or higher the patient is immediately referred to the dietician for a full assessment and appropriate intervention.

If the score is less than 2 the patient is commenced on food record charts and offered Build Up drinks if less than half of their meals are eaten.

The dietician has many roles in stroke management:

  1. Nutrition support for those who may be unable to take food or drink orally for a period of time as a result of their stroke.
  2. Those with swallowing difficulties requiring a modified diet (as advised by the Speech and Language therapist)
  3. Patients who are unable to meet their requirements through food alone.
  4. Healthy eating advice for overweight patients.

When a patient is referred to the dietician they will first carry out a full assessment, taking into account:

  1. The patients pre and post incident nutritional status
  2. Calculate the individuals nutritional requirements based on their weight.
  3. Take into account the current medical condition and increased stress upon the body.
  4. Discuss an appropriate intervention with the patient and their family, taking into consideration advice from the medical and nursing teams.

During rehabilitation, the dietician will work with the rest of the team to:

  1. Help the patient to resume normal eating habits where possible.
  2. Ensure nutritional adequacy and advise on any nutrition related problems that may have contributed to the stroke.

Following a stroke, many patients may find they have swallowing difficulties.

A simple swallow screen is carried out by nursing staff on all new admissions to detect any problems, and if necessary a referral to the speech and language therapist is made for a full swallow assessment.

In some cases it may be diagnosed that it is unsafe for a patient to take food or drink orally due to an unsafe swallow which may result in food or drink passing down into the lungs, rather than the stomach, and causing an infection. If this is the case, alternative feeding methods are usually advised.

This will be discussed with the patient where possible, however if the patient is unable to express their wishes clearly a decision will be made by the team which is deemed in the ‘best interests of the patient’ with guidance, as appropriate, from the family.

Most commonly a Nasogastric tube is used as a first line feeding method. This involves a very narrow tube being passed through the nose and down into the stomach. This is usually a temporary measure and the patient will continue to be assessed regularly by the speech language therapist to ascertain when it is safe for the patient to begin taking some oral diet again. A feeding regimen will be devised by the dietician based on the patient’s weight and administered via a pump

f a patients swallow does not improve over a period of 6 weeks, and it is thought that it is unlikely to in the near future, alternative feeding methods will need to be discussed. The next line of treatment is to insert a tube known as a ‘PEG’ tube (Percutaneous Endoscopic Gastrostomy).

This is placed by the endoscopy department under sedation using an endoscope with a light on the end. This is passed into the stomach and the light can be seen to identify where the incision should be made.

The tube can then be placed through this incision in the stomach wall and the skin heals around the tube within a matter of minutes. Feeding can begin after six hours.

If a patient is allowed to take food and fluid orally but has been identified as having swallowing difficulties, a texture modified diet may be advised. This could be pureéd, ‘easy to eat’ or normal. Fluids may need to be thickened to improve oral control when swallowing.

If a modified diet is required, the dietician will advise on suitable foods and ways to ensure nutritional requirements are still met. If food intake is very limited, supplement drinks or snacks may be required.

These offer condensed amounts of calories in a drink or pudding which can be taken in addition to meals. They are not however suitable as meal replacements. These will be based on a patient’s likes and dislikes and reviewed weekly or as required.

Additional snacks or suitable meals can also be arranged for those patients who require specialist diets such as gluten or dairy free.

How does the brain recover after a stroke?

Despite increasing research into how the brain recovers after a stroke, the mechanisms for recovery in humans are still largely unknown. Various mechanisms have been suggested to explain recovery:

  • In the very early days, brain cells around the centre of the stroke which were damaged but not irreversibly so may begin to recover because of improving blood supply, re supply of nutrients and reduction of brain swelling around the stroke.
  • It is suspected that parts of the brain not directly damaged by the stroke are made to shut down shortly after a stroke by the influence that the damaged part has on the functioning of remote parts. These remotely 'shut down' parts may regain function and help recovery.
  • Later improvements are explained by a process called brain 'plasticity' - the damaged brain can compensate to some extent by rewiring its connections to bypass the damaged areas and allow other parts to take over its function

 

What is the timescale of recovery?

Every patient is different and it is not possible to predict accurately what might happen. The rate of recovery or its completeness cannot be predicted without observing the patient for a few weeks. A few general points can be made:

  • The rate of recovery is usually highest in the first few weeks after a stroke.
  • Some recovery may continue at a slower rate for many months and in some patients for up to 18 months or 2 years.

 

What are the factors that can allow clinicians to predict the extent of recovery?

Although no prediction can be absolutely accurate and there will be exceptions, doctors and therapists use certain signs to estimate the extent of recovery. These can be divided into 'Good signs' and 'Bad'. The bad signs reflect the severity of the stroke.

'Good'  Signs:

  • Younger and fitter patient
  • Independent in activities of daily living before the stroke
  • Small stroke
  • Normal speech
  • Good arm strength
  • Able to walk without the help of another person (may use stick or other walking aids)

'Bad' Signs:

  • Excessive sleepiness or coma
  • Severe paralysis
  • Urinary incontinence
  • Poor balance and postural control
  • Confusion, memory loss, reduced attention and ability to learn
  • Difficulty with vision and spatial awareness
  • Poor motivation
  • Initial complete dependence for activities of daily living