What is stroke rehabilitation?Stroke rehabilitation is a very important part of recovery for many people who have had a stroke. It helps build your strength, coordination, endurance and confidence. In stroke rehabilitation, you may learn how to move, talk, think and care for yourself. The goal of stroke rehabilitation is to help you learn how to do things that you did before the stroke.
A stroke occurs when one of the vessels supplying blood to the brain tissue becomes damaged or blocked. When the brain tissue is cut off from its supply of oxygen for more than three to four minutes, it begins to die. Nerve cells in the brain tissue communicate with other cells to control such functions as memory, speech and movement. When a stroke happens, nerve cells in the brain tissue become injured. As a result, they cannot communicate with other cells and certain functions are impaired.
About 20% of patients die in the first month after stroke, and more than half of the survivors will require specialist rehabilitation. Once the patient's condition stabilises medically, there is less need for the facilities of the acute hospital, and the focus of the rehabilitation program moves to improving function and independence, and preparing the stroke survivor and his or her carers for life after discharge in the context of their previous health, home and family situation, avocational and vocational needs.
Despite the best care, a stroke can cause some degree of disability such as weakness, partial paralysis, memory loss, inability to speak or understand words, change in personality or confusion.
However, there are several key factors to a successful rehabilitation which can help people resume their normal lives as much as possible:
- The extent of the brain injury - the less severe the injury, the better the chances for recovery.
- The stroke survivor's attitude - a survivor's positive attitude can help him or her cope with difficult times and focus on getting better.
- Family support - a stroke survivor's family can be the most important form of support during rehabilitation. Family members can reassure stroke survivors that they're wanted, needed and still important to the family.
- Immediate rehabilitation - rehabilitation must begin as soon after the stroke as possible. Even simple tasks such as exercising paralyzed muscles and turning the person in bed should begin very soon after the stroke. Stroke rehabilitation is most successful when it's a team effort. The stroke survivor and his or her family must work together with the doctor, nurse and other rehabilitation specialists.
The stroke rehabilitation team is a group of specialists and allied health professionals who work together to provide stroke survivors with the comprehensive medical care, therapy, counseling and family training needed to recover from a stroke. Team members strive to restore a patient's ability to perform the daily activities of life.
Team members usually include:
- Physiotherapists may focus on limb weakness, abnormal tone (flaccid or spastic) and balance, to meet the agreed aim of independent mobility, but need to work closely with occupational therapists to achieve this.
- Occupational therapists may take the lead in teaching independence in activities of daily living, guiding the patient (if improvement allows) through personal hygiene to domestic and community activities, but success in these domains will demand input from physiotherapists as well.
- Speech therapists deal with communication and motor production of speech, as well as chewing and swallowing.
- Nurses have specific expertise in bladder and bowel function, and have a critical role in consolidating rehabilitation gains. They spend many more hours with the patients and family than any other team members.
- A neuropsychologist is an important member of a specialised stroke rehabilitation team, as cognitive deficits are common. These often include impaired memory and concentration, as well as difficulties in planning and problem solving. Personality changes are frequent. Damage to specific areas of the brain can lead to distinctive clinical syndromes, and their accurate definition is helpful to the team (eg, a frontal haemorrhage will often affect learned social inhibitions, emotional responses and control, while lesions of the parietal lobe, particularly in the non-dominant hemisphere, tend to impair perception and planning). A particularly formidable task, often delegated to neuropsychologists, is assessment of a patient's capacity to make a will, and there are few guidelines on which to base this difficult decision.
- All team members work together to deal with other important sequelae of stroke, often ignored by those without rehabilitation expertise. These include perceptual impairment, reduced attention and awareness of body parts or the environment, and visual field loss.
- Social workers play an important role in evaluating a patient's premorbid state within his or her social network and society as a whole, and in determining what aspects were previously determinants of the patient's quality of life. Social workers often take on a critically important counselling role with the patient and next-of-kin, and link professionals in arranging and coordinating community resources before and after discharge. This task can be a complex nightmare for uninitiated family members.
- A rehabilitation physician usually leads the team and works closely with the nurses to deal with comorbidities, such as hypertension and diabetes, and to treat or prevent secondary complications, such as pressure areas and seizures (about 5% of patients will have a seizure in the first year after stroke).
- The end of the formal rehabilitation program is usually signalled by a functional plateau after which little or no recovery occurs. This may be hard to pinpoint, but if no improvement occurs over a period of more than 3 weeks then further significant improvement of brain function is unlikely, although patients may still learn further compensatory techniques. However (as mentioned above), some patients show "late" functional improvement, even two years after the initial stroke.
In recent years, clinicians have been pressured (militated by a combination of political, financial and clinical determinants) towards discharging stroke patients from the hospital environment as early as possible. However, this is only possible, or safe, when community resources and infrastructure are adequate, and the timing depends as much on such resources as the patient's degree of functional recovery. Successful discharge depends on accurate assessment of the domestic environment, and the establishment of networks to meet critical needs (eg, personal care, domestic help, home modifications and carer respite).