The long-term consequences of stroke may result in widespread long-lasting health complications. Many people may need long-term support to help regain maximum independence.
As the recovery from a stroke can take a long time, even years, it is important that you and your family and / or carers have access to information and support from the rehabilitation team to enable you to actively participate in the development of your personalised rehabilitation plan and setting goals. It is also important for the Stroke rehabilitation plans to be reviewed regularly by the rehabilitation team as your needs may change over time.
Common complications of stroke requiring long-term rehabilitation include:
Your vision may be affected by your stroke and therefore you should be screen for visual difficulties before discharge.People who have persisting double vision after stroke should be referred for formal orthoptic assessment.
Eye movement therapy should be offered to people who have persisting hemianopia after stroke and who are aware of the condition.
Sometimes following a stroke, some people experience a disturbance in their emotional functioning. This needs to be assessed before discharge and appropriate therapies need to considered and will need to take into consideration the type or complexity of the person’s neuropsychological presentation and relevant personal history.
Family members, carers and the person who has suffered the stroke may need support and education in relation to emotional adjustment to the stroke and psychological needs may change over time.When new or persisting emotional difficulties are identified at the person’s 6-month or annual stroke reviews, they may be referred to appropriate services for detailed assessment and treatment.
Depression and anxiety in people after stroke is very common and need to be addressed and treated.
Cognitive deficits can occur in patients after a stroke and therefore it is important to screen for it and once identified education and support needs to offered. Again it is usually the family and carers that may be more affected by this than the patient themselves.
The two main modalities of cognitive function are 1. Memory and 2. Attention and each needs a different approaches.
Visual neglect after a stroke can affect daily activities such as mobility, dressing, eating and using a wheelchair.Interventions for visual neglect after stroke are focused on relevant functional task and depending on the underlying impairment. Examples of interventions:
Swallowing difficulties, dysphagia, can be a serious issue in people after stroke. Swallowing therapy should be intense at the beginning and should be continued for as long as improvements are made.Swallowing therapy could include compensatory strategies, exercises and postural advice.
Mouth care is important in people with difficulty swallowing after stroke, in order to decrease the risk of aspiration pneumonia.Healthcare professionals with relevant skills and training in the diagnosis, assessment and management of swallowing disorders should regularly monitor and reassess people with dysphagia after stroke who are having modified food and liquid until they are stable.
Nutritional support needs to be provided for people with dysphagia. Assessment and treatment for communication difficulties People with suspected communication difficulties after stroke need to be assessed by a speech and language therapist Speech and language therapists should:
• Provide direct impairment-based therapy for communication impairments (for example, aphasia or dysarthria)
• Help the person with stroke to use and enhance their remaining language and communication abilities
• Teach other methods of communicating, such as gestures, writing and using communication props
• Coach people around the person with stroke (including family members, carers and health and social care staff) to develop supportive communication skills to maximise the person’s communication potential
• Help the person with aphasia or dysarthria and their family or carer to adjust to a communication impairment
• Support the person with communication difficulties to rebuild their identity
• Support the person to access information that enables decision-making
It is important to provide opportunities for people with communication difficulties after stroke to have conservations and social enrichment with people who are trained and have the skills and knowledge to support communication. This would be in addition to the opportunities provided by family, friends and carers.
Tell the person with communication difficulties after stroke about community-based communication and support groups (such as those provided by the voluntary sector) and encourage them to participate.Ensure that environmental barriers to communication are minimised for people after stroke. For example, make sure signage is clear and background noise is minimised.
Make sure that all written information (including that relating to medical conditions and treatment) is adapted for people with aphasia after stroke. This should include, for example, appointment letters, rehabilitation timetables and menus.Offer training in communication skills (such as slowing down, not interrupting, using communication props, gestures, drawing) to the conversation partners of people with aphasia after stroke.
Speech and language therapists should assess people with limited functional communication after stroke for their potential to benefit from using a communication aid or other technologies (for example, home-based computer therapies or smartphone applications).Communication aids can be provided for those people after stroke who have the potential to benefit, and offer training in how to use them.
Occupation therapy can help to address difficulties with personal activities of daily living.Therapy may consist of restorative or compensatory strategies.
Treatment should continue until the person is stable or able to progress independently.
Assessments should be made for equipment needs and whether their family or carers need training to use the equipment. This assessment should be carried out by an appropriately qualified professional. Equipment may include hoists, chair raisers and small aids such as long-handled sponges.
Appropriate equipment is provided and available for use by people after stroke when they are transferred from hospital, whatever the setting (including care homes).
Physiotherapy should be provided for people who have weakness in their trunk or upper or lower limb, sensory disturbance or balance difficulties after stroke that have an effect on function.
Treatment should continue until the person is able to maintain or progress function either independently or with assistance from others (for example, rehabilitation assistants, family members, carers or fitness instructors).
People should be encouraged to participate in physical activity after stroke.
Assessment should be made of people who are able to walk and are medically stable after their stroke so that appropriate individual goals for cardiorespiratory and resistance training can be made.
Cardiorespiratory and resistance training for people with stroke should be started by a physiotherapist with the aim that the person continues the programme independently based on the physiotherapist’s instructions (see recommendation below).
Tell people who are participating in fitness activities after stroke about common potential problems, such as shoulder pain, and advise them to seek medical advice from their GP or therapist if these occur.
Consider strength training for people with muscle weakness after stroke. This could include progressive strength building through increasing repetitions of body weight activities (for example, sit-to-stand repetitions), weights (for example, progressive resistance exercise), or resistance exercise on machines such as stationary cycles.
Repetitive task training after stroke on a range of tasks for upper limb weakness (such as reaching, grasping, pointing, moving and manipulating objects in functional tasks) and lower limb weakness (such as sit-to-stand transfers, walking and using stairs) are also helpful.
Shoulder pain is a common problem and information can be provided to the person who suffered the stroke and to families and carers about how to prevent pain or trauma to the shoulder if they are at risk of developing shoulder pain (for example, if they have upper limb weakness and spasticity).
Shoulder pain after stroke can be prevented by using appropriate positioning and other treatments according to each person’s need.
Walking training cab be provided to people after stroke who are able to walk, with or without assistance, to help them build endurance and move more quickly.
Consider treadmill training, with or without body weight support, as one option of walking training for people after stroke who are able to walk with or without assistance.
Consider ankle–foot orthoses for people who have difficulty with swing-phase foot clearance after stroke (for example, tripping and falling) and/or stance-phase control (for example, knee and ankle collapse or knee hyper-extensions) that affects walking.
It is also important to assess the ability of the person with stroke to put on the ankle–foot orthosis or ensure they have the support needed to do so.
Assess the effectiveness of the ankle–foot orthosis for the person with stroke, in terms of comfort, speed and ease of walking.
Assessment for and treatment with ankle–foot orthoses should only be carried out as part of a stroke rehabilitation programme and performed by qualified professionals.