Stroke rehabilitation in hospital or within the community is a patient centred process with a variety of professional staff contributing to the overall management of an individual patient. An important principle of rehabilitation is goal setting. Stroke unit care usually incorporates a process in which individual recovery goals are identified and monitored (see RCP London stroke guideline¹⁷).

3.1 Multidisciplinary team membership

The core multidisciplinary team should consist of appropriate levels (see section 6) of nursing, medical, physiotherapy, occupational therapy, speech and language therapy, and social work staff. Other disciplines are also regularly involved in the management of stroke patients including clinical psychologists, psychiatrists, dietitians, and others. Evidence level 1+

The typical staffing structure within stroke unit trials was as follows (approximated to a 10-bed stroke unit).¹⁸ Evidence level 1+

• Nursing: 10 whole time equivalents (WTE) per 24 hour shift (see section 6.1.2)
• Medical: 0.6-1.5 WTE of medical input (divided between consultant and junior staff). Staffing levels tended to be higher in units with acute admission than in second line rehabilitation units
• Physiotherapy: one to two WTE divided between qualified and assistant staff
• Occupational therapy: one to two WTE divided between qualified and assistant staff
• Speech and language therapy: 0.2-0.6 WTE
• Social work: part-time social work input.
  Evidence level 1+

The core multidisciplinary team should consist of appropriate levels of nursing, medical, physiotherapy, occupational therapy, speech and language therapy, and social work staff.

Members of the core team should identify problems and invite allied health care professionals to contribute to the treatment and rehabilitation of their patients as appropriate.

3.1.1 PATIENT AND CARER INVOLVEMENT

A characteristic feature of stroke unit care is the early active involvement of patients, carers and family in the rehabilitation process. How best to involve all relevant individuals in this process is less clear.¹⁸ Evidence level 1+

Patients and carers should have an early active involvement in the rehabilitation process.

Where appropriate, carers should be invited to attend therapy sessions at an early stage.

3.1.2 MULTIDISCIPLINARY TEAM COMMUNICATION

Regular weekly meetings for members of the stroke unit multidisciplinary team have been shown to improve patient outcome.¹⁸ These meetings serve as a focus for collective decision making. Evidence level 1+

Stroke unit teams should conduct at least one formal multidisciplinary meeting per week at which patient problems are identified, rehabilitation goals set, progress monitored and discharge is planned.

A number of units also incorporate one or two informal operational meetings per week attended by nursing and therapy staff, and often patients and family. These meetings are an additional opportunity for noting progress, highlighting problems and providing patients and carers with information.

Occasional “family conferences” between the multidisciplinary team and the patient and carers should be arranged.

3.2 Education and training

Effective stroke unit care includes programmes of education and training for staff to provide them with the knowledge, skills and interest, to deliver effective therapeutic care and rehabilitation. A variety of approaches have been described, from weekly short seminars to less frequent study days.¹⁸ Evidence level 1+

A programme of training and education for members of the stroke unit multidisciplinary team has been reported in four case studies (which contributed to the systematic review for the effectiveness of stroke units).¹⁰ These ranged from informal weekly educational events, to a programme of formal education ranging from one to six days per year. Evidence level 3

There was concern that specialist staff would reduce the skills of junior staff, however, this was felt to be easily overcome by rotating staff and students through the unit.

Members of the multidisciplinary stroke team should undertake a continuing programme of specialist training and education.

Healthcare providers should provide adequately funded training opportunities.

3.3 Early mobilisation

A number of post-stroke complications are associated with immobility. Early mobilisation therefore seems to be a useful intervention. In the systematic review of stroke unit trials, there was a high degree of consistency in the reporting of policies of early mobilisation, usually beginning on the day of admission.¹⁸ A survey of stroke unit trials indicated that early mobilisation was a component of stroke unit care in eight out of nine relevant trials. It is difficult to assess the clinical impact as the available information describes one part of a much larger package of stroke unit care, but the current evidence suggests that early mobilisation benefits patients. Evidence level 1+

Stroke patients should be mobilised as early as possible after stroke.

3.4 Information provision

A characteristic feature of stroke unit care is the provision of information about stroke and stroke rehabilitation to patients and carers. What is less clear is how best to disseminate such information.

Results from a Cochrane review of information provision indicate that educational sessions, compared with the provision of information in leaflet (or similar) form, may result in improved knowledge about stroke but do not improve mood, perceived health status, or quality of life for patients or carers. The effectiveness of structured information provision has not been demonstrated.¹⁹ However, the provision of information is generally regarded as a very important task for all members of the multidisciplinary team. Evidence level 1+

Stroke patients and their carers should be offered information about stroke and rehabilitation.

3.5 Carer support

It is common for carers to experience strain, including anxiety and/or depression at some point after the stroke, into longer term care.^{20, 21} In other areas of acquired brain injury, anxiety has been associated with the presence of cognitive deficits or behavioural changes in the patient. Studies of carers of stroke patients have also found this but not consistently. Patients who are irritable or depressed may be more likely to have a depressed spouse. There is no evidence that any of these associations are causative. However, these factors may serve as warning signs to those assessing whether a family is under strain. Evidence level 3

Where a carer is suspected of being clinically depressed or anxious, they should be encouraged to seek help by contacting the appropriate member of the general practice team.

Family support workers have been shown to be of benefit to carers (see section 3.8). A list of some of the organisations that provide support and information for stroke patients and their carers is included in section 7.5.

3.6 Rehabilitation for people living at home within one year of stroke

Trials including a total of 1,617 patients (who were never admitted to hospital or treated after discharge home from hospital) were identified which compared a therapy intervention with a control group who received either an alternative form of therapy or no therapy intervention.^{22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34} Some trials showed inadequate reporting of randomisation and/ or allocation procedures and/ or blinded outcome assessor. Evidence level 1++,1+

Three types of therapy-based rehabilitation service for stroke patients living at home within one year of stroke were included. These were provided by physiotherapy, occupational therapy or multidisciplinary team. The nature of therapy-based rehabilitation services evaluated varied across groups. However, they have been included together as they have the common aim of reducing physical disability by altering task orientated behaviour. Evidence level 1++,1+

Data on death or poor outcome (i.e. deterioration or dependency) were available for 1,350 (83.4%) patients from 12 trials. The pooled results show that overall, outcome was improved. Evidence level 1++,1+

The main conclusion is that patients living at home, who receive therapy-based services, are on average more likely to avoid a poor outcome and achieve a higher level of function in activities of daily living. Evidence level 1++,1+

Stroke patients living at home, within one year of stroke onset, should be considered for specialist therapy-based rehabilitation services.

3.7 Rehabilitation for people living at home more than one year after stroke

Four RCTs^{29, 35, 36, 37} and one crossover trial³⁸ (385 patients), comparing therapy-based rehabilitation services for stroke patients more than one year post-stroke and living at home, were identified. Three types of therapy-based rehabilitation service were included and were provided by either physiotherapy, occupational therapy or multidisciplinary teams. Some of these trials are small and subject to methodological limitations, resulting in only weak evidence to support these interventions. Until further evidence is available, health care professionals should not assume that any one service for patients living at home one year after stroke is more efficacious than others in improving limited activity and participation. Evidence level 1++,1+,1-

Stroke patients should have access to services, which can review their long term rehabilitation needs after stroke.

3.8 Stroke family support workers

The potential role and clinical competencies of family support workers have been investigated in four RCTs.^{39, 40, 41, 42} A review of these four studies concluded that there were no significant benefits for patients but there were significant psychosocial benefits for carers in two of the studies.⁴³ One study identified improved activities for carers. The Edinburgh study⁴² identified a significantly poorer emotional outcome for patients allocated the family support worker. Although the role and input of these workers need to be clarified and defined, the overall benefit of having stroke family support workers is clear. The role of the stroke family support worker is different and complements that of the stroke liaison nurse/co-ordinator (see section 2.1.2). Evidence level 1+

The provision of stroke family care workers by charities, voluntary groups, social services and Health Boards should be considered as part of a strategy of improving the care of families affected by stroke.