Stroke rehabilitation — factors to consider before initiating long-term rehabilitation

Every stroke patient deserves an assessment and consideration for intensive rehabilitation. Selection is about matching the programme to the person, never about denying entry.

Formal assessment before entry is essential — to confirm the problems are remediable and to determine optimal management. It is unfair to subject a person who cannot benefit to a demanding programme, raise false expectations and waste resources; equally, those who can benefit even to a limited extent must not be denied access.

Availability and Is a properly resourced multidisciplinary team, unit and follow-up implementation of a sound service actually available? A good candidate with no programme programme gains nothing

Mentation Cognition, comprehension, memory and learning capacity — rehabilitation is motor relearning, so a patient who cannot retain instruction cannot progress

Motivation The patient’s drive to engage; the strongest modifiable predictor of outcome

Prognosis for neurological Site, size and type of lesion; severity of deficit; time since onset return

Vigour Physiological reserve, stamina, cardiorespiratory fitness, nutrition — the capacity to tolerate daily therapy

Mentation in detail: assess conscious level, orientation, attention, memory, comprehension and executive function, using tools such as the Abbreviated Mental Test. Look for pre-existing dementia, post-stroke delirium and post-stroke dementia (roughly a quarter of stroke survivors are demented after stroke, of whom about 10% were already demented before the first stroke). Aphasia must be distinguished from cognitive failure — a patient with pure expressive dysphasia may have intact learning capacity.

Motivation in detail: use Kemp’s model — motivation is driven by the patient’s wants, beliefs and rewards, opposed by the cost in pain and effort. Modify each element: set attainable goals, correct false beliefs, create rewards, reduce the physical and emotional cost. At one extreme are patients who set ambitious goals; at the other, those who surrender autonomy and adopt the “sick role”.

Screen for depression before and during rehabilitation. Depression is common after stroke, persists despite participation in a rehabilitation programme, and worsens prognosis — an untreated depression will be misread as “poor motivation” and wrongly used to exclude the patient. Use the Geriatric Depression Scale; treat before concluding the patient is unsuitable.

Prognosis for neurological return depends heavily on timing. Most neurological recovery occurs in the first month after stroke; by the end of the third month, little if any further return can be expected. Rehabilitation must therefore be started early.

Not all deficits are equally disabling. Motor loss is often the least disabling. Sensory and perceptual loss, aphasia, loss of balance, hemispatial (hemicorporeal) neglect, hemianopia and cognitive impairment cause more severe and often untreatable disability.

Vigour and reserve: assess premorbid functional status, cardiorespiratory fitness, nutrition, anaemia, sarcopenia, pain and continence. The elderly patient’s core problem is lack of physiological reserve. Coexisting impairments (osteoarthritis, Parkinson’s disease, visual and hearing loss, prior stroke) each multiply disability.

Medical stability and complication risk must be settled first. Confirm swallowing safety, control of blood pressure and glycaemia, absence of active sepsis, adequate cardiac status, control of seizures. Complications to prevent actively: pressure sores, contractures, phlebitis, pulmonary embolism, aspiration pneumonia and faecal impaction.

Social and environmental factors decide participation. Intrinsic: attitude, personality, ability to adjust, cultural factors. Extrinsic: financial resources, housing, availability of a carer, social supports. Elderly women living alone are especially disadvantaged.

Set the goals before starting. Goals must be realistic, agreed by the patient and every team member, ambitious but achievable, split into short-term and long-term goals with flexible, regularly reviewed time frames. Goal divergence between team members is the commonest cause of a failed programme.

Decide the discharge destination and the endpoint at the start — home with family, home with supports, day hospital, or long-term care. Assessment must address both “the problem in the individual” and “the individual with the problem”.

Acute phase measures: change position at least 2-hourly; position joints to prevent contractures; position to prevent aspiration pneumonia; perform range-of-motion exercises. A flaccid hemiplegic limb is at risk of shoulder subluxation — proper handling and limb positioning in the immediate post-stroke period minimises this risk.

Later phase measures: ADL training, ambulation training, functional activities for the affected side, muscle re-education exercises, perceptual training, and training in transfer technique. Treatment aims both to re-educate affected muscles and to enhance remaining capacity in unaffected areas.

Specific evidence-based techniques: constraint-induced movement therapy produces significant and clinically relevant improvement in arm motor function in patients 3–9 months after a first stroke; treadmill training repeatedly improves gait and balance; robot-assisted motor training and brain–computer interfaces show early positive results.

Long-term: ongoing exercise and physical activity after the formal programme are critical — they maintain function and quality of life and help prevent further strokes.

Organised stroke unit care improves survival and functional outcomes (Stroke Unit Trialists’ Collaboration). Patients cared for in stroke centres are more likely to be alive, independent and living at home one year after the stroke.

Stroke patients may do better in dedicated acute rehabilitation facilities than in skilled nursing facilities. Whatever the setting, the basic principles and the multidisciplinary team remain the same.

When the patient stops making progress despite intensive therapy, the goal shifts from restoration to coping. Assess the need for braces, orthoses and assistive devices for both ambulation and ADLs, and switch to maintenance of function and prevention of decline.

Even the most severely affected can gain something. Complete functional recovery occurs in less than half of stroke patients, but immobility and its complications can almost always be prevented or minimised.

Discharge is a transition, not the conclusion. Follow-up is essential so that any new or worsening activity or participation restriction is detected and remedied.

NICE NG236 (18 October 2023) — the biggest change is dose NICE’s stroke rehabilitation guideline, which replaces CG162, recommends: offer needs-based rehabilitation for at least 3 hours a day, on at least 5 days a week, covering a range of multidisciplinary therapy including physiotherapy, occupational therapy and speech and language therapy. Once the person has left hospital, care and rehabilitation should continue for as long as it continues to help them achieve their treatment goals. Early supported discharge should be offered to people who can move from bed to chair independently or with assistance, provided a safe environment can be arranged, with therapy continued at the same intensity and level of skilled support as in hospital. The previous daily target of 40–45 minutes has been raised to 3 hours.

NG236 rationale and the ESD evidence The committee found that early supported discharge reduced physical dependency and length of hospital stay, and either improved or did not worsen health-related quality of life, with no difference in mortality, carer quality of life, Caregiver Strain Index or readmission rates, though a clinically important increase in falls was seen in a limited number of studies. Rehabilitation should not be withdrawn after a fixed period. NG236 also recommends NMES as an option for shoulder pain, and a trial of NMES, FES or TENS for focal spasticity.

VA/DoD 2024 and drugs for motor recovery The 2024 VA/DoD Clinical Practice Guideline, updating the 2019 version, provides recommendations for rehabilitation management after stroke with explicit emphasis on an interdisciplinary care approach. AHA/ASA guidance holds that the effectiveness of fluoxetine or other SSRIs to enhance motor recovery is not well established, the effectiveness of levodopa is not well established, and dextroamphetamine or methylphenidate to facilitate motor recovery is not recommended. NMES may be considered for shoulder pain; a formal fall-prevention programme during hospitalisation is recommended, with exercise plus balance training after discharge.

Neuromodulation has entered clinical practice The 2021 FDA approval of the Vivistim paired vagus nerve stimulation system was the first regulator-approved VNS therapy for upper-extremity motor recovery after stroke. Long-term follow-up shows sustained benefit at one year, with 66% of patients achieving clinically meaningful improvement. Transcutaneous approaches remain investigational. Current evidence supports implantable VNS paired with rehabilitation in carefully selected patients with chronic upper limb impairment.

India — the ATTEND trial is the key cautionary result India has only about 35 stroke units, mainly in urban centres, so most people have no access to specialised stroke care or conventional rehabilitation. The ATTEND trial randomised 1250 patients within one month of stroke to family-led, trained caregiver-delivered, home-based rehabilitation across 14 Indian hospitals. It more than doubled inpatient rehabilitation time (5 hours vs 2 hours) and added 30 minutes daily for one month after discharge — yet produced no improvement in modified Rankin Scale outcome. Exam interpretation: quantity of therapy alone is not enough — the skill and specificity of the therapy delivered matters, which is why NG236 specifies “multidisciplinary therapy”, not simply “3 hours of activity”.

Delivering the dose is the current bottleneck The first six months after stroke is the optimum window for neuroplasticity, and exercise must be repetitive, task-specific and high-dose. However, delivering three hours a day in community settings is difficult, and around 40% of stroke survivors are discharged home without any further rehabilitation. Telerehabilitation is recommended in the new guidance as one way to bridge this gap.

Five prognostic factors: availability of a sound programme, Mentation, Motivation, Prognosis for neurological return, Vigour.

Most neurological recovery occurs in the first month; little further return after 3 months.

Motor loss is the least disabling deficit; neglect, hemianopia, aphasia, sensory loss, balance loss and cognitive damage are far more disabling.

Depression is not poor motivation — screen with GDS and treat before excluding a patient.

Kemp’s model: motivation = wants + beliefs + rewards − cost.

Acute phase: 2-hourly turning, joint positioning, aspiration-preventing posture, range-of-motion exercises.

Later phase: ADL training, ambulation, affected-side functional activity, muscle re-education, perceptual training, transfer technique.

Flaccid hemiplegia → shoulder subluxation; prevented by correct handling and positioning from day one.

CIMT works 3–9 months after a first stroke for arm motor function.

Stroke units improve survival and function — the strongest evidence in rehabilitation.

NICE NG236 (2023): ≥3 hours of multidisciplinary therapy per day, ≥5 days per week.

ATTEND (India): family-led rehabilitation doubled therapy time but did not improve mRS.

When progress stops, shift the goal from restoration to coping — braces, orthoses and assistive devices.

Complete functional recovery occurs in fewer than half, but complications of immobility are almost always preventable.