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Rehabilitation of stroke patients

By Dr. Charuni Kohombange

Strokes are the second leading cause of death and the major cause of disability worldwide. In 2019, strokes affected 101.5 million people across the globe. In high-income countries, stroke incidence and mortality are declining substantially. However, about 70% of strokes and 87% of both stroke-related deaths and disabilities occur in low-income and middle-income countries. According to available studies, the prevalence of stroke in Sri Lanka is 10 per 1,000.

The goal of rehabilitation of stroke is to assist relearning the skills you lost when a stroke affected part of your brain and regain independence to improve the quality of life. This article explains the important aspects of stroke rehabilitation.

Madara Sarasi Kodithuwakku, a chartered physiotherapist in neuro-rehabilitation, with over two decades of experience in rehabilitation of patients in the UK, shared her expertise on rehabilitation of stroke survivors. Being a renowned journalist in print media, she has authored the book Anshabaagaye Wagavibaga to share her experience with fellow Sri Lankans.

Following are excerpts of the interview.

According to your experience, how long should a person continue with rehabilitation following a stroke?

Strokes affect many systems/functions of the body, such as movements/mobility, balance, speech, vision, cognitive abilities (memory, concentration, understanding, decision-making, ability to do a skilled task, etc.) and psychological wellbeing. This results in a loss of functional abilities.

Therefore, the patient becomes disabled and the patient needs rehabilitation. Rehabilitation should continue until the patient reaches their potential. This potential depends on a few factors such as the severity of the stroke, medical stability of the patient, the expectations of the patient and also of the family, willingness and compliance of the patient, etc. Hence, it varies from patient to patient.

Basically, every patient should be given every opportunity to reach their potential. Firstly, we should always find out the patient’s premorbid mobility, functional and cognitive levels.

From a physiotherapy point of view, I will take mobility as an example. If the patient has been independently mobile without using any walking aids and managing all the activities of daily living independently prior to the stroke, that is their baseline we should target for.

However, according to the severity of the stroke, the patient might not achieve this premorbid level. On such occasions, we should aim for the next best. For example, improving their mobility with a walking stick might be the next best. So, this might be their new baseline or the new potential. Having the patient’s compliance and motivation, it is a possibility.

Rehabilitation of other problems would be the same. The relevant professionals will set their goals accordingly.

Now, if you look at the time frame, it also varies from patient to patient based on various factors including severity of the stroke. However, the patient does not need to stay in the hospital throughout the whole journey of rehabilitation. In the UK, we have various rehabilitation services established in the community, enabling the patients to reach their potential.

Unfortunately, in developing countries, the available facilities and the financial status of the patient have also become a significant factor in reaching this potential.

What percentage of patients will make a complete recovery following rehabilitation?

Based on the figures by the National Stroke Association, it is stated that 10% of patients recover almost completely, 25% recover with minor impairments, and 40% experience moderate to severe impairments requiring special care.

What are the methods of rehabilitation available in developed countries, and are they feasible for a developing country like Sri Lanka?

There are three categories: In-patient, out-patient, and community-based rehabilitation.

Patients firstly receive rehabilitation as in-patients. This in-patient rehabilitation starts at a hyper acute stroke unit or at an acute stroke ward. Once the patient is medically stable, these patients will be transferred to a stroke rehabilitation ward to continue with their rehabilitation.

Some patients reach a level that they don’t need stroke rehabilitation as an in-patient but needs some level of rehabilitation. Therefore, these patients will be referred to a team called Early Supported Discharge (ESD) team. This ESD team will see these patients at their homes for a period of six weeks and consists of multiple disciplines including physiotherapists.

Again, there is another group of stroke patients who would not qualify for in-patient stroke rehabilitation or rehabilitation under the ESD team, but still they need a level of rehabilitation to achieve independence to their potential. These patients are referred to a team called the reablement team. The reablement team also sees the patients for a period of six weeks in the community.

The patient’s suitability is decided according to their presentation and also the inclusion criteria of those services. This inclusion criteria is established to provide the best and most appropriate service for the patient.

Alongside these services, the neuro out-patients service is also available to cater for stroke patients. The patients who are seen under the ESD or reablement teams but presented with unresolved goals with further potential to achieve those goals would be referred to this service.  The neuro out-patients physiotherapy service would also receive the patients who have suffered with a stroke in the past but presented with some deterioration in their mobility or functioning.

All these services are very effective services in rehabilitating stroke patients.

All these services also seem feasible for Sri Lanka, but I am not aware of any community rehabilitation services such as ESD or reablement service under the national health service established in Sri Lanka yet. If there are such services, stroke patients from all socioeconomic backgrounds can be given the best opportunity to rebuild their lives.

Unfortunately, a stroke collapses not only the patient’s life, but also their whole families’. The patient might be the only breadwinner of the family. Painstakingly, the patients and families in such situations are in real trouble, as there is no established social security system to support those families financially.

Again, with the stroke patients in working age, it would also affect the gross domestic product (GDP) of the country indirectly.

In essence, when the quality of the stroke care and rehabilitation services is poor, there is a knock on effect on the economy of the country.

What are your suggestions to improve stroke rehabilitation in Sri Lanka?

  • My first and foremost suggestion is stroke units. Stroke units consist of skilled multidisciplinary teams. Every health board has got a stroke unit in the UK. The literature greatly supports the effectiveness of stroke units in combating the burden of strokes. But I don’t think neither the total number of stroke units nor the number of allocated beds in a stroke unit are in a position to be adequate in Sri Lanka
  • Appointing enough staff for stroke care and provision of appropriate training to the staff in stroke care should also be considered as one of the priorities. When the staff across the team are knowledgeable and skilled, the service offered will be of high quality, ensuring the best outcomes
  • Commitment from all the staff for continuous professional development and evidence-based practice would also yield great outcomes. Such a culture should be established across the multidisciplinary team
  • The physiotherapists and other therapists should be equipped with the best and latest techniques of rehabilitation. Unfortunately, this training is costly. But these costs should be considered as an investment
  • Ensuring the availability of necessary equipment such as seating/specialist chairs, transfer aids such as appropriate hoists, handling aids such as sliding sheets, etc. would also enhance best outcomes and safe handling for both the patients and staff. It is likely for a patient suffering with stroke to be presented with some weakness. This weakness can range from mild weakness of one side to complete paralysis of one side resulting in total dependence on others for movement and mobility. But it is not recommended for staff to lift patients as lifting can compromise the health and wellbeing of staff.  Therefore, the staff should follow minimal handling techniques
  • Establishing community physiotherapy/rehabilitation services under the national health service would enhance the vision of stroke care for all, ensuring fair provision of treatment across the island

(The writer is a Medical Officer at the Directorate of Healthcare Quality and Safety of the Ministry of Health)