THIS is the whole problem in a nutshell; 'Guidelines' NOT PROTOCOLS! If you had protocols you would get an objective damage diagnosis, that would point to EXACT REHAB PROTOCOLS THAT WOULD DELIVER RECOVERY! If you can't see that, you need to get out of stroke and find an easier job.
National Clinical Guideline for Stroke for the United Kingdom and Ireland: Part I – An overview of the updated recommendations
The National Clinical Guideline for Stroke 2023 (Intercollegiate Stroke Working Party, 2023)
marks a new ambition for stroke rehabilitation. Launched in April 2023,
they propose a raft of recommendations that will transform occupational
therapy provided to people with stroke and their families. It should be
noted that the guidelines are a ‘partial’ update with some sections
being out of scope for update, in which case the 2016 recommendations
are carried forward. At the guidelines launch, two stroke survivors
presented the plain language summary [https://www.strokeguideline.org/plainlanguagesummary/]
and highlighted the importance of using this accessible educational
tool with stroke survivors and their families to inform them of what
they can expect along the pathway.
Over the next two editions of The British Journal of Occupational Therapy,
we will firstly present the new recommendations most pertinent to
occupational therapists and secondly explore the opportunities and
challenges these recommendations present for occupational therapy
practice across the stroke pathway.
Principles of rehabilitation
Culture
The
guidelines offer an entirely new section devoted to the Principles of
Rehabilitation with the concept of ‘rehabilitation potential’ addressed
at length for the first time. The guidelines clearly state that ‘people
with stroke should be considered to have the potential to benefit from
rehabilitation at any point after their stroke’ (2023: 63). Importantly,
access to rehabilitation should not be time limited, or restricted
based on discharge destination. The new section and the accompanying
recommendations mark a significant culture shift that will need to be
translated into the core of our service provision.
Stroke services
Attention
grabbing is the recommendation of assessment to commence within 24
hours of admission, as opposed to the 72-hour window recommended in the
2016 (Intercollegiate Stroke Working Party, 2016).
Reflecting the demands for a culture shift towards need-led services at
all points along the post-stroke journey, it is recommended that stroke
survivors be able to re-access services at any point along the pathway
if new goals or needs are identified. This includes stroke survivors
discharged to residential or nursing care.
The
initial post-stroke 6-month and subsequent annual reviews are
recommended to expand their scope from a narrow medical focus to a
review that is truly holistic. The guidelines advocate a review with
both the breadth and depth to capture stroke survivors’ ongoing physical
and psychological needs while living with a chronic condition. Reviews
should result in a need- and goal-based formulation that takes a
holistic view of the stroke survivor within their psychosocial context.
Workforce
Recommended
staffing levels are provided for hyperacute, acute and rehabilitation
units and have been adjusted to reflect 7 days working and the increased
intensity of therapy provision in the rehabilitation phase. This is
also true for community-based rehabilitation teams, with staffing level
recommendations provided for the first time.
Motor recovery and physical effects of stroke
Arm function
In relation to motor recovery, the primary rehab approach recommended by the guideline is repetitive task practice (RTP) (da Silva et al., 2020; French et al., 2016; Grattan et al., 2016; Pollock et al., 2014; Veerbeek et al., 2014a; Wattchow et al., 2018) over all other approaches including Bobath (Dorsch et al., 2023). Further, the guidelines recommend, functional electrical stimulation for wrist and finger extension (Kristensen et al., 2022; Loh et al., 2022; Tang et al., 2021; Yang et al., 2019) to enable engagement with RTP, constraint-induced movement therapy (Barzel et al., 2015; Corbetta et al., 2015; Kwakkel et al., 2015; Liu et al., 2016; Yadav et al., 2016) in those with mild-moderate weakness (see guidelines for specific parameters), and both mirror therapy (Thieme et al., 2018; Yang et al., 2018; Zeng et al., 2018; Zhang et al., 2022) and mental practice (Di Rienzo et al., 2014; Barclay et al., 2020; Page and Peters, 2014; Poveda-Garcia et al., 2021; Stockley et al., 2020) as adjuncts to support RTP. Transcutaneous vagal nerve stimulation (Ahmed et al., 2022; Xie et al., 2021; Zhao et al., 2022)
has been recommended for the first time as an addition to usual therapy
to enhance the effect of RTP. Reflecting the ongoing research around
dose of motor recovery interventions, a total of 3 hours of therapy per
day is recommended, thereby bringing the United Kingdom and Ireland into
alignment with other national guidelines (Stroke Foundation, 2022a; Teasell et al., 2020; Veerbeek et al., 2014a).
To support the recommended increase in dose, self-directed therapy
receives a new focus, and cautious recommendations for
tele-rehabilitation, open gyms and increased use of family to support
practice outside of therapy sessions are also provided.
Physical activity
Widening the focus away from ‘arm function’, the guidelines recommend that people after stroke are active for up to 6 hours day−1.
More specifically, cardiorespiratory fitness receives increased focus
in the guidelines, with a recommendation that all stroke survivors
including those with severe stroke are to be supported to engage in some
form of cardiorespiratory or mixed training when medically stable, with
clear parameters outlined.
Fatigue
Occupational
therapists should routinely assess for fatigue, marking a change from
the 2016 guidelines where assessment of fatigue was only required if the
person with stroke raised a concern. Additionally, it is recommended
that we consider fatigue more holistically, by adopting a
biopsychosocial approach in our assessments, with both the cognitive and
physical aspects of fatigue considered (Ablewhite et al., 2022; Drummond et al., 2021).
This more holistic approach should also be reflected in the support and
education provided by occupational therapists to manage fatigue.
Psychological effects of stroke
In
contrast to the 2016 guidelines the psychological effects of stroke are
now listed together in a section that covers both the cognitive, and
mood or well-being impacts of a stroke.
Cognition
This
section provides a much needed differentiation between cognitive
screening and assessment. Further, the guidelines recommend that both
screening and assessment are conducted by registered healthcare
professionals. Therefore, occupational therapists are to be equipped
with the necessary skills and knowledge to select, administer and
crucially to interpret the results in the context of the individual and
their cognitive history. Routine delirium screening is a new addition to
the guideline reflecting the increasing evidence of the incidence of
delirium post-stroke (Fleischmann et al., 2022) and its detrimental impact on outcomes. Additionally, screening for apathy (Tay et al., 2021)
in stroke survivors that present with reduced motivation, a reduction
in emotional responsiveness and goal directed behaviour, is recommended.
Routine explanation of screening and assessment results to the person
with stroke and their family is recommended, to educate and build
insight or awareness. Further clarity is now provided regarding
transitions of care, with routine reassessment of cognition following
transfers of care not indicated unless the results of previous
assessment are unattainable. However, it should be noted that community
stroke services should accept referrals for further cognitive assessment
where indicated.
Mood
The
guideline also provides more detailed information on the assessment and
management of mood disorders following stroke. Routine assessment for
anxiety and depression is continued from the 2016 guidelines, but with
greater clarity on assessments being undertaken by healthcare
professionals with the appropriate skills and knowledge to facilitate
interpretation of results, within the individual’s context, while
acknowledging relevant psychological history. Reflecting the improved
evidence base for interventions to manage post-stroke psychological
care, four psychological interventions are recommended for those who are
able to engage: motivational interviewing, cognitive behavioural
therapy, problem-solving therapy and acceptance and commitment therapy (Allida et al., 2020a, 2020b; Knapp et al., 2017; Niu et al., 2022). Recommendations include both the stepped and matched care models (Gillham and Clark, 2011; NICE, 2022c), with an emphasis not only on the treatment of mood disorders as they arise but also to support with post-stroke adjustment (Allida et al., 2020a) in those at risk.
Return to work (in activity and participation)
Importantly,
it is recommended that discussions surrounding return to work begin
early in the post-stroke journey. Interventions should include support,
education and guidance, while also engaging with employers to make
recommendations to facilitate a return to work. Alongside this, a
coordinator role or central point of contact is also recommended for
those with return-to-work goals. Provision of Fit notes (Department for Work & Pensions, 2023) are also referenced.
Adopting and growing evidence-based practice
The
raft of recommendations within these new guidelines highlights the
increasing evidence base within stroke that covers both more aspects of
practice and is beginning to offer more certainty as to what does and
does not work in areas such as motor recovery for the upper limb. The
new recommendations not only recommend what should be done but also
clearly state what should not be done, reflecting that stopping
low-evidence low-value activity is often as important as implementing
novel and effective practices. This being the case, there is a need for
the profession to engage directly with the evidence base provided by the
guidelines and as ever to engage in the building of this evidence base
for the efficacy of our profession and for the benefit of stroke
survivors.
In the next edition of this
journal, we will present the second part of this editorial on the
National Clinical Guidelines for Stroke and the challenges and
opportunities they pose for occupational therapists.
Acknowledgments
We
would like to thank the remaining members of the Royal College of
Occupational Therapist Specialist Section Neurological Practice Stroke
Clinical Forum, Sarah Broughton, Louise Clark, Rowena Padamsey and
Nicole Walmsley for their tireless commitment to improving occupational
therapy in stroke and their role in reviewing the evidence and in
shaping the National Clinical Guideline for Stroke 2023. A special thank
you to Louise Clark, who, as editor for the Rehabilitation and Recovery
section of the guideline, has raised the profile and increased the
opportunities for occupational therapy post-stroke inexorably.
Declaration of conflicting interests
The
author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The
author(s) disclosed receipt of the following financial support for the
research, authorship, and/or publication of this article: JC is funded
by Health Education England (HEE)/National Institute for Health and Care
Research (NIHR), Grant Reference: 302124. AS is funded by the Stroke
Association (SA PGF 18\100029). The views expressed in this article are
those of the authors and not necessarily those of Health Education
England (HEE), National Institute for Health and Care Research (NIHR) or
Stroke Association (UK). The funders had no involvement in the
development of the editorial or the decision to publish.
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