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New National Clinical Guidelines for Stroke

May 1, 2023

The National Clinical Guideline for Stroke provides recommendations based on current research into the experience of healthcare professionals and people affected by stroke, to define best practices for treating people who have had a stroke or transient ischaemic attack (TIA or “mini stroke”)

The Intercollegiate Stroke Working Party has produced six editions of the National Clinical Guideline for Stroke since 2000; The most recent update was published at the beginning of April 2023, the recommendations have changed quite significantly to support Intensive Rehabilitation and have increased from 45 minutes a day to now 3+ hours a day, we know this is currently being under achieved in the NHS but it is something we can offer as standard in our Intensive Rehabilitation packages. These standards should be met in England, Scotland, Wales, Northern Ireland and have now been expanded to include the Republic of Ireland. 

Hobbs Rehabilitation is the largest independent provider of specialist neurological therapy in the UK, currently providing specialist inpatient and outpatient neurological rehabilitation services for adults and children across the south of England with services available in Berkshire, Bristol, Dorset, Hampshire, Lymington, Salisbury and Winchester.

Charlotte Barnes, Specialist Neurological Physiotherapist at Hobbs Rehabilitation Intensive Neurotherapy Centre in Bristol shares her thoughts: “It’s great to see an increase in the intensive rehabilitation recommendations in the National Clinical Guidelines for Stroke in line with the current evidence, however we know the previous recommendations of 45 minutes a day per patient was not being met and without significant change to processes and procedures, the NHS is going to be unable to meet the new recommendations of 3 hours a day of interdisciplinary rehab per patient. At Hobbs Rehabilitation, we have a range of intensive Rehabilitation Packages available that we tailor to each patients’ individual requirements and goals, offering input from a variety of specialist neurological therapists, that can be started at any time in the patients’ stroke recovery and not just the acute stage.”

Quotes from The National Clinical Guideline for Stroke and how this is met in Hobbs Rehabilitation Intensive Rehabilitation Packages:

“People with stroke should be considered to have the potential to benefit from rehabilitation at any point after their stroke.”

We consider starting rehab at any point of the recovery journey, not just at the acute phase. We work with our patients to design a bespoke interdisciplinary rehabilitation programme to suit their individual needs and desired outcomes. 

“Greater amounts of physical therapy (i.e. dose) are associated with better recovery (Kwakkel et al, 1999; Kwakkel & Wagenaar, 2002; Bhogal et al, 2003a; Bhogal et al, 2003b; Kwakkel et al, 2004). The dose of therapy is multi-faceted, encompassing not only the number of treatment sessions, but also their duration and frequency.”

We combine hands-on concentrated rehabilitation services alongside state-of-the-art neurotechnology to help our patients significantly speed up their recovery process. Evidence shows, it takes 400 to 600 repetitions of one movement to start to create a neuroplastic change in the brain. This is met through an intensive therapy package and the dosage of repetitions is enhanced using neurotechnology where appropriate. 

“there is evidence that motor learning is best accomplished with challenging, motivating tasks and variable training schedules (Krakauer, 2006)”

Hobbs Rehabilitation sessions are varied and engaging;the use of conventional therapy and neurotechnology provides an element of fun and keeps patients motivated when completing mundane exercises that some could find boring. 

“the most effective therapy for promoting motor recovery after stroke is based on exercise and practice of functional tasks augmented as necessary by technological and priming techniques (Veerbeek et al, 2014b; French et al, 2016a; Wattchow et al, 2018; Scrivener et al, 2020) The main points of post-stroke therapy aimed at motor recovery are understanding the impairments, activity, and individualised goals, leading to a high number of repetitions of relevant exercise and functional tasks.”

Our therapists have experience working in the field of stroke rehabilitation; each patient is assessed to help identify specific individual needs, set therapy goals and create a tailor-made treatment programme. Conventional physiotherapy and prep work is used alongside task-specific practice. Interdisciplinary input on the packages involves joint working towards functional goals with Physiotherapy, Occupational therapy and Speech and Language therapy input, plus Neuropsychology where appropriate. 

“People with motor recovery goals undergoing rehabilitation after a stroke should receive a minimum of 3 hours of multidisciplinary therapy a day (delivered or supervised by a therapist or rehabilitation assistant focused on exercise, motor retraining and/or functional practice), at least 5 days out of 7, to enable the range of required interventions to be delivered at an effective dose.”

Our bespoke intensive rehabilitation packages are designed to improve patient outcomes by providing 20, 40, 60 or 80 hours of intensive therapy over 2-8 weeks with 2-4 hours per day, across, 3-5 days per week. The hours are determined after an initial assessment and based on getting the best outcomes, while considering a patient’s specific needs and requirements. 

“People with limitations of personal activities of daily living after stroke should be referred to an occupational therapist with knowledge and skills in neurological rehabilitation. Assessment should include consideration of the impact of hidden deficits affecting function including neglect, executive dysfunction and visual impairments.”

Occupational Therapists are a valuable part of our interdisciplinary team, which includes Speech and Language, Physiotherapy, Children’s Physiotherapy, Rehabilitation Medicine, Neuropsychology and Orthotics. The team work together to ensure the patient can achieve realistic goals set during an initial assessment.

“People with wrist and finger weakness which limits function after stroke should be considered for functional electrical stimulation applied to the wrist and finger extensors, as an adjunct to conventional therapy. Stimulation protocols should be individualised to the person’s presentation and tolerance, and the person with stroke, their family/carers and clinicians in all settings should be trained in the safe application and use of electrical stimulation devices.”

Hobbs Rehabilitation uses FES as part of neurotherapy at a number of a centres, in weekly 1:1 sessions as well as in our intensive rehabilitation packages. All Hobbs Rehabilittion clinicians are trained in using a number of FES devices and due to this, our clinicians work with patients to find the right FES device that works best for their abilities.

“People who cannot walk independently after stroke should be considered for electromechanical-assisted gait training including body weight support. [2023] People with stroke who are able to walk (albeit with the assistance of other people or assistive devices) and who wish to improve their mobility at any stage after stroke should be offered access to equipment to enable intensive walking training such as treadmills or electromechanical gait trainers.”

LEXO is just one of our chosen gait trainers; the end-effector system encourages self activity and increased levels of repitition for the patient. With its high adaptability, LEXO can be adjusted precisely and used for a wide range of patients.

“People with swallowing difficulty after stroke should be considered for swallowing rehabilitation by a specialist in dysphagia management.  This should be based on a thorough assessment of dysphagia, such as by a speech and language therapist, to decide on the most appropriate behavioral intervention, and may include a variety of muscle strengthening and/or skill training exercises.”

Hobbs Rehabilitation speech and language therapists can assess and give guidance in managing swallowing and communication difficulties following a stroke. We consider each patient, identify specific needs, set therapy goals and create a tailor made therapy programme to work towards achieving these goals. As well as seeing all our patients on a 1:1 basis, we also offer groups for individuals with communication impairments following a stroke. In addition to clinical services, our Specialist Speech and Language Team provide clinical education for care staff and have recently developed an online course, with certification, on Dysphagia. The certificate shows completion of Level 3 Dysphagia Training in line with Eating, Drinking and Swallowing Competency Framework (EDSCF). 

“Intensive speech and language therapy such as comprehensive aphasia programmes may be considered from 3 months after stroke for those who can tolerate high-intensity therapy.”

Hobbs Rehabilitation speech and language therapists are part of our interdisciplinary team included in our intensive rehabilitation packages. The high intensity of sessions are focussed on supporting people with communication impairments post-stroke to achieve their communication goals. The therapy delivered combines conventional therapy as well as the use of app based intervention to achieve communication goals. 

“People with aphasia after stroke should be offered access to appropriate practice-based digital therapies.  Adherence to and engagement with these digital therapies will likely be improved if supported by a carer or healthcare professional.”

Access to the latest neurotechnology at Hobbs includes app based resources that can be used following an assessment deeming them appropriate. The app based technology will not only enhance 1:1 treatment, but also support therapy at home. Our speech and language therapists can also recommend apps and computer programs depending on patient needs and appropriateness. 

We accept self-referrals and referrals from Consultants, General Practitioners, other Health Care Professionals and Case Managers. To refer, please complete a contact form and a member of the team will be in touch. 

References from: https://www.strokeguideline.org

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