Stroke patients can adopt simple strategies, where appropriate, to help independent rehabilitation if they can’t access specialist support
Earlier this month new NHS guidance issued by the National Institute of Health and Care Excellence (Nice) recommended that stroke patients receive at least three hours of rehabilitation five days a week. Yet the current provision is falling well below the new target.
“Research shows that frequent and more intense rehabilitation leads to better recovery following a stroke, but many stroke survivors only receive a fraction of what these guidelines suggest,” says Dr Maeva May, associate director for policy and influencing at the Stroke Association.
“Sadly, we know that, despite incredible efforts by NHS staff, few stroke survivors are getting recommended levels of rehab – there isn’t the workforce capacity to deliver the care patients need and it is placing recoveries at risk.”
Yet the need is growing all the time. Currently, every five minutes someone has a stroke in the UK, and between 2015 and 2035, the number is projected to increase by 60 per cent according to a 2020 study published in the British Geriatric Society’s Age and Ageing Journal.
Around a third of sufferers will go on to have another stroke and each year there are around 38,000 stroke-related deaths.
There is some good news. Stroke-related deaths have declined by 49 per cent in the past 15 years, thanks to a combination of better prevention and treatment. This leaves 1.3 million stroke survivors in Britain, many of whom require some form of rehabilitation.
Rehabilitation protocols vary hugely between patients. Everyone will have their own programme, goals and ability level. There are no one-size-fits-all silver bullets to recover. However, stroke patients can adopt some simple strategies, where appropriate, to help independent rehabilitation if they can’t access specialist support.
Frequent rehabilitation leads to better recovery following a stroke, but many survivors only receive a fraction of what these guidelines suggest
Exercise to the best of your ability
One of the most effective things patients can do is to exercise, according to experts, who take pains to point out that this must be done in conjunction with clinical rehabilitation plans. Exercise can help both physical and neurological recovery as the brain has the ability to create new neural pathways through a process called neuroplasticity, which is boosted by exercise.
Lead physiotherapist at the Queen Elizabeth’s Foundation for Disabled People (QEF), Ellie Kearney, says: “Research shows that intensity and repetitive task practice gets the best results. The more people can practise and do things for themselves, the better the effects. In any rehabilitation, cardiovascular exercise is important and that will be very different depending on ability and mobility. Seated exercise programmes will be more appropriate for some, while for others accessing a gym may be possible.”
Patients can get GP referrals for supervised gym sessions and home physiotherapy sessions.
“It is not a quick fix,” explains Kearney. “It becomes part of a routine, an individualised daily programme, which people do independently.”
Marilla Cameron, neurorehabilitation specialist at Neurokinex, a not-for-profit organisation, which provides activity-based rehabilitation programmes, advises patients to get out of chairs as often as possible.
“Use target-based actions combining full-body movement with a full field of vision,” she says. “Try throwing a ball into a wastepaper basket positioned on the affected side to access this visual field. Move the goal once mastered to promote progress.”
She also recommends deep breathing to oxygenate the blood and aid recovery.
Don’t forget to exercise your brain
Brain function can also be improved in some patients by tackling mental tasks such as puzzles or jigsaws, which can also improve dexterity and enhance short-term memory and reinforce connections in the brain.
Brain teasers such as crosswords, Sudoku, learning a new language, cognitive brain training on apps and talking to people, which help improve communication and also alleviate social isolation, can all boost neural pathways and analytical thinking.
David Werring is professor of neurology at University College London (UCL) and president-elect of the British & Irish Association of Stroke Physicians. “The general maxim ‘use it or lose it’ goes for things like cognition,” he says. “Find something that is enjoyable. That might be puzzle-solving or reading. Anything that challenges the brain is likely to be helpful even though it might be challenging after a stroke, depending on what type of stroke has happened.”
Don’t neglect the hobbies that relax you
Leisure activities can often be overlooked in stroke rehabilitation. Hobbies and pastimes that were previously enjoyed fall by the wayside. Leisure, however, comes with therapeutic benefits, which include mood enhancement and increased wellbeing.
Liz Lightbody is professor of stroke care and improvement at the University of Central Lancaster (UCLan). “About two thirds of patients have reduced participation in activities they valued before their stroke,” she says. “Those aren’t things we traditionally concentrate on in rehabilitation but there is a huge need there.”
One survey of over 3,000 participants, conducted by Prof Lightbody and her team, found that physical leisure activities, such as dancing, sport and even knitting, which requires hand dexterity, were replaced after a stroke with more passive pastimes, such as watching TV.
“Often people are scared to return to leisure activities; they are not sure how much they can push themselves, and whether increasing heart rate might bring on another stroke,” says Prof Lightbody. She advises patients to talk to their rehabilitation specialists or GP first before embarking on leisure activities and recommends exploring adapted options for those with limited function, such as adapted and electric bicycles for cyclists.
Prof Werring reassures that it is “very rarely the case” that activity causes harm. The Stroke Association has information on activities and local groups that organise special events and activities for stroke survivors.
There is a range of different apps designed to enhance rehabilitation. NHS-backed MyTherappy provides links to some of these. UCL has also developed an app to help people with reading after certain types of strokes, while UCLan is piloting a project to deliver a mixture of different therapies, including cognition, communication, psychological support, and physical therapy, remotely via video calls, and is also exploring the delivery of psychological support therapy online.
“A third of patients suffer from depression, a quarter from anxiety and half will suffer from debilitating fatigue,” says Prof Lightbody. “The service provided is inadequate. We don’t have enough clinical psychologists to go around, so we need to think differently about how we support patients.”
Pay attention to symptoms that may not seem obvious
It is important that patients look out for things that they might not necessarily expect to be a consequence of a stroke. These include fatigue, difficulty with sleep and anxiety, all of which can impact rehabilitation.
Family members should be aware of these effects and should offer support where needed. They should also be aware that impulsive behaviour and hostility can also result from strokes, as Dr Monika Hunter, senior lecturer in psychology at London Met’s School of Social Sciences and Professions explains.
“It is essential to help stroke patients to find meaning in life and self-acceptance while fostering hope. Hence, social support is crucial,” she says.
For those caring for stroke survivors who are undergoing rehabilitation, which can often be slow and frustrating, she advises using clear and straightforward communication with visual aids if necessary, avoiding metaphors or symbolic language and “modifying interaction styles to reduce emotional escalation”.
“Relaxation or distraction techniques, such as walking away from upsetting situations or listening to music, can be beneficial. Encouraging stroke survivors to set goals, both short-term and long-term, and breaking down problems into smaller parts can also help them to better organise their thoughts and prioritise their rehabilitation efforts,” she explains.