Restoring movement after cerebrovascular disease may require training transferring, standing, walking, turning, balance, and movement in daily life anew. The plan should correspond with the diagnosis, medical stability, the impairments, the previous capability, the goals, fatigue, cognition, communication, the condition of the home, and the help available. More therapy or more technology is not automatically better. Rehabilitation should hold to the needs of the person, be safe, and be adjusted according to the response.
If there is a drooping face, weakness or numbness of the limbs on one side, difficulty speaking, sudden change in vision, a severe headache, or sudden loss of balance, whether newly arisen or recurring, an emergency assessment for cerebrovascular disease must be received. Do not wait for the rehabilitation appointment.
When should restoring movement begin
Patients with acute cerebrovascular disease should be helped to sit out of bed, stand, or walk as soon as the clinical state allows, under a specialist stroke service. However, NICE does not recommend high-intensity mobilisation in the first 24 hours (opens in a new tab) if the patient still needs someone to help them sit, stand, or walk. The timing and the amount of training must take account of the neurological state, the blood pressure, the stability of the heart and breathing, fatigue, the level of consciousness, and other acute risks.
For continuing rehabilitation, the NICE guideline on stroke rehabilitation (opens in a new tab) recommends multidisciplinary therapy according to need for at least 3 hours a day, at least 5 days a week, when the patient is able and agrees to take part. If they are unable or do not want to do 3 hours a day, the necessary therapy should still be given no fewer than 5 days a week. These figures are recommendations for services, not targets to be forced through pain, severe fatigue, or a medical state that is not yet stable.
The assessment determines the priorities and the intensity
The assessment may cover transferring, the control of the trunk, strength, sensation, coordination, muscle tone, the range of movement of the joints, balance, the pattern of walking, endurance, cognition, vision, neglect, footwear, and the risk of falling. The goals should be meaningful and measurable, such as getting up from a chair with less assistance, going to the toilet safely, walking a set route in the house, or going up and down a step at home.
Progress after cerebrovascular disease differs and cannot be predicted from the diagnosis alone. The review should consider both the benefits and any unwanted responses. Pain, great fatigue, dizziness, difficulty breathing, new neurological symptoms, or repeated near-falls may require the plan to be adjusted or a medical assessment.
Repeated task-specific training
NICE recommends repetitive task training for a weak leg, which includes getting up and sitting down, walking, and going up and down stairs. The training should be specific enough to develop the activities that matter, while caring for the accompanying factors, such as strength, the range of movement, balance, or endurance.
Examples of the training are
- Training transferring repeatedly, using the safest level of assistance
- Transferring weight, stepping, turning, and stopping
- Walking on surfaces and distances that relate to the real environment
- Strength and aerobic training adjusted according to the medical state
- Training in doing two tasks at once, or training in the community, when the basic safety is already sufficient
The number of repetitions should be increased gradually. The goal is not repetition of poor or unsafe quality, and sometimes the use of a compensatory posture may be suitable if it increases safety and self-reliance.
Walking aids, supportive devices, and technology
A walking stick, a walking frame, a wheelchair, or other mobility equipment should be chosen after an assessment, adjusted to the right size, and trained in the environment in which it will really be used. The patient and the carer should understand transferring, the use of the brakes, stairs, changes of level, and when someone must help.
An ankle-foot orthosis may be considered when lifting the toes or the control while bearing weight affects the walking. A qualified expert should assess the fit, the comfort, the skin, the ability to put it on, and the effect on the safety of the walking. The device must be reviewed when the strength, the muscle tone, the swelling, or the movement changes.
Robotic gait training or training on a treadmill with or without a body-weight support system may help some patients train stepping repeatedly. These technologies are a supplement, not a substitute for clinical reasoning or for training in real tasks. The choice should take account of medical stability, the ability to take part, the goals, the staff, the fit of the equipment, and the transfer of the result to movement in daily life, without guaranteeing that the person will walk by themselves.
Preventing falls and safety at home
The risk of falling after cerebrovascular disease may relate to reduced strength, abnormal sensation or vision, neglect, impulsiveness, dizziness, the effects of medicines, urgency of urination, unsuitable footwear, or obstacles. The care may include supervised training of balance and walking, suitable equipment, training the carer, a review of medicines, an assessment of the eyesight, and adjusting the lighting, the floor, the stairs, the bathroom, or the arrangement of the furniture.
A fall or a near-fall should be brought for a review of the event, not for blame. There should be a medical examination after a knock to the head, new neurological symptoms, severe pain, being unable to bear weight, or a clearly reduced ability.
Rehabilitation and preventing a further cerebrovascular event
Restoring movement helps with function, but it does not by itself prevent a further cerebrovascular event. Secondary prevention may include antiplatelet or anticoagulant medicines where there is an indication, control of blood pressure and lipids, care of diabetes, giving up smoking, physical activity, diet, and treatment of atrial fibrillation or other causes. Medicines should be reviewed with the stroke team and not adjusted by yourself.
The family should know the signals of cerebrovascular disease and the local emergency number. Familiar symptoms should not be regarded as "part of recovery" if they arise suddenly or get worse.
Long-term review and goals that change
Recovery may continue after leaving hospital, and a period in which progress is steady does not always mean that there is no opportunity to increase function. The goals, the equipment, falls, pain, fatigue, mood, participation, and the needs of the carer should be reviewed when the context changes. NICE recommends reviewing health and social needs at 6 months and every year after that, while urgent problems should be dealt with before the scheduled time.
Frequently asked questions
Is more intensive therapy always better
No. Rehabilitation should give training that is meaningful enough while still being safe and tolerable. The intensity in the guidelines holds to the needs of the person and is multidisciplinary. It must be adjusted when the patient's medical condition is not stable, when they cannot take part, or when there are adverse effects.
Is training walking alone enough
Walking is important, but movement may also require training transferring, balance, strength, endurance, cognition, vision, adjusting the home, and the carer. The components depend on the results of the assessment and the goals.
Does robotic gait training suit everyone
No. Technology may help train stepping repeatedly in some patients, but it does not replace training on real ground or guarantee a better outcome. Suitability depends on medical stability, body size, the ability to move, safety, tolerance, the goals, and supervision by trained people.
In summary
Restoring movement after cerebrovascular disease should begin when it is clinically suitable and continue at an intensity in which the patient can take part safely. Assessment specific to the individual, repeated task training, suitable equipment, preventing falls, preventing a further event, and regular review matter more than the instruments or the place alone