Families who are considering restoration after cerebrovascular disease in Thailand are making a decision that is both medical and practical. It must be understood whether the patient is ready to travel or not, how the restoration should proceed after leaving hospital, what the timetable of the treatment will be like, and what level of support from the family or the carer may be needed

Language, privacy, religious practice, needs in respect of food, accommodation, and transport may affect whether a programme abroad can be used or not

A programme of restoration of cerebrovascular disease abroad may be considered when the patient has medical stability and the family wants multidisciplinary care that has coordination. However, the programme must be adjusted specifically to the individual. The diagnosis alone does not set the intensity, the technology, the progress expected, or the suitability for travel. The NICE guideline on restoration after cerebrovascular disease (opens in a new tab) emphasises multidisciplinary restoration according to the needs, joint goals, and the taking part of the family or the carer when the patient wants it

Why families consider restoration after cerebrovascular disease abroad

Some families in the Middle East are interested in restoration at the international level, because they are looking for an approach that has structure, which combines medical assessment, repeated therapy, specialised technology of restoration, and clear goals of functioning

Their priorities may include:

A second assessment of restoration after leaving hospital
Treatment that has structure or is more intensive
Access to a robot for restoring walking or the limbs
A private environment of treatment
Coordination in the Arabic language
The close taking part of the family
Consideration of the prayers, the month of Ramadan, the needs in respect of food, and preferences in respect of the sex of the physician
Planning the following of the result on returning home

Travelling abroad is not automatically the best choice for every survivor of cerebrovascular disease. Families should compare the programme offered with the suitable services that exist near home, and consider whether the benefit that may be possible suits the needs in respect of the travel or not

What survivors of cerebrovascular disease may need after leaving hospital

Leaving hospital usually means that the patient no longer needs to receive acute inpatient care at the same level. It does not mean that the recovery from the cerebrovascular disease is complete

Depending on the position and the severity of the cerebrovascular disease, the survivor may still have a problem with:

Balance in sitting and standing
Transferring between the bed, the chair, and the wheelchair
Walking and using the stairs
The movement of the arm and the hand
Dressing, eating food, washing, or going to the bathroom
Communication
Giving attention and following recommendations
Physical endurance
Confidence while moving

The plan of restoration should begin with the ability of the patient in functioning at present, rather than making an assumption from the date on which the cerebrovascular disease arose alone

Before travelling, the receiving team should understand whether the patient can sit safely for the travel, must use a wheelchair, needs help in transferring or in personal care, can communicate basic needs, and can tolerate repeated periods of restoration

Neurological symptoms that arise anew or worsen must receive a medical assessment immediately, instead of planning the travel as usual

Begin with medical stability and a review of the information before travelling

If it is possible, the team of restoration should examine the clinical information of the patient before the family books the flight and the accommodation

The documents that are of benefit may include:

The summary of the discharge from hospital
The diagnosis of the cerebrovascular disease and the date the symptoms began
The report of the imaging of the brain
The record of the medical or the surgical treatment
The list of current medicines
The medical precautions that are connected
The report of the restoration that has passed
A description of the movement at present and of the caring for oneself
The details concerning the limitations in respect of communication or of perception
Information concerning braces, a wheelchair, or a walking aid

The team may ask for further information concerning sitting, standing, transferring, or walking. The family should confirm which documents and which forms must be used before sending medical information that is sensitive

The review of the information before travelling does not replace the examination of the patient directly, but it helps in assessing in the first stage whether the provider is likely to be able to support the needs or not, whether further medical certification is required or not, and how equipment, access, or a carer should be prepared

The important goals of restoration after cerebrovascular disease

Restoration after cerebrovascular disease should connect the clinical progress with meaningful daily activities. The goal is not merely finishing the exercise or using advanced equipment

Movement and transferring the body

For some patients, the first goal may not be walking independently. It may be sitting without receiving much help, standing safely, transferring with fewer people helping, or following the steps that are supported

Other patients may have to walk a longer distance, on different surfaces, or have more independence in the house and the community

Balance and the reducing of the risk of falling

Cerebrovascular disease may affect the balance, the coordination, the distribution of the weight, and the perception of one side of the body

The training may speak of:

The control of sitting and standing
The transfer of weight
Reaching and turning
Beginning and stopping
Walking with a suitable aid
Confidence during movement in daily life

The level of difficulty should support the progress without overlooking the risk of falling of the patient, the medical state, or the necessity in respect of care

The working of the arm and the hand

The restoration of the upper limb may be connected with the shoulder, the elbow, the wrist, the hand, sensation, and coordination

The goals may include reaching, opening the hand, grasping and releasing an object, supporting the body during transferring, eating food, dressing, caring for the hair, or using both hands together

Even an improvement that is limited may have value when it increases independence or reduces the giving of help by the carer

Independence and confidence in daily life

Restoration should take into account eating food, dressing, hygiene, using the bathroom, moving around the house, communicating needs, and taking part in the life of the family

Confidence develops through repeated experience of completing suitable tasks safely. The patient should receive enough help to reduce the risk, but should still have a meaningful opportunity to take part

How intensive restoration of the nervous system helps the recovery

Intensive restoration of the nervous system relies on repeated training that has a goal and is adjusted according to the state and the ability of the patient

A programme of this kind should be:

Adjusted specifically to the individual
Emphasising the functioning
Repeated sufficiently
Followed up and increased in level
Adjusted according to the fatigue and the tolerance of the treatment

"Intensive" should not mean making the patient exhausted or filling every hour with treatment. The suitable intensity depends on the medical stability, the alertness, the endurance, the pain, the cognition, and the recovery between times

NICE (opens in a new tab) recommends multidisciplinary restoration according to the needs of at least 3 hours a day, at least 5 days a week, for those who can take part, while stressing that more or less should be arranged according to what each person needs. Some people must use shorter periods, rest more, or increase the level gradually. This criterion is a standard of service; it is not a guarantee that a greater number of hours always brings about more recovery

The role of the robot for restoration

A robotic system and a system supporting the weight of the body may help some patients practise walking, balancing, moving the arm, or using the hand with assisting force and repetition. The evidence and the suitability differ according to the equipment, the goals, and the stage of recovery. Having an instrument does not mean that the patient needs to use it or that it gives a better result than training with a therapist that proceeds suitably

These technologies do not replace physicians of rehabilitation medicine, therapists, clinical judgement, or taking part actively

Not every survivor of cerebrovascular disease suits every system. The choosing may depend on the movement of the joints, the muscles, the ability to follow recommendations, the endurance of the heart and the blood vessels, the compatibility of the equipment, the needs in respect of help, and the specific goals of the restoration

Helping the family during the restoration after cerebrovascular disease

For many families, the recovery from cerebrovascular disease is a joint responsibility. Relatives may help in communication, in making decisions, in personal care, in travelling, and in emotional support

Members of the family may need recommendations concerning:

Transferring the body safely
The walking aid
Arranging the position of the arm that has been affected
Encouraging activity without having to force
Communication when there is a limitation of speech
Identifying the tasks that the patient should carry out independently
Recognising symptoms that must receive examination by a physician
Continuing the programme on returning home after departing

Too little help may not be safe, while too much may reduce the chance that the patient will come back to doing things by themselves. The team of restoration can help set the suitable level of support

Care with respect for privacy and culture

Preferences in respect of culture and privacy should be discussed during the planning before arriving, instead of being considered after arriving

Families may want to make clear:

Whether coordination in the Arabic language is necessary or not
Whether a physician or therapist of a particular sex is wanted especially or not
Which member of the family may receive the latest medical information
The way of managing consent and the making of decisions
Whether the times of prayer affect the setting of the timetable or not
Whether the treatment will fall during Ramadan or not
Whether halal food or another preparation of food is necessary or not
Whether an accompanying person should take part in the appointment or not
Whether there is a setting of privacy during the examination or the training of personal care

The provider should state clearly which support in respect of language and which choices of personnel really exist, whether the interpreters have passed training in the medical field or not, and how the needs in respect of religion, food, privacy, consent, and the family will be recorded. The needs within the Middle Eastern community are diverse, so it should be asked instead of guessed

Planning the travel and the accommodation

The travel should be prepared only after the team giving the treatment has considered the medical stability and the readiness of the patient for the travel

The support of the flight and of the airport

The family may have to prepare the medical certification of the airline, help in respect of a wheelchair, a seat that can be accessed, help in transferring the body, a carer travelling together, and suitable transport from the airport. The travel recommendation of the CDC (opens in a new tab) lays down that the airline should be informed in advance when oxygen, a wheelchair, or help in lifting must be used, and that a letter from the physician stating the disease, the medicine, the history of allergy, and the necessary equipment should be carried

The medicine and the necessary medical supplies should be planned carefully. The requirements of each airline differ and should be examined directly before booking

Accommodation and travel that are convenient

A hotel in the vicinity is not suitable for a survivor of cerebrovascular disease. The family should examine:

Access without steps
A lift that can be relied on
Space for a wheelchair
A bathroom for those who have a disability
A safe height of the bed
Space for transferring the body
A room for the carer
A point for getting out of the vehicle that can really be used
A reasonable length of time in travelling to the treatment

Frequent or difficult transfers between the hotel, the vehicle, and the centre of restoration may use the energy that is needed for the therapy

The timetable of the treatment and the rest

The daily plan should take into account the length of time in taking the medicine, the food, the prayers, the sleep, the exhaustion, the travel, the readiness of the carer, and the recovery after a demanding period

The patient may get benefit from intensive restoration while still needing much rest. The exhaustion should be followed rather than interpreted as a lack of effort

Preparing to return home

Before departing, the family should ask for:

A summary of the progress
Recommendations in respect of mobility and of help at present
Exercise at home or a plan of activity
Recommendations on equipment
Recommendations of the carer
Information for the team of restoration at home
A plan of following the result

The value of a programme abroad depends in part on whether it can support the progress after the patient returns home or not

The way of assessing a provider of restoration abroad

The provider should explain the clinical supervision, the professional licences, the emergency plan, the personnel, the fields of the therapy, the process of the interpreter, the equipment, the forms of measurement, the fees, the conditions of cancellation, and the passing on of the medical records back home. Statements in respect of intensity or technology should be connected with goals that have been assessed; they should not be sold as a standard package

The programme should cover more than walking. It may include movement, balance, the arm and the hand, communication, swallowing, cognition, mood, fatigue, and the routine according to the result of the assessment. The family should also confirm which emergencies the medical establishment supports and does not support

The questions that must be asked before confirming the travel

Before making the booking, the family should ask:

Can the physician of rehabilitation medicine examine the medical records before the travel or not?
Does the patient suit the programme offered both medically and in respect of functioning or not?
Which assessments will be completed after arriving?
Which goals of restoration will receive priority?
How will the intensity of the treatment be set?
Which technologies may receive consideration, and for what reason?
Is a full-time carer necessary or not?
Can the requests in respect of language and culture be confirmed or not?
Is this accommodation suitable for the transport service and the use of a wheelchair or not?
Which information for following the result will the team caring at home be provided with?

The centre should explain what can be planned before arriving, and what can be confirmed only after the assessment in person

Review the clinical side completely before deciding to travel

International restoration after cerebrovascular disease should begin with clinical information, goals of functioning, and a realistic understanding of what the patient can tolerate, not with booking a flight or a list of technology

The team giving the treatment at present and the team of restoration at the destination may have to use the summary of the discharge, the report of the diagnostic images, the list of medicines, the record of the therapy that has passed, and a description of the movement and of the needs in respect of care at present. The medical records should be sent through a safe channel, after the identity of the provider and the conditions of privacy have been confirmed

A review in the first stage helps make clear whether restoration abroad is reasonable both medically and practically or not, what further must be assessed, and whether there is a suitable choice near home that reduces the burden of the travel or not