All patients with acute stroke should be assessed to determine the severity of stroke and early rehabilitation needs.
All patients admitted to hospital with acute stroke should have an initial assessment, conducted by rehabilitation professionals, as soon as possible after admission [Evidence Level A].
The core rehabilitation professional team should include Rehabilitation Physician, or other physicians with expertise/core training in stroke rehabilitation, occupational therapists, physiotherapists, speech-language pathologists, nurses, social workers and dietitians [Evidence Level A].
All professional members of the rehabilitation team should have specialized training in stroke care and recovery [Evidence Level A].
In this setting, the main goal of rehabilitation should be to prevent early complications and assess safety and feasibility of early mobilization (Coleman et al. 2017). In this context the key domains of care are:
a. Impact of stroke with particular focus on presenting impairments and their severity (impairment mapping).
b. Co-morbidities and their premorbid impact on function.
c. Pre-existing musculoskeletal conditions and/or deformities.
d. Pre-existing disability(ies).
e. Family setup and support.
f. Work and social status.
a. Early swallow screening by a trained professional, who is adequately trained in dysphagia management or by another professional (nurse or doctor), is recommended (Palli et al. 2017)
b. The patient should not be fed orally or given oral medications unless cleared by swallow screening (Duncan et al. 2005).
c. Enteral feeding should be initiated early in patients with dysphagia to avoid malnourishment. This should be considered as soon as it is clinically established that the patient is not able to swallow, as the delay in introducing the enteral feeding should not exceed 3 days (Yamada 2015; Ojo and Brooke 2016).
d. Evidence indicate that early insertion of per-endoscopic gastrostomy (PEG) tube should be avoided (George et al. 2017).
e. In patients requiring enteral feeding, nasogastric tube feeding is recommended for as long as 3 weeks, beyond which insertion of PEG may be considered (George et al. 2017). Please note that nasogastric tube feeding can be associated with regurgitation and aspiration if the patient lies down immediately after a meal. Practice pearl: If nasogastric tube feeding is prolonged, early PEG tube insertion should be considered. In practice insertion on PEG also depends on
i. Availability of the staff / professionals to insert the PEG
ii. The patient (preference and medical status)
iii. Family and environmental support
An important role of rehabilitation team in early rehabilitation is prevention of complications. This has now been highlighted as key responsibility of rehabilitation teams in hyperacute and acute rehabilitation settings (Winstein et al. 2016). The rehabilitation team must take steps to prevent, rapidly detect and treat:
a. Malnutrition and dehydration.
b. Pressure sores.[d]
c. Aspiration-related chest infections.
d. Over dependence on ancillary devices such as urinary catheter, tracheostomy tube and feeding tube.
e. Contractures.
f. Excessive muscle wasting.
g. Hemiplegic sShoulder pain subluxation
h. Agitation and restlessness.
i. Mood disorder/depression
j. Bladder disorders eg; urinary tract infection, incontinence, acute urinary retention
k. Bowel disorders – constipation, impaction, diarrhea
For stroke patients, starting intensive out-of-bed activities within 24 hours of stroke onset is not recommended. (Rethnam et al. 2020 [14], Langhorne et al. 2018 [15], Bernhardt et al. 2015 [9])
All stroke patients should commence mobilization (out-of-bed activity) within 48 hours of stroke onset unless otherwise contraindicated (e.g. receiving end-of-life care). (Bernhardt et al. 2015 [9]; Lynch et al. 2014 [10])
For patients with mild and moderate stroke, frequent, short sessions of out-of-bed activity should be provided within 24 hours, but the optimal duration is unclear. (Bernhardt et al. 2015)