INPATIENT REHABILITATION POST STROKE
B. Subacute Stroke Rehabilitation

Subacute stroke rehabilitation is the next level of care for stroke patients. In the subacute stage of stroke, interventions should be intensive, challenging, task specific and tailored towards the individual needs of the patients. Evidence has shown that that relatively greater functional improvements are made by patients rehabilitated on specialized stroke units when compared to general medical units in the long term (level 1a).

1. General Inclusion Criteria for Stroke Rehabilitation

Transfer Criteria to Subacute Rehabilitation Facility

Whilst transfer criteria differs from place to place and depends on the services available at the subacute rehabilitation facility, some general criteria for transfer from acute to subacute level of rehabilitation may be applied:

  • All investigations required for determining the nature and cause of stroke have been completed.
    All required interventions for secondary preventions have been optimized.
  • Medical stability has been achieved with satisfactory control of blood pressure and diabetes mellitus.
  • Patient continues to need close physician supervision.
  • Patient continues to need specialized nursing care.
  • Patient is cognitively able to engage meaningfully in therapies and demonstrate carry-over.
  • Patient is able to tolerate higher intensity of therapies.
  • Patient requires more than one therapy input daily.
  • Patient and family have been suitably counselled to accept lesser level of medical surveillance and higher intensity of rehabilitation.
  • Inpatient rehabilitation goals expectations are discussed with patients and carer.
  • Patient and family have agreed to the transfer and fully understand its need

Four exclusion criteria for subacute rehabilitation sted below based on consensus opinion.

  • Person with stroke has returned to pre-morbid function, i.e. made a full recovery in all aspects including physical, emotional, psychological and cognitive function.
  • Palliation: death is imminent; person with stroke should be referred to the palliative care team.
  • Coma/non-responsive (not drowsy).
  • Patients’s refusal to rehabilitation

2. Subacute Rehabilitation Facility

The subacute rehabilitation facility for stroke patients should have an integrated multidisciplinary set up for provision of this level of rehabilitation. The patient should be offered intensive therapies. We recommend that for optimal functioning a facility should at least meet the following standards:

  • The physical space and environment should be optimal and conducive to adequately accommodate the number of patients a given facility is likely to serve.
  • The multidisciplinary team should include the following categories of staff:
    • Physician(s) with expertise in neurorehabilitation.
    • Rehabilitation-trained nurses.
    • Neurological physical therapists.
    • Neurological occupational therapists.
    • Neurological speech and language therapist with expertise in dysphagia management and communication rehabilitation.
    • Dietician(s).
    • Social worker(s)/case manager(s).
    • When available, the provision of neuropsychological and orthoptic services is recommended.
  • The facility should have:
    • links with or access to orthotic, neurological, urological, psychiatry, ophthalmology and general medical services
    • all essential therapy equipment and aids.
    • dedicated therapy areas, e.g. for physiotherapy, occupational therapy and speech and language therapy.
    • Social networking spaces and provision for community re-integration (shopping, leisure trips, etc.) are desirable.
  • The ideal staff to patient ratios have not been optimally evaluated and differ in various settings. We recommend that the following ratios be considered for planning such facilities (MSQH and MOH):
    • Physician (with expertise in neurorehabilitation) to patient ratio should not exceed 1 to 20 inpatients.
    • Nurse to patient ratio: No more than 4 patients to one nurse.
    • Physiotherapist to patient ratio: No more than 8 patients to one physiotherapist
    • Occupational therapist to patient ratio: No more than 8 patients to one occupational therapist.
    • Speech and language therapist to patient ratio: No more than 20 patients to one speech and language therapist.
    • Neuropsychologist to patient ratio : No more 40 patients to one Neuropsychologist is recommended.

3. Subacute Rehabilitation

    • After admission, the patient should be provided with structured care. The facility should have standardized policies for all sessions and domains of care. These include:
      • Functional mobility training including transfer training, truncal balance training, gait training and higher balance training. For those with severe physical impairment- therapeutic ambulation training with properequipmentand where necessary training for full or semi-independence from wheelchair mobility. Management of cognitive-communication impairment and cognitive rehabilitation.
      • Management of perceptual deficits.
      • Management of dysphagia with the aim of retraining for oral feeding where this is possible to do safely.
      • Participation in activities of daily living.
      • Upper limb retraining including task specific repetition practices with or without adaptive equipments.
      • Neuropathic pain management.
      • Spasticity management.
      • Management of mood disorder.
      • Management of bladder and bowel dysfunction.
      • Prevention of secondary complications of stroke and optimise all modifiable risk factors.
      • Caregiver training closer to discharge.
      • Patient and family education on secondary stroke prevention and reintegration to the community.
      • Adjustment and “beginning to live with disability” training.
      • Readiness for discharge to home or modified living.

 

    • The following are some guiding parameters in this context:
      • Patient(s) should undergo full multidisciplinary team (MDT) assessment within 24–72 h of admission.
      • The MDT should develop a goal-directed care plan with specific timelines.
      • The patient and family should be fully briefed about the care plan which would be adjusted after taking into consideration their suggestions and concerns.
      • The progress of the patient should be reviewed by the MDT at least every week and goals and care plan are modified to adjust for change.
      • Discharge planning should start early, preferably within 1 week of admission.
      • Periodic patient and family meetings should be held to brief them about the progress.
      • Discharge planning meetings must always[i] be convened.

 

  • A minimum of three hours a day of scheduled therapy (occupational therapy and physiotherapy) is recommended, ensuring at least two hours of active task practice occurs during this time. (Lohse et al. 2014 [26]; Schneider et al. 2016 [32])

4. Health Facilities Providing npatient Acute / Subacute Rehabilitation

    • Acute / Hyperacute Stroke Rehabilitation :
      • All major state government hospitals
      • Public University hospitals
      • Private rehabilitation hospitals with rehabilitation physicians and MDT rehabilitation teams
  • Subacute Stroke Rehabilitation
    • All Major State Government Hospital
    • Universities Hospitals
    • Private Rehabilitation Hospital with Rehabilitation Physician and MDT Rehabilitation Team
    • Rehabilitation Hospitals [k]Centres with MDT Rehabilitation Team ( Hospital Rehabilitasi Cheras / PERKESO Rehabilitation Centre / Private Rehabilitation Centre)
    • Government District Hospital with Program Kontinuum Rehabilitasi Stroke ( PKRS)