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Here at Manchester Neuro Physio, I often provide Physiotherapy treatment to clients who have had a Stroke. For these clients, like all my clients, I want to give the best possible treatment which I can. One of the best ways I can do this is making sure that my practice follows what research states is best for patient care and rehabilitation.

The fifth edition of the National Clinical guidelines for Stroke came out in October 2016. Here all of the most up to date and best quality research in Stroke is collected together and is used to help guide clinicians like me in their treatment approaches.

I decided to see what’s new in this edition and have a ponder about how the information will affect me and my practice here at physio.co.uk. Here is what I learned!

Intensity of Therapy

Therapy should be:

1. Accumulation of 45 minutes of therapy a day.

2. In the first 2 weeks post stroke, mobility rehab should frequent, short and every day

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45 Minutes a Day

The recommendation of 45 minutes of therapy each day after stroke is not new. This recommendation was present in the last guidelines and aims to ensure clients are getting the amount of therapy needed to make improvements.

What does this mean to me and my practice?

Repetition is key. Practice needs to happen every day! Educating and empowering my clients and their family, friends or carer is essential to make this happen. The guidelines emphasise the accumulation of 45 minutes a day. Here are 5 ways that I can help my clients accumulate that much-needed practice:
1. One to one therapy time
The guidelines suggest that the number of available therapists should be increased and rehabilitation services should reorganise to increase the proportion of time each therapist spends in face-to-face contact with clients.

2. Exercise programmes
Photographs, videos, diagrams or written programmes. Clients are not going to be able to practice out with therapy time unless they have a clear individualised programme that they are able to follow easily and independently.

3. Activities of daily living
The guidelines recommend that therapy targeted at other activities of daily living should be task-specific, progressive and practised frequently, and incorporated into routine activities over 24 hours every day of the week
Getting dressed in the morning, making a cup of tea, going out to lunch with friends, playing bridge, going to church, cleaning the kitchen worktops. All these tasks can contribute to activity levels. Thinking of previous activity levels and hobbies can be really helpful and all helps to contribute to practice. Modifying these and gradually reincorporating tasks is a key part of rehabilitation.

4. Using technologies to increase the amount of time spent active. Using computer-assisted therapy.
Things like simple pedometers to track steps taken. Apps which can be downloaded and used on your phone to play games and undertake exercises. my-therappy is a website where information regarding apps for use after stroke and brain injury. These apps have been trialled and are rated by clinicians. Using technologies such as robotics, gloves, virtual reality, sensors and interactive metronomes can help get that much-needed practice in an interactive and stimulating way. Making practice a personal challenge or a fun way to track progress helps motivation. Tasks that clients are motivated to do produces better results!

5. Group sessions
For my practice, looking into local services and helping clients integrate into the community is key. There are such a wide variety of resources to tap into, such as walking groups and exercise classes- from chair based exercises to tai chi classes. There are lots to choose from and find what might suit my client and their needs is part of my role.Neurological PhysiotherapyMobility practice should be short, frequent and every day in the first 2 weeks after stroke

“The large international AVERT trial suggested that in the first two weeks after stroke, therapy targeted at the recovery of mobility should be redesigned around frequent, short interventions, except for those people who require little or no assistance to mobilise.”
“Patients with difficulty moving early after stroke who are medically stable should be offered frequent, short daily mobilisations (sitting out of bed, standing or walking) by appropriately trained staff with access to appropriate equipment, typically beginning between 24 and 48 hours of stroke onset. Mobilisation within 24 hours of onset should only be for patients who require little or no assistance to mobilise.”

What does this mean to me and my practice?

Working in longer term rehabilitation, this will likely have little impact on my current practice. This information looks set to redesign current acute stroke services, where therapy can historically be given within sessions, but out with these sessions clients can face long periods of inactivity for clients, with little chance for practice. An interesting and important point to learn is that the trial showed extra mobilisation (in addition to usual care) within 24 hours of stroke onset led to greater disability at three months with no effect on immobility-related complications or walking recovery.

Electro-mechanical assisted gait

Another new aspect of this recommendation is advice regarding gait (walking) rehabilitation. The highest priority for many clients who have difficulties with their mobility after stroke is to walk independently. It is stated in these guidelines, as well in lots of other rehabilitation guidance, that goal setting should take place. The person who has had a stroke, alongside family and carers if they wish, should find treatment goals which are individual to them, meaningful, challenging and have personal value. As clients often have their main goal as walking, knowing what the evidence recommends for improving walking is of great importance. Research shows again that repetition is key.

“People with stroke who are able to walk with or without assistance should undergo task-specific walking training with a cardiorespiratory and/or muscle strength focus at sufficient intensity to improve endurance and walking speed”.
“People who are able to walk independently after stroke should be offered treadmill training with or without body weight support or other walking-orientated interventions at a higher intensity than usual care and as an adjunct to other treatments.”

What does this mean to me and my practice?

This evidence has got me thinking about my current practice, and I will now be encouraging the clients who I treat who fall into this category to attend our clinics at St John’s Street, Minshull Street and Sale, where we have access to treadmills as well as the body weight support treadmills which I can use as part of their treatment plan. Historically, I considered treadmill training for those individuals who required more assistance to walk, however now I will be keeping in mind the benefits of treadmill training for those who are able to walk on their own.
“People who cannot walk independently after stroke should be considered for electromechanical-assisted gait training including body weight support.”

What does this mean to me and my practice?

This is a new addition to the guideline and not an area of practice which I had any experience of prior.
The Cochrane Library (a database of systematic reviews) reviewed the research papers which either assessed the effects of an exoskeleton robot driven orthosis or an electrical mechanical solution with 2 driven footplates simulating the different phases of gait. Full details of this can be found here – Cochrane.
The conclusion of the Cochrane review was that people who receive electro-mechanical gait training in combination with Physiotherapy after Stroke are more likely to achieve independent walking than people who receive gait training without these devices. It was noted that people in the first 3 months after their Stroke who were not able to walk seemed to benefit the most from this treatment. The authors did note that more research is needed in this field. Here you can see myself and my colleagues trying out an exoskeleton – My Twitter. I am looking forwards to learning more about these technologies and incorporating them in my practice here at physio.co.uk!Neurological Physiotherapy

Useful resources

Exercise programmes:

www.physiotherapyexercises.com

Technologies:

www.my-therappy.co.uk

Electro-mechanical assisted gait:

www.hocoma.com

Group sessions:

www.nhs.uk

www.ageuk.org.uk

www.differentstrokes.co.uk

www.walkingforhealth.org.uk

www.manchestersportandleisure.org

6 responses to “Stroke guidelines 2012 to 2016 – What’s new?”

  1. Natasha says:

    Thank you for sharing!

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  6. Thomas says:

    Great post! Have nice day ! 🙂 73g4x

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