Rehabilitation of patients after stroke has been central to the development of rehabilitation since the 1970s. Confirmation that stroke rehabilitation units improved outcomes, including reducing mortality, transformed the standing of rehabilitation. (here) This evidence was not the first proof of the effectiveness of rehabilitation, but it was the first recognised proof. The transformation of the prognosis after acute spinal cord injury from a predictable early death to a whole life was only recognised as proof sometime later. Therefore all organisations concerned with stroke are likely to be part of any UK national rehabilitation community.
Stroke as an exemplar
Patients who have had a stroke have clinical problems that cover almost every aspect of rehabilitation. Consequently, clinical professionals need excellent rehabilitation expertise and services to manage patients with nearly any problem in all settings.
Clinically, the losses range from minor (as judged externally) after a transient ischaemic attack or minor stroke to severe, for example, when someone is in a prolonged disorder of consciousness. [Stroke is one of the common causes of this state. (here)] They can range from complete motor loss with preserved cognition, as in the locked-in syndrome, to severe anterograde amnesia and blindness from a posterior cerebral infarction affecting hippocampi and visual cortices. Recovery can occur over a few days or weeks, or not at all. Though predominantly a disorder of people aged over 65 years, it can occur at any age. So-called ‘behavioural problems’ are relatively infrequent after cerebral thrombotic infarction but occur after subarachnoid haemorrhage.
Stroke patients will need rehabilitation in every possible setting: the intensive care unit, high-dependency ward, regular acute hospital medical ward; in other hospital wards such a cardiological wards, long-stay wards, and renal wards; in nursing homes and different residential settings; and at home. More importantly, rehabilitation needs to be seamless, following the patient as they transfer from setting to setting.
Stroke patients also need services not simply over the first few months but potentially indefinitely. Stroke is a recurrent disorder, and patients can have further strokes. Some patients enter a phase of slowly progressive loss.
Also, since most patients are relatively old, they will often have other complicating conditions such as osteoarthritis of hips and knees or heart failure.
The rehabilitation challenges presented by stroke are as complex as any.
Therefore, one could consider stroke as an exemplar condition. How well do we manage stroke? If we manage it well, we are also likely to manage other conditions well. We are improving (from a low base) with early acute care. (here) Data from the community and care homes are still incomplete, but rehabilitation is patchy and limited.
Stroke physician training and rehabilitation
Stroke medicine has been recognised as a speciality by the General Medical Council since 2007, the same year that Rehabilitation Medicine was recognised as a speciality. Formal training in stroke medicine is always a part of another speciality’s training programme. It is available to trainees in Neurology, Geriatric Medicine and Acute Internal Medicine without any barrier.
However, it is now a speciality that participates in acute, unselected medical take, so all trainees need urgent care medical skills. Rehabilitation Medicine trainees with the necessary Core Medical Training can undertake Stroke Specialist training. Other rehabilitation trainees can and should gain experience but cannot acquire certified specialist training.
The curriculum for Stroke Medicine (here) has three Capabilities in Practice (see here if unfamiliar with these). One concerns acute treatment and the second concerns primary and secondary prevention. The third is “Managing early and late stroke rehabilitation in hospital and community settings.” The descriptors given suggest that trainees will have limited expertise in rehabilitation. For example, the descriptors do not include using the biopsychosocial model of illness or undertaking formulation and setting goals. The role seems supervisory, ensuring rehabilitation occurs, rather than an active engagement on rehabilitation.
This curriculum overview suggests that, quite appropriately, there is an emphasis on medical aspects of stroke management. The importance of rehabilitation is acknowledged, but the training only gives limited expertise in rehabilitation. Some patients are likely to need access to more significant rehabilitation expertise.
British Association of Stroke Physicians.
The British Association of Stroke Physicians was founded in 1999 to promote stroke medicine within the UK. (here) Members of the association have been central to the development of stroke services. The Association has formal links with many influential groups, as the list of affiliated societies shows. (here) Members and the Association are closely involved with the UK Stroke Forum annual meetings, a large and influential gathering every year, and the Intercollegiate Stroke Working Party which has been very effective over the last 25 years.
Its primary focus is on the medical aspects of stroke, including service delivery. Its active educational links are primarily with stroke and neurological organisations. However, it does have an association with the British Geriatric Society, which recognises that stroke is a disease of the elderly.
Stroke and Rehabilitation Community
All organisations associated with stroke will inevitably be interested in rehabilitation because the great majority of patients who have a stroke are left with some disability after the first 24 hours, needing rehabilitation. Some organisations will have a strong focus on rehabilitation, but others less so. The British Association of Stroke Physicians illustrates this: it acknowledges the importance of rehabilitation, supports rehabilitation research and the development of rehabilitation, and its members acquire some expertise but limited.
Stroke services can give much to the rehabilitation community. They have developed mechanisms to audit service delivery and outcome on a population level, which is unrivalled anywhere in the world. I am referring to the Sentinel Stroke National Audit Programme, usually referred to as SSNAP. (here) The UK Rehabilitation Outcomes Collaborative (UKROC) for inpatient rehabilitation services and the Trauma Audit and Research Network (TARN) for major trauma are much less comprehensive or complete. Many of the processes can be adapted for general use.
Conclusions
Organisations that have a significant interest in stroke would be essential in any UK National Rehabilitation Community. And, if a community develops, stroke patients would benefit from those organisations being part of the community. The British Association of Stroke Physicians would be one of several vital members.