What are the key components of a rehabilitation plan for a patient recovering from a stroke?

A rehabilitation plan for a patient recovering from a stroke should include the following key components:

• Specialist stroke service involvement: Rehabilitation should be delivered by a specialist stroke service, either in a dedicated stroke unit, a level 1 or 2 specialist inpatient neurorehabilitation unit, or by a specialist stroke team in the community, including early supported discharge options.
• Multidisciplinary team approach: The rehabilitation team should be multidisciplinary, including consultant physicians specialising in stroke or rehabilitation medicine, nurses, physiotherapists, occupational therapists, speech and language therapists, dietitians, clinical psychologists or neuropsychologists, orthoptists, rehabilitation assistants, and social workers.
• Individualised goal setting: Rehabilitation sessions must be tailored to the person’s goals, medical needs (including post-stroke fatigue), psychological factors, and interests, with the person’s agreement.
• Environment and facilities: Rehabilitation should take place in an environment equipped with dedicated stroke rehabilitation facilities such as a bed area, dining area, gym, and access to assessment kitchens.
• Involvement of family and carers: Families and carers should be involved in rehabilitation sessions when appropriate to support recovery.
• Addressing communication and cognitive needs: Special arrangements should be made for patients with communication or cognitive impairments, for example, joint speech and language therapy and physiotherapy sessions.
• Support for social participation: The plan should include support for participation in community activities, social roles (work, education, volunteering, leisure, family, sexual relationships), and provide information about transport and driving.
• Use of telerehabilitation: Consider telerehabilitation as an alternative or adjunct to face-to-face therapy if it aligns with the patient’s preferences and rehabilitation goals, ensuring appropriate equipment and support are provided.
• Information and education: Provide tailored information to the patient and their carers, considering any impairments such as aphasia or cognitive difficulties.
• Ongoing assessment and review: Regular review of health and social care needs should be conducted at 6 months post-stroke and annually thereafter, including assessment of participation in everyday activities and carers’ needs.
• Coordination of care: Clear documentation and communication of roles and responsibilities within the multidisciplinary team throughout the care pathway are essential.

These components ensure a comprehensive, person-centred rehabilitation plan that addresses physical, psychological, social, and practical needs after stroke.

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