What are the recommendations for stroke rehabilitation in a low-resource setting?

Stroke Rehabilitation in Low-Resource Settings

In low-resource settings, stroke rehabilitation should focus on community-based approaches with caregiver training, early initiation of rehabilitation, and at least three hours of therapy on five days per week when possible, with home-based care as a viable alternative when inpatient facilities are unavailable. 1

Core Rehabilitation Principles for Low-Resource Settings

Early Initiation and Intensity

• Begin rehabilitation as soon as the patient is medically stable 1
• Aim for at least 3 hours of therapy daily, 5 days per week 1
• When full intensity cannot be achieved due to resource constraints, ensure therapy is still offered at least 5 days per week 1
• Early supported discharge is appropriate for medically stable patients with mild to moderate impairment, provided community rehabilitation is available 1

Community-Based Model

• Implement home-based care and rehabilitation when inpatient facilities are unavailable 1
• Utilize "step-down" facilities for patients who are stable but need continued care 1
• Develop community participation programs that can be implemented with minimal resources 1
• Train caregivers to be active participants in the rehabilitation process 1

Specific Rehabilitation Interventions

Low-Cost Effective Interventions

• Upper limb rehabilitation:

  • Constraint-induced movement therapy
  • Mirror therapy
  • These interventions have strong evidence (Level I) for improving upper limb function 2

• Lower limb rehabilitation:

  • Multimodal interventions including motor imagery for gait improvement
  • Sit-to-stand training for balance (Level II evidence) 2

Interdisciplinary Approach

• Utilize a specialized multidisciplinary team (MDT) when available 1
• Include physiotherapy, occupational therapy, and speech therapy 1
• Ensure regular communication between team members to work toward common goals 1

Implementation in Resource-Constrained Settings

Workforce Development

• Provide in-service training for healthcare professionals and home-based carers 1
• Train nurse practitioners and community health workers to monitor blood pressure and medication compliance 1
• Strengthen the rehabilitation workforce to improve outcomes 2

Education and Training

• Implement stroke education for caregivers and patients 1
• Address cultural sensitivities when discussing rehabilitation interventions 1
• Promote awareness of stroke and cardiovascular risk factors in the community 1

Eligibility Considerations

• Initial stroke severity is an important predictor of rehabilitation outcome 1
• Prestroke disability affects outcomes but should not automatically exclude patients from rehabilitation 1
• For patients unable to participate actively, provide passive movements to prevent contractures and pressure sores 1

Assessment and Monitoring

Key Assessments

• Conduct standardized assessment of fatigue in early rehabilitation and at six-month review 1
• Screen for hearing problems within six weeks after stroke 1
• Consider using validated scales like the Fatigue Severity Scale 1

Common Pitfalls and Challenges

• Pitfall: Early discharge without adequate community support increases mortality 1

  • Solution: Ensure community-based rehabilitation is in place before discharge

• Pitfall: Excluding patients with prestroke dependency from rehabilitation 1

  • Solution: Consider rehabilitation for all patients, adapting intensity based on individual capacity

• Pitfall: Inadequate caregiver training leading to poor outcomes 1

  • Solution: Implement structured caregiver education programs

• Pitfall: Low therapy doses, especially after the first 3 months post-stroke 3

  • Solution: Maintain rehabilitation throughout the first year after stroke 1

By implementing these evidence-based approaches, even resource-constrained settings can provide effective stroke rehabilitation, improving functional outcomes and quality of life for stroke survivors.