See also section 5.1
This section encompasses guidelines and evidence from therapies which are designed to help patients adapt to their impairments, so that they may participate as fully as possible in their chosen daily activities of life. Adaptive therapies include the teaching of new skills, the provision of information, the use of problem-solving aids or appliances and environmental modification. The topics covered range from a relatively restricted area such as self-care to environmental changes.
4.7.1 Activities of daily living
Much of stroke rehabilitation aims, directly or indirectly, to increase independence and ability in all activities of daily living (ADL), not only personal (eg dressing) but also domestic (eg cooking) and communal (eg shopping). Many of the techniques described earlier in this section might help in this task. Furthermore it has been convincingly shown that organised rehabilitation directly improves ADL. However, there is little research on direct treatment techniques.
Recommendations
a All patients with difficulties in ADL should be assessed by an occupational therapist with specialist knowledge in neurological rehabilitation (A)
b All patients should be assessed by an occupational therapist within four working days of referral (C)
c Patients showing unexplained persistent difficulties in ADL should be assessed specifically for perceptual impairments (B)
d Patients with difficulties in ADL should be treated by a specialist multidisciplinary team that includes an occupational therapist (A)
e All patients must be given opportunities to practise personal ADL and, as appropriate, relevant domestic and community activities (D)
f Patients should be offered advice on, and treatment aimed to achieve, employment or wanted leisure activities as appropriate (D)
Evidence (Table 4.7.1)
a Walker et al 1999; Gilbertson et al 2000 (Ib)
b National Association of Neurological Occupational Therapists (NANOT) standards 2002
c Lincoln et al 1997 (IIb)
d Stroke Unit Trialists’ Collaboration 2004; Walker et al 1999 (Ia) e Consensus of working party (IV)
f Consensus of working party (IV)
Local guidelines
Local guidelines will need to specify:
1 the availability of, and means of access to, therapeutic areas such as kitchens;
2 how to undertake and achieve expert advice and treatment to return to employment.
Patient’s view: Letting me do things on my own, which is wonderful really. Even buttering bread – they see I was having difficulty but they were just standing there, ‘Go on Bill!’ (73 year old man)
Patient’s view: The only thing that worries me is that I mustn’t let my husband do everything for me. Yes, but he knows. I’ve already prepared him that he has to let me, doesn’t matter if it takes me all day. I have to do it. He understands that. (68 year old woman)
4.7.2 Equipment and adaptations (personal aids)
Small timely changes in an individual’s local ‘environment’ can greatly increase independence, for example the use of a wheelchair, walking stick or adapted cutlery. Many of these ‘treatments’ are so simple and small that it is unlikely that anyone will ever research into them. This section covers small items for personal use.
Recommendations
a The need for special equipment should be assessed on an individual basis; once provided the value and need for equipment should be evaluated on a regular basis (B)
b Patients should be supplied as soon as possible with all aids, adaptations and equipment they need (A)
Evidence (Tables 4.7.2)
a Gladman et al 1995; Mann et al 1995; Logan et al 1997 (IIa)
b Huck & Bonhotal 1997; Mann et al 1999 demonstrated cost effectiveness of equipment provision for elderly patients (not just stroke) (Ib)
Local guidelines
Local clinicians will need to:
1 formulate local policies concerning assessment for equipment, and its supply and retrieval;
2 agree funding arrangements and budgets with all funding organisations (eg social services);
3 ensure that orthoses are made or fitted correctly for the individual patient.
Patient’s view: What I’d really like, I’d like one of them reclining chairs …. that you can lie back and at night when I can’t sleep in my bed, cos I can’t sleep on my back. I’ve got chronic bronchitis, I can’t sleep on the other side with my shoulder and it’s very awkward. I’ve not had, I’ve never had a night’s sleep since I came out of hospital. (65 year old man)
4.7.3 Equipment and adaptations (environment)
Equipment and adaptations in this context refers to any larger items or structural changes needed to alleviate the impact of a stroke-related impairment. Many patients have residual disability that can be helped by adapting their environment on a larger scale, for example with stairlifts, hoists, perching stools or adaptations to buildings.
Recommendations
a Every patient who is at home or leaving hospital should be assessed fully to determine whether equipment or adaptations can increase safety or independence (A)
b Prescription of equipment and adaptations should be based on careful assessment of the patient and the physical and social environment in which it is to be used (B) c All equipment supplied should have proven reliability and safety (C)
d The patient and/or caregiver should be thoroughly trained in the safe and effective use of any equipment supplied (D)
e The suitability and use of equipment should be reviewed over time as needs will change (B)
f All patients should be given a contact number for future advice or help with equipment provided (D)
Evidence (Tables 4.7.3)
The evidence is largely secondary, derived from observations in RCTs or from surveys.
a Chamberlain et al 1981; Hesse et al 1996b; Mann et al 1999; Logan et al 1997; Audit Commission Report ‘Fully equipped’ 2000, and 2002 (Ib)
b Gitlin et al 1993: Neville-Jan et al 1993 (III) c Gardner et al 1993 (IV)
d Consensus of working party (IV)
e Bynum & Rogers 1987; Sonn et al 1996 (III) f Consensus of working party (IV)
Local guidelines
Local guidelines will need to specify:
1 how equipment is accessed locally;
2 local eligibility criteria for each piece of equipment;
3 how it is funded locally.
Patient’s view: I couldn’t get in and out [of my house]... I could hardly get up my drive... I waited one full year before I could have the rail from the front door down to the gate. It took us a year to get that, and a lot of trouble for the wife.
Carer’s view: We got a lot of help when he came out, more than I would have thought, but I think we’re probably quite lucky living in this area because the help is there. It just appeared, all this help – I never asked for anything.
Patient’s view: Financial, financially, you know. Financially, it’s come down, down, down. (61 year old man)
5 Transfer to community
The majority of patients will be managed in hospital initially. The time of transfer from inpatient hospital care to home (or residential or nursing home care) constitutes an important watershed. There is some research-based evidence that this is often poorly managed.