Organising rehabilitation

	SPREAD V Ed.			Prognosis and organisation of post-acute care

Prognosis and organisation of post-acute care

R 14.1 Grade D	After the acute phase of stroke, structured care of disabled patients is recommended, programming the interventions in dedicated, multidisciplinary services taking into account the long-term needs of the patient.
S 14-1	Care activities for rehabilitation of patients with stroke are different according to the timing of intervention, and the involvement of different professional figures depends on proposed goals, patient’s clinical conditions and available resources.
S 14-2	The selection of post-acute patients to be addressed to rehabilitation services is based upon benefit likelihood and resource availability.
R 14.2 *GPP	It is recommended to establish an efficient organization dedicated to stroke patient care through an expert, multidisciplinary teamwork. According to the available resources, the team should comprise non-medical (nurses, physiotherapists, speech therapists, occupational therapists, neuropsychologists, social workers) as well as medical (physicians specialized in cerebrovascular disease management, general physicians) professionals, with the involvement of patients organisations’ representatives.
R 14.3 Grade D	The identification of predictors of functional recovery is recommended, to adequately programme the care interventions and allocate the available resources.
S 14-3	Elderly age does not limit the functional recovery after stroke, unless it is associated with negative outcome predictors.
S 14-4	Female sex is a weak predictor of unfavourable outcome. A higher risk for institutionalisation is reported in female subjects compared with married males, but a clear causal relationship between these factors has not been found.
S 14-5	Patients who were institutionalised at stroke onset are at high risk of further deterioration of their functional independence.
S 14-6	Non disabling comorbidities of stroke patients can negatively influence mortality rate, but they do not reduce the level of functional recovery despite a possible delay.
S 14-7	Total anterior cerebral infarctions, defined according to Bamford classification, independently of the side, are associated with higher residual disability. There are no significant differences of functional outcome for the other Bamford's subtypes.
R 14.4 Grade D	It is recommended to plan the rehabilitation treatment according to predictors of dependency, such as stroke severity at onset (coma, incontinence, severe neurological impairment) or other specific clinical features (severe muscle tone disturbances, dysphagia, hemineglect, global aphasia).
S 14-8	Coma at stroke onset, persisting urinary and bowel incontinence and persistent paralysis are negative predictors of independence.
S 14-9	Persistent flaccidity or severe spasticity negatively influence motor recovery.
S 14-10	Severe aphasia negatively affects recovery of independence in activities of daily living.
S 14-11	Spatial hemineglect negatively affects functional recovery.
S 14-12	Apraxia is a negative prognostic predictor of functional recovery.
S 14-13	Patients with dysphagia have a risk of pneumonia more than three times higher than those without dysphagia. Such risk becomes extremely high among patients with aspiration.
S 14-14	A moderate disability and recovery of trunk control are associated with a higher effectiveness of the rehabilitation treatment.
R 14.5 Grade D	Functional assessment by means of validated scales is recommended in planning the rehabilitation treatment of stroke patients.
R 14.6 Grade D	An early screening for mood disturbances is recommended as part of the rehabilitation assessment of stroke patients. The diagnosis of depression should be made according to a multidimensional approach and by means of standardised scales for evaluating and monitoring symptoms.
S 14-15	Functional Magnetic Resonance allows to evaluate the activation of some cerebral areas during the functional re-organization that occurs post-stroke and to record the changes attending the rehabilitation procedures.
S 14-16	Given the facilities provided by the Italian National Health Service, the socio-economic level of stroke patients should not play a predictive role on recovery. Familiar and social networks favour returning home from hospital and support long term care. Length of hospital stay may be reduced by active involvement of caregivers in rehabilitation planning and by an efficient healthcare and social local support.
S 14-17	Referral of stroke patients to dedicated multidisciplinary Stroke Units is associated with a better functional outcome.
R 14.7 Grade C	The rehabilitation treatment should be initiated as soon as the general patient's conditions make it feasible.
S 14-18	Rehabilitative options may be provided within the context of a network of dedicated services that are differentiated into intensive or extensive rehabilitation according to type and intensity of interventions.
R 14.8 Grade C	Intensive rehabilitation should be performed within the context of a tailored network of both inpatient and outpatient dedicated services.
R 14.9 Grade C	Referral to territorial rehabilitative services is recommended for stroke patients with minor residual disability.
R 14.10 Grade B	Factors such as elderly age and neurological severity of stroke should not be considered as exclusion criteria for accessing hospital rehabilitation.
R 14.11 Grade A	In patients with slight-to-moderate disability following stroke, early discharge from the rehabilitation hospital is recommended if territorial services are able to provide a teamwork as dedicated and expert as that acting in the hospital.
R 14.12 *GPP	Hospital units dedicated to stroke care are recommended to adopt discharge protocols and local operating procedures and to issue timely advice to the territorial inpatient or outpatient rehabilitation services.
R 14.13 *GPP	Before hospital discharge of a stroke survivor, planning territorial transfer of care is recommended by involving the patient, the caregivers and the family physician and by activating social and healthcare local services.
R 14.14 Grade D	Planning a day-hospital rehabilitation approach is recommended for those patients who need continuation of intensive, multidisciplinary (physiotherapy, logotherapy, cognitive and occupational) rehabilitation after hospital discharge.
R 14.15 Grade D	Planning ambulatory rehabilitation is recommended for those patients who need an interdisciplinary, rehabilitative care but not an intensive approach.
R 14.16 Grade D	Home rehabilitation is recommended when patients and caregivers need a specific training in performing exercises and mobilisation, in using aids and prostheses or in practicing occupational therapy activities.
R 14.17 Grade A	To limit the progression of disability and improve the activities of daily living, programmes of occupational therapy should be activated at the territorial level.
R 14.18 Grade C	Supervised exercises are recommended during the chronic phase to maintain and improved the acquired abilities. Also the non-supervised self-managed exercises have some efficacy.
R 14.19 Grade D	Caregivers should be provided with all the aids useful to help the stroke patients and to safely perform positioning and transfer.
R 14.20 Grade D	Before hospital discharge of stroke patients, assessment of home is recommended to set up all the appropriate adaptations.
R 14.21 Grade B	A multidisciplinary team should review the long-term rehabilitation needs of stroke survivors living at home within one year after stroke onset.
S 14-19	Stroke is a frequent cause of death and disability in the elderly. In elderly patients, disability following stroke often overlap with that due to comorbidities.
R 14.22 Grade D	The territorial stroke care team should regularly (every 6 months) assess ability and participation of elderly stroke patients to daily activities.
R 14.23 Grade D	Stroke survivors should undergo regular cardiovascular and metabolic assessments, as well as monitoring of body weight, to control cerebrovascular risk factors and to adjust the pharmacological therapy according to clinical and laboratory changes.
R 14.24 Grade D	Rehabilitation planned to prevent the loss of autonomy long after the event is recommended if focussed on the most relevant objectives (e.g., locomotion). Rehabilitation of stroke survivors long after the event is recommended in case of deterioration of functional status and it should be aimed at achieving specific rehabilitative goals.
R 14.25 *GPP	A long-term rehabilitation programme promoting independence in daily activities is recommended to reduce the deterioration of the independence status obtained by the intensive or extensive rehabilitation.
R 14.26 *GPP	Assessment and treatment of comorbidities are recommended during rehabilitation of elderly patients.
R 14.27 Grade B	A multidimensional geriatric assessment is recommended in planning the rehabilitative interventions for elderly patients.
R 14.28 Grade D	Services for elderly patients should be organised as a network directed by the Geriatric Evaluation Unit and coordinated by a case manager who assesses the care needs and addresses the patients to the best fitting service.
S 14-20	Oldest patients are often excluded from rehabilitation for no valid reasons. This approach considerably limits their possible recovery and the preservation of their functional independence.
R 14.29 *GPP	Rehabilitative protocols for elderly patients are recommended to be flexible and to have a longer duration than in younger patients, if necessary.
S 14-21	In the rehabilitative phase of stroke patients, nutritional strategies aim at preventing and treating malnutrition. Planning of nutritional treatment is based on the assessment of swallowing function, on the use of diagnostic protocols to evaluate nutritional status and nutritional risk and on the implementation of procedures for appropriate nutritional management during hospital stay. Nutritional needs should be gradually met, especially after prolonged fasting or in case of nutritional disturbances.
R 14.30 *GPP	Overweight or obese subjects should gradually reach a sustained decrease of body weight post stroke. is recommended to reach a BMI <25 kg/m² and waist circumference <88 cm in women and <102 cm in men or, at least, reach a body weight decrease of 10%-15% from the initial body weight.
R 14.31 a Grade D	It is recommended that non-dysphagic patients with normal nutritional status are fed with normal oral diet tailored to the age- and sex-related nutritional needs according to the Italian Recommended Nutrients Levels (LARN). Vitamin supplementation should be used in case of hyperhomocysteinaemia. Disease-specific diets have to be applied in case of comorbidities.
R 14.31 b Grade D	In non-dysphagic patients with protein-energy malnutrition, it is recommended to increase the dietary intake to obtain a gradual correction of the nutritional deficiencies, also through nutritional supplementation or enriched food, if necessary.
R 14.31 c Grade B	In patients with protein-energy malnutrition and a proven insufficient dietetic intake, enteral nutrition by means of naso-gastric tube or percutaneous endoscopic gastrostomy (PEG) tube is recommended.
S 14-22	The dietary treatment of dysphagia consists of modification of food and liquid density according to four different levels of bolus consistency: mashed food, chopped food, soft food and modified normal food. Nutritional supplementation is suggested if dietary intake is insufficient.
R 14.32 a Grade C	In dysphagic patients who can have an adequate oral nutritional intake, a progressively modified diet is recommended according to four different levels of bolus consistency: mashed food, chopped food, soft food and modified normal food. In cases of severe dysphagia, artificial nutrition is recommended.
R 14.32 b *GPP	The hospital catering operators should be trained on the techniques to prepare modified-consistency diets.
S 14-23	At the time of discharge, the members of the rehabilitative team provide the patient and the carers with a dietetic programme designed according to the patient's needs and the practical information that favours reaching the energy, fluid and nutritional requirements. The carers should be informed and trained on how to monitor the nutritional status at home, by checking the body weight and the food intake.
R 14.33 a *GPP	Patients, carers and relatives should be informed on the food management techniques (how to prepare and enrich food, optimal posture, appropriate aids to administer the food).
R 14.33 b *GPP	At the time of discharge, it is indicated to train the carers on body weight monitoring and on the assessment of the dietary intake.
S 14-24	Advice and education on stroke and on the most appropriate behaviour may be useful in any phase of the disease, if given in a proper way. Further studies are needed to investigate what kind of information and which modality of diffusion are the most appropriate to implement. Patients and caregivers should be involved in designing such studies.
R 14.34 Grade A	Education and advice of patients and carers have a relevant role for stroke awareness. Such interventions are recommended to be performed through regular meetings between patients, caregivers and members of the interdisciplinary team.
R 14.35 Grade D	From the acute phase of stroke up to social reintegration, appropriate places and scheduled times are recommended to be set for promoting meeting, talking and collaboration with the patient.
R 14.36 Grade D	Interventions, targeted to promote education and participation of caregivers and patients to the care activities, are recommended because they can improve psychological well-being of stroke patients and help rehabilitation.
R 14.37 Grade D	Implementation of a dedicated phone line answered by expert personnel is recommended for stroke survivors and their carers to plan interventions and to provide counselling whenever necessary.

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