The latest national clinical guideline for stroke

Editor – The recent Clinical Medicine CME review of stroke is very welcome.¹ May I make three comments?

1. Rudd et al discuss the late effects of stroke purely in terms of the need for further research,¹ but the series of reviews lacks any discussion of these late effects, which can be devastating for those left with severe impairments following one or more strokes. Rodgers and Price discuss inpatient rehabilitation and early supported discharge, but the management of the late effects of stroke is discussed in terms of a referral to ‘other community services’.² This is regrettable as it gives no guidance to the primary care team about the management of stroke following the withdrawal of the early discharge team. Late symptoms of stroke that are amenable to medical intervention include the monitoring of blood pressure, management of fatigue and depressed mood in addition to the ongoing rehabilitation needed to optimise participation. This should be provided by a community-based rehabilitation team when this service is not provided by a hospital-based service.

2. For those experiencing a stroke at working age, a return to work strategy must start in hospital with a preliminary discussion relating to the nature of the patient’s work, advice to remain in contact with their employer and to avoid premature prognostication about potential return to work.³ Patients should be advised that there are many ways of assisting those with residual impairments in returning to employment⁴ although stroke-specific vocational rehabilitation services are notably deficient in the UK.

3. The reviews made no reference to the role of assistive technology in the rehabilitation of those with residual stroke impairments. This is surprising as powered wheelchairs (available through the NHS for those fulfilling specific criteria) can be used for the following aspects of stroke care as described in Box 1 by Rodgers and Price:² activities of daily living, driving, work and leisure, arm function, communication (with communication aids attached to the wheelchair), fatigue, mobility, reduced psychological distress related to immobility, pain management, spasticity, swallowing and vision. Thus, about 6% of 544 users of electric-powered indoor/outdoor wheelchairs provided by a specialist wheelchair service had cerebrovascular disease. Powered wheelchairs are now seen as powerful therapeutic tools⁵ and examples of their use in other chronic neurological conditions have recently been reported.

The recent World Health Organization report provides ‘evidence-based, expert-informed recommendations and good practice statements to support health systems and stakeholders in strengthening and extending high-quality rehabilitation services’.⁶ It is therefore regrettable that a CME section lacks any significant content on the needs of community residing individuals with residual impairments following episodes of cerebrovascular disease.

Conflicts of interest

The author has no conflicts of interest to declare.