IM18.15-16 | Stroke Rehabilitation and Counselling — Summary & Reflection

KEY TAKEAWAYS

Stroke rehabilitation is multidisciplinary, begins within 24–48 hours, and continues for 12 months or beyond.

Indications for rehabilitation (by deficit): motor deficit → physiotherapy; dysphagia → speech therapy day 1; aphasia → speech therapy; ADL/neglect → occupational therapy; depression → SSRI (escitalopram) + psychological support; spasticity → baclofen/tizanidine oral, or botulinum toxin type A for focal spasticity.

Phases:
- Acute (days 1–14): early mobilisation, dysphagia screen, prevent complications
- Sub-acute (weeks 2–12): maximum neuroplasticity window; ≥45 min PT/day; inpatient rehabilitation if available; CIMT for arm paresis
- Community (3–12 months+): outpatient, maintenance, vocational rehabilitation

Prognosis communication:
- NIHSS <6 at 24–72h → 70–80% independence at 3 months
- Motor recovery maximum at 3–6 months; language recovery slower, continues to 1–2 years
- Post-stroke depression: 30–35%; treat actively; PHQ-9 screen every visit
- SPIKES protocol for structured bad-news communication

Specific counselling topics: driving (formal assessment required, minimum 3–6 months); secondary prevention (antiplatelet/anticoagulant/statin/BP/diabetes); sexual function (raise proactively); post-stroke epilepsy (5–10%, no prophylactic AED); RESTART trial — antiplatelet after ICH with vascular indication is evidence-based.

Carer support: assess at every visit; respite and support groups; carer burnout predicts poor survivor outcomes.

REFLECT

Return to Mr Rajan Pillai in the hook. His wife has asked: 'Will he ever walk again? Will he speak properly? Should we put him in a home?' You now have the framework to answer. Walking: likely, with intensive physiotherapy over the next 3–6 months — his NIHSS has fallen, and he is only 3 weeks post-stroke, still in the peak neuroplasticity window. Speaking: Broca's aphasia with preserved comprehension has a reasonable recovery trajectory with intensive speech therapy — he will communicate again, though possibly not in exactly the same way. Home: he does not need institutional care — he needs intensive outpatient rehabilitation and a home that is adapted to his current needs.

But Mr Pillai himself is watching you, unable to speak freely, understanding every word. The deeper reflection is this: in post-stroke care, the patient is often present but silenced by aphasia, disability, or assumed incompetence. What protocols do you have — in your documentation, your consultation style, your use of communication aids — to ensure that Mr Pillai's own goals and preferences are captured, not just his wife's? Rehabilitation is ultimately goal-directed work. Without the patient's goals, it is guesswork.