Prevention and early intervention in neurorehabilitation

Written by Dr Barend ter Haar

The updated National Clinical Guidelines for Stroke¹ were published in April 2023, and the updated NICE Guidelines on Stroke Rehabilitation in Adults² were published in October. These were two documents which received a lot of attention at last December’s UK Stroke Forum in Birmingham. In this article we look at a few of the issues which were discussed in the sessions and on the exhibition floor. These messages under Stroke management are as relevant in many other areas of Neurorehabilitation.

From July 2022 Integrated Care Boards (ICBs) took over from Clinical Commissioning Groups (CCGs). Why is this important? The CCGs were purely involved with NHS-funded patient provision, whereas the ICBs take in other aspects of the patient journey and include Social Care, Third Sector (e.g. Charities), funding, etc. ICBs look at the bigger picture in general, with the intention of enabling a more cohesive and integrated approach, and thereby delivering improved outcomes.

The bigger picture

At the UK Stroke Forum in Birmingham, last December, Dr Rob Morgan from Dorset County Hospital NHS Foundation Trust, illustrated the importance of ICBs in covering stroke provision, and where they cover the total picture – Acute, NHS, Social Care, Domestic support – of the stroke patient journey. Under CCGs it would be Year 1 of a patient’s journey that would be considered on its own, but the major costs come in the years afterwards. From the Stroke Association’s 2015 data: in year 1 the cost of Stroke Patients across England comes out at £1.6 billion (bn) in NHS costs, £0.6 bn in social care costs, £3 bn in ‘informal care’ (i.e. supplied outside state costs), and lost productivity of £0.1bn - a total of £5.3 bn. In subsequent years, the stroke survivors costs are: NHS care £1.8 bn, social care £4.4 bn, informal care £12.5 bn, and lost productivity £1.4 bn – a total of £20.1 bn a year. As can be seen, the financial burden of social and informal care of stroke survivors is huge.

ICBs have four aims:

Improve outcomes in population health and healthcare
Tackle inequalities in outcomes, experience, and access
Enhance productivity and value for money
Help the NHS support broader social and economic development

Two thirds of stroke patients leave hospital with a disability and two thirds with speech and communication challenges. Although stroke mortality has halved, the incidence (Year 1) and prevalence (Year 2+) are rising. There are currently 1.3 million stroke survivors in the UK, and this is set to rise to 2 million by 2035.

Investing in better outcomes

Investing in better earlier intervention and improving outcomes would therefore not only help people have less complex needs over time, but would also reduce the prevalence (i.e. long term) costs, and thus represent an annual cost saving for those survivors, so would offer recurrent savings to all concerned. This is even more critical as we have the financial pressures that, with current survival rates improving, the concurrent costs are increasing substantially, and therefore better outcomes and reduced care needs are even more imperative.

Investing in better outcomes will not be a cash releasing benefit that the NHS will see, but it will lead to cost avoidance later on for Local Authorities. This is the benefit of ICBs considering the total picture.

Early intervention

If this is the case, how can we achieve better outcomes? The updated National Clinical Guidelines for Stroke¹ have upped the recommended hours of therapy. They indicate that people with motor recovery goals undergoing rehabilitation after a stroke should receive a minimum of 3 hours of multidisciplinary therapy, for at least 5 out of every 7 days, to enable the range of required interventions to be delivered at an effective dose. Treatment to help mobility should begin 24 to 48 hours after the stroke and should consist of a number of treatment sessions several times a day.

The continuity of therapy needs to proceed after hospital discharge, and this has often been lacking due to over-stretched resources. Dr Louise Cornell from Lancaster University recounted how 17 years ago research showed that patients were mostly inactive, spending a third of the day sleeping or lying and, sadly, 17 years later the situation had not changed! Telerehabilitation is one solution that is being increasingly explored to allow the small available cohort of therapists to attend to more people in a day. In the North West of England, the Neuro Rehabilitation Online (NROL) programme⁴ allows multiple patients to be covered at one time by a Teams call. This has so far saved thousands of miles of driving, considerable associated costs, and increased the available therapy multifold.

Prevention better than cure

Many people who’ve had a stroke end up with mobility difficulties, and as a result come to depend on a wheelchair. 80% of these individuals develop shoulder subluxation as a result of muscle

weakness creating shoulder joint destabilization, together with gravity pulling down on the head of the humerus bone⁵. This subluxation makes rehabilitation exercise and functional improvement less feasible. Linked to this, 29% of post-stroke patients suffer from shoulder pain⁶.

The Bodypoint Dynamic Arm Support

The National Guidelines¹ have highlighted that research on shoulder pain should be seen as a priority, and some treatments have been given approval within the updated NICE guidelines^2,3. However a means for prevention is not mentioned! At the UK Stroke Forum, a star of the exhibition floor was the recently released prevention tool: the Bodypoint Dynamic Arm Support⁷ (see also the November issue of NR Times). This device supports the arm from dropping down, while allowing lateral movement which also enables dynamic therapy. Feedback from Stroke Ward managers was that this would be ideal, especially while sitting out away from the bed, and do away with badly positioned pillows ineffectively trying to achieve the same end!

The future

Now that the total patient journey cost is being considered by ICBs, and thus getting us away from the previous CCG silo thinking (together with the updated guidelines), there is more chance that we will be seeing increased early intervention, and cost-effective preventative measures. This all points to better outcomes and increased ‘Quality Adjusted Life Years’. This will not only benefit the individual, but also reduce the caring burden (including financially) of their partners and carers.

References

The National Clinical Guideline for Stroke. https://www.stroke.org.uk/professionals/resources-professionals/national-clinical-guideline-stroke
Stroke rehabilitation in adults. NICE guideline [NG236] https://www.nice.org.uk/guidance/ng236
Stroke rehabilitation in adults. Evidence reviews for interventions for shoulder pain after stroke. https://www.nice.org.uk/guidance/ng236/evidence/o-shoulder-pain-pdf-474910116411
https://elht.nhs.uk/services/integrated-therapy-service/neuro-rehabilitation-online
Arya KN, et al. 2018 Rehabilitation methods for reducing shoulder subluxation in post-stroke hemiparesis: a systematic review. Topics in Stroke Rehabilitation 25, 68-81
Adey-Wakeling Z, et al. 2015 Incidence and Associations of Hemiplegic Shoulder Pain Poststroke: Prospective Population-Based Study. Archives of Physical Medicine and Rehabilitation 96, 241-247.
https://www.besrehab.net/find-a-solution/by-brand/bodypoint/dynamic-arm-support/