Available data support the usefulness of a coordinated rehabilitation program for treating stroke-related functional impairment. Such a rehabilitation program may also reduce mortality. The rehabilitation program should provide an environment of high motivation to help achieve the patient’s maximal physical and psychological functional capacity and should be tailored to meet the needs of each patient and family. For planning and implementing this program most effectively, a coordinated, interdisciplinary team approach is required. Besides a physician who is knowledgeable in stroke rehabilitation, the composition of the team varies but often includes rehabilitation nurses, physical therapists, occupational therapists, speech therapists, psychologists, and social workers. The roles of key members of the multidisciplinary team (MDT) are usually as follows. The consultant physician coordinating the MDT should ideally be a dedicated specialist with a specific interest in stroke. The doctor should monitor the patient medically for complications from the stroke and optimize management to prevent stroke recurrence and medical complications. Nursing staff should be shown how to handle stroke patients, without causing injury. They should be educated in rehabilitation principles, decubitus ulcer prevention, and management of continence. They should exercise emotional and psychological expertise in their interaction with stroke patients and their families. The nursing team provides other members of the MDT with information regarding the patient’s progress in the care/treatment plans from their observation of the patient 24 hours a day. In addition, nurses must reinforce the plan of action implemented by other members of the MDT (such as the exercise and mobility plan initiated by the physical therapists). Nurse staffing levels should be sufficient to ensure the safety of stroke patients. Physical therapists should gain experience in managing stroke patients. In particular, the protection of the hemiplegic shoulder and arm should be emphasized, and this important activity should be followed by other members of the MDT. A major goal of the physical therapist is to optimize mobility. The occupational therapist should aim to enhance function, reeducate, and, if possible, reapply the life role for the patient. The occupational therapist has an important role with regard to perceptive and cognitive assessments. A functional assessment, both in the hospital and in the patient’s home, is essential in most cases. Therapy to optimize function should be ongoing. During the acute phase of the stroke, patients should be assessed for dysphagia either by the speech/language therapist or by the occupational therapist. This will require ongoing monitoring in the rehabilitation ward. For inpatients who are unable to swallow, an alternative feeding route should be used (if not already in place) soon after transfer to the rehabilitation ward. Patients with communication/language difficulty should receive long-term
speech therapy. A social worker should provide patient and caregiver support and initiate community support services at the time of discharge. They also facilitate the transition to skilled nursing facility care should that be necessary after the rehabilitation center stay. The pharmacist should review medications critically, collaborate with the other caregivers in providing a medication listing on discharge, assist staff in supervising a self-medication program, and provide assistance to patients and their families in promoting compliance. The dietitian should ensure that patients receive adequate nutrition and coordinate provision of feeding that is appropriate to patient needs. The dietitian should work closely with the speech/language therapist, particularly in cases in which alternative feeding is required. For inpatients with hyperlipidemia or diabetes, appropriate advice should be offered. It is also advisable to get a clinical neuropsychologist involved in the early evaluation and treatment of stroke survivors, especially for young patients with cognitive deficits. Discharge planning should begin early in the course of admission and involve full collaboration with primary healthcare and local social services. Community-based rehabilitation services should develop partnerships with hospital-based stroke services.

Rehabilitation should be started with early, systematic, and realistic increases in the patient’s activities and should be advanced in stages in a local hospital, in an outpatient clinic, at home, or in a specialized rehabilitation unit. The program must include rehabilitation that is specific to the deficit. For productive rehabilitation, the patient must willingly participate and have the cognitive ability to follow at least one-step commands and the memory to remember the lessons learned in therapy. For patients who have cerebrovascular disease and who have significant cardiac dysfunction (such as angina, arrhythmia, or myocardial infarction), the rehabilitation program should be combined with a cardiac rehabilitation program. The frequency of rehabilitation treatment sessions varies with the setting and timing after a stroke and with the patient’s response to therapy. Generally, therapy is provided twice daily in an inpatient setting; 3 times per week in an outpatient setting; and daily, when requested by a physician, in a nursing home setting. On the basis of the Mayo Clinic experience, approximately 50% of patients who survive an ischemic stroke for 1 week are good candidates that benefit from physical therapy (the median number of sessions is 16); 40% benefit from occupational therapy (the median number of sessions is eight); and 13% benefit from speech therapy. Approximately 15% of patients eventually are transferred to a rehabilitation unit, in which the median duration of stay is about 32 days. Approximately half of the patients who survive for 6 months after stroke are partially or totally dependent in activities of daily living such as bathing, dressing, feeding, and mobility (including 10% of survivors who need long-term nursing care). About one third of patients who survive after stroke for 1 year are unable to remain independent, and this proportion remains relatively unchanged in survivors who are followed up for as long as 5 years.