5.3 Early coordinated multidisciplinary rehabilitation

Early rehabilitation improves outcomes for stroke  patients[301]. Patients who get care and rehabilitation in a stroke unit (i.e. a multi-disciplinary team of medical, nursing and therapy staff who meet at least once a week) rather than on a general medical hospital ward, are less likely to die and less likely to be dependent on other people after they leave hospital[226].

However, the therapies that patients can access often depend on where in a country they live (e.g. Belgium[302], Netherlands[9], Portugal[303], UK[237]). In some countries, specialised neurology/stroke inpatient rehabilitation centres have very limited capacity or are non-existent (Bulgaria[304]; Croatia[305]; Cyprus[306]; Ireland[307], Lithuania[308], Poland[308] and Slovakia[9]).

There is wide variation across Europe in how well countries meet their targets for assessment and rehabilitation. Early multidisciplinary assessment is one example. In Sweden the national stroke audit records whether eligible patients are assessed by a multidisciplinary team within 48 hours of admission.

“I was six weeks in emergency care, nearly six months in total in hospital, and afterwards directly in rehabilitation. That means I was half a year away from home. I continued my therapies, my rehabilitation therapies over seven years…they kept me too long in the hospital because I was a private patient. I should have gone three months earlier to rehabilitation. I think that would have helped a lot.”
(Female stroke survivor, Austria)

This target is met for 78% of patients[309]. In contrast, in Ireland, although two thirds of applicable patients have a physiotherapy assessment within 48 hours of admission, less than half of patients have an occupational therapy assessment in that timeframe[129].

Early multidisciplinary therapies in hospitals are meant to be standard practice across Europe but in some countries access is inadequate e.g. Austria,[9]; Finland[310]; Ireland[129] or many patients are often not treated early enough. For example, in one study in Poland about half of patients were not seen for rehabilitation within 3 months[311].

Across Europe, access to therapies other than physiotherapy can be especially poor. For example, in some countries patients do not usually get occupational therapy and/or psychological therapy.

This is the case for occupational therapy in Bulgaria[9], Croatia[9], Cyprus[306], Italy[244], and Slovakia[9] ; and for psychological therapies in Bulgaria[9], Croatia[9], Czech Republic[9], Ireland[312] and the UK[161].

There is little data collected across Europe on how much therapy patients actually get. The available data suggests that patients get therapies for only brief periods of each day in hospital, due to e.g. time pressures and staff availability[313, 314].

For example, in a Netherlands study (of physiotherapists across most acute hospital stroke units) patients only had an average of 22 minutes per day of exercise therapy on weekdays[314]. In the UK during a similar time period, patients had physiotherapy on only half of the days they were in hospital, giving an average per day of stay of under 15 minutes vs a target of 27 minutes[315] (provision in the UK has on average improved since then[55]). Some evidence suggests that more formal management of therapy, for instance having defined phases of rehabilitation, can improve provision as therapists spend more time with patients and less time on nontherapeutic activities[313].

“I think that receiving psychological support, not only for myself but also for my family, since the beginning of the ‘illness’ would have been very positive…It was very difficult to be away from my children [while in rehabilitation centre] … the fear of dying or being stuck in a wheelchair forever …”
(Female stroke survivor, Portugal)