National Clinical Guideline for Stroke for the UK and Ireland: Part ll – The challenges and opportunities posed for occupational therapists

In last month’s editorial we outlined the new recommendations from the National Clinical Guideline for Stroke (2023) that impact occupational therapists and how they practice along the stroke pathway. In this edition we will explore the opportunities and challenges these recommendations present for occupational therapy practice in stroke.

Principles of rehabilitation

Culture

While changes to the proposed staffing levels are eye-catching and have certainly garnered much attention since the launch, the new guidelines underline an important cultural shift in post-stroke rehabilitation. Reorienting services towards commissioning and delivering need-led services could easily be overlooked, but it is a key tenet of the guidelines. Perhaps the most outstanding example of this culture shift is the new chapter on ‘rehabilitation potential’, which calls for an end to the phrase ‘no rehab potential’ (Goodwin and Cowley, 2022; Lam Wai Shun et al., 2022; Oliver, 2022). This joins calls from others, who have recently suggested that the concept of rehabilitation potential lacks clear rationale and is often used to manage demand on stretched rehabilitation services. It is hoped that occupational therapists will embrace this unique opportunity to realign their practice with the core philosophies of their profession, which have been under severe tension in previous decades, to meet a medicalised approach to stroke care.

Stroke services

There are significant changes to the recommendation for timeliness of assessment by an occupational therapist. The new 24 hours target requires the delivery of a seven-day service that will pose increased demand on staffing. Further demands on staffing are clear from the need-led focus, regardless of discharge destination, thereby requiring an expansion of occupational therapy services across the stroke pathway to include re-access to services. This increasing demand for occupational therapy post-stroke, comes at a time of significant pressures on services alongside an ageing and increasingly multi-morbid population (Kingston et al., 2018). The change in approach advocated by the guidelines aligns more than ever with the occupational therapy’s core philosophy of valuing the individual within the context of their physical and psychosocial environment (Townsend and Polatajko, 2007). The new holistic focus of the 6-month post-stroke review and the move away from the previous narrow medical focus create an opportunity for occupational therapy-led reviews.

Workforce

Underpinning the fact that many of the guideline recommendations have implications for the occupational therapy workforce, service structure and the way we work, updated staffing levels are provided to serve as guidance to commissioners of stroke services on the staffing levels required to meet these new recommendations.

Motor recovery and physical effects of stroke

Arm function

There are numerous new recommendations in this section reflecting a substantial increase in the evidence base. This equips us as a profession with a toolkit of evidence-based interventions to be implemented in clinical practice. The primary approach of Repetitive Task Practice coheres with restoring occupational performance through repetitive practice of meaningful tasks identified by stroke survivors. Undoubtedly the new 3 hours of therapy per day (Teasell et al., 2020; Veerbeek, 2014; Stroke Foundation, 2022) for stroke survivors with motor recovery goals, has caused alarm in some quarters regarding the deliverability of such recommendations within current service delivery models.

The Stroke Sentinel National Audit Programme shows that stroke survivors are not receiving the 45 minutes of occupational therapy previously recommended. This is despite the evidence showing that increased amounts of occupational therapy received are associated with less disability and lower rates of institutionalisation (Gittins et al., 2020). The question therefore is ‘how do we achieve higher doses?’. In appropriate circumstances, there will need to be a reorientation of service delivery and culture away from 1:1 therapy sessions towards group and self-practice. Alongside this, new recommendations on tele-rehabilitation may also offer opportunities to meet the new ambitions of these guidelines. Other implementable recommendations include open gyms and increased use of family to support with practice outside of therapy sessions.

Physical activity

Implementing 6 hours of activity will require the whole multidisciplinary team to evaluate how our stroke and rehabilitation units function as a physical and psychosocial environment. With our professional expertise in this area, occupational therapy is well placed to lead these changes to create a more active and engaged environment. Creating ‘enriched environments’, has been shown to be feasible in early research studies (Rosbergen et al., 2019) in both reducing sedentary behaviour which is associated with poorer outcomes (Morton et al., 2019) and in increasing the amount of time spent in active rehabilitation whether cognitive or physical. We as a profession have a crucial role in maximising opportunities for occupational engagement throughout the day, including periods where occupational therapists are not present, by activating family and carers during visiting, and in creating the structures to support stroke survivors to engage in self-practice. This will require occupational therapist to challenge assumptions and routines of the physical and psychosocial hospital environment and to advocate boldly for occupation supported by the recommendations of the guidelines.

Fatigue

The section covering post-stroke fatigue also sees expanded recommendations that are pragmatic and implementable within daily practice. Again, the biopsychosocial approach is recommended for assessment and treatment of fatigue, realigning our practice with our core values. Here, occupational therapists are well equipped to lead.

Psychological effects of stroke

This section now includes both cognition and mood, and will be of keen interest to an occupational therapist and again presents some new challenges but also opportunities.

Cognition

The recommendations will reduce an unnecessary burden on people with stroke and will undoubtedly improve both the depth and quality of assessment received, beyond the broad brush strokes of cognitive screening. They allow for the identification of further needs and goals at time points post-stroke, which are more appropriate for detailed assessment, again reflecting the needs of the person with stroke rather than the confines of service provision. Services where screening is traditionally delivered by support staff will need to consider changes to their practice to meet the current guidelines and further education and training will need to be considered for occupational therapists to be able to select, administer and interpret the results in context.

Mood

As occupational therapists, we will need to consider what additional skills and training are required to deliver the psychological interventions recommended. Knowledge of the stepped and matched care models (Gillham and Clark, 2011; National Institute for Health and Care Excellence, 2022), and how to support post-stroke adjustment is required. This provides opportunities for experienced and skilled occupational therapists to both prevent mood disorders and to manage those with more complex presentations working in conjunction with clinical psychology or neuropsychology. It also places a focus on the occupational therapy teams, ensuring that their workforce feels adequately supported to deliver these interventions.

Return to work (in activity and participation)

The expansion of the recommendations provided for those wishing to return to work is a welcome addition to the guidelines. It is incumbent on occupational therapists to have the appropriate knowledge and skills to be able to support, educate and guide people with stroke, while also engaging with employers to make recommendations to facilitate return to work. This again presents opportunities for the profession with the guidelines recommending that services supporting people back to work have a coordinator or central point of contact, with occupational therapist well placed to be able to fulfil such a role. Fit notes Gov.UK (2022) are also referenced, reflecting the expanded responsibilities for issuing sick notes that allied health professionals, including occupational therapists, have received with a role in issuing fit notes along the pathway.

The future

There are numerous opportunities and challenges posed by the guidelines to occupational therapists working in clinical roles, as managers of services and as researchers. We owe it to stroke survivors and their families to ensure that we familiarise ourselves with these guidelines and that we understand the evidence base underlying the interventions we utilise to improve occupational performance and engagement. There are clear opportunities for occupational therapists, with the profession being ideally placed to embrace the more holistic biopsychosocial approach advocated in the guidelines at 6-month and yearly reviews, in the assessment of fatigue and in the commissioning of need-led services, to name but a few. Woven within the guidelines are further opportunities for occupational therapists to better connect with the social fabric of the communities in which we work to be able to prescribe occupation as a means of supporting the recommendations for stroke survivors to remain physically active. Additionally, those domains in which we have traditionally carved a niche as a profession such as the rehabilitation of arm function, return to work, cognition and psychological support have enhanced recommendations reflecting an improved evidence base to guide improvements in the services we deliver.

If these new guidelines seem overwhelming, anxiety inducing or impossible to achieve in the current climate, remember progress can be achieved. Implementation will take time and we need to just start somewhere and start small. In the wise words of the late Desmond Tutu ‘there is only one way to eat an elephant, a bit at a time’ (Shadyac, 2010).