Rehabilitation and recovery – sensory effects of stroke

There is no good evidence to support any particular passive or active intervention for sensory impairment after stroke.  Studies evaluating mirror therapy (Thieme et al., 2012) and electrical stimulation (Veerbeek et al., 2014b) show promising results but further research is needed into specific interventions as part of goal-directed rehabilitation (Pollock et al., 2014b). [2016]

All patients with stroke should be screened for visual impairment early after their stroke. Given that visual impairment is frequently asymptomatic, screening should be carried out by those with the appropriate knowledge and skills, such as an occupational therapist, or with specialist skills in visual assessment, such as an orthoptist or optometrist. These specialists can carry out further assessment and targeted treatment specific to the type of visual impairment (Rowe, 2017). One study found that it is feasible to undertake a visual screen for most patients within the first 3 days after stroke and a full visual assessment within 4 days (Rowe et al, 2019). Therefore, a visual screen could be completed in the same 72-hour time frame as other therapy assessments, given that visual problems can impact on delivery of other rehabilitation interventions. [2023]

An agreed visual care pathway is required to ensure appropriate access to a range of specialists, including orthoptists, ophthalmologists, optometrists and low vision rehabilitation workers. Recommendations for orthoptist staffing levels in hyperacute and acute stroke units are set out in a British and Irish Orthoptists Society consensus document (British and Irish Orthoptic Society, 2021) which advises orthoptic staffing for hyperacute units as 0.4 WTE/10 beds, and for acute units as 0.2 WTE/10 beds. Specialists are required for identification of post-stroke visual impairment, diagnosis of eye movement disorders and the assessment of functional and driving implications (also see Section 4.14 Driving). [2023]

With regard to visual impairment of central vision and eye movement deficits, management may include interventions such as compensatory (e.g. head scanning training to adjust for poor eye movements), substitutive (e.g. magnifiers to increase print size) and restitutive (e.g. botulinum toxin/eye muscle surgery to correct strabismus) approaches, which require referral to specialist eye services. [2023]

For people with visual field loss after stroke, interventions are proposed to work by either compensating for the visual field defect by changing their behaviour or activity, substituting for the defect by using devices such as prisms to shift the field of view from the affected side, or restoring the visual field through repetitive stimulation of the affected field of vision. Compensatory training includes both visual scanning training, which involves repetitive symmetrical movements to each (right/left) side and visual search training, which involves repeatedly looking for (searching) for objects on each side. A Cochrane review found that there is limited, low quality evidence that compensatory training, and in particular visual scanning and search training, may be more beneficial than placebo, sham or control at improving quality of life, but not other outcomes (Hanna & Rowe, 2017; Howard & Rowe, 2018; Liu et al, 2019; Pollock et al, 2019). There is insufficient evidence to reach any generalised conclusions about the effect of substitutive interventions (prisms) or restitutive interventions as compared to placebo, control, or no treatment. There is low-quality evidence that prisms may cause minor adverse events (Pollock et al, 2019). All these areas warrant further research. [2023]