Stroke rehabilitation in adults

1.1.1 People with disability after stroke should receive rehabilitation in a dedicated stroke inpatient unit and subsequently from a specialist stroke team within the community.

1.1.2 An inpatient stroke rehabilitation service should consist of the following:

1.1.3 A core multidisciplinary stroke rehabilitation team should comprise the following professionals with expertise in stroke rehabilitation:

1.1.4 Throughout the care pathway, the roles and responsibilities of the core multidisciplinary stroke rehabilitation team should be clearly documented and communicated to the person and their family or carer.

1.1.5 Members of the core multidisciplinary stroke team should screen the person with stroke for a range of impairments and disabilities, in order to inform and direct further assessment and treatment.

1.1.6 Health and social care professionals should work collaboratively to ensure a social care assessment is carried out promptly, where needed, before the person with stroke is transferred from hospital to the community. The assessment should:

1.1.7 Offer training in care (for example, in moving and handling and helping with dressing) to family members or carers who are willing and able to be involved in supporting the person after their stroke.

1.1.8 Offer early supported discharge to people with stroke who are able to transfer from bed to chair independently or with assistance, as long as a safe and secure environment can be provided.

1.1.9 Early supported discharge should be part of a skilled stroke rehabilitation service and should consist of the same intensity of therapy and range of multidisciplinary skills available in hospital. It should not result in a delay in delivery of care.

1.1.10 Hospitals should have systems in place to ensure that:

1.1.11 Before transfer from hospital to home or to a care setting, discuss and agree a health and social care plan with the person with stroke and their family or carer (as appropriate), and provide this to all relevant health and social care providers.

1.1.12 Before transfer of care from hospital to home for people with stroke:

1.1.13 On transfer of care from hospital to the community, provide information to all relevant health and social care professionals and the person with stroke. This should include:

1.1.14 Ensure that people with stroke who are transferred from hospital to care homes receive assessment and treatment from stroke rehabilitation and social care services to the same standards as they would receive in their own homes.

1.1.15 Local health and social care providers should have standard operating procedures to ensure the safe transfer and long-term care of people after stroke, including those in care homes. This should include timely exchange of information between different providers using local protocols.

1.1.16 After transfer of care from hospital, people with disabilities after stroke (including people in care homes) should be followed up within 72 hours by the specialist stroke rehabilitation team for assessment of patient-identified needs and the development of shared management plans.

1.1.17 Provide advice on prescribed medications for people after stroke in line with recommendations in the NICE guideline on medicines adherence.

1.2.1 On admission to hospital, to ensure the immediate safety and comfort of the person with stroke, screen them for the following and, if problems are identified, start management as soon as possible:

1.2.2 Perform a full medical assessment of the person with stroke, including cognition (attention, memory, spatial awareness, apraxia, perception), vision, hearing, tone, strength, sensation and balance.

1.2.3 A comprehensive assessment of a person with stroke should take into account:

1.2.4 Information collected routinely from people with stroke using valid, reliable and responsive tools should include the following on admission and discharge:

1.2.5 Information collected from people with stroke using valid, reliable and responsive tools should be fed back to the multidisciplinary team regularly.

1.2.6 Take into consideration the impact of the stroke on the person's family, friends and/or carers and, if appropriate, identify sources of support.

1.2.7 Inform the family members and carers of people with stroke about their right to have a carer's needs assessment.

1.2.8 Ensure that people with stroke have goals for their rehabilitation that:

1.2.9 Ensure that goal-setting meetings during stroke rehabilitation:

1.2.10 Ensure that during goal-setting meetings, people with stroke are provided with:

1.2.11 Give people copies of their agreed goals for stroke rehabilitation after each goal-setting meeting.

1.2.12 Review people's goals at regular intervals during their stroke rehabilitation.

1.2.13 Provide information and support to enable the person with stroke and their family or carer (as appropriate) to actively participate in the development of their stroke rehabilitation plan.

1.2.14 Stroke rehabilitation plans should be reviewed regularly by the multidisciplinary team. Time these reviews according to the stage of rehabilitation and the person's needs.

1.2.15 Documentation about the person's stroke rehabilitation should be individualised, and should include the following information as a minimum:

1.2.16 Offer initially at least 45 minutes of each relevant stroke rehabilitation therapy for a minimum of 5 days per week to people who have the ability to participate, and where functional goals can be achieved. If more rehabilitation is needed at a later stage, tailor the intensity to the person's needs at that time (for intensity of therapy for dysphagia, provided as part of speech and language therapy, see recommendation 1.7.2).

1.2.17 Consider more than 45 minutes of each relevant stroke rehabilitation therapy 5 days per week for people who have the ability to participate and continue to make functional gains, and where functional goals can be achieved.

1.2.18 If people with stroke are unable to participate in 45 minutes of each rehabilitation therapy, ensure that therapy is still offered 5 days per week for a shorter time at an intensity that allows them to actively participate.

1.4.3 Assess the effect of visual neglect after stroke on functional tasks such as mobility, dressing, eating and using a wheelchair, using standardised assessments and behavioural observation.

1.4.4 Use interventions for visual neglect after stroke that focus on the relevant functional tasks, taking into account the underlying impairment. For example:

1.4.5 Assess memory and other relevant domains of cognitive functioning (such as executive functions) in people after stroke, particularly where impairments in memory affect everyday activity.

1.4.6 Use interventions for memory and cognitive functions after stroke that focus on the relevant functional tasks, taking into account the underlying impairment. Interventions could include:

1.4.7 Assess attention and cognitive functions in people after stroke using standardised assessments. Use behavioural observation to evaluate the impact of the impairment on functional tasks.

1.4.8 Consider attention training for people with attention deficits after stroke.

1.4.9 Use interventions for attention and cognitive functions after stroke that focus on the relevant functional tasks. For example, use generic techniques such as managing the environment and providing prompts relevant to the functional task.

1.9.4 Consider strength training for people with muscle weakness after stroke. This could include progressive strength building through increasing repetitions of body weight activities (for example, sit-to-stand repetitions), weights (for example, progressive resistance exercise), or resistance exercise on machines such as stationary cycles.

1.9.5 Encourage people to participate in physical activity after stroke.

1.9.6 Assess people who are able to walk and are medically stable after their stroke for cardiorespiratory and resistance training appropriate to their individual goals.

1.9.7 Cardiorespiratory and resistance training for people with stroke should be started by a physiotherapist with the aim that the person continues the programme independently based on the physiotherapist's instructions (see recommendation 1.9.8).

1.9.8 For people with stroke who are continuing an exercise programme independently, physiotherapists should supply any necessary information about interventions and adaptations so that where the person is using an exercise provider, the provider can ensure their programme is safe and tailored to their needs and goals. This information may take the form of written instructions, telephone conversations or a joint visit with the provider and the person with stroke, depending on the needs and abilities of the exercise provider and the person with stroke.

1.9.9 Tell people who are participating in fitness activities after stroke about common potential problems, such as shoulder pain, and advise them to seek advice from their GP or therapist if these occur.

1.9.10 Do not routinely offer wrist and hand splints to people with upper limb weakness after stroke.

1.9.11 Consider wrist and hand splints in people at risk after stroke (for example, people who have immobile hands due to weakness, and people with high tone), to:

1.9.12 Where wrist and hand splints are used in people after stroke, they should be assessed and fitted by appropriately trained healthcare professionals and a review plan should be established.

1.9.13 Teach the person with stroke and their family or carer how to put the splint on and take it off, care for the splint and monitor for signs of redness and skin breakdown. Provide a point of contact for the person if concerned.

1.9.14 Do not routinely offer people with stroke electrical stimulation for their hand and arm.

1.9.15 Consider a trial of electrical stimulation in people who have evidence of muscle contraction after stroke but cannot move their arm against resistance.

1.9.16 If a trial of treatment is considered appropriate, ensure that electrical stimulation therapy is guided by a qualified rehabilitation professional.

1.9.17 The aim of electrical stimulation should be to improve strength while practising functional tasks in the context of a comprehensive stroke rehabilitation programme.

1.9.18 Continue electrical stimulation if progress towards clear functional goals has been demonstrated (for example, maintaining range of movement, or improving grasp and release).

1.9.19 Consider constraint-induced movement therapy for people with stroke who have movement of 20 degrees of wrist extension and 10 degrees of finger extension. Be aware of potential adverse events (such as falls, low mood and fatigue).

1.9.20 Provide information for people with stroke and their families and carers on how to prevent pain or trauma to the shoulder if they are at risk of developing shoulder pain (for example, if they have upper limb weakness and spasticity).

1.9.21 Manage shoulder pain after stroke using appropriate positioning and other treatments according to each person's need.

1.9.22 For guidance on managing neuropathic pain follow the advice in the NICE guideline on neuropathic pain in adults.

1.9.23 Offer people repetitive task training after stroke on a range of tasks for upper limb weakness (such as reaching, grasping, pointing, moving and manipulating objects in functional tasks) and lower limb weakness (such as sit-to-stand transfers, walking and using stairs).

1.9.24 Offer walking training to people after stroke who are able to walk, with or without assistance, to help them build endurance and move more quickly.

1.9.25 Consider treadmill training, with or without body weight support, as one option of walking training for people after stroke who are able to walk with or without assistance.

1.9.26 Offer electromechanical gait training to people after stroke only in the context of a research study.

1.9.27 Consider ankle–foot orthoses for people who have difficulty with swing-phase foot clearance after stroke (for example, tripping and falling) and/or stance-phase control (for example, knee and ankle collapse or knee hyper-extensions) that affects walking.

1.9.28 Assess the ability of the person with stroke to put on the ankle–foot orthosis or ensure they have the support needed to do so.

1.9.29 Assess the effectiveness of the ankle–foot orthosis for the person with stroke, in terms of comfort, speed and ease of walking.

1.9.30 Assessment for and treatment with ankle–foot orthoses should only be carried out as part of a stroke rehabilitation programme and performed by qualified professionals.

1.9.31 For guidance on functional electrical stimulation for the lower limb see the NICE interventional procedures guidance on functional electrical stimulation for drop foot of central neurological origin.

1.10.5 Return-to-work issues should be identified as soon as possible after the person's stroke, reviewed regularly and managed actively. Active management should include:

1.10.6 Manage return to work or long-term absence from work for people after stroke in line with recommendations in the NICE guideline on workplace health: long-term sickness absence and capability to work.