Rehabilitation after stroke: summary of NICE guidanceBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3615 (Published 12 June 2013) Cite this as: BMJ 2013;346:f3615
- Katharina Dworzynski, senior research fellow1,
- Gill Ritchie, guideline lead1,
- Elisabetta Fenu, health economist lead1,
- Keith MacDermott, GP guideline development group member2,
- E Diane Playford, guideline chair3
- on behalf of the Guideline Development Group
- 1National Clinical Guideline Centre, Royal College of Physicians of London, London NW1 4LE, UK
- 29 Kilburn Road, York YO10 4DF, UK
- 3UCL Institute of Neurology, London WC1N 1PJ, UK
- Correspondence to: K Dworzynski
Each year, about 150 000 people in the UK have a first or recurrent stroke.1 Despite UK health policies that place a great emphasis on reducing stroke (such as the National Stroke Strategy2) and improvements in mortality and morbidity, guidance is needed on access to and provision of effective rehabilitation services to maximise quality of life after stroke. This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE) on long term rehabilitation after stroke.3
NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations can be based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.
Organising rehabilitation and care for people with stroke
Rehabilitation may take place in a variety of settings—in hospital, in outpatient clinics, in the community, and in individuals’ own homes.
People with disability after stroke should receive rehabilitation in a dedicated stroke inpatient unit and subsequently from a specialist stroke team within the community. [Based on modified Delphi consensus statements]
The core stroke rehabilitation team should comprise the following professionals with expertise in stroke rehabilitation: consultant physician, nurse, physiotherapist, occupational therapist, speech and language therapist, clinical psychologist, rehabilitation assistant, and social worker. [Based on modified Delphi consensus statements]
Offer early supported discharge to people with stroke who are able to transfer from bed to chair independently or with assistance if a safe and secure environment can be provided. [Based on high to very low quality evidence from randomised controlled trials]
Planning and delivering stroke rehabilitation
To ensure the safety of the person with stroke while maintaining a patient centred approach, key processes need to be in place. These processes include assessment on admission to the rehabilitation service, individualised goal setting, and patient centred care planning.
Ensure that goal setting meetings during stroke rehabilitation
-Are timetabled into the working week
-Involve the person with stroke and, where appropriate, the person’s family or carer in the discussion.
[Based on modified Delphi consensus statements]
Offer initially at least 45 minutes of each relevant stroke rehabilitation therapy for a minimum of five days a week to people who are able 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.
If people with stroke are unable to participate in 45 minutes of rehabilitation therapy, ensure that therapy is still offered five days a week for a shorter time at an intensity that allows them to participate actively. [Based on moderate to low quality evidence from randomised controlled trials and a new cost effectiveness analysis]
Many people who have had a stroke experience distress that affects their ability to benefit from rehabilitation and prevents them from engaging in daily activities. Psychological therapies that are tailored to individual needs and circumstances (including web based approaches) may help the individuals and their families or carers with post-stroke emotional disorders and relationship issues.
Assess emotional functioning in the context of cognitive difficulties in people after stroke. Any intervention chosen should take into consideration the type or complexity of the person’s neuropsychological presentation and relevant personal history. [Based on low to very low quality evidence from a randomised controlled trial]
After stroke, many people experience difficulties in attention, concentration, memory, perception, and other areas of cognition.
Screen all people after stroke for cognitive deficits. When a cognitive deficit is identified, carry out a detailed assessment using tools that are valid, reliable, and responsive before designing a treatment programme. [Based on modified Delphi consensus statements]
Use interventions for memory and cognitive functions after stroke that focus on the relevant functional tasks, taking into account the underlying impairment. Interventions can include
-Increasing awareness of the memory deficit
-Enhancing learning by means of errorless learning and elaborative techniques (making associations, use of mnemonics, internal strategies related to encoding information such as “preview, question, read, state, test”)
-External aids (such as diaries, lists, calendars, and alarms)
-Environmental strategies (routines and environmental prompts).
[Based on moderate to low quality evidence from randomised controlled trials]
Dysphagia (difficulty swallowing) is common after stroke, occurring in up to 67% of stroke patients.
Offer swallowing therapy at least three times a week to people with dysphagia after stroke who are able to participate while they continue to make functional gains. Swallowing therapy could include compensatory strategies, exercises, and postural advice. [Based on moderate to very low quality evidence from randomised controlled trials]
To aid rehabilitation of people who have aphasia and other communication disorders after stroke:
Refer people with suspected communication difficulties after stroke to a speech and language therapist for detailed analysis of speech and language impairments and assessment of their impact.
Provide appropriate information, education, and training to the multidisciplinary stroke team to enable them to support and communicate effectively with the person with communication difficulties. This support may include
-Minimising environmental barriers to communication (for example, make sure signage is clear and background noise is minimised)
-Making sure that all written information (including that relating to medical conditions and treatment) is adapted for people with aphasia after stroke. This should include, for example, appointment letters, rehabilitation timetables, and menus
-Training in communication skills (such as slowing down, not interrupting, using communication props, gestures, drawing) to the conversation partners of people with aphasia.
[All based on high to very low quality evidence from randomised controlled trials]
Weakness limits a person’s ability to move the body, including changing body position, transferring from one place to another, walking, and using arms for functional tasks such as washing and dressing.
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). [Based on moderate to very low quality evidence from randomised controlled trials]
Do not routinely offer wrist and hand splints to people with upper limb weakness after stroke. [Based on moderate to low quality evidence from randomised controlled trials]
Offer walking training (such as treadmill exercise) for people with stroke who are able to walk, with or without assistance, to help them build endurance and move more quickly. [Based on moderate to very low quality evidence from randomised controlled trials]
Patients will need support to ensure they can care for themselves.
Occupational therapists with core skills and training in the analysis and management of activities of daily living should therefore regularly monitor and treat the person who has had a stroke. Treatment should continue until the person is stable or able to progress independently.
People after stroke are assessed for their equipment needs and whether their family or carers need training to use the equipment. [Based on moderate to very low quality evidence from randomised controlled trials]
Return to work
The UK’s stroke strategy3 highlighted the need for people who have had a stroke and their carers to be enabled to participate in paid, supported, and voluntary employment.
Potential problems with returning to work should be identified as soon as possible after the person’s stroke, reviewed regularly, and managed actively. Active management should include
-Identifying the job’s physical, cognitive, communication, and psychological demands (for example, multitasking by answering emails and telephone calls in a busy office)
-Identifying any impairments on work performance (such as physical limitations, anxiety, and fatigue affecting attendance, and cognitive impairments affecting multitasking and communication difficulties)
-Tailoring an intervention to the individual’s difficulties in the work setting (for example, teaching strategies to support multitasking or improve memory, teaching the use of voice activated software for people with difficulty typing, and delivery of work simulations)
-Educating about the Equality Act 20104 and support available (such as the “Access to Work” scheme)
-Workplace visits and liaison with employers to establish reasonable accommodations, such as provision of equipment and graded return to work.
[Based on very low quality evidence from a randomised controlled trial]
Long term health and social support
To help people who have had a stroke to reintegrate into the community, encourage them to focus on life after stroke and help them to achieve their goals. This may include:
Facilitating participation in community activities, such as shopping, civic engagement, sports and leisure pursuits, and visiting their place of worship and stroke support groups.
Supporting their social roles (such as work, leisure, family, and sexual relationships).
Providing information about transport and driving (including requirements of the Driver and Vehicle Licensing Agency (DVLA)). [Based on modified Delphi consensus statements]
Information should be provided to the person who has had a stroke and the person’s family or carer in an accessible format taking account of any cognitive, communication, and emotional difficulties.
Take into consideration the individual’s personal history and background when planning rehabilitation programmes and provide equipment and adaptations, and support in how to use them, whatever the setting (including care homes). Prompt provision of documentation to the person and his or her family and all relevant health and social care professionals is a priority, to overcome current delays or lack of communication between agencies before discharge or transfer of care. Sufficient training given to the multidisciplinary team, family, and carers on the particular needs of an individual with stroke and ways to support the person would also facilitate the rehabilitation processes since these needs are often poorly addressed.
Primary care clinicians are important, in the re-referral for assessment of people after stroke when necessary and in supporting continuing rehabilitation in the community. To achieve this, timely communication with these clinicians—such as the provision of documentation of agreed goals, plans for employment or return to work, and information about other programmes of ongoing rehabilitation—is important.
Further information on the guidance
The guideline provides further guidance on cognitive functions, vision, movement (including electrical stimulation, constraint induced movement therapy, treadmill training, electromechanical gait training, ankle-foot orthoses, visual impairments, and shoulder pain) and self care.
There are several challenges to providing information for people who have had a stroke and their carers, including
The need to present complex information in an accessible format.
Working with the person and his or her family or carer to identify their information needs and how to deliver them, taking into account specific impairments such as aphasia and cognitive impairments.
Pacing the information to the person’s emotional adjustment. [Based high to low quality evidence from randomised controlled trials]
The interface between health and social care is also challenging, particular when considering transfer of care from hospital to home (keeping in mind that people transferring to care homes should receive assessment and treatment from stroke rehabilitation and social care services to the same standards that they would receive in their own home):
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 the family or carer, and provide this to all relevant health and social care professionals. [Based on modified Delphi consensus statements]
The guideline was developed in accordance with NICE guideline development methods (http://publications.nice.org.uk/the-guidelines-manual-pmg6). This involved systematic searching, critical appraisal, and summarisation of the clinical and cost effectiveness evidence. The quality of evidence for all outcome measures was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE).5 New cost effectiveness analysis was also undertaken for intensity of stroke rehabilitation. A modified Delphi consensus survey was also conducted among the 168 members of an expert panel for areas with little or no evidence. Delphi survey statements were drawn up from published national and international guidance, and recommendations were drawn up by the Guideline Development Group (GDG) based on statements that reached consensus. The GDG was composed of clinicians with an expertise in stroke rehabilitation, including physicians, a primary care physician, a nurse, occupational therapists, physiotherapists, a speech and language therapist, and a clinical psychologist as well as individuals with personal experience of stroke.
NICE has produced four different versions of the guideline: a full version; a quick reference guide; a version known as the “NICE guideline” that summarises the recommendations; and a version for patients and the public. All these versions are available from the NICE website (http://guidance.nice.org.uk/CG162). Future updates of the guideline will be published according to the NICE guideline development programme.
The Guideline Development Group highlighted some important questions that need to be answered:
Is electrical stimulation effective as an adjunct to rehabilitation to improve hand and arm function after stroke?
Is intensive rehabilitation (6 hours/day) more effective than moderate rehabilitation (2 hours/day) on activity, participation, and quality of life outcomes?
Which cognitive and emotional interventions provide better outcomes for identified subgroups of people with stroke and their families and carers at different stages of the stroke pathway?
Which people with a weak arm after stroke are at risk of developing shoulder pain? What management strategies are effective in the prevention or management of shoulder pain of different aetiologies?
Cite this as: BMJ 2013;346:f3615
This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
The members of the Guideline Development Group were: Khalid Ali, Martin Bird, Robin Cant, Sandra Chambers, Louise Clark, Tamara Diaz, Avril Drummond until October 2012, Anne Foster until March 2013, Kathryn Head, Pamela Holmes, Helen E Hunter, Najma Khan-Bourne, Keith MacDermott, Rory O’Connor, Diane Playford (chair), and Sue Thelwell. Members of the technical team were: Lola Adedokun, Katharina Dworzynski, Elisabetta Fenu, Lina Gulhane, Kate Lovibond, Antonia Morga, Jonathan Nyong, Grammati Sari, and Gill Ritchie (guideline lead).
Contributors: KD, GR, EF, and EDP drafted the article. All authors revised it critically for important intellectual content and approved the final version to be published. All authors are guarantors for this article.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: all authors were members of the Guideline Development Group for the NICE guideline. No author has financial relationships with any organisation that might have an interest in the submitted work. None of the authors has other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.