stoke rehabilitation nice guidelines

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  National Clinical Guideline Centre Final Full Guideline      Stroke Rehabilitation Long term rehabilitation after stroke Clinical guideline 162 Methods, evidence and recommendations 29 May 2013 Final Draft   Commissioned by the National Institute for Health and Care Excellence

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Stoke Rehabilitation NICE Guidelines

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  • NationalClinicalGuidelineCentre

    FinalFullGuideline

    StrokeRehabilitationLongtermrehabilitationafterstroke

    Clinicalguideline162Methods,evidenceandrecommendations

    29May2013

    FinalDraft

    CommissionedbytheNationalInstituteforHealthandCareExcellence

  • StrokeRehabilitationContents

    NationalClinicalGuidelineCentre,2013.

    StrokeRehabilitation

    DisclaimerHealthcareprofessionalsareexpectedtotakeNICEclinicalguidelinesfullyintoaccountwhenexercisingtheirclinicaljudgement.However,theguidancedoesnotoverridetheresponsibilityofhealthcareprofessionalstomakedecisionsappropriatetothecircumstancesofeachpatient,inconsultationwiththepatientand/ortheirguardianorcarer.

    CopyrightNationalClinicalGuidelineCentre,2013.

    FundingNationalInstituteforHealthandCareExcellence

  • StrokeRehabilitationContents

    NationalClinicalGuidelineCentre,2013.4

    ContentsGuidelinedevelopmentgroupmembers.......................................................................................11

    Acknowledgments......................................................................................................................13

    1 Introduction..........................................................................................................................14

    2 Developmentoftheguideline...............................................................................................16

    2.1 WhatisaNICEclinicalguideline?.......................................................................................16

    2.2 Remit...................................................................................................................................16

    2.3 Whodevelopedthisguideline?..........................................................................................17

    2.4 Whatthisguidelinecovers..................................................................................................17

    2.5 Whatthisguidelinedoesnotcover....................................................................................17

    2.6 RelationshipsbetweentheguidelineandotherNICEguidance.........................................17

    3 Guidelinesummary...............................................................................................................20

    3.1 Keyprioritiesforimplementation.......................................................................................20

    3.1.1 Strokeunits............................................................................................................20

    3.1.2 Thecoremultidisciplinarystroketeam..................................................................20

    3.1.3 Healthandsocialcareinterface.............................................................................20

    3.1.4 Transferofcarefromhospitaltocommunity........................................................20

    3.1.5 Settinggoalsforrehabilitation...............................................................................21

    3.1.6 Intensityofstrokerehabilitation............................................................................21

    3.1.7 Cognitivefunctioning.............................................................................................21

    3.1.8 Emotionalfunctioning............................................................................................21

    3.1.9 Swallowing.............................................................................................................21

    3.1.10 Returntowork.......................................................................................................21

    3.1.11 Longtermhealthandsocialsupport.....................................................................22

    3.2 Fulllistofrecommendations..............................................................................................22

    3.3 Keyresearchrecommendations.........................................................................................34

    4 Methods................................................................................................................................35

    4.1 Developingthereviewquestionsandoutcomes................................................................35

    4.2 Searchingforevidence........................................................................................................41

    4.2.1 Clinicalliteraturesearch.........................................................................................41

    4.2.2 Healtheconomicliteraturesearch.........................................................................42

    4.3 Evidenceofeffectiveness....................................................................................................42

    4.3.1 Inclusion/exclusioncriteria....................................................................................42

    4.3.2 Methodsofcombiningclinicalstudies...................................................................43

    4.3.3 Typeofstudies.......................................................................................................44

    4.3.4 Typeofanalysis......................................................................................................44

    4.3.5 Appraisingthequalityofevidencebyoutcomes...................................................44

  • StrokeRehabilitationContents

    NationalClinicalGuidelineCentre,2013.5

    4.3.6 Gradingthequalityofclinicalevidence.................................................................46

    4.3.7 Studylimitations....................................................................................................46

    4.3.8 Inconsistency..........................................................................................................47

    4.3.9 Indirectness............................................................................................................47

    4.3.10 Imprecision.............................................................................................................47

    4.4 Evidenceofcosteffectiveness............................................................................................50

    4.4.1 Literaturereview....................................................................................................51

    4.4.2 Undertakingnewhealtheconomicanalysis..........................................................52

    4.4.3 Costeffectivenesscriteria......................................................................................53

    4.5 PostconsultationprotocolincludingmodifiedDelphimethodology.................................53

    4.6 Developingrecommendations............................................................................................57

    4.6.1 Researchrecommendations..................................................................................57

    4.6.2 Validationprocess..................................................................................................57

    4.6.3 Updatingtheguideline...........................................................................................58

    4.6.4 Disclaimer...............................................................................................................58

    4.6.5 Funding...................................................................................................................58

    5 Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke..................59

    5.1 Strokeunits.........................................................................................................................59

    5.1.1 EvidenceReview:Inpeopleafterstroke,doesorganisedrehabilitationcare(comprehensive,rehabilitationandmixedrehabilitationstrokeunits)improveoutcome(mortality,dependency,requirementforinstitutionalcareandlengthofhospitalstay)?..................................................................................59

    5.1.2 Recommendationsandlinkstoevidence..............................................................77

    5.2 Thecoremultidisciplinarystroketeam..............................................................................78

    5.2.1 EvidenceReview:Whatshouldbetheconstituencyofamultidisciplinaryrehabilitationteamandhowshouldtheteamworktogethertoensurethebestoutcomesforpeoplewhohavehadastroke?...............................................78

    5.2.2 Delphistatementswhereconsensuswasachieved...............................................79

    5.2.3 Delphistatementwhereconsensuswasnotreached...........................................80

    5.2.4 RecommendationsandlinkstoDelphiconsensussurvey.....................................82

    5.3 Healthandsocialcareinterface..........................................................................................84

    5.3.1 Delphistatementswhereconsensuswasachieved...............................................84

    5.3.2 RecommendationsandlinkstoDelphiconsensussurvey.....................................85

    5.4 Transferofcarefromhospitaltocommunity.....................................................................87

    5.4.1 Earlysupporteddischarge......................................................................................87

    5.4.2 EvidenceReview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofearlysupporteddischargeversususualcare?.............................87

    5.4.3 Recommendationsandlinktoevidence..............................................................113

    5.4.4 Transferofcarefromhospitaltocommunity......................................................115

    5.4.5 EvidenceReview:Whatplanningandsupportshouldbeundertakenbythe

  • StrokeRehabilitationContents

    NationalClinicalGuidelineCentre,2013.6

    multidisciplinaryrehabilitationteambeforeapersonwhohadastrokeisdischargedfromhospitalortransferstoanotherteam/settingtoensureasuccessfultransitionofcare?...............................................................................115

    5.4.6 Delphistatementswhereconsensuswasachieved.............................................116

    5.4.7 Delphistatementwhereconsensuswasnotreached.........................................117

    5.4.8 RecommendationsandlinkstoDelphiconsensussurvey...................................119

    6 Planninganddeliveringstrokerehabilitation......................................................................123

    6.1 Screeningandassessment................................................................................................123

    6.1.1 EvidenceReview:Inplanningrehabilitationforapersonafterstrokewhatassessmentsandmonitoringshouldbeundertakentooptimisethebestoutcomes?............................................................................................................123

    6.1.2 Delphistatementswhereconsensuswasachieved.............................................123

    6.1.3 Delphistatementwhereconsensuswasnotreached.........................................126

    6.1.4 RecommendationsandlinkstoDelphiconsensussurvey...................................127

    6.2 Settinggoalsforrehabilitation..........................................................................................130

    6.2.1 EvidenceReview:Doestheapplicationofpatientgoalsettingaspartofplanningstrokerehabilitationactivitiesleadtoanimprovementinpsychologicalwellbeing,functioningandactivity?..............................................130

    6.2.2 Economicevidencesummary...............................................................................140

    6.2.3 Evidencestatements............................................................................................141

    6.2.4 Economicevidencestatements...........................................................................142

    6.2.5 Recommendationsandlinkstoevidence............................................................142

    6.2.6 Delphistatementswhereconsensuswasachieved.............................................144

    6.2.7 Delphistatementswhereconsensuswasnotachieved......................................145

    6.2.8 RecommendationsandlinkstoDelphiconsensussurvey...................................147

    6.3 Planningrehabilitation......................................................................................................148

    6.3.1 Delphistatementswhereconsensuswasachieved.............................................148

    6.3.2 Delphistatementwhereconsensuswasnotreached.........................................150

    6.3.3 RecommendationsandlinkstoDelphiconsensussurvey...................................151

    6.4 Intensityofstrokerehabilitation......................................................................................153

    6.4.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofintensiverehabilitationversusstandardrehabilitation?...........153

    6.4.2 Recommendationsandlinktoevidence..............................................................166

    7 Supportandinformation.....................................................................................................170

    7.1 Providingsupportandinformation...................................................................................170

    7.1.1 Evidencereview:Whatistheclinicalandcosteffectivenessofsupportedinformationprovisionversusunsupportedinformationprovisiononmoodanddepressioninpeoplewithstroke?................................................................170

    7.1.2 Recommendationsandlinktoevidence..............................................................179

    8 Cognitivefunctioning..........................................................................................................181

    8.1 Visualneglect....................................................................................................................181

  • StrokeRehabilitationContents

    NationalClinicalGuidelineCentre,2013.7

    8.1.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofcognitiverehabilitationversususualcaretoimprovespatialawarenessand/orvisualneglect?.......................................................................181

    8.1.2 Recommendationsandlinktoevidence..............................................................194

    8.2 Memoryfunction..............................................................................................................195

    8.2.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofmemorystrategiesversususualcaretoimprovememory.......196

    8.2.2 Recommendationsandlinktoevidence..............................................................201

    8.3 Attentionfunction.............................................................................................................202

    8.3.2 Recommendationsandlinktoevidence..............................................................210

    9 Emotionalfunctioning.........................................................................................................213

    9.1 Psychologicaltherapies.....................................................................................................213

    9.1.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofpsychologicaltherapiesprovidedtothefamily(includingthepatient)?...............................................................................................................213

    9.1.2 Recommendationsandlinktoevidence..............................................................222

    10 Vision..................................................................................................................................225

    10.1 Eyemovementtherapy.....................................................................................................225

    10.1.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofeyemovementtherapyforvisualfieldlossversususualcare?225

    10.1.2 Recommendationsandlinktoevidence..............................................................233

    10.2 Diplopiaorotherongoingvisualsymptomsafterstroke.................................................234

    10.2.1 Evidencereview:Howshouldpeoplewithvisualimpairmentsincludingdiplopiabebestmanagedafterastroke?...........................................................235

    10.2.2 Delphistatementswhereconsensuswasachieved.............................................235

    10.2.3 Delphistatementwhereconsensuswasnotreached.........................................235

    10.2.4 RecommendationsandlinkstoDelphiconsensussurvey...................................237

    11 Swallowing..........................................................................................................................238

    11.1.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofinterventionsforswallowingversusalternativeinterventions/usualcaretoimprovedifficultyswallowing(dysphagia)?.................................238

    11.1.2 EconomicLiteraturereview.................................................................................245

    11.1.3 Evidencestatements............................................................................................245

    11.1.4 Recommendationsandlinktoevidence..............................................................247

    12 Communication...................................................................................................................249

    12.1 Aphasia..............................................................................................................................249

    12.1.1 EvidenceReview:Inpeoplewhohaveaphasiaafterstrokeisspeechandlanguagetherapycomparedtonospeechandlanguagetherapyorplacebo(socialsupportandstimulation)effectiveinimprovinglanguage/communicationabilitiesand/orpsychologicalwellbeing?..................249

    12.2 Dysarthria..........................................................................................................................279

    12.2.1 EvidenceReview:Inpeopleafterstrokeisspeechandlanguagetherapy

  • StrokeRehabilitationContents

    NationalClinicalGuidelineCentre,2013.8

    comparedtosocialsupportandstimulationeffectiveinimprovingdysarthria?...........................................................................................................279

    12.2.2 Recommendationsandinktoevidence...............................................................282

    12.3 Speechandlanguagetherapiesfordysarthriaandapraxiaofspeech.............................286

    12.3.1 Whatinterventionsimprovecommunicationinpeopledysphasia,dysarthriaandapraxiaofspeech?.........................................................................................286

    12.3.2 Delphistatementswhereconsensuswasachieved.............................................286

    12.3.3 Delphistatementwhereconsensuswasnotreached.........................................287

    12.3.4 RecommendationsandlinkstoDelphiconsensussurvey...................................291

    12.4 Intensityofspeechandlanguagetherapy........................................................................292

    12.4.1 Evidencereview:Inpeopleafterstrokewithcommunicationdifficultieswhatistheclinicalandcosteffectivenessofintensivespeechtherapyversusstandardspeechtherapy?....................................................................................292

    12.4.2 Recommendationsandlinktoevidence..............................................................305

    12.5 Listeneradvice..................................................................................................................307

    12.5.1 Whatlisteneradviceskills/trainingorinformationwouldhelpfamilymembers/carersimprovecommunicationinpeoplewithaphasiaafterstroke?..................................................................................................................307

    12.5.2 Recommendationsandlinktoevidence..............................................................312

    13 Movement..........................................................................................................................313

    13.1 Strengthtraining...............................................................................................................313

    13.1.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofstrengthtrainingversususualcareonimprovingfunctionandreducingdisability?.......................................................................................314

    13.1.2 Recommendationsandlinktoevidence..............................................................336

    13.2 FitnessTraining.................................................................................................................338

    13.2.1 Inpeopleafterstroke,doescardiorespiratoryorresistancefitnesstrainingimproveoutcome(fitness,function,qualityoflife,mood)andreducedisability?.............................................................................................................338

    13.2.2 Recommendationsandlinkstoevidence............................................................395

    13.3 Handandarmtherapies:orthosesfortheupperlimb.....................................................397

    13.3.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessoforthosesforpreventionoflossofrangeofmovementintheupperlimbversususualcare?..............................................................................397

    13.3.2 Recommendationsandlinktoevidence..............................................................403

    13.4 Electricalstimulation:upperlimb....................................................................................404

    13.4.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofelectricalstimulation(ES)forhandfunctionversususualcare?.....................................................................................................................404

    13.4.2 Recommendationsandlinktoevidence..............................................................437

    13.5 Constraintinducedmovementtherapy............................................................................438

    13.5.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofconstraintinducedtherapyversususualcareonimproving

  • StrokeRehabilitationContents

    NationalClinicalGuidelineCentre,2013.9

    functionandreducingdisability?.........................................................................438

    13.5.2 Recommendationsandlinktoevidence..............................................................456

    13.6 Shoulderpain....................................................................................................................458

    13.6.1 Howshouldpeoplewithshoulderpainafterstrokebemanagedtoreducepain?.....................................................................................................................458

    13.6.2 Delphistatementswhereconsensuswasachieved.............................................458

    13.6.3 Delphistatementwhereconsensuswasnotreached.........................................459

    13.6.4 RecommendationsandlinkstoDelphiconsensussurvey...................................460

    13.7 Repetitivetasktraining.....................................................................................................461

    13.7.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofrepetitivetasktrainingversususualcareonimprovingfunctionandreducingdisability?.........................................................................461

    13.7.2 Recommendationsandlinktoevidence..............................................................472

    13.8 Walkingtherapies:treadmillandtreadmillwithbodyweightsupport...........................473

    13.8.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofalltreadmillversususualcareonimprovingwalking?..............474

    13.8.2 Evidencereview:Inpeopleafterstrokewhocanwalk,whatistheclinicalandcosteffectivenessoftreadmillplusbodysupportversustreadmillonlyonimprovingwalking?..............................................................................................474

    13.8.3 Recommendationsandlinktoevidence..............................................................496

    13.9 Electromechanicalgaittraining........................................................................................498

    13.9.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofelectromechanicalgaittrainingversususualcareonimprovingfunctionandreducingdisability?........................................................498

    13.9.2 Recommendationsandlinktoevidence..............................................................517

    13.10Anklefootorthoses..........................................................................................................518

    13.10.1Evidencereview:InpeopleafterstrokewhatistheclinicalandcosteffectivenessofAnkleFootorthosesofalltypestoimprovewalkingfunctionversususualcare?................................................................................................518

    13.10.2Recommendationsandlinktoevidence..............................................................527

    14 Selfcare..............................................................................................................................530

    14.1 Intensityofoccupationaltherapyforpersonalactivitiesofdailyliving...........................530

    14.1.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofintensiveoccupationaltherapyfocusedspecificallyonpersonalactivitiesofdailyliving(dressing/others)versususualcare?.............530

    14.1.2 RecommendationsandLinktoEvidence.............................................................540

    15 Communityparticipationandlongtermrecovery................................................................543

    15.1 Returntowork..................................................................................................................543

    15.1.1 EvidenceReview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofinterventionstoaidreturntoworkversususualcare?.............543

    15.1.2 Clinicalevidence...................................................................................................544

    15.1.3 Recommendationsandlinktoevidence..............................................................548

  • StrokeRehabilitationContents

    NationalClinicalGuidelineCentre,2013.10

    15.2 Longtermhealthandsocialsupport................................................................................551

    15.2.1 Whatongoinghealthandsocialsupportdothepersonafterstrokeandtheircarer(s)requiretomaximisesocialparticipationandlongtermrecovery?........551

    15.2.2 Delphistatementswhereconsensuswasachieved.............................................551

    15.2.3 Delphistatementwhereconsensuswasnotreached.........................................553

    15.2.4 RecommendationsandlinkstoDelphiconsensussurvey...................................555

    16 Acronymsandabbreviations...............................................................................................558

    17 Glossary..............................................................................................................................560

    18 Referencelist......................................................................................................................573

  • StrokeRehabilitationGuidelinedevelopmentgroupmembers

    NationalClinicalGuidelineCentre,2013.11

    GuidelinedevelopmentgroupmembersName OrganisationDr.DianePlayford(Chair)

    ReaderinneurologicalrehabilitationUCLInstituteofNeurologyHonoraryConsultantNeurologistNationalHospitalforNeurologyandNeurosurgery,UCLHNHSFoundationTrust

    Dr.KhalidAli SeniorLecturerinGeriatricsBrightonandSussexMedicalSchool

    Mr.MartinBird Carermember

    Mr.RobinCant Patientmember

    Ms.SandraChambers

    ClinicalSpecialistStrokeandNeurorehabilitation,PhysiotherapyDepartment,GuysandSt.ThomasHospitalNHSFoundationTrust

    Ms.LouiseClark

    TraineeConsultantPractitionerinNeurology(Stroke)NHSSouthCentralSeniorOccupationalTherapistspecialisinginStroke

    Dr.AvrilDrummond DeputyDirector,TrentLocalResearchNetworkforStroke(ResignedfromtheGuidelineDevelopmentGroupinOctober2012)

    Prof.AnneForster

    ProfessorofStrokeRehabilitationInstituteofHealthSciences,UniversityofLeedsandBradfordInstituteforHealthResearch(ResignedfromtheGuidelineDevelopmentGroupinMarch2013)

    Dr.KathrynHead

    PrincipalSpeechandLanguageTherapistStrokeservice,CwmTafHealthBoard,SouthWales

    Ms.PamelaHolmes

    RepresentativeSocialCareInstituteforExcellence

    Ms.HelenE.Hunter ClinicalSpecialistNeurophysiotherapistNorthumberlandCareTrust

    Dr.NajmaKhanBourne ConsultantClinicalNeuropsychologistClinicalLeadforNeuropsychologicalNeurorehabilitationKingsCollegeHospital,KingsCollegeHospitalNHSFoundationTrust

    Dr.KeithMacDermott

    GeneralPractitioner(RetiredfromGeneralPracticeinApril2010)Drs.Priceandpartners,York

    Dr.RoryOConnor

    HonoraryConsultantinRehabilitationMedicineCommunityRehabilitationUnit,LeedsCommunityHealthcareNHSTrustLeedsHonoraryConsultantinRehabilitationMedicineNationalDemonstrationCentreinRehabilitation,LeedsTeachingHospitalsNHSTrust,Leeds

    Ms.SueThelwell

    StrokeServicesCoordinatorUniversityHospitalsCoventryandWarwickshireNHSTrust

  • StrokeRehabilitationGuidelinedevelopmentgroupmembers

    NationalClinicalGuidelineCentre,2013.12

    Cooptees/ExpertAdvisors

    Name OrganisationDr.CharlieDavie ConsultantNeurologistattheRoyalFreeLondonNHSFoundationTrust

    ProgrammeDirectorforNeuroscienceatUniversityCollegeLondonPartners

    Ms.JuliaParnaby HeadofStrokeInformationServicesStrokeAssociation

    Ms.CarolePound ResearcheraphasiatherapyandsupportservicesCentreforResearchandRehabilitation,BrunelUniversity

    Dr.FionaRowe SeniorLecturerinOrthopticsUniversityofLiverpool

    Mr.MirekSkrypak ClinicalCoordinatorandManager,CamdenEarlySupportedDischargeandStrokeNavigationServices

    Mr.RonaldBarneyWhite SeniorOrthotistSandwellandWestBirminghamHospitalsNHSTrust

    NCGCStaffmembersontheguidelinedevelopmentgroup

    Name RoleMs.GillRitchie GuidelineLeadMs.TamaraDiaz ProjectManager

    Dr.KatharinaDworzynski SeniorResearchFellow

    Ms.ElisabettaFenu SeniorHealthEconomist

    Ms.LinaGulhane JointHeadofInformationScience

    Dr.JonathanNyong ResearchFellow

    Dr.AngelaCooper SeniorResearchFellow untilJuly2010Dr.PaulineTurner ResearchFellow untilAugust2010

    Dr.AntoniaMorga HealthEconomist untilApril2011

    Ms.LolaAdedokun HealthEconomist untilJune2012

    Dr.GrammatiSarri SeniorResearchFellow untilJuly2012

    Ms.KateLovibond SeniorHealthEconomist untilAugust2012

  • StrokeRehabilitationAcknowledgments

    NationalClinicalGuidelineCentre,2013.13

    AcknowledgmentsThedevelopmentofthisguidelinewasgreatlyassistedbythefollowingpeople:

    NCGC: RoleIanBullock ChiefOperatingOfficer

    SerenaCarville SeniorResearchFellow/ProjectManager

    RalphHughes HealthEconomist

    RosaLau ResearchFellow

    SharanginiRajesh ResearchFellow

    JaymeeniSolanki Projectcoordinator

    PhilippeLaramee HealthEconomist

    RichardWhitome InformationScientist

    DavidWonderling HeadofHealthEconomics

    HatiZorba Projectcoordinator

    External RoleJacobyPatterson ResearchFellow

    ClaireTurner NICECommissioningManagerfromJuly2010

    SarahWillett NICECommissioningmanageruntilJuly2010

  • StrokeRehabilitationIntroduction

    NationalClinicalGuidelineCentre,2013.14

    1 IntroductionStrokeisamajorhealthproblemintheUK.EachyearinEngland,approximately110,000people230,inWales11,000andinNorthernIreland4,000peoplehaveafirstorrecurrentstroke250.Mostpeoplesurviveafirststroke,butoftenhavesignificantmorbidity.Morethan900,000peopleinEnglandarelivingwiththeeffectsofstroke.StrokemortalityratesintheUKhavebeenfallingsteadilysincethelate1960s25.ThedevelopmentofstrokeunitsfollowingthepublicationoftheStrokeUnitTrialistsCollaborationmetaanalysisofstrokeunitcare1,andthefurtherreorganisationofservicesfollowingtheadventofthrombolysishaveresultedinfurthersignificantimprovementsinmortalityandmorbidityfromstroke(asdocumentedintheNationalSentinelAuditforStroke123).However,theburdenofstrokemayincreaseinthefutureasaconsequenceoftheageingpopulation.

    Despiteimprovementsinmortalityandmorbidity,strokesurvivorsneedaccesstoeffectiverehabilitationservices.Over30%ofpeoplehavepersistingdisabilityandtheyneedaccesstostrokeserviceslongterm.Strokerehabilitationisamultidimensionalprocess,whichisdesignedtofacilitaterestorationof,oradaptationto,thelossofphysiologicalorpsychologicalfunctionwhenreversaloftheunderlyingpathologicalprocessisincomplete.Rehabilitationaimstoenhancefunctionalactivitiesandparticipationinsocietyandthusimprovequalityoflife.

    Astrokerehabilitationservicecomprisesamultidisciplinaryteamofpeoplewhoworktogethertowardsgoalsforeachpatient,involveandeducatethepatientandfamily,haverelevantknowledgeandskillstohelpaddressmostcommonproblemsfacedbytheirpatients276Keyaspectsofrehabilitationcareincludemultidisciplinaryassessment,identificationoffunctionaldifficultiesandtheirmeasurement,treatmentplanningthroughgoalsetting,deliveryofinterventionswhichmayeithereffectchangeorsupporttheindividualinmanagingpersistingchange,andevaluationofeffectiveness.

    AssessmentistypicallyundertakenusingtheWorldHealthOrganisation(WHO)InternationalClassificationofFunctioning,DisabilityandHealth(ICF)whichprovidesabiopsychosocialmodelofdisability.AswellassupportingcomprehensiveassessmenttheICFcanbeusedingoalsetting&treatmentplanningandmonitoring,aswellasoutcomemeasurement.Treatmentsarelargelydeliveredviaphysiotherapists,occupationaltherapists,speechandlanguagetherapists,nursesandpsychologists.Othercomponentsofrehabilitationincludethelearningofnewskillstocircumventthoselost;adaptationtolossbyboththepatientandfamily;theapplicationofnewtechnologies,appliancesandenvironmentalmodifications;andthedevelopmentofnewservicedeliverysystems.Therehabilitationprocessaimstomaximisetheparticipationofthepatientinhisorhersocialsetting,includingsupportingpeopletoestablishrolesandoccupations,andminimisethepainanddistressexperiencedbythepatientandtheirfamilycarers276.

    Clearstandardsexistforstrokerehabilitation,forinstanceasdescribedbothintheNationalClinicalGuidelineforStrokedevelopedbytheIntercollegiateStrokeWorkingParty122.ThesearereflectedintheNICEqualitystandards189andtheNationalStrokeStrategy61.Overallthereislittledoubtthattherehabilitationapproachiseffective;whatindividualinterventionsshouldtakeplacewithinthisstructureislessclear.

    Advancesintheneurosciencesincludinggreaterunderstandingofthemechanismsofimpairmentwillleadtonoveltreatments.Thereisawealthofevidencesuggestingthatcentralnervoussystemreorganisationunderliesmuchoftheimprovementinimpairmentthatisfrequentlyseen.Experimentsshowthatsomeregionsinthenormaladultbrain,particularlythecortex,havethecapacitytochangestructureandconsequentlyfunctioninresponsetoenvironmentalchange,aprocessdescribedasplasticity.Inadditionfunctionallyrelevantadaptivechangeshavebeendemonstratedfollowingfocaldamagetothebrain.Itissuggestedthatrehabilitationtherapiesinteractswiththeseplasticchanges,thusreducingimpairmentviaactivitydependentplastic

  • StrokeRehabilitationIntroduction

    NationalClinicalGuidelineCentre,2013.15

    change.280Examplesofsuchtherapiesalreadyexistinrehabilitationpracticesuchasupperorlowerlimbsensorimotorfunctionbytaskrelatedtrainingusingconstraintinducedtherapy173,treadmilltraining109,andprismadaptation(toreversevisualneglect)87,109.

    Theaimofthisguidelinedevelopmentgroupwastoreviewthestructure,processesandinterventionscurrentlyusedinrehabilitationcare,andtoevaluatewhethertheyimproveoutcomesforpeoplewithstroke.Suchstudiesarecomplexandresearchmethodologiesneedtoberobust.Evaluationofclinicaleffectivenessneedsstudiesthathaverobusttheoreticalunderpinnings,capturechangesthatarerelevanttothetreatmentevaluatedandreflectwhatisimportanttopatients,andbelargeenoughtoallowreliabledatainterpretation.Thisguidelinereviewssomeoftheavailableinterventionsthatcanbeusedinstrokerehabilitation,andhighlightswheretherearegapsintheevidence.Itisnotintendedtobecomprehensive.

    Allinterventionsshouldtakeplaceinthecontextofacomprehensivestrokepathwaywhichrecognisesthatearlymanagement,whilecritical,isacomponentofaprocesswhichaimstoamelioratethelongtermconsequencesoflivingwithstrokeforindividualsandtheirfamiliesandtoenablethemtoliveathome,abletoparticipateinasmanyactivitiesastheyareable.Atthepointofdischargethepersonwhohashadastrokemayneedsupportfromarangeofotheragenciessuchashousing,JobcentrePlus,socialservicesandstrokevoluntaryorganisations.Randomisedcontrolledtrialevidence,althoughthegoldstandardforinterventionstudiesmaynotbeavailableorappropriateforexaminingrehabilitationprocesses.AmodifiedDelphisurveywasconductedtoobtainformalconsensusaroundareassuchasservicedeliveryandcareplanning.Itneedstoberecognisedthatevenwheretheevidencebaseisclear,rehabilitationinterventionsneedtobetargetedandrelevanttotheindividual.Someindividualsmaydeclinetreatmentwhichhealthcareprofessionalsseeasimportant.Insuchcircumstancesissuessuchascapacityandconsentneedtobeconsidered108.

  • StrokeRehabilitationDevelopmentoftheguideline

    NationalClinicalGuidelineCentre,2013.16

    2 Developmentoftheguideline2.1 WhatisaNICEclinicalguideline?

    NICEclinicalguidelinesarerecommendationsforthecareofindividualsinspecificclinicalconditionsorcircumstanceswithintheNHSfrompreventionandselfcarethroughprimaryandsecondarycaretomorespecialisedservices.Webaseourclinicalguidelinesonthebestavailableresearchevidence,withtheaimofimprovingthequalityofhealthcare.Weusepredeterminedandsystematicmethodstoidentifyandevaluatetheevidencerelatingtospecificreviewquestions.

    NICEclinicalguidelinescan: providerecommendationsforthetreatmentandcareofpeoplebyhealthprofessionals beusedtodevelopstandardstoassesstheclinicalpracticeofindividualhealthprofessionals beusedintheeducationandtrainingofhealthprofessionals helppatientstomakeinformeddecisions improvecommunicationbetweenpatientandhealthprofessional

    Whileguidelinesassistthepracticeofhealthcareprofessionals,theydonotreplacetheirknowledgeandskills.

    Weproduceourguidelinesusingthefollowingsteps: GuidelinetopicisreferredtoNICEfromtheDepartmentofHealth Stakeholdersregisteraninterestintheguidelineandareconsultedthroughoutthedevelopment

    process ThescopeispreparedbytheNationalClinicalGuidelineCentre(NCGC) TheNCGCestablishesaguidelinedevelopmentgroup Adraftguidelineisproducedafterthegroupassessestheavailableevidenceandmakes

    recommendations Thereisaconsultationonthedraftguideline Thefinalguidelineisproduced

    TheNCGCandNICEproduceanumberofversionsofthisguideline: thefullguidelinecontainsalltherecommendations,plusdetailsofthemethodsusedandthe

    underpinningevidence theNICEguidelineliststherecommendations theNICEPathwayisanonlinetoolforhealthprofessionalsthatbringstogetherthe

    recommendationsfromthisguidanceandallrelatedNICEguidance. informationforthepublic(understandingNICEguidanceorUNG)iswrittenusingsuitable

    languageforpeoplewithoutspecialistmedicalknowledge

    Thisversionisthefullversion.TheotherversionscanbedownloadedfromNICEatwww.nice.org.uk

    2.2 RemitNICEreceivedtheremitforthisguidelinefromtheDepartmentofHealth.TheycommissionedtheNCGCtoproducetheguideline.

    Theremitforthisguidelineis:toproduceajointclinicalandsocialcareguidelineonthelongtermrehabilitationandsupportofstrokepatients.

  • StrokeRehabilitationDevelopmentoftheguideline

    NationalClinicalGuidelineCentre,2013.17

    2.3 Whodevelopedthisguideline?AmultidisciplinaryGuidelineDevelopmentGroup(GDG)comprisingprofessionalgroupmembersandconsumerrepresentativesofthemainstakeholdersdevelopedthisguideline(seesectiononGuidelineDevelopmentGroupMembershipandacknowledgements).

    TheNationalInstituteforHealthandClinicalExcellencefundstheNationalClinicalGuidelineCentre(NCGC)andthussupportedthedevelopmentofthisguideline.TheGDGwasconvenedbytheNCGCandchairedbyDrDianePlayfordinaccordancewithguidancefromtheNationalInstituteforHealthandClinicalExcellence(NICE).

    Thegroupmetapproximatelyevery5weeksduringthedevelopmentoftheguideline.AtthestartoftheguidelinedevelopmentprocessallGDGmembersdeclaredinterestsincludingconsultancies,feepaidwork,shareholdings,fellowshipsandsupportfromthehealthcareindustry.AtallsubsequentGDGmeetings,membersdeclaredarisingconflictsofinterest,whichwerealsorecorded(Appendix[C]).

    Memberswereeitherrequiredtowithdrawcompletelyorforpartofthediscussioniftheirdeclaredinterestmadeitappropriate.ThedetailsofdeclaredinterestsandtheactionstakenareshowninAppendix[C].

    StafffromtheNCGCprovidedmethodologicalsupportandguidanceforthedevelopmentprocess.Theteamworkingontheguidelineincludedaprojectmanager,systematicreviewers,healtheconomistsandinformationscientists.Theyundertooksystematicsearchesoftheliterature,appraisedtheevidence,conductedmetaanalysisandcosteffectivenessanalysiswhereappropriateanddraftedtheguidelineincollaborationwiththeGDG.

    2.4 WhatthisguidelinecoversTheguidelinecoversadultsandyoungpeople16orolderwhohavehadastrokeandhavecontinuingimpairment(2weeksormorepoststroke),limitedactivityorparticipationrestriction.

    Theclinicalareascoveredincluded:therapiestoimprovephysical,cognitiveandspeechfunctions,activitiesofdailylivingandvocationalrehabilitation,interventionstoaddressdysphagiaandvisualfieldloss,informationandsupportforpatientsandcarers,earlysupporteddischargeandintensityofrehabilitationtherapy.Theinterventionsconsideredandthesubsequentrecommendationsmadearenotsettingspecificandincludehealthorsocialcareservices.

    ForfurtherdetailspleaserefertothescopeinAppendixAandreviewquestionsinAppendixE.

    2.5 WhatthisguidelinedoesnotcoverChildrenunder16yearsandpeoplewhohadhadatransientischaemicattackwerenotincluded.Theguidelinedidnotconsiderprimaryorsecondarypreventionofstroke,acutestrokeorassessmentforrehabilitation.

    2.6 RelationshipsbetweentheguidelineandotherNICEguidanceRelatedNICEInterventionalProcedures:

    Electricalstimulationfordropfootofcentralneurologicalorigin.NICEinterventionalprocedureguidance278(2009).Availablefromwww.nice.org.uk/guidance/IPG278

  • StrokeRehabilitationDevelopmentoftheguideline

    NationalClinicalGuidelineCentre,2013.18

    RelatedNICEClinicalGuidelines:

    Depressioninadults(update).NICEclinicalguidelineCG90(2009).Availablefrom:http://publications.nice.org.uk/depressioninadultscg90.

    Depressioninadultswithachronicphysicalhealthproblem:Treatmentandmanagement.NICEclinicalguidelineCG91(2009).Availablefrom:http://publications.nice.org.uk/depressioninadultswithachronicphysicalhealthproblemcg91.

    Faecalincontinence:ThemanagementoffaecalincontinenceinadultsNICEclinicalguidelineCG49(2007).Availablefrom:http://publications.nice.org.uk/faecalincontinencecg49.

    Falls:theassessmentandpreventionoffallsinolderpeople.NICEclinicalguidelineCG21(2004)http://publications.nice.org.uk/fallscg21.

    Generalisedanxietydisorderandpanicdisorder(withorwithoutagoraphobia)inadults:Managementinprimary,secondaryandcommunitycare.NICEclinicalguidelineCG113(2011).Availablefrom:http://publications.nice.org.uk/generalisedanxietydisorderandpanicdisorderwithorwithoutagoraphobiainadultscg113.

    Neuropathicpain:ThepharmacologicalmanagementofneuropathicpaininadultsinnonspecialistsettingsNICEclinicalguidelineCG96(2010).http://publications.nice.org.uk/neuropathicpaincg96.

    Nutritionsupportinadults:Oralnutritionsupport,enteraltubefeedingandparenteralnutrition.NICEclinicalguidelineCG32(2006).Availablefrom:http://publications.nice.org.uk/nutritionsupportinadultscg32.

    PatientexperienceinadultNHSservices:improvingtheexperienceofcareforpeopleusingadultNHSservices.NICEclinicalguidelineCG138(2012)http://publications.nice.org.uk/patientexperienceinadultnhsservicesimprovingtheexperienceofcareforpeopleusingadultcg138.

    Stroke:Diagnosisandinitialmanagementofacutestrokeandtransientischaemicattack(TIA).NICEclinicalguidelineCG68(2008).Availablefrom:http://publications.nice.org.uk/strokecg68.

    Urinaryincontinenceinneurologicaldisease:managementoflowerurinarytractdysfunctioninneurologicaldisease.NICEclinicalguidelineCG148(2012).Availablefrom:http://guidance.nice.org.uk/CG148.

    Medicinesadherence:involvingpatientsindecisionsaboutprescribedmedicinesandsupportingadherence.NICEclinicalguidelineCG76(2009).Availablefrom:http://www.nice.org.uk/CG76

    Lipidmodification:Cardiovascularriskassessmentandthemodificationofbloodlipidsfortheprimaryandsecondarypreventionofcardiovasculardisease.NICEclinicalguidelineCG67(2008).Availablefrom:http://www.nice.org.uk/CG67.

    Hypertension:clinicalmanagementofprimaryhypertensioninadults.NICEclinicalguidelineCG127(2011):Availablefrom:http://guidance.nice.org.uk/CG127.

    Type2Diabetes:themanagementoftype2diabetes(update).NICEclinicalguidelineCG87(2009):Availablefrom:http://www.nice.org.uk/CG87.

    Atrialfibrillation.NICEclinicalguidelineCG36(2006):Availablefrom:http://www.nice.org.uk/CG36

    RelatedNICEPublicHealthGuidance:

    Managementoflongtermsicknessandincapacityforwork:Guidanceforprimarycareandemployersonthemanagementoflongtermsicknessandincapacity.NICEpublichealthguidance19(2009).Availablefrom:www.nice.org.uk/guidance/PH19.

  • StrokeRehabilitationDevelopmentoftheguideline

    NationalClinicalGuidelineCentre,2013.19

    NICERelatedGuidancecurrentlyindevelopment:

    Falls(update)NICEclinicalguideline(publicationexpectedJune2013).

    Lipidmodification(update).NICEclinicalguideline(publicationTBC).

    Neuropathicpain:pharmacologicalmanagementinadultsinnonspecialistsettings.NICEclinicalguideline(publicationexpectedAugust2013).

    Type2diabetesNICEclinicalguideline(publicationTBC).

    Oralhealth:innursingandresidentialcareNICEpublichealthguidance(publicationTBC).

    Workplacehealth:employeeswithchronicdiseasesandlongtermconditionsNICEpublichealthguidance(publicationTBC).

  • StrokeRehabilitationGuidelinesummary

    NationalClinicalGuidelineCentre,2013.20

    3 Guidelinesummary3.1 Keyprioritiesforimplementation

    TheGDGidentifiedkeyprioritiesforimplementation.Theyselectedrecommendationsthatwould: Haveahighimpactonoutcomesthatareimportanttopatients Haveahighimpactonreducingvariationincareandoutcomes LeadtoamoreefficientuseofNHSresources Promotepatientchoice

    IndoingthistheGDGalsoconsideredwhichrecommendationswereparticularlylikelytobenefitfromimplementationsupport.Theconsideredwhetherarecommendation:

    Requireschangesinservicedelivery Requiresretrainingofprofessionalsorthedevelopmentofnewskillsandcompetencies Affectsandneedstobeimplementedacrossvariousagenciesorsettings Maybeviewedaspotentiallycontentiousordifficulttoimplementforotherreasons

    Thefollowingrecommendationshavebeenidentifiedasprioritiesforimplementation.

    3.1.1 Strokeunits1. Peoplewithdisabilityafterstrokeshouldreceiverehabilitationinadedicatedstrokeinpatient

    unitandsubsequentlyfromaspecialiststroketeamwithinthecommunity.

    3.1.2 Thecoremultidisciplinarystroketeam2. Acoremultidisciplinarystrokerehabilitationteamshouldcomprisethefollowingprofessionals

    withexpertiseinstrokerehabilitation:o consultantphysicianso nurseso physiotherapistso occupationaltherapistso speechandlanguagetherapistso clinicalpsychologistso rehabilitationassistantso socialworkers.

    3.1.3 Healthandsocialcareinterface3. Healthandsocialcareprofessionalsshouldworkcollaborativelytoensureasocialcare

    assessmentiscarriedoutpromptly,whereneeded,beforethepersonwithstrokeistransferredfromhospitaltothecommunity.Theassessmentshould:o identifyanyongoingneedsofthepersonandtheirfamilyorcarer,forexample,accessto

    benefits,careneeds,housing,communityparticipation,returntowork,transportandaccesstovoluntaryservices

    o bedocumentedandallneedsrecordedinthepersonshealthandsocialcareplan,withacopyprovidedtothepersonwithstroke.

    3.1.4 Transferofcarefromhospitaltocommunity4. Offerearlysupporteddischargetopeoplewithstrokewhoareabletotransferfrombedtochair

    independentlyorwithassistance,aslongasasafeandsecureenvironmentcanbeprovided.

  • StrokeRehabilitationGuidelinesummary

    NationalClinicalGuidelineCentre,2013.21

    3.1.5 Settinggoalsforrehabilitation5. Ensurethatgoalsettingmeetingsduringstrokerehabilitation:

    o aretimetabledintotheworkingweeko involvethepersonwithstrokeand,whereappropriate,theirfamilyorcarerinthediscussion.

    3.1.6 Intensityofstrokerehabilitation6. Offerinitiallyatleast45minutesofeachrelevantstrokerehabilitationtherapyforaminimumof

    5daysperweektopeoplewhohavetheabilitytoparticipate,andwherefunctionalgoalscanbeachieved.Ifmorerehabilitationisneededatalaterstage,tailortheintensitytothepersonsneedsatthattimea.

    3.1.7 Cognitivefunctioning7. Screenpeopleafterstrokeforcognitivedeficits.Whereacognitivedeficitisidentified,carryouta

    detailedassessmentusingvalid,reliableandresponsivetoolsbeforedesigningatreatmentprogramme.

    3.1.8 Emotionalfunctioning8. Assessemotionalfunctioninginthecontextofcognitivedifficultiesinpeopleafterstroke.Any

    interventionchosenshouldtakeintoconsiderationthetypeorcomplexityofthepersonsneuropsychologicalpresentationandrelevantpersonalhistory.

    3.1.9 Swallowing9. Offerswallowingtherapyatleast3timesaweektopeoplewithdysphagiaafterstrokewhoare

    abletoparticipate,foraslongastheycontinuetomakefunctionalgains.Swallowingtherapycouldincludecompensatorystrategies,exercisesandposturaladvice.

    3.1.10 Returntowork10. Returntoworkissuesshouldbeidentifiedassoonaspossibleafterthepersonsstroke,reviewed

    regularlyandmanagedactively.Activemanagementshouldinclude:o identifyingthephysical,cognitive,communicationandpsychologicaldemandsofthejob(for

    example,multitaskingbyansweringemailsandtelephonecallsinabusyoffice)o identifyinganyimpairmentsonworkperformance(forexample,physicallimitations,anxiety,

    fatiguepreventingattendanceforafulldayatwork,cognitiveimpairmentspreventingmultitasking,andcommunicationdeficits)

    o tailoringanintervention(forexample,teachingstrategiestosupportmultitaskingormemorydifficulties,teachingtheuseofvoiceactivatedsoftwareforpeoplewithdifficultytyping,anddeliveryofworksimulations)

    o educatingabouttheEqualityAct2010bandsupportavailable(forexample,anaccesstoworkscheme)

    o workplacevisitsandliaisonwithemployerstoestablishreasonableaccommodations,suchasprovisionofequipmentandgradedreturntowork.

    aIntensityoftherapyfordysphagia,providedaspartofspeechandlanguagetherapyisaddressedin

    recommendation58.

    bHMGovernment(2010)EqualityAct[online]

  • StrokeRehabilitationGuidelinesummary

    NationalClinicalGuidelineCentre,2013.22

    3.1.11 Longtermhealthandsocialsupporto Reviewthehealthandsocialcareneedsofpeopleafterstrokeandtheneedsoftheircarersat

    6monthsandannuallythereafter.Thesereviewsshouldcoverparticipationandcommunityrolestoensurethatpeoplesgoalsareaddressed.

    3.2 Fulllistofrecommendations

    1. Peoplewithdisabilityafterstrokeshouldreceiverehabilitationinadedicatedstrokeinpatientunitandsubsequentlyfromaspecialiststroketeamwithinthecommunity.

    2. Aninpatientstrokerehabilitationserviceshouldconsistofthefollowing:

    adedicatedstrokerehabilitationenvironment

    acoremultidisciplinaryteam(seerecommendation3)whohavetheknowledge,skillsandbehaviourstoworkinpartnershipwithpeoplewithstrokeandtheirfamiliesandcarerstomanagethechangesexperiencedasaresultofastroke.

    accesstootherservicesthatmaybeneeded,forexample:

    - continenceadvice

    - dietetics

    - electronicaids(forexample,remotecontrolsfordoors,lightsandheating,andcommunicationaids)

    - liaisonpsychiatry

    - orthoptics

    - orthotics

    - pharmacy

    - podiatry

    - wheelchairservices

    amultidisciplinaryeducationprogramme.

    3. Acoremultidisciplinarystrokerehabilitationteamshouldcomprisethefollowingprofessionalswithexpertiseinstrokerehabilitation:

    consultantphysicians

    nurses

    physiotherapists

    occupationaltherapists

    speechandlanguagetherapists

    clinicalpsychologists

    rehabilitationassistants

    socialworkers.

    4. Throughoutthecarepathway,therolesandresponsibilitiesofthecoremultidisciplinarystrokerehabilitationteamshouldbeclearlydocumentedandcommunicatedtothepersonandtheirfamilyorcarer.

  • StrokeRehabilitationGuidelinesummary

    NationalClinicalGuidelineCentre,2013.23

    5. Membersofthecoremultidisciplinarystroketeamshouldscreenthepersonwithstrokeforarangeofimpairmentsanddisabilities,inordertoinformanddirectfurtherassessmentandtreatment.

    6. Healthandsocialcareprofessionalsshouldworkcollaborativelytoensureasocialcareassessmentiscarriedoutpromptly,whereneeded,beforethepersonwithstrokeistransferredfromhospitaltothecommunity.Theassessmentshould:

    identifyanyongoingneedsofthepersonandtheirfamilyorcarer,forexample,accesstobenefits,careneeds,housing,communityparticipation,returntowork,transportandaccesstovoluntaryservices.

    bedocumentedandallneedsrecordedinthepersonshealthandsocialcareplan,withacopyprovidedtothepersonwithstroke.

    7. Offertrainingincare(forexample,inmovingandhandlingandhelpingwithdressing)tofamilymembersorcarerswhoarewillingandabletobeinvolvedinsupportingthepersonaftertheirstroke.

    Reviewfamilymembersandcarerstrainingandsupportneedsregularly(asaminimumatthepersons6monthandannualreviews),acknowledgingthattheseneedsmaychangeovertime.

    8. Offerearlysupporteddischargetopeoplewithstrokewhoareabletotransferfrombedtochairindependentlyorwithassistance,aslongasasafeandsecureenvironmentcanbeprovided.

    9. Earlysupporteddischargeshouldbepartofaskilledstrokerehabilitationserviceandshouldconsistofthesameintensityoftherapyandrangeofmultidisciplinaryskillsavailableinhospital.Itshouldnotresultinadelayindeliveryofcare.

    10. Hospitalsshouldhavesystemsinplacetoensurethat:

    peopleafterstrokeandtheirfamiliesandcarers(asappropriate)areinvolvedinplanningfortransferofcare,andcarersreceivetrainingincare(forexample,inmovingandhandlingandhelpingwithdressing)

    peopleafterstrokeandtheirfamiliesandcarersfeeladequatelyinformed,preparedandsupported

    GPsandotherappropriatepeopleareinformedbeforetransferofcare

    anagreedhealthandsocialcareplanisinplace,andthepersonknowswhomtocontactifdifficultiesarise

    appropriateequipment(includingspecialistseatingandawheelchairifneeded)isinplaceatthepersonsresidence,regardlessofsetting.

    11. Beforetransferfromhospitaltohomeortoacaresetting,discussandagreeahealthandsocialcareplanwiththepersonwithstrokeandtheirfamilyorcarer(asappropriate),andprovidethistoallrelevanthealthandsocialcareproviders.

    12. Beforetransferofcarefromhospitaltohomeforpeoplewithstroke:

    establishthattheyhaveasafeandenablinghomeenvironment,forexample,checkthatappropriateequipmentandadaptationshavebeenprovidedandthatcarersaresupportedtofacilitateindependence,and

  • StrokeRehabilitationGuidelinesummary

    NationalClinicalGuidelineCentre,2013.24

    undertakeahomevisitwiththemunlesstheirabilitiesandneedscanbeidentifiedinotherways,forexample,bydemonstratingindependenceinallselfcareactivities,includingmealpreparation,whileintherehabilitationunit.

    13. Ontransferofcarefromhospitaltothecommunity,provideinformationtoallrelevanthealthandsocialcareprofessionalsandthepersonwithstroke.Thisshouldinclude:

    asummaryofrehabilitationprogressandcurrentgoals

    diagnosisandhealthstatus

    functionalabilities(includingcommunicationneeds)

    careneeds,includingwashing,dressing,helpwithgoingtothetoiletandeating

    psychological(cognitiveandemotional)needs

    medicationneeds(includingthepersonsabilitytomanagetheirprescribedmedicationsandanysupporttheyneedtodoso)

    socialcircumstances,includingcarersneeds

    mentalcapacityregardingthetransferdecision

    managementofrisk,includingtheneedsofvulnerableadults

    plansforfollowup,rehabilitationandaccesstohealthandsocialcareandvoluntarysectorservices.

    14. Ensurethatpeoplewithstrokewhoaretransferredfromhospitaltocarehomesreceiveassessmentandtreatmentfromstrokerehabilitationandsocialcareservicestothesamestandardsastheywouldreceiveintheirownhomes.

    15. Localhealthandsocialcareprovidersshouldhavestandardoperatingprocedurestoensurethesafetransferandlongtermcareofpeopleafterstroke,includingthoseincarehomes.Thisshouldincludetimelyexchangeofinformationbetweendifferentprovidersusinglocalprotocols.

    16. Aftertransferofcarefromhospital,peoplewithdisabilitiesafterstroke(includingpeopleincarehomes)shouldbefollowedupwithin72hoursbythespecialiststrokerehabilitationteamforassessmentofpatientidentifiedneedsandthedevelopmentofsharedmanagementplans.

    17. ProvideadviceonprescribedmedicationsforpeopleafterstrokeinlinewithrecommendationsinMedicinesadherence(NICEclinicalguideline76).

    18. Onadmissiontohospital,toensuretheimmediatesafetyandcomfortofthepersonwithstroke,screenthemforthefollowingand,ifproblemsareidentified,startmanagementassoonaspossible:

    orientation

    positioning,movingandhandling

    swallowing

    transfers(forexample,frombedtochair)

    pressurearearisk

    continence

  • StrokeRehabilitationGuidelinesummary

    NationalClinicalGuidelineCentre,2013.25

    communication,includingtheabilitytounderstandandfollowinstructionsandtoconveyneedsandwishes

    nutritionalstatusandhydration(followtherecommendationsinStroke[NICEclinicalguideline68]andNutritionsupportinadults[NICEclinicalguideline32]).

    19. Performafullmedicalassessmentofthepersonwithstroke,includingcognition(attention,memory,spatialawareness,apraxia,perception),vision,hearing,tone,strength,sensationandbalance.

    20. Acomprehensiveassessmentofapersonwithstrokeshouldtakeintoaccount:

    theirpreviousfunctionalabilities

    impairmentofpsychologicalfunctioning(cognitive,emotionalandcommunication)

    impairmentofbodyfunctions,includingpain

    activitylimitationsandparticipationrestrictions

    environmentalfactors(social,physicalandcultural).

    21. Informationcollectedroutinelyfrompeoplewithstrokeusingvalid,reliableandresponsivetoolsshouldincludethefollowingonadmissionanddischarge:

    NationalInstitutesofHealthStrokeScale

    BarthelIndex.

    22. Informationcollectedfrompeoplewithstrokeusingvalid,reliableandresponsivetoolsshouldbefedbacktothemultidisciplinaryteamregularly.

    23. Takeintoconsiderationtheimpactofthestrokeonthepersonsfamily,friendsand/orcarersand,ifappropriate,identifysourcesofsupport.

    24. Informthefamilymembersandcarersofpeoplewithstrokeabouttheirrighttohaveacarersneedsassessment.

    25. Ensurethatpeoplewithstrokehavegoalsfortheirrehabilitationthat:

    aremeaningfulandrelevanttothem

    focusonactivityandparticipation

    arechallengingbutachievable

    includebothshorttermandlongtermelements.

    26. Ensurethatgoalsettingmeetingsduringstrokerehabilitation:

    aretimetabledintotheworkingweek

    involvethepersonwithstrokeand,whereappropriate,theirfamilyorcarerinthediscussion.

    27. Ensurethatduringgoalsettingmeetings,peoplewithstrokeareprovidedwith:

    anexplanationofthegoalsettingprocess

    theinformationtheyneedinaformatthatisaccessibletothem

    thesupporttheyneedtomakedecisionsandtakeanactivepartinsettinggoals.

  • StrokeRehabilitationGuidelinesummary

    NationalClinicalGuidelineCentre,2013.26

    28. Givepeoplecopiesoftheiragreedgoalsforstrokerehabilitationaftereachgoalsettingmeeting.

    29. Reviewpeoplesgoalsatregularintervalsduringtheirstrokerehabilitation.

    30. Provideinformationandsupporttoenablethepersonwithstrokeandtheirfamilyorcarer(asappropriate)toactivelyparticipateinthedevelopmentoftheirstrokerehabilitationplan.

    31. Strokerehabilitationplansshouldbereviewedregularlybythemultidisciplinaryteam.Timethesereviewsaccordingtothestageofrehabilitationandthepersonsneeds.

    32. Documentationaboutthepersonsstrokerehabilitationshouldbeindividualised,andshouldincludethefollowinginformationasaminimum:

    basicdemographics,includingcontactdetailsandnextofkin

    diagnosisandrelevantmedicalinformation

    listofcurrentmedications,includingallergies

    standardisedscreeningassessments(seerecommendation18)

    thepersonsrehabilitationgoals

    multidisciplinaryprogressnotes

    akeycontactfromthestrokerehabilitationteam(includingtheircontactdetails)tocoordinatethepersonshealthandsocialcareneeds

    dischargeplanninginformation(includingaccommodationneeds,aidsandadaptations)

    jointhealthandsocialcareplans,ifdeveloped

    followupappointments.

    33. Offerinitiallyatleast45minutesofeachrelevantstrokerehabilitationtherapyforaminimumof5daysperweektopeoplewhohavetheabilitytoparticipate,andwherefunctionalgoalscanbeachieved.Ifmorerehabilitationisneededatalaterstage,tailortheintensitytothepersonsneedsatthattimec.

    34. Considermorethan45minutesofeachrelevantstrokerehabilitationtherapy5daysperweekforpeoplewhohavetheabilitytoparticipateandcontinuetomakefunctionalgains,andwherefunctionalgoalscanbeachieved.

    35. Ifpeoplewithstrokeareunabletoparticipatein45minutesofeachrehabilitationtherapy,ensurethattherapyisstilloffered5daysperweekforashortertimeatanintensitythatallowsthemtoactivelyparticipate.

    36. Workingwiththepersonwithstrokeandtheirfamilyorcarer,identifytheirinformationneedsandhowtodeliverthem,takingintoaccountspecificimpairmentssuchasaphasiaandcognitiveimpairments.Pacetheinformationtothepersonsemotionaladjustment.

    37. Provideinformationaboutlocalresources(forexample,leisure,housing,socialservicesandthevoluntarysector)thatcanhelptosupporttheneedsandprioritiesofthepersonwithstrokeandtheirfamilyorcarer.

    cIntensityoftherapyfordysphagia,providedaspartofspeechandlanguagetherapyisaddressedin

    recommendation58.

  • StrokeRehabilitationGuidelinesummary

    NationalClinicalGuidelineCentre,2013.27

    38. Reviewinformationneedsatthepersons6monthandannualstrokereviewsandatthestartandcompletionofanyinterventionperiod.

    39. NICEhasproducedguidanceonthecomponentsofgoodpatientexperienceinadultNHSservices.FollowtherecommendationsinPatientexperienceinadultNHSservices(NICEclinicalguideline138)d.

    40. Screenpeopleafterstrokeforcognitivedeficits.Whereacognitivedeficitisidentified,carryoutadetailedassessmentusingvalid,reliableandresponsivetoolsbeforedesigningatreatmentprogramme.

    41. Provideeducationandsupportforpeoplewithstrokeandtheirfamiliesandcarerstohelpthemunderstandtheextentandimpactofcognitivedeficitsafterstroke,recognisingthatthesemayvaryovertimeandindifferentsettings.

    42. Assesstheeffectofvisualneglectafterstrokeonfunctionaltaskssuchasmobility,dressing,eatingandusingawheelchair,usingstandardisedassessmentsandbehaviouralobservation.

    43. Useinterventionsforvisualneglectafterstrokethatfocusontherelevantfunctionaltasks,takingintoaccounttheunderlyingimpairment.Forexample:

    interventionstohelppeoplescantotheneglectedside,suchasbrightlycolouredlinesorhighlighterontheedgeofthepage

    alertingtechniquessuchasauditorycues

    repetitivetaskperformancesuchasdressing

    alteringtheperceptualinputusingprismglasses.

    44. Assessmemoryandotherrelevantdomainsofcognitivefunctioning(suchasexecutivefunctions)inpeopleafterstroke,particularlywhereimpairmentsinmemoryaffecteverydayactivity.

    45. Useinterventionsformemoryandcognitivefunctionsafterstrokethatfocusontherelevantfunctionaltasks,takingintoaccounttheunderlyingimpairment.Interventionscouldinclude:

    increasingawarenessofthememorydeficit

    enhancinglearningusingerrorlesslearningandelaborativetechniques(makingassociations,useofmnemonics,internalstrategiesrelatedtoencodinginformationsuchaspreview,question,read,state,test)

    externalaids(forexample,diaries,lists,calendarsandalarms)

    environmentalstrategies(routinesandenvironmentalprompts).

    46. Assessattentionandcognitivefunctionsinpeopleafterstrokeusingstandardisedassessments.Usebehaviouralobservationtoevaluatetheimpactoftheimpairmentonfunctionaltasks.

    47. Considerattentiontrainingforpeoplewithattentiondeficitsafterstroke.

    48. Useinterventionsforattentionandcognitivefunctionsafterstrokethatfocusontherelevantfunctionaltasks.Forexample,usegenerictechniquessuchasmanagingtheenvironmentandprovidingpromptsrelevanttothefunctionaltask.

    dForrecommendationsoncontinuityofcareandrelationshipsseesection1.4andforrecommendationson

    enablingpatientstoactivelyparticipateintheircareseesection1.5.

  • StrokeRehabilitationGuidelinesummary

    NationalClinicalGuidelineCentre,2013.28

    49. Assessemotionalfunctioninginthecontextofcognitivedifficultiesinpeopleafterstroke.Anyinterventionchosenshouldtakeintoconsiderationthetypeorcomplexityofthepersonsneuropsychologicalpresentationandrelevantpersonalhistory.

    50. Supportandeducatepeopleafterstrokeandtheirfamiliesandcarers,inrelationtoemotionaladjustmenttostroke,recognisingthatpsychologicalneedsmaychangeovertimeandindifferentsettings.

    51. Whenneworpersistingemotionaldifficultiesareidentifiedatthepersons6monthorannualstrokereviews,referthemtoappropriateservicesfordetailedassessmentandtreatment.

    52. ManagedepressionoranxietyinpeopleafterstrokewhohavenocognitiveimpairmentinlinewithrecommendationsinDepressioninadultswithachronicphysicalhealthproblem(NICEclinicalguideline91)andGeneralisedanxietydisorder(NICEclinicalguideline113).

    53. Screenpeopleafterstrokeforvisualdifficulties.

    54. Offereyemovementtherapytopeoplewhohavepersistinghemianopiaafterstrokeandwhoareawareofthecondition.

    55. Whenadvisingpeoplewithvisualproblemsafterstrokeaboutdriving,consulttheDriverandVehicleLicensingAgency(DVLA)regulations.

    56. Referpeoplewithpersistingdoublevisionafterstrokeforformalorthopticassessment.

    57. AssessswallowinginpeopleafterstrokeinlinewithrecommendationsinStroke(NICEclinicalguideline68).

    58. Offerswallowingtherapyatleast3timesaweektopeoplewithdysphagiaafterstrokewhoareabletoparticipate,foraslongastheycontinuetomakefunctionalgains.Swallowingtherapycouldincludecompensatorystrategies,exercisesandposturaladvice.

    59. Ensurethateffectivemouthcareisgiventopeoplewithdifficultyswallowingafterstroke,inordertodecreasetheriskofaspirationpneumonia.

    60. Healthcareprofessionalswithrelevantskillsandtraininginthediagnosis,assessmentandmanagementofswallowingdisordersshouldregularlymonitorandreassesspeoplewithdysphagiaafterstrokewhoarehavingmodifiedfoodandliquiduntiltheyarestable(thisrecommendationisfromNutritionsupportinadults[NICEclinicalguideline32]).

    61. ProvidenutritionsupporttopeoplewithdysphagiainlinewithrecommendationsinNutritionsupportinadults(NICEclinicalguideline32)andStroke(NICEclinicalguideline68).

    62. Screenpeopleafterstrokeforcommunicationdifficultieswithin72hoursofonsetofstrokesymptoms.

    63. Eachstrokerehabilitationserviceshoulddeviseastandardisedprotocolforscreeningforcommunicationdifficultiesinpeopleafterstroke.

    64. Provideappropriateinformation,educationandtrainingtothemultidisciplinarystroketeamtoenablethemtosupportandcommunicateeffectivelywiththepersonwithcommunicationdifficultiesandtheirfamilyorcarer.

    65. Speechandlanguagetherapyforpeoplewithstrokeshouldbeledandsupervisedbyaspecialistspeechandlanguagetherapistworking

  • StrokeRehabilitationGuidelinesummary

    NationalClinicalGuidelineCentre,2013.29

    collaborativelywithotherappropriatelytrainedpeopleforexample,speechandlanguagetherapyassistants,carersanfriends,andmembersofthevoluntarysector.

    66. Provideopportunitiesforpeoplewithcommunicationdifficultiesafterstroketohaveconversationandsocialenrichmentwithpeoplewhohavethetraining,knowledge,skillsandbehaviourstosupportcommunication.Thisshouldbeinadditiontotheopportunitiesprovidedbyfamilies,carersandfriends.

    67. Speechandlanguagetherapistsshouldassesspeoplewithlimitedfunctionalcommunicationafterstrokefortheirpotentialtobenefitfromusingacommunicationaidorothertechnologies(forexample,homebasedcomputertherapiesorsmartphoneapplications).

    68. Providecommunicationaidsforthosepeopleafterstrokewhohavethepotentialtobenefit,andoffertraininginhowtousethem.

    69. Tellthepersonwithcommunicationdifficultiesafterstrokeaboutcommunitybasedcommunicationandsupportgroups(suchasthoseprovidedbythevoluntarysector)andencouragethemtoparticipate.

    70. Whenpersistingcommunicationdifficultiesareidentifiedatthepersons6monthorannualstrokereviews,referthembacktoaspeechandlanguagetherapistfordetailedassessment,andoffertreatmentifthereispotentialforfunctionalimprovement.

    71. Makesurethatallwritteninformation(includingthatrelatingtomedicalconditionsandtreatment)isadaptedforpeoplewithaphasiaafterstroke.Thisshouldinclude,forexample,appointmentletters,rehabilitationtimetablesandmenus.

    72. Helpandenablepeoplewithcommunicationdifficultiesafterstroketocommunicatetheireverydayneedsandwishes,andsupportthemtounderstandandparticipateinbotheverydayandmajorlifedecisions.

    73. Ensurethatenvironmentalbarrierstocommunicationareminimisedforpeopleafterstroke.Forexample,makesuresignageisclearandbackgroundnoiseisminimised.

    74. Referpeoplewithsuspectedcommunicationdifficultiesafterstroketoaspeechandlanguagetherapistfordetailedanalysisofspeechandlanguageimpairmentsandassessmentoftheirimpact.

    75. Speechandlanguagetherapistsshould:

    providedirectimpairmentbasedtherapyforcommunicationimpairments(forexample,aphasiaordysarthria)

    helpthepersonwithstroketouseandenhancetheirremaininglanguageandcommunicationabilities

    teachothermethodsofcommunicating,suchasgestures,writingandusingcommunicationprops

    coachpeoplearoundthepersonwithstroke(includingfamilymembers,carersandhealthandsocialcarestaff)todevelopsupportivecommunicationskillstomaximisethepersonscommunicationpotential

    helpthepersonwithaphasiaordysarthriaandtheirfamilyorcarertoadjusttoacommunicationimpairment

  • StrokeRehabilitationGuidelinesummary

    NationalClinicalGuidelineCentre,2013.30

    supportthepersonwithcommunicationdifficultiestorebuildtheiridentity

    supportthepersontoaccessinformationthatenablesdecisionmaking.

    76. Offertrainingincommunicationskills(suchasslowingdown,notinterrupting,usingcommunicationprops,gestures,drawing)totheconversationpartnersofpeoplewithaphasiaafterstroke.

    77. Providephysiotherapyforpeoplewhohaveweaknessintheirtrunkorupperorlowerlimb,sensorydisturbanceorbalancedifficultiesafterstrokethathaveaneffectonfunction.

    78. Peoplewithmovementdifficultiesafterstrokeshouldbetreatedbyphysiotherapistswhohavetherelevantskillsandtraininginthediagnosis,assessmentandmanagementofmovementinpeoplewithstroke.

    79. Treatmentforpeoplewithmovementdifficultiesafterstrokeshouldcontinueuntilthepersonisabletomaintainorprogressfunctioneitherindependentlyorwithassistancefromothers(forexample,rehabilitationassistants,familymembers,carersorfitnessinstructors).

    80. Considerstrengthtrainingforpeoplewithmuscleweaknessafterstroke.Thiscouldincludeprogressivestrengthbuildingthroughincreasingrepetitionsofbodyweightactivities(forexample,sittostandrepetitions),weights(forexample,progressiveresistanceexercise),orresistanceexerciseonmachinessuchasstationarycycles.

    81. Encouragepeopletoparticipateinphysicalactivityafterstroke.

    82. Assesspeoplewhoareabletowalkandaremedicallystableaftertheirstrokeforcardiorespiratoryandresistancetrainingappropriatetotheirindividualgoals.

    83. Cardiorespiratoryandresistancetrainingforpeoplewithstrokeshouldbestartedbyaphysiotherapistwiththeaimthatthepersoncontinuestheprogrammeindependentlybasedonthephysiotherapistsinstructions(seerecommendation84).

    84. Forpeoplewithstrokewhoarecontinuinganexerciseprogrammeindependently,physiotherapistsshouldsupplyanynecessaryinformationaboutinterventionsandadaptationssothatwherethepersonisusinganexerciseprovider,theprovidercanensuretheirprogrammeissafeandtailoredtotheirneedsandgoals.Thisinformationmaytaketheformofwritteninstructions,telephoneconversationsorajointvisitwiththeproviderandthepersonwithstroke,dependingontheneedsandabilitiesoftheexerciseproviderandthepersonwithstroke.

    85. Tellpeoplewhoareparticipatinginfitnessactivitiesafterstrokeaboutcommonpotentialproblems,suchasshoulderpain,andadvisethemtoseekadvicefromtheirGPortherapistiftheseoccur.

    86. Donotroutinelyofferwristandhandsplintstopeoplewithupperlimbweaknessafterstroke.

    87. Considerwristandhandsplintsinpeopleatriskafterstroke(forexample,peoplewhohaveimmobilehandsduetoweakness,andpeoplewithhightone),to:

    maintainjointrange,softtissuelengthandalignment

    increasesofttissuelengthandpassiverangeofmovement

  • StrokeRehabilitationGuidelinesummary

    NationalClinicalGuidelineCentre,2013.31

    facilitatefunction(forexample,ahandsplinttoassistgriporfunction)

    aidcareorhygiene(forexample,byenablingaccesstothepalm)

    increasecomfort(forexample,usingasheepskinpalmprotectortokeepfingernailsawayfromthepalmofthehand).

    88. Wherewristandhandsplintsareusedinpeopleafterstroke,theyshouldbeassessedandfittedbyappropriatelytrainedhealthcareprofessionalsandareviewplanshouldbeestablished.

    89. Teachthepersonwithstrokeandtheirfamilyorcarerhowtoputthesplintonandtakeitoff,careforthesplintandmonitorforsignsofrednessandskinbreakdown.Provideapointofcontactforthepersonifconcerned.

    90. Donotroutinelyofferpeoplewithstrokeelectricalstimulationfortheirhandandarm.

    91. Consideratrialofelectricalstimulationinpeoplewhohaveevidenceofmusclecontractionafterstrokebutcannotmovetheirarmagainstresistance.

    92. Ifatrialoftreatmentisconsideredappropriate,ensurethatelectricalstimulationtherapyisguidedbyaqualifiedrehabilitationprofessional.

    93. Theaimofelectricalstimulationshouldbetoimprovestrengthwhilepractisingfunctionaltasksinthecontextofacomprehensivestrokerehabilitationprogramme.

    94. Continueelectricalstimulationifprogresstowardsclearfunctionalgoalshasbeendemonstrated(forexample,maintainingrangeofmovement,orimprovinggraspandrelease).

    95. Considerconstraintinducedmovementtherapyforpeoplewithstrokewhohavemovementof20degreesofwristextensionand10degreesoffingerextension.Beawareofpotentialadverseevents(suchasfalls,lowmoodandfatigue).

    96. Provideinformationforpeoplewithstrokeandtheirfamiliesandcarersonhowtopreventpainortraumatotheshoulderiftheyareatriskofdevelopingshoulderpain(forexample,iftheyhaveupperlimbweaknessandspasticity).

    97. Manageshoulderpainafterstrokeusingappropriatepositioningandothertreatmentsaccordingtoeachpersonsneed.

    98. ForguidanceonmanagingneuropathicpainfollowNeuropathicpain(NICEclinicalguideline96).

    99. Offerpeoplerepetitivetasktrainingafterstrokeonarangeoftasksforupperlimbweakness(suchasreaching,grasping,pointing,movingandmanipulatingobjectsinfunctionaltasks)andlowerlimbweakness(suchassittostandtransfers,walkingandusingstairs).

    100. Offerwalkingtrainingtopeopleafterstrokewhoareabletowalk,withorwithoutassistance,tohelpthembuildenduranceandmovemorequickly.

    101. Considertreadmilltraining,withorwithoutbodyweightsupport,asoneoptionofwalkingtrainingforpeopleafterstrokewhoareabletowalkwithorwithoutassistance.

    102. Offerelectromechanicalgaittrainingtopeopleafterstrokeonlyinthecontextofaresearchstudy.

  • StrokeRehabilitationGuidelinesummary

    NationalClinicalGuidelineCentre,2013.32

    103. Consideranklefootorthosesforpeoplewhohavedifficultywithswingphasefootclearanceafterstroke(forexample,trippingandfalling)and/orstancephasecontrol(forexample,kneeandanklecollapseorkneehyperextensions)thataffectswalking.

    104. Assesstheabilityofthepersonwithstroketoputontheanklefootorthosisorensuretheyhavethesupportneededtodoso.

    105. Assesstheeffectivenessoftheanklefootorthosisforthepersonwithstroke,intermsofcomfort,speedandeaseofwalking.

    106. Assessmentforandtreatmentwithanklefootorthosesshouldonlybecarriedoutaspartofastrokerehabilitationprogrammeandperformedbyqualifiedprofessionals.

    107. ForguidanceonfunctionalelectricalstimulationforthelowerlimbseeFunctionalelectricalstimulationfordropfootofcentralneurologicalorigin(NICEinterventionalprocedureguidance278).

    108. Provideoccupationaltherapyforpeopleafterstrokewhoarelikelytobenefit,toaddressdifficultieswithpersonalactivitiesofdailyliving.Therapymayconsistofrestorativeorcompensatorystrategies.

    Restorativestrategiesmayinclude:

    - encouragingpeoplewithneglecttoattendtotheneglectedside

    - encouragingpeoplewitharmweaknesstoincorporatebotharms

    - establishingadressingroutineforpeoplewithdifficultiessuchaspoorconcentration,neglectordyspraxiawhichmakedressingproblematic.

    Compensatorystrategiesmayinclude:

    - teachingpeopletodressonehanded

    - teachingpeopletousedevicessuchasbathinganddressingaids.

    109. Peoplewhohavedifficultiesinactivitiesofdailylivingafterstrokeshouldhaveregularmonitoringandtreatmentbyoccupationaltherapistswithcoreskillsandtrainingintheanalysisandmanagementofactivitiesofdailyliving.Treatmentshouldcontinueuntilthepersonisstableorabletoprogressindependently.

    110. Assesspeopleafterstrokefortheirequipmentneedsandwhethertheirfamilyorcarersneedtrainingtousetheequipment.Thisassessmentshouldbecarriedoutbyanappropriatelyqualifiedprofessional.Equipmentmayincludehoists,chairraisersandsmallaidssuchaslonghandledsponges.

    111. Ensurethatappropriateequipmentisprovidedandavailableforusebypeopleafterstrokewhentheyaretransferredfromhospital,whateverthesetting(includingcarehomes).

    112. Returntoworkissuesshouldbeidentifiedassoonaspossibleafterthepersonsstroke,reviewedregularlyandmanagedactively.Activemanagementshouldinclude:

    identifyingthephysical,cognitive,communicationandpsychologicaldemandsofthejob(forexample,multitaskingbyansweringemailsandtelephonecallsinabusyoffice)

    identifyinganyimpairmentsonworkperformance(forexample,physicallimitations,anxiety,fatiguepreventingattendanceforafulldayat

  • StrokeRehabilitationGuidelinesummary

    NationalClinicalGuidelineCentre,2013.33

    work,cognitiveimpairmentspreventingmultitasking,andcommunicationdeficits)

    tailoringanintervention(forexample,teachingstrategiestosupportmultitaskingormemorydifficulties,teachingtheuseofvoiceactivatedsoftwareforpeoplewithdifficultytyping,anddeliveryofworksimulations)

    educatingabouttheEqualityAct2010eandsupportavailable(forexample,anaccesstoworkscheme)

    workplacevisitsandliaisonwithemployerstoestablishreasonableaccommodations,suchasprovisionofequipmentandgradedreturntowork.

    113. ManagereturntoworkorlongtermabsencefromworkforpeopleafterstrokeinlinewithrecommendationsinManaginglongtermsicknessandincapacityforwork(NICEpublichealthguidance19).

    114. Informpeopleafterstrokethattheycanselfrefer,usuallywiththesupportofaGPornamedcontact,iftheyneedfurtherstrokerehabilitationservices.

    115. Provideinformationsothatpeopleafterstrokeareabletorecognisethedevelopmentofcomplicationsofstroke,includingfrequentfalls,spasticity,shoulderpainandincontinence.

    116. Encouragepeopletofocusonlifeafterstrokeandhelpthemtoachievetheirgoals.Thismayinclude:

    facilitatingtheirparticipationincommunityactivities,suchasshopping,civicengagement,sportsandleisurepursuits,visitingtheirplaceofworshipandstrokesupportgroups

    supportingtheirsocialroles,forexample,work,education,volunteering,leisure,familyandsexualrelationships

    providinginformationabouttransportanddriving(includingDVLArequirements;seewww.dft.gov.uk/dvla/medical/aag).

    117. ManageincontinenceafterstrokeinlinewithrecommendationsinUrinaryincontinenceinneurologicaldisease(NICEclinicalguideline148)andFaecalincontinence(NICEclinicalguideline49).

    118. Reviewthehealthandsocialcareneedsofpeopleafterstrokeandtheneedsoftheircarersat6monthsandannuallythereafter.Thesereviewsshouldcoverparticipationandcommunityrolestoensurethatpeoplesgoalsareaddressed.

    119. Forguidanceonsecondarypreventionofstroke,followrecommendationsinLipidmodification(NICEclinicalguideline67),Hypertension(NICEclinicalguideline127),Type2diabetes(NICEclinicalguideline87)andAtrialfibrillation(NICEclinicalguideline36).

    120. ProvideadviceonprescribedmedicationsinlinewithrecommendationsinMedicinesadherence(NICEclinicalguideline76).

    eHM Government (2010) Equality Act [online]

  • StrokeRehabilitationGuidelinesummary

    NationalClinicalGuidelineCentre,2013.34

    3.3 Keyresearchrecommendations

    3.3.1 Upperlimbelectricalstimulation(ES)What is the clinical and cost effectiveness of electrical stimulation (ES) as an adjunct

    to rehabilitation to improve hand and arm function in people after stroke, from early

    rehabilitation through to use in the community?

    3.3.2 IntensiverehabilitationafterstrokeIn people after stroke what is the clinical and cost effectiveness of intensive

    rehabilitation (6 hours per day) versus moderate rehabilitation (2 hours per day) on

    activity, participation and quality of life outcomes?

    3.3.3 NeuropsychologicaltherapiesWhich cognitive and which emotional interventions provide better outcomes for

    identified subgroups of people with stroke and their families and carers at different

    stages of the stroke pathway?

    3.3.4 ShoulderpainWhich 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?

    ForfurtherdetailspleaserefertoAppendixL.

  • StrokeRehabilitationMethods

    NationalClinicalGuidelineCentre,2013.35

    4 MethodsThischaptersetsoutindetailthemethodsusedtogeneratetherecommendationsthatarepresentedinsubsequentchapters.ThisguidancewasdevelopedinaccordancewiththemethodsoutlinedintheNICEGuidelinesManual2009187.

    4.1 DevelopingthereviewquestionsandoutcomesReviewquestionsweredevelopedinaPICOframework(patient,intervention,comparisonandoutcome)forinterventionreviews.Thiswastoguidetheliteraturesearchingprocess,appraisal,andsynthesisofevidenceandtofacilitatethedevelopmentofrecommendationsbytheguidelinedevelopmentgroup(GDG).TheyweredraftedbytheNCGCtechnicalteamandrefinedandvalidatedbytheGDG.Thequestionswerebasedonthekeyclinicalareasidentifiedinthescope(AppendixA).

    Atotalof22reviewquestionswereidentified.Fullliteraturesearches,criticalappraisalsandevidencereviewswerecompletedforallthespecifiedclinicalquestions.

    Chapter Reviewquestions OutcomesStructureandsettings:strokeunits

    Inpeopleafterstroke,doesorganisedrehabilitationcare(comprehensive,rehabilitationandmixedrehabilitationstrokeunits)improveoutcome(mortality,dependency,requirementforinstitutionalcareandlengthofhospitalstay)?

    Death Deathordependency Deathorinstitutionalcare Durationofstayinhospitalorinstitutionorboth

    Qualityoflife Patientandcarersatisfaction

    Structureandsettings:earlysupporteddischarge

    Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofearlysupporteddischargeversususualcare?

    BarthelIndex Lengthofhospitalstay FunctionalIndependenceMeasure(FIM) Caregiverstrainindex Falls Readmissionstohospital HospitalAnxietyandDepressionScale(HADS)

    Mortality QualityOfLife NottinghamExtendedActivitiesofDailyLiving

    Servicedelivery:goalsetting

    Doestheapplicationofpatientgoalsettingaspartofplanningstrokerehabilitationactivitiesleadtoanimprovementinpsychological

    wellbeing,functioningandactivity?

    Psychologicalwellbeing viewsaboutthequalityofthegoalsettingprocess

    satisfactionwithoutcome healthrelatedqualityoflife physicalfunction ActivitiesofDailyLiving(ADL)

    Servicedelivery:intensityof

    Inpeopleafterstrokewhatistheclinicalandcosteffectivenessof

    Lengthofstay FunctionalIndependenceMeasure(FIM)

  • StrokeRehabilitationMethods

    NationalClinicalGuidelineCentre,2013.36

    Chapter Reviewquestions Outcomesrehabilitation intensiverehabilitationversus

    standardrehabilitation? BarthelIndex QualityofLife(anymeasure) NottinghamActivitiesofDailyLiving Rankin Rivermeadmobilityindex FrenchayActivitiesIndex

    Supportandinformation:supportedinformationprovision

    Whatistheclinicalandcosteffectivenessofsupportedinformationprovisionversusunsupportedinformationprovisiononmoodanddepressioninpeoplewithstroke?

    Impactonmood/depression: HospitalAnxietyandDepressionScale(HADS)

    GeneralHealthQuestionnaire VisualAnalogueMoodScale StrokeAphasicDepressionQuestionnaire(SADQ)

    GeriatricDepressionScale BeckDepressionInventory Selfefficacy GeneralSelfefficacyScale StrokeSelfefficacyQuestionnaire LocusofControlScale Extendedactivitiesofdailyliving(EADL) NottinghamextendedADL FrenchayActivitiesIndex Yalemoodquestion

    Cognitivefunctions:visualneglect

    Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofcognitiverehabilitationversususualcaretoimprovespatialawarenessand/orvisualneglect?

    Minimentalstateexamination(MMSE), BehaviouralInattentionTest(BIT), Drawingtests(forexample:clockdrawing), LineBisectiontests, Allcancellationtests(including:linecancellation,bellcancellation),

    Sentencereading, Targetscreenexaminations(lumptogetherallcancellationtestsanddrawingtests),

    RivermeadPerceptualAssessmentBattery(RPAB)

    Cognitivefunctions:memoryfunctions

    Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofmemorystrategiesversususualcaretoimprovememory?

    WechslerMemoryScale, Rivermeadbehaviouralmemoryassessment,

    Minimentalstateexamination(MMSE), AddenbrooksCognitiveExaminationRevised,

    AbbreviatedMentalTestScore.Cognitivefunctions:attentionfunction

    Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofsustainedattentiontrainingversususualcaretoimproveattention?

    Minimentalstateexamination,Behaviouralinattentiontest,drawingtests,linebisectiontest,cancellationtests,sentencereading,targetscreenexaminations,RivermeadPerceptualAssessmentBattery

    Emotionalfunctioning

    Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofpsychologicaltherapiesprovidedto

    QualityofLife(forbothcarerandpatient) AnyQOLanddepressionoutcomes

  • StrokeRehabilitationMethods

    NationalClinicalGuidelineCentre,2013.37

    Chapter Reviewquestions Outcomesthefamily(includingthepatients)? includingthefollowing:strokeimpactscale,

    EuroQoL,caregiverburdenscale,caregiverstrainindex,carerstrainindex,burdenofstrokescale,Strokeandaphasiaqualityoflifescale,ASCOTscale.

    Occurrenceofdepression/anxiety/moodincarers

    BeckDepressionInventory,BeckDepressionInventory2,GeriatricDepressionScale,neuropsychiatricinventory,HospitalAnxietyandDepressionScale(HADS),Generalhealthquestionnaire,VisualAnalogueMoodScale,SADQ.

    Vision:eyemovementtherapy

    Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofeyemovementtherapyforvisualfieldlossversususualcare?

    Reading(speedandaccuracy) Eyemovementtasks Scanning LetterCancellationTest

    Digestivesystems:swallowing

    Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofinterventionsforswallowingversusalternativeinterventions

    Occurrenceofaspirationpneumonia Occurrenceofchestinfections Reductioninhospitalstay Reductioninreadmission Returntonormaldiet

    Communication:Aphasia

    Inpeopleafterstrokeisspeechandlanguagetherapycomparedtonospeechandlanguagetherapyorplacebo(socialsupportandstimulation)effectiveinimprovinglanguage/communicationabilitiesand/orpsychologicalwellbeing?

    Functionalcommunication(languageorcommunicationskillssufficienttopermitthetransmissionofmessageviaspoken,writtenornonverbalmodalities,oracombinationofthesechannels)

    Formalmeasuresofreceptivelanguageskills(languageunderstanding)

    Formalmeasuresofexpressivelanguageskills(languageproduction)

    Overalllevelofseverityofaphasiaasmeasuredbyspecialisttestbatteries(mayincludeWesternAphasiaBatteryorPorchIndexofCommunicativeAbilities)

    Psychologicalorsocialwellbeingincludingdepression,anxietyanddistress

    Patientsatisfaction/carerandfamilyviews Compliance/dropout

    Communication:Dysarthria

    Inpeopleafterstrokeisspeechandlanguagetherapycomparedtosocialsupportandstimulationeffectiveinimprovingdysarthria?

    Measuresoffunctionalcommunication Formalmeasuresofreceptivelanguageskills(languageunderstanding)

    Formalmeasuresofexpressivelanguageskills(languageproduction)