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Summary for primary care

Stroke Rehabilitation in Adults

NICE

Overview

This Guidelines summary covers primary care recommendations on the organisation and delivery of stroke rehabilitation for people aged over 16. The guideline aims to ensure that people are assessed for common problems and conditions linked to stroke to facilitate the care and therapy that they need.

View the related summary: Stroke Rehabilitation in Adults in Secondary Care.

Organising Health and Social Care for People Needing Rehabilitation After Stroke

Transfer of Care from Hospital to Community, Including Early Supported Discharge

  • Once the person has left hospital after having a stroke, continue their care and rehabilitation for as long as it continues to help them achieve their treatment goals.
  • Offer early supported discharge to people after stroke who can move from a bed to a chair independently or with assistance, as long as a safe and secure environment can be provided.
  • Early supported discharge should:
    • be part of a multidisciplinary stroke rehabilitation service working across hospital and community settings
    • ensure therapy is continued at the same intensity and level of support from skilled staff as is provided in hospital
    • not result in a delay in delivery of care.
  • Before and during early supported discharge:
    • provide the person after stroke, and their family members and carers, with information about early supported discharge, including details of who to contact if problems arise, to support shared decision making about their care
    • assign a member of the early supported discharge team or the stroke rehabilitation service (for example, a stroke key worker) to the person to coordinate their care
    • take into account the needs of family members and carers and offer relevant training and support to help reduce caregiver strain, in line with NICE's guideline on supporting adult carers
    • be aware, and ensure family members and carers understand, that the person's psychological needs can change after stroke (for recommendations on identifying and managing psychological problems, see the section on psychological functioning).
  • On transfer of care from hospital to the community, provide information to all relevant health and social care professionals and the person after stroke. This should include a summary of the person's rehabilitation progress and current goals and details of their:
    • diagnosis and health status
    • functional abilities (including communication needs)
    • care needs, including washing, dressing, help with going to the toilet and eating
    • psychological (cognitive and emotional) needs
    • medication needs (including the person's ability to manage their prescribed medicines and any support they need to do so)
    • social circumstances, including carers' needs
    • mental capacity regarding the transfer decision
    • management of risk, including the needs of vulnerable adults
    • plans for follow-up, rehabilitation and access to health and social care and voluntary sector services.
  • Ensure that people after stroke who are transferred from hospital to care homes receive assessment and treatment from stroke rehabilitation and social care services to the same standard as they would receive in their own homes.
  • Local health and social care providers should have standard operating procedures to ensure the safe transfer and long-term care of people after stroke, including those in care homes. This should include timely exchange of information between different providers using local protocols.
  • After transfer of care from hospital, people with rehabilitation needs after stroke (including those in care homes) should be followed up within 72 hours by the specialist stroke rehabilitation team to assess the needs of the person and develop shared management plans.

Planning and Delivering Stroke Rehabilitation

For recommendations on screening and assessment, refer to the secondary care summary.

Setting Goals for Rehabilitation

  • Ensure that people after stroke have goals for their rehabilitation that:
    • are meaningful and relevant to them
    • focus on activity and participation
    • are challenging but achievable
    • include both short- and long-term elements.
  • Ensure that goal-setting meetings during stroke rehabilitation:
    • are timetabled and held regularly
    • involve the person after stroke and, where appropriate, their family members and carers, in discussions.
  • During goal-setting meetings, ensure people after stroke are provided with:
    • an explanation of the goal-setting process
    • the information they need in a format that is accessible to them (in line the NHS accessible information standard)
    • the support they need to make decisions and take an active part in setting goals.
  • Give people copies of their agreed goals for stroke rehabilitation after each goal-setting meeting.
  • Review people's goals at regular intervals during their stroke rehabilitation.

Planning Rehabilitation

  • Provide information and support to enable the person after stroke and their family members and carers (as appropriate) to actively take part in developing their stroke rehabilitation plan.
  • Review stroke rehabilitation plans regularly in multidisciplinary team meetings. Time these reviews according to the stage of rehabilitation and the person's needs.
  • Ensure any documentation is tailored to the person after stroke and, as a minimum, includes:
    • the person's basic details, including contact details and next of kin
    • details of their diagnosis and relevant medical information
    • a list of any medicines they are taking or are allergic to
    • details of standardised screening assessments (see the section on screening and assessment in the full guideline)
    • information about the person's rehabilitation goals
    • the multidisciplinary team's progress notes
    • details about a key contact from the stroke rehabilitation team (including their contact details) to coordinate the person's health and social care needs
    • discharge planning information (including accommodation needs, aids and adaptations)
    • joint health and social care plans, if developed
    • details of follow-up appointments.

Intensity of Stroke Rehabilitation

  • For information on high-intensity mobilisation during the first 24 hours after the onset of stroke symptoms, see the section on early mobilisation in NICE's guideline on stroke and transient ischaemic attack in over 16s.
  • Offer needs-based rehabilitation to people after stroke. This should be for at least 3 hours a day, on at least 5 days of the week, and cover a range of multidisciplinary therapy including physiotherapy, occupational therapy and speech and language therapy.
  • Where it is agreed with the person after stroke that they are unable, or do not wish, to participate in rehabilitation therapy for at least 3 hours a day, on at least 5 days of the week, ensure that any therapy needed is still offered for a minimum of 5 days per week.
  • Before rehabilitation begins, provide information on:
    • the benefits of having intensive therapy after stroke that starts as soon as it is safe to do so and
    • what the person can expect from the sessions.
  • Ensure all rehabilitation sessions:
    • include activities linked to the person's goals
    • are tailored to any ongoing medical needs, including post-stroke fatigue
    • take into account any psychological factors (such as the person's mood or motivation on the day of the session).
  • Base the timing, sequencing and content of the sessions on these goals, interests and needs, with the person's agreement.
  • Involve families and carers in rehabilitation sessions, when appropriate (see NICE's guideline on patient experience in adult NHS services).
  • Make special arrangements for people after stroke who have communication or cognitive needs (for example, by holding joint speech and language therapy and physiotherapy sessions for those with communication difficulties).
  • When planning or delivering rehabilitation for people after they have left hospital:
    • check whether they will be at their own home or elsewhere after discharge (for example, a care home or the home of a family member)
    • ensure they will be able to travel from where they are currently living to attend sessions at the arranged time and location
    • take into account any travel needs or issues they may have and reassess these needs or issues if the person moves location (for example, back to their own home or to a care home).

Telerehabilitation

  • Consider telerehabilitation instead of, or as well as, face-to-face therapy, only if:
    • the person after stroke agrees to this approach or it is their preferred type of therapy and
    • it aligns with their rehabilitation goals.
  • Ensure that anyone taking part in telerehabilitation has, or when needed is provided with, the correct equipment (for example, a loaned laptop) and any training or technical support they need to use it.
  • Monitor people who are taking part in telerehabilitation to ensure they are:
    • benefiting from this method of delivering therapy and
    • are not developing symptoms or signs of depression.

Providing Support and Information

  • Work with the person after stroke, and their family members and carers, to identify their information needs and how to deliver this information.
  • Take into account any specific impairments such as aphasia (loss or impairment of the ability to use and comprehend language) and cognitive impairments. Pace the way information is given to allow time for the person to make an emotional adjustment.
  • Provide information about local resources (for example, leisure, housing, social services and voluntary organisations) that can help support the needs and priorities of the person after stroke and their family members and carers.
  • Review the person's information needs at their 6-month and annual stroke reviews, and at the start and end of any therapy.

Cognitive Functioning

  • Screen people after stroke for cognitive impairment. Where cognitive impairment is identified, carry out a detailed assessment using valid, reliable and responsive tools before designing a treatment programme.
  • Provide education and support for people after stroke, and their families and carers, to help them understand the extent and impact of cognitive impairment, recognising that these may vary over time and in different settings.

Visual Inattention

  • Use standardised assessments and behavioural observation to assess the effect of visual inattention (an inability to orient towards and attend to stimuli, including body parts, on the side of the body affected by stroke) on functional tasks such as mobility, dressing, eating and using a wheelchair.
  • Use interventions for visual inattention that focus on the relevant functional tasks, taking into account the underlying impairment. For example:
    • interventions to help people scan to the neglected side of their visual field, such as brightly coloured lines or highlighter on the edge of the page
    • using sounds to alert the person
    • repeating tasks such as dressing
    • using prism glasses to broaden the field of view.

Memory Function

  • Assess memory and other relevant domains of cognitive functioning (such as executive functions) in people after stroke, particularly where impairments in memory affect everyday activity.
  • Use interventions for memory and cognitive functions that focus on the relevant functional tasks, taking into account the underlying impairment.
  • Interventions could include:
    • increasing the person's own awareness of the memory impairment
    • enhancing learning using errorless learning and elaborative techniques (making associations, use of mnemonics and internal strategies related to encoding information such as 'preview, question, read, state, test')
    • external aids (for example, diaries, lists, calendars and alarms)
    • environmental strategies (using routines and environmental prompts).

Attention Function

  • Assess attention and cognitive functions in people after stroke using standardised assessments. Use behavioural observation to evaluate the impact of any impairment on functional tasks.
  • Consider attention training for people with attention deficits after stroke.
  • Use interventions for attention and cognitive functions after stroke that focus on the relevant functional tasks. For example, by minimising distractions and providing prompts related to the task.

Psychological Functioning

  • Assess the person after stroke for changes to:
    • their emotional functioning, such as the onset of emotionalism
    • their behaviour
    • their mental health including the development of any signs that could indicate an increased risk of suicide (suicidality) such as suicidal thoughts, plans and actions, and suicide attempts
    • the way they are adjusting and coping after stroke.
  • When choosing any intervention for problems with emotional functioning, take into account the type or complexity of the person's neuropsychological presentation and relevant personal history.
  • Support and educate people and their families and carers to help them make an emotional adjustment after stroke, recognising that their psychological needs may change over time and in different settings.
  • When new or persisting changes to mood or emotional difficulties are identified at the person's 6-month or annual stroke review, refer them to appropriate services for detailed assessment and treatment.
  • Manage depression or anxiety in people after stroke who have no cognitive impairment in line with NICE's guidelines on depression in adults with a chronic physical health problem and generalised anxiety disorder and panic disorder in adults.

Fatigue

  • Consider a standardised assessment for fatigue in people after stroke in the early stage of their rehabilitation programme and at their 6-month stroke review.
  • Consider 1 of the following for the assessment:
    • the Fatigue Severity Scale
    • the Fatigue Assessment Scale
    • the Modified Fatigue Impact Scale.
For recommendations on vision and hearing, refer to the secondary care summary.

Mouth Care

  • Assess oral hygiene in people after stroke using national or local protocols.
  • Encourage people after stroke to do the following at least twice a day:
    • brush their teeth and gums, using an electric or battery-powered toothbrush if needed
    • use mouthwash and oral gels with antibacterial and antifungal properties, if needed.
  • Ensure that a suitably trained healthcare professional, family member or carer delivers or supervises mouth care for people after stroke who cannot, or find it difficult to, follow a mouth care regimen.

Swallowing

  • Assess swallowing in people after stroke in line with NICE's guideline on stroke and transient ischaemic attack in over 16s.
  • Provide information to people with dysphagia (difficulty in swallowing) after stroke, and their families and carers, on what the condition is and its risks.
  • Give families and carers information on how they can help someone who is coughing or choking while eating or drinking.
  • If the person has dysphagia and is unable to take tablets, review the need for the medication and, if it is still needed, change either its formulation or the route of administration.
  • Support people who have oropharyngeal dysphagia (OPD) to eat and drink as safely as possible, using 1 or more of the following methods (as advised by a dysphagia-trained healthcare professional):
    • adaptions to their physical position
    • modifying fluid intake (for example, taking small sips or drinking thickened fluids)
    • modifying their diet (for example, changing the texture of the food)
    • adapting the way food and drink is served (for example, serving food with different cutlery)
    • using compensatory strategies and manoeuvres appropriate for the person (for example, the Mendelsohn manoeuvre).
  • Offer behavioural exercises (for example, chin tuck against resistance) to people with OPD for at least 5 days per week.
  • Consider physical stimulation (for example, thermal or tactile stimulation) for people with OPD for at least 5 days per week.
  • Ensure people with dysphagia after stroke are supported in following an effective mouth care regimen, because this decreases the risk of aspiration pneumonia (see the section on mouth care).
  • Healthcare professionals with relevant skills and training in the diagnosis, assessment and management of swallowing disorders should regularly monitor and reassess people with dysphagia after stroke who are having modified food and liquid until they are stable (this recommendation is from NICE's guideline on nutrition support for adults).
  • Provide nutrition support to people with dysphagia in line with NICE's guidelines on nutrition support for adults and stroke and transient ischaemic attack in over 16s.
  • If the person with dysphagia is at risk of aspiration but wishes to eat and drink without the assistance of aids and interventions (such as the methods listed in recommendations 5–7 in this section for people with OPD):
For recommendations on communication, movement, and spasticity, refer to the full guideline.

Managing Shoulder Pain

  • Provide information for people after stroke, and their families and carers, on how to prevent pain or trauma to the shoulder if they are at risk of developing shoulder pain (for example, if they have upper limb weakness and spasticity).
  • Assess people with shoulder pain after stroke to identify its cause and use the results of the assessment to decide how to manage the pain.
  • Encourage or help the person to adapt their position to help ease shoulder pain.
  • Consider 1 or more of the following options for managing shoulder pain:
    • taping
    • neuromuscular electrical stimulation (NMES)
    • intra-articular corticosteroid injection
    • nerve block (local anaesthetic).
For guidance on managing neuropathic pain, see NICE's guideline on neuropathic pain in adults.

Self Care

  • Provide occupational therapy for people after stroke who are likely to benefit from it and to address difficulties with activities of daily living. Therapy may consist of restorative or compensatory strategies.
    • Restorative strategies may include:
      • encouraging people with hemisensory inattention (a difficulty in detecting or acting on information on 1 side of their personal space) to attend to the neglected side
      • encouraging people with arm weakness to use both arms
      • establishing a dressing routine for people with difficulties such as poor concentration, hemisensory inattention or dyspraxia (difficulty in planning and executing movement) which make dressing problematic.
    • Compensatory strategies may include training people how to:
      • dress one-handed
      • use devices such as bathing and dressing aids.
  • People who have difficulties with activities of daily living after stroke should have regular monitoring and treatment by occupational therapists with core skills and training in the analysis and management of activities of daily living. Treatment should continue until the person's condition is stable or able to progress independently.
  • Assess people after stroke for their equipment needs and to see whether their family or carers need training to use the equipment. This assessment should be done by an appropriately qualified professional.
  • Equipment may include hoists, chair raisers and small aids such as long-handled sponges.

Returning to Work

  • Identify any return-to-work issues for the person as soon as possible after stroke. Review these regularly and manage them actively, for example by:
    • identifying the physical, cognitive, communication and psychological demands of the job (such as multi-tasking by answering emails and telephone calls in a busy office)
    • identifying any problems that affect work performance (for example, physical limitations, anxiety, fatigue preventing attendance for a full day at work, cognitive impairments preventing multi-tasking, and communication problems)
    • tailoring interventions (for example, teaching strategies to support multi-tasking or memory difficulties, teaching the use of voice-activated software for people with difficulty typing, and delivery of work simulations)
    • providing information about the Equality Act 2010 and support available (for example, an access-to-work scheme)
    • workplace visits and liaison with employers to make reasonable adjustments such as provision of equipment and phased return to work.
  • Consider a referral to a return-to-work programme for people who were working before they had a stroke.
  • Manage people's return to work or long-term absence after stroke in line with NICE's guideline on workplace health.

Long-term Health and Social Support

  • Explain to people after stroke that they can self-refer, usually with the support from a health or care professional working in primary care (for example, a GP or a social prescriber) or named contact from the stroke rehabilitation service, if they need further help or support.
  • Provide information so that people after stroke, and their family and carers, can recognise the complications of the condition, including frequent falls, spasticity, shoulder pain and incontinence.
  • Encourage people to focus on life after stroke and help them to achieve their goals. This may include:
    • giving them information about voluntary organisations that can support them
    • helping them to participate in community activities, such as shopping, civic engagements, sports and leisure pursuits, visiting their place of worship and joining stroke support groups
    • supporting their social roles, for example, in work, education, volunteering, leisure activities, within their family and with sexual relationships
    • providing information about transport and driving (including DVLA requirements; see the UK Government's web page on stroke and driving).
  • Manage incontinence after stroke in line with NICE's guidelines on urinary incontinence in neurological disease and faecal incontinence in adults.
  • Review the health and social care needs of people after stroke, and the needs of their carers, at 6 months and then annually. These reviews should cover participation in activities of everyday life to ensure that people's goals are met.
For guidance on the secondary prevention of stroke, see NICE's guidelines on cardiovascular disease, hypertension in adults, type 2 diabetes in adults and atrial fibrillation. For advice on involving people in decisions about prescribed medications and supporting adherence, follow NICE's guideline on medicines adherence.

Community Participation Programmes

  • Consider referral for people after stroke, and their families and carers (if appropriate), to community participation programmes that:

References

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