Overview
This specialist Guidelines summary covers rehabilitation after stroke for over 16-year-olds in secondary care. It aims to ensure people are assessed for common problems and conditions linked to stroke, and get the care and therapy they need.
This summary is intended for use by neurologists, cardiologists, audiologists, and orthoptists working in a secondary care setting. A summary for primary care is also available, which covers recommendations on setting goals for rehabilitation, swallowing, and long-term health and social support.
Please refer to the full guideline for the complete set of recommendations, including those on communication, movement, and spasticity.
Organising Health and Social Care for People Needing Rehabilitation After Stroke
Stroke Services
- People who need rehabilitation after stroke should receive it from a specialist stroke service:
- in a stroke unit and subsequently from a specialist stroke team in the community, or
- directly from a specialist stroke team in the community if they have left hospital through early supported discharge (where people in an inpatient setting are offered early discharge to continue rehabilitation at home), or
- in a level 1 or 2 specialist inpatient neurorehabilitation unit, and subsequently from a specialist stroke team in the community
- An inpatient stroke unit should:
- have a dedicated stroke rehabilitation environment
- be led by a core multidisciplinary stroke rehabilitation team (see recommendation below) with expertise in working alongside people who have had a stroke, and their families and carers, to manage the changes experienced as a result of stroke
- provide access to other services that may be needed, for example:
- audiology
- continence advice
- electronic aids (for example remote controls for doors, lights and heating, and communication aids)
- liaison psychiatry
- orthotics
- pharmacy
- podiatry
- wheelchair services
- include a multidisciplinary education programme.
The Core Multidisciplinary Stroke Rehabilitation Team
- A core multidisciplinary stroke rehabilitation team should comprise the following professionals with expertise in stroke rehabilitation:
- consultant physicians specialising in stroke, or rehabilitation medicine
- nurses
- physiotherapists
- occupational therapists
- speech and language therapists
- dietitians
- clinical psychologists or clinical neuropsychologists
- orthoptists
- rehabilitation assistants
- social workers
- Throughout the care pathway, document the roles and responsibilities of the multidisciplinary team clearly, and communicate these to the person and their family members and carers.
Planning and Delivering Stroke Rehabilitation
Screening and Assessment
- When a person is admitted to hospital after stroke, screen for the following and, if problems are identified, take action as soon as possible to ensure their safety and comfort:
- signs of disorientation
- how they should be positioned
- swallowing function
- how they move (for example, from a bed to a chair)
- pressure area risk
- their continence
- their communication, including their ability to understand and follow instructions and to convey their needs and wishes
- their nutritional status and hydration (follow NICE guidelines on stroke and transient ischaemic attack in over 16s and nutrition support for adults)
- Perform a full medical assessment of the person after stroke, including cognition (attention, memory, spatial awareness, apraxia of speech, perception), vision, hearing, muscle tone, strength, sensation and balance
- Carry out a comprehensive assessment of a person after stroke that both identifies and takes into account:
- their previous functional abilities
- changes to, or impairment of, psychological and neuropsychological functioning relating to:
- cognitive, emotional or behavioural functioning, such as new signs of emotionalism (difficulty controlling emotions which can cause uncontrollable crying or laughter)
- mental health (for example, the onset of depression, anxiety or post-traumatic stress disorder), including signs indicating an increased risk of suicide (suicidality) such as suicidal thoughts, plans, actions and suicide attempts
- the way the person is adjusting and coping after stroke
- communication
- impairment of body functions, including pain
- activity limitations and participation restriction
- environmental factors (social, physical and cultural)
- When collecting information from people who have had a stroke, on admission and discharge:
- use valid, reliable and responsive tools including the National Institutes of Health Stroke Scale and the Barthel Index
- feed this information back to the multidisciplinary team regularly
- Take into account the impact of stroke on the person's family, friends and carers and, if appropriate, identify sources of support for them
- Inform the family members and carers of people after stroke about their right to a carer's needs assessment.
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.
Vision
- Offer people who are in hospital after stroke a specialist orthoptist assessment as soon as possible. If this cannot be done before discharge, offer the person an urgent outpatient appointment
- Offer eye movement therapy to people who have persisting hemianopia (blindness in 1 half of the visual field of 1 or both eyes) after stroke
- When advising people with visual problems after stroke about driving, consult the Driver and Vehicle Licensing Agency (DVLA) regulations.
Hearing
- Screen people for hearing problems within the first 6 weeks after stroke
- Consider the Handicap Hearing Inventory in the Elderly or Amsterdam Inventory Auditory of Disability questionnaires for screening
- During screening, ask the person, and their family members and carers, about any changes to their hearing since the stroke
- Refer people with hearing difficulties for an audiology assessment, in line with NICE's guideline on hearing loss in adults.
Spasticity
- Provide information on spasticity for people after stroke, and their families and carers, including details about what it is and what can make it better or worse
- Assess whether spasticity in people after stroke is focal (that is, it affects a specific limb or part of a limb) or generalised
- Discuss options for managing focal or generalised spasticity in the person after stroke with the multidisciplinary team
- Consider 1 or more of the following as part of a goal-directed plan to manage focal or generalised spasticity in people after stroke:
- stretching the affected limb or limbs
- splints, when needed (see the section on wrist and hand splints in the full guideline)
- advice on identifying and managing triggers of spasticity
- For people who have focal spasticity of the upper limb after stroke, consider treatment with either Dysport at a dose of up to 1,000 units per treatment or with Xeomin at a dose of up to 400 units per treatment, unless they are already receiving a different type or dose of botulinum toxin A. Ensure that:
- the dose is spread across appropriate injection sites in the affected limb, and
- people do not receive more than 1 treatment every 3 months, and
- response to the treatment is monitored and it is stopped if it is not effective
- For people who are already receiving botulinum toxin A of a different type or dose, continue with this treatment if it is effective
- Consider a trial of neuromuscular electrical stimulation, functional electrical stimulation or transcutaneous electrical nerve stimulation for people after stroke with focal spasticity
- Consider oral baclofen for people after stroke with generalised spasticity but monitor closely for adverse effects
- Refer people after stroke to a specialist spasticity service if:
- they have ongoing spasticity that has not responded to treatment
- other treatments are not tolerated
- the person has complex needs in relation to spasticity (for example, if the injection is for small muscles or treatment is needed for spasticity-related pain).
References
References