NICE guidance - stroke rehabilitation - long-term rehabilitation after stroke

Last reviewed 01/2018

• stroke units
  • people with disability after stroke should receive rehabilitation in a dedicated stroke inpatient unit and subsequently from a specialist stroke team within the community
  • an inpatient stroke rehabilitation service should consist of the following: a dedicated stroke rehabilitation environment a core multidisciplinary team who have the knowledge, skills and behaviours to work in partnership with people with stroke and their families and carers to manage the changes experienced as a result of a stroke
    • access to other services that may be needed, for example:
  • continence advice
  • dietetics
  • electronic aids (for example, remote controls for doors, lights and heating, and communication aids)
  • liaison psychiatry
  • orthoptics
  • orthotics
  • pharmacy
  • podiatry
  • wheelchair services
  • a multidisciplinary education programme.
    
    
  • the core multidisciplinary stroke team for a stroke unit
    • a core multidisciplinary stroke rehabilitation team should comprise the following professionals with expertise in stroke rehabilitation:
      • consultant physicians
      • nurses
      • physiotherapists
      • occupational therapists
      • speech and language therapists
      • clinical psychologists
      • rehabilitation assistants
      • social workers

Screening and assessment

• on admission to hospital, to ensure the immediate safety and comfort of the person with stroke, screen them for the following and, if problems are identified, start management as soon as possible:
  • orientation
  • positioning, moving and handling
  • swallowing
  • transfers (for example, from bed to chair)
  • pressure area risk
  • continence
  • communication, including the ability to understand and follow instructions and to convey needs and wishes
  • nutritional status and hydration
• perform a full medical assessment of the person with stroke, including cognition (attention, memory, spatial awareness, apraxia, perception), vision, hearing, tone, strength, sensation and balance)

Planning and delivering stroke rehabilitation

• to ensure the safety of the person with stroke while maintaining a patient centred approach, key processes need to be in place
  • processes include assessment on admission to the rehabilitation service, individualised goal setting, and patient centred care planning. Ensure that goal setting meetings during stroke rehabilitation
    • are part of the weekly timetable
    • involve the person with stroke and, where appropriate, the person's family or carer in the discussion
    • offer initially at least 45 minutes of each relevant stroke rehabilitation therapy for a minimum of 5 days per week to people who have the ability to participate, and where functional goals can be achieved. If more rehabilitation is needed at a later stage, tailor the intensity to the person's needs at that time
    • consider more than 45 minutes of each relevant stroke rehabilitation therapy 5 days per week for people who have the ability to participate and continue to make functional gains, and where functional goals can be achieved
    • if people with stroke are unable to participate in 45 minutes of each rehabilitation therapy, ensure that therapy is still offered 5 days per week for a shorter time at an intensity that allows them to actively participate
      

Emotional functioning

• assess emotional functioning in the context of cognitive difficulties in people after stroke. Any intervention chosen should take into consideration the type or complexity of the person's neuropsychological presentation and relevant personal history
  • many people who have had a stroke experience distress that affects their ability to benefit from rehabilitation and prevents them from engaging in daily activities. Psychological therapies that are tailored to individual needs and circumstances may help the individuals and their families or carers with post-stroke emotional disorders and relationship issues

Cognitive functioning

• screen people after stroke for cognitive deficits. Where a cognitive deficit is identified, carry out a detailed assessment using valid, reliable and responsive tools before designing a treatment programme
  • after stroke, many people experience difficulties in attention, concentration, memory, perception, and other areas of cognition
    • use interventions for memory and cognitive functions after stroke that focus on the relevant functional tasks, taking into account the underlying impairment. Interventions can include
      • increasing awareness of the memory deficit
      • enhancing learning by means of errorless learning and elaborative techniques (making associations, use of mnemonics, internal strategies related to encoding information such as "preview, question, read, state, test")
      • external aids (such as diaries, lists, calendars, and alarms)
      • environmental strategies (routines and environmental prompts)

Swallowing

• offer swallowing therapy at least 3 times a week to people with dysphagia after stroke who are able to participate, for as long as they continue to make functional gains. Swallowing therapy could include compensatory strategies, exercises and postural advice
  • dysphagia (difficulty swallowing) is common after stroke, occurring in up to 2/3 of stroke patients

Communication

• to aid rehabilitation of people who have aphasia and other communication disorders after stroke:
  • refer people with suspected communication difficulties after stroke to a speech and language therapist for detailed analysis of speech and language impairments and assessment of their impact
  • provide appropriate information, education, and training to the multidisciplinary stroke team to enable them to support and communicate effectively with the person with communication difficulties. This support may include
    • minimising environmental barriers to communication (for example, make sure signage is clear and background noise is minimised)
    • making sure that all written information (including that relating to medical conditions and treatment) is adapted for people with aphasia after stroke. This should include, for example, appointment letters, rehabilitation timetables, and menus
    • training in communication skills (such as slowing down, not interrupting, using communication props, gestures, drawing) to the conversation partners of people with aphasia.

Movement

• weakness limits a person's ability to move the body, including changing body position, transferring from one place to another, walking, and using arms for functional tasks such as washing and dressing
  • offer people repetitive task training after stroke on a range of tasks for upper limb weakness (such as reaching, grasping, pointing, moving, and manipulating objects in functional tasks) and lower limb weakness (such as sit-to-stand transfers, walking, and using stairs).
  • do not routinely offer wrist and hand splints to people with upper limb weakness after stroke
  • offer walking training (such as treadmill exercise) for people with stroke who are able to walk, with or without assistance, to help them build endurance and move more quickly

Self care

• patients will need support to ensure they can care for themselves
  • occupational therapists with core skills and training in the analysis and management of activities of daily living should therefore regularly monitor and treat the person who has had a stroke. Treatment should continue until the person is stable or able to progress independently
  • people after stroke are assessed for their equipment needs and whether their family or carers need training to use the equipment

Transfer of care from hospital to community

• offer early supported discharge to people with stroke who are able to transfer from bed to chair independently or with assistance, as long as a safe and secure environment can be provided
• early supported discharge should be part of a skilled stroke rehabilitation service and should consist of the same intensity of therapy and range of multidisciplinary skills available in hospital. It should not result in a delay in delivery of care

Return to work

• return-to-work issues should be identified as soon as possible after the person's stroke, reviewed regularly and managed actively. Active management should include:
  • identifying the physical, cognitive, communication and psychological demands of the job (for example, multi-tasking by answering emails and telephone calls in a busy office)
  • identifying any impairments on work performance (for example, physical limitations, anxiety, fatigue preventing attendance for a full day at work, cognitive impairments preventing multi-tasking, and communication deficits)
  • tailoring an intervention (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)
  • educating about the Equality Act 2010 and support available (for example, an access to work scheme)
  • workplace visits and liaison with employers to establish reasonable accommodations, such as provision of equipment and graded return to work

Long-term health and social support

• review the health and social care needs of people after stroke and the needs of their carers at 6 months and annually thereafter. These reviews should cover participation and community roles to ensure that people's goals are addressed.

Reference:

• 1) NICE (June 2013).Stroke rehabilitation - Long-term rehabilitation after stroke