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NationalClinicalGuidelineCentre
FinalFullGuideline
StrokeRehabilitationLongtermrehabilitationafterstroke
Clinicalguideline162Methods,evidenceandrecommendations
29May2013
FinalDraft
CommissionedbytheNationalInstituteforHealthandCareExcellence
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StrokeRehabilitationContents
NationalClinicalGuidelineCentre,2013.
StrokeRehabilitation
DisclaimerHealthcareprofessionalsareexpectedtotakeNICEclinicalguidelinesfullyintoaccountwhenexercisingtheirclinicaljudgement.However,theguidancedoesnotoverridetheresponsibilityofhealthcareprofessionalstomakedecisionsappropriatetothecircumstancesofeachpatient,inconsultationwiththepatientand/ortheirguardianorcarer.
CopyrightNationalClinicalGuidelineCentre,2013.
FundingNationalInstituteforHealthandCareExcellence
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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.
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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
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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.
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NationalClinicalGuidelineCentre,2013.19
NICERelatedGuidancecurrentlyindevelopment:
Falls(update)NICEclinicalguideline(publicationexpectedJune2013).
Lipidmodification(update).NICEclinicalguideline(publicationTBC).
Neuropathicpain:pharmacologicalmanagementinadultsinnonspecialistsettings.NICEclinicalguideline(publicationexpectedAugust2013).
Type2diabetesNICEclinicalguideline(publicationTBC).
Oralhealth:innursingandresidentialcareNICEpublichealthguidance(publicationTBC).
Workplacehealth:employeeswithchronicdiseasesandlongtermconditionsNICEpublichealthguidance(publicationTBC).
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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.
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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]
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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.
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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
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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
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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.
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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.
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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.
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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
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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
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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
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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.
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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
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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]
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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.
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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)
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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
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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)