All people with suspected stroke should be admitted directly to a specialist acute stroke unit. People who have had a suspected transient ischaemic attack (TIA) who are at high risk of stroke should have a specialist assessment and investigation within 24 hours of the onset of symptoms.
The main burden of stroke (to individuals and societies) is disability - about 40% of stroke survivors are left with some degree of functional impairment. Reducing this burden requires optimising stroke prevention and improving acute care but rehabilitation is equally essential.
Patients' suitability for early, active rehabilitation should be considered. Early mobilisation, including positioning in bed, sitting on the edge of the bed, or standing up should be considered for patients within the first three days after a stroke.
What is rehabilitation?
Rehabilitation is a complex set of processes, usually involving several professional disciplines and aimed at improving quality of life for people facing daily living difficulties caused by chronic disease.
Rehabilitation starts in hospital but continues after the individual has returned to the community. It is extremely important in terms of making the patient as independent as possible, with enormous implications for the physical and psychological well-being of the person and cost to the community.
Rehabilitation after a cerebrovascular event (CVE) is a multidisciplinary function. It is also important to remember that the disease affects not just the individual but the whole family. Secondary prevention of stroke must not be overlooked.
- Each year in England, approximately 110,000 people have a first or recurrent stroke and a further 20,000 people have a TIA.
- More than 900,000 people in England are living with the effects of stroke; about half of these people are dependent on other people for help with everyday activities.
National Institute for Health and Care Excellence guidelines
- People with disability after stroke should receive rehabilitation in a dedicated stroke inpatient unit and subsequently from a specialist stroke team within the community. A core multidisciplinary stroke rehabilitation team should include consultant physicians, nurses, physiotherapists, occupational therapists, speech and language therapists, clinical psychologists and social workers.
- Other services that may be needed include continence advice, dietetics, electronic aids (eg, remote controls for doors, lights and heating and communication aids), liaison psychiatry, orthoptics, orthotics, podiatry and wheelchair services.
- On admission to hospital, any person with stroke should be screened and, if problems are identified, management started as soon as possible for the following: orientation, positioning, moving and handling, swallowing, transfers (eg, from bed to chair), pressure area risk, continence, communication, nutritional status and hydration.
- A full medical assessment of the person with stroke should include (taking into account previous functional abilities):
- Psychological functioning: cognition (attention, memory, spatial awareness, apraxia, perception), memory, attention, emotional state and communication (including the ability to understand and follow instructions and to convey needs and wishes).
- Vision, hearing. Assess the effect of visual neglect after stroke on functional tasks such as mobility, dressing, eating and using a wheelchair, using standardised assessments and behavioural observation.
- Muscle tone, strength, sensation and balance.
- Impairment of bodily functions, including pain.
- Activity limitations and participation restrictions.
- Environmental factors (social, physical and cultural).
- Provide education and support for people with stroke and their families and carers to help them understand the extent and impact of cognitive deficits after stroke, recognising that these may vary over time and in different settings.
- Use interventions for visual neglect after stroke that focus on the relevant functional tasks, taking into account the underlying impairment:
- Examples include interventions to help people scan to the neglected side (eg, brightly coloured lines or highlighter on the edge of the page), alerting techniques (eg, auditory cues), repetitive task performance (eg, dressing) and altering the perceptual input using prism glasses.
- Refer people with persisting double vision after stroke for a formal orthoptic assessment.
- Offer eye movement therapy to people who have persisting hemianopia after a stroke.
- When advising people with visual problems after stroke about driving, consult the Driver and Vehicle Licensing Agency (DVLA) regulations.
Use interventions for memory and cognitive functions after stroke that focus on the relevant functional tasks, taking into account the underlying impairment - eg, external aids (such as diaries, lists, calendars and alarms) and environmental strategies (routines and environmental prompts).
- Crying and emotional lability are very common. Patients should be given the opportunity to talk and the social situation should be examined.
- Support and educate people after stroke, and their families and carers, in relation to emotional adjustment to stroke, recognising that psychological needs may change over time and in different settings.
- When new or persisting emotional difficulties are identified at the person's six-month or annual stroke reviews, refer them to appropriate services for detailed assessment and treatment.
- Manage depression or generalised anxiety as indicated. See separate Depression and Generalised Anxiety Disorder articles.
- All stroke patients should be screened for dysphagia before being given food or drink.
- Offer swallowing therapy at least three times a week to people with dysphagia after stroke who are able to participate, for as long as they continue to make functional gains.
- Ensure that effective mouth care is given in order to decrease the risk of aspiration pneumonia.
- Provide nutrition support to people with dysphagia.
- See also separate Dysarthria and Dysphasia article.
- Refer people with suspected communication difficulties after stroke to speech and language therapy, for detailed analysis of speech and language impairments and assessment of their impact.
- Provide opportunities for people with communication difficulties after stroke to have conversation and social enrichment with people who have the training, knowledge, skills and behaviours to support communication. This should be in addition to the opportunities provided by families, carers and friends.
- Speech and language therapists should assess people who have limited functional communication after stroke for their potential to benefit from using a communication aid or other technologies - eg, home-based computer therapies or smart phone applications).
- When persisting communication difficulties are identified at the person's six-month or annual stroke reviews, refer them back to a speech and language therapist.
- Ensure that environmental barriers to communication are minimised for people after stroke - eg, make sure signage is clear and background noise is minimised.
- Make sure that all written information (including that relating to medical conditions and treatment) is adapted for people with aphasia after stroke.
- Offer training in communication skills (eg, slowing down, not interrupting, using communication props, gestures, drawing) to the carers and family of people with aphasia after stroke.
- Provide physiotherapy for people who have weakness, sensory disturbance or balance difficulties after stroke that have an effect on function.
- Consider strength training for people with muscle weakness after stroke. This could include progressive strength building through increasing repetitions of body weight activities (eg, sit-to-stand repetitions), weights (eg, progressive resistance exercise), or resistance exercise on machines such as stationary cycles.
- Fitness training: encourage people to participate in physical activity after stroke.
- Cardiorespiratory and resistance training for people with stroke should be started by a physiotherapist with the aim that the person should continue the programme independently based on the physiotherapist's instructions.
- Offer walking training (treadmill with or without body weight support) to people after stroke who are able to walk, with or without assistance, to help them build endurance and move more quickly.
- Tell people who are participating in fitness activities after stroke about common potential problems, such as shoulder pain, and advise them to seek advice from their GP or therapist if these occur.
- Therapy aids:
- Consider wrist and hand splints in people at risk after stroke - eg, people who have immobile hands due to weakness, and people with high tone.
- Consider a trial of electrical stimulation in people who have evidence of muscle contraction after stroke but cannot move their arm against resistance.
- Consider constraint-induced movement therapy for people with stroke who have movement of 20° of wrist extension and 10° of finger extension. Be aware of potential adverse events (such as falls, low mood and fatigue).
- Offer people repetitive task training after stroke, on a range of tasks for upper limb weakness (eg, reaching, grasping, pointing, moving and manipulating objects in functional tasks) and lower limb weakness (eg, sit-to-stand transfers, walking and using stairs).
- Consider ankle-foot orthoses for people who have difficulty with swing-phase foot clearance after stroke (eg, tripping and falling) and/or stance-phase control (eg, knee and ankle collapse or knee hyperextension) that affects walking.
- Functional electrical stimulation may be used to produce muscle contractions that mimic normal voluntary gait movement (lifting the foot and achieving correct placement on the ground) by applying electrical pulses to the common peroneal nerve, either through the skin surface or implanted electrodes.
- Provide information for people with stroke and their families and carers on how to prevent pain or trauma to the shoulder if they are at risk of developing shoulder pain - eg, if they have upper limb weakness and spasticity.
- Manage shoulder pain after stroke, using appropriate positioning and other treatments according to each person's need.
- Management of neuropathic pain as indicated.
- Provide occupational therapy for people after stroke who are likely to benefit, to address difficulties with personal activities of daily living. Therapy may consist of restorative or compensatory strategies.
- Ensure that appropriate equipment is provided and available for use by people after stroke when they are transferred from hospital, whatever the setting (including care homes).
Return to work
Return-to-work issues should be identified as soon as possible after the person's stroke, reviewed regularly and managed actively.
For management of long-term sickness and incapacity for work, see separate Long-term Sickness and Incapacity article.
Long-term health and social support
- Inform people after stroke that they can self-refer, usually with the support of a GP or named contact, if they need further stroke rehabilitation services.
- Provide information so that people after stroke are able to recognise the development of complications of stroke, including frequent falls, spasticity, shoulder pain and incontinence.
- Provide information about transport and driving (including DVLA requirements).
- See separate Urinary Incontinence and Faecal Incontinence articles.
- Review the health and social care needs of people after stroke and the needs of their carers at six months and annually thereafter.
- For guidance on secondary prevention of stroke, see the separate Stroke Prevention article.
Further reading and references
Brain injury rehabilitation in adults; Scottish Intercollegiate Guidelines Network - SIGN (Mar 2013)
Stroke and transient ischaemic attack in over 16s: diagnosis and initial management; NICE Clinical Guideline (July 2008)
Young J, Forster A; Review of stroke rehabilitation. BMJ. 2007 Jan 13334(7584):86-90.
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention; Scottish Intercollegiate Guidelines Network - SIGN (December 2008)
Stroke Guidelines; Royal College of Physicians (2016)
Stroke and TIA; NICE CKS, December 2013 (UK access only)
Stroke rehabilitation in adults; NICE Clinical Guideline (June 2013)
Assessing fitness to drive: guide for medical professionals; Driver and Vehicle Licensing Agency
Management of patients with stroke: Identification and management of dysphagia; Scottish Intercollegiate Guidelines Network - SIGN (June 2010)
Functional electrical stimulation for drop foot of central neurological origin; NICE Interventional Procedure Guidance, January 2009