2 Research recommendations
The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future.
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?
After stroke an estimated 30–70% of people have reduced or no use of one arm and hand. ES has long been thought to be a possible useful adjunct to rehabilitation to improve arm and hand function. ES is believed to enhance the training effect of active, task-specific and strengthening rehabilitation programmes. However, the evidence to date does not inform clinicians or people with stroke whether ES will be an effective addition to rehabilitation for them. A linked-series of studies are needed to:
1. Identify the dose, practice parameters and rehabilitation programme content needed to effect change in hand and arm function with ES.
2. Characterise the clinical profiles of people who will benefit from ES in early, middle and late stages of the stroke pathway.
The primary outcome measure should be the person's assessment of improvement in function. Secondary outcomes should include measures of impairment, function and quality of life and these should reflect people with low-, middle- and high-functioning upper limbs.
In 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?
Rehabilitation aims to maximise activity and participation and minimise distress for people with stroke and their families and carers. The physical and mental capacity to participate in rehabilitation possessed by people with stroke varies widely. Some people who are unwell may not be able to participate at all, whereas others may be able to tolerate 6 hours of therapy a day. The potential long-term cost benefits of even small changes in function may be significant.
Evidence suggests that increasing rehabilitation intensity early after stroke results in improved outcomes, but the evidence for this is not robust. Previous studies comparing different levels of intensity have used rehabilitation inputs that are lower than the current levels recommended by the NICE stroke quality standard.
If it were shown that increasing the intensity of rehabilitation in people who are able to participate results in functional and cost benefits, stroke rehabilitation services and funding tariffs should be reviewed.
Which 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?
There are many well-established studies showing that mood disorders such as depression and anxiety occur frequently after stroke and may occur at any point along the rehabilitation pathway, causing distress to people with stroke and their families and carers and adversely affecting outcomes.
Cognitive and communication impairments interact with mood and often compound difficulties by compromising people's abilities to participate in standard evidence-based psychological therapies. The need for psychological input for people with stroke is well recognised (for example, by the 'National service framework for long-term neurological conditions'). However, the literature does not provide robust evidence about which psychological interventions will be most effective for different subgroups of people.
Which 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?
Shoulder pain after stroke is a common problem, with some prevalence estimates as high as 84%. Onset has been reported to occur from 2 weeks to several months after the stroke.
Most experts agree that prevention of shoulder pain after stroke is an important goal and should be prioritised as an aim of rehabilitation from the first day after a stroke. However, the means of preventing hemiplegic shoulder pain (HSP) is not universally agreed. This may be due, in part, to the large array of identified causes of HSP.
Because of this, there is little agreement on which treatment is best. Treatments include positioning, upper limb support (including slings and orthotics), strapping of the shoulder, range-of-motion exercises, ultrasound, oral non-steroidal anti-inflammatory medications, electrical stimulation for muscle contraction, electrical stimulation for pain relief (TENS), surgery, intra-articular steroid injection, and intramuscular botulinum toxin injections.