NICE publishes guideline on rehabilitation for people who have had a stroke

NICE has published guidance aimed at improving outcomes for people who have a disability caused by a stroke. Thanks to improvements in stroke care, each year most of the 125,000 people in England, Wales and Northern Ireland who have a stroke survive but often at the cost of long-term disability. More than 900,000 people are living with the effects of stroke.

NICE says people should be given targeted therapy immediately after their stroke while staying in a dedicated stroke inpatient unit, to give them the opportunity to relearn old skills or get new ones. When they return home, they should receive care from a specialist community stroke team.

The Director of the Centre for Clinical Practice at NICE, Professor Mark Baker said: “Stroke can have a devastating and lasting impact on people's lives. This guideline makes practical recommendations about what should be provided as part of a comprehensive stroke rehabilitation service, what reviews and reassessments should be carried out, and what additional information, support or care to consider when delivering services or therapies. However it does not cover every aspect of stroke rehabilitation in detail.”

Since the 1960s the proportion of people who survive a stroke has been increasing steadily. This has largely been due to the development of stroke units, the advent of clot-busting drugs and the reorganisation of stroke services so these drugs can be delivered in an efficient and effective way. But despite these improvements over 30% of people who have had a stroke will have persisting disability, and consequently require access to effective rehabilitation services.

Among the key priorities for implementation highlighted in the guideline are:

  • People with residual disability after stroke should receive rehabilitation in a dedicated stroke inpatient rehabilitation unit and subsequently from a specialist stroke team within the community.
  • Offer early supported discharge to people with stroke who are able to transfer from bed to chair independently or with assistance, provided a safe and secure environment can be provided.
  • Offer initially at least 45 minutes of each relevant rehabilitation therapy for a minimum of five days per week to people who have the ability to participate, and where functional goals that can be achieved.
    • If more rehabilitation is needed at a later stage, tailor the intensity to the person's needs at that time.
  • Return-to-work issues should be identified as soon as possible after stroke, reviewed regularly and managed actively. Active management should include:
    • identifying the physical, cognitive, communication and psychological demands of the job (for example, multi-tasking by answering emails and telephone calls in a busy office)
    • identifying any impairments on work performance (for example, physical limitations, anxiety, fatigue preventing attendance for a full day at work, cognitive impairments preventing multi-tasking, and communication deficits)
    • tailoring an intervention (for example, teaching strategies to support multi-tasking or memory difficulties, teaching the use of voice-activated software for people with difficulty typing and delivery of work simulations)
    • educating about the Equality Act and support available (for example, an access to work scheme)
    • workplace visits and liaison with employers to establish reasonable accommodations such as provision of equipment and graded return to work.
  • Offer therapy at least three times a week to people with difficulty swallowing (dysphagia) after stroke who are able to participate. Swallowing therapy could include compensatory strategies, exercises and postural advice.

Professor Mark Baker added: “Stroke is the single biggest cause of complex impairment in England. That burden may increase as the population ages. Although there is little doubt the overall approach to stroke rehabilitation is effective, there is less clarity about the clinical and cost effectiveness of the individual interventions within this overall structure. With patients and carers very much at its centre this guideline addresses this issue and will contribute to the provision of better care for people who have had a stroke.”

Diane Playford, Reader in neurological rehabilitation and Chair of the guideline development group, said: “This guideline emphasises the importance of careful multidisciplinary assessment and treatment in stroke rehabilitation, and provides guidance to support the long term rehabilitation and care of people living with stroke. As well as recognising the benefits of a range of stroke rehabilitation interventions that are targeted and relevant to the individual, the guideline also highlights where there are gaps in the evidence to support best practice, and signposts the way for appropriate research projects to address these.”

Pamela Holmes, Practice Development Manager, the Social Care Institute for Excellence and member of the guideline development group, said: “Following a stroke, clinical concerns are the first priority, quickly followed by social care issues; people want to return, as quickly as possible, to a full and active life. This means getting them - and their family - involved in rehabilitation, and working out what they want to achieve. This guideline advises on how to make sure people's care in the short and long term is coordinated. A joined up approach is essential for getting the transfer of care from health services to social care right and the guideline highlights the need for a jointly written discharge plan incorporating both health and social care management.”

Kathryn Head, a speech and language therapist and member of the guideline development group, said: “The evidence considered for this guideline suggests there may be a correlation between intensity of therapy and improved outcomes for people who have had a stroke. In this vein the provision of early speech and language and swallowing therapy to address communication and swallowing impairment is highlighted. These recommendations will facilitate the planning, organisation and delivery of stroke rehabilitation based on high quality evidence and balanced expert consensus.”

Sue Thelwell, a nurse and member of the guideline development group, said: "This guideline offers best practice advice to ensure that, whatever the care setting, people with stroke get access to the level of rehabilitation that meets their needs. The guideline addresses the evidence for the structure of multidisciplinary stroke teams, rehabilitation units, early supported discharge and the intensity of rehabilitation. Patients and carers are very much at the centre of this guideline and implementation of the recommendations will contribute to the provision of best quality care to help people to recover from a stroke.”

Robin Cant, a stroke survivor and member of the guideline development group, said: “Many stroke survivors in the past have been frustrated and have experienced a sense of abandonment once the acute stage of their stroke has been treated. These guidelines will provide a framework to guide and support their expectations for a fully inclusive and comprehensive programme of rehabilitation.”

Karin Bishop, Interim Head of Professional Practice, College of Occupational Therapists said: “The guideline is an important starting point for joined up rehabilitative care that meets the wider and longer term needs of someone affected by stroke, their family and carers. While it does not cover every aspect of rehabilitation in detail, the guideline will form a key part of the growing resources for stroke rehabilitation services. We particularly welcome the recommendations highlighting occupational therapists' expertise in some key areas including returning people to work, training family members to help with dressing and other activities of daily living and ensuring that occupational therapy is provided for at least 45 minutes 5 days a week.“

Ends

Notes to Editors

About the guideline

1. The guideline is available on the NICE website from 12 June.

2. NICE has produced practice-based advice to help with the implementation of this guideline. It includes example pathways and signposts to resources from other organisations that may help. It draws from the learning and experience of practitioners working in services to provide support for users who may wish to develop an action plan to implement certain aspects of the guideline and is available from the NICE website (from 12 June).

References

i. Stroke rehabilitation is a multidimensional process designed to facilitate either restoration of, or adaptation to, the loss of physiological or psychological function when reversal of the underlying pathological process is incomplete. It aims to enhance functional activities and societal participation and thus improve quality of life. Key aspects of the process include multidisciplinary assessment, problem definition and measurement, treatment planning through goal setting, delivery of interventions which may either effect change or support the individual in managing persisting change, and evaluation of effectiveness.

A stroke rehabilitation service comprises a multidisciplinary team of people who work together towards goals for each patient, involve and educate the patient and family, have relevant knowledge and skills and can resolve most common problems faced by their patients.

Clear standards have been described for the delivery of inpatient and outpatient rehabilitation endorsed by the British Society of rehabilitation medicine and reflected in the NICE quality standards {National Institute for Health and Clinical Excellence, 2010} and the stroke strategy {Department of Health, 2007}.

Assessment is typically undertaken using the World Health Organisation International Classification of Function which provides a biopsychosocial model of disability. As well as supporting comprehensive assessment the ICF can be used in goal setting & treatment planning and monitoring, as well as outcome measurement.

Treatments are largely delivered via physical, occupational, cognitive and speech and language therapists.

Other components of the overall rehabilitation package include the learning of new skills to circumvent those lost; adaptation to loss by both the patient and family; the application of new technologies, appliances and environmental modifications; and the development of new service delivery systems.

About stroke

1. Stroke is a major health problem in the UK. There are approximately 152,000 strokes in the UK every year[1]. Although one in five strokes is fatal1 most people survive a first stroke, but often have significant problems. There are approximately 1.1 million stroke survivors living in the UK and more than half of all stroke survivors are left dependent on others for everyday activities1.

2. The number of people dying each year from strokes in the UK has been falling steadily since the late 1960s, with recent reorganisation in acute care leading to further significant improvements in the numbers of people disabled or killed by stroke. However, stroke commonly affects older people. The burden of stroke may therefore increase in the future as a consequence of the ageing population.

About NICE

The National Institute for Health and Care Excellence (NICE) is the independent body responsible for driving improvement and excellence in the health and social care system. We develop guidance, standards and information on high-quality health and social care. We also advise on ways to promote healthy living and prevent ill health.

Formerly the National Institute for Health and Clinical Excellence, our name changed on 1 April 2013 to reflect our new and additional responsibility to develop guidance and set quality standards for social care, as outlined in the Health and Social Care Act (2012).

Our aim is to help practitioners deliver the best possible care and give people the most effective treatments, which are based on the most up-to-date evidence and provide value for money, in order to reduce inequalities and variation.

Our products and resources are produced for the NHS, local authorities, care providers, charities, and anyone who has a responsibility for commissioning or providing healthcare, public health or social care services.

To find out more about what we do, visit our website: www.nice.org.uk and follow us on Twitter: @NICEComms.



[1] Stoke association.www.stroke.org.uk/resource-sheet/stroke-statistics. Accessed 21/5/13

This page was last updated: 11 June 2013