Rationale and impact

These sections briefly explain why the committee made the recommendations and how they might affect practice or services.

Transfer of care from hospital to community, including early supported discharge

Recommendations 1.1.8 and 1.1.11

Why the committee made the recommendations

Qualitative evidence showed that rehabilitation support after hospital is sometimes withdrawn after a set period, even when the person feels this is too early and that they need more rehabilitation. The committee recognised this can make some feel abandoned but also that therapists' time is limited and must be used effectively. Weighing up these factors, the committee agreed that care and rehabilitation should be continued after hospital as long as they help people meet their rehabilitation goals. This will ensure therapy is not withdrawn too soon for those who still need it.

The 2013 guideline recommended early supported discharge for some people. For the 2023 update, the committee looked at new evidence which found the process:

  • had the clinically important benefit of reducing physical dependency (the need for support with activities at home such as transfers, mobility and washing) as well as length of hospital stay

  • either improved, or had no negative impact on, health-related quality of life

  • reduced psychological distress.

The evidence also showed no difference between early supported discharge and usual care in mortality, the person or carer's quality of life or the Caregiver Strain Index (which is used to assess carers' wellbeing), or to hospital readmission rates. An increase in falls, which is a clinically important harm, was seen in a limited number of studies. However, the committee noted this did not cause an increase in the rates of hospital readmission. The published evidence also suggested that early supported discharge was cost effective when compared to usual care.

Qualitative evidence also found that people after stroke, their families and carers, and healthcare professionals saw early supported discharge as beneficial. They viewed it as an opportunity for the person to go home and be in a familiar setting sooner, and as a way of motivating the person by providing new challenges. They found it made no difference to the intensity of the therapy on offer (when delivered appropriately). In light of all the evidence in favour of early supported discharge, the committee agreed to retain the 2013 recommendations.

The committee also noted that the way early supported discharge is offered and organised can still vary between settings. The evidence also found that the level of coordination between services can affect outcomes. Better coordination between all services involved in the care of people after stroke led to reduced mortality and levels of physical dependency, when compared to usual care. Services that did not coordinate as well reported higher rates of mortality and no reduced levels of physical dependency, when compared to usual care. The qualitative evidence reviewed in the study also highlighted some factors that could improve coordination of care (such as having a dedicated care coordinator assigned to the individual), as well as factors that may encourage the use of early supported discharge. Many of these were already captured in the 2013 guideline but some important ones were not, so the committee agreed to list these factors in a new recommendation.

How the recommendations might affect services

Current systems for early supported discharge vary, and some places do not have dedicated early supported discharge coordinators. Some parts of the country provide better access to early supported discharge services than others. Changes will therefore be required to improve access. The way services work may need to change, and the degree of change needed will vary depending on what services currently provide. Offering care and rehabilitation to those who need it after they have left hospital, if it continues to help them meet their rehabilitation goals, is current practice so is not expected to have a significant resource impact.

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Intensity of stroke rehabilitation

Recommendations 1.2.15 to 1.2.22

Why the committee made the recommendations

The committee agreed that intensive rehabilitation had clinically important benefits. Based on the evidence, they agreed that people should be offered combined therapies for at least 3 hours a day, 5 days a week. However, they also emphasised that therapy should be provided for as little or as long as the person requires it and should be based on their needs, to ensure they can get the most out of their rehabilitation.

The 2013 guideline recommended at least 45 minutes of physiotherapy for 5 days a week for some people. However, evidence reviewed for the 2023 update found that more intensive physiotherapy improved quality of life and activities of daily living. The optimal intensity of physiotherapy was shown to be between 1 and 2 hours a day, for at least 5 days per week, with the proviso that there may be days when the person is not able to take part for the full duration. The evidence also showed that people after stroke (and their families and carers) felt that more intensive physiotherapy helped them recover faster, especially if it was delivered in the first 6 months after stroke. Although longer physiotherapy sessions will require more resources, they were still found to be cost-effective for the NHS. The committee agreed that longer physiotherapy sessions could be included in a recommended minimum of 3 hours total therapy a day if this was needed.

The committee also reviewed evidence on the optimal duration of occupational therapy and speech and language therapy sessions, but this was limited to a small number of studies and therefore, insufficient to recommend any increase in the timings alone. However, there was nothing to suggest that the intensity should be less than a minimum of 45 minutes a day, 5 days per week, the timings recommended in the 2013 guideline. On reviewing this evidence together with that on physiotherapy and noting that some people might benefit from joint therapy sessions, the committee recommended a total therapy time rather than specifying timings for each form of therapy. They also noted that the evidence did not distinguish between people with and without communication difficulties, and agreed that it could apply to both groups. There was not enough evidence to recommend rehabilitation for 7 days instead of 5 days a week. However, the committee made recommendation for research into the clinical and cost effectiveness of providing rehabilitation for 7 days a week. They also made recommendations for research into the possible benefits of more intensive cognitive and psychological therapy, and of more intensive swallowing therapy.

The studies also revealed several factors that could encourage people, or prevent them from, fully participating in rehabilitation therapies. These were supported by the personal experiences of committee members and were included in the recommendations to encourage effective delivery of rehabilitation.

How the recommendations might affect practice

Current practice is inconsistent. The 2013 guideline recommended that people should initially be offered at least 45 minutes of each relevant stroke rehabilitation therapy for a minimum of 5 days a week. However, this is not always provided to people after stroke. The 2023 recommendation increases the recommended amount of therapy to a total of at least 3 hours spread across the therapy types. This could lead to a change in practice which may impact on resources, although this will be balanced out by long-term health benefits and potential care savings.

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Recommendations 1.3.1 to 1.3.3

Why the committee made the recommendations

The committee looked at evidence on telerehabilitation used both alone and in addition to face-to-face sessions. It found telerehabilitation to be beneficial in improving quality of life and in activities of daily living. However, the committee also stressed that telerehabilitation should only be used if it is the person's preferred option. The relationship between the therapist and the person after stroke should also be maintained, with the option of using in-person therapy instead if needed. As with face-to-face therapy, telerehabilitation should aim to meet the goals the person has agreed with their therapist. Some people may not have the right equipment for this type of therapy so it should be made available to them when needed. The committee also wanted to emphasise that anyone involved in telerehabilitation (including families or carers) should get training in how to use the equipment if they need it.

Some detrimental effects were noticed in some people who had telerehabilitation, particularly the effect on mood. The reasons for this are unknown. Therefore, the committee agreed that anyone receiving telerehabilitation should be monitored carefully for symptoms or signs of depression. They also made a recommendation for research on the impact of telerehabilitation on cognition and mood.

How the recommendations might affect practice

The recommendations reflect current practice as many stroke services use telerehabilitation, with its usage increasing in many areas of practice since the start of the COVID-19 pandemic. Therefore, these recommendations will not lead to big changes to current practice, depending on the type of communication technology used. In some areas, the recommendations could lead to an increase in telerehabilitation as an alternative to face-to-face appointments.

The resource impact of this will probably be neutral. Some people will need extra equipment at home (although this equipment may be loaned by providers and then returned and reused over time) and some resource will be needed to train and support people after stroke and carers who will use it. Currently, telephone calls and videoconferencing are widely used for rehabilitation and require low or no additional resources. The use of virtual reality (VR) programmes or interactive games, which could incur a higher cost, is less common. Telerehabilitation will also reduce travel costs for both therapists and people after stroke, and could be a more efficient use of therapists' time.

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Recommendations 1.7.1 and 1.7.2

Why the committee made the recommendations

People often experience fatigue after stroke and find its effects disabling. While more research is needed on specific treatments for fatigue, the committee agreed that a standardised assessment would:

  • help with identifying and characterising the symptom

  • help ensure the rehabilitation team take fatigue into account when setting goals for people after stroke

  • provide a clear baseline measure for treatment trials.

The Fatigue Assessment Scale, Fatigue Severity Scale and Modified Fatigue Impact Scale were found to be valid and reliable tools that were easy to use and effective in discriminating between the physical, cognitive and mood disorders that can interact with fatigue. The committee agreed any of the 3 could be used to assess fatigue while the person was taking part in their rehabilitation programme and during their 6‑month stroke review. They also made a recommendation for more research into the clinical and cost effectiveness of these 3 scales.

The committee did not specify when the first assessment should take place as this could not be determined from the evidence they reviewed. However, they agreed it should not be done too quickly after the person's stroke since fatigue levels may be changing rapidly at that stage, but should be done soon enough to help plan ongoing rehabilitation. The timing will need to be determined on an individual basis.

The committee was unable to recommend a specific tool to measure fatigue in people with communication difficulties because the evidence was inadequate. There was evidence for a vertical numeric rating scale that used a faces rating scale but this only examined 1 domain of fatigue. Therefore, the committee made a recommendation for research on tools for fatigue in people with communication difficulties.

How the recommendations might affect practice

Current practice is inconsistent. Only some services assess fatigue and there is no standardised measurement tool. The recommendation to consider an assessment for fatigue during rehabilitation and the 6-month review may require a change from current practice by many providers. The Fatigue Assessment Scale, Fatigue Severity Scale and Modified Fatigue Impact Scale are short assessments that can be filled in by the person after stroke, so the associated costs will be low.

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Recommendation 1.8.1

Why the committee made the recommendation

No evidence that specifically addressed the clinical and cost effectiveness of visual screening after stroke was identified, so the committee made conclusions based on their own knowledge and experience.

Many people experience problems with their eyesight after stroke. These are often identified by stroke units during either an examination by an orthoptist or an assessment carried out by another healthcare professional using basic methods or a validated screening tool. The committee agreed that eyesight problems were more likely to be identified during an orthoptist assessment when compared to other forms of assessment. Significant issues are often identified at a later stage if they were missed initially, but by this time they may have already affected the person's quality of life and their ability to fully participate in stroke rehabilitation. Eyesight problems also pose potential safety risks, including the possibility of driving accidents.

Where possible, the committee agreed that people should be assessed by an orthoptist before leaving hospital. However, they recognised this might not be possible and would cause significant delays at discharge if it was the only option available. Therefore, they agreed that people who do not have the assessment before discharge should instead be given an urgent referral so they can have the same assessment as an outpatient.

How the recommendation might affect practice

Current practice is inconsistent across the country because many stroke units do not have a designated orthoptist. Therefore, the recommendation will lead to a change in practice. However, the time and costs involved in offering an orthoptic assessment on the stroke unit is the same as that for assessment using basic screening and validated screening tools.

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Recommendations 1.9.1 to 1.9.4

Why the committee made the recommendations

Many people have hearing problems after stroke which often go undetected and can significantly impact on their quality of life and ability to engage with rehabilitation. The committee agreed it was important to identify hearing problems as soon as possible. However, it may be difficult to do this adequately in the period immediately after admission when the person's condition is not stable, and when they may be in a noisy hospital environment. Based on their experience and expertise, the committee agreed that people should have a hearing screening within the first 6 weeks following stroke. They also highlighted the need to involve family and carers during screening because they can often help identify hearing problems. They also made a recommendation for research on the prevalence of hearing problems in people after stroke.

The committee looked at evidence from a small study comparing the diagnostic accuracy of 4 types of screening – 2 types of hearing questionnaire, a handheld hearing screener combined with 1 questionnaire, and a handheld hearing screener alone. All options were effective in ruling out hearing problems, but none were as accurate as audiologist's assessment in diagnosing hearing difficulties after stroke. The committee agreed to include details of the questionnaires used in the study as these are inexpensive and could help identify people who need further assessment. However, they did not recommend handheld hearing screeners as an option because of their cost and a lack of availability. They instead made a recommendation for research on their clinical and cost effectiveness, and diagnostic accuracy.

The committee agreed that people experiencing hearing problems after stroke should be assessed by an audiologist in line with standard practice.

How the recommendations might affect practice

Current practice is inconsistent. Hearing assessments after stroke are not standardised and often do not include the use of a questionnaire, so this may lead to a change in practice. It is also possible that there will be an increase in audiology referrals.

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Mouth care

Recommendations 1.10.1 to 1.10.3

Why the committee made the recommendations

The committee agreed by consensus that mouth hygiene should be formally assessed in people after stroke because poor hygiene can lead to increase in significant problems including aspiration pneumonia. There are different protocols available for this but the evidence did not compare these, so the committee did not specify which should be used.

The type and frequency of mouth care varied across studies, but they all showed reductions in mortality in people who received a standardised oral hygiene regimen compared with those who received usual care. Some studies also found mouth care interventions reduced cases of pneumonia, gingivitis and oral infections. The evidence on frequency of mouth care was less clear although most studies used a twice-daily mouth care regimen, which the NHS recommends for all people. The specific components of the mouth care regimen differed across studies, but none involved the use of a manual brush alone and most included an electric or battery-powered toothbrush and mouthwash. Oral gel with antibacterial or antifungal properties was also shown to help reduce mortality and occurrence of pneumonia in a study based in an NHS setting.

Trained healthcare professionals supervised mouth care in all studies. Therefore, the committee agreed it should be delivered or supervised, when needed, by people with appropriate training and that this could include family members or carers.

How the recommendations might affect practice

The recommendations reflect current best practice. For some, these recommendations will not change current practice (for example, care for people who are able to follow a more intensive mouth care regimen). However, the level of care provided to people who find it difficult to follow a more intensive regimen is currently inconsistent, so these recommendations are likely to involve a change in practice in this area. Healthcare professionals may also need additional time to supervise or help deliver mouth care more frequently for some people, including those using additional interventions such as electric toothbrushes, mouthwash and oral gels with antibacterial or antifungal properties. There will also be an additional cost in purchasing these items for services that do not currently use them.

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Recommendations 1.11.2 to 1.11.7, and recommendation 1.11.11

Why the committee made the recommendations

Dysphagia can be distressing for people after stroke and their family members and carers. Therefore, based on their expertise and experience, the committee agreed it would be useful to provide them with information about the condition. It is also important to give families and carers advice on what to do if someone is having difficulties while eating and drinking.

A study with 204 participants identified some adaptations that could reduce mortality, chest infections and improve oropharyngeal dysphagia (OPD). Based on this limited amount of evidence and the committee's expert opinion, they agreed that 1 or more of these adaptations could be used to support safe swallowing. They also highlighted that, where needed, the use of oral medication should be reviewed and the formulation or route of administration could be changed so the person can continue with the medication.

The committee noted that behavioural exercises and physical stimulation are effective in reducing mortality, chest infections and aspiration caused by OPD, and can help people to return to a normal diet. There was a substantial amount of evidence to support the use of behavioural exercises, but only a limited amount of evidence to support using physical stimulation. However, the committee noted that both types of intervention were often used as usual care across all the evidence. For the studies, both interventions were provided for an average of 30 minutes a day, 5 days a week, for 2 to 4 weeks, during the acute and subacute periods after stroke. Based on this and taking the evidence reviewed for the recommendations on intensity of stroke rehabilitation into account, the committee agreed that behavioural exercises should be offered for at least 5 days a week to maximise its benefits. However, they agreed that physical simulation should only be considered as an option for people with OPD because of the limited evidence available.

On evaluating other treatments, the committee noted that neuromuscular electrical stimulation (NMES) improved quality of life, reduced dysphagia and chest infections, and helped people to return to a normal diet. The evidence on the effect of NMES on mortality was uncertain because of small trial sizes and short follow-up times. The committee noted that, while a clinically important harm was reported in the evidence, this was unlikely to be related to the use of NMES because the intervention was found to reduce dysphagia and chest infections, and it was unlikely that the intervention would cause death in another way. Taking into account the lack of quality-of-life data required to conduct health economic modelling, the potential high cost of the intervention, the size of the trials and the low quality of the evidence, the committee agreed further research is needed before the use of NMES can be recommended. The evidence on other interventions was insufficient. Therefore, the committee made recommendations for research to gather more information about the use of NMES, as well as neurostimulation and acupuncture, for dysphagia.

The committee also looked at the evidence for the free water protocol. This intervention aims to provide some people who have dysphagia and are suspected to have, or known to be at risk of, aspiration with the option of consuming unthickened water between mealtimes. The committee did not recommend its use because, although the evidence was promising, it was limited to 2 small studies (with a total of 34 participants) which found the approach did not reduce chest infections or improve hydration when compared to usual care. Therefore, they made a recommendation for research to investigate the use of the free water protocol, particularly in studies with a larger number of participants.

The committee also acknowledged that people with dysphagia may want to eat and drink without the use of any aid or intervention, despite the acknowledged risks associated with this. They agreed that they should be supported in making an informed decision on how to proceed.

How the recommendations might affect practice

Some recommendations are consistent with current practice, including the use of adaptations to support people who have OPD with eating and drinking. Others will lead to a change in current practice. Increasing the intensity of behavioural exercise and physical stimulation from the previously recommended 3 days a week to 5 days is likely to have a cost implication.

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Recommendation 1.12.8

Why the committee made the recommendation

The evidence for computer-based tools for speech and language therapy varied in quality and was uncertain because of the complexity of the interventions and the risks of bias and imprecision. However, clinically important benefits were seen when interventions focused on, or included, word finding. The overall cost effectiveness of this type of therapy was uncertain, but data from a large UK-based study showed it was cost effective when it had a word finding component. The committee agreed that computer-based therapy aimed at improving word finding could be given in addition to face-to-face speech and language therapy rather than instead of it, as this was the approach taken in most studies. However, therapy would need to be adapted to the person's needs (for example, activities could include words that are important to them).

The committee did not recommend the use of computer-based tools for other goals relating to speech and language therapy but instead made a recommendation for research on the clinical and cost effectiveness of these tools for managing communication difficulties after stroke.

How the recommendation might affect

Computer-based therapy is not routinely used by speech and language therapists in the NHS, so this recommendation could lead to a change in practice.

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Robot-assisted arm training

Recommendation 1.13.18

Why the committee made the recommendation

Extensive studies have shown that robot-assisted arm training can improve arm strength, including grip strength. However, the committee were not convinced that the clinical benefits of using such devices outweighed those achieved by physiotherapy of similar intensity. The evidence also found robot-assisted arm training did not improve arm function or the ability to complete daily activities – improvements the committee agreed would be more important to people after stroke. The studies did not reveal any other benefits to using these devices, for example, in improving measures of quality of life or activities of daily living, or in the incidence of spasticity.

These devices are expensive to purchase and maintain, and a large study found their use was not cost effective. In view of this, and the wide range of studies that showed they had limited clinical benefits, the committee decided not to recommend their use.

How the recommendation might affect practice

Currently, only a few stroke units have access to robot-assisted arm training devices and this recommendation should reduce or discourage their use. Overall, it is unlikely that the recommendation will lead to a widespread change in current practice.

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Walking therapies and group circuit training

Recommendation 1.13.23

Why the committee made the recommendation

The evidence base for group circuit training was large and there was considerable variation in group sizes and participant-to-staff ratios, as well as the type, duration and intensity of the exercises on offer. It was not possible to recommend the optimal number of staff who should be involved as this was not consistently reported across studies. The quality of the evidence was also low because of the small size of trials and risk of bias. However, the committee agreed there was enough evidence to recommend group circuit training as an option in addition to one-to-one walking therapy.

Some of the training in the studies included an educational element, such as advice on self-management, preventing falls or avoiding further strokes by controlling blood pressure and cholesterol levels. Greater improvements in walking and balance were seen in people who took part in programmes that included an educational element, compared to participants in programmes without this. The evidence was supported by the personal experiences of some committee members, who also emphasised the positive effect of interacting with other people who have had a stroke. They agreed this peer support helped people to know what to expect from their rehabilitation, share solutions to problems and engage more with therapy.

Overall, studies showed group circuit training, with or without an educational element, improved 6‑minute walk test scores (a measure of how far the person can walk). People who took part in group circuit training with an educational element did not perform as well in the 6‑minute walk test, but the committee noted that this result may be explained by a difference in baseline values between groups that included an educational element and groups that did not. Overall, some of the evidence suggested people could walk faster and found it easier to complete daily tasks after attending group circuit training. Adverse events were noted in groups taking part in training with an educational element, but the committee noted that the events were unlikely to be related to the circuit training itself.

Overall, the training was found to have potential benefits and there was no convincing evidence of it causing any harm. There was some inconsistency in results (which is probably because of the variation in programme content). Therefore, the committee agreed it could be considered as an option for some people if it included educational and peer support elements, rather than something offered to anyone able to walk with or without assistance after stroke.

How the recommendation might affect practice

There is variation in the availability of group circuit training across current practice, so additional resources (including staff training costs) may be needed to introduce it in some areas. The committee agreed that circuit training can be delivered by band 4 or 5 physiotherapists, as well as physiotherapy assistants, so would be unlikely to incur large additional costs. The educational requirement for this training may also impact on resources.

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Mirror therapy for the upper or lower limb

Recommendations 1.13.30 and 1.13.31

Why the committee made the recommendations

The committee reviewed evidence from studies on mirror therapy that varied in setting, the time period after stroke and the participants' affected limbs. In some cases, mirror therapy was also combined with other therapies. Despite these differences, the studies showed mirror therapy led to improved outcomes for people after stroke, especially in their activities of daily living, and this was still the case after their 6‑month follow-up. The committee agreed these outcomes should be the main focus of this type of treatment. They also recommended that mirror therapy could be used for the upper and lower limb as an adjunct to the person's existing rehabilitation programme because this was the approach taken in many of the studies.

The committee agreed mirror therapy should ideally begin within 1 month of stroke because the studies mainly included people in the acute or subacute period after stroke. However, a later start to the therapy may still be beneficial. The committee noted that, if offered, mirror therapy should be provided on a frequent basis, so people experience its full benefits. They suggested sessions of around 30 minutes, 5 days per week, for at least 4 weeks, as this was the average length and frequency reported in the studies.

The committee agreed that a member of the stroke rehabilitation team, for example a physiotherapist or occupational therapist, should supervise mirror therapy at first with a focus on explaining how it will work and what the person can expect from it. This was supported by a lay member on the committee who said they initially found mirror therapy 'somewhat alien and confusing' but, after further training from an occupational therapist, saw it as extremely beneficial. The committee agreed that some people, for example those with cognitive difficulty, may need more supervision but others can complete the therapy alone, either in hospital or once home (with a loaned mirror).

The committee were unable to specify which groups of people would benefit from this therapy the most as the studies involved varied populations. Therefore, they made a recommendation for research on groups that could benefit from mirror therapy after stroke.

How the recommendations might affect practice

Mirror therapy is a recognised therapy but is not used as standard throughout the NHS. It is often used at the discretion or preference of healthcare professionals as part of other therapy sessions. These recommendations would therefore require a change to current practice for some stroke units.

Additional resources may be required because healthcare professionals will need time to provide initial training and then to supervise the therapy for around 4 weeks for some people. However, most people are likely to be able to continue with mirror therapy unsupervised after initial training. There may be additional costs for stroke units if they need to purchase mirrors, especially if people can take them home. However, these will usually be returned and reused.

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Music therapy and interventions

Why the committee made no recommendations

The evidence for music therapy and interventions showed they could have some benefit, but this was too limited to recommend their use. Published studies were limited and difficult to compare because of the:

  • small number of participants

  • lack of cost effectiveness data

  • use of varied outcome measures, which differed between studies but all lacked patient- and carer-specific outcome measures

  • prominent use of a no-treatment comparison (or usual care provided to both groups, with the intervention group receiving additional music therapy)

  • diverse type of audio and music on offer.

Based on this, the committee made a recommendation for research on the clinical and cost effectiveness of music therapy for people after a first stroke or recurrent strokes. In particular, they highlighted the need for larger, pragmatic, randomised controlled trials that compare music therapy or interventions with another social activity as a control, and where both types of activity are provided for an equal amount of time. The committee also agreed there was a need for more research into whether music therapy and interventions are cost effective and improve patient-centred outcomes (such as participation in everyday and social activities).

Managing shoulder pain

Recommendations 1.14.2 and 1.14.4

Why the committee made the recommendations

The evidence on interventions for shoulder pain was limited because it did not explore the underlying causes of pain. Post-stroke shoulder pain can be caused by various factors (for example, glenohumeral joint subluxation, spasticity of shoulder muscles, impingement, soft tissue injury, rotator cuff tears, glenohumeral capsulitis or biceps tendonitis) and these can also change over time. The committee recommended that the cause of the person's shoulder pain should be identified wherever possible so they can get the right treatment. However, they also recognised this was often difficult to do in practice and so made recommendations for research to identify both the most useful tests to establish the causes of shoulder pain after stroke and how to manage shoulder pain depending on its cause.

None of the interventions used in the studies were found to have a large or consistent benefit. However, a small number of studies found some treatments to be beneficial. The use of taping, NMES, intra-articular corticosteroid injections and nerve blocks helped reduce pain and led to improvements in shoulder function. The committee therefore agreed to include these as potential treatment options.

How the recommendations might affect practice

All the recommended interventions for shoulder pain, except NMES, are widely used in the NHS. NMES is just 1 of several treatment options and is unlikely to be needed by many people. The recommendations are therefore unlikely to lead to a major change in practice.

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Recommendations 1.15.1 to 1.15.8

Why the committee made the recommendations

The committee agreed it was important to differentiate between generalised and focal spasticity (which affects a particular limb or part of a limb) because focal spasticity is more likely to improve with treatment aimed at a specific area of the body. Most of the available evidence was on focal spasticity, particularly of the upper limb.

Spasticity can be difficult to treat, so it is important that people after stroke, and their families and carers, are given information on the condition. This will help ensure they know when to seek help but also to understand that spasticity is a difficult condition to manage. The multidisciplinary stroke rehabilitation team should also be involved in individual plans for managing focal and generalised spasticity. Based on their experience, the committee also highlighted some interventions that have been widely used for a long time, for example, stretches or advice on how to avoid triggers.

For focal spasticity, the committee looked at the evidence for different types of botulinum toxin A, including Dysport, Botox and Xeomin. Dysport and Xeomin were found to be both cost effective and beneficial in terms of both reducing spasticity in the upper limb and improving activities of daily living. However, Dysport and Xeomin were only cost effective if certain doses were given and if:

  • the injections were spread across multiple points in the affected limbs and

  • the treatment was only given every 3 months and

  • treatment was based on the person's needs and discontinued if ineffective.

The cost effectiveness of Botox in upper limb was not evaluated in the health economic analysis carried out for this update because there was a lack of clinical evidence relating to Modified Ashworth Scale responder outcomes. The published economic evidence regarding the use of Botox in the upper limb was also limited. Therefore, the committee agreed there was not enough evidence to support its use for this indication.

Other preparations of botulinum toxin A are licensed for focal spasticity, including those that are referred to in SIGN's 2023 edition of the National clinical guideline for stroke for the UK and Ireland. If these preparations are already being used and are proving effective, then treatment with these can continue.

There was no cost effectiveness evidence and insufficient clinical evidence to recommend botulinum toxin A for spasticity of the lower limb. Only 1 published health economic analysis included a lower limb indication, but this only compared Botox and Dysport and therefore did not explore whether botulinum toxin A was cost effective compared to no treatment. Given the lack of high‑quality economic evidence, the committee made a recommendation for research to compare the clinical and cost effectiveness of Botox, Dysport and Xeomin with each other and to usual care for focal spasticity, including in the lower limb.

The committee looked at 3 forms of electrical stimulation therapy for focal spasticity: functional electrical stimulation (FES), NMES and transcutaneous electrical stimulations (TENS). All were found to reduce spasticity and improve the ability to use the affected limb when compared to usual care. NMES and TENS also showed benefits in comparison to sham or placebo treatment. However, improvements seen in the studies were modest and the benefits of these treatments were only reported during time periods of less than 6 months. There was insufficient data to recommend 1 treatment over another. The 3 treatments are currently available in the NHS and TENS is widely used for many conditions, so the committee agreed they should only be potential treatment options. They also made a recommendation for research into the clinical and cost effectiveness of these 3 forms of electrotherapy compared to usual care.

There was limited evidence on treatments for generalised spasticity, and only 1 study examining oral medicines was identified. However, the committee noted that oral baclofen and tizanidine are often used to treat this condition. The use of oral baclofen is more common, while tizanidine is usually prescribed by specialists. Therefore, the committee recommended that oral baclofen could be an option for generalised spasticity but agreed its use needed to be closely monitored as it can sometimes be too effective in reducing muscle tone and can impair function more than the original spasticity. They did not recommend tizanidine because the evidence was limited, of low quality and did not report any clinically important benefits.

The committee were aware that some people may need other treatments (such as intrathecal baclofen) because they have complex needs, or spasticity that is difficult to manage. There was insufficient evidence to recommend these treatments, so the committee agreed by consensus that people should be referred to specialised units for further treatment.

Evidence showed acupuncture and electroacupuncture for treating spasticity improved some, but not many, outcomes. The committee also noted this treatment is not widely available. Therefore, they did not recommend its use but made a recommendation for research on its clinical and cost effectiveness.

How the recommendations might affect practice

Measures such as splinting, stretching and offering advice on how to avoid triggers are routinely used in current practice. Botulinum toxin A is widely used for focal spasticity but the recommendation for 2 forms, to be used at a certain dose and only for the upper limb, is likely to be cost saving. Electrical stimulation therapy is also widely available and, although most units do not have access to all 3 forms, this recommendation will have a minimal effect on practice. Oral baclofen is a low-cost medicine that is widely available in the NHS, so this recommendation should not alter practice. Multidisciplinary teams already discuss spasticity in their meetings and are aware of the potential need for specialist referral, so this recommendation will not change practice.

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Returning to work

Recommendation 1.16.5

Why the committee made the recommendation

A single study from South Africa, whose participants took part in a focused return-to-work programme led by a physiotherapist and occupational therapist, found there were clinically important benefits to returning to work. Based on this evidence, which was reviewed for the section on community participation programmes, the committee agreed by consensus to recommend referral to return-to-work programmes, where available, for those wishing to resume work after stroke.

How the recommendation might affect practice

This recommendation may increase the demand for return-to-work programmes for people after stroke.

Return to the recommendation

Self-management interventions

Why the committee made no recommendations

The committee did not make any recommendations for self-management interventions, which focus on empowering the person after stroke to manage their own symptoms (for example through components like problem-solving, goal-setting, decision-making, self-monitoring or using coping strategies). This is because they were not found to be more clinically effective than other interventions. The evidence was supported by the committee's own experiences of self-management interventions, although some committee members did report having positive personal experiences of using them. The committee therefore agreed self-management interventions could still play a useful role in supporting the health of people after stroke but further studies were needed into their benefits, as well as effective components and optimal frequency. They made a recommendation for research on the clinical and cost effectiveness of self-management interventions for people after stroke.

Community participation programmes

Recommendation 1.17.6

Why the committee made the recommendation

Community participation programmes can cover a wide range of interests and activities. The content of each programme and the degree to which healthcare professionals run or oversee them also varies. The evidence mainly looked at different types of group-based physical exercise, but some covered art or music activities. In general, people who took part in these programmes found their quality of life improved although, as expected, the benefits they experienced varied between the programmes used in the studies. Members of the committee also had positive experiences of taking part in these programmes and agreed they were of value to people after stroke. Therefore, the committee recommended that people could be referred to a community programme if there was 1 available which met their needs. They also agreed that family members and carers could find the programmes beneficial because they can help prevent feelings of social isolation, improve quality of life and reduce caregiver strain.

How the recommendation might affect practice

Current practice is inconsistent across the country, with some programmes commissioned by the NHS and delivered by charities, and others delivered purely by charities with funding from grants. Availability and programme type also varies. This recommendation may increase the demand for community participation programmes.

Return to the recommendation

  • National Institute for Health and Care Excellence (NICE)