Stroke rehabilitation in adults

People who need rehabilitation after stroke should receive it from a specialist stroke service:

• in a stroke unit and subsequently from a specialist stroke team in the community or

• directly from a specialist stroke team in the community if they have left hospital through early supported discharge (where people in an inpatient setting are offered early discharge to continue rehabilitation at home) or

• in a level 1 or 2 specialist inpatient neurorehabilitation unit and subsequently from a specialist stroke team in the community. [2013, amended 2023]

An inpatient stroke unit should:

• have a dedicated stroke rehabilitation environment

• be led by a core multidisciplinary stroke rehabilitation team (see recommendation 1.1.3) with expertise in working alongside people who have had a stroke, and their families and carers, to manage the changes experienced as a result of stroke

• provide access to other services that may be needed, for example:

  • audiology

  • continence advice

  • electronic aids (for example remote controls for doors, lights and heating, and communication aids)

  • liaison psychiatry

  • orthotics

  • pharmacy

  • podiatry

  • wheelchair services

• include a multidisciplinary education programme. [2013, amended 2023]

A core multidisciplinary stroke rehabilitation team should comprise the following professionals with expertise in stroke rehabilitation:

• consultant physicians specialising in stroke, or rehabilitation medicine

• nurses

• physiotherapists

• occupational therapists

• speech and language therapists

• dietitians

• clinical psychologists or clinical neuropsychologists

• orthoptists

• rehabilitation assistants

• social workers. [2013, amended 2023]

Throughout the care pathway, document the roles and responsibilities of the multidisciplinary team clearly and communicate these to the person and their family members and carers. [2013]

Health and social care professionals should collaborate to ensure a social care assessment is carried out promptly, where needed, before the person who has had a stroke is transferred from hospital to the community. The assessment should:

• identify any ongoing needs of the person, and their family members and carers, for example, access to benefits, care needs, housing, participation in everyday and community activities, return to work, transport and access to voluntary services

• be documented, with all needs recorded in the person's health and social care plan and a copy provided to the person who has had a stroke.
  
  For further guidance, see NICE's guideline on care and support of people growing older with learning disabilities. [2013]

Offer training in care (for example, in how to move people and to help them with dressing) to family members and carers who are willing and able to be involved in supporting the person after stroke. [2013]

Review family members' and carers' training and support needs regularly (as a minimum at the person's 6‑month and annual reviews), acknowledging that these needs may change over time. [2013]

Once the person has left hospital after having a stroke, continue their care and rehabilitation for as long as it continues to help them achieve their treatment goals. [2023]

Offer early supported discharge to people after stroke who can move from a bed to a chair independently or with assistance, as long as a safe and secure environment can be provided. [2013]

Early supported discharge should:

• be part of a multidisciplinary stroke rehabilitation service working across hospital and community settings

• ensure therapy is continued at the same intensity and level of support from skilled staff as is provided in hospital

• not result in a delay in delivery of care. [2013]

Before and during early supported discharge:

• provide the person after stroke, and their family members and carers, with information about early supported discharge, including details of who to contact if problems arise, to support shared decision making about their care

• assign a member of the early supported discharge team or the stroke rehabilitation service (for example, a stroke key worker) to the person to coordinate their care

• take into account the needs of family members and carers and offer relevant training and support to help reduce caregiver strain, in line with NICE's guideline on supporting adult carers

• be aware, and ensure family members and carers understand, that the person's psychological needs can change after stroke (for recommendations on identifying and managing psychological problems, see the section on psychological functioning). [2023]

Before transfer from hospital to home or to a care setting, discuss and agree a health and social care plan with the person after stroke, and their family members and carers (as appropriate), and provide this to all relevant health and social care providers. [2013]

Before transfer of care from hospital to home:

• establish that the person has a safe and enabling home environment (for example, check that their home or care home has the necessary equipment, any adaptations have been made, and that carers have the support they need to ensure the person can live as independently as possible) and

• accompany the person on a home visit unless their abilities and needs can be identified in other ways, for example, by demonstrating independence in all self-care activities, including meal preparation, while in a hospital unit. [2013]

On transfer of care from hospital to the community, provide information to all relevant health and social care professionals and the person after stroke. This should include a summary of the person's rehabilitation progress and current goals and details of their:

• diagnosis and health status

• functional abilities (including communication needs)

• care needs, including washing, dressing, help with going to the toilet and eating

• psychological (cognitive and emotional) needs

• medication needs (including the person's ability to manage their prescribed medicines and any support they need to do so)

• social circumstances, including carers' needs

• mental capacity regarding the transfer decision

• management of risk, including the needs of vulnerable adults

• plans for follow-up, rehabilitation and access to health and social care and voluntary sector services. [2013]

Ensure that people after stroke who are transferred from hospital to care homes receive assessment and treatment from stroke rehabilitation and social care services to the same standard as they would receive in their own homes. [2013]

Local health and social care providers should have standard operating procedures to ensure the safe transfer and long-term care of people after stroke, including those in care homes. This should include timely exchange of information between different providers using local protocols. [2013]

After transfer of care from hospital, people with rehabilitation needs after stroke (including those in care homes) should be followed up within 72 hours by the specialist stroke rehabilitation team to assess the needs of the person and develop shared management plans. [2013]

When a person is admitted to hospital after stroke, screen for the following and, if problems are identified, take action as soon as possible to ensure their safety and comfort:

• signs of disorientation

• how they should be positioned

• swallowing function

• how they move (for example, from a bed to a chair)

• pressure area risk

• their continence

• their communication, including their ability to understand and follow instructions and to convey their needs and wishes

• their nutritional status and hydration (follow NICE's guidelines on stroke and transient ischaemic attack in over 16s and nutrition support for adults). [2013]

Perform a full medical assessment of the person after stroke, including cognition (attention, memory, spatial awareness, apraxia of speech, perception), vision, hearing, muscle tone, strength, sensation and balance. [2013]

Carry out a comprehensive assessment of a person after stroke that both identifies and takes into account:

• their previous functional abilities

• changes to, or impairment of, psychological and neuropsychological functioning relating to:

  • cognitive, emotional or behavioural functioning, such as new signs of emotionalism (difficulty controlling emotions which can cause uncontrollable crying or laughter)

  • mental health (for example, the onset of depression, anxiety or post-traumatic stress disorder), including signs indicating an increased risk of suicide (suicidality) such as suicidal thoughts, plans, actions and suicide attempts

  • the way the person is adjusting and coping after stroke

  • communication

• impairment of body functions, including pain

• activity limitations and participation restriction

• environmental factors (social, physical and cultural). [2013, amended 2023]

When collecting information from people who have had a stroke on admission and discharge:

• use valid, reliable and responsive tools including the National Institutes of Health Stroke Scale and the Barthel Index

• feed this information back to the multidisciplinary team regularly. [2013]

Take into account the impact of stroke on the person's family, friends and carers and, if appropriate, identify sources of support for them. [2013]

Inform the family members and carers of people after stroke about their right to a carer's needs assessment. [2013]

Ensure that people after stroke have goals for their rehabilitation that:

• are meaningful and relevant to them

• focus on activity and participation

• are challenging but achievable

• include both short- and long-term elements. [2013]

Ensure that goal-setting meetings during stroke rehabilitation:

• are timetabled and held regularly

• involve the person after stroke and, where appropriate, their family members and carers, in discussions. [2013]

During goal-setting meetings, ensure people after stroke are provided with:

• an explanation of the goal-setting process

• the information they need in a format that is accessible to them (in line the NHS accessible information standard)

• the support they need to make decisions and take an active part in setting goals. [2013]

Give people copies of their agreed goals for stroke rehabilitation after each goal-setting meeting. [2013]

Review people's goals at regular intervals during their stroke rehabilitation. [2013]

Provide information and support to enable the person after stroke and their family members and carers (as appropriate) to actively take part in developing their stroke rehabilitation plan. [2013]

Review stroke rehabilitation plans regularly in multidisciplinary team meetings. Time these reviews according to the stage of rehabilitation and the person's needs. [2013]

Ensure any documentation is tailored to the person after stroke and, as a minimum, includes:

• the person's basic details, including contact details and next of kin

• details of their diagnosis and relevant medical information

• a list of any medicines they are taking or are allergic to

• details of standardised screening assessments (see recommendation 1.2.1)

• information about the person's rehabilitation goals

• the multidisciplinary team's progress notes

• details about a key contact from the stroke rehabilitation team (including their contact details) to coordinate the person's health and social care needs

• discharge planning information (including accommodation needs, aids and adaptations)

• joint health and social care plans, if developed

• details of follow-up appointments. [2013]

For information on high-intensity mobilisation during the first 24 hours after the onset of stroke symptoms, see recommendation 1.7.3 in the section on early mobilisation in NICE's guideline on stroke and transient ischaemic attack in over 16s. [2023]

Offer needs-based rehabilitation to people after stroke. This should be for at least 3 hours a day, on at least 5 days of the week, and cover a range of multidisciplinary therapy including physiotherapy, occupational therapy and speech and language therapy. [2023]

Where it is agreed with the person after stroke that they are unable, or do not wish, to participate in rehabilitation therapy for at least 3 hours a day, on at least 5 days of the week, ensure that any therapy needed is still offered for a minimum of 5 days per week. [2023]

Before rehabilitation begins, provide information on:

• the benefits of having intensive therapy after stroke that starts as soon as it is safe to do so and

• what the person can expect from the sessions. [2023]

Ensure all rehabilitation sessions:

• include activities linked to the person's goals

• are tailored to any ongoing medical needs, including post-stroke fatigue

• take into account any psychological factors (such as the person's mood or motivation on the day of the session).
  
  Base the timing, sequencing and content of the sessions on these goals, interests and needs, with the person's agreement. [2023]

Involve families and carers in rehabilitation sessions, when appropriate (see NICE's guideline on patient experience in adult NHS services). [2023]

Make special arrangements for people after stroke who have communication or cognitive needs (for example, by holding joint speech and language therapy and physiotherapy sessions for those with communication difficulties). [2023]

When planning or delivering rehabilitation for people after they have left hospital:

• check whether they will be at their own home or elsewhere after discharge (for example, a care home or the home of a family member)

• ensure they will be able to travel from where they are currently living to attend sessions at the arranged time and location

• take into account any travel needs or issues they may have and reassess these needs or issues if the person moves location (for example, back to their own home or to a care home). [2023]

Use standardised assessments and behavioural observation to assess the effect of visual inattention (an inability to orient towards and attend to stimuli, including body parts, on the side of the body affected by stroke) on functional tasks such as mobility, dressing, eating and using a wheelchair. [2013]

Use interventions for visual inattention that focus on the relevant functional tasks, taking into account the underlying impairment. For example:

• interventions to help people scan to the neglected side of their visual field, such as brightly coloured lines or highlighter on the edge of the page

• using sounds to alert the person

• repeating tasks such as dressing

• using prism glasses to broaden the field of view. [2013]

Assess memory and other relevant domains of cognitive functioning (such as executive functions) in people after stroke, particularly where impairments in memory affect everyday activity. [2013]

Use interventions for memory and cognitive functions that focus on the relevant functional tasks, taking into account the underlying impairment. Interventions could include:

• increasing the person's own awareness of the memory impairment

• enhancing learning using errorless learning and elaborative techniques (making associations, use of mnemonics and internal strategies related to encoding information such as 'preview, question, read, state, test')

• external aids (for example, diaries, lists, calendars and alarms)

• environmental strategies (using routines and environmental prompts). [2013]

Assess attention and cognitive functions in people after stroke using standardised assessments. Use behavioural observation to evaluate the impact of any impairment on functional tasks. [2013]

Consider attention training for people with attention deficits after stroke. [2013]

Use interventions for attention and cognitive functions after stroke that focus on the relevant functional tasks. For example, by minimising distractions and providing prompts related to the task. [2013]

Consider strength training for people with muscle weakness after stroke. This could include progressive strength building through increasing repetitions of body weight activities (for example, sit-to-stand repetitions), weights (for example, progressive resistance exercise), or resistance exercise on machines such as stationary cycles. [2013]

Encourage people to participate in physical activity after stroke. [2013]

Assess people who are able to walk and are medically stable after stroke for cardiorespiratory and resistance training that is appropriate to their individual goals. [2013]

Cardiorespiratory and resistance training for people after stroke should be started by a physiotherapist who can give them instructions on how to continue the programme independently. [2013]

If people after stroke choose to continue with an exercise programme independently, ensure physiotherapists supply any necessary information about interventions and adaptations to the provider so they can make sure the programme is:

• safe for the person and

• tailored to their needs and goals.
  
  This information may be given through written instructions, telephone conversations or a joint visit with the exercise provider and the person, depending on the needs and abilities of both. [2013]

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. [2013]

Do not routinely offer wrist and hand splints to people with upper limb weakness after stroke. [2013]

Consider wrist and hand splints for people at risk after stroke (for example, people who have hands that are immobile due to weakness or high tone), to:

• maintain joint range, soft tissue length and alignment

• increase soft tissue length and passive range of movement

• facilitate function (for example, a hand splint to assist grip or function)

• aid care or hygiene (for example, by enabling access to the palm)

• increase comfort (for example, using a sheepskin palm protector to keep fingernails away from the palm of the hand). [2013]

Ensure wrist and hand splints used by people after stroke are fitted by appropriately trained healthcare professionals, and a review plan is established. [2013]

Teach the person after stroke, and their family members and carers, how to put the splint on and take it off, care for it and monitor for signs of redness and skin breakdown. Provide a point of contact for the person if concerned. [2013]

Do not routinely offer people after stroke electrical stimulation for their hand or arm. [2013]

Consider a trial of electrical stimulation therapy as part of a comprehensive rehabilitation programme for people who have evidence of muscle contraction after stroke but cannot move their arm against resistance. [2013]

Continue electrical stimulation therapy if the person's strength and their ability to practise functional tasks (for example, maintaining range of movement, or improving grasp and release) is found to be improving. [2013]

If a trial of electrical stimulation therapy is appropriate, ensure the treatment is guided by a qualified rehabilitation professional. [2013]

Do not offer robot-assisted arm training as part of an upper limb rehabilitation programme. [2023]

Consider constraint-induced movement therapy for people after stroke who have movement of 20 degrees of wrist extension and 10 degrees of finger extension. Be aware of potential adverse events (such as falls, low mood and fatigue). [2013]

Offer people after stroke repetitive task training on a range of activities for upper limb weakness (such as tasks that involve reaching, grasping, pointing, moving and manipulating objects) and lower limb weakness (such as sit-to-stand transfers, walking and using stairs). [2013]

Offer walking training to people after stroke who are able to walk, with or without assistance, to help them build endurance and move more quickly. [2013]

Consider treadmill training, with or without body weight support, as an option for people after stroke who are able to walk with or without assistance. [2013]

In addition to one-to-one walking therapy for people after stroke who are able to walk, with or without assistance, consider a programme of group circuit training that:

• includes an educational element (for example, advice on preventing falls) and

• involves interaction with other participants to create an environment of peer support. [2023]

Offer electromechanical gait training to people after stroke only in the context of a research study. [2013]

Consider ankle–foot orthoses (devices that support or correct limb function) for people who have difficulty with swing-phase foot clearance after stroke (for example, tripping and falling) or stance-phase control (for example, knee and ankle collapse or knee hyper-extensions) that affects walking. [2013]

Assess the ability of the person to put on the ankle–foot orthosis or ensure they have the support needed to do so. [2013]

Assess the effectiveness of the ankle–foot orthosis for the person, in terms of comfort, speed and ease of walking. [2013]

Assessment for and treatment with ankle–foot orthoses should only be carried out as part of a stroke rehabilitation programme and performed by qualified professionals. [2013]

Follow NICE's interventional procedures guidance on functional electrical stimulation for drop foot of central neurological origin. [2013]

Consider mirror therapy for people with muscle weakness in their upper or lower limbs after a stroke as an adjunct to their rehabilitation programme. [2023]

If provided, start mirror therapy within the first 6 months after a stroke. Sessions should be:

• around 30 minutes long, held at least 5 times per week over 4 weeks and

• supervised initially and, if necessary, for longer. [2023]

Identify any return-to-work issues for the person as soon as possible after stroke. Review these regularly and manage them actively, for example by:

• identifying the physical, cognitive, communication and psychological demands of the job (such as multi-tasking by answering emails and telephone calls in a busy office)

• identifying any problems that affect work performance (for example, physical limitations, anxiety, fatigue preventing attendance for a full day at work, cognitive impairments preventing multi-tasking, and communication problems)

• tailoring interventions (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)

• providing information about the Equality Act 2010 and support available (for example, an access-to-work scheme)

• workplace visits and liaison with employers to make reasonable adjustments such as provision of equipment and phased return to work. [2013]

Consider a referral to a return-to-work programme for people who were working before they had a stroke. [2023]

Manage people's return to work or long-term absence after stroke in line with NICE's guideline on workplace health. [2013]

Consider referral for people after stroke, and their families and carers (if appropriate), to community participation programmes that:

• are suited to the person's rehabilitation goals and

• take into account their needs, views and preferences in line with NICE's guideline on patient experience in adult NHS services. [2023]