Rehabilitation for chronic neurological disorders including acquired brain injury

  • NICE guideline
  • NG252
  • Published: 
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Rehabilitation to maintain, improve or support function

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Health, mental health and social care practitioners should follow our general guidelines for people delivering care:

1.13 Pain management

Follow NICE's guidelines on pain, as appropriate:

1.13.2

Proactively support people in managing their pain and ensure that they have adequate analgesia (if appropriate), to facilitate rehabilitation.

1.13.3

Think about the causes of pain and how pain might be managed when discussing and agreeing rehabilitation goals and plans. Take into account that the following interventions may reduce pain or improve pain management:

  • fatigue management approaches

  • physical exercise and activity

  • interventions for stability, mobility and limb function (including muscle tone and postural management strategies)

  • psychological interventions for low mood, anxiety or support with acceptance and adjustment

  • interventions to support independent living, including provision of equipment and environmental adaptations.

1.13.4

Seek specialist advice on pain management for children and young people with chronic or neuropathic pain.

1.13.5

Consider referral to a pain specialist if there is difficulty in identifying the causes of pain or for advice on a biopsychosocial approach to pain management.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on pain management.

Full details of the evidence and the committee's discussion are in evidence review C: assessment, planning and review, evidence review D: personal care and activities of daily living, evidence review E: stability, mobility and upper limb function, evidence review H: emotional health and mental wellbeing, evidence review J: fatigue management and evidence review O: access to physical activity.

1.14 Fatigue

Follow the recommendations on fatigue in the section on symptom management and rehabilitation in NICE's guideline on multiple sclerosis in adults (recommendations 1.5.3 to 1.5.16 and 1.5.19 to 1.5.23), as appropriate.

Assessment

1.14.2

Find out how fatigue impacts the person's daily life and how their usual day-to-day activities impact their fatigue, when the person is feeling at both their best and worst.

1.14.3

Take into account the person's awareness and understanding of their fatigue and its impact when assessing and managing fatigue.

1.14.4

Check for treatable factors that may be affecting fatigue, for example, mood difficulties, sleep problems, nutritional problems, abnormal endocrine function, medication and some neurological symptoms, including vestibular problems and sensory symptoms. Seek specialist advice, if needed.

Interventions

1.14.5

Explain to the person how and why their condition or injury may cause fatigue, the factors that can influence fatigue and how fatigue can fluctuate and impact their daily life, including their mood.

1.14.6

Help the person's family, carers and other people important to them to recognise and understand how fatigue affects the person and how to respond to this appropriately.

1.14.7

Offer a fatigue management approach, if needed, that prioritises what is important to the person, meets their goals and is integrated within their overall rehabilitation plan. This could include:

  • pacing and other energy-conservation strategies

  • cognitive behavioural therapy

  • appropriate physical activity.

1.14.8

Encourage appropriate physical activity for longer-term general health benefits, even in the presence of fatigue.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on fatigue.

Full details of the evidence and the committee's discussion are in evidence review J: fatigue management.

1.15 Physical activity and exercise

Follow the recommendations about physical activity and exercise for specific chronic neurological disorders or traumatic injury, as appropriate, in the sections on:

1.15.1

Develop an exercise and physical activity programme with the person to optimise their muscle strength, exercise capacity and physical functioning, if needed, and:

  • take into account their executive function and levels of fatigue and pain

  • think about risks and potential harmful consequences of exercise and physical activity

  • think about what level of support and supervision will best meet their needs

  • consider supervised and unsupervised exercises (for example, online resources or local subsidised programmes)

  • agree a clinically relevant exercise dose (frequency, duration and intensity).

1.15.2

For people with a functional neurological disorder offer activities that encourage and enable recovery of movement and function. These should:

  • focus on planned and purposeful movement to achieve a specific outcome (goal-oriented movement) and

  • acknowledge the presence and impact of symptoms while redirecting attention away from them and

  • focus on the potential for recovery.

1.15.3

A registered practitioner with expertise in exercise programmes and physical health (for example, a physiotherapist or occupational therapist), and an understanding of the person and the effects of their condition or injury, should develop and oversee the exercise and physical activity programme.

1.15.4

Discuss and agree outdoor or indoor activities that the person could do to maintain or improve their general physical health, led by the person's preferences.

1.15.5

Help the person to participate in, and sustain engagement with, physical activity using behaviour change strategies, if needed. This may require a family-centred approach.

1.15.6

Consider the following approaches to encourage lifelong behaviour change around physical activity:

  • cognitive behavioural therapy

  • self-determination theory

  • social context theory

  • motivational interviewing or coaching techniques.

1.15.7

Discuss any barriers preventing the person from achieving their physical activity goals and work together to overcome these. Barriers could relate to:

  • the need for support, which may be practical, physical or cognitive

  • cultural, social or socioeconomic factors

  • availability of suitable facilities to undertake physical activity.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on physical activity and exercise.

Full details of the evidence and the committee's discussion are in evidence review E: stability, mobility and upper limb function and evidence review O: access to physical activity.

1.16 Stability, mobility and limb function

1.16.1

If the person has problems with stability, mobility, or upper or lower limb function, work with them to develop specific and targeted training and exercises. This may include:

1.16.2

Provide equipment, including orthoses and splinting, to support movement and protect against injury and secondary impairment.

1.16.3

Think about using gaming modalities or virtual reality to help the person engage with training and exercises to improve stability, mobility or limb function.

1.16.4

Incorporate training and exercises for stability, mobility or limb function into the person's day-to-day activities, at home and in the community.

1.16.5

Agree targeted training and exercises that the person can continue to undertake independently, or with the support of family or carers, as part of their day-to-day activities.

1.16.6

As part of rehabilitation to restore or maintain limb structure and function, provide serial or removable casting.

1.16.7

Take into account the potential harms of inappropriate use of interventions if these might limit the possibility or extent of recovery, (for example, serial or removal casting), particularly for people with a functional neurological disorder.

1.16.8

Consider 24-hour postural management strategies (for example, regular positional changes, bed positioning, wheelchair and seating systems, arm supports and splints) if the person is:

  • not able, or is less able, to sit up or stand up unaided or move independently, and

  • at risk of skin breakdown, pain, sleep disturbance, respiratory dysfunction or muscle or joint contracture.

Treadmill gait training

1.16.9

When planning treadmill gait training, take into account that it may also improve the person's exercise capacity during the training period and motivate them to be physically active over the longer term.

1.16.10

If the person has a progressive neurological condition, think about low- or intermediate-frequency treadmill gait training over a longer period to optimise their mobility and exercise capacity.

1.16.11

Consider robot-assisted treadmill gait training where this equipment is available to further improve mobility and exercise capacity.

1.16.12

When stopping supervised treadmill gait training, support the person to maintain their exercise capacity, as appropriate.

Electrical stimulation

1.16.13

Consider neuromuscular electrical stimulation in addition to muscle strengthening exercise and functional activity.

Interventions for vestibular problems

1.16.15

If vestibular problems are suspected, provide central and peripheral vestibular assessment, and, if needed, exercises or procedures such as ocular motor exercises for stability or canalith repositioning manoeuvres.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on stability, mobility and limb function.

Full details of the evidence and the committee's discussion are in evidence review D: personal care and activities of daily living and evidence review E: stability, mobility and upper limb function.

1.17 Emotional health and mental wellbeing

Follow NICE's guidelines on specific mental health conditions, as appropriate:

Principles of assessment, referral and intervention selection

1.17.1

Think about the person's emotional health and mental wellbeing throughout rehabilitation, paying particular attention to key life stages.

1.17.2

A registered mental health practitioner (for example, a psychologist, psychiatrist or mental health nurse) with an understanding of the person and the effects of their condition or injury, should oversee assessment for emotional health and mental wellbeing and develop and oversee the emotional health and mental wellbeing element of the person's rehabilitation plan.

1.17.3

Be aware that neurological injuries and conditions can result in:

  • neurobehavioural disturbance

  • neurobehavioural changes such as apathy, disinhibition and perseveration

  • difficulties with emotion regulation

  • abrupt fluctuations in a person's emotional state, known as emotional lability.

1.17.4

Assess emotional health and mental wellbeing, behaviour and cognitive function together (see the section on cognitive function), if completing a combined neuropsychological assessment.

1.17.5

Take into account the person may need time and support to adjust to, and accept, any changes caused by their condition, and incorporate these changes into, or alongside, their sense of identity.

1.17.6

If an assessment shows that a person's emotional health and mental wellbeing are negatively impacted by unmet needs in other areas of rehabilitation, follow the other recommendations in this guideline to meet those needs.

1.17.7

Work with the person's family, carers, social networks and people important to the person when agreeing the most appropriate interventions to improve or sustain emotional health and mental wellbeing.

1.17.8

Ensure that goals and interventions for emotional health and mental wellbeing are agreed within the context of other rehabilitation goals and interventions and think about the impact of emotional health and wellbeing on the progress of other rehabilitation goals.

1.17.9

Make referrals to emotional health and mental wellbeing services with the most appropriate expertise, based on the person's needs and circumstances. Assessments or interventions may be provided by:

  • neurorehabilitation services

  • mental health services

  • voluntary, community and social enterprise (VCSE) sector

  • education services (for example, for children and young people, those delivered by a special educational needs coordinator or through an emotional literacy support assistant programme).

1.17.10

When assessments for, or interventions to improve, emotional health and mental wellbeing are provided by a service separate to other rehabilitation services, ensure there is ongoing two-way communication and coordination between services.

1.17.11

Enable the person to opt in and opt out of services for emotional health and mental wellbeing, as needed, in order to manage their fluctuating needs. The arrangement may be direct with the service or via a single point of contact.

Interventions

1.17.12

If the person has low mood or anxiety, or is distressed by, or having difficulties adjusting to, the impact of their neurological condition, consider cognitive behavioural therapy (CBT), mindfulness-based talking therapy or acceptance-based interventions.

1.17.13

If low mood, anxiety or difficulties adjusting to the impact of a chronic neurological condition present barriers to participation in activities of daily living, consider psychoeducation, motivational interviewing and cognitive behavioural approaches.

1.17.14

When delivering talking therapy, take into account the person's cognitive and communication needs and other impacts of their neurological condition. This may require adjustments to:

  • therapy techniques, for example, using memory or communication aids

  • the number, length and frequency of sessions

  • the type of intervention (for example, CBT or mindfulness) and form of delivery (for example, online or face-to-face interventions).

1.17.15

If the person has difficulty engaging in talking therapy because of cognitive or communication problems, or if speaking is not the person's preferred way of communicating, consider creative therapy (for example, music, art or drama therapy).

1.17.16

Offer individual or group interventions, or a mixture of both, for low mood, anxiety and adjustment difficulties, based on the person's needs and preferences.

1.17.17

If the person displays behaviours that challenge, consider neurobehavioural approaches, for example, positive behaviour support.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on emotional health and mental wellbeing.

Full details of the evidence and the committee's discussion are in evidence review H: emotional health and mental wellbeing.

1.18 Cognitive function

Principles

1.18.1

Help the person, and their family or carers, if appropriate, to understand, build insight and awareness of, and adjust to any difficulties with cognitive function.

1.18.2

Support the person to adjust to cognitive changes before or alongside rehabilitation.

1.18.3

For a child or young person, repeat cognitive assessments to track cognitive development and to understand how their condition or injury might impact their academic attainment and developmental trajectory.

Assessment

1.18.4

A registered practitioner with expertise in neuropsychology (for example, a clinical psychologist, counselling psychologist or neuropsychologist), and an understanding of the person and the effects of their condition or injury, should oversee and interpret cognitive assessments and oversee the cognitive functioning element of the person's rehabilitation plan.

1.18.6

Be aware that emotional disturbance (for example, low mood, anxiety and psychological trauma) can impact cognitive function.

1.18.8

Assess for cognitive strengths and weaknesses across the following domains:

1.18.11

When deciding which assessment techniques to use and how to interpret any results, take into account the following:

  • the person's sensory, cognitive, intellectual and communication abilities before neurological injury or development of their neurological disorder

  • the demands of the tests and functional assessments and the environment in which they are being undertaken

  • how symptoms such as fatigue, low mood, the effects of physical or psychological trauma or pain may affect testing and assessment

  • the person's cultural, linguistic and educational background

  • the impact of any other health conditions on testing and assessment.

1.18.12

Explain the format and purpose of any cognitive tests before using them unless this would invalidate the test.

Interventions

1.18.13

Plan cognitive rehabilitation based on the results of the cognitive assessment, taking into account

  • everyday problems with cognitive function

  • any interaction between the domains listed in recommendation 1.18.9

  • the person's preferences

  • the suitability of group or individual activities

  • the person's retained and emerging cognitive skills

  • the input of family, carers and other people important to the person and involved in their rehabilitation.

1.18.14

Provide advice about ways to optimise or maintain cognitive function, such as taking up new hobbies, getting out of the house to socialise, or playing games or puzzles.

1.18.15

Offer advice and support to help the person minimise risk factors for cognitive decline and help maintain existing cognitive function. For example, advice about physical activity, smoking cessation, blood pressure control and sleep. Refer people to relevant healthcare practitioners, if needed.

1.18.16

Discuss and agree ways to help the person to manage difficulties with memory and learning in daily life. This may include compensatory aids (for example, paper diaries, electronic calendars or smartphone apps) and activities to restore or maintain memory and learning (for example, virtual reality or computerised cognitive tasks).

1.18.18

Explain compensatory strategies to the person's family or carers and other people who are important to them and involved in their rehabilitation so they can offer support outside of therapy sessions.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on cognitive function.

Full details of the evidence and the committee's discussion are in evidence review C: assessment, planning and review and evidence review G: rehabilitation for cognitive function.

1.19 Speech, language and communication

Follow the recommendations for specific chronic neurological disorders, as appropriate, in the sections on:

1.19.2

If difficulties with speech, language and communication are suspected, offer an initial screening by a speech and language therapist.

1.19.3

Following initial screening, a speech and language therapist should carry out further assessment, if needed. Do this urgently if the person has a severe speech, language or communication impairment, for example, when it is having a significant impact on their usual day-to-day activities.

1.19.4

Offer therapy that supports functional change for identified speech, language and communication needs, focusing on the person's rehabilitation goals (see the section on goal setting).

1.19.5

If the person has a severe speech, language or communication impairment, refer them for assessment for alternative and augmentative communication equipment, if clinically indicated.

1.19.6

Consider teaching functional speech, language and communication skills that the person can practise and use in real-life environments.

1.19.7

Consider providing a speech and language therapist-led education and training programme in communication skills for family, carers or others important to the person.

1.19.8

Offer early referral for voice banking to people with, or who are likely to experience, voice loss.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on speech, language and communication.

Full details of the evidence and the committee's discussion are in evidence review F: speech, language and communication and evidence review K: access to support for education, employment and social participation.

1.20 Eating, drinking and swallowing

Follow the recommendations for specific chronic neurological disorders, as appropriate, in the sections on:

Assessment and management

1.20.1

Assess oral hygiene and support the person to follow an effective mouthcare regime, if needed.

1.20.4

To prevent deterioration in, or sustain or improve, the person's ability to eat, drink and swallow, provide 1 or more of the following:

  • advice on the best position and posture for eating and drinking

  • speech and language therapist-led interventions to improve swallowing safety, including swallowing manoeuvres (for example, the supraglottic swallow and effortful swallow)

  • rehabilitation techniques to regain the ability to swallow (for example, the Shaker exercise, the Masako manoeuvre, expiratory muscle strength training and neuromuscular retraining)

  • adapted equipment for eating and drinking, including cutlery and crockery, for example one-way straws and angled cups

  • sensory interventions, for example, for taste, smell and thermal stimulation, particularly if the person is nil by mouth.

1.20.5

Modify food and fluids, as directed by a speech and language therapist, taking into account the person's comfort, safety and preferences.

1.20.6

Where modified food and fluids are recommended, regularly review the person's ability to eat, drink and swallow.

1.20.7

Provide nutrition support if the person is malnourished, or at risk of malnutrition, and has inadequate or unsafe oral intake, in line with their preferences, or best interests or advance directives if they lack capacity. For recommendations on screening, indications and interventions for nutrition support, see NICE's guideline on nutrition support for adults.

1.20.8

Only introduce feeding mechanisms that may restrict the person's choice and autonomy, such as enteral tube feeding:

  • when absolutely necessary and

  • provided consent is obtained or

  • it is in line with the person's best interests or advance directives, if they lack capacity.

Principles of care

1.20.9

Have timely discussions with the person to help them maintain their autonomy about what, how and when to eat and drink.

1.20.10

Offer advice to the person, and their family or carers, if appropriate, about the risks and benefits of eating and drinking, and training in how to use any adapted equipment.

1.20.11

When assessing the risks of eating and drinking by mouth:

  • take account of the person's wishes about what, and how, they eat and drink, and respect these wishes wherever possible

  • ensure the person and their family and carers understand any risks involved and provide information to inform decision making (for example, if there are indicators of dysphagia or risks of aspiration or choking)

  • explain that decision making must be based on the provision of safe care

  • provide appropriate safety guidance and advice about eating and drinking by mouth.

1.20.12

Anticipate and address future escalation of risks and needs around eating and drinking.

1.20.13

Undertake advance care planning to capture the person's future preferences regarding nutrition, if appropriate.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on eating, drinking and swallowing.

Full details of the evidence and the committee's discussion are in evidence review D: personal care and activities of daily living.

1.21 Independent living, equipment and environmental adaptations

Follow NICE's guidelines about home care and preventing falls for older people who also have a chronic neurological disorder, as appropriate:

Follow the recommendations about equipment and adaptations to aid independence in activities of daily living for specific chronic neurological disorders, as appropriate, in the sections on:

Follow the recommendations about occupational therapy for specific chronic neurological disorders, as appropriate, in the sections on:

Follow NICE's guidelines on bladder and bowel management, as appropriate:

Supporting independence with activities of daily living

1.21.1

Assess the person's ability to carry out activities of daily living, including the impact of their condition on this.

1.21.2

A registered practitioner (for example, an occupational therapist), with an understanding of the person and the effects of their condition or injury, should develop and oversee the element of the person's rehabilitation plan concerned with improving or maintaining independence with activities of daily living.

1.21.4

Support the person to optimise independence and aid participation in daily life. This may include providing equipment, such as orthoses, a wheelchair or other assistive devices, for postural support and movement.

1.21.5

Take into account the potential harms of inappropriate use of equipment, compensatory aids, assistive devices and adaptive approaches if these might limit the possibility or extent of recovery, particularly for people with a functional neurological disorder.

Occupational therapy and skills-based learning

1.21.6

Consider early access to occupational therapy to develop, maintain or prevent deterioration in skills for independent living.

1.21.7

When providing occupational therapy, use settings and scenarios that are appropriate for the person's rehabilitation goals.

Environmental adaptations, assistive technology and equipment

1.21.9

Identify and address any environmental barriers to activities of daily living in the home or residential setting. This could involve moving furniture or commonly used cooking or bathing items to a more accessible place, providing moving and handling equipment (for example, a hoist) and environmental adaptations (for example, using ramps where steps exist).

1.21.10

Give the person advice and support to access, or to access funding for, equipment, assistive technology or environmental adaptations in their home or residential setting, education or workplace setting, where this is not available from the NHS. This may include funding or provision from the government, their local authority or from voluntary, community and social enterprise (VCSE) organisations.

1.21.11

Work collaboratively with required services to ensure timely delivery of equipment and environmental adaptations.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on independent living, equipment and environmental adaptations.

Full details of the evidence and the committee's discussion are in evidence review B: identification and referral, evidence review D: personal care and activities of daily living and evidence review K: access to support for education, employment and social participation.