Stroke Rehabilitation in Adults
National Institute for Health and Care Excellence. (2023).
London (United Kingdom): National Institute for Health and Care Excellence, (NICE Guideline NG236), 73.
This evidence-based guideline provides recommendations for rehabilitation for individuals over 16 who have experienced stroke. The target audience includes healthcare professionals, adults who have had stroke, and care partners. This document updates the the National Institute for Health Care and Excellence's 2013 guideline on Stroke Rehabilitation in Adults. Only those recommendations pertinent to the practice of speech-language pathology will be included in this summary.
National Institute for Health and Care Excellence (United Kingdom)
This guideline was reviewed with the following:<br />
<ul>
<li>National Institute for Health and Care Excellence. (2016). <em>Stroke in Adults (Quality Standard 2)</em>. Retrieved from <a title="https://www.nice.org.uk/guidance/qs2" href="https://www.nice.org.uk/guidance/qs2" target="_blank" rel="noopener">www.nice.org.uk</a> </li>
<li>National Institute for Health and Care Excellence. (2019). <em>Air Pollution: Outdoor Air Quality and Health (Quality Standard 181)</em>. Retrieved from <a title="https://www.nice.org.uk/guidance/qs181" href="https://www.nice.org.uk/guidance/qs181" target="_blank" rel="noopener">www.nice.org.uk</a></li>
</ul>
<div>The following are recommendations for organizing health and social care for people needing rehabilitation after stroke: </div>
<ul>
<li>Stroke services and the core multidisciplinary stroke rehabilitation team: Those who require stroke rehabilitation should receive it from a specialist stroke team either in a specialist inpatient neurorehabilitation unit, a stroke unit, or the community. An inpatient stroke unit should be led by a core multidisciplinary stroke rehabilitation team consisting of physicians, nurses, PT, OT, speech-language pathologists, and dieticians, amongst others. The unit should also consist of a dedicated stroke rehabilitation environment, provide access to other services such as audiology, and include a multidisciplinary education program. The team should document roles and responsibilities and communicate them to the patient and care partners.</li>
<li>Transfer of care from hospital to community, including early supported discharge: Once the individual has left the hospital, continue rehabilitation as long as they are making progress toward goals. Early supported discharge should not result in delay of care and should be offered at the same intensity and level of support as provided in the hospital. Information should be provided to the individual and their care partners (including a summary of rehabilitation progress and goals, functional abilities, and plans for follow up) and take their needs into account. For transfer from hospital to a care home, individuals should receive stroke rehabilitation assessment and treatment at the same standard that they would receive in their own homes. The specialist stroke rehabilitation team should follow up regarding rehabilitation needs within 72 hours of transfer from the hospital.</li>
</ul>
<div>The following are recommendations for planning and delivering stroke rehabilitation:</div>
<ul>
<li>Screening and Assessment: When admitted to the hospital after stroke, an individual should be screened for signs of disorientation, swallowing function, and communication. They should have a full medical assessment that includes apraxia of speech, cognition, hearing, and balance. Comprehensive assessment should account for prior level of function, cognitive functioning, communication, participation, and environmental factors. At admission and discharge, valid, reliable, and responsive tools should be used with information being shared with the multidisciplinary team.</li>
<li>Setting Goals for Rehabilitation: Goals should be meaningful, functional, achievable, and timetabled and they should actively involve the individual and care partners as appropriate. During goal-setting meetings, copies of goals should be provided and the information should be in an accessible format. Goals should be updated regularly. </li>
<li>Planning Rehabilitation: Information should be provided to support the individual and care partners in actively taking part in the stroke rehabilitation plan. Plans should be regularly reviewed with the multidisciplinary team. Documentation should include details of diagnoses and medications, details of standardized assessments, information about rehabilitation goals and progress, a key contact, discharge planning, and follow-up information. </li>
<li>Intensity of Stroke Rehabilitation: Offer needs-based rehabilitation after stroke at least 3 hours a day, 5 days a week to cover a range of multidisciplinary therapy including speech-language therapy. Provide information regarding the benefits of intensive therapy following stroke and other expectations. Include activities linked to the person's goals, tailor rehabilitation sessions to ongoing medical needs, account for psychological factors, base the timing and content of sessions on goals, needs, and interests, include care partners in sessions, and make special arrangements for those with cognitive-communication needs (e.g., joint speech-language and PT sessions).</li>
</ul>
<div>The following are recommendations regarding telerehabilitation: Consider telerehabilitation in place of or in addition to face-to-face therapy if agreed to or preferred by the patient and if this approach aligns with their goals. Ensure those taking part have the correct equipment. Monitor those involved in telerehabilitation to be sure they are benefiting from this service delivery method.</div>
<div>The following are recommendations for providing support and information: Work to identify information needs and how best to deliver the information. Account for cognitive-linguistic impairments. Pace information and allow time for emotional adjustment. Provide information about local resources that can help support the person after stroke. Review their information at 6-month and annual stroke reviews and at the start and end of therapy.</div>
<div>The following are recommendations regarding cognitive functioning:</div>
<ul>
<li>Screen people for cognitive impairment after stroke. When identified, carry out assessment using valid, reliable, responsive tools. Provide education and support to understand the impact of impairment and may that may change over time.</li>
<li>Visual attention: Use standardized assessment and behavioral observation to assess effects of visual inattention on functional tasks. Use interventions that focus on relevant functional tasks.</li>
<li>Memory function: Assess memory and other cognitive functioning domains after stroke. Use interventions that focus on relevant functional tasks.</li>
<li>Attention function: Assess attention using standardized assessments. Use behavioral observation to evaluate the impact of attention on functional tasks. Consider attention training. Use interventions for attention that focus on relevant functional tasks.</li>
</ul>
<div>The following are recommendations regarding hearing: Screen for hearing within 6 weeks following stroke. Consider the Handicap Hearing Inventory or Amsterdam Inventory Auditory of Disability questionnaires for screening. Ask about changes in hearing since stroke. Refer those with hearing difficulty to an audiologist for assessment.</div>
<div>The following are recommendations regarding mouth care: Assess oral hygiene, encourage people to brush teeth and use mouthwash following stroke, and ensure that a trained healthcare professional or care partner can deliver or supervise mouth care for people after stroke who find it difficult to follow a mouth care regimen. Recommendations regarding assessment of mouth hygiene were formed by consensus.</div>
<div>The following are recommendations regarding swallowing: Assess swallowing after stroke. Provide information regarding dysphagia and how to help when an individual is coughing or choking. Support those with oropharyngeal dysphagia by modifying position, modifying diet or fluid intake, or using compensatory strategies. Offer behavioral exercises. Consider electrical stimulation. Regularly monitor and assess those with modified diets until they are stable. If the person with dysphagia is at risk of aspiration but wishes to eat without aid or intervention, respect their choice and follow recommendations for enacting shared decision-making and communicating risks, benefits, and consequences.</div>
<div>The following are recommendations for individuals with suspected aphasia secondary to stroke: </div>
<ul>
<li><span style="color: #333333;">Receive screening using a standardized protocol for communication difficulty within 72 hours following onset of stroke symptoms and refer those suspected of impairment to a speech-language pathologist. </span></li>
<li><span style="color: #333333;">Receive individualized treatment from a speech-language pathologist. Treatment should enhance preserved abilities, teach other methods of communication (e.g., assess the benefits of using communication aids or technology), provide communication partner training, provide opportunities for social contact and minimize environmental barriers. </span></li>
<li><span style="color: #333333;">Consider computer-based therapy alongside face-to-face therapy. </span></li>
<li><span style="color: #333333;">Receive education regarding community-based support groups and access to information that enables decision making. Education should also be provided to to the multidisciplinary team to support effective communication with people who have communication difficulty and their care partners.</span></li>
</ul>
<div>The following are recommendations regarding returning to work: Identify cognitive-communication and psychological conditions of the job, identify problems that affect work performance, tailor interventions to the individual, and visit the workplace/liaison with employers. Consider referral to a return-to-work program.</div>
<div>The following are recommendations regarding long term health and social support:</div>
<ul>
<li>Provide information regarding referral for further help or support. Provide information so individuals and their care partners can identify complications. Encourage people to focus on life after stroke (e.g., provide information regarding organizations that can support them, help them to participate in community activities, support social roles). Review needs at 6 months and annually.</li>
<li>Community participation programs: Consider referral to community participation programs that are suited to rehabilitation goals and account for needs and preferences.</li>
</ul>
