Rehabilitation After Stroke-summary of NICE-bmj

8/11/2019 Rehabilitation After Stroke-summary of NICE-bmj

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GUIDELINES

Rehabilitation after stroke: summary of NICE guidance

Katharina Dworzynski senior research fellow 1, Gill Ritchie guideline lead 1, Elisabetta Fenu health

economist lead 1

, Keith MacDermott GP guideline development group member 2

, E Diane Playfordguideline chair 3, on behalf of the Guideline Development Group

1National Clinical Guideline Centre, Royal College of Physicians of London, London NW1 4LE, UK; 29 Kilburn Road, York YO10 4DF, UK; 3UCLInstitute of Neurology, London WC1N 1PJ, UK

This is one of a series of BMJ summaries of new guidelines based onthe best available evidence; they highlight important recommendationsfor clinical practice, especially where uncertainty or controversy exists.

Each year, about 150 000 people in the UK have a first orrecurrent stroke. 1 Despite UK health policies that place a greatemphasis on reducing stroke (such as the National StrokeStrategy 2) and improvements in mortality and morbidity,guidance is needed on access to and provision of effectiverehabilitation services to maximise quality of life after stroke.This article summarises the most recent recommendations fromthe National Institute for Health and Care Excellence (NICE)on long term rehabilitation after stroke. 3

RecommendationsNICE recommendations are based on systematic reviews of thebest available evidence and explicit consideration of costeffectiveness. When minimal evidence is available,recommendations can be based on the Guideline DevelopmentGroups experience and opinion of what constitutes good

practice. Evidence levels for the recommendations are given initalic in square brackets.

Organising rehabilitation and care for peoplewith strokeRehabilitation may take place in a variety of settingsinhospital, in outpatient clinics, in the community, and inindividuals own homes.

People with disability after stroke should receiverehabilitation in a dedicated stroke inpatient unit andsubsequently from a specialist stroke team within thecommunity. [ Based on modified Delphi consensusstatements ]

The core stroke rehabilitation team should comprise thefollowing professionals with expertise in strokerehabilitation: consultant physician,nurse, physiotherapist,

occupational therapist, speech and language therapist,clinical psychologist, rehabilitation assistant, and socialworker. [ Based on modified Delphi consensus statements ]

Offer early supported discharge to people with stroke whoare able to transfer from bed to chair independently or withassistance if a safe andsecure environmentcan be provided.

[ Based on high to very low quality evidence fromrandomised controlled trials ]

Planning and delivering stroke rehabilitationTo ensure the safety of the person with stroke while maintaininga patient centred approach, key processes need to be in place.These processes include assessment on admission to therehabilitation service, individualised goal setting, and patientcentred care planning.

Ensure that goal setting meetings during strokerehabilitation-Are timetabled into the working week

-Involve the person with stroke and, where appropriate,the persons family or carer in the discussion.

[ Based on modified Delphi consensus statements ] Offer initially at least 45 minutes of each relevant stroke

rehabilitation therapy for a minimum of five days a week to people who are able to participate, and where functionalgoals can be achieved. If more rehabilitation is needed ata later stage, tailor the intensity to the persons needs atthat time.

If people with stroke areunable to participate in 45 minutesof rehabilitation therapy, ensure that therapy is still offeredfive days a week for a shorter time at an intensity thatallows them to participate actively. [ Based on moderate tolow quality evidence from randomised controlled trialsand a new cost effectiveness analysis ]

Correspondence to: K Dworzynski [email protected]

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BMJ 2013;346:f3615 doi: 10.1136/bmj.f3615 (Published 12 June 2013) Page 1 of 3

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Emotional functioningMany people who have had a stroke experience distress thataffects their ability to benefit from rehabilitation and preventsthem from engaging in daily activities. Psychological therapiesthatare tailored to individualneeds and circumstances (includingweb based approaches) may help the individuals and theirfamilies or carers with post-stroke emotional disorders andrelationship issues.

Assess emotional functioning in the context of cognitivedifficulties in people after stroke.Any intervention chosenshould take into consideration the type or complexity of the persons neuropsychological presentation and relevantpersonalhistory. [ Based on low to very low quality evidence from a randomised controlled trial ]

Cognitive functioningAfter stroke, many people experience difficulties in attention,concentration, memory, perception, and other areas of cognition.

Screen all people after stroke for cognitive deficits. Whena cognitive deficit is identified, carry out a detailedassessment using tools that are valid, reliable, andresponsive before designing a treatment programme. [ Based on modified Delphi consensus statements ]

Use interventions for memory and cognitive functions afterstroke that focus on the relevant functional tasks, takinginto account the underlying impairment. Interventions caninclude-Increasing awareness of the memory deficit

-Enhancing learning by means of errorless learning andelaborative techniques (making associations, use of

mnemonics, internal strategies related to encodinginformation such as preview, question, read, state, test)

-External aids (such as diaries, lists, calendars, and alarms)

-Environmental strategies (routines and environmentalprompts).

[ Based on moderate to low quality evidence fromrandomised controlled trials ]

SwallowingDysphagia (difficulty swallowing) is common after stroke,occurring in up to 67% of stroke patients.

Offer swallowing therapy at least three times a week topeople with dysphagia after stroke who are able toparticipate while they continue to make functional gains.Swallowing therapy could include compensatory strategies,exercises, and postural advice. [ Based on moderate to verylow quality evidence from randomised controlled trials ]

CommunicationTo aid rehabilitation of people who have aphasia and othercommunication disorders after stroke:

Refer people with suspected communication difficultiesafter stroke to a speech and language therapist for detailedanalysis of speech and language impairments and

assessment of their impact. Provide appropriate information, education, and training

to the multidisciplinary stroke team to enable them tosupport and communicate effectively with the person withcommunication difficulties. This support may include

-Minimising environmentalbarriers to communication (forexample, make sure signage is clear and background noiseis minimised)

-Making sure that all written information (including thatrelating to medical conditions and treatment) is adaptedfor people with aphasia after stroke. This should include,for example, appointment letters, rehabilitation timetables,and menus

-Training in communication skills (such as slowing down,not interrupting, using communication props, gestures,drawing) to the conversation partners of people withaphasia.

[ All based on high to very low quality evidence fromrandomised controlled trials ]

MovementWeakness limits a persons ability to move the body, includingchanging body position, transferring from one place to another,walking, and using arms for functional tasks such as washingand dressing.

Offer people repetitive task training after stroke on a rangeof tasks for upper limb weakness (such as reaching,grasping, pointing, moving, and manipulating objects infunctional tasks) and lower limb weakness (such assit-to-stand transfers, walking, and using stairs). [ Based onmoderate to very low quality evidence from randomised controlled trials ]

Do not routinely offer wrist and hand splints to people withupper limb weakness after stroke. [ Based on moderate tolow quality evidence from randomised controlled trials ]

Offer walking training (such as treadmill exercise) forpeople with stroke who are able to walk, with or withoutassistance, to help them build endurance and move morequickly. [ Based on moderate to very low quality evidence from randomised controlled trials ]

Self carePatients will need support to ensure they cancare for themselves.

Occupational therapists with core skills and training in theanalysis and management of activities of daily living shouldtherefore regularly monitor and treat the person who hashad a stroke. Treatment should continue until the person

is stable or able to progress independently. People after stroke are assessed for their equipment needs

and whether their family or carers need training to use theequipment. [ Based on moderate to very low qualityevidence from randomised controlled trials ]

Return to workThe UKs stroke strategy 3 highlighted the need for people whohave had a stroke and their carers to be enabled to participatein paid, supported, and voluntary employment.

Potential problems with returning to work should beidentified as soon as possible after the persons stroke,reviewed regularly, and managed actively. Activemanagement should include-Identifying the jobs physical, cognitive, communication,and psychological demands (for example, multitasking byanswering emails and telephone calls in a busy office)

-Identifying any impairments on work performance (suchas physical limitations, anxiety, and fatigue affecting



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attendance, and cognitive impairments affectingmultitasking and communication difficulties)

-Tailoring an intervention to the individuals difficultiesin the work setting (for example, teaching strategies tosupport multitasking or improve memory, teaching the useof voice activated software for people with difficultytyping, and delivery of work simulations)

-Educating about the Equality Act 2010 4 and supportavailable (such as the Access to Work scheme)

-Workplace visits and liaison with employers to establishreasonable accommodations, such as provision of equipment and graded return to work.

[ Based on very low quality evidence from a randomised controlled trial ]

Long term health and social supportTo help people who have had a stroke to reintegrate into thecommunity, encourage them to focus on life after stroke andhelp them to achieve their goals. This may include:

Facilitating participation in community activities, such asshopping, civic engagement, sports and leisure pursuits,and visiting their place of worship and stroke supportgroups.

Supporting their social roles (such as work, leisure, family,and sexual relationships).

Providing information about transport and driving(including requirements of the Driver and VehicleLicensing Agency (DVLA)). [ Based on modified Delphiconsensus statements ]

Overcoming barriersInformation should be provided to the person who has had astroke and the persons family or carer in an accessible formattaking account of any cognitive, communication, and emotionaldifficulties.

Take into consideration the individuals personal history andbackground when planning rehabilitation programmes andprovide equipment and adaptations, and support in how to usethem, whatever the setting (including care homes). Promptprovision of documentation to the person and his or her familyand all relevant health and social care professionals is a priority,

to overcome current delays or lack of communication between

agencies before discharge or transfer of care. Sufficient traininggiven to the multidisciplinary team, family, and carers on theparticular needs of an individual with stroke and ways to supportthe person would also facilitate the rehabilitation processes sincethese needs are often poorly addressed.

Primary care clinicians are important, in the re-referral forassessment of people after stroke when necessary and insupporting continuing rehabilitation in the community. Toachieve this, timely communication with these clinicianssuchas the provision of documentation of agreed goals, plans foremployment or return to work, and information about otherprogrammes of ongoing rehabilitationis important.

The members of the Guideline Development Group were: Khalid Ali,Martin Bird, Robin Cant, Sandra Chambers, Louise Clark, Tamara Diaz,Avril Drummond until October 2012, Anne Foster until March 2013,Kathryn Head, Pamela Holmes, Helen E Hunter, Najma Khan-Bourne,Keith MacDermott, Rory OConnor, Diane Playford (chair), and SueThelwell. Members of the technicalteam were: Lola Adedokun, KatharinaDworzynski, Elisabetta Fenu, Lina Gulhane, Kate Lovibond, AntoniaMorga, Jonathan Nyong, Grammati Sari, and Gill Ritchie (guidelinelead).

Contributors: KD, GR, EF, and EDP drafted the article. All authorsrevised it critically for important intellectual content and approved thefinal version to be published. All authors are guarantors for this article.

Competing interests: All authors have completed the ICMJE uniformdisclosure form at www.icmje.org/coi_disclosure.pdf and declare: allauthors were members of the Guideline Development Group for theNICE guideline. No author has financial relationships with anyorganisation that might have an interest in the submitted work. None ofthe authors has other relationships or activities that could appear tohave influenced the submitted work.

Provenance and peer review: Commissioned; not externally peerreviewed.

1 Townsend N, Wickramasinghe K, Bhatnagar P, Smolina K, Nichols M, Leal J, et al.Coronary heart disease statistics. 2012 edition . British Heart Foundation, 2012.

2 Department of Health. National stroke strategy. (Report No 284536.) DoH, 2007.3 National Institute for Health and Care Excellence. Stroke rehabilitation: long-term

rehabilitation after stroke (clinical guideline CG162). 2013. http://guidance.nice.org.uk/ CG162 .

4 HM Government. Equality Act. 2010. www.legislation.gov.uk/ukpga/2010/15/contents.5 GRADE Working Group. Grading of Recommendations Assessment, Development and

Evaluation Working Group. 2011. www.gradeworkinggroup.org/ .

Cite this as: BMJ 2013;346:f3615

BMJ Publishi ng Group Ltd 2013



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Further information on the guidance

The guideline provides further guidance on cognitive functions, vision,movement (including electrical stimulation, constraint inducedmovementtherapy, treadmill training, electromechanical gait training, ankle-foot orthoses, visual impairments, and shoulder pain) and self care.

There are several challenges to providing information for people who have had a stroke and their carers, including The need to present complex information in an accessible format.

Working with the person and his or her family or carer to identify their information needs and how to deliver them, taking into accountspecific impairments such as aphasia and cognitive impairments.

Pacing the information to the persons emotional adjustment. [ Based high to low quality evidence from randomised controlled trials ]

The interfacebetweenhealth and social careis alsochallenging,particular whenconsidering transferof carefrom hospital to home(keepingin mind that people transferring to care homes should receive assessment and treatment from stroke rehabilitation and social care servicesto the same standards that they would receive in their own home):

Before transfer from hospital to home or to a care setting, discuss and agree a health and social care plan with the person with strokeand the family or carer, and provide this to all relevant health and social care professionals. [ Based on modified Delphi consensus statements ]

Methods The g uideline was developed in accordancewith NICEguideline development methods ( http://publications.nice.org.uk/the-guidelines-manual-pmg6 ). This involved systematic searching, critical appraisal, and summarisation of the clinical and cost effectiveness evidence. The qualityof evidence for all outcome measures was assessed using Grading of Recommendations Assessment, Development and Evaluation(GRADE). 5 New cost effectiveness analysis was also undertaken for intensity of stroke rehabilitation. A modified Delphi consensus surveywas also conducted among the 168 members of an expert panel for areas with little or no evidence. Delphi survey statements were drawnup from published national and international guidance, and recommendations were drawn up by the Guideline Development Group (GDG)based on statements that reached consensus. The GDG was composed of clinicians with an expertise in stroke rehabilitation, includingphysicians, a primary care physician, a nurse, occupational therapists, physiotherapists, a speech and language therapist, and a clinicalpsychologist as well as individuals with personal experience of stroke.

NICE has produced four different versions of the guideline: a full version; a quick reference guide; a version known as the NICE guidelinethat summarises the recommendati ons; and a version for patients and the public. All these versions are available from the NICE website(http://guidance.nice.org.uk/CG162 ). Future updates of the guideline will be published according to the NICE guideline developmentprogramme.

Future research The Guideline Development Group highlighted some important questions that need to be answered:

Is electrical stimulation effective as an adjunct to rehabilitation to improve hand and arm function after stroke?

Is intensive rehabilitation (6 hours/day) more effective than moderate rehabilitation (2 hours/day) on activity, participation, and qualityof life outcomes?

Which cognitive and emotional interventions provide better outcomes for identified subgroups of people with stroke and their familiesand carers at different stages of the stroke pathway?

Which people with a weak arm after stroke are at risk of developing shoulder pain? What management strategies are effective in theprevention or management of shoulder pain of different aetiologies?



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Rehabilitation After Stroke-summary of NICE-bmj