Guidance

Recommendations

Recommendations

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.

1.1 Organising health and social care for people needing rehabilitation after stroke

Stroke services

1.1.1 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]

1.1.2 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]

The core multidisciplinary stroke rehabilitation team

1.1.3 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]

1.1.4 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]

Assessing care and support needs

1.1.5 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]

1.1.6 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]

1.1.7 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]

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

1.1.8 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]

1.1.9 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]

1.1.10 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]

1.1.11 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]

1.1.12 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]

1.1.13 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]

1.1.14 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]

1.1.15 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]

1.1.16 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]

1.1.17 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]

For a short explanation of why the committee made the 2023 recommendations and how they might affect services, see the rationale and impact section on transfer of care from hospital to community, including early supported discharge.

Full details of the evidence and the committee's discussion are in evidence reviews A1 to A4: early supported discharge.

1.2 Planning and delivering stroke rehabilitation

Screening and assessment

1.2.1 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:

1.2.2 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]

1.2.3 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]

1.2.4 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]

1.2.5 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]

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

Setting goals for rehabilitation

1.2.7 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]

1.2.8 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]

1.2.9 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]

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

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

Planning rehabilitation

1.2.12 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]

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

1.2.14 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]

Intensity of stroke rehabilitation

1.2.15 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]

1.2.16 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]

1.2.17 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]

1.2.18 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]

1.2.19 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]

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

1.2.21 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]

1.2.22 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]

For a short explanation of why the committee made the 2023 recommendations and how they might affect practice, see the rationale and impact section on intensity of stroke rehabilitation.

Full details of the evidence and the committee's discussion are in evidence reviews E1 to E5: intensity of rehabilitation.

1.3 Telerehabilitation

1.3.1 Consider telerehabilitation instead of, or as well as, face-to-face therapy, only if:

  • the person after stroke agrees to this approach or it is their preferred type of therapy and

  • it aligns with their rehabilitation goals. [2023]

1.3.2 Ensure that anyone taking part in telerehabilitation has, or when needed is provided with, the correct equipment (for example, a loaned laptop) and any training or technical support they need to use it. [2023]

1.3.3 Monitor people who are taking part in telerehabilitation to ensure they are:

  • benefiting from this method of delivering therapy and

  • are not developing symptoms or signs of depression. [2023]

For a short explanation of why the committee made the 2023 recommendations and how they might affect practice, see the rationale and impact section on telerehabilitation.

Full details of the evidence and the committee's discussion are in evidence review G: telerehabilitation.

1.4 Providing support and information

1.4.1 Work with the person after stroke, and their family members and carers, to identify their information needs and how to deliver this information. Take into account any specific impairments such as aphasia (loss or impairment of the ability to use and comprehend language) and cognitive impairments. Pace the way information is given to allow time for the person to make an emotional adjustment. [2013]

1.4.2 Provide information about local resources (for example, leisure, housing, social services and voluntary organisations) that can help support the needs and priorities of the person after stroke and their family members and carers. [2013]

1.4.3 Review the person's information needs at their 6‑month and annual stroke reviews, and at the start and end of any therapy. [2013]

See the recommendations on continuity of care and relationships, tailoring healthcare services for each patient and enabling patients to actively participate in their care in the NICE guideline on patient experience in adult NHS services. For guidance on supporting informal carers, see NICE's guideline on supporting adult carers.

1.5 Cognitive functioning

1.5.1 Screen people after stroke for cognitive impairment. Where cognitive impairment is identified, carry out a detailed assessment using valid, reliable and responsive tools before designing a treatment programme. [2013]

1.5.2 Provide education and support for people after stroke, and their families and carers, to help them understand the extent and impact of cognitive impairment, recognising that these may vary over time and in different settings. [2013]

Visual inattention

1.5.3 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]

1.5.4 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]

Memory function

1.5.5 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]

1.5.6 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]

Attention function

1.5.7 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]

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

1.5.9 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]

1.6 Psychological functioning

1.6.1 Assess the person after stroke for changes to:

  • their emotional functioning, such as the onset of emotionalism

  • their behaviour

  • their mental health including the development of any signs that could indicate an increased risk of suicide (suicidality) such as suicidal thoughts, plans and actions, and suicide attempts

  • the way they are adjusting and coping after stroke. [2013, amended 2023]

1.6.2 When choosing any intervention for problems with emotional functioning, take into account the type or complexity of the person's neuropsychological presentation and relevant personal history. [2013]

1.6.3 Support and educate people and their families and carers to help them make an emotional adjustment after stroke, recognising that their psychological needs may change over time and in different settings. [2013]

1.6.4 When new or persisting changes to mood or emotional difficulties are identified at the person's 6‑month or annual stroke review, refer them to appropriate services for detailed assessment and treatment. [2013]

1.6.5 Manage depression or anxiety in people after stroke who have no cognitive impairment in line with NICE's guidelines on depression in adults with a chronic physical health problem and generalised anxiety disorder and panic disorder in adults. [2013]

1.7 Fatigue

1.7.1 Consider a standardised assessment for fatigue in people after stroke in the early stage of their rehabilitation programme and at their 6‑month stroke review. [2023]

1.7.2 Consider 1 of the following for the assessment:

  • the Fatigue Severity Scale

  • the Fatigue Assessment Scale

  • the Modified Fatigue Impact Scale. [2023]

For a short explanation of why the committee made the 2023 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 B: optional tool for the assessment of fatigue.

1.8 Vision

1.8.1 Offer people who are in hospital after stroke a specialist orthoptist assessment as soon as possible. If this cannot be done before discharge, offer the person an urgent outpatient appointment. [2023]

1.8.2 Offer eye movement therapy to people who have persisting hemianopia (blindness in 1 half of the visual field of 1 or both eyes) after stroke. [2013, amended 2023]

1.8.3 When advising people with visual problems after stroke about driving, consult the Driver and Vehicle Licensing Agency (DVLA) regulations. [2013]

For a short explanation of why the committee made the 2023 recommendation and how it might affect practice, see the rationale and impact section on vision.

Full details of the evidence and the committee's discussion are in evidence review C: routine orthoptist assessment.

1.9 Hearing

1.9.1 Screen people for hearing problems within the first 6 weeks after stroke. [2023]

1.9.2 Consider the Handicap Hearing Inventory in the Elderly or Amsterdam Inventory Auditory of Disability questionnaires for screening. [2023]

1.9.3 During screening, ask the person, and their family members and carers, about any changes to their hearing since the stroke. [2023]

1.9.4 Refer people with hearing difficulties for an audiology assessment, in line with NICE's guideline on hearing loss in adults. [2023]

For a short explanation of why the committee made the 2023 recommendations and how they might affect practice, see the rationale and impact section on hearing.

Full details of the evidence and the committee's discussion are in evidence review D: optimal tool for hearing assessment.

1.10 Mouth care

1.10.1 Assess oral hygiene in people after stroke using national or local protocols. [2023]

1.10.2 Encourage people after stroke to do the following at least twice a day:

  • brush their teeth and gums, using an electric or battery-powered toothbrush if needed

  • use mouthwash and oral gels with antibacterial and antifungal properties, if needed. [2023]

1.10.3 Ensure that a suitably trained healthcare professional, family member or carer delivers or supervises mouth care for people after stroke who cannot, or find it difficult to, follow a mouth care regimen. [2023]

For a short explanation of why the committee made the 2023 recommendations and how they might affect practice, see the rationale and impact section on mouth care.

Full details of the evidence and the committee's discussion are in evidence review J: oral hygiene interventions.

1.11 Swallowing

1.11.1 Assess swallowing in people after stroke in line with NICE's guideline on stroke and transient ischaemic attack in over 16s. [2013]

1.11.2 Provide information to people with dysphagia (difficulty in swallowing) after stroke, and their families and carers, on what the condition is and its risks. [2023]

1.11.3 Give families and carers information on how they can help someone who is coughing or choking while eating or drinking. [2023]

1.11.4 If the person has dysphagia and is unable to take tablets, review the need for the medication and, if it is still needed, change either its formulation or the route of administration. [2023]

1.11.5 Support people who have oropharyngeal dysphagia (OPD) to eat and drink as safely as possible, using 1 or more of the following methods (as advised by a dysphagia-trained healthcare professional):

  • adaptions to their physical position

  • modifying fluid intake (for example, taking small sips or drinking thickened fluids)

  • modifying their diet (for example, changing the texture of the food)

  • adapting the way food and drink is served (for example, serving food with different cutlery)

  • using compensatory strategies and manoeuvres appropriate for the person (for example, the Mendelsohn manoeuvre). [2023]

1.11.6 Offer behavioural exercises (for example, chin tuck against resistance) to people with OPD for at least 5 days per week. [2023]

1.11.7 Consider physical stimulation (for example, thermal or tactile stimulation) for people with OPD for at least 5 days per week. [2023]

1.11.8 Ensure people with dysphagia after stroke are supported in following an effective mouth care regimen, because this decreases the risk of aspiration pneumonia (see the section on mouth care). [2013]

1.11.9 Healthcare professionals with relevant skills and training in the diagnosis, assessment and management of swallowing disorders should regularly monitor and reassess people with dysphagia after stroke who are having modified food and liquid until they are stable (this recommendation is from NICE's guideline on nutrition support for adults). [2013]

1.11.10 Provide nutrition support to people with dysphagia in line with NICE's guidelines on nutrition support for adults and stroke and transient ischaemic attack in over 16s. [2013]

1.11.11 If the person with dysphagia is at risk of aspiration but wishes to eat and drink without the assistance of aids and interventions (such as the methods listed in recommendations 1.11.5 to 1.11.7 for people with OPD):

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

Full details of the evidence and the committee's discussion are in evidence review I: eating and drinking.

1.12 Communication

1.12.1 Screen people for communication difficulties within 72 hours of onset of stroke symptoms. [2013]

1.12.2 Each stroke rehabilitation service should devise a standardised protocol to screen for communication difficulties in people after stroke. [2013]

1.12.3 Refer people with suspected communication difficulties after stroke to a speech and language therapist for detailed analysis of any impairments and assessment of their impact. [2013]

1.12.4 Provide appropriate information, education and training to the multidisciplinary team to enable them to support and communicate effectively with people who have communication difficulties and their families and carers. [2013]

1.12.5 Speech and language therapy for people after stroke should be led and supervised by a specialist speech and language therapist working collaboratively with other appropriately trained people (for example, speech and language therapy assistants, carers and friends, or members of the voluntary sector). [2013]

1.12.6 Provide opportunities for people with communication difficulties after stroke to have conversations and social contact with people who have the training, knowledge, skills and behaviours to support them. This should be in addition to the opportunities provided by families, carers and friends. [2013]

1.12.7 Speech and language therapists should assess people experiencing severe communication difficulties after stroke to see if they could benefit from using a communication aid or other technologies (for example, home-based computer therapies or mobile apps). [2013]

1.12.8 Consider a computer-based programme (or apps) tailored to individual goals and circumstances in relation to word finding, alongside face-to-face speech and language therapy. [2023]

1.12.9 Provide communication aids to people who could benefit from them after stroke and offer training in how to use them. [2013]

1.12.10 Tell people with communication difficulties after stroke about community-based communication and support groups (such as those provided by voluntary organisations) and encourage them to participate in them. [2013]

1.12.11 Speech and language therapists should:

  • provide individualised therapy for specific communication impairments such as aphasia or dysarthria (difficulty in articulating words)

  • help people after stroke to use and enhance their remaining language and communication abilities

  • teach other methods of communicating, such as gestures, writing and using communication props

  • coach those around the person after stroke (including family members, carers, and health and social care staff) to develop supportive communication skills to maximise the person's communication potential

  • help people with aphasia or dysarthria, and their families and carers, to adjust to communication impairment

  • support people with communication difficulties to rebuild their identity

  • support people to access information that enables decision making. [2013]

1.12.12 When persisting communication difficulties are identified at the person's 6‑month or annual stroke review, refer them back to a speech and language therapist for detailed assessment, and offer treatment if they could benefit from it. [2013]

1.12.13 Help and enable people with communication difficulties after stroke to express their everyday needs and wishes, and support them to understand and participate in both everyday and major life decisions. [2013]

1.12.14 Ensure that environmental barriers to communication are minimised for people after stroke. For example, make sure signage is clear and background noise is limited. [2013]

1.12.15 Make sure that all written information (including that relating to medical conditions and treatment) is adapted for people with aphasia after stroke. This should include, for example, appointment letters, rehabilitation timetables and menus. [2013]

1.12.16 Offer training in communication skills (such as slowing down, not interrupting and using communication props, gestures or drawing) to those who regularly communicate with people who have aphasia after stroke. [2013]

For a short explanation of why the committee made the 2023 recommendation and how it might affect practice, see the rationale and impact section on communication.

Full details of the evidence and the committee's discussion are in evidence review K: computer-based tools for speech and language therapy.

1.13 Movement

1.13.1 Provide physiotherapy for people after stroke who have weakness in their trunk or upper or lower limbs, sensory disturbance or balance difficulties that affect their movement. [2013]

1.13.2 People with movement difficulties after stroke should be treated by physiotherapists with the relevant skills and training in diagnosis, assessment and management. [2013]

1.13.3 Continue to treat people with movement difficulties until they are able to maintain or progress function either independently or with assistance from others (for example, rehabilitation assistants, family members, carers or fitness instructors). [2013]

Strength training

1.13.4 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]

Fitness training

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

1.13.6 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]

1.13.7 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]

1.13.8 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]

1.13.9 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]

Wrist and hand splints

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

1.13.11 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]

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

1.13.13 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]

Electrical stimulation therapy for the upper limb

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

1.13.15 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]

1.13.16 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]

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

Robot-assisted arm training

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

For a short explanation of why the committee made the 2023 recommendation and how it might affect practice, see the rationale and impact section on robot-assisted arm training.

Full details of the evidence and the committee's discussion are in evidence review M: robot-assisted arm training.

Constraint-induced movement therapy

1.13.19 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]

Repetitive task training

1.13.20 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]

Walking therapies and group circuit training

1.13.21 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]

1.13.22 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]

1.13.23 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]

For a short explanation of why the committee made the 2023 recommendation and how it might affect practice, see the rationale and impact section on walking therapies and group circuit training.

Full details of the evidence and the committee's discussion are in evidence review L: circuit training for walking.

Electromechanical gait training

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

Ankle–foot orthoses

1.13.25 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]

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

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

1.13.28 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]

Mirror therapy for the upper or lower limb

1.13.30 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]

1.13.31 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]

For a short explanation of why the committee made the 2023 recommendations and how they might affect practice, see the rationale and impact section on mirror therapy for the upper or lower limb.

Full details of the evidence and the committee's discussion are in evidence review Q: mirror therapy.

Music therapy and interventions

NICE has made a recommendation for research about music therapy for people after a first stroke or recurrent strokes.

For a short explanation of why the committee made this recommendation for research, see the rationale section on music therapy and interventions.

Full details of the evidence and the committee's discussion are in evidence review N: music therapy.

1.14 Managing shoulder pain

1.14.1 Provide information for people after stroke, and their families and carers, on how to prevent pain or trauma to the shoulder if they are at risk of developing shoulder pain (for example, if they have upper limb weakness and spasticity). [2013]

1.14.2 Assess people with shoulder pain after stroke to identify its cause and use the results of the assessment to decide how to manage the pain. [2023]

1.14.3 Encourage or help the person to adapt their position to help ease shoulder pain. [2013, amended 2023]

1.14.4 Consider 1 or more of the following options for managing shoulder pain:

For a short explanation of why the committee made the 2023 recommendations and how they might affect practice, see the rationale and impact section on managing shoulder pain.

Full details of the evidence and the committee's discussion are in evidence review O: shoulder pain.

1.15 Spasticity

1.15.1 Provide information on spasticity for people after stroke, and their families and carers, including details about what it is and what can make it better or worse. [2023]

1.15.2 Assess whether spasticity in people after stroke is focal (that is, it affects a specific limb or part of a limb) or generalised. [2023]

1.15.3 Discuss options for managing focal or generalised spasticity in the person after stroke with the multidisciplinary team. [2023]

1.15.4 Consider 1 or more of the following as part of a goal-directed plan to manage focal or generalised spasticity in people after stroke:

  • stretching the affected limb or limbs

  • splints, when needed (see the section on wrist and hand splints)

  • advice on identifying and managing triggers of spasticity. [2023]

1.15.5 For people who have focal spasticity of the upper limb after stroke, consider treatment with either Dysport at a dose of up to 1,000 units per treatment or with Xeomin at a dose of up to 400 units per treatment, unless they are already receiving a different type or dose of botulinum toxin A. Ensure that:

  • the dose is spread across appropriate injection sites in the affected limb and

  • people do not receive more than 1 treatment every 3 months and

  • response to the treatment is monitored and it is stopped if it is not effective.

    For people who are already receiving botulinum toxin A of a different type or dose, continue with this treatment if it is effective. [2023]

1.15.6 Consider a trial of NMES, functional electrical stimulation (FES) or transcutaneous electrical nerve stimulation (TENS) for people after stroke with focal spasticity. [2023]

1.15.7 Consider oral baclofen for people after stroke with generalised spasticity but monitor closely for adverse effects. [2023]

1.15.8 Refer people after stroke to a specialist spasticity service if:

  • they have ongoing spasticity that has not responded to treatment

  • other treatments are not tolerated

  • the person has complex needs in relation to spasticity (for example, if the injection is for small muscles or treatment is needed for spasticity-related pain). [2023]

For a short explanation of why the committee made the 2023 recommendations and how they might affect practice, see the rationale and impact section on spasticity.

Full details of the evidence and the committee's discussion are in evidence review P: spasticity.

1.16 Self-care

1.16.1 Provide occupational therapy for people after stroke who are likely to benefit from it and to address difficulties with activities of daily living. Therapy may consist of restorative or compensatory strategies.

  • Restorative strategies may include:

    • encouraging people with hemisensory inattention (a difficulty in detecting or acting on information on 1 side of their personal space) to attend to the neglected side

    • encouraging people with arm weakness to use both arms

    • establishing a dressing routine for people with difficulties such as poor concentration, hemisensory inattention or dyspraxia (difficulty in planning and executing movement) which make dressing problematic.

  • Compensatory strategies may include training people how to:

    • dress one-handed

    • use devices such as bathing and dressing aids. [2013]

1.16.2 People who have difficulties with activities of daily living after stroke should have regular monitoring and treatment by occupational therapists with core skills and training in the analysis and management of activities of daily living. Treatment should continue until the person's condition is stable or able to progress independently. [2013]

1.16.3 Assess people after stroke for their equipment needs and to see whether their family or carers need training to use the equipment. This assessment should be done by an appropriately qualified professional. Equipment may include hoists, chair raisers and small aids such as long-handled sponges. [2013]

Returning to work

1.16.4 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]

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

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

For a short explanation of why the committee made the 2023 recommendation and how it might affect practice, see the rationale and impact section on returning to work.

Full details of the evidence and the committee's discussion are in evidence review H: community participation interventions.

Self-management interventions

NICE has made a recommendation for research about self-management interventions for people after stroke.

For a short explanation of why the committee made this recommendation for research, see the rationale section on self-management interventions.

Full details of the evidence and the committee's discussion are in evidence review F: self-management.

1.17 Long-term health and social support

1.17.1 Explain to people after stroke that they can self-refer, usually with the support from a health or care professional working in primary care (for example, a GP or a social prescriber) or named contact from the stroke rehabilitation service, if they need further help or support. [2013]

1.17.2 Provide information so that people after stroke, and their family and carers, can recognise the complications of the condition, including frequent falls, spasticity, shoulder pain and incontinence. [2013]

1.17.3 Encourage people to focus on life after stroke and help them to achieve their goals. This may include:

  • giving them information about voluntary organisations that can support them

  • helping them to participate in community activities, such as shopping, civic engagements, sports and leisure pursuits, visiting their place of worship and joining stroke support groups

  • supporting their social roles, for example, in work, education, volunteering, leisure activities, within their family and with sexual relationships

  • providing information about transport and driving (including DVLA requirements; see the UK Government's web page on stroke and driving). [2013]

1.17.4 Manage incontinence after stroke in line with NICE's guidelines on urinary incontinence in neurological disease and faecal incontinence in adults. [2013]

1.17.5 Review the health and social care needs of people after stroke, and the needs of their carers, at 6 months and then annually. These reviews should cover participation in activities of everyday life to ensure that people's goals are met. [2013]

For guidance on the secondary prevention of stroke, see NICE's guidelines on cardiovascular disease, hypertension in adults, type 2 diabetes in adults and atrial fibrillation. For advice on involving people in decisions about prescribed medications and supporting adherence, follow NICE's guideline on medicines adherence.

Community participation programmes

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

For a short explanation of why the committee made the 2023 recommendation and how it might affect practice, see the rationale and impact section on community participation programmes.

Full details of the evidence and the committee's discussion are in evidence review H: community participation interventions.

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline.

Apraxia of speech

Difficulty in controlling the muscles for speech because of damage to the brain, which can affect speech or changes in the rhythm or rate of speaking.

Community participation programmes

Programmes encouraging involvement in social activities that either take place outside the home or are non-domestic. They focus on providing education, support or practice in areas such as:

  • participation in peer support groups

  • political or civic roles

  • leisure activities like exercise, art or music

  • involvement in faith-based groups or organisations

  • education and learning

  • walking or using other means of transport, such as buses, mobility scooters or taxis

  • employment or voluntary work.

Level 1 or 2 specialist inpatient neurorehabilitation unit

Specialist rehabilitation services that are led or supported by consultants who specialise in rehabilitation medicine. Level 1 units are for people with highly complex rehabilitation needs who typically require longer lengths of stay than other people in hospital after a stroke, such as those in level 2 units. They have a higher number of specialist staff with the expertise, as well as access to specialist facilities, to provide high-intensity rehabilitation that meets the needs of people admitted to these units. Level 2 units are for people who need more help, support and care from a rehabilitation team than they would get on a stroke unit but their needs are less than people who are normally admitted to a level 1 unit.

Stroke unit

An environment in which multidisciplinary stroke teams deliver care in a dedicated ward which has a bed area, dining area, gym, and access to assessment kitchens.

Telerehabilitation

Rehabilitation delivered remotely instead of face-to-face interaction between the person after stroke and the healthcare professional. Components can include interventions, supervision, education, consultations and counselling. This may be delivered in real time (synchronous) or with delay where immediate response is not required (asynchronous).