Rehabilitation and recovery - principles of rehabilitation - National Clinical Guideline for Stroke (2024)

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  • What’s new in the 2023 edition

  • Guideline development

    • 1.0 Introduction
    • 1.1 Scope
    • 1.2 Context and use of this guideline
    • 1.3 Models underpinning guideline development
    • 1.4 Methodology of guideline development
    • 1.5 Funding and conflicts of interest
    • 1.6 Treatments not mentioned in this guideline
    • 1.7 Participation in clinical research
    • 1.8 Licensing and approval of medication
    • 1.9Contributors
    • 1.10 Notes on the text
  • Organisation of stroke services

    • 2.0 Introduction
    • 2.1 Public awareness of stroke
    • 2.2 Definitions of specialist stroke services
    • 2.3 Transfer to acute stroke services
    • 2.4 Organisation of inpatient stroke services
    • 2.5 Resources – inpatient stroke services
    • 2.6 Location of service delivery
    • 2.7 Transfers of care – general principles
    • 2.8 Transfers of care from hospital to home – community stroke rehabilitation
    • 2.9 Remotely delivered therapy and telerehabilitation
    • 2.10 Measuring rehabilitation outcomes
    • 2.11 Psychological care – organisation and delivery
    • 2.12 Vocational rehabilitation
    • 2.13 Follow-up review and longer term support
    • 2.14 Stroke services for younger adults
    • 2.15 End-of-life (palliative) care
    • 2.16 Carers
    • 2.17 People with stroke in care homes
    • 2.18 Service governance and quality improvement
  • Acute care

    • 3.0 Introduction
    • 3.1 Pre-hospital care
    • 3.2 Management of TIA and minor stroke – assessment and diagnosis
    • 3.3 Management of TIA and minor stroke – treatment and vascular prevention
    • 3.4 Diagnosis and treatment of acute stroke – imaging
    • 3.5 Management of ischaemic stroke
    • 3.6 Management of intracerebral haemorrhage
    • 3.7 Management of subarachnoid haemorrhage
    • 3.8 Cervical artery dissection
    • 3.9 Cerebral venous thrombosis
    • 3.10 Acute stroke care
    • 3.11 Positioning
    • 3.12 Early mobilisation
    • 3.13 Deep vein thrombosis and pulmonary embolism
  • Rehabilitation and recovery – principles of rehabilitation

    • 4.0 Introduction
    • 4.1 Rehabilitation potential
    • 4.2 Rehabilitation approach – intensity of therapy (motor recovery and function)
    • 4.3 Rehabilitation approach – goal setting
    • 4.4 Self-management
    • 4.5 Remotely delivered therapy and telerehabilitation
    • 4.6 Self-directed therapy
  • Rehabilitation and recovery – activity and participation

    • 4.7 Introduction
    • 4.8 Independence in daily living
    • 4.9 Hydration and nutrition
    • 4.10 Mouth care
    • 4.11 Continence
    • 4.12 Extended activities of daily living
    • 4.13 Sex
    • 4.14 Driving
    • 4.15 Return to work
  • Rehabilitation and recovery – motor recovery and physical effects of stroke

    • 4.16 Introduction
    • 4.17 Motor impairment
    • 4.18 Arm function
    • 4.19 Ataxia
    • 4.20 Balance
    • 4.21 Falls and fear of falling
    • 4.22 Walking
    • 4.23 Pain
    • 4.23.1 Neuropathic pain (central post-stroke pain)
    • 4.23.2 Musculoskeletal pain
    • 4.23.3 Shoulder subluxation and pain
    • 4.24 Spasticity and contractures
    • 4.25 Fatigue
    • 4.26 Swallowing
  • Rehabilitation and recovery – psychological effects of stroke

    • 4.27 Introduction
    • 4.28 Psychological effects of stroke – general
    • 4.29 Cognitive screening
    • 4.30 Cognitive assessment
    • 4.31 Apraxia
    • 4.32 Attention and concentration
    • 4.33 Memory
    • 4.34 Executive function
    • 4.35 Mental capacity
    • 4.36 Perception
    • 4.37 Neglect
    • 4.38 Mood and well-being
    • 4.39 Anxiety, depression and psychological distress
    • 4.40 Apathy
    • 4.41 Emotionalism
  • Rehabilitation and recovery – communication and language

    • 4.42 Introduction
    • 4.43 Aphasia
    • 4.44 Dysarthria
    • 4.45 Apraxia of speech
  • Rehabilitation and recovery – sensory effects of stroke

    • 4.46 Introduction
    • 4.47 Sensation
    • 4.48 Vision
  • Long-term management and secondary prevention

    • 5.0 Introduction
    • 5.1 A comprehensive and personalised approach
    • 5.2 Identifying risk factors
    • 5.3 Carotid artery stenosis
    • 5.4 Blood pressure
    • 5.5 Lipid modification
    • 5.6 Antiplatelet treatment
    • 5.7 Anticoagulation
    • 5.8 Other risk factors
    • 5.9 Paroxysmal atrial fibrillation
    • 5.10 Patent foramen ovale
    • 5.11 Other cardioembolism
    • 5.12 Vertebral artery disease
    • 5.13 Intracranial artery stenosis
    • 5.14 Oral contraception and hormone replacement therapy
    • 5.14.1 Oral contraception
    • 5.14.2 Hormone replacement therapy
    • 5.15 Obstructive sleep apnoea
    • 5.16 Antiphospholipid syndrome
    • 5.17 Insulin resistance
    • 5.18 Fabry disease
    • 5.19 Cerebral Amyloid Angiopathy
    • 5.20 CADASIL
    • 5.21 Cerebral microbleeds
    • 5.22 Lifestyle measures
    • 5.23 Physical activity
    • 5.24 Smoking cessation
    • 5.25 Nutrition (secondary prevention)
    • 5.26 Life after stroke
    • 5.27 Further rehabilitation
    • 5.28 Social integration and participation
  • Implementation of this guideline

    • 6.0 Introduction
    • 6.1 Overall structure of stroke services
    • 6.2 Acute stroke services
    • 6.3 Secondary prevention services
    • 6.4 Stroke rehabilitation services
    • 6.5 Long-term support services
  • Acronyms and abbreviations

  • Glossary

  • Bibliography

  • Contributors

  • Appendices

  • Previous editions of the guideline

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4.0 Introduction

This section addresses the core principles of rehabilitation and its delivery. All subsequent sections of this chapter should be read keeping these overarching principles and reco...

This section addresses the core principles of rehabilitation and its delivery. All subsequent sections of this chapter should be read keeping these overarching principles and recommendations in mind. It is acknowledged that rehabilitation, recovery, and adjustment are different albeit linked concepts that may take place over differing time frames and require differing levels of support. Where necessary and appropriate, community rehabilitation may be delivered by combined stroke and neuro-therapy teams; however, these teams should have the skills and resources (including staffing) to be able to meet the standards within this guideline. Interventions and support provided by rehabilitation and life after stroke services should span these varying needs and timescales to fulfil the requirement of the United Nations Convention on the Rights of Persons with Disabilities (United Nations, 2022) to deliver “effective and appropriate measures, including through peer support, to enable persons with disabilities to attain and maintain maximum independence, full physical, mental, social and vocational ability, and full inclusion and participation in all aspects of life”. [2023]

4.1 Rehabilitation potential

Decisions about rehabilitation potential have far-reaching consequences for individual patients, including the withdrawal of active rehabilitation. The term ‘rehabilitation potenti...

Decisions about rehabilitation potential have far-reaching consequences for individual patients, including the withdrawal of active rehabilitation. The term ‘rehabilitation potential’ is viewed negatively by stroke survivors and can be inappropriately used by clinicians as justification for rationing access to services. Access to rehabilitation should be driven by the presence of stroke-specific goals. These should not be limited to functional improvement and should include domains such as adjustment, psychological well-being, education regarding stroke, social participation, management of complications, and the management of care needs. All domains should be considered as aspects of rehabilitation and therefore the term ‘no rehabilitation potential’ is not appropriate and should not be used. [2023]

Given the dynamic nature of stroke recovery, fixed decisions around appropriateness of rehabilitation should not be made too early after stroke. Co-existent conditions such as dementia, sensory impairments, or other comorbidities can complicate delivery of rehabilitation, but they should not be the sole reason for not pursuing a rehabilitative approach. [2023]

Selection of an appropriate rehabilitation pathway (e.g. inpatient rehabilitation, early supported discharge) should be determined by the patient’s goals coupled with an understanding of their impairments, abilities, prognosis and the evidence base, informing access to the right service at the right time, at an appropriate intensity. Information should be shared with the person with stroke and their carer(s), to ensure goals and expectations are informed and achievable. There are predictive tools (such as the Orpington Prediction Scale (Mohapatra & Jones, 2015), PREP2 (Stinear et al, 2017a), and TWIST (Smith et al, 2017)) that give useful information at a population level and can be used to inform such discussions. [2023]

Decisions regarding discharge from rehabilitation should be made with involvement of the person with stroke (shared decision making) when stroke-related goals have been met. This should never be an irrevocable decision, but should include the opportunity for review and access back into services at any time via self referral or professional referral. The decision should relate to the person’s rehabilitation needs at a single point in time. It should be understood that a person with stroke may have stroke-related needs or goals at any point following their stroke. Life after stroke services should be available to support and advise during, between, and following different phases of rehabilitation (Section 5.27 Further rehabilitation). [2023]

Recommendations

A

People with stroke should be considered to have the potential to benefit from rehabilitation at any point after their stroke. [2023]

B

People with stroke and their carers should be involved in a collaborative process with healthcare professionals to agree rehabilitation options, guided by the person’s own needs, goals and preferences. [2023]

C

The multidisciplinary team should consider all available rehabilitation options and recommend the service that is most likely to enable the person with stroke to meet their goals and needs.

  • For those people for whom standard rehabilitation services (such as early supported discharge, or community stroke teams) may not be appropriate, collaborative local decision making should ensure that a stroke-skilled multidisciplinary team works with the person with stroke and their family towards achievable and meaningful goals, which may be in conjunction with other statutory or voluntary provision;
  • People with stroke involving the spinal cord should be referred to specialist spinal injuries service for advice and support and/or to provide rehabilitation. [2023]

D

Stroke rehabilitation should be needs-led and not time-limited, and available to those people with stroke for whom:

  • ongoing needs have been identified by the person with stroke, their carer(s) or the multidisciplinary team across all areas of stroke recovery, e.g. functional abilities, mental health, cognitive function, psychological well-being, education regarding stroke, social participation, management of complications and care needs;
  • and their needs remain related to the stroke and/or are best met by the skills of the stroke team. [2023]

E

Clinicians should facilitate shared decision making and communicate the likelihood of the individual achieving their goals in an informed, compassionate, and individualised manner. [2023]

F

From an early stage in rehabilitation, clinicians should prepare people with stroke and their carer(s) that discharge from the service will occur and ensure an adequate transition plan is created collaboratively. Discharge information should include how to re-access services if required. [2023]

G

Statistically derived tools which predict future functional capacity should be considered to guide expectations of treatment or to predict risk:

  • Tools should only be applied in the population and phase of stroke within which the tool was developed;
  • Clinicians need to be trained to understand the limitations of tools, and how to use the tools effectively. [2023]

H

The multidisciplinary team should complete weekly reviews whilst providing rehabilitation in any setting, considering the needs, goals and progress of the person with stroke, and their treatment and discharge plans. The choice of rehabilitation pathway should be regularly reviewed to ensure rehabilitation continues to best meet the person’s needs. [2023]

I

For people with stroke who are no longer receiving stroke rehabilitation at 6 months, a primary focus of the 6 month review should be to identify and redirect those with ongoing needs and/or goals back into stroke services. Reviews should be holistic in nature and be completed by a stroke specialist with appropriate skills and expertise. [2023]

J

People with stroke should receive a holistic annual review conducted by a professional with a broad range of skills and knowledge across physical, psychological and social domains. Those for whom new or ongoing stroke rehabilitation goals can be identified and agreed should be referred to stroke services for further rehabilitation. [2023]

Sources, evidence to recommendations, implications

Source

A-J

Guideline Development Group consensus

Evidence to recommendations

This section has been written by an expert group reaching consensus on the topic of rehabilitation potential, its definition, appropriateness of use and implications for people with stroke and the stroke pathway. More research is needed to identify which people with stroke will gain the most from different approaches and intensities of rehabilitation, and how to reliably identify those people who will not benefit from such interventions. Provision of six month reviews is currently inequitable (Sentinel Stroke National Audit Programme, 2022) and continues to be a focus for improvement to ensure unmet need is identified and people are redirected back into stroke specialist services appropriately. [2023]

4.2 Rehabilitation approach – intensity of therapy (motor recovery and function)

Rehabilitation is an adaptive process, and the practice and repetition of functional tasks for months or years is a key component of optimal recovery. The evidence for intensity of...

Rehabilitation is an adaptive process, and the practice and repetition of functional tasks for months or years is a key component of optimal recovery. The evidence for intensity of therapy within this chapter mainly relates to physical and functional rehabilitation after stroke. Less is known about the intensity of therapy required for psychological, cognitive or sensory effects of stroke; however, some principles regarding practice and training may be relevant. [2023]

Greater amounts of physical therapy (i.e. dose) are associated with better recovery (Kwakkel et al, 1999; Kwakkel & Wagenaar, 2002; Bhogal et al, 2003a; Bhogal et al, 2003b; Kwakkel et al, 2004). The dose of therapy is multi-faceted, encompassing not only the number of treatment sessions, but also their duration and frequency. It is unclear whether therapy needs to be more intense (i.e. the same amount of therapy over a shorter time) but there is evidence that motor learning is best accomplished with challenging, motivating tasks and variable training schedules (Krakauer, 2006). In reality, stroke therapy is rarely delivered intensively or in high doses. Studies have shown that therapy sessions commonly feature low numbers of repetitions, low cardiovascular activity , and with the patient frequently inactive (Bernhardt et al, 2004; Lang et al, 2009; Scrivener et al, 2012; West & Bernhardt, 2012; Hayward & Brauer, 2015). This is a particular issue in the UK, where many services are unable to deliver guideline-recommended levels of activity. In the year April 2021-22 the Sentinel Stroke National Audit Programme (SSNAP) reported that 16.8% of patients received more than 45 minutes of occupational therapy 7 days a week, 11.9% received more than 45 minutes of physiotherapy 7 days a week and 6.6% received at least 45 minutes of speech and language therapy 7 days a week in participating UK hospitals. In recent years other countries such as Australia (Stroke Foundation, 2022), Canada (Teasell et al, 2020) and the Netherlands (Veerbeek et al, 2014a) have significantly progressed this target to the expectation that patients receive at least three hours of therapy per day. [2023]

The content of therapy is also important. An ineffective therapy will not benefit patients whatever the dose or intensity. As detailed in this chapter, the most effective therapy for promoting motor recovery after stroke is based on exercise and practice of functional tasks augmented as necessary by technological and priming techniques (Veerbeek et al, 2014b; French et al, 2016a; Wattchow et al, 2018; Scrivener et al, 2020). The main points of post-stroke therapy aimed at motor recovery are understanding the impairments, activity, and individualised goals, leading to a high number of repetitions of relevant exercise and functional tasks. The amount of activity that patients are able to undertake during rehabilitation is more important than how much time patients spend in face-to-face therapy with qualified therapists. These principles apply to inpatient, outpatient and community settings. Commissioners/service planners, service managers and clinicians must drive improvements in the culture and processes of rehabilitation to maximise both therapist-delivered therapy and opportunities and support for practice and activity outside formal therapy sessions, recognising that rehabilitation can be delivered in a number of ways including supervised practice, group work and self practice. Delivery methods should be considered to ensure both effective delivery for patients and efficient use of resources. [2023]

Recommendations

A

People with motor recovery goals undergoing rehabilitation after a stroke should receive a minimum of 3 hours of multidisciplinary therapy a day (delivered or supervised by a therapist or rehabilitation assistant focused on exercise, motor retraining and/or functional practice), at least 5 days out of 7, to enable the range of required interventions to be deliveredat an effective dose.

  • Rehabilitation programmes should be individualised to account for comorbidities, baseline activity levels, post-stroke fatigue, tolerance, goals and preferences. Therapy can be paced throughout the day, to accumulate at least 3 hours of motor/functional therapy;
  • For people unable to tolerate 3 hours of therapy a day, the barriers to doing so should be fully assessed and actively managed with strategies to ensure they are able to participate in therapy and be active as far as possible;
  • People undergoing rehabilitation after a stroke should be supported to remain active for up to 6 hours a day (including therapist-delivered therapy), for example through the use of open gyms, self-practice, carer-assisted practice, engaging in activities of daily living, and activities promoting cardiovascular fitness. [2023]

B

Services delivering rehabilitation for people after stroke should:

  • deliver a range of individualised one-to-one therapies, structured semi-supervised practice and group work (including rehabilitation gym sessions and a range of exercise and activity groups relevant to the person’s needs);
  • have access to adequate rehabilitation space such as a gym and areas for functional practice (e.g. kitchen and bathroom), appropriate space to accommodate group work, and quiet space for psychological assessment and sensitivediscussions;
  • ensure that delivery of rehabilitation intensity includes education for both the person with stroke and their family/carers to better understand their difficulties, and their recovery and rehabilitation;
  • be organised to encourage and support people with stroke to remain active outside of therapist-delivered sessions. [2023]

C

In the first two weeks after stroke, therapy targeted at the recovery of mobility should consist of frequent, short interventions every day, typically beginning between 24 and 48 hours after stroke onset. [2016]

D

Multidisciplinary stroke teams should incorporate the practice of functional skills gained in therapy into the person’s daily routine in a consistent manner, and the care environment should support people with stroke to practise their activities as much as possible. Functional activities should be individualised to the person’s goals and interests. [2023]

E

Healthcare staff who support people with stroke to practise their activities should do so under the guidance of a qualified therapist. [2016]

Sources, evidence to recommendations, implications

Sources

A, B

Veerbeek et al, 2014a; Stroke Foundation, 2022; Teasell et al, 2020; Guideline Development Group consensus

C

AVERT Trial Collaboration group, 2015; Bernhardt et al, 2016

D

Smith et al, 1981; Langhorne et al, 1996; Kwakkel et al, 1994, 2004; Lincoln et al, 1999; Kwakkel and Wagenaar, 2002

E

Working Party consensus

Evidence to recommendations

The large international AVERT trial (AVERT Trial Collaboration group, 2015; Bernhardt et al, 2016) suggested that in the first two weeks after stroke, therapy targeted at the recovery of mobility should be redesigned around frequent, short interventions, except for those people who require little or no assistance to mobilise (see Section 3.12 Early mobilisation). Therapy targeted at other activities of daily living should be task-specific, progressive and practised frequently. Practice should be incorporated into routine activities on the stroke unit by the entire healthcare team every day of the week, rather than confined to lengthy therapy sessions separated by long periods of inactivity. The objective is for rehabilitation to be a pervasive activity, combining time spent with therapists in assessment and treatment with time spent practising with other professional and/or support staff, or with family/carers or alone. Rehabilitation intensity in both acute and longer-term settings remains an area which requires more research. [2016]

The recommendation for people with stroke to receive 45 minutes of each therapy per day in previous editions of this guideline was set pragmatically as a minimum through consensus by the Working Party at the time. The Guideline Development Group has debated this further and has increased the recommended amount of therapy in this edition to stimulate much-needed transformation of rehabilitation to improve clinical outcomes. This is supported by evidence regarding the effects of greater amounts of therapy (dose) (Kwakkel et al, 1999; Kwakkel & Wagenaar, 2002; Bhogal et al, 2003a; Bhogal et al, 2003b; Kwakkel et al, 2004) and is reflected in other clinical guidelines around the world (Australia (Stroke Foundation, 2022), Canada (Teasell et al, 2020) and the Netherlands (Veerbeek et al, 2014a)). The revised recommendation is based on the cumulative evidence that the interventions recommended within this chapter need to be delivered in a significant dose to be effective, and this dose is rarely provided in clinical practice. Progress implementing the previous recommendation (at least 45 minutes/day) has been incomplete, not least because it is commonly considered a target rather than a minimum dose and many clinicians underestimate the dose of therapy that people with stroke can tolerate. Increasing time in therapist-delivered sessions allows effective delivery of these interventions, with the added focus on self-directed or semi-supervised practice aimed at shifting the culture of rehabilitation. [2023]

4.3 Rehabilitation approach – goal setting

Goal setting can be defined as a behavioural target that is central to rehabilitation, but is also effective in secondary risk factor reduction such as weight loss, smoking cessati...

Goal setting can be defined as a behavioural target that is central to rehabilitation, but is also effective in secondary risk factor reduction such as weight loss, smoking cessation or alcohol reduction. Goal setting is the process by which the person with stroke (and their family or carers if they wish) and members of the stroke team identify individual treatment goals which are meaningful, challenging and have personal value. Goals are worked towards over a specified period of time, both short and long term. Traditionally goals have been therapy-led and orientated to specific therapy targets which are realistic and measurable. This method has proved to be an effective and efficient rehabilitation tool when used flexibly to reflect that the person’s ability and motivation to participate may fluctuate over time. A balance should be made between practicality, working in a step wise approach and supporting the aspirations of the person with stroke. Recently a move towards self-management and self-efficacy has been promoted as a more person-centred approach to goal setting. [2016]

Recommendations

A

People with stroke should be actively involved in their rehabilitation through:

  • having their feelings, wishes and expectations for recovery understood and acknowledged;
  • participating in the process of goal setting unless they choose not to, or are unable to because of the severity of their cognitive or linguistic impairments;
  • being given help to understand the process of goal setting, and to define and articulate their personal goals. [2016]

B

People with stroke should be helped to identify goals that:

  • are meaningful and relevant to them;
  • are challenging but achievable;
  • aim to achieve both short-term (days/weeks) and long-term (weeks/months) objectives;
  • are documented, with specific, time-bound and measurable outcomes;
  • have achievement measured and evaluated in a consistent way;
  • include family/carers where this is appropriate;
  • are used to guide and inform therapy and treatment. [2016]

C

People with stroke should be supported and involved in a self-management approach to their rehabilitation goals. [2016]

Sources, evidence to recommendations, implications

Sources

A, B

Malec et al, 1991; Wressle et al, 2002; Stein et al, 2003; Hurn et al, 2006; Levack et al, 2006; Holliday et al, 2007a, b; Working Party consensus

C

Rosewilliam et al, 2011; Sugavanam et al, 2013; Taylor et al, 2012

Evidence to recommendations

Recent literature includes one systematic review of qualitative and quantitative studies (Sugavanam et al, 2013) which examined 17 trials and concluded that no consistent approach was used and there were difficulties implementing a self-management approach. A qualitative paper by Jones et al. (2013) highlighted a lack of training and awareness of the self-management approach. A Cochrane review of 39 RCTs in 2846 subjects participating in rehabilitation with a variety of conditions including acquired brain injury (Levack et al, 2015) concluded there was low-quality evidence that goal setting may improve health-related quality of life and other psychosocial outcomes such as emotional status and self-efficacy. Goal setting should involve the person with stroke and their family/carers where appropriate, and be measured and evaluated in a consistent and standardised way.[2016]

4.4 Self-management

There is increasing evidence of psychological factors that influence confidence and adjustment to life after stroke. Self-efficacy has been defined as an ‘individual’s belief in th...

There is increasing evidence of psychological factors that influence confidence and adjustment to life after stroke. Self-efficacy has been defined as an ‘individual’s belief in their own capability’ and has been found to be positively associated with mobility, activities of daily living, and quality of life and negatively associated with depression after stroke (Korpershoek et al, 2011). Self-efficacy is closely related to mood and self-esteem, and there are relations between self-efficacy and emotional states (depression, anxiety) and quality of life. [2016]

Self-efficacy may mediate self-management skills such as problem solving and goal setting and is used as an outcome measure in some self-management programmes (Korpershoek et al, 2011; Lennon et al, 2013; Parke et al, 2015; Warner et al, 2015). There is emerging evidence on the utility of changing self-efficacy to influence independence and the promotion of self-management after stroke. Self-management has been defined in various ways but many programmes refer to the ‘actions and confidence of individuals to manage the medical and emotional aspects of their condition in order to maintain or create new life roles’ (Corbin, 1998; Parke et al, 2015). Programmes mainly focus on supporting the knowledge and skills required to self-manage, and range from educational approaches to interventions to support behaviour change. [2016]

Recommendations

A

People with stroke should be offered self-management support based on self-efficacy, aimed at the knowledge and skills needed to manage life after stroke, with particular attention given to this at reviews and transfers of care. [2016]

B

People with stroke whose motivation and engagement in rehabilitation appears reduced should be assessed for changes in self-esteem, self-efficacy or identity and mood. [2016]

C

People with significant changes in self-esteem, self-efficacy or identity after stroke should be offered information, support and advice and considered for one or more of the following psychological interventions:

  • increased social interaction;
  • increased exercise;
  • other psychosocial interventions, such as psychosocial education groups.[2016]

Sources, evidence to recommendations, implications

Sources

A

Lennon et al, 2013; Parke et al, 2015; Warner et al, 2015; Working Party consensus

B

Working Party consensus

C

Kendall et al, 2007; Watkins et al, 2007; De Man-van Ginkel et al, 2010; Jones et al, 2010

Evidence to recommendations

Evidence suggests that self-management programmes based on self-efficacy can influence functional capability and social participation. Recent systematic reviews support self-management interventions after stroke although meta-analysis was not possible because of heterogeneity in the methods of delivery, clinical outcomes and stroke severity (Lennon et al, 2013; Parke et al, 2015; Warner et al, 2015). Not all studies in these reviews used self-efficacy as a mediator nor explicitly used self-efficacy outcome measures. A recent feasibility cluster RCT showed it was feasible to integrate stroke self-management into community rehabilitation and provided data to design future definitive trials (Jones et al, 2016). More research is needed to understand the role of self-efficacy in rehabilitation, the skills required by professionals, and how participants perceive the impact of self-management interventions on their self-efficacy. [2016]

Implications

These recommendations serve to emphasise the important interaction between newly-recognised psychosocial concepts of self-efficacy and self-management, and functional outcomes and social participation after recovery from stroke. Stroke services need to consider how to develop the knowledge and skills in rehabilitation staff to support self-management, and how to provide psychological interventions as an adjunct to more familiar physical treatments, including in community stroke services. [2016]

4.5 Remotely delivered therapy and telerehabilitation

Remotely delivered therapy is rehabilitation delivered using technology, with a remote therapist personalising a programme or tasks to specifically address identified impairments o...

Remotely delivered therapy is rehabilitation delivered using technology, with a remote therapist personalising a programme or tasks to specifically address identified impairments or goals. This may take place with a therapist present during the session remotely to adapt and give feedback in real time, or asynchronous practice, when the therapist gives and receives feedback offline. Therapy can be delivered via videoconferencing, and can be individual or in a group. The term is used synonymously with telerehabilitation, which has been defined as “the use of telecommunication, by either direct video or audio, to deliver rehabilitative interventions” (Appleby et al, 2019). Telehealth or telemedicine often uses similar technologies but focuses on risk factors, secondary prevention, behaviour or lifestyle modifications (Bashshur, 1995). [2023]

Telerehabilitation saw significant advances during the COVID-19 pandemic, with programmes such as N-ROL (Neuro Rehab On-Line) and the Bridges community of practice (www.bridgesselfmanagement.org.uk) providing examples and guidance to assist patients and therapists to engage in remotely delivered rehabilitation. [2023]

A range of technologies can be used for communication between the patient and therapist, such as telephone, videoconferencing, apps, sensors (e.g. pedometers, wearable devices) and virtual reality (Laver et al, 2020). Technological innovations such as telerehabilitation may help address barriers to accessing face-to-face rehabilitation, such as time and resource limitations, geographical isolation and compliance with rehabilitation (Appleby et al, 2019). There are potential advantages of remotely delivered therapy in terms of patient satisfaction (although studies are affected by selection bias), motivation, agency, the patient and therapist not needing to travel, and efficiency for multidisciplinary teams. Barriers to use by patients and therapists can include difficulties with equipment set up, connectivity and problems with the interface (Tyagi et al, 2018) and lack of privacy in the home setting. Additional barriers may impact on ability to engage with telerehabilitation for those with reduced comprehension, cognitive processing difficulties, or visual deficits. [2023]

Local systems should consider digital inequities and digital literacy, as well as socio economic impact on availability of equipment. Careful consideration should be taken as to whether remotely delivered therapy is best placed to meet the needs of individuals (particularly those with cognitive or language deficits), and which programs and equipment may be most accessible. For those unable to access remotely delivered therapy, a face-to-face alternative should be available. Support such as volunteers or peer support should be considered for those who are keen to trial technology-based options. [2023]

Recommendations

A

People undergoing rehabilitation after stroke should be considered for remotely delivered rehabilitation to augment conventional face-to-face rehabilitation. Telerehabilitation programmes should:

  • be personalised to the individual’s goals and preferences;
  • be used when it is considered to be the most beneficial option to promote recovery and should not be used as a substitute for essential in-person rehabilitation;
  • be monitored and adapted by the therapist according to progress towards goals;
  • be supplemented with face-to-face reviews and include the facility for contact with the therapist as required. [2023]

B

People receiving rehabilitation after stroke should have an assessment of their ability to use assistive technology and programmes and equipment should be adapted accordingly. [2023]

C

Stroke services should ensure adequate technology is available to enable access to telerehabilitation for people with stroke (this could be resourced via grants, community health services, library loan services etc.). [2023]

D

People with stroke receiving telerehabilitation should be trained and supported in the use of the appropriate technology. [2023]

E

Stroke rehabilitation staff who are recommending the use of telerehabilitation devices should be trained in their use, technological specification and limitations. This should include the review of technologies for appropriateness, safety and information governance (storage of personal data). [2023]

F

Therapists should promote engagement and adherence to telerehabilitation through a coaching style relationship with the person with stroke. [2023]

Sources, evidence to recommendations, implications

Source

A-F

Guideline Development Group consensus

Evidence to recommendations

The evidence base for remotely delivered therapy is new and developing. The evidence reviewed was heterogeneous in terms of the types of remote therapy, location (hospital versus home), comparison group and the selection of patients, which makes synthesis challenging. A systematic review of 31 studies showed high levels of adherence to telerehabilitation, interventions observed were comparable to in-person rehabilitation and no safety concerns related to the delivery of telerehabilitation interventions were reported. A systematic review and meta-analysis of 13 studies of technology-based distant physical rehabilitation interventions found comparable effects to traditional treatments on ADL but not walking, although there was heterogeneity in the interventions and people with cognitive impairments were often excluded (Rintala et al, 2019). A Cochrane review of 22 RCTs of telerehabilitation in stroke found evidence of variable quality from heterogeneous studies suggesting no difference between telerehabilitation and conventional rehabilitation (Laver et al, 2020). Limited data were reported on safety and economic analyses. Many studies were small, pilot and/or non-randomised and did not account for attrition from the intervention. Few studies had long-term follow-up and there was variability in the level of detail provided about the intervention, including personalisation and adherence. The evidence base is therefore of insufficient quality to strongly recommend specific remotely delivered therapy approaches. Therefore, the Guideline Development Group has made consensus recommendations for this topic. [2023]

Consideration needs to be given to the person with stroke being cognitively able to manage the approach being used, being motivated to participate, having appropriate privacy and physical space where required, and their technological proficiency. [2023]

Telehealth has the potential to decrease the burden of treatment for patients with long-term and multiple conditions. It also has the ability to introduce inequities (Eddison et al, 2022). [2023]

4.6 Self-directed therapy

Self-directed rehabilitation (or self-practice) refers to approaches for promoting independent therapeutic activity away from a clinical setting (Da-Silva et al, 2018). Self-direct...

Self-directed rehabilitation (or self-practice) refers to approaches for promoting independent therapeutic activity away from a clinical setting (Da-Silva et al, 2018). Self-directed rehabilitation can be considered as an option alongside other rehabilitation approaches to increase overall therapy time and dose. Personalising programmes to the individual’s health beliefs, situation, preferences and needs is important for facilitating adherence to self-practice (Vadas et al, 2021). Self-directed rehabilitation is often part of a comprehensive rehabilitation approach rather than a separate entity. [2023]

Recommendations

A

People with stroke should be offered training and resources to support them to carry out appropriately targeted self-directed therapy practice in addition to their standard rehabilitation, in accordance with the individual’s goals and preferences. Self directed therapy should be monitored and reviewed regularly. [2023]

B

People with stroke who are able to follow regimes independently or with the support of a carer should be considered for self-directed rehabilitation to increase practice in addition to standard rehabilitation; for example, patients undergoing constraint-induced movement therapy, electrical stimulation or computerised speech and language therapy. [2023]

C

For people undergoing rehabilitation after stroke, the use of competition (with self or others) may be considered to give people motivation to practise self-directed rehabilitation. [2023]

Sources, evidence to recommendations, implications

Sources

A

Guideline Development Group consensus

B

Da-Silva et al, 2018; Palmer et al, 2019; Working Party consensus

C

Guideline Development Group consensus

Evidence to recommendations

Self-directed rehabilitation is a new topic for this edition of the guideline. There is limited high quality evidence available on the particular groups of people with stroke who may benefit most from self-directed rehabilitation and the optimal timing for these interventions. It is also important that further research identifies those who may not benefit from this approach. [2023]

A systematic review of 40 studies evaluated the effectiveness of self-directed interventions for arm rehabilitation after stroke (Da-Silva et al, 2018). Self-directed interventions using constraint-induced movement therapy and electrical stimulation were found to have a beneficial effect on arm function, although studies had a risk of bias and used different types of stimulation, dose, timing and outcome measures. Constraint-induced movement therapy and therapy programmes which increase practice without using additional technology improved independence in activities of daily living assessed on a self-perceived outcome measure. [2023]

Results of a proof-of-concept study (Studer et al, 2016) suggest that experimental or perceived competition may be beneficial in enhancing self-directed cognitive training but more robust evidence is required to guide practice. [2023]

Acute care Rehabilitation and recovery – activity and participation
Rehabilitation and recovery - principles of rehabilitation - National Clinical Guideline for Stroke (2024)

References

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