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Rehabilitation and recovery – activity and participation

4.7 Introduction

This section covers difficulties that can occur after stroke affecting personal, domestic and extended activities of daily living (e.g. work and driving), and recommendations to he...

4.8 Independence in daily living

Personal activities of daily living (PADL) refer to a range of basic activities such as washing, dressing, bathing, going to the toilet, eating and drinking; these activities usual...


People with stroke should be formally assessed for their safety and independence in all relevant personal activities of daily living by a clinician with the appropriate expertise, and the findings should be recorded using a standardised assessment tool. [2016]


People with limitations of personal activities of daily living after stroke should:

  • be referred to an occupational therapist with knowledge and skills in neurological rehabilitation. Assessment should include consideration of the impact of hidden deficits affecting function including neglect, executive dysfunction and visual impairments;
  • be assessed by an occupational therapist within 24 hours of admission to a stroke unit;
  • be offered treatment for identified problems (e.g. feeding, work) by the occupational therapist, in discussion with other members of the specialist multidisciplinary team. [2023]

People with stroke should be offered, as needed, specific treatments that include:

  • dressing practice for people with residual problems with dressing;
  • as many opportunities as appropriate to practise self-care as possible;
  • assessment, provision and training in the use of equipment and adaptations that increase safe independence;
  • training their family/carers in how to help them. [2016]
Sources, evidence to recommendations, implications

4.9 Hydration and nutrition

This section should be considered in conjunction with Section 4.26 Swallowing. [2023]

Dehydration and malnutrition are common in hospital inpatients with stroke and associated w...


Patients with acute stroke should have their hydration assessed using a standardised approach within four hours of arrival at hospital, and should be reviewed regularly and managed so that hydration is maintained. [2023]


Patients with acute stroke should be screened for the risk of malnutrition on admission and at least weekly thereafter.  Screening should be conducted by trained staff using a structured, standardised, validated tool. [2023]


Patients with acute stroke who are at low risk of malnutrition on admission, and are able to meet their nutritional needs orally, should not routinely receive oral nutritional supplements. [2023]


Patients with acute stroke who are at risk of malnutrition or who require tube feeding or dietary modification should be referred to a dietitian for specialist nutritional assessment, advice and monitoring. [2023]


Patients with stroke who are at risk of malnutrition should be offered nutritional support.  This may include oral nutritional supplements, specialist dietary advice and/or tube feeding in accordance with their expressed wishes or, if the patient lacks mental capacity, in their best interests. [2023]


Patients with stroke who are unable to maintain adequate nutrition and hydration orally should be:

  • referred to a dietitian for specialist nutritional assessment, advice and monitoring;
  • be assessed for nasogastric tube feeding within 24 hours of admission;
  • assessed for a nasal bridle if the nasogastric tube needs frequent replacement, using locally agreed protocols;
  • assessed for gastrostomy feeding if they are unable to tolerate a nasogastric tube with nasal bridle. [2023]

People with stroke who require food or fluid of a modified consistency should:

  • be referred to a dietitian for specialist nutritional assessment, advice and monitoring;
  • have the texture of modified food or fluids prescribed using internationally agreed descriptors;
  • be referred to a pharmacist to review the formulation and administration of medication. [2023]

People with stroke should be considered for gastrostomy feeding if they:

  • need but are unable to tolerate nasogastric tube feeding, including a trial with a nasal bridle if appropriate and other measures such as taping the tube or increased supervision;
  • are unable to swallow adequate food and fluids orally by four weeks from the onset of stroke and gastrostomy feeding is considered to be required long-term;
  • reach the point where shared decision making by the person with stroke, their family/carers, and the multidisciplinary team has agreed that artificial nutrition is appropriate due to the high long-term risk of malnutrition. [2023]

People with difficulties self-feeding after stroke should be assessed and provided with the appropriate equipment and assistance including physical help and encouragement, environmental considerations, and postural support to promote independent and safe feeding. [2023]


People with stroke discharged from stroke services with continuing problems meeting their nutritional needs should have a documented care plan to ensure their dietary intake and nutritional status are monitored at a frequency appropriate to their needs and which identifies who will be responsible for ongoing monitoring (such as district nurses or family/carers). [2023]


People with stroke receiving end-of-life (palliative) care should not have burdensome restrictions on oral food and fluid intake, if those restrictions would exacerbate suffering. [2023]


The carers and family of those with a gastrostomy tube should receive training, equipment and ongoing support from a specialist team, e.g. a home enteral feeding team. [2023]

Sources, evidence to recommendations, implications

4.10 Mouth care

Mouth care (also referred to as oral care) refers to the promotion and maintenance of a clean oral cavity including the teeth, gums, cheeks, tongue and palate. A clean mouth requir...


People with stroke, especially those who have difficulty swallowing or who are tube fed, should have mouth care at least three times a day (particularly after mealtimes), which includes removal of food debris and excess secretions, and application of lip balm. [2023]


People with stroke, including those who have full or partial dentition and/or wear dentures and especially those who have difficulty swallowing or who are tube fed, should have mechanical removal of plaque at least twice a day by the brushing of teeth and cleaning of gums and tongue with a low foaming, fluoride-containing toothpaste.  Chlorhexidine dental gel may be prescribed short term and requires regular review.  A powered toothbrush should be considered. [2023]


People with stroke who have dentures should have their dentures:

  • put in during the day, using a fixative if required;
  • cleaned regularly using a denture cleansing agent or soap and water;
  • checked, and the individual referred to a dental professional if ill-fitting or replacement is required.

Any remaining teeth should be cleaned with a toothbrush and fluoride-containing toothpaste. [2023]


Staff delivering mouth care in hospital or in a care home or domiciliary setting should receive training on mouth care, which should include:

  • assessment of oral hygiene;
  • selection and use of appropriate oral hygiene equipment and cleaning agents;
  • provision of mouth care routines;
  • awareness and recognition of swallowing difficulties. [2023]

People with stroke and their family/carers should receive information and training in mouth care and maintaining good oral hygiene before transfer of their care from hospital.  This information should be clearly communicated within and across care settings, e.g. within a care plan which includes regular dental reviews. [2023]

Sources, evidence to recommendations, implications

4.11 Continence

Loss of bladder and bowel control is common in the acute phase of stroke and may persist. Incontinence of urine greatly increases the risk of skin breakdown and pressure ulceration...


Stroke unit staff should be trained in the use of standardised assessment and management protocols for urinary and faecal incontinence and constipation in people with stroke. [2016]


People with stroke should not have an indwelling (urethral) catheter inserted unless indicated to relieve urinary retention or when fluid balance is critical. [2016]


People with stroke who have continued loss of bladder and/or bowel control 2 weeks after onset should be reassessed to identify the cause of incontinence, and be involved in deriving a treatment plan (with their family/carers if appropriate). The treatment plan should include:

  • treatment of any identified cause of incontinence;
  • training for the person with stroke and/or their family/carers in the management of incontinence;
  • referral for specialist treatments and behavioural adaptations if the person is able to participate;
  • adequate arrangements for the continued supply of continence aids and services. [2016]

People with stroke with continued loss of urinary continence should be offered behavioural interventions and adaptations prior to considering pharmaceutical and long-term catheter options, such as:

  • timed toileting;
  • prompted voiding;
  • review of caffeine intake;
  • bladder retraining;
  • pelvic floor exercises;
  • external equipment. [2016]

People with stroke with constipation should be offered:

  • advice on diet, fluid intake and exercise;
  • a regulated routine of toileting;
  • a prescribed medication review to minimise use of constipating medication;
  • oral laxatives;
  • a structured bowel management programme which includes nurse-led bowel care interventions;
  • education and information for the person with stroke and their family/carers;
  • rectal laxatives if severe problems persist. [2016]

People with continued continence problems on transfer of care from hospital should receive follow-up with specialist continence services in the community. [2016]

Sources, evidence to recommendations, implications

4.12 Extended activities of daily living

Extended activities of daily living (EADL) encompass both domestic and community activities such as shopping, cooking and housework that allow complete or virtually complete indepe...


People whose activities have been limited by stroke should be:

  • assessed by an occupational therapist with expertise in neurological disability;
  • trained in how to achieve activities safely and given as many opportunities to practise as reasonable under supervision, provided that the activities are potentially achievable;
  • provided with and trained in how to use any adaptations or equipment needed to perform activities safely. [2016]

People with stroke who cannot undertake a necessary activity safely should be offered alternative means of achieving the goal to ensure safety and well-being. [2016]

Sources, evidence to recommendations, implications

4.13 Sex

The physical and psychological impact of stroke can affect role identity and relationships with sexual partners, and sexual dysfunction can amplify these problems. Sexual dysfuncti...


People with stroke should be asked, soon after discharge and at their 6-month and annual reviews, whether they have any concerns about sex.  Partners should also have an opportunity to raise any problems. [2016]


People with sexual dysfunction after stroke who want further help should be:

  • assessed for treatable causes including a medication review;
  • reassured that sexual activity is not contraindicated after stroke and is extremely unlikely to precipitate a further stroke;
  • assessed for erectile dysfunction and the use of a phosphodiesterase type 5 inhibitor (e.g. sildenafil);
  • advised against the use of a phosphodiesterase type 5 inhibitor for 3 months after stroke and/or until blood pressure is controlled;
  • referred to a professional with expertise in psychosexual problems if sexual dysfunction persists. [2016]
Sources, evidence to recommendations, implications

4.14 Driving

Being able to drive is important to people with stroke for practical reasons and because it influences self- esteem and mood. However, there are potential risks associated with dri...


People who have had an acute stroke or TIA should be asked about driving before they leave the hospital or specialist outpatient clinic. [2016]


People with stroke who wish to drive should:

  • be advised of the exclusion period from driving and their responsibility to notify the DVLA, DVA or NDLS if they have any persisting disability which may affect their eligibility;
  • be asked about or examined for any absolute bars to driving e.g. epileptic seizure (excluding seizure within 24 hours of stroke onset), significant visual field defects, reduced visual acuity or double vision;
  • be offered an assessment of the impairments that may affect their eligibility, including their cognitive, visual and physical abilities;
  • receive a written record of the findings and conclusions, copied to their general practitioner. [2016]

People with persisting cognitive, language or motor disability after stroke who wish to return to driving should be referred for on-road screening and evaluation. [2016]


People who wish to drive after a stroke should be informed about eligibility for disabled concessions (e.g. Motability, the Blue Badge scheme). [2016]

Sources, evidence to recommendations, implications

4.15 Return to work

Returning to work is an important goal for many people after a stroke, and people should be asked about their work at the earliest opportunity to enable staff to better understand ...


People with stroke should be asked about their work at the earliest opportunity, irrespective of whether they plan to return.  This will enable staff to have a better understanding of their role before having a stroke, and offer the person an opportunity to discuss their thoughts and feelings. [2023]


People who need or wish to return to any type of work after stroke should:

  • be provided with information regarding rights, financial support and vocational rehabilitation. This should include information regarding driving, where appropriate (e.g. in the work role or travelling to work);
  • be supported to understand the consequences of their stroke in relation to work;
  • be supported by an appropriate professional with an understanding of the person’s work-related needs to discuss with their employer their return to work, at a time that is appropriate, taking account of their job role and the support available. Timing should be mutually agreed between the person with stroke, the employer and the professional delivering vocational rehabilitation.  This should include human resources where appropriate;
  • be supported to identify their work requirements with their employer, with input from occupational health, where available;
  • be assessed on relevant work-related skills and competencies to establish their potential for return;
  • participate in discussions and decision making regarding the most suitable time and way to return to work, including the nature and amount of work;
  • be referred to statutory employment support (e.g. Jobcentre Plus, Intreo) or vocational rehabilitation (VR), as appropriate to their needs. VR may be provided by publicly funded organisations (such as the NHS), the independent sector (including services funded through the UK’s Department for Work and Pensions such as Access to Work) or the voluntary sector (including support from stroke key workers);
  • signposted if required to seek advice from their employer’s human resources department (or equivalent), trade union and/or seek specific legal advice. [2023]

Services supporting people with stroke to return to work should ensure that:

  • there is a co-ordinator (or co-ordinating team or joint cross-agency working) responsible for liaison and support with planning and negotiating return to work with all those involved (including co-workers and managers, where applicable) and who ensures all involved are aware of their roles, responsibilities, and relevant legislation;
  • employers are provided with information and education regarding the individual needs of the person following stroke such as communication needs or fatigue;
  • workplaces offer flexibility (e.g. workplace accommodation) to enable people with stroke to adapt their return to work, in line with the requirements of the Equality Act (2010) in the UK and Employment Equality Acts (1998-2015) in Ireland. [2023]

Vocational rehabilitation programmes for people returning to work after stroke should include:

  • assessment of potential barriers and facilitators to returning to work, based on the work role and demands from both the employee’s and employer’s perspectives;
  • an action plan for how barriers may be overcome;
  • interventions as required by the individual, which may include vocational counselling and coaching, emotional support, adaptation of the working environment, strategies to compensate for functional limitations (e.g. communication, cognition, mobility and arm function), and fatigue management;
  • collaboration between the person with stroke, their employer and healthcare professional in planning, facilitating and monitoring their return to work. [2023]

Healthcare professionals who work with people following stroke should have knowledge and skills about supporting them to return to work, appropriate to the nature and level of service they provide. [2023]


Authorised healthcare professionals should provide a statement of fitness to work (e.g. ‘fit note’) to support people to return to work, including recommended alterations to work patterns, tasks undertaken or environment. [2023]

Sources, evidence to recommendations, implications