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...

Recommendations

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

Sources

A	Working Party consensus
B	Legg et al, 2006; Guideline Development Group consensus
C	Walker et al, 2011; Working Party consensus

Evidence to recommendations

There is limited new research in this area since the 2012 edition of this guideline. The main evidence is summarised in a Cochrane systematic review (Legg et al, 2006) which found that people with stroke who received occupational therapy targeting PADL performed better and had a reduced risk of a poor outcome (dependency in PADL, deterioration or death) compared to those without occupational therapy input. [2016]

However, there was limited information on the content of the therapy and research investigating the specific interventions that improve PADL is still required. A feasibility RCT has shown potential benefits of a systematic neuropsychological approach to dressing therapy after stroke (Walker et al, 2011) but more robust evidence is required to guide practice. A recent Cochrane review (Elsner et al, 2016) found low to moderate quality evidence that transcranial direct current stimulation (tDCS) was effective in eliciting short-term improvements in ADL, but it is unclear whether these effects are lasting and benefits were not seen in an analysis confined to high quality RCTs. There are ongoing trials of tDCS which may improve the quality of the evidence. Informal carers often provide support with PADL but, as described elsewhere (Section 2.16 Carers), how and when to train informal carers remains unclear despite a large RCT (Forster et al, 2012). [2016]

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...

Recommendations

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

Sources

A, B	Guideline Development Group consensus
C, D	NICE, 2017b, 2022e; Geeganage et al, 2012
E	Geeganage et al, 2012; Guideline Development Group consensus
F	NICE, 2023b; Beavan et al, 2010; Guideline Development Group consensus
G	British Dietetic Association, 2009; Carnaby et al, 2006; National Patient Safety Agency et al, 2011
H	Dennis et al, 2005; NICE, 2017b
I	Guideline Development Group consensus
J	NICE, 2017b
K	Royal College of Physicians, 2021; Royal College of Speech and Language Therapists, 2021; Guideline Development Group consensus
L	Guideline Development Group consensus

Evidence to recommendations

There is little RCT evidence to guide the management of hydration in people with acute stroke. A Cochrane review by Hooper et al (2015) of the signs and symptoms of impending and current dehydration in older people concluded that there is little evidence that any one symptom, sign or test, including many that clinicians customarily rely on, has any diagnostic utility for dehydration. [2016]

A Cochrane review (Geeganage et al, 2012) included eight trials of the effectiveness of nutritional support in people with acute and subacute stroke (less than six months) who were non-dysphagic. Although nutritional supplementation resulted in significantly reduced pressure sores, increased energy intake and increased protein intake, this did not affect length of hospital stay, dependency or mortality. Studies included people with variable baseline nutritional status, not just those who were malnourished or at risk of malnutrition. The effects of the nutritional composition of nutritional support warrants further study, including the role of leucine supplementation (Yoshimura et al, 2019). [2023]

Since the 2012 edition of this guideline, two Cochrane reviews have compared routes of enteral tube feeding. One reviewed 11 RCTs comparing gastrostomy versus nasogastric tubes in adults with swallowing difficulties (Gomes Jr et al, 2015), including four trials in people after stroke (Norton et al, 1996; Bath et al, 2000; Dennis et al, 2005; Hamidon et al, 2006). Although gastrostomy reduced intervention failure, there was no difference between the interventions in weight change, pneumonia or mortality. Most studies were small with considerable heterogeneity and methodological limitations. Geeganage et al (2012) reviewed five RCTs comparing gastrostomy with nasogastric tube feeding in people with acute and subacute stroke. Although gastrostomy feeding was associated with fewer feeding failures, less gastrointestinal bleeding and fewer pressure sores, there was no significant difference in length of hospital stay, dependency or mortality. [2016]

Beavan et al. (2010) conducted a multicentre RCT in people with stroke who required nasogastric tube feeding due to dysphagia (Section 4.26 Swallowing). In a sample of 104 people, those who had a nasogastric tube secured using a nasal bridle received a higher proportion of prescribed feed and fluid compared to the control group who had tubes secured using standard practice. Mahoney et al (2015) identified the need for training and protocols in confirming the placement and securing of nasogastric tubes. [2016]

There is insufficient evidence to determine the effectiveness and acceptability of hand mittens or other measures used to prevent nasogastric tube dislodgement. The impact of practical strategies and environmental modifications to support people after stroke who are at risk of malnutrition are recommended areas for future research. [2023]

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...

Recommendations

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

Sources

A	Guideline Development Group consensus
B, D	Campbell et al, 2020; Guideline Development Group consensus
C, E	Brady et al, 2006; Guideline Development Group consensus

Evidence to recommendations

A Cochrane systematic review (Campbell et al, 2020) compared the effectiveness of oral health care interventions with usual care or other treatment options. There was low quality evidence suggesting oral health care interventions can improve the cleanliness of patient’s dentures. There was very low quality evidence that such interventions can improve the knowledge and attitudes of people after a stroke and healthcare providers. The review acknowledged that maintenance of oral health care after a stroke should be a priority in clinical care and research. It also noted that co-ordination of future research is required to address the wide range of outcome measures and associated measurement tools. [2023]

Establishing locally agreed roles and responsibilities for oral health care is regarded as important to enable the delivery of high quality oral health care, the efficacy of which should be evaluated to improve practice. A care plan for oral health, including for people with stroke in care homes, would support information sharing and emphasise the importance of oral health care. [2023]

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...

Recommendations

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

Sources

A, B	Working Party consensus
C	Thomas et al, 2008; Working Party consensus
D	NICE, 2013; NICE, 2015
E	NICE, 2007; Coggrave et al, 2006; Working Party consensus
F	Working Party consensus

Evidence to recommendations

A 2013 review of bowel management strategies (Lim & Childs, 2013) identified three small studies of varying quality, and concluded that the evidence was limited but a structured nurse-led approach may be effective. In a review of therapeutic education for people with stroke, Daviet et al (2012) concluded from small non-randomised studies that a nurse-targeted education programme may improve longer-term continence. A small RCT by Moon et al (2012) provided no evidence for bladder reconditioning with intermittent clamping. A small study by Guo et al (2014) examined the use of transcutaneous electrical nerve stimulation for the treatment of urinary incontinence over six months and found an improvement in nocturia, urgency and frequency. Thomas et al (2015) demonstrated the feasibility of a systematic voiding programme for urinary incontinence in a cluster RCT and proposed a definitive trial. Recommendations are therefore largely based on NICE guidance and Working Party consensus. [2016]

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...

Recommendations

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

Sources

A	Legg et al, 2004
B	Working Party consensus

Evidence to recommendations

New evidence in this area is problematic and has not changed the recommendations since a systematic review (Legg et al, 2004) found that therapy improved EADL. Although several studies have included EADL as a secondary outcome, the interventions did not plausibly target EADL. For example, a systematic review of transcranial direct current stimulation found only limited evidence of any effect on EADL (Elsner et al, 2016). The Working Party excluded for methodological reasons one small, non-randomised trial of community-dwelling people with stroke which substituted a portion of physiotherapy time with virtual reality games (Singh et al, 2013). [2016]

One large multi-centre RCT included people with stroke who wanted to get out of the house more often. It compared an intervention to increase outdoor mobility (e.g. exercise, activities and confidence-building, provided by a therapist over an average of seven sessions) with a single session of personalised advice and leaflets on transport and mobility (Logan et al, 2014). This increased the number of journeys made and had a lasting effect, but practical limitations in collecting the data on the number of journeys may have limited the reliability of the outcome measure. The intervention did not affect the primary (quality of life) or any other outcome, and was not cost-effective. More appropriate and reliable outcome measures are needed in future trials. [2016]

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...

Recommendations

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

Sources

A	Thompson and Ryan, 2009; Schmitz and Finkelstein, 2010; Rosenbaum et al, 2014; Working Party consensus
B	Cheitlin et al, 1999; Melnik et al, 2007; Lorberboym et al, 2010; Song et al, 2007

Evidence to recommendations

The Working Party found no new evidence that could inform a recommendation. A narrative literature review (Rosenbaum et al, 2014) identified the need for staff training and a structured approach to assessment. There is little evidence of the risks and benefits of phosphodiesterase type 5 inhibitors after stroke (e.g. sildenafil), as people within 6 months of stroke or with ischaemic heart disease were excluded from the original trials. There is no reason to suspect that people are at increased risk of side effects after stroke but the consensus of the Working Party is to wait for 3 months after stroke before prescribing sildenafil, once blood pressure is controlled. [2016]

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...

Recommendations

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

Sources

A, B	Working Party consensus
C	Devos et al, 2011; Working Party consensus
D	Working Party consensus

Evidence to recommendations

A Cochrane review of four small trials of interventions to improve on-road driving skills after stroke concluded there was insufficient evidence to guide practice (George et al, 2014). No trials evaluated on-road driving lessons, and one study investigated simulator training. This showed promise but is not sufficient to recommend routine use in rehabilitation after stroke. [2016]

Observational studies of the predictive value of neuropsychological tests and screening tools for on-road driving performance suggest several that may support decision making when referring people with stroke for on-road driving tests (Korner-Bitensky et al, 2011; Aslaksen et al, 2013; Devos et al, 2014). A systematic review suggested that the Road Sign Recognition and Compass subtests of the Stroke Drivers Screening Assessment, together with Trail Making Test B, may be indicators of those at risk of failing an on-road assessment (Devos et al, 2011). Many cognitive tests are not valid for people with aphasia (Section 4.43 Aphasia) for whom on-road assessment may be needed. Studies investigating fitness to drive often exclude people with visual impairments and therefore clinicians should ensure that they assess all relevant impairments including vision (Section 4.48 Vision) and cognition (Sections 4.28 Psychological effects of stroke – general, 4.29 Cognitive screening, 4.30 Cognitive assessment). [2016]

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 ...

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 their role in society. ‘Work’ comprises different forms of occupation, including paid employment, vocational training, sheltered, therapeutic or voluntary work, and adult education (Tyerman, 2012). The UN Convention on the Rights of Persons with Disabilities (United Nations, 2022) discusses the importance of work and education and recreation in equal measure. Specifically, Article 27 identifies “the right of persons with disabilities to work, on an equal basis with others”. The average rate of return to work after stroke is 56% at 1 year (Duong et al, 2019). Not being in work after stroke is associated with health risks (Waddel & Aylward, 2005) reduced quality of life and poorer psychosocial outcomes (Busch et al, 2009; Robison et al, 2009). Benefits of returning to work include improvements in quality of life (Matérne et al, 2018), better perceived general health, reduced pain and depression, and higher perceived participation and autonomy compared to those not returning to work (Westerlind et al, 2020). [2023]

Returning to work is often complex and depends on a range of interacting factors and the engagement of different stakeholders (Schwarz et al, 2018). Barriers and facilitators after stroke include personal factors, workplace factors and factors related to rehabilitation services (Brannigan et al, 2017; Schwarz et al, 2018). Given the complexity of returning to work after stroke, many people require co-ordinated action involving trained staff with the required competencies and knowledge of the relevant legislation (Scott & Bondoc, 2018), involving all stakeholders. [2023]

Vocational rehabilitation (VR) is summarised as ‘a co-ordinated plan supported by all those working with the employee to optimise their work capability’ (British Society of Rehabilitation Medicine, 2021). VR is a neglected area within statutory health services, and returning to work remains a largely unmet need (BSRM, 2021). The BSRM (2021) and the National Stroke Service Model for England (2021) outline three levels of VR services, ranging from routine guidance to specialist VR for people with complex problems. VR services need to be aware of recommendations based on the experiences of people who have had a stroke, their colleagues and managers (Hellman et al, 2016; Brannigan et al, 2017; Öst Nilsson et al, 2017; Öst Nilsson et al, 2020). [2023]

Recommendations

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

Sources

A	Guideline Development Group consensus
B	Ntsiea et al, 2015; Guideline Development Group consensus
C	Öst Nilsson et al, 2017, 2020; Guideline Development Group consensus
D	Guideline Development Group consensus
E	Scott and Bondoc, 2018; Guideline Development Group consensus
F	Guideline Development Group consensus

Evidence to recommendations

There is a paucity of evidence to inform recommendations on returning to work after a stroke. In countries where usual care includes a statutory programme of vocational rehabilitation (VR), it may not be possible to conduct RCTs where the control group is denied VR. An RCT by Ntsiea (2015) involving 80 participants (N=40 each in the intervention and control group) reported benefits from a workplace intervention versus usual care in improving return to work rates after stroke (60% versus 20%, odds ratio (OR) 5.2, 95% CI 1.8 to 15.0 at 6 months). The 6-week person-centred intervention included a multiprofessional, multiphase intervention involving collaboration between the person with stroke, healthcare professionals and their employer. Participants were mainly better-educated, in higher paid jobs, and were independent in ADL after their stroke. The intervention was based in each person’s workplace. This was a small study, undertaken in South Africa, where policies, employment circumstances and services for people with stroke will differ from those in the UK and Ireland. [2023]

Key factors for a successful return to work include having an understanding of the consequences of stroke, clear communication and active participation in planning the process (Öst Nilsson et al, 2017). This study also identified the important role of a co-ordinator, acting as a liaison by providing information and support for planning and negotiating return to work. Continuing communication and support were considered important, as well as flexibility to ensure work can be adapted to the individual (Öst Nilsson et al, 2017). [2023]

In addition to the person with stroke, successfully returning to work may also require consideration of their colleagues. Returning to work is likely to be stressful, as relationships need to be re-established and increased responsibility and workload for colleagues need to be managed (Öst Nilsson et al, 2020). This study identified the need for co-ordination to ensure the person with stroke, their co-workers and managers are aware of roles, responsibilities, and relevant legislation, along with commitment and support from the employer (Öst Nilsson et al, 2020). [2023]

A RCT is underway in the UK (RETAKE, ISRCTN12464275) which will help identify the key ingredients of effective VR and guide the future model of clinical delivery. [2023]

Rehabilitation and recovery – principles of rehabilitation Rehabilitation and recovery – motor recovery and physical effects of stroke