Rehabilitation and recovery – motor recovery and physical effects of stroke

4.16 Introduction

This section focuses on the physical effects of stroke which are common in the majority of people following stroke, and often lead to activity limitations. This section reviews the...

4.17 Motor impairment

Muscle Weakness
Weakness of the limbs and face are amongst the most common impairments after stroke, giving rise to a hemiplegia. Weakness is the strongest factor influencing dext...

Muscle Weakness
Weakness of the limbs and face are amongst the most common impairments after stroke, giving rise to a hemiplegia. Weakness is the strongest factor influencing dexterity and upper limb function, activities of daily living, balance and walking (Jørgensen et al, 1995; Tyson et al, 2006b; Harris & Eng, 2007; Veerbeek et al, 2011; Preston et al, 2021). This is reflected in tools to predict recovery of upper limb function and walking after stroke, in which the degree of weakness is the main predictive factor (Smith et al, 2017; Stinear et al, 2017b; Selles et al, 2021). Weakness should therefore be the main focus of treatment to improve movement and subsequently physical function and activity. [2023]

Weakness is defined as an inability to generate muscle forces. It is caused by loss of facilitatory drive to anterior horn motor neurones from higher centres, primarily the motor cortex via the corticospinal tract. This primary impairment is exacerbated by further weakness and stiffness secondary to inactivity and disuse (Gracies, 2005; Kamper et al, 2006; Gray et al, 2007; Hoffmann et al, 2016). Limited force generation is seen in all types of muscle contraction (isometric, concentric and eccentric), speed of contractions (power), sustained and repeated contractions (endurance) and integration within and between muscle groups (co-ordination; Kristensen et al, 2017). In most cases, the degree of weakness is similar between the upper and lower limbs, and in all muscle groups within a limb. The degree of weakness is mainly determined by stroke severity, location and pre-morbid strength; age, sex and side or type of stroke are not factors (Tyson et al, 2006a). Strengthening interventions increase strength, improve activity, and do not increase spasticity (Ada et al, 2006); however, selection of appropriate exercises for an individual is important. [2023]

Cardiorespiratory fitness
Cardiorespiratory or aerobic fitness is defined as the ability to transport and use oxygen (Saunders et al, 2020), which confers some degree of endurance. Many people with stroke have low cardiorespiratory fitness pre-morbidly (Kurl et al, 2003) which is exacerbated by the increased energy costs of moving, and by inactivity after stroke (Ivey et al, 2005; Smith et al, 2012; Tieges et al, 2015; Kramer et al, 2016). Low cardiorespiratory fitness is seen in all stages of recovery and can make it difficult for people with stroke to engage in rehabilitation and maintain basic mobility and daily activities (Kunkel et al, 2015). In turn, this feeds into further inactivity, limits participation and increases the risk of recurrent stroke (Mayo et al, 1999; Billinger et al, 2015), making cardiorespiratory fitness an important target for rehabilitation to both maximise recovery and to reduce the risk of recurrence. [2023]

The principal approach to treat both weakness and cardiorespiratory fitness after a stroke is exercise, which is defined as “physical activity that is planned, structured and repetitive to condition any part of the body” (Saunders et al, 2020). There is overlap between exercise and repetitive task practice (where functional tasks or activities are practised intensively) and physical activity in which exercise is often set in a recreational context. These terms are sometimes used interchangeably. There are many different ways of exercising, often classified as:

cardiorespiratory training - generally walking (often on a treadmill) or cycling (stationary or recumbent) at sufficient intensity to produce a cardiorespiratory training effect;
resistance or strength training using body weight or equipment to resist muscle contractions with a primary aim of improving muscle strength, power and endurance;
mixed training – a combination of cardiorespiratory and resistance training e.g. circuit training classes. [2023]

Treadmills with and without bodyweight support (including underwater and robot-assisted treadmills) and other equipment (such as arm ergometers, seated steppers and static bicycles) are all ways of delivering aerobic and strength training and have been recommended as training methods. Exercise in any form can be delivered individually or in groups, supervised, semi-supervised or independently in health-related or community venues (Mahmood et al, 2022a; Mahmood et al, 2022b). People with stroke report that they value exercise activity and are willing to exercise intensively, even early after stroke. As well as the physical benefits, exercise helps to build confidence, reduce boredom and fosters autonomy. Many also appreciate the camaraderie and peer support experienced in group exercise, preferably in non-healthcare community settings. However, patients also often lack confidence and the self-efficacy to exercise, needing information and the support of professionals and family to overcome the difficulties caused by the stroke and other health conditions (Luker et al, 2015; Poltawski et al, 2015; Young et al, 2021). Health care professionals also face barriers to implementing exercise after stroke. Many feel they lack the knowledge and skills to prescribe exercise effectively, are concerned about safety and have misconceptions about the capabilities and motivation of people with stroke. Lack of resources in terms of staffing, resources, knowledge and training are also an issue (Gaskins et al, 2021; Moncion et al, 2022). [2023]

Recommendations

People with stroke should be assessed for weakness and cardiovascular fitness using a standardised approach, and have the impairment explained to them and their family/carers. Assessment and outcome measures used should encompass the range of effects of exercise including weakness, cardiovascular fitness and activities. [2023]

People with weakness after stroke sufficient to limit their activities should be assessed within 24 hours of admission by a therapist with knowledge and skills in neurological rehabilitation. [2023]

Clinicians should screen for, prescribe and monitor exercise programmes for people with stroke, e.g. using a 6 minute walk test or shuttle test. Programmes should be individualised to the person’s goals and preferences. Screening equipment (such as treadmills, ECG and blood pressure monitors) should be available, and clinicians should liaise with other services that offer exercise-based rehabilitation (e.g. cardiac or pulmonary rehabilitation) with regard to integrating screening and exercise resources. [2023]

People with weakness after stroke should be taught task-specific, repetitive, intensive exercises or activities to increase their strength. Exercise and repetitive task practice should be the principal rehabilitation approaches, in preference to other therapy approaches including Bobath. [2023]

People with stroke should be offered cardiorespiratory training or mixed training once they are medically stable, regardless of age, time since stroke and severity of impairment.

Facilities and equipment to support high-intensity (greater than 70% peak heart rate) cardiorespiratory fitness training (such as bodyweight support treadmills and/or static/recumbent cycles) should be available;
The dose of training should be at least 30-40 minutes, 3 to 5 times a week for 10-20 weeks;
Programmes of mixed training (medium intensity cardiorespiratory [40%-60% of heart rate reserve] and strength training [50-70% of one-repetition maximum]) such as circuit training classes should also be available at least 3 days per week for 20 weeks;
Exercise aimed at increasing heart rate should be used for those with more severe weakness, such as using arm cycles or seated exercise groups;
The choice of programme should be guided by patients’ goals and preferences and delivery of the programme individualised to their level of impairment and goals. [2023]

People with respiratory impairment and at risk of pneumonia after stroke should be considered for respiratory muscle training using a threshold resistance trainer or flow-oriented resistance trainer.

Training should be carried out for at least 20 minutes per day, 3 days per week for 3 weeks;
The relevant clinicians (nurses, speech and language therapists, physiotherapists and support staff) should be trained in how to use the training equipment. [2023]

People with stroke who are unable to exercise against gravity independently should be considered for adjuncts to exercise (such as neuromuscular or functional electrical stimulation), to support participation in exercise training. [2023]

People with stroke should be supported with measures to maximise exercise adherence such as:

measures to build confidence and self-efficacy (such as the use of social networking apps or physical activity platforms);
ensuring patients and family/carers know the benefits of exercise and why they are doing it, including how the exercises given relate to their individual needs;
incorporation of exercise into documented goal setting;
individualisation of exercise programme to suit their abilities and goals;
use of technology (e.g. apps, videos, phone check-ins);
ongoing coaching to support written exercise instructions;
the involvement of family and carers with exercise. [2023]

Clinicians should not use risk assessment protocols that limit training for fear of cardiovascular or other adverse events except where screening has identified intensive exercise is contraindicated for an individual. [2023]

Sources, evidence to recommendations, implications

Sources

A, B	Guideline Development Group consensus
C	MacKay-Lyons et al, 2020
D	Pollock et al, 2014a, c; Veerbeek et al, 2014b; Scrivener et al, 2020; Dorsch et al, 2020, 2023
E	Guideline Development Group consensus
F	Zheng et al, 2020; Zhang et al, 2022; Guideline Development Group consensus
G	MacKay-Lyons et al, 2020; Guideline Development Group consensus
H	Miller et al, 2017; Gunnes et al, 2019; García-Cabo and López-Cancio, 2020; Mahmood et al, 2022; Guideline Development Group consensus
I	Guideline Development Group consensus

Evidence to recommendations

Seven high quality systematic reviews including one Cochrane review that assessed the effect of exercise on motor impairments (weakness and/or cardio-respiratory fitness) (Lloyd et al, 2018; Lee & Stone, 2020; Luo et al, 2020; MacKay-Lyons et al, 2020; Saunders et al, 2020; Anjos et al, 2022; Machado et al, 2022). These reviews provided a moderate to high level of evidence that all types of exercise are safe and feasible for all stages of stroke recovery in people with all severities of stroke, even those with severe impairments who are unable to walk (English et al, 2017; Lloyd et al, 2018; Luo et al, 2020; MacKay-Lyons et al, 2020; Pogrebnoy & Dennett, 2020; Saunders et al, 2020; Anjos et al, 2022). A high quality review (albeit with a small number of trials) indicated improvements in cardiorespiratory fitness can be maintained over six months after training (Machado et al, 2022). Exercise did not negatively affect spasticity, muscle tone, quality of movement, pain, falls, fatigue, or cardiac events (Ada et al, 2006; Kuys et al, 2011; Mead et al, 2012; Billinger et al, 2014). However, it should be noted that safety was rarely a focus in the selected trials and safety reporting often lacked detail. One high quality trial of aerobic training in people with subacute stroke that specifically completed a safety assessment as a planned secondary analysis (Rackoll et al, 2022) reported a higher incidence of serious adverse events in the aerobic training group than the control group. However, these were not, or were highly unlikely to be, related to the training. Regression analyses indicated that risk was greater in people with diabetes or atrial fibrillation, unmodified by age or stroke severity. The trial was not powered for this analysis so any interpretation needs to be treated with caution. However, it does highlight that more research is needed to fully understand the safety aspects of aerobic training, particularly in those with stroke-related co-morbidities. [2023]

Cardiorespiratory training, especially when involving walking, appears to be the most effective (with a moderate effect size) for cardiorespiratory fitness, and walking and balance. Mixed training has a slightly lesser effect. Resistance training is most effective in improving muscle strength and endurance (Saunders et al, 2020). The type of exercise prescribed depends, therefore, on the patient’s treatment goals. However, cardiorespiratory training involving walking has the greatest overall benefit, which can persist into the long term (Saunders et al, 2020). [2023]

Although the optimal way to deliver exercise after stroke is still not clear, there is an indication from high quality meta-analyses (albeit of a small number of trials) that treadmill gait training may be more effective than cycle ergometry (Luo et al, 2020), and that high intensity interval training (HIIT, in which periods of maximal intensity exercise are interspersed with low activity or rest) may be more effective than continuous aerobic training in terms of cardiorespiratory fitness, strength and function (Anjos et al, 2022). The optimal dose of exercise is unclear and there have been no dose-response studies of sufficient quality to inform practice. Nonetheless, several high quality meta-analyses have made recommendations for the minimum dose of exercise needed to be effective:

cardiorespiratory training: High-intensity exercise (70-85% heart rate reserve / VO₂ peak) for 30-40 minutes, 3 to 5 times a week for about 12 weeks. High-intensity exercise can also be defined as ‘achieving greater than 70% peak heart rate’ or ‘a score of more than 14/20 on the Borg Rating of Perceived Exertion (RPE) scale’ (Luo et al, 2020; Anjos et al, 2022).
mixed training: Moderate intensity aerobic training (40%-60% of heart rate reserve) plus moderate intensity resistance training (50%-70% of one-repetition maximum) 3 days per week for at least 20 weeks. Longer training sessions promote greater cardiorespiratory fitness; moderate frequency and lower volume exercise (number of repetitions) benefit muscle strength; and moderate frequency and longer duration benefit walking capacity (Lee & Stone, 2020).
non-ambulant individuals are able to take part in cardiorespiratory training using bodyweight-supported treadmill training (increasing the treadmill incline as well as speed to achieve the required heart rate), electromechanical gait training or static or recumbent cycle ergometry. A high quality meta-analysis found insufficient evidence to make specific recommendations but the dose of cardiorespiratory training that improved fitness and mobility was similar to that above (Lloyd et al, 2018; Shen et al, 2018; MacKay-Lyons et al, 2020). [2023]

A key issue when prescribing exercise is that the effects of exercise are specific to the movements or tasks trained. Two high quality systematic reviews with meta-analysis have also concluded that respiratory muscle training using a threshold resistance trainer or flow-oriented resistance trainer can reduce the risk of post-stroke respiratory complications (i.e. pneumonia; RR 0.11-0.51) with a number needed to treat of 15 (Zheng et al, 2020; Zhang et al, 2022). However, the nature or extent of the respiratory impairment and proportion of participants who had dysphagia were unclear. The most effective training protocol was more than 20 minutes per day, three times per week for three weeks (Zhang et al, 2022). [2023]

Exercise is only effective if people do it. Although adherence to supervised exercise in a treatment setting is often good, the rates tend to fall when people are not directly supervised, whether outside therapy sessions whilst an inpatient, or when exercising at home. Clinicians need to take measures to support adherence, such as ensuring people and their family/carers know the benefits of exercise and why they are doing it, incorporating exercise into goal setting, individualising the exercise programme to suit patients’ abilities and goals, using technology (e.g. apps, videos, phone check-ins), providing ongoing supervision and coaching to support written exercise instructions, and involving family and carers (Miller et al, 2017; Gunnes et al, 2019; García-Cabo & López-Cancio, 2020; Mahmood et al, 2022a). [2023]

4.18 Arm function

Approximately 70% of people experience loss of arm function after a stroke, and this persists for about 40%. This section includes interventions intended to deliver repetitive and ...

Approximately 70% of people experience loss of arm function after a stroke, and this persists for about 40%. This section includes interventions intended to deliver repetitive and functionally relevant practice to improve arm function. Guideline users should also refer to other relevant sections that cover the following: weakness (Section 4.17 Motor impairment), sensation (Section 4.47 Sensation), shoulder subluxation and pain (Section 4.23.3 Shoulder subluxation and pain), activities of daily living (Section 4.8 Independence in daily living). [2023]

Patterns of arm recovery are varied and are largely dependent on the initial degree of weakness and patency of the corticospinal tract (Stinear et al, 2017a), particularly preservation or return of finger extension and shoulder abduction. This has led to the development of tools to predict arm recovery in clinical practice: for example the SAFE and PREP2 tools (Nijland et al, 2010; Stinear et al, 2017b) and the Viatherapy app, an app to guide evidence-based rehabilitation (Wolf et al, 2016). Prognostic tools may be useful to help identify who is most likely to benefit from intensive upper limb interventions and who requires a compensatory approach focusing on reduction of secondary complications such as shoulder subluxation, pain and spasticity. [2023]

Whilst research regarding interventions to promote motor recovery has progressed, continued focus is required to ensure these are implemented into practice. Intensity of practice of movements and tasks during therapy must be coupled with efforts to translate movements into everyday activities. Current practice in the UK indicates too few rehabilitation sessions are dedicated to the upper limb and within sessions too few repetitions are achieved (Stockley et al, 2019). A co-ordinated multidisciplinary approach should be taken to maximise upper limb rehabilitation as well as ensuring that people are supported to practise outside of therapist-delivered sessions. [2023]

Management and recovery of the hemiplegic upper limb often takes place over months or years and must be considered in the context of other impairments including sensation, sensory or visual neglect, learnt non-use, spasticity and balance. Whilst promoting motor recovery (particularly early after stroke) is of the utmost importance, enabling the person to be independent in daily life activities, such as eating and drinking, is essential, and compensatory strategies should be used where appropriate. [2023]

Repetitive task practice
Recovery of the upper limb is best achieved through training that involves repetition of functional tasks and targeted exercises that follow motor learning principles. Components of functional tasks may be practised but should then be incorporated into practice of the whole functional task. Training should be supplemented with aids and equipment as necessary to enable safe, intensive and functionally relevant practice. [2023]

Electrical stimulation
Electrical stimulation has been used as an adjunctive treatment for the upper limb for many years. The most common form is therapeutic or cyclical electrical stimulation (also known as neuromuscular electrical stimulation [NMES]) to the wrist and finger extensors, which stimulates the muscles to contract in order to improve weakness and reduce motor impairment. [2023]

Vagus nerve stimulation
Vagus nerve stimulation (VNS) aims to enhance the effects of repetitive task training by stimulating the vagus nerve during the movement(s) being practised. It is therefore limited to use in people with mild-moderate upper limb weakness (typically, a Fugl-Meyer Upper limb Assessment score of 20-50/100). The stimulation is applied either by an implanted device directly attached to the vagus nerve, or indirectly by transcutaneous nerve stimulation over the vagus nerve in the left side of the neck or the sensory area of the nerve on the external part of the ear. The exact mechanism of action is unknown but it is associated with increased neuroplasticity (Hays et al, 2013; Engineer et al, 2019). [2023]

Constraint-induced movement therapy
The original constraint-induced movement therapy (CIMT) protocol incorporates three components of rehabilitation consisting of (1) intensive graded practice of the paretic arm for 6 hours a day for 2 weeks (shaping), (2) constraining the non-paretic arm with a mitt to promote use of the weak arm for 90% of waking hours, (3) a transfer training package to learn to use the paretic arm in a real-world environment completing functional tasks (Wolf et al, 2006; Taub et al, 2013). Original protocols for CIMT were found to be effective in improving arm function for people following a subacute stroke but only when all three components were used, and ‘forced use’ is not effective alone (Kwakkel et al, 2015). The time resource needed for CIMT has made this approach challenging to adopt in clinical practice. [2023]

In subsequent years various protocols have been developed aiming for 3-4 hours of CIMT, core components of which are consistent with the original intervention. These are now more commonly adopted in clinical practice, delivered by a combination of qualified therapists, rehabilitation assistants and self-practice, supported remotely as appropriate. Using the paretic arm in functional daily tasks remains a key feature of all modified CIMT (mCIMT) programmes and should be aligned to individualised goals. [2023]

Mental practice
Mental practice is a training method that involves repetitive cognitive rehearsal of physical movements in the absence of physical, voluntary attempts. From a practical perspective, mental practice constitutes a feasible alternative to other rehabilitation approaches to produce the movement because it does not require physical movement, can be performed without direct supervision, and requires minimal expense and equipment (Page & Peters, 2014). Mental practice may promote neuroplasticity, as neuroimaging studies have shown that similar overlapping brain areas are activated in mental practice and with physical movement (Di Rienzo et al., 2014). [2023]

Mirror therapy
Mirror therapy involves performing movements of the non-affected arm, whilst watching its mirror reflection hiding the affected arm. This creates a visual illusion of enhanced movement capability of the affected arm (Yang et al, 2018). The precise mechanisms of mirror therapy are not fully understood, but it is proposed that it promotes motor function of the upper limb via activation of the primary motor cortex or mirror neurones (Garry et al, 2005; Cattaneo & Rizzolatti, 2009). [2023]

Robotics
A robot is defined as a reprogrammable, multifunctional manipulator designed to move material, parts, or specialised devices through variable programmed motions to accomplish a task (Chang & Kim, 2013). Robot-mediated treatment uses devices to provide passive, active-assisted or resistive limb movement, and has the potential to offer extended periods of treatment and an opportunity to increase intensity through repetition. Some robots may be able to adapt treatment in response to performance. [2023]

Recommendations

People with some upper limb movement at any time after stroke should be offered repetitive task practice as the principal rehabilitation approach, in preference to other therapy approaches including Bobath. Practice should be characterised by a high number of repetitions of movements that are task-specific and functional, both within and outside of therapy sessions (self-directed). Repetitive task practice:

may be bilateral or unilateral depending on the task and level of impairment;
should be employed regardless of the presence of cognitive impairment such as neglect or inattention;
may be enhanced by using trunk restraint and priming techniques. [2023]

People with stroke who have at least 20 degrees of active wrist extension and 10 degrees of active finger extension in the affected hand should be considered for constraint-induced movement therapy. [2023]

People with wrist and finger weakness which limits function after stroke should be considered for functional electrical stimulation applied to the wrist and finger extensors, as an adjunct to conventional therapy. Stimulation protocols should be individualised to the person’s presentation and tolerance, and the person with stroke, their family/carers and clinicians in all settings should be trained in the safe application and use of electrical stimulation devices. [2023]

People with stroke without movement in the affected arm or hand (and clinicians, families and carers) should be trained in how to care for the limb in order to avoid complications (e.g. loss of joint range, pain). They should be monitored for any change and repetitive task practice should be offered if active movement is detected. [2023]

People with stroke may be considered for mirror therapy to improve arm function following stroke as an adjunct to usual therapy. [2023]

People with stroke who are able and motivated to participate in the mental practice of an activity should be offered training and encouraged to use it to improve arm function, as an adjunct to usual therapy. [2023]

People with arm weakness after stroke, who are able and motivated to follow regimes independently or with the support of a carer, should be considered for self-directed upper limb rehabilitation to increase practice in addition to usual therapy, e.g. patients undergoing constraint-induced movement therapy or functional electrical stimulation. [2023]

People with mild-moderate arm weakness after stroke may be considered for transcutaneous vagus nerve stimulation in addition to usual therapy. Implanted vagus nerve stimulation should only be used in the context of a clinical trial. [2023]

People with reduced arm function after a stroke may be considered for robot-assisted movement therapy to improve motor recovery of the arm as an adjunct to usual therapy, preferably in the context of a clinical trial. [2023]

Sources, evidence to recommendations, implications

Sources

A	Veerbeek et al, 2014b; French et al, 2016; Grattan et al, 2016; Wattchow et al, 2018; Chen et al, 2019; Zhang et al, 2021; da Silva et al,2020
B	Kwakkel et al, 2015; Corbetta et al, 2015; Barzel et al, 2015; Yadav et al, 2016; Liu et al, 2017; Abdullahi, 2018
C, D	Guideline Development Group consensus
E	Thieme et al, 2018; Yang et al, 2018; Zeng et al, 2018; Zhang et al, 2021
F	Page and Peters, 2014; Di Rienzo et al, 2014; Barclay et al, 2020; Stockley et al, 2021; Poveda-Garcia et al, 2021
G	Da-Silva et al, 2018; Guideline Development Group consensus
H	Dawson et al, 2021; Ahmed et al, 2022; Guideline Development Group consensus
I	Mehrholz et al, 2018; Takebayashi et al, 2020

Evidence to recommendations

Repetitive task practice
There is good quality evidence for interventions involving intensive, repetitive, task-oriented and task-specific training including constraint-induced movement therapy, mental practice, virtual reality and interactive video games (Pollock et al, 2014b). It remains unclear whether practising unilateral functional activities is more beneficial than bilateral practice, but this is likely to depend on a person’s level of impairment. The evidence base for virtual reality and interactive video gaming-based interventions for the arm (as an adjunct to usual care to increase overall therapy time) is developing, though studies are often of low quality and further research is needed before recommendations can be made regarding their use. [2023]

The ideal dose of repetitive task practice required to be beneficial remains unclear (Lang et al, 2009; French et al, 2016a) but is likely to be substantially higher than is currently being delivered (Schneider et al, 2016; Clark et al, 2021) and in the order of several hundred repetitions per day (McCabe et al, 2015; Daly et al, 2019; Ward et al, 2019; Hayward et al, 2021). This can lead to both short-term and sustained improvements in arm and hand function in people with both subacute and chronic stroke (French et al, 2016a; Wattchow et al, 2018) even in those with cognitive impairments such as neglect or inattention (Grattan et al, 2016). [2023]

Adding trunk restraint to task-oriented arm and hand training can further improve impairments and activity within the first six months after stroke by limiting compensatory movements (Zhang et al, 2022). There is some evidence that priming activities can enhance training effects, with moderate quality evidence for brain stimulation or sensory priming, and low quality evidence for motor priming to enhance improvements in impairments and activity (da Silva et al, 2020). Brain stimulation usually involves transcranial magnetic or direct current stimulation, sensory priming involves electrical or sensory stimulation and motor priming involves aerobic activity or bilateral activities (da Silva et al, 2020) but there is little information on the appropriate dose, timing or type of priming activity. [2023]

High quality systematic reviews and meta-analyses provide sufficient evidence to discourage routine use of Bobath therapy in place of repetitive training or practice of functional tasks (Veerbeek et al, 2014b; Wattchow et al, 2018). [2023]

Electrical stimulation
Four good quality systematic reviews with meta-analysis have shown that electrical stimulation to the wrist and hand can improve motor impairments and function (Yang et al, 2019; Tang et al, 2021; Kristensen et al, 2022; Loh et al, 2022). Tang et al (2021) included a network meta-analysis which indicated that functional electrical stimulation to the wrist and finger extensors during practice of functional tasks was more effective at improving upper limb function than passive neuromuscular electrical stimulation, especially when used to enable repetitive task practice (Yang et al, 2019). A suggested way to do this is by coupling stimulation of the weak arm with movements of the unaffected arm (referred to as contralaterally controlled functional electrical stimulation; Loh et al, 2022). The optimal dose and stimulation protocol are still unclear so clinical decisions should be made according to an individual person’s needs, goals and preferences. [2023]

Vagus nerve stimulation
High quality evidence from systematic reviews of six RCTs of vagus nerve stimulation (VNS; n=237; (Xie et al, 2021; Zhao et al, 2021; Ahmed et al, 2022)); including a phase III trial of implanted VNS in 108 people with chronic stroke (Dawson et al, 2021), showed VNS can enhance the effect of repetitive task practice on upper limb impairment, with a moderate effect size. All trials which reported on safety found VNS to be safe. However, many factors remain unclear, such as the optimal dose and stimulation parameters, integration of stimulation with repetitive task practice and identifying those who benefit most. Further research is needed to understand these factors, and the relative merits of implanted or transcutaneous stimulation. Furthermore, the dose of repetitive task training is likely to be important; it is unlikely that VNS would be effective without a high dose of repetitive task practice, which is currently rarely achieved in practice. VNS may be considered, when it can be provided without reducing the amount of practice completed, alongside other priming techniques according to patients’ presentation, goals and preferences. [2023]

Intensive upper limb programmes
Whilst findings from single-centre studies of specialist intensive upper limb programmes for selected patients appear promising (Daly et al, 2019; Ward et al, 2019), there was insufficient high quality evidence to make general recommendations regarding provision of such programmes. Providing the evidence-based, intensive upper limb treatments contained in the recommendations in this section at a sufficient dose should remain the priority, along with delivering generalisable RCTs of intensive upper limb programmes in chronic stroke. Providers and commissioners/service planners should ensure access for all people with stroke who could benefit from rehabilitation at the intensities recommended, including measures to ensure therapy can be replicated and maintained over the longer term at home. [2023]

Constraint-induced movement therapy
Constraint-induced movement therapy (CIMT) includes an extended daily period of constraint of the non-paretic arm, repetitive task training for the paretic arm (shaping and task practice) and a ‘transfer package’ to support implementation into everyday life. Evidence suggests the transfer package is of particular importance, ensuring that motor gains translate into functional tasks and improve outcomes. Outcomes generally relate to arm function and effects are mostly confined to the trained activities (Pollock et al, 2014a; Pollock et al, 2014b; Veerbeek et al, 2014b). Challenges in clinical delivery and adherence to original CIMT protocols have resulted in modified CIMT (mCIMT) being adopted, where the time during which the non-paretic arm is constrained is reduced and the training hours spread over a longer period of time. Other mCIMT protocols have explored different methods and locations of delivery, for example home, clinic or remote delivery. Both CIMT and mCIMT improve arm function and activities of daily living in people with mild-moderate weakness (that is at least 20 degrees of active wrist extension and 10 degrees of active finger extension in the affected hand) in people with acute and subacute stroke (Corbetta et al, 2015; Kwakkel et al, 2015; Liu et al, 2016). However, mCIMT protocols vary and the optimal way to modify CIMT is unclear (Barzel et al, 2015; Yadav et al, 2016; Abdullahi, 2018). [2023]

Future research should aim to identify the most effective mCIMT protocols to use in clinical practice for people with different degrees of weakness and disability (e.g. the duration and frequency of constraint). Research should also consider the acceptability of CIMT and mCIMT for people with stroke and consider the support required for its use. There is emerging evidence of successful alternative ways to administer CIMT/mCIMT for example through video games or telehealth (Smith & Tomita, 2020; Taub et al, 2021; Gauthier et al, 2022) that merit further investigation. [2023]

Mental practice
Mental practice is an adjunct to conventional therapy, which can lead to significant improvement in upper limb function in the acute, subacute and chronic phases after stroke (Barclay et al, 2020). There is some evidence that mental practice may be more effective in the first three months after stroke in people with the most severe arm weakness, but the required dose is unclear and further research is warranted (Barclay et al, 2020; Stockley et al, 2021). A small observational study has indicated that the ability to mentally visualise (i.e. imagine) movements should be assessed before prescribing mental practice (Poveda-Garcia et al, 2021). [2023]

Mirror therapy
Systematic reviews and meta-analyses provide moderate evidence that mirror therapy can improve arm function and activities of daily living for people after a stroke (Thieme et al, 2018; Yang et al, 2018; Zeng et al, 2018; Zhang et al, 2021). [2023]

Mirror therapy is only effective for improving arm function as an adjunct to therapy or compared to a placebo (Thieme et al, 2018). Mirror therapy is not superior to dose-matched, conventional rehabilitation that involves upper limb action observation, movement or functional training (Lin et al, 2019). More robust research is required, and future research should focus on defining the most effective treatment protocols and the patients for whom it is most beneficial (Morkisch et al, 2019). Systematic reviews also suggest that mirror therapy may be effective in the treatment of pain and neglect, but this was not a focus of the 2023 update. [2023]

Robotics
A Cochrane review (Mehrholz et al, 2018) concluded that electromechanical and robot-assisted arm training resulted in a slight improvement in activities of daily living, muscle strength and arm function. However, a variety of types of robot were used and the dose of training was under-reported making it unclear how robotics could be routinely adopted in practice. Further uncertainty comes from suggestions from other trials that the effects of robotic therapy on arm function are confined to secondary outcomes in people with subacute stroke when combined with conventional therapy (Takebayashi et al, 2022) or only if enhanced by the addition of functional electrical stimulation (Straudi et al, 2020). A further systematic review suggested robotic therapy maybe slightly superior to therapist-led training (Chen et al, 2020) while other studies indicate that including robotic therapy in a conventional therapy session could achieve similar improvements to conventional therapist-led treatment but with less staffing resource (Aprile et al, 2020; Budhota et al, 2021). Further research is needed to find ways to translate the improvements in upper limb impairment seen with robot-assisted training into meaningful benefits in upper limb function and activities of daily living (Rodgers et al, 2019a). In the meantime, teams may consider or continue supplementing face-to-face therapy with robot-assisted arm training and be reassured regarding its safety, and seek opportunities for their patients to participate in research studies. Future research should include non-inferiority or equivalence trials, as it may be that equivalent clinical outcomes can be achieved using less resource. The target population should be people with severe arm weakness and less potential for spontaneous recovery (Wu et al, 2021). An economic evaluation concluded that robot-assisted therapy was not cost-effective, and also recommended further research (Fernandez-Garcia et al, 2021). [2023]

4.19 Ataxia

Ataxia occurs in around 3% of people with ischaemic strokes, principally in cases involving the cerebellum or its connections (Tohgi et al, 1993). It is characterised by four cardi...

Recommendations

People with posterior circulation stroke should be assessed for ataxia using a standardised approach, and have the impairment explained to them, their family/carers and the multidisciplinary team. [2023]

People with ataxia after stroke sufficient to limit their activities should be assessed by a therapist with knowledge and skills in neurological rehabilitation. [2023]

People with ataxia after stroke should be taught task-specific, repetitive, intensive exercises or activities to increase strength and function. [2023]

People with ataxia after stroke should be considered for compensatory techniques to aid functional independence and safety, such as proximal stabilisation, and provision of equipment (small aids). [2023]

Sources, evidence to recommendations, implications

Sources

A, B	Guideline Development Group consensus
C	Pollock et al, 2014a, c; Veerbeek et al, 2014c
D	Guideline Development Group consensus

Evidence to recommendations

The Scale for Assessment and Rating of Ataxia (SARA) is a standardised measures of ataxia which has been validated for stroke-related ataxia (Kim et al, 2011b; Choi et al, 2018). [2023]

There is little research evidence specific to stroke to guide the management of ataxia. Therefore our recommendations are informed by those for the inherited ataxias and multiple sclerosis (NICE, 2022d) and a systematic review of 19 studies of ataxia included a small proportion of people with stroke (Marquer et al, 2014). These provide low quality evidence that intensive rehabilitation programmes involving balance, walking (including treadmill training) and co-ordination training, and strengthening exercises were effective. No specific recommendations about the type or dose of training could be made. Virtual reality and visual or auditory feedback may be useful adjuncts to exercise and task-specific training. [2023]

4.20 Balance

Many people experience difficulty with balance after a stroke. This is primarily because of lower limb weakness, but limited trunk control, altered sensation, difficulties with dua...

Recommendations

People with impaired balance after a stroke should receive a structured multi-factorial assessment including investigation of other causes such as medication, and issues with vision, weakness, dual tasking and the peripheral vestibular system. The assessment should include impacts on daily activities, safety and independence. Onward specialist referral for vestibular rehabilitation should be considered for those people with peripheral vestibular problems. [2023]

People with impaired balance at any level (sitting, standing, stepping, walking) at any time after stroke should receive repetitive task practice in the form of progressive balance training such as trunk control exercises, treadmill training, circuit and functional training, fitness training, and strengthening exercises. [2023]

People with impaired balance after stroke should be offered repetitive task practice and balance training as the principal rehabilitation approach, in preference to other therapy approaches including Bobath. [2023]

People with limitations of dorsiflexion or ankle instability causing balance limitations after stroke should be considered for ankle-foot orthoses and/or functional electrical stimulation. The person with stroke, their family/carers and clinicians in all settings should be trained in the safe use and application of orthoses and electrical stimulation devices. [2023]

People with limitations of their standing balance or confidence after stroke should be offered walking aids to improve their stability. [2023]

People with difficulties with sitting balance after stroke should receive an assessment of postural and seating needs. Equipment should be available and provided for patients with identified seating and postural needs regardless of setting. [2023]

Sources, evidence to recommendations, implications

Sources

A	Guideline Development Group consensus
B	van Duijnhoven et al, 2016; Tally et al, 2017; Arienti et al, 2019; Hugues et al, 2019; Nindorera et al, 2021
C	Scrivener et al, 2020; C Scrivener et al, 2020
D	Hong et al, 2018; Nascimento et al, 2020; Johnston et al, 2021; Guideline Development Group consensus
E, F	Guideline Development Group consensus

Evidence to recommendations

Evidence from Cochrane (Pollock et al, 2014a; French et al, 2016b; English et al, 2017; Mehrholz et al, 2017; Laver et al, 2020; Saunders et al, 2020) and other good quality reviews (Veerbeek et al, 2014b; Tally et al, 2017b; Hugues et al, 2019; Van Criekinge et al, 2019; Nindorera et al, 2021) indicate that the basis of balance rehabilitation after stroke should be repetitive task practice and exercise, supplemented by aids such as ankle foot orthoses and functional electrical stimulation as necessary to enable safe intensive and functionally relevant practice and function in everyday life (Tyson & Kent, 2013; Hong et al, 2018; Johnston et al, 2021). Several methods for delivering repetitive task practice and exercise have been found to improve balance including treadmill training (Mehrholz et al, 2017; Tally et al, 2017a; Nindorera et al, 2021), circuit and functional training classes (English et al, 2017), fitness training (Saunders et al, 2020), practising functional tasks including trunk control (Veerbeek et al, 2014b; Van Criekinge et al, 2019; Moreno-Segura et al, 2022) and exercise (van Duijnhoven et al, 2016). These effects are seen at any time after stroke including the chronic stages (French et al, 2016a; Hugues et al, 2019) and included all aspects of balance (sitting, standing, stepping, standing up and sitting down). However, the optimal type of training for people with stroke at different stages and levels of ability remains unclear, but it is likely to be substantially higher than is currently delivered. For example, Nindorera et al. (2021) found at least 30 minutes of treadmill training, 3 times per week for 8 weeks was needed to have an effect, while Hugues et al. (2019) reported that in trials with a positive effect, patients received on average an additional 300 minutes of treadmill training in 12 sessions over 3 weeks. There was insufficient evidence to reach conclusions about the effect on balance of virtual reality and interactive video gaming (Laver et al, 2017). [2023]

A high quality systematic review and meta-analysis has shown that repetitive task practice is more effective than Bobath therapy for the recovery of lower limb activities including balance (Scrivener et al., 2020), and thus Bobath therapy (also known as neurophysiological or neurodevelopmental approaches or interventions which aim to use facilitative handling which prioritises normal movement and tone or inhibition of reflex activity rather than maximising practice and patient activity) should not be used in preference to repetitive task training. [2023]

Several systematic reviews with meta-analysis (Johnston et al., 2021, Nascimento et al., 2021, Hong et al., 2018) have found strong evidence that functional electrical stimulation of dorsiflexion can improve balance. One meta-analysis (Johnston et al., 2021) found no difference in benefit between an ankle-foot orthosis or functional electrical stimulation, so either could be used depending on the person’s needs, goals and preferences. An ankle-foot orthosis is less expensive than functional electrical stimulation but practical considerations such as comfort, ability to don and doff, and ability to accommodate the device with the person’s footwear and clothing need to be considered. [2023]

4.21 Falls and fear of falling

People with stroke are at high risk of falls at all stages in their recovery (Verheyden et al, 2013). Falls are associated with balance and mobility problems, assisted self-care, s...

Recommendations

People with stroke should be offered a falls risk assessment and management as part of their stroke rehabilitation, including training for them and their family/carers in how to get up after a fall. Assessment should include physical, sensory, psychological, pharmacological and environmental factors. [2023]

People with stroke should be offered an assessment of fear of falling as part of their falls risk assessment and receive psychological support if identified. [2016]

People at high risk of falls after stroke should be offered a standardised assessment of fragility fracture risk as part of their stroke rehabilitation. [2016]

People with stroke with symptoms of vitamin D deficiency, or those who are considered to be at high risk (e.g. housebound) should be offered calcium and vitamin D supplements. [2016]

People at high risk of falls after stroke should be advised to participate in physical activity/exercise which incorporates balance and co-ordination at least twice per week. [2016]

People with stroke and limitations of dorsiflexion or ankle instability causing impaired balance and risk or fear of falling should be considered for referral to orthotics for an ankle-foot orthosis and/or functional electrical stimulation. The person with stroke, their family/carers and clinicians in all settings should be trained in the safe use and application of orthoses and electrical stimulation devices. [2023]

Sources, evidence to recommendations, implications

Sources

A	NICE, 2013b; Guideline Development Group consensus
B	Working Party consensus
C, D	NICE, 2017a; SIGN, 2021; Working Party consensus
E	Department of Health (UK), 2019; Working Party consensus
F	Hong et al, 2018; Johnston et al, 2021; Guideline Development Group consensus

Evidence to recommendations

Several studies have tried to identify people with stroke at risk of falls using composite and single tests, but none of these tools accurately predict falls (Nystrom & Hellstrom, 2013; Breisinger et al, 2014) and nearly all people with stroke can be presumed to be at high falls risk (as high as 73% in the first year after severe stroke (Sackley et al, 2008) and their care planned accordingly (NICE, 2013a). [2016]

Despite evidence for the effectiveness of progressive muscle strengthening and balance training to prevent falls among community-dwelling older people, a Cochrane review (Denissen et al, 2019) found insufficient evidence that exercise interventions were effective in people with stroke. Two trials suggested reduced falls with bone protection medication (vitamin D or alendronic acid), but low statistical power means that they cannot be routinely recommended. More research is needed to evaluate interventions to reduce falls, injuries and fear of falling in people with stroke. Future studies should evaluate multi-factorial interventions including education and adaptations, strength and balance training, bone protection and strategies that target specific stroke-related factors. [2023]

A clinical practice guideline has provided strong evidence that functional electrical stimulation to the dorsiflexor muscles or an ankle-foot orthosis can reduce falls and fear of falling (Johnston et al, 2021). An ankle-foot orthosis or functional electrical stimulation were equally effective, so selection should be based on the person’s needs, goals and preferences. An ankle-foot orthosis is less expensive but practical considerations such as comfort, ability to apply and remove the orthosis, and the ability to accommodate the device with the person’s footwear and clothing need to be considered. [2023]

4.22 Walking

Approximately half of people with stroke are unable or are limited in their ability to walk. Although most regain some mobility, few regain their previous level. Impaired speed, en...

Recommendations

People with limited mobility after stroke should be assessed for, provided with and trained to use appropriate mobility aids, including a wheelchair, to enable safe independent mobility. [2023]

People with stroke, including those who use wheelchairs or have poor mobility, should be advised to participate in exercise with the aim of improving aerobic fitness and muscle strength unless there are contraindications. [2023]

People with impaired mobility after stroke should be offered repetitive task practice as the principal rehabilitation approach, in preference to other therapy approaches including Bobath. [2023]

People who cannot walk independently after stroke should be considered for electromechanical-assisted gait training including body weight support. [2023]

People with stroke who are able to walk (albeit with the assistance of other people or assistive devices) and who wish to improve their mobility at any stage after stroke should be offered access to equipment to enable intensive walking training such as treadmills or electromechanical gait trainers. To achieve this, training needs to be at 60-85% heart rate reserve (by adjustment of inclination or speed) for at least 40 minutes, three times a week for 10 weeks. [2023]

People with stroke with limited ankle/foot stability or limited dorsiflexion (‘foot drop’) that impedes mobility or confidence should be offered an ankle-foot orthosis (using a lightweight, flexible orthosis in the first instance) or functional electrical stimulation to improve walking and balance, including referral to orthotics if required.

Any orthosis or electrical stimulation device should be evaluated and individually fitted before long-term use.
The person with stroke, their family/carers and clinicians in all settings should be trained in the safe application and use of orthoses and electrical stimulation devices.
People using an orthosis after stroke should be educated about the risk of pressure damage from their orthosis, especially if sensory loss is present in addition to weakness. Services should provide timely access for orthotic repairs and adaptations. [2023]

Stroke services should have local protocols and agreements in place to ensure specialist assessment, evaluation and follow-up is available for long-term functional electrical stimulation use. [2023]

People with stroke who are mobile should be assessed for real-world walking such as road crossing, walking on uneven ground, over distances and inclines. This should include assessment of the impact of dual tasking, neglect, vision and confidence in busy environments. [2023]

Stroke services should consider building links with voluntary sector and recreational fitness facilities such as gyms or leisure centres or providing equipment in outpatient departments to enable community-dwelling people with stroke to access treadmills and other relevant fitness equipment. [2023]

Clinicians should not use risk assessment protocols that limit training for fear of cardiovascular or other adverse events, given the good safety record of repetitive gait training however it is delivered. [2023]

Sources, evidence to recommendations, implications

Sources

A	Guideline Development Group consensus
B	Meek et al, 2003; Saunders et al, 2004; Ada et al, 2006; Pang et al, 2006; Brazzelli et al, 2011
C	Scrivener et al, 2020; Veerbeek et al, 2014b
D	Mehrholz et al, 2013, 2020
E	Mehrholz et al, 2017, 2018; French et al, 2016; Nindorera et al, 2021; Nascimento et al, 2020; Luo et al, 2020; Balinski and Madhavan, 2021; Klassen et al, 2020
F	Johnston et al, 2021; Nascimento et al, 2020; Prenton et al, 2016; Tyson et al, 2018; Guideline Development Group consensus
G-J	Guideline Development Group consensus

Evidence to recommendations

Evidence from Cochrane (Pollock et al, 2014b; French et al, 2016a; Mehrholz et al, 2017) and other high quality systematic reviews with meta-analyses and network meta-analysis (Veerbeek et al, 2014b; Prenton et al, 2016; Mehrholz et al, 2018; Luo et al, 2020; Scrivener et al, 2020; Johnston et al, 2021; Nascimento et al, 2021; Nindorera et al, 2021; Balinski & Madhavan, 2022) was considered. [2023]

At any time after stroke, people benefit from intensive task-specific gait training in the short and long term. For those who are already able to walk (albeit with assistance) interventions that can achieve this effect should be considered, including treadmill training with or without body weight support (Mehrholz et al, 2017), electromechanical gait training using an end-effector device (Mehrholz et al, 2018), strengthening exercises for the leg, over-ground walking with activity and heart rate monitors (Klassen et al, 2020) and circuit classes (English et al, 2017). Regardless of the intervention, treatment should be ‘intensive’, and involve walking at a pace to generate a cardiovascular training effect i.e. heart rate of 60-85% of heart rate reserve (Luo et al, 2020). Walking speed (and inclination if using a treadmill) should be adjusted as necessary to achieve the required target heart rate. For more severely impaired individuals, the use of up to 40% body weight support may also be useful to enable the required training protocol to be achieved, but this should be reduced as the person progresses. [2023]

The evidence to date indicates that the amount of training is important, as greater amounts of training are associated with greater, more sustained improvements. Programmes which involved at least 30 training sessions within 10 weeks (i.e. three times per week) and at least 40 minutes per session appear necessary to reach a meaningful change in gait speed (of 0.1 m/s) and overall mobility (Mehrholz et al, 2017; Klassen et al, 2020; Luo et al, 2020; Nindorera et al, 2021; Balinski & Madhavan, 2022). It may be possible to achieve these training levels without using equipment if the cardiovascular training level is reached and around 4,000 steps per training session are achieved (Klassen et al, 2020). [2023]

It appears that treadmill training is at least as effective as over-ground training (Nascimento et al, 2021) and that training using an end-effector electro-mechanical gait trainer is more effective than treadmill training with or without bodyweight support (Mehrholz et al, 2018). [2023]

People who are not able to walk independently at the start of treatment do not appear to benefit from treadmill training (Mehrholz et al, 2017) but electromechanical-assisted gait training (in addition to standard physiotherapy) does enable more people to regain independent mobility, especially in the first three months after stroke (Mehrholz et al, 2020). [2023]

Several studies have included adverse events as an outcome and report that repetitive gait training, however delivered, is safe (French et al, 2016b; Mehrholz et al, 2017; Klassen et al, 2020; Luo et al, 2020; Mehrholz et al, 2020). [2023]

Intensive walking training can be supplemented by aids and equipment to enable safe walking both during treatment and in real life, including walking sticks/canes and an ankle-foot orthosis to support the hemiplegic foot and ankle. People with stroke sometimes choose to use a walking aid to help them practise walking earlier rather than waiting until they can walk without one (Tyson & Rogerson, 2009). A systematic review and meta-analysis of ankle-foot orthosis for people after stroke (Tyson & Kent, 2013) found improvements in walking activity in short-term studies. An alternative device is functional electrical stimulation, in which the peroneal nerve is stimulated electrically to produce a contraction of the ankle dorsiflexors. A foot switch is used to time the stimulation with the swing phase of gait and thus prevent foot drop. Several systematic reviews have shown strong evidence that functional electrical stimulation and ankle-foot orthoses improve mobility in terms of gait speed and endurance in both the short and long term (Prenton et al, 2016; Johnston et al, 2021; Nascimento et al, 2021) with no difference in efficacy between the devices. Thus the choice about which to use should be based on the person’s goals, needs and preferences and other practical considerations, such as cost. [2023]

A high quality systematic review and meta-analysis has shown that repetitive task practice is more effective than Bobath therapy for the recovery of walking and other lower limb activities (Scrivener et al, 2020), and Bobath therapy should not be used in preference to repetitive task practice. [2023]

A systematic review of nine studies of real world walking showed a small but significant effect, indicating that programmes that included behavioural change interventions appeared to be more effective at improving real world walking habits than exercise alone (Stretton et al, 2017). [2023]

4.23 Pain

Pain is a frequent problem after stroke and can be due to many causes including neuropathic pain, musculoskeletal pain including spasticity, and depression. It may also be due to a...

4.23.1 Neuropathic pain (central post-stroke pain)

Stroke is one cause of pain following damage to neural tissues (called neuropathic pain or central post-stroke pain [CPSP]). The incidence of CPSP is uncertain, with estimates vary...

Recommendations

People with central post-stroke pain should be initially treated with amitriptyline, gabapentin or pregabalin:

amitriptyline starting at 10 mg per day, with gradual titration as tolerated, but no higher than 75 mg per day (higher doses could be considered in consultation with a specialist pain service);
gabapentin starting at 300 mg twice daily with titration as tolerated to a maximum of 3.6 g per day;
pregabalin starting at 150 mg per day (in two divided doses; a lower starting dose may be appropriate for some people), with titration as tolerated but no higher than 600 mg per day in two divided doses. [2016]

People with central post-stroke pain who do not achieve satisfactory pain reduction with initial pharmacological treatment at the maximum tolerated dose should be considered for treatment with another medication of or in combination with the original medication:

if initial treatment was with amitriptyline switch to or combine with pregabalin;
if initial treatment was with gabapentin switch to pregabalin;
if initial treatment was with pregabalin switch to or combine with amitriptyline. [2016]

People with central post-stroke pain should be regularly reviewed including physical and psychological well-being, adverse effects, the impact on lifestyle, sleep, activities and participation, and the continued need for pharmacological treatment. If there is sufficient improvement, treatment should be continued and gradual reductions in the dose over time should be considered if improvement is sustained. [2016]

Sources, evidence to recommendations, implications

Sources

A-C	NICE, 2020; Wiffen et al, 2013

Evidence to recommendations

There is very little trial evidence specific to the management of CPSP, and it may well be that CPSP is different from neuropathic pain resulting from other conditions such as peripheral neuropathy or spinal cord pathology. There is no evidence that simple or opioid analgesics have any role in the treatment of neuropathic pain, and many anticonvulsant and antidepressant medicines have a very poor quality evidence base despite their frequent use. The NICE guideline CG173 on neuropathic pain (NICE, 2020) recommends the initial use of amitriptyline, duloxetine (based purely on evidence of effectiveness in painful diabetic neuropathy), gabapentin or pregabalin for neuropathic pain, switching between them if the response is inadequate. [2016]

4.23.2 Musculoskeletal pain

Musculoskeletal pain is not uncommon in people with stroke. Prolonged immobility and abnormal posture can cause pain and exacerbate pre-existing musculoskeletal conditions such as ...

Recommendations

People with musculoskeletal pain after stroke should be assessed to ensure that movement, posture and moving and handling techniques are optimised to reduce pain. [2016]

People who continue to experience musculoskeletal pain should be offered pharmacological treatment with simple analgesic medication. Paracetamol, topical non-steroidal anti-inflammatory drugs (NSAIDs) or transcutaneous electrical nerve stimulation (TENS) should be offered before considering the addition of opioid analgesics. [2016]

Sources, evidence to recommendations, implications

4.23.3 Shoulder subluxation and pain

Hemiplegic shoulder pain affects 30-65% of people with stroke and is often associated with upper limb weakness, gleno-humeral subluxation and restricted range of shoulder movement ...

Recommendations

People with functional loss in their arm after stroke should have the risk of shoulder pain reduced by:

careful positioning of the arm, with the weight of the limb supported, including the use of wheelchair arm rests;
ensuring that healthcare staff and family/carers handle the affected arm correctly, avoiding mechanical stress and excessive range of movement;
avoiding the use of overhead arm slings/ shoulder supports and pulleys. [2023]

People with arm weakness after stroke should be asked regularly about shoulder pain. [2016]

People who develop shoulder pain after stroke should:

be assessed for causes and these should be managed accordingly, including musculoskeletal issues, subluxation and spasticity;
have the severity monitored and recorded regularly, using a validated pain assessment tool;
have preventative measures put in place;
be offered regular simple analgesia. [2016]

People with shoulder pain after stroke should only be offered intra-articular steroid injections if they also have inflammatory arthritis. [2016]

People with inferior shoulder subluxation within 6 months of hemiplegic stroke should be considered for neuromuscular electrical stimulation, unless contraindicated. The stimulation protocol should be individualised to the person’s presentation and tolerance. The person with stroke, their family/carers and clinicians in all settings should be trained in the safe application and use of electrical stimulation devices. [2023]

People with persistent shoulder pain after stroke should be considered for other interventions such as orthotic provision, spasticity management, or suprascapular nerve block, including specialist referral if required. [2023]

Sources, evidence to recommendations, implications

Sources

A	Guideline Development Group consensus
B, C	Working Party consensus
D	Kalita et al, 2006; Lakse et al, 2009; Rah et al, 2012
E	Lee et al, 2017; Guideline Development Group consensus
F	Guideline Development Group consensus

Evidence to recommendations

The literature on hemiplegic shoulder pain and shoulder subluxation in stroke consists of small trials and systematic reviews that evaluate interventions such as electrical stimulation of the long head of biceps (Manigandan et al., 2014), subacromial injections of corticosteroid (Rah et al., 2012) or local injections of botulinum toxin (Singh and Fitzgerald, 2010). Botulinum toxin injections showed some positive benefits in reducing pain and improving shoulder function and range of motion. Low statistical power means that this intervention cannot be confidently recommended and larger high-quality RCTs are required. There is little evidence to support shoulder strapping as a way of preventing or treating shoulder subluxation. Strapping may have a preventative role by making it clear to carers that the shoulder is at risk of damage from incorrect handling or positioning. [2023]

A high quality systematic review and meta-analysis of 11 trials including 432 participants provided moderate-good evidence that neuromuscular stimulation can reduce shoulder subluxation for people when used in the acute or sub-acute stages of stroke (i.e. up to 6 months; Lee et al., 2017). The meta-analysis was underpowered to test the effects for people with chronic stroke and the impact on pain and function. Further research is needed to establish the optimal stimulation parameters and dose of stimulation. [2023]

4.24 Spasticity and contractures

There is considerable debate on the definition, physiological nature and importance of spasticity. Although spasticity is less common than assumed in the past, it represents a cons...

Recommendations

People with motor weakness after stroke should be assessed for spasticity as a cause of pain, as a factor limiting activities or care, and as a risk factor for the development of contractures. [2016]

People with stroke should be supported to set and monitor specific goals for interventions for spasticity using appropriate clinical measures for ease of care, pain and/or range of movement. [2016]

People with spasticity after stroke should be monitored to determine the extent of the problem and the effect of simple measures to reduce spasticity e.g. positioning, passive movement, active movement (with monitoring of the range of movement and alteration in function) and/or pain control. [2016]

People with persistent or progressive focal spasticity after stroke affecting one or two areas for whom a therapeutic goal can be identified (e.g. ease of care, pain) should be offered intramuscular botulinum toxin. This should be within a specialist multidisciplinary team and be accompanied by rehabilitation therapy and/or splinting or casting for up to 12 weeks after the injections. Goal attainment should be assessed 3-4 months after the injections and further treatment planned according to response. [2016]

People with generalised or diffuse spasticity after stroke should be offered treatment with skeletal muscle relaxants (e.g. baclofen, tizanidine) and monitored for adverse effects, in particular sedation and increased weakness. Combinations of antispasticity medication should only be initiated by healthcare professionals with specific expertise in managing spasticity. [2016]

People with stroke should only receive intrathecal baclofen, intraneural phenol or similar interventions in the context of a specialist multidisciplinary spasticity service. [2016]

People with stroke with increased tone that is reducing passive or active movement around a joint should have the range of passive joint movement assessed. They should only be offered splinting or casting following individualised assessment and with monitoring by appropriately skilled staff. [2016]

People with stroke should not be routinely offered splinting for the arm and hand. [2016]

People with spasticity in the upper or lower limbs after stroke should not be treated with electrical stimulation to reduce spasticity. [2023]

People with spasticity in their wrist or fingers who have been treated with botulinum toxin may be considered for electrical stimulation (cyclical/neuromuscular electrical stimulation) after the injection to maintain range of movement and/or to provide regular stretching as an adjunct to splinting or when splinting is not tolerated. [2023]

People with stroke at high risk of contracture should be monitored to identify problematic spasticity and provided with interventions to prevent skin damage, or significant difficulties with hygiene, dressing, pain or positioning. [2023]

Sources, evidence to recommendations, implications

Sources

A	Working Party consensus
B	Turner-Stokes et al, 2013; Working Party consensus
C	Royal College of Physicians et al, 2018; Working Party consensus
D	Royal College of Physicians et al, 2018; Gracies et al, 2015
E	Montane et al, 2004; Working party consensus
F	Sampson et al, 2002; Royal College of Physicians et al, 2018
G, H	College of Occupational Therapists and Association of Chartered Physiotherapists in Neurology, 2015; Lannin et al, 2007b; Working party consensus
I	Tang et al, 2021; Johnston et al, 2021; Guideline Development Group consensus
J, K	Guideline Development Group consensus

Evidence to recommendations

The evidence for spasticity management includes a clinical guideline (Royal College of Physicians et al, 2018) and several RCTs of botulinum toxin (McCrory et al, 2009; Shaw et al, 2011; Ward et al, 2014; Gracies et al, 2015). There are systematic reviews (Rosales & Chua, 2008; Elia et al, 2009; Rosales et al, 2012) and a Cochrane review (Katalinic et al, 2011) of splinting and stretching and two systematic reviews with meta-analyses of electrical stimulation (Johnston et al, 2021; Tang et al, 2021). [2023]

Botulinum toxin administration improves spasticity, range of movement and ease of care (i.e. passive function) and clinical goal attainment (Turner-Stokes et al, 2013) but not activity-level function (i.e. active function). This may partly reflect limitations in some of the measurement tools used. Improvements in activity for leg spasticity require further evaluation, but one study indicates improvements in goal attainment and ambulatory outcomes (Demetrios et al, 2014). [2016]

The evidence base for splinting remains limited and therapists must be circumspect in identifying who and when to splint and when not to splint. Splints should only be assessed, fitted and reviewed by appropriately skilled staff. NICE-accredited national guidance has been published to support best practice (College of Occupational Therapists & Association of Chartered Physiotherapists in Neurology, 2015). [2016]

High quality evidence from two meta-analyses showed that electrical stimulation does not affect spasticity after stroke and should not be used alone for the purpose of reducing spasticity (Johnston et al, 2021; Tang et al, 2021). [2023]

4.25 Fatigue

Post-stroke fatigue has been described by people with stroke as ‘a fatigue like no other’ (Thomas et al, 2019a). It is characterised by a disproportionate sense of tiredness, a lac...

Post-stroke fatigue has been described by people with stroke as ‘a fatigue like no other’ (Thomas et al, 2019a). It is characterised by a disproportionate sense of tiredness, a lack of energy, and a need to rest that is greater than usual, although rest may not be effective in alleviating it (Lanctot et al, 2020). There is no consensus on how to define post-stroke fatigue, but case definitions have been proposed (Lynch et al, 2007). Post-stroke fatigue needs to be differentiated from post-stroke apathy (see Section 4.40 Apathy). [2023]

Post-stroke fatigue can profoundly impact the lives of people with stroke, particularly their return to work, mobility, physical activity, mood, cognitive function, functional ADL (e.g. shopping) and social activities (Worthington et al, 2017). Post-stroke fatigue can also impact on a person’s ability to engage in rehabilitation, requiring therapists to adopt strategies to manage it during therapy (Riley, 2017). Post-stroke fatigue often affects the lives of families and carers, as it may limit their social life and result in increased loneliness and isolation (Ablewhite et al, 2022b). As family members or carers are often involved in overseeing the implementation of post-stroke fatigue management strategies, fatigue may add considerably to the burden of care. [2023]

Post-stroke fatigue is common and may be the sole residual problem in people who have made an otherwise good recovery (Stroke Association, 2022). Between 35 and 92% of people with stroke are estimated to have post-stroke fatigue (Duncan et al, 2012), with estimates varying by the type of measure, the point at which it is measured during recovery, and the type of stroke (Alghamdi et al, 2021). Post-stroke fatigue may present early or later after stroke, whilst early-onset fatigue persists in a proportion of cases (Wu et al, 2015). Persistent fatigue may continue to impact on functioning and participation several years after stroke (Elf et al, 2016). [2023]

The causes of post-stroke fatigue are not fully understood. It needs to be considered in a holistic manner (Thomas et al, 2019a) and a biopsychosocial model has been proposed (Wu et al, 2015). Post-stroke fatigue appears to be multi-factorial (Wu et al, 2015; Aarnes et al, 2020), and may fluctuate over the course of the day and vary in severity. It is commonly associated with pre-stroke fatigue (Wu et al, 2015), demographic (older age, female gender), clinical (stroke site, immune response characteristics, pain, sleep disturbance), physical (disability severity), emotional (depression, anxiety, avoidant or confrontational coping styles), cognitive (impaired information processing), and social factors (lack of social support) (Aarnes et al, 2020). It is plausible that different factors are associated with early compared to late-onset post-stroke fatigue, while psychological factors play a role in both (Wu et al, 2015; Chen & Marsh, 2018). There is overlap between post-stroke fatigue and depression, but post-stroke fatigue should be considered a condition in its own right (Aarnes et al, 2020). Potential triggers include physical or cognitive exertion, emotional experiences and sedentary behaviour, but in a proportion of cases there are no known triggers, rendering it unpredictable (Worthington et al, 2017). [2023]

The multifactorial nature of post-stroke fatigue should be captured in tools used to assess it, but a systematic review showed that the most commonly used outcome measures do not address potentially relevant aspects of post-stroke fatigue (Skogestad et al, 2021). Measures for post-stroke fatigue have been reviewed by Mead et al (2007) and Skogestad et al (2021). [2023]

People with stroke indicate that their fatigue is often not understood by healthcare professionals (Thomas et al, 2019a), that they are rarely provided with information or advice on how to manage it (Worthington et al, 2017; Thomas et al, 2019a; Drummond et al, 2021) and that recommended approaches may be conflicting (Thomas et al, 2019a). People with post-stroke fatigue indicate that this lack of awareness by healthcare professionals can cause anxiety (Drummond et al, 2021). Healthcare professionals’ understanding of post-stroke fatigue varies widely (Thomas et al, 2019b), and in the absence of clear evidence, their management of it largely relies on their own clinical experience (Riley, 2017). [2023]

Recommendations

Healthcare professionals should anticipate post-stroke fatigue, and ask people with stroke (or their family/ carers) if they experience fatigue and how it impacts on their life. [2023]

Healthcare professionals should use a validated measure in their assessment of post-stroke fatigue, with a clear rationale for its selection, and should also consider physical and psychological fatigue, personality style, context demands and coping styles. [2023]

People with stroke should be assessed and periodically reviewed for post-stroke fatigue, including for factors that might precipitate or exacerbate fatigue (e.g. depression and anxiety, sleep disorders, pain) and these factors should be addressed accordingly. Appropriate time points for review are at discharge from hospital and then at regular intervals, including at 6 months and annually thereafter. [2023]

People with stroke should be provided with information and education regarding fatigue being a common post-stroke problem, and with reassurance and support as early as possible, including how to prevent and manage it, and signposting to peer support and voluntary sector organisations. Information should be provided in appropriate and accessible formats. [2023]

People with post-stroke fatigue should be involved in decision making about strategies to prevent and manage it that are tailored to their individual needs, goals and circumstances. [2023]

People with post-stroke fatigue should be referred to appropriately skilled and experienced clinicians as required, and should be considered for the following approaches, whilst being aware that no single measure will be effective for everyone:

building acceptance and adjustment to post-stroke fatigue and recognising the need to manage it;
education on post-stroke fatigue for the person with stroke, and their family/ and carers;
using a diary to record activities and fatigue;
predicting situations that may precipitate or exacerbate fatigue;
pacing and prioritising activities;
relaxation and meditation;
rest;
setting small goals and gradually expanding activities;
changing diet and/or exercise (applied with caution and tailored to individual needs);
seeking peer support and/or professional advice;
coping methods including compensatory techniques, equipment and environmental adaptations. [2023]

Healthcare professionals working with people affected by post-stroke fatigue should be provided with education and training on post-stroke fatigue, including its multi-factorial nature and impact, potential causes and triggers, validated assessment tools and the importance of involving people affected by post-stroke fatigue in designing strategies to prevent and manage it. [2023]

Healthcare professionals working with people with post-stroke fatigue should consider the impact of fatigue on their day-to-day ability to engage with assessment and rehabilitation, and tailor the scheduling and length of such activities accordingly. [2023]

Service planners and managers should consider people with stroke whose ability to engage in rehabilitation is affected by post-stroke fatigue, and provide access to alternative solutions to ensure that they are still able to benefit from personalised rehabilitation input as required. [2023]

Sources, evidence to recommendations, implications

Sources

A	Lanctot et al, 2020; Drummond et al, 2022a; Guideline Development Group consensus
B	Drummond et al, 2021; Ablewhite et al, 2022b
C	Hinkle et al, 2017; Lanctot et al, 2020; Guideline Development Group consensus
D	Lanctot et al, 2020; Drummond et al, 2021; Ablewhite et al, 2022a, 2022b; Guideline Development Group consensus
E	Thomas 2019b; Drummond et al, 2021; Ablewhite et al, 2022a, 2022b; Guideline Development Group consensus
F	Drummond et al, 2021; Ablewhite et al, 2022a, 2022b; Guideline Development Group consensus
G	Thomas et al, 2019b; Drummond et al, 2021; Ablewhite et al, 2022a
H, I	Guideline Development Group consensus

Evidence to recommendations

Recommendations are based on one Cochrane systematic review (Legg et al, 2019), three other systematic reviews (Mead et al, 2019; Pacheco et al, 2019; Chen et al, 2022); four randomised controlled trials (Bivard et al, 2017; Dennis et al, 2020; Hankey et al, 2020; Dong et al, 2021) and one follow-up study (Hankey et al, 2021), one survey (Ablewhite et al, 2022a), two qualitative studies (Drummond et al, 2021; Ablewhite et al, 2022b), one scientific statement (Hinkle et al, 2017), and best practice recommendations (Lanctot et al, 2020) together with the consensus of the Guideline Development Group. [2023]

Two high quality systematic reviews (Legg et al, 2019; Mead et al, 2019) and two large, high quality RCTs including a follow-up study (Dennis et al, 2020; Hankey et al, 2020; Hankey et al, 2021) provide clear evidence that fluoxetine should not be used to prevent post-stroke fatigue as it is not effective, but increases the likelihood of falls, fractures and epileptic seizures. [2023]

One high quality but small RCT (Bivard et al, 2017) of modafinil found a significant reduction in post-stroke fatigue without any serious adverse events. However, a large RCT is ongoing and until its findings have been published, modafinil for people with post-stroke fatigue should only be provided in the context of a clinical trial. [2023]

A systematic review of acupuncture of acceptable quality (Chen & Marsh, 2018) found a statistically significant reduction in post-stroke fatigue, but only one of the studies included had received ethical approval. All studies were small and at risk of bias, and only one study reported adverse events (which were absent). Until more rigorous evidence has been published, acupuncture for people with post-stroke fatigue should only be provided in the context of a clinical trial. [2023]

One small RCT of transcranial direct current stimulation (tDCS) of acceptable quality (Dong et al, 2021) reported a significant reduction in post-stroke fatigue without any serious adverse events, but until more rigorous evidence has been published, tDCS for post-stroke fatigue should only be provided in the context of a clinical trial. [2023]

In the absence of clear evidence, healthcare professionals and people affected rely on their own expertise and experience to prevent and manage post-stroke fatigue (Drummond et al, 2021; Ablewhite et al, 2022b). A UK survey of clinical approaches to post-stroke fatigue found variations in the type, amount and duration of support, including access to follow-up, and that a proportion of healthcare professionals lack confidence in managing post-stroke fatigue (Ablewhite et al, 2022a). This survey also found that assessment of post-stroke fatigue lacks standardisation, both in terms of the tools used and in the timing of assessment (Ablewhite et al, 2022a). [2023]

A qualitative study of healthcare professionals in the UK found that fatigue management approaches commonly used include: diaries to record activities and fatigue; pacing and prioritising; education on post-stroke fatigue for the person with stroke, their family, friends and carers; coping methods including compensatory techniques, equipment and environmental adaptations; and exercise applied with caution and tailored to individual needs (Drummond et al, 2021). A qualitative study of people with stroke and their carers indicated that raising the topic of post-stroke fatigue and receiving support from professionals and peers can be helpful (Ablewhite et al, 2022b). The following measures were used to self-manage fatigue: learning to accept post-stroke fatigue and recognise the need to manage it, predicting situations that may precipitate fatigue, pacing, using a diary, relaxation or meditation, rest, setting small goals and gradually expanding activities, optimising diet and exercise, seeking peer support and professional advice, and educating family and friends about their fatigue and its management (Ablewhite et al, 2022b). However, the findings also showed that no single approach was effective for everyone, and any measure should be tailored to the individual and their personal circumstances (Ablewhite et al, 2022b). [2023]

4.26 Swallowing

Dysphagia (swallowing difficulty associated with foods, fluids and saliva) is common after acute stroke with an incidence between 40 and 78%. There is an association between dyspha...

Dysphagia (swallowing difficulty associated with foods, fluids and saliva) is common after acute stroke with an incidence between 40 and 78%. There is an association between dysphagia and poor outcomes including a higher risk of longer hospital stay, chest infection, disability and death (Martino et al, 2005). Evidence from national audit shows that delays in the screening and assessment of dysphagia are associated with an increased risk of stroke-associated pneumonia (Bray et al, 2017). Prompt detection of dysphagia in patients with acute stroke is therefore essential. In patients with dysphagia on initial screening, a specialist swallowing assessment is indicated that includes consideration of function and cognition and a broader range of food and fluids of varying texture. [2016]

The majority of people with dysphagia after stroke will recover, in part due to bilateral cortical representation of neurological pathways (Hamdy et al, 1998). A proportion will have persistent abnormal swallow and continued aspiration at 6 months (Mann et al, 1999) and a small proportion, particularly those with brainstem lesions, will have chronic and severe swallowing difficulty. People with persistent swallowing problems may avoid eating in social settings and thus lose the physical and social pleasures connected with food and drink. [2016]

This section should be read in conjunction with the sections on hydration and nutrition (Section 4.9 Hydration and nutrition), mental capacity (Section 4.35 Mental capacity) and end-of-life (palliative) care (Section 2.15 End-of-life (palliative) care). In particular, these recommendations are not intended as burdensome restrictions on oral food and fluid intake for people with stroke receiving holistic palliative care. The decision-making process to support people to eat and drink with acknowledged risks should be person-centred and involve the person and/or family/carers, and other members of the multidisciplinary team, and include a swallowing assessment and steps to minimise risk (Royal College of Physicians, 2021). [2023]

Recommendations

Patients with acute stroke should have their swallowing screened, using a validated screening tool, by a trained healthcare professional within four hours of arrival at hospital and before being given any oral food, fluid or medication. [2023]

Until a safe swallowing method is established, patients with swallowing difficulty after acute stroke should:

be immediately considered for alternative fluids;
have a comprehensive specialist assessment of their swallowing completed by a specialist in dysphagia management within 24 hours of admission;
be considered for nasogastric tube feeding within 24 hours;
be referred to a dietitian for specialist nutritional assessment, advice and ongoing monitoring;
receive adequate hydration, nutrition and medication by alternative means;
be referred to a pharmacist to review medication formulation. [2023]

Patients with swallowing difficulty in the acute phase of stroke should only be given food, fluids and medications in a form that minimizes the risk of aspiration. [2023]

People with stroke who require modified food or fluid consistency should have these provided in line with internationally agreed descriptors e.g. International Dysphagia Diet Standardisation Initiative (IDDSI). [2023]

Patients with stroke with suspected aspiration or who require tube feeding or dietary modification should be considered for instrumental assessment (videofluoroscopy or fibre-optic endoscopic evaluation of swallowing [FEES]). [2023]

Patients with stroke who require instrumental assessment of swallowing (videofluoroscopy or fibre-optic endoscopic evaluation of swallowing [FEES]) should only receive this:

in conjunction with a specialist in dysphagia management;
in order to investigate the nature and causes of swallowing difficulties;
to facilitate shared decision making and direct an active treatment/rehabilitation programme for swallowing difficulties. [2023]

Patients with swallowing difficulty after stroke should be considered for compensatory measures and adaptations to oral intake aimed at reducing the risks of aspiration and choking, improving swallowing efficiency and optimising nutrition and hydration. This should be based on a thorough assessment of dysphagia and may include:

texture modification of food and fluids;
sensory modification, such as altering the volume, taste and temperature of foods or carbonation of fluids;
compensatory measures such as postural changes (e.g. chin tuck) or swallowing manoeuvres (e.g. supraglottic swallow). [2023]

People with swallowing difficulty after stroke should be considered for swallowing rehabilitation by a specialist in dysphagia management. This should be based on a thorough assessment of dysphagia, such as by a speech and language therapist, to decide on the most appropriate behavioural intervention, and may include a variety of muscle strengthening and/or skill training exercises. [2023]

People with dysphagia after stroke may be considered for neuromuscular electrical stimulation as an adjunct to behavioural rehabilitation where the device is available and it can be delivered by a trained healthcare professional. [2023]

Patients with tracheostomy and severe dysphagia after stroke may be considered for pharyngeal electrical stimulation to aid decannulation where the device is available and it can be delivered by a trained healthcare professional. [2023]

People with difficulties feeding themselves after stroke should be assessed and provided with the appropriate equipment and assistance (including physical help and verbal encouragement) to promote independent and safe feeding. [2023]

People with swallowing difficulty after stroke should be provided with written guidance for all staff and carers to follow when feeding them or providing fluids. [2023]

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

need, but are unable to tolerate, nasogastric tube feeding, even after 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]

For people with dysphagia after stroke the option to eat and drink orally despite acknowledged risks should be considered. This decision-making process should be person-centred and taken together with the person with stroke, their family/carers and the multidisciplinary team. It should include a swallowing assessment and steps to minimise risk. [2023]

People with stroke who are discharged from specialist treatment with continuing problems with swallowing food or fluids safely should be trained, or have family/carers trained, in the management of their swallowing and be regularly reassessed. [2023]

People with stroke receiving end-of-life (palliative) care should not have burdensome restrictions on oral food or fluids if those restrictions would exacerbate suffering. In particular, following assessment this may involve a decision, taken together with the person with stroke, their family/carers and the multidisciplinary team, to allow oral food or fluids despite risks including aspiration and choking. [2023]

Sources, evidence to recommendations, implications

Sources

A	Kertscher et al, 2014; Martino et al, 2014; Bray et al, 2017
B	Geeganage et al, 2012; NICE, 2017c, 2022e
C	Guideline Development Group consensus
D	Cichero et al, 2017
E	Wilson and Howe, 2012; Bax et al, 2014; Kertscher et al, 2014
F	Martino et al, 2005; Carnaby et al, 2006; Royal College of Speech and Language Therapists, 2007, 2008; Terre and Mearin, 2012
G	Bath et al 2018; Dziewas et al, 2021
H	Bath et al, 2018; Dziewas et al, 2021; Zhang et al 2022
I	Bath et al, 2018; Dziewas et al, 2021; Wang et al, 2021a; Li et al, 2021; Zhao et al, 2022; Hsiao et al, 2022; He et al, 2022
J	Dziewas et al, 2018
K, L	Guideline Development Group consensus
M	Dennis et al, 2005; Geeganage et al, 2012; NICE, 2017c
N	Royal College of Physicians, 2021; Royal College of Speech and Language Therapists, 2021; Guideline Development Group consensus
O	Heckert et al, 2009; Drury et al, 2014; NICE, 2017c; Guideline Development Group consensus
P	Royal College of Physicians, 2021; Royal College of Speech and Language Therapists, 2021; Guideline Development Group consensus

Evidence to recommendations

There is good evidence that a multi-item dysphagia screening protocol that includes at least a water intake test of 10 teaspoons and a lingual motor test is more accurate than screening protocols with only a single item (Martino et al, 2014). Additionally a systematic review (Kertscher et al, 2014) and cost-effectiveness analysis (Wilson & Howe, 2012) suggest that the investigation of dysphagia with instrumental assessments (providing direct imaging for evaluation of swallowing physiology) helps to predict outcomes and improve treatment planning (Bax et al, 2014). [2016]

A number of treatments for dysphagia after stroke have been studied, including swallowing exercises, acupuncture, medicines, neuromuscular electrical stimulation (NMES), pharyngeal electrical stimulation (PES), thermal stimulation, transcranial direct current (tDCS), transcranial magnetic stimulation (TMS) and expiratory muscle strength training (EMST). The aim of treatment in these studies is to improve swallowing and to reduce the risk of the person developing aspiration pneumonia. A Cochrane review of swallowing therapy, which included acupuncture, behavioural interventions, medication, NMES, PES, physical stimulation, tDCS, and TMS concluded that as a whole, swallowing therapy did not change outcomes of death or dependency/disability, case fatality or penetration aspiration score, but may have reduced length of hospital stay, dysphagia, chest infections, and improved swallowing ability (Bath et al, 2018). However, the results were based on studies of variable quality and did not distinguish between specific interventions. The review concluded that additional high quality trials in the field are required to investigate the effectiveness of individual swallowing therapies. [2023]

Two systematic reviews investigating non-invasive neurostimulation therapies reported some positive effects on swallowing function and quality of life for NMES, tDCS, TMS (Li et al, 2021a; Wang et al, 2021a) but not PES (Wang, 2021). Similar findings were also reported in recent European Stroke Organisation and European Society for Swallowing Disorders guidelines, although there is a lack of evidence of improvements in other outcomes such as mortality, pneumonia, length of stay or feeding tube removal (Dziewas et al, 2018). [2023]

More high quality research is required on NMES treatment regimens, including a comparison with a sham intervention (Wang et al, 2021a). Similarly, treating dysphagia with tDCS, repetitive transcranial magnetic stimulation (rTMS) or PES appeared to be safe, but the interventions require further investigation in larger, high quality trials (Bath et al, 2018; Dziewas et al, 2021; Li et al, 2021a; Wang et al, 2021a; He et al, 2022; Hsiao et al, 2022; Zhao et al, 2022). Currently tDCS and rTMS are only carried out as part of a clinical trial. [2023]

Two systematic reviews have suggested that respiratory muscle training may reduce the occurrence of respiratory complications and reduce laryngeal penetration in patients with dysphagia after stroke (Zheng et al, 2020; Zhang et al, 2022). However, the time since stroke and the proportion of participants who had dysphagia were unclear, and the authors recommended that further research was needed (Zhang et al, 2022). [2023]

PES to aid decannulation in patients with a tracheostomy and dysphagia after stroke was shown to be effective in a single blind RCT (Dziewas et al, 2018). In this trial, PES significantly increased the number of patients who were ready to be decannulated compared to sham stimulation. [2023]

In the presence of dysphagia, eating and drinking with acknowledged risks should be considered. This is recognised as a complex and personalised decision. Whilst there is a need for more research on this topic, recent multiprofessional guidance describes the characteristics of shared decision making. These include that decisions should be person-centred and involve the person and/or family/carers and other members of the multidisciplinary team, and include a swallowing assessment and steps to minimise risk, principally of aspiration and choking (Royal College of Physicians, 2021). [2023]

Rehabilitation and recovery – activity and participation Rehabilitation and recovery – psychological effects of stroke