-
- 4.16 Introduction
- 4.17 Motor impairment
- 4.18 Arm function
- 4.19 Ataxia
- 4.20 Balance
- 4.21 Falls and fear of falling
- 4.22 Walking
- 4.23 Pain
- 4.23.1 Neuropathic pain (central post-stroke pain)
- 4.23.2 Musculoskeletal pain
- 4.23.3 Shoulder subluxation and pain
- 4.24 Spasticity and contractures
- 4.25 Fatigue
- 4.26 Swallowing
Rehabilitation and recovery – 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...
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 evidence associated with the various physical effects of stroke with a particular focus on intensive rehabilitation approaches to promote motor recovery. [2023]
Various therapeutic options may be appropriate for a person during their rehabilitation after a stroke. It is important that interventions are selected in collaboration with the person, considering their goals, preferences and other impairments. Whatever the intervention chosen, it must be delivered at the appropriate intensity and dose to achieve optimal outcomes, and at the right point in the person’s recovery. Multidisciplinary planning and collaboration are essential in the delivery of rehabilitation programmes, and all interventions should be regularly monitored and evaluated using appropriate outcome measures to guide ongoing rehabilitation plans. Exercise should be commenced early after stroke (see Section 3.12 Early mobilisation) and to a level appropriate to the medical status of the individual. [2023]
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]
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]
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]
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]
| 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 |
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...
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 cardinal signs; gait and limb ataxia, dysarthria and nystagmus (Deluca et al., 2011). It may also occur as a consequence of severe sensory dysfunction (known as sensory ataxia). Balance problems and falls are also common, as is the presence of dysphagia. Examples of standardised measures of motor impairment include the Motricity Index and the Scale for the Assessment and Rating of Ataxia (SARA). Ataxia UK published a guideline in 2016 on management of various types of ataxia (Ataxia UK, 2016); however there is little high quality evidence in stroke populations to support specific interventions. [2023]
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]
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...
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 dual tasking and perception of verticality can also be factors. Whatever its cause, impaired balance reduces confidence and increases the risk of falls (Section 4.21 Falls and fear of falling). See also Section 4.22 Walking and Section 4.48 Vision. [2023]
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]
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...
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, sedative or psychotropic medications, cognitive impairment, depression, history of falling (Xu et al, 2018) and circumstances involving dual tasking and the planning and execution of tasks (Baetens et al, 2013). Falls may have serious physical and psychological consequences, including an increased risk of hip fracture (usually on the weaker side), reduced physical activity, and greater morbidity and mortality (Ramnemark et al, 2000; Pouwels et al, 2009). Support for the sensory, physical and psychological difficulties contributing to fear of falling should be available. [2023]
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]
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...
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, endurance and energy efficiency often limit activity and participation even in those who are independently mobile. Unsurprisingly, walking is a high priority for many people after a stroke and enables increased independence in functional tasks and participation. This section focuses on treatments and equipment to improve walking, the basis of which should be intensive practice of walking and exercise using aids and equipment as necessary to enable safe practice and mobility during usual activities (such as treadmills, electro-mechanical gait trainers, activity and heart rate monitors). Walking practice at a level that promotes cardiovascular training builds motor skills, strength and cardiovascular fitness which enables greater activity in everyday life. Real-world walking is an important aspect of rehabilitation and is often a goal identified by people with stroke who need to traverse uneven ground, walk dogs or manage inclines. [2023]
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]
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...
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 pre-existing problem which is not directly related to the stroke. This section includes musculoskeletal pain, neuropathic pain and shoulder pain, as well as shoulder subluxation. Guideline users may need to refer to separate sections on sensation (Section 4.47 Sensation) and spasticity (Section 4.24 Spasticity and contractures). Pain management includes non-pharmacological and medical approaches and may require collaboration with a specialist pain management team. [2016]
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...
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 varying between 5% and 20% of people with stroke, and it can often be overlooked. There may be some overlap with spasticity which can cause pain, and with sensory loss which can be associated with unpleasant sensory phenomena. It is separate from musculoskeletal pain, which is considered in Section 4.23.2 Musculoskeletal pain. [2016]
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]
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 ...
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 osteoarthritis. The most specific musculoskeletal pain problem after stroke, shoulder pain, is considered in Section 4.23.3 Shoulder subluxation and pain. Pain management may be non-pharmacological (e.g. physiotherapy) as well as pharmacological. [2016]
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]
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 ...
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 (Kumar et al, 2022). Furthermore, shoulder pain and subluxation are associated with reduced function and recovery of the upper limb, interference with rehabilitation, higher rates of depression and poorer quality of life, so they are important targets for rehabilitation (Adey-Wakeling et al, 2016; Paolucci et al, 2016). The precise aetiology of shoulder pain is unknown, but it is often associated with subluxation of the joint and, in the later stages, spasticity. Shoulder subluxation is not always associated with pain and the two may have different causes. Addressing shoulder subluxation is a priority in order to optimise upper limb motor recovery, and manage spasticity and pain. [2023]
Slings to support the upper limb should be used with caution, as they are often ineffective at reducing the subluxation and encourage the upper limb to rest in adduction, internal rotation and flexion at the elbow, which can result in muscle shortening. [2023]
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]
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...
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 considerable burden for those who develop it, affecting up to 40% of people with severe weakness after stroke, and is considered severe and disabling in about 15% of people. It is associated with pain, contracture and other motor impairments (Wissel et al, 2013; Zorowitz et al, 2013; Glaess-Leistner et al, 2021). [2023]
Any joint that does not move frequently is at risk of developing shortening of surrounding tissues leading to restricted movement. This is referred to as a contracture, and is not uncommon in limbs affected by spasticity. Contractures can impede activities such as washing or dressing, and may also be uncomfortable or painful and limit the ability to sit in a wheelchair or mobilise. Splinting is the process of applying a prolonged stretch through an external device, most commonly splints or serial casts, historically believed to prevent or treat contractures. Standardised measures for ease of care and resistance to passive stretches include the Arm Activity measure and modified Ashworth Scale respectively. [2023]
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]
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]
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]
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]
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]