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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...

Recommendations
A

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]

B

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]

C

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]

D

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]

E

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]
F

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]
G

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]

H

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]
I

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

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 ...

Recommendations
A

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]
B

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]

C

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]

D

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]

E

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

F

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]

G

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]

H

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]

I

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

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
A

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]

B

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

C

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

D

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

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
A

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]

B

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]

C

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]

D

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]

E

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

F

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
A

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]

B

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]

C

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]

D

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]

E

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]

F

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

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
A

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]

B

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]

C

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]

D

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

E

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]

F

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]
G

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]

H

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]

I

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]

J

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

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
A

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]
B

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]
C

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

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
A

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]

B

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
A

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]
B

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

C

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]
D

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

E

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]

F

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

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
A

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]

B

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]

C

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]

D

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]

E

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]

F

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

G

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]

H

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

I

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

J

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]

K

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

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...

Recommendations
A

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]

B

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]

C

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]

D

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]

E

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]

F

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]
G

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]

H

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]

I

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

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...

Recommendations
A

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]

B

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]
C

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]

D

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]

E

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]

F

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]
G

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]
H

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]

I

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]

J

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]

K

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]

L

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]

M

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]
N

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]

O

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]

P

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