Rehabilitation of patients with stroke: summary of SIGN guidance
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2845 (Published 15 June 2010) Cite this as: BMJ 2010;340:c2845
- Lorraine N Smith, professor of nursing1,
- Roberta James, programme manager2,
- Mark Barber, lead clinician, stroke managed clinical network3,
- Scott Ramsay, consultant physician and geriatrician, lead clinician for stroke4,
- David Gillespie, consultant clinical neuropsychologist5,
- Charlie Chung, clinical specialist occupational therapist (stroke)6
- on behalf of the Guideline Development Group
- 1Nursing and Health Care, Faculty of Medicine, University of Glasgow, Glasgow G12 8LL
- 2Scottish Intercollegiate Guidelines Network (SIGN), Edinburgh EH7 5EA
- 3Department of Medicine for the Elderly, Monklands Hospital, Airdrie ML6 0JS
- 4St John’s Hospital, Livingston EH54 6PP
- 5Department of Clinical Psychology, Astley Ainslie Hospital, Edinburgh EH9 2HL
- 6Stroke Unit, Victoria Hospital, Fife KY2 5AH
- Correspondence to: L N Smith l.n.smith{at}clinmed.gla.ac.uk
Stroke is the third most common cause of death and the most frequent cause of severe adult disability in Scotland.1 Despite considerable advances in organised stroke care over recent years, improvements are still needed,2 because patients have been reported to spend up to 50% of their time in bed3 and only 20% of their time in treatment.4 Since publication of the previous Scottish Intercollegiate Guidelines Network (SIGN) guideline on rehabilitation after stroke (SIGN 64), several small studies have shown the effectiveness of new therapeutic techniques and technologies.5 This guideline supersedes the earlier guideline and summarises the most recent recommendations from SIGN on rehabilitation after stroke.6 It also complements SIGN guidelines 119 and 108 on other aspects of the management of stroke.7 8
Recommendations
SIGN recommendations are based on systematic reviews of best available evidence. The strength of the evidence is graded as A, B, C, or D (figure⇓), but the grading does not reflect the clinical importance of the recommendations. Recommended best practice (“good practice points”), based on the clinical experience of the guideline development group, is also indicated (as GPP).
Arranging appropriate care
Admit stroke patients who require admission to hospital to a stroke unit staffed by a coordinated multidisciplinary team with a special interest in stroke care (A).
In exceptional circumstances, when admission to a stroke unit is not possible, provide rehabilitation in a generic rehabilitation ward on an individual basis (B).
The core multidisciplinary team should include appropriate levels of nursing, medical, physiotherapy, occupational therapy, speech and language therapy, and social work staff (B).
Stroke inpatients should be treated 24 hours a day by nurses who specialise in stroke and are based in a stroke unit (B).
Actively involve patients and carers early in the rehabilitation process (A) and routinely provide them with information using active information strategies, which include a mixture of education and counselling techniques (A).
Mobility and activities of daily living
Mobilise patients as early as possible after stroke (B).
Physiotherapists should not limit their practice to one “approach” but should select interventions according to the patient’s individual needs (B).
Where the aim of treatment is the immediate improvement of walking speed, walking efficiency, gait pattern, or weight bearing during stance, an appropriately qualified health professional should assess the patient’s suitability for ankle foot orthoses (A).
Consider treadmill training to improve gait speed in people who are walking independently at the start of treatment (B).
When the goal of treatment is to improve functional ambulation, offer gait oriented physical fitness training to all patients assessed as medically stable and functionally safe to participate (A).
When the aim of treatment is to improve gait speed, walking distance, functional ambulation, or “sit to stand to sit,” include repetitive task training, where it is assessed to be safe and acceptable to the patient (B).
Where considered safe, pursue every opportunity to increase the intensity of treatment for improving gait (B).
Occupational therapists should include training in personal activities of daily living as part of an inpatient stroke rehabilitation programme (B).
Splinting is not recommended for improving upper limb function because it does not prevent the development of contractures or improve muscle extensibility (B).
Assessment of nutritional status and continence
Include ongoing monitoring of nutritional status with the following parameters (D):
- Swallowing status
- Nutritional intake
- Feeding assessment and dependence
- Unintentional weight loss
- Biochemical measures (low prealbumin, impaired glucose metabolism).
Every service caring for patients with stroke should develop and adhere to local urinary and faecal continence guidelines, including advice on appropriate referral (GPP).
Cognitive and emotional assessment
Fully assess for cognitive strengths and weaknesses when undergoing rehabilitation or when returning to cognitively demanding activities such as driving or work (GPP).
Occupational therapists with expertise in neurological care may carry out cognitive assessment, although some patients with more complex needs should be referred for specialist neuropsychological expertise (GPP).
Screen all stroke patients for visual problems and refer appropriately (C).
Consider appropriate referral to health and clinical psychology services for patients and carers to promote good recovery and adaptation and to prevent and treat abnormal adaptation to the consequences of stroke (GPP).
Screen all stroke patients for mood disturbance as early as possible using a validated tool, such as the stroke aphasic depression questionnaire (SAD-Q)9 or general health questionnaire of 12 items (GHQ-12)10 (GGP).
Screen patients with post-stroke fatigue for depression (GPP).
Consider patients with post-stroke depression for treatment with antidepressants (A).11
Choose the appropriate antidepressant on an individual basis (GPP).
Pain assessment
Ask patients about pain and assess the severity of pain (using a validated pain assessment tool such as the visual analogue scale or numerical rating scale)12 and treat appropriately as soon as possible (GPP).
In patients with central post-stroke pain that does not respond to standard treatment, and where clinician and patient are aware of potential side effects, consider the use of amitriptyline (titrated to a dose of 75 mg). If amitriptyline is ineffective or contraindicated, lamotrigine or carbamazepine are alternatives, although they have a high incidence of side effects (B).13
Given the complexity of post-stroke shoulder pain, consider the use of algorithms or an integrated care pathway for its diagnosis and management (GPP).
Shoulder subluxation
Consider electrical stimulation to the supraspinatus and deltoid as soon as possible after stroke in patients at risk of developing shoulder subluxation from having little or no activity in shoulder muscles (A).
Transfer from hospital to home
Patients with mild to moderate stroke should be able to access stroke specialist early supported discharge services in addition to conventional organised stroke inpatient services (A).
Health boards should consider providing a specific local expert therapist to advise rehabilitation teams on subjects such as providing information on relevant statutory services such as disability employment advisers at job centres, organisations that provide opportunities for people with disabilities (such as Momentum), or voluntary services that can provide help and support (such as Chest Heart and Stroke Scotland (CHSS) and the Stroke Association (GPP)).
Living in the community
Ask patients about vocational activities, initiate liaison with employers early in the rehabilitation pathway, and assess the patient’s ability to meet the needs of current or potential employment (GPP).
Advise patients that they must not drive for at least one month after their stroke (GPP).
If there is doubt about a patient’s ability to drive, refer the patient to the local Disabled Drivers’ Assessment Centre (www.dft.gov.uk/dvla) (D).
Overcoming barriers
Specialist rehabilitation is central to successful recovery after stroke and specific standards and targets to drive improvements must be implemented. The evidence base for rehabilitation interventions is expanding, and it challenges traditional patterns of care in many areas. Stroke rehabilitation teams need to adopt these evidence based changes and translate them into routine clinical practice. Patients should receive treatment seven days a week, and increasing the use of generic therapy assistants across rehabilitation disciplines may help achieve this. Moving rehabilitation from hospital to home at an earlier stage improves outcomes but will need further development of early supported discharge teams with specialist stroke skills.14 Recovery often continues at a slower rate for many years after stroke. It is important to maintain access to rehabilitation services throughout this time, and the use of local leisure centres to facilitate ongoing exercise programmes should be encouraged.15 Finally, despite the best medical care, around 20% of stroke patients die within the first 30 days.16 The provision of high quality palliative care by stroke teams to these patients and their families is an area that requires further development.
Further information on the guidance
The guidance provides new recommendations for rehabilitation after stroke in the following areas: treatment of physical impairments and limitations (such as balance, mobility, upper limb function, shoulder subluxation, incontinence, and central post-stroke and hemiplegic pain), treatment of visual disturbances (including visual neglect), assessment and management of patients at nutritional risk, treatment of disturbances of mood and emotional behaviour (including emotional adjustment), the organisation and delivery of services (early supported discharge, home versus outpatient or hospital care), and the information needs of patients and their caregivers.
Methods
SIGN guideline 118 was developed using established SIGN methodology based on a systematic review of the evidence. SIGN is a collaborative, multidisciplinary network of healthcare professionals and patient organisations and is part of NHS Quality Improvement Scotland. Further details about SIGN and the guideline development methodology are available in SIGN 50: A Guideline Developer’s Handbook (www.sign.ac.uk/guidelines/fulltext/50/index.html).
SIGN 118 is a substantial update of SIGN 64. We reviewed new evidence that could alter the content of SIGN 64 recommendations and made such changes if necessary. Where new evidence did not require existing recommendations to be updated, no new evidence was identified, or no key question was posed to update a section, the guideline text and recommendations were reproduced from SIGN 64. The original supporting evidence was not reappraised by the current guideline development group.
Future research and remaining uncertainties
Areas identified for further research include:
Effectiveness of different treatment interventions, the optimum intensity of treatment, the optimum timing of such interventions, and identification of which patients benefit most from which interventions
Assessment of and interventions for visual impairments and eye movement problems after stroke
Exploration of attitudes and beliefs (of patients and caregivers) about recovery and their effect on adjustment and recovery
Development of management algorithms for the assessment, prevention, and treatment of post-stroke shoulder pain (including research into effective interventions)
Effective screening and intervention for post-stroke mood disturbances and cognitive impairments
Interventions for post-stroke spasticity
Treatment of aphasia and interventions for dysarthria and sialorrhoea
Pharmacological and exercise interventions for post-stroke fatigue
Treatments that require more assessment include visual and auditory feedback; electrical stimulation; different types of ankle foot orthoses (and longer term risks and benefits of this intervention); and electromechanical assisted gait training to improve balance, gait, or mobility. Other areas include virtual reality training, bilateral training, repetitive tasks training, imagery and mental practice, splinting, electromechanical and robot assisted arm training to improve upper limb function.
Useful resources
Chest, Heart and Stroke Scotland, Head Office, 65 North Castle Street, Edinburgh EH2 3LT. Tel: +44(0)131 225 6963; email: admin{at}chss.org.uk; website: www.chss.org.uk
Stroke Association, Links House, 15 Links Place, Edinburgh EH6 7EZ. Tel: +44(0)131 555 7240; email: scotland{at}stroke.org.uk; website: www.stroke.org.uk
Stroke Training and Awareness Resources (STARs)—This is an elearning resource that incorporates stroke core competencies and more specialised resources and is aimed at staff working in acute stroke services (www.StrokeTraining.org)
Different Strokes, 9 Canon Harnett Court, Wolverton Mill, Milton Keynes MK12 5NF. Tel: +44(0)1908 317618; email: info{at}differentstrokes.co.uk; website: www.differentstrokes.co.uk
Connect, 16-18 Marshalsea Road, London SE1 1HL. Tel: +44(02)0 7367 0840; email: info{at}ukconnect.org; website: www.ukconnect.org
Speakability, 1 Royal Street, London SE1 7LL. Tel: +44(0)20 7261 9572; email: speakability{at}speakability.org.uk; website: www.speakability.org.uk
Communication Forum Scotland. Talk for Scotland. A practical toolkit for engaging with people with communication support needs. website: www.communicationforumscotland.org.uk
Notes
Cite this as: BMJ 2010;340:c2845
Footnotes
This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists
The members of the Guideline Development Group are Lorraine N Smith (chair), professor of nursing, University of Glasgow; Mark Barber, stroke managed clinical network lead clinician, Monklands Hospital, Airdrie; Phil Birschel, consultant stroke physician, Southern General Hospital, Glasgow; Sheena Borthwick, speech and language therapist, Western General Hospital, Edinburgh; Gill Bowler, lay representative, Edinburgh; Michelle Brogan, speech and language therapy manager, Astley Ainslie Hospital, Edinburgh; John Brown, lay representative, North Berwick; Charlie Chung, clinical specialist occupational therapist (stroke), Victoria Hospital, Fife; Ronald Collie, lay representative, Aberdeen; Kenneth Collins, general practitioner, Glasgow; Fiona Coupar, chief scientist office research training fellow, Glasgow Royal Infirmary; David Gillespie, consultant clinical neuropsychologist, Astley Ainslie Hospital, Edinburgh; Niall Hughes, consultant physician in care of the elderly/stroke, Wishaw General Hospital; Michele Hilton Boon, information officer, SIGN; Roberta James, programme manager, SIGN; Sara Joice, chartered health psychologist, Social Dimensions of Health Institute/School of Nursing and Midwifery, University of Dundee; Thomas Jones, Chest, Heart and Stroke Scotland stroke liaison nurse, St Johns Hospital, Livingston; Maggie Lawrence, research fellow, Glasgow Caledonian University; Christine McAlpine, NHS Greater Glasgow and Clyde stroke managed clinical network lead clinician, Stobhill Hospital, Glasgow; Alex Pollock, research fellow, Stroke Programme, Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University; Scott Ramsay, consultant in stroke, St John’s Hospital, Livingston; Lynn Robertson, lead physiotherapist, Stroke Rehabilitation, Dumfries and Galloway Hospital; Alexandra Shearer, lay representative, Orkney; Fiona Smith, senior dietitian, Aberdeen Royal Infirmary; Janice Whittick, consultant clinical psychologist, Stratheden Hospital, Fife; Kathryn Wood, lead clinical pharmacist, Ashludie Hospital, Monifieth.
Contributors: LNS had the idea for the article and is guarantor. All authors helped perform the literature search, appraise the evidence, write the article, and correct it.
Funding: No funding was received for writing this summary.
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: (1) No financial support for the submitted work from anyone other than their employers; (2) No financial relationships with commercial entities that might have an interest in the submitted work; (3) No spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; (4) No non-financial interests that may be relevant to the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.