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SIGN Scottish Intercollegiate Guidelines Network Part of NHS Quality Improvement Scotland 118 Management of patients with stroke: Rehabilitation, prevention and management of complications, and discharge planning A national clinical guideline June 2010 KEY TO EVIDENCE STATEMENTS AND GRADES OF RECOMMENDATIONS LEVELS OF EVIDENCE 1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias 1+ Well conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias 1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias High quality systematic reviews of case control or cohort studies 2++ High  quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal 2+ Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal 2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal 3 Non-analytic studies, eg case reports, case series 4 Expert opinion GRADES OF RECOMMENDATION Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation. A B  t least one meta-analysis, systematic review, or RCT rated as 1++, A and directly applicable to the target population; or  body of evidence consisting principally of studies rated as 1+, A directly applicable to the target population, and demonstrating overall consistency of results A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 1++ or 1+ C A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 2++ D Evidence level 3 or 4; or Extrapolated evidence from studies rated as 2+ GOOD PRACTICE POINTS  Recommended best practice based on the clinical experience of the guideline development group NHS Evidence has accredited the process used by Scottish Intercollegiate Guidelines Network to produce guidelines. Accreditation is valid for three years from 2009 and is applicable to guidance produced using the processes described in SIGN 50: a guideline developer’s handbook, 2008 edition (www.sign.ac.uk/guidelines/ fulltext/50/index.html). More information on accreditation can be viewed at www.evidence.nhs.uk NHS Quality Improvement Scotland (NHS QIS) is committed to equality and diversity and assesses all its publications for likely impact on the six equality groups defined by age, disability, gender, race, religion/belief and sexual orientation. SIGN guidelines are produced using a standard methodology that has been equality impact assessed to ensure that these equality aims are addressed in every guideline. This methodology is set out in the current version of SIGN 50, our guideline manual, which can be found at www.sign.ac.uk/guidelines/fulltext/50/index.html. The EQIA assessment of the manual can be seen at www.sign. ac.uk/pdf/sign50eqia.pdf. The full report in paper form and/or alternative format is available on request from the NHS QIS Equality and Diversity Officer. Every care is taken to ensure that this publication is correct in every detail at the time of publication. However, in the event of errors or omissions corrections will be published in the web version of this document, which is the definitive version at all times. This version can be found on our web site www.sign.ac.uk. This document is produced from elemental chlorine-free material and is sourced from sustainable forests. Scottish Intercollegiate Guidelines Network Management of patients with stroke: Rehabilitation, prevention and management of complications, and discharge planning A national clinical guideline June 2010 stroke Rehabilitation ISBN 978 1 905813 63 6 Published June 2010 SIGN consents to the photocopying of this guideline for the purpose of implementation in NHSScotland Scottish Intercollegiate Guidelines Network Elliott House, 8 -10 Hillside Crescent Edinburgh EH7 5EA www.sign.ac.uk CONTENTS Contents 1 Introduction................................................................................................................. 1 1.1 The need for a guideline............................................................................................... 1 1.2 Remit of the guideline................................................................................................... 2 1.3 Statement of intent........................................................................................................ 4 2 Key recommendations.................................................................................................. 5 2.1 Organisation of services................................................................................................ 5 2.2 Management and prevention strategies.......................................................................... 5 2.3 Transfer from hospital to home...................................................................................... 6 2.4 Roles of the multidisciplinary team............................................................................... 6 2.5 Provision of information................................................................................................ 6 3 Organisation of services............................................................................................... 7 3.1 Referral to stroke services.............................................................................................. 7 3.2 Organisation of hospital care......................................................................................... 7 3.3 Multidisciplinary team membership.............................................................................. 9 4 Management and prevention strategies........................................................................ 12 4.1 General rehabilitation principles................................................................................... 12 4.2 Gait, balance and mobility............................................................................................ 15 4.3 Upper limb function...................................................................................................... 19 4.4 Cognition...................................................................................................................... 22 4.5 Visual problems............................................................................................................ 23 4.6 Communication............................................................................................................ 25 4.7 Nutrition and swallowing.............................................................................................. 26 4.8 Continence................................................................................................................... 29 4.9 Post-stroke spasticity..................................................................................................... 31 4.10 Prevention and treatment of shoulder subluxation......................................................... 34 4.11 Pain.............................................................................................................................. 35 4.12 Prevention of post-stroke shoulder pain......................................................................... 36 4.13 Treatment of post-stroke shoulder pain.......................................................................... 39 4.14 Post-stroke fatigue......................................................................................................... 42 4.15 Disturbances of mood and emotional behaviour........................................................... 43 4.16 Sexuality....................................................................................................................... 46 4.17 Infection........................................................................................................................ 47 4.18 Pressure ulcer prevention.............................................................................................. 47 4.19 Venous thromboembolism............................................................................................ 47 4.20 Falls.............................................................................................................................. 48 4.21 Recurrent stroke............................................................................................................ 48 stroke Rehabilitation Control of pain in adults with cancer 5 Transfer from hospital to home.................................................................................... 49 5.1 Pre-discharge................................................................................................................ 49 5.2 Discharge...................................................................................................................... 50 5.3 Early supported discharge and post-discharge support................................................... 50 5.4 Home based or outpatient rehabilitation?...................................................................... 51 5.5 Longer term stroke rehabilitation in the community...................................................... 51 5.6 Moving on after a stroke................................................................................................ 52 5.7 General practitioner care............................................................................................... 54 6 Roles of the multidisciplinary team.............................................................................. 56 6.1 Nursing care................................................................................................................. 56 6.2 Physician care............................................................................................................... 56 6.3 Physiotherapy............................................................................................................... 57 6.4 Speech and language therapy........................................................................................ 58 6.5 Occupational therapy.................................................................................................... 59 6.6 Social work................................................................................................................... 60 6.7 Clinical psychology....................................................................................................... 60 6.8 Dietetic care................................................................................................................. 61 6.9 Orthoptic care............................................................................................................... 62 6.10 Pharmaceutical care...................................................................................................... 63 7 Provision of information............................................................................................... 64 7.1 Information needs of patients and carers....................................................................... 64 7.2 Carer support................................................................................................................ 65 7.3 Sources of further information....................................................................................... 65 7.4 Checklist for provision of information........................................................................... 69 8 Implementing the guideline.......................................................................................... 71 8.1 Resource implications of key recommendations ........................................................... 71 8.2 Auditing current practice............................................................................................... 73 8.3 Additional advice to NHSScotland from the Scottish Medicines Consortium................. 75 9 The evidence base........................................................................................................ 76 9.1 Systematic literature review........................................................................................... 76 9.2 Recommendations for research..................................................................................... 76 10 Development of the guideline...................................................................................... 78 10.1 Introduction.................................................................................................................. 78 10.2 The guideline development group................................................................................. 78 10.3 Consultation and peer review........................................................................................ 80 Abbreviations............................................................................................................................... 83 Annexes ..................................................................................................................................... 85 References................................................................................................................................... 96 1 INTRODUCTION 1 Introduction 1.1 the need for a guideline 1.1.1 updating the evidence This guideline is an update of SIGN 64 Management of patients with stroke: rehabilitation, prevention and management of complications, and discharge planning and supersedes it. Since the publication of SIGN 64 in 2002, new evidence has been published in many areas covered by the recommendations in that guideline resulting in the need for this selective update. Where this evidence was thought likely to significantly change the content of these recommendations, it has been identified and reviewed. The guideline development group based its recommendations on the evidence available to answer a series of key questions, listed in Annex 1. Details of the systematic literature review can be found in section 9.1. Where new evidence does not update existing recommendations, no new evidence was identified to support an update or no key question was posed to update a section, the guideline text and recommendations are reproduced from SIGN 64. The original supporting evidence was not re-appraised by the current guideline development group. 1.1.2 summary of updates to the guideline, by section 1.1.3 2 Key recommendations New 3 Organisation of services Partial update 4 Management and prevention strategies Extensive update 5 Transfer from hospital to home Partial update 6 Roles of the multidisciplinary team Partial update 7 Provision of information New background Stroke is the third commonest cause of death and the most frequent cause of severe adult disability in Scotland. Seventy thousand individuals are living with stroke and its consequences and each year, there will be approximately 12,500 new stroke events.1 Immediate mortality is high and approximately 20% of stroke patients die within 30 days. For those who survive, the recovery of neurological impairment takes place over a variable time span. About 30% of survivors will be fully independent within three weeks, rising to nearly 50% by six months.2 Disabling conditions such as stroke are best considered within an agreed framework of definitions. The World Health Organization (WHO) International Classification of Impairments, Disabilities and Handicaps (ICIDH) provides the following framework for considering the impact of stroke on the individual:3,4 ƒƒ ƒƒ ƒƒ ƒƒ pathology (disease or diagnosis): operating at the level of the organ or organ system impairment (symptoms and signs): operating at the level of the whole body activity limitations (disability): observed behavior or function participation restriction (handicap): social position and roles of the individual. 1 stroke Rehabilitation A number of contextual factors may influence this framework as recognised in the International Classification of Functioning, Disability and Health (ICF).5 ICF has two parts, each with two components: ƒƒ Part 1 Functioning and disability a) Body functions and structures b) Activities and participation ƒƒ Part 2 Contextual factors c) Environmental factors d) Personal factors. The ICF also outlines nine domains of activity and participation which can provide the focus for rehabilitation efforts: ƒƒ ƒƒ ƒƒ ƒƒ ƒƒ ƒƒ ƒƒ ƒƒ ƒƒ Learning and applying knowledge General tasks and demands Communication Mobility Self care Domestic life Interpersonal interactions and relationships Major life areas Community, social and civic life. Within this framework, rehabilitation aims to maximise the individual’s activity, participation (social position and roles) and quality of life, and minimise the distress to carers. 1.1.4 REHABILITATION The conventional approach to rehabilitation is a cyclical process: ƒƒ ƒƒ ƒƒ ƒƒ assessment: patients’ needs are identified and quantified goal setting: goals are defined for improvement (long/medium/short term) intervention: to assist in the achievement of the goals re-assessment: progress is assessed against the agreed goals. Rehabilitation goals can be considered at several levels: ƒƒ aims: often long term and referring to the situation after discharge ƒƒ objectives: usually multiprofessional at the level of disability ƒƒ targets: short term time-limited goals. The process of rehabilitation can be interrupted at any stage by previous disability, co-morbidities and complications of the stroke itself. 1.1.5 tERMINOLOGY ‘Disability’ and ‘handicap’ have been replaced with the new terms ‘activity limitations’ and ‘participation restrictions’, respectively. The above terms are used interchangeably in this document. 1.2 REMIT of the guideline 1.2.1 overall objectives The aim of this national guideline is to assist individual clinicians, primary care teams and hospital departments to optimise their management of stroke patients. The focus is on general management, rehabilitation, the prevention and management of complications and discharge planning, with an emphasis on the first 12 months after stroke. 2 1 INTRODUCTION The guideline complements SIGN 119 Management of patients with stroke: identification and management of dysphagia6 and SIGN 108 Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention.7 Although stroke can cause continuing problems in subsequent years and decades, a review of the continued management of people with stroke is beyond the scope of this guideline. However, the guideline includes some guidance that may also be relevant beyond the first year of stroke. Approximately 20% of people who experience a stroke will die within 30 days of its occurrence. While care of the dying and of their family is an important and sometimes unrecognised aspect of stroke care, it is beyond the scope of this guideline. Guidance on palliative and end of life care is available from the NHS National End of Life Care Programme.8 A number of important topics not included in SIGN 64 nor in this selective update were identified during peer review of this guideline. These topics will be considered in the update of this guideline and include: ƒƒ ƒƒ ƒƒ ƒƒ ƒƒ ƒƒ contracture apraxia participation restrictions palliative and end of life care social work interventions people living in a care home before and/or after having a stroke. This guideline has five main sections: ƒƒ Organisation of services: this section addresses the issue of how services should be configured to provide optimal care for people who have had a stroke. This section will be of most relevance to those responsible for planning and providing rehabilitation services. ƒƒ Management and prevention strategies: this section addresses general rehabilitation principles, which are relevant to the majority of stroke patients. It also aims to inform the assessment and management of common impairments or complications resulting from a stroke. It is based on studies which have identified common and important impairments, disabilities and complications following stroke. It aims to be useful to multidisciplinary teams and individual clinicians when planning treatment of individual patients. ƒƒ Transfer from hospital to home: this section addresses the planned transfer of care of patients from the hospital to the home setting. ƒƒ Roles of the multidisciplinary team: this section is derived from clinical studies and supporting information and aims to provide guidance on the levels of care and expertise to be provided within stroke services. ƒƒ Provision of information: This section reflects the issues likely to be of most concern to patients and their carers. It will be of most relevance to health professionals discussing rehabilitation after stroke with patients and carers and in guiding the production of locally produced information materials. Creating regional/local consensus on the use of a standardised set of assessments when patientrelated information is transferred from one centre to another (or the community) may be an important aspect for improving the quality of care of stroke patients. 1.2.2 target users of the guideline This guideline will be of particular interest to anyone with an interest in stroke, including but not exclusively, stroke physicians, nurses especially those caring for people with stroke, specialists in geriatric medicine and care of the elderly, rehabilitation specialists, general physicians, speech and language therapists, dietitians, physiotherapists, occupational therapists, orthoptists, orthotists, pharmacists, psychologists, neurologists, general practitioners, specialists in public health, healthcare service planners, people who have had a stroke, their carers and families. 3 stroke Rehabilitation 1.2.3 Patient version A patient version of this guideline is available at www.sign.ac.uk. 1.3 Statement of intent This guideline is not intended to be construed or to serve as a standard of medical care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgement regarding a particular clinical procedure or treatment plan must be made in light of the clinical data presented by the patient and the diagnostic and treatment options available. However, it is advised that significant departures from the national guideline or any local guidelines derived from it should be fully documented in the patient’s case notes at the time the relevant decision is taken. 1.3.1 prescribing oF licensed medicines outwith their marketing authorisation Recommendations within this guideline are based on the best clinical evidence. Some recommendations may be for medicines prescribed outwith the marketing authorisation (product licence). This is known as “off label” use. It is not unusual for medicines to be prescribed outwith their product licence and this can be necessary for a variety of reasons. Generally the unlicensed use of medicines becomes necessary if the clinical need cannot be met by licensed medicines; such use should be supported by appropriate evidence and experience.9 Medicines may be prescribed outwith their product licence in the following circumstances: ƒƒ for an indication not specified within the marketing authorisation ƒƒ for administration via a different route ƒƒ for administration of a different dose. ‘Prescribing medicines outside the recommendations of their marketing authorisation alters (and probably increases) the prescribers’ professional responsibility and potential liability. The prescriber should be able to justify and feel competent in using such medicines.’9 Any practitioner following a SIGN recommendation and prescribing a licensed medicine outwith the product licence needs to be aware that they are responsible for this decision, and in the event of adverse outcomes, may be required to justify the actions that they have taken. Prior to prescribing, the licensing status of a medication should be checked in the current version of the British National Formulary (BNF). 1.3.2 additional advice to nhsscotland from NHS quality improvement scotland and the scottish medicines consortium NHS QIS processes multiple technology appraisals (MTAs) for NHSScotland that have been produced by the National Institute for Health and Clinical Excellence (NICE) in England and Wales. The Scottish Medicines Consortium (SMC) provides advice to NHS Boards and their Area Drug and Therapeutics Committees about the status of all newly licensed medicines and any major new indications for established products. SMC advice relevant to this guideline is summarised in the section on implementation. No relevant NICE MTAs were identified. 4