卒中康复指南-美国2025

Introduction

Stroke affects approximately 117,600 individuals per year, with more than 1.2 million stroke survivors currently in the UK (Stroke Association, 2017). The number of stroke survivors aged 45 years and over is also expected to rise by 123% over the next 20 years (King et al, 2020; Stroke Association, 2025a). Traditionally, stroke was regarded as an issue for the older individual, but there is increasing evidence to suggest that it is also a significant problem for the younger to middle-aged community (Zhong et al, 2023).

Almost two-thirds of stroke survivors leave the hospital with a disability, hence the demand for care and support is growing. This is emphasised further by the advent of improved stroke treatments, such as thrombolysis and mechanical thrombectomy, which have led to greater numbers of stroke survivors that could potentially benefit from rehabilitation. Given the increasing number of stroke patients, promising rehabilitation strategies to meet their needs has become a critical issue.

Rehabilitation is an essential aspect in the care of stroke patients, both in the acute and long-term setting to improve patient outcomes and enhance their independence. It should be emphasised that stroke rehabilitation is personalised and focused on the patient's individual needs and goals rather than solely representing a package of uniform measures to be applied across the entire population (NICE,

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2023). This is particularly important as there is a lack of evidence into when recovery should start and stop for a patient, and when available stroke services should stop intervening (Ward and Kitago, 2016). Moreover, these are likely to be contingent on the individual patient and hence a personalised “rehabilitation prescription” needs to be implemented (Chang, 2022).

In this review, we aim to summarise the pertinent points of the updated UK guidelines surrounding stroke rehabilitation to aid the general clinician. Importantly, we discuss inpatient and community rehabilitation strategies, recognising the unequal resource distribution across geographical locations that may be partly addressed by the new guidance, but also the remaining knowledge gaps that require further research.

Environment

Stroke rehabilitation in the hospital setting should either be undertaken in a specialist stroke unit or inpatient neurohabilitation facility (Rodgers and Price, 2017). Furthermore, it should be facilitated by a specialist multidisciplinary team (MDT) who are experienced in working alongside stroke patients as well as their families/carers (see Table 1) (NICE, 2023). The roles and responsibilities of the MDT members should be made familiar to the patients and their caregivers at the earliest opportunity, and rehabilitation benefits conveyed to manage their expectations. Alongside this, a named stroke rehabilitation coordinator should be made known to the MDT, the patient and their family/carers and a personalised rehabilitation plan put in place.

Acute Screening

A comprehensive medical assessment by the MDT in the acute post-stroke period should be undertaken in all stroke patients, which is invaluable to provide an initial understanding of potential deficits.

This should include an assessment of cognition (including memory and attention), emotional and behavioural functioning, mental health (including adjustment to the stroke diagnosis), vision (including examination for attention), hearing, muscle tone, strength, pain, sensation, and balance (NICE, 2023). The use of reliable tools is encouraged to assess these formally, such as the National Institute of Health Stroke Scale or Barthel Index for Activities of Daily Living, with the findings communicated with the rest of the MDT (National Institute of Neurological Disorders and Stroke, 2024; Wade and Collin, 1988). Compiling these with information about the patient's previous functional baseline would subsequently allow the MDT to delineate the patient's rehabilitation needs and assist in forming a rehabilitation plan that is tailored and patient-specific.

# Rehabilitation Plans and Goal Setting

The MDT are advised to meet regularly to review patients' rehabilitation plans, with the frequency of these meetings dependent on the stage of rehabilitation and

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|Team members|Responsibility| |---|---| |Consultant stroke or rehabilitation physicians|Lead the MDT and oversee the rehabilitation processEnsure the patients' medical needs are being met across the spectrum of care| |Nurses|Provide daily care for stroke patients and monitor for complicationsAssist with mobilization and functional activity as part of early rehabilitation| |Physiotherapists|Evaluate and develop individualised rehabilitation plans to improve mobility, muscle strength, coordination, balance and motor functionHelp the patient to regain independence in walking, transferring, and using assisted devices if needed| |Occupational therapists|Focus on strategies to improve independence in activities of daily living, using adaptive equipment and techniquesHelp the patient to adapt to their environment or work, accommodating their physical and cognitive abilities| |Speech and language therapists|Assess communication and swallowing difficulties and provide plans to improve speech and languageEducate patients and carers about strategies to enhance communication and ensure safety during feeding| |Dietitians|Work together with speech and language therapists whilst advising on dietary needs, taking into account the patient's weight, hydration and electrolyte status| |Clinical psychologists/neuropsychologists|Offer psychological support to patients dealing with emotional and cognitive consequences of stroke| |Orthoptists|Manage visual problems related to stroke including eye coordination and alignment issues, using visual aids or exercises| |Rehabilitation assistants|Provide hands-on care to assist the patient to practice functional tasks in a supportive environment| |Social workers|Assess the social, emotional and financial needs of stroke patients and their familiesAdvocate for patients to attain appropriate support and living arrangements|

MDT, multidisciplinary team.

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needs of each specific patient. Fig. 1 details essential information to be included in the rehabilitation plans of stroke patients.

 Fig. 1. Important aspects to be included in stroke rehabilitation plans (NICE, 2023). Figure created using Microsoft Word 2016 (Microsoft Corporation, Redmond, WA, USA).

The patient and their carers should be involved in setting meaningful, tailored, and challenging (yet achievable) short- and long-term goals with the MDT (Littooij et al, 2022). Regular timetabled goal review meetings should then be held to review progress and consider new goals. Exemplar frameworks have been proposed to assist with this (Leonardi and Fheodoroff, 2021). Communication during goal-setting meetings should be optimised to ensure that the patient can understand and take an active role in setting the goals themselves. The goals should reinforce the need for activity and participation of the patient to optimise their rehabilitation potential. It is important to recognise that there may also be significant cultural factors that influence the rehabilitation journey of a patient, such as faith engagement, extent of family involvement and beliefs in traditional and complimentary therapies (Naftchi et al, 2021). Hence, it would be important to consider these when constructing these goals.

When Should Rehabilitation Start?

Early mobilisation is encouraged in the updated guidance, supporting patients to sit out of bed, stand or walk as soon as their condition permits (NICE, 2023). If they require assistance, they should not be offered high-intensity mobilisation (3 additional out-of-bed sessions compared with usual care) in the first 24 hours after symptom onset. Importantly, the A Very Early Rehabilitation Trial after stroke (AVERT), which was a large scale multicentre single-blind randomised controlled trial involving 2104 patients, showed that patients who undertook their first mobilisation intervention within 24 hours of stroke showed a less favourable outcome at three months compared to patients who underwent usual stroke care (Langhorne et

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al, 2017b). Therefore, it may be pragmatic that other baseline assessments should be performed in the first 24 hours of stroke onset, and less emphasis should be placed on mobilisation on those that are deemed inappropriate for high-intensity mobilisation.

How Much Daily Rehabilitation Should Be Offered?

The updated recommendations advise that rehabilitation sessions should be offered for at least 3 hours (rather than 45 minutes as previously recommended) per day for 5 days per week (NICE, 2023). This was on the basis that more intensive physiotherapy improves quality of life and cost-effectiveness, facilitates independence with activities of daily living and patients felt this enabled them to recover faster in the first 6 months post-stroke (Royal College of Physicians, 2013). Furthermore, this is supported by a study, which demonstrated that intensive therapy led to better functional outcomes and clinically meaningful improvements for stroke survivors (Schneider et al, 2016). A further study also advocated for this, suggesting higher intensity and sessions up to 3 hours per day leads to better improvements in motor function (Winstein et al, 2016). These suggested extended sessions do not define a time commitment to physiotherapy specifically, but combined therapy input including physiotherapy, occupational therapy and speech and language therapy so that patients with varying degrees of disability can be catered for. Most stroke units may be able to provide 7 days per week of therapy, but there remains insufficient evidence to recommend an increased intensity of physiotherapy to every day, hence achieving this should be at the discretion of the therapy teams.

Rehabilitation strategies for severe stroke patients require a tailored approach, as these patients may be less likely to engage in conventional rehabilitation techniques due to motor and cognitive impairments. Bedside rehabilitation strategies, such as passive range-of-motion (ROM) exercises and positioning techniques, may subsequently be more appropriate and should be offered in these subgroups (Ada et al, 2005; Hosseini et al, 2019). Further empirical studies are required to establish clearer strategies for such groups of patients and critical cases.

How to Deliver 3 Hours of Rehabilitation Per Day?

Stroke units are encouraged to offer individual and group sessions, which can be led by trained therapists or therapy assistants. Some units also encourage patients' carers to be taught how to deliver these sessions to facilitate continuity of care, especially when the patient has transitioned into the community. A culture of activities on stroke units, such as music, art and gardening groups assist the patient in remaining engaged with a reasonable target of 60% per day of rehabilitation time. Telerehabilitation and self-delivered therapy are also encouraged once the patient returns home as adjuncts to therapy sessions.

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Specific Needs

Cognition, Vision and Hearing

Cognition is commonly affected but also may significantly fluctuate post-stroke, hence it is important to prepare patients and their carers for this (Elendu et al, 2023). Additionally, increasing patients' awareness of a specific cognitive impairment should be considered as this may enhance their ability to improve with rehabilitation.

Memory impairment may be identified, to which the current guidelines advise for techniques, such as errorless learning and exercises (e.g., use of mnemonics), aids (e.g., calendars) and environmental strategies (e.g., prompts) to improve this (Fish et al, 2015; NICE, 2023). Attention training (e.g., by minimising distractions) should also be considered for patients with attention deficits (Barker-Collo et al, 2009).

An initial bedside visual assessment should be performed in all stroke patients, as impairment is a common and often missed entity in practice, despite possessing significant implications on activities, such as driving (Falkenberg et al, 2020). Patients with visual impairment on initial screening should be offered a specialist orthoptist assessment as soon as possible. Eye movement therapy (saccadic training to compensate for visuoperceptive impairment) may be offered in cases of persistent hemianopia (Leff and Barton, 2021). Functional tasks (such as using bright coloured lines on the edge of a page) should also be considered in patients with visual inattention. Referral to specialist clinics that support patients with post-stroke visual impairment, providing further invaluable exercises and information, should also be considered (UCL, 2022). These referrals can be facilitated by the patient's primary care provider.

It is recommended that hearing impairment is to be screened for within the first 6 weeks following stroke symptoms, using assessment tools such as the Handicap Hearing Inventory in the Elderly or Amsterdam Inventory Auditory of Disability questionnaires (Cassarly et al, 2020; Ventry and Weinstein, 1982). If identified, an examination should be undertaken to exclude impacted wax or acute infections, such as otitis externa, before referring the patient for a specialist audiology assessment.

Dysphagia and Nutrition

It is imperative that good oral hygiene be maintained by encouraging patients to brush their teeth and gums at least twice per day and similarly use mouthwash and oral gels (with antibacterial and antifungal properties if needed), to prevent the risk of aspiration pneumonia. Aspiration pneumonia causes the highest attributable mortality of all medical complications following stroke (Armstrong and Mosher, 2011). If the patient struggles to do this themselves, it is advised that a suitably trained healthcare professional or carer should be provided with adequate support to help them. Additionally, electric or battery-powered toothbrushes should be utilised if this is more amenable to the patients' abilities.

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Swallowing assessments should be performed upon admission by an appropriately trained professional before deeming oral intake safe for the patient (Labeit et al, 2023). If a swallowing issue is identified, a specialist assessment is warranted no more than 72 hours after (NICE, 2023). Feeding via a nasogastric tube should also be instigated within 24 hours of the acute stroke admission within those with inadequate oral intake, unless the patient received thrombolysis. Insertion of a nasogastric tube should be avoided, if possible, during the first 24 hours in thrombolysed patients (Adams et al, 1996). It is advised that a nasal bridle tube or gastrostomy should be considered if the patient is unable to tolerate a nasogastric tube.

Patients with suspected dysphagia for three days should be re-assessed, considered for instrumental examination and referred for dietary advice. Education on dysphagia should also be provided to the patient and their family/carer to ensure they comprehend the risks and helpful techniques in the event of coughing or choking following oral consumption. Patients with oropharyngeal dysphagia should be supported to make adaptations to their position, modify their diet and/or make compensatory strategies to optimise their ability to consume safely (Geeganage et al, 2012). Behavioural exercises, such as the Mendelsohn manoeuvre, should be offered at least 5 days per week to such patients as well as physical stimulation (e.g., thermal or tactile stimulation) (Fukuoka et al, 2013; Inamoto et al, 2018; McCullough and Kim, 2013). Thermal-tactile stimulation is performed by passing a cold laryngeal mirror along the anterior faucial pillars and the tongue, with the patient being asked to swallow their saliva immediately after the stimulus (Olchik et al, 2020). A cold teaspoon is then used to stimulate the back of the tongue with forward-moving strokes to stimulate automatic elevation of the tip of the tongue, and again following the strokes the patient is asked to swallow the saliva. It may also be necessary to modify the formulation/route of administration or rationalise medications for patients who find it difficult to consume tablets.

It should be noted that some patients with dysphagia and a risk of aspiration may still wish to consume food and drink without assistance or modification. In these instances, provided the patient understands the risks and benefits of this choice, it is advised that their wishes be respected.

Patients requiring a nasogastric tube at 4 weeks following a stroke should be considered for a percutaneous endoscopic gastrostomy (PEG) tube. A requirement for a PEG tube is generally considered a useful indicator for a severely disabling stroke, hence decisions surrounding insertion should ideally be facilitated by a specialist feeding issues MDT in conjunction with the patient and their family/carers (Iizuka and Reding, 2005; Sutcliffe et al, 2020). It is important to be mindful that the thirty-day mortality rate following PEG insertion can be up to 23.5% in such patients, hence this should be taken into consideration when discussions about insertion are being held (Lima et al, 2023).

Stroke patients are particularly at risk of malnutrition, hence should be screened regularly for this using reliable and established tools, such as the body mass index, percentage unintentional weight loss and the Malnutrition Universal Screening Tool (Bouziana and Tziomalos, 2011; Ferguson et al, 1999). Specialist dietary advice, including oral supplementation and/or tube feeding can subsequently be used to en-

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sure prompt commencement of nutritional support. It is advised that patients with modified diets are reassessed regularly until they are stable.

Communication

It is recommended that difficulties in communication, particularly aphasia and dysarthria, are screened for within the first 72 hours from the onset of stroke symptoms (NICE, 2023). In patients who may have cognitive impairment, it is also important to consider presence of a cognitive-communication disorder (Rodriguez et al, 2022). All affected patients should be referred promptly to a speech and language therapist for a further detailed analysis of the impairment and its impact. The MDT should subsequently be trained on how to adapt to the individual's communication needs to best support them and their carers. Similarly, the patient's family/carers should be trained to develop supportive communication, such as minimising background noise and ensuring the patient is not interrupted. A focus on the patient's remaining language and communication abilities is encouraged as well as teaching alternative communication methods, such as writing and gestures. Together, it is advised that such measures will support patients to express their needs and wishes, and empower them to participate in everyday and major life decisions to help to rebuild their identity post-stroke.

Mobility

Patients with weakness, sensory or balance disturbance affecting movement should be offered physiotherapy until able to maintain or progress their function independently (or with minimal assistance) (NICE, 2023). Strength training, which focuses on strength building, should also be considered (Noguchi et al, 2025). This may involve increasing repetitions of body weight activities, weight-lifting or resistance exercises using machines. Cardiorespiratory and resistance training should be initially commenced by the physiotherapist with the aim that the patient is subsequently taught how to undertake the programme independently. Repetitive task training can be offered to improve strength in the upper and lower limbs, for example by reaching, grasping, sit-to-stand transfers and stair walking (French et al, 2016). Walking therapies additionally help to build endurance and improve speed, which could be further facilitated using a treadmill (Moore et al, 2022). Group circuit training is an alternative option, offering an educational element (e.g., falls prevention) and involves interaction with similar patients and creates an environment of peer support (English et al, 2017).

Shoulder Pain

Upper limb weakness and spasticity can often lead to shoulder pain, hence encouraging patients to adjust their position may be helpful as a preventative measure (Lakra et al, 2023a). It is recommended that patients with significant shoulder pain are referred to specialist upper limb clinics, e.g., the Queen Square Upper Limb service (UCL, 2019). Several stroke units additionally possess specific pathways focused on addressing shoulder pain. A shoulder X-ray should be considered in patients with severe symptoms, with magnetic resonance imaging (MRI) being a

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potential adjunctive measure although is not formally advised in all cases. Corticosteroid injections could be offered in suspected capsulitis before considering further specialist measures, such as taping, neuromuscular electrical stimulation, nerve blocks and other neuropathic pain medications (Lakra et al, 2023b).

Spasticity

Spasticity can be difficult to treat, so it is important to give patients and carers information on the condition. This will help to ensure that they know when to seek help, but also if there is anything simple that they can do to relieve the symptoms. If left untreated, spasticity can result in the shortening of affected muscles and rapidly lead to contractures. Progressive loss of joint range is often painful and can adversely impact critical daily activities such as washing, dressing, and transfers. Spasticity should be assessed to determine if focal or generalised, as these possess differing management options, and education provided to the patient as well as their carers. Conservative strategies for spasticity should be considered first, in particular identifying and avoiding triggers (see Fig. 2), stretching the affected limb(s) and using orthoses. Electrical stimulation (e.g., neuromuscular electrical stimulation or transcutaneous electrical nerve stimulation) could also be considered for focal spasticity. If conservative measures for focal spasticity are ineffective or inadequate, botulinum toxin should be considered. Different formulations of botulinum toxin A (Dysport, Xeomin and Botox) are widely used. However, limited evidence for pre-agreed outcomes have resulted in specific recommendations for Dysport up to 1000 units or Xeomin up to 400 units. If other preparations are already in use and proving effective, treatment can continue. Injections should not be given more than once every 3 months and should be spread across the appropriate injection sites.

A trial of baclofen could be considered for generalised spasticity if conservative measures are ineffective or inadequate, with monitoring for adverse effects such as dizziness, drowsiness, visual problems and unsteadiness (Ghanavatian and Derian, 2024). This should be started at a low dose and titrated up according to symptoms and side effects. In the event of ongoing spasticity that is unresponsive to treatment, intolerable side effects to other treatments or the patient has complex spasticity needs (e.g., small muscles affected or spasticity-related pain) the current guidelines advised that these patients be referred to a specialist spasticity service.

Pressure Area Risk

The risk of developing pressure ulcers, particularly in the sacral area, may be higher in stroke patients, often due to unsatisfactory hygiene, malnourishment and incorrect preventative mattresses being used (Farid et al, 2022). It is therefore important for all patients to be assessed for pressure ulcer risk using formal assessment tools, such as the Waterlow score, to ensure that high-risk patients are provided with education, preventative measures (such as air mattresses) and repositioning if needed (Ferris et al, 2019; Mahalingam et al, 2014; Nayar et al, 2021). Patients' carers should also be educated on these preventative measures to facilitate transition of care into the community.

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![graph TD\n A1[Spasticity triggers] --> A2[Extremes of temperature]\n A1 --> A3[Stress and anxiety]\n A1 --> A4[Pain]\n A1 --> A5[Infection, e.g. UTI]\n A1 --> A6[Tight-fitting clothing]\n A1 --> A7[Constipation]\n](1/parseimages/figure057107fcbce14f378217050a76cc054a_0_1.png)

Continence

Incontinence is a common issue post-stroke, with approximately one half of stroke patients experiencing bladder incontinence and one-third of patients losing bowel control (Stroke Association, 2023a). Almost 15% of patients will continue to have continence issues one year after their stroke. Incontinence following stroke is likely multifactorial, being related to the underlying brain injury, poor mobility, medications and potentially urinary tract infections.

Patients may require incontinence pads in the acute phase, which need to be regularly monitored and changed if soaked or soiled. However, long-term use can be detrimental to skin integrity. Encouraging the use of a commode in regular intervals may be needed in patients with preserved bladder and bowel function but a loss of awareness of when they need to void. Catheterisation is advised in patients with post-void urinary retention or soreness through skin contact with urine. Faecal containment bags are not routinely offered in the stroke ward but are primarily limited

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to the intensive care setting. Instead, implementation of a regular bowel regimen can encourage regular bowel opening and reduce episodes of faecal incontinence.

Persistent incontinence should be assessed with simple investigations in the first instance, such as a urine dipstick and/or culture to exclude infection, stool chart and input/output measurements. Further imaging may subsequently be needed, such as a bladder ultrasound scan or abdominal X-ray based on the clinical picture.

Management of incontinence should be tailored to the patient's individual needs, such as bladder training, pelvic floor exercises, bladder stimulation, weight loss or medications (e.g., anticholinergics, botulinum toxin) and spinal neuromodulation for urinary incontinence (Agapiou et al, 2024). Patients with bowel incontinence may alternatively benefit from bowel training, dietary changes, medications (e.g., laxatives) as well as a bowel regimen. Involvement of a specialist continence advisor should also be considered in patients if further support is needed or the patient has complex incontinence needs.

Fatigue

Post-stroke fatigue can be a highly debilitating condition, affecting up to 68% of individuals (Alghamdi et al, 2021). It remains poorly understood, but is likely multifactorial resulting from the physical impact of the stroke itself and its effects on mental health (particularly depression), sleep disturbance, pain, diet and medication side effects (Stroke Association, 2025b). It is important for the clinician to exclude any reversible causes that may be contributory to fatigue, such as infection. The fatigue can last for several months (potentially up to a year), not usually improving with rest. It can therefore portray a significant barrier to rehabilitation and should be assessed formally by the MDT using assessment tools, such as the Fatigue Assessment Scale, Fatigue Severity Scale or Modified Fatigue Impact Scale (Krupp et al, 1989; Larson, 2013; Michielsen et al, 2003; Michielsen et al, 2004).

There is no specific medication to treat post-stroke fatigue, however patients should be given an explanation of their symptoms and likely trajectory, of which post-stroke fatigue generally tends to improve with time (Stroke Association, 2022). Several patients may additionally possess or notice triggers that exacerbate their fatigue, hence they should be encouraged and supported to avoid these to maximise rehabilitation potential. Modafinil (a central nervous system stimulator) may represent an effective medication for post-stroke fatigue for the future. The Modafinil in Debilitating Fatigue After Stroke (MIDAS) randomised double-blind placebo-controlled trial suggested it results in an improvement in fatigue and quality of life when compared with placebo (Bivard et al, 2017). However, further validation is still required using larger scale studies.

Specific Therapies

Mirror Box Therapy

Mirror therapy (30-minute sessions at least 5 times per week for over 4 weeks) could be offered as an adjunct in the first 6 months following stroke in patients with upper or lower limb weakness (Zeng et al, 2018). Mirror therapy creates a

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visual illusion to make it appear as if the affected limb is actually moving when the unaffected limb is moved. Previous studies have been largely heterogeneous, although can suggest a significant improvement in motor function with this intervention (Zeng et al, 2018).

Robotic Assisted Therapy

The Robot Assisted Training for the Upper Limb after Stroke (RATULS) study, which is a multicentre randomised controlled trial, compared robot-assisted training against an enhanced upper limb therapy programme and usual stroke care (Rodgers et al, 2019). The trial suggested that robot assisted training does not improve upper limb function compared to usual care. Patients in the robot assisted training arm also suffered a greater number of serious adverse events compared to usual care patients, although these were felt not attributable to the actual intervention. It was stated in a Cochrane review that electromechanical and robot assisted arm training can improve outcomes, such as muscle strength and arm function, however the heterogeneity in robot types and under-reporting of training dose led to an unclear adaptation in practice (Mehrholz et al, 2018). Robot assisted arm training is therefore advised against in the updated guidelines due to insufficient evidence regarding its clinical benefit. However, this remains an ongoing area of interest for stroke research and further investigation is additionally needed to improve its cost effectiveness, as the expense of robotic equipment can be considerable.

Orthoses and Electrical Stimulation

Upper and lower limb splints may be offered for several reasons in stroke patients, with examples provided in Fig. 3 (Althoff and Reeves, 2025; NICE, 2023). Orthoses should be fitted by a trained professional, with the patient and their family/carers also instructed on how to apply and remove them, and a review plan established. Furthermore, signs of redness or skin breakdown should be regularly monitored for, with contact details provided of who to contact in the event of any of these occurrences.

![graph TD\n A1[Splints] --> A2[Wrist/hand]\n A1 --> A8[Ankle/foot]\n A2 --> A3[Maintain joint range]\n A2 --> A4[Maintain soft tissue length/alignment]\n A2 --> A5[Increase passive range of movement]\n A2 --> A6[Facilitate function(e.g. grip)]\n A2 --> A7[Maintain comfort]\n A8 --> A9[Aid swing-phase foot clearance]\n A8 --> A10[Aid stance-phase control]\n](1/parseimages/figurec88b5d08d5f24d9aaea7f5d0e53077d2_0_6.png) Electrical stimulation as a means to enhance muscle strength in the upper limb can be trialled if there is evidence of muscle contraction but insufficient strength for

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the patient to move their arm against resistance, and continued if function improves with this (NICE, 2023). Neuromuscular, functional, or transcutaneous electrical stimulation should also be considered in patients with focal spasticity. Stimulation of the lower limb should be considered in cases of foot drop secondary to stroke. The current guidance recommends that constraint-induced movement therapy could be considered for the upper limb if there is evidence of 20 degrees of wrist extension and 10 degrees of finger extension (NICE, 2023). This would involve restraining the unaffected limb whilst the patient works to rehabilitate the affected limb.

Functional electrical stimulation and constraint-induced therapy should only be delivered by trained stroke/neurorehabilitation professionals. Clinical trials assessing these interventions are also limited by small sample sizes and variable control groups, hence larger randomised controlled trials are encouraged to further validate their utility.

Occupational Therapy

It is recommended that a review by an occupational therapist is performed regularly in stroke patients until their condition is stable or they are able to progress independently, as this will assist in determining any difficulties in undertaking activities of daily living. Restorative strategies may subsequently be considered, such as encouraging those with inattention to attend to the neglected side or encouraging a routine for people with difficulties in concentration or dyspraxia (Gopi et al, 2022). Patients may additionally be encouraged to adopt compensatory strategies to better manage with their deficit, such as dressing one-handed or using bath aids (Gitlin et al, 2017).

Family members should be encouraged to upload photos/videos of the patient's home environment to their case notes to assist with discharge planning as soon as possible following a stroke. Home visits can be further helpful to look at specific issues and improve confidence in the home environment.

Discharge Planning

Early Supported Discharge

Early supported discharge (ESD) allows patients to continue rehabilitation at the same intensity in a community setting, irrespective of discharge destination (Chouliara et al, 2023). Encouraging patients to be transitioned to the home setting with an ESD team as early as possible is subsequently now a service standard in the UK, with approximately 40% of stroke patients using this approach. Trials and studies have suggested that ESD can lead to a reduction in long-term dependency and length of hospital stay (Fisher et al, 2016; Langhorne et al, 2017a).

However, it is advised that ESD be offered to patients only with mild to moderate disability, who are able to transfer from bed to chair independently or with minimal assistance, and a safe and secure environment can be maintained at their destination (Fisher et al, 2016). ESD is proven to be cost-effective and is much preferred by stroke survivors (Langhorne et al, 2017a).

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Telerehabilitation

This offers a further opportunity to transition stroke patients earlier into the community, but should only be offered if the patient is agreeable or this is the preferred form of rehab and aligns with their rehabilitation goals. Furthermore, given the unequal and limited healthcare resources across different geographical areas, tel-erehabilitation may offer an avenue to overcome such barriers and provide a more uniform national rehabilitation service (Appleby et al, 2019).

The COVID pandemic hastened the implementation of telerehabilitation (Vieira et al, 2022; Yang et al, 2024). Evidence relating to telerehabilitation has been positive to augment face to face physiotherapy sessions and increase the overall “dose” of therapy, being particularly useful in the more rural areas. Its use has declined post-pandemic, but services should be encouraged to implement telerehabilitation if/when possible. Sufficient equipment, training and technical support should be in place for this to be safely implemented, with the benefits being regularly assessed. Certain apps have been recommended previously to enhance telerehabilitation, such as “NeuroRHB” or “Farmalarm”, however they do possess limitations precluding their wider use in practice (Salgueiro et al, 2023).

It is important to acknowledge that there may also be significant barriers to implementing telerehabilitation, notably relating to equipment setup, connectivity/interface problems and privacy issues in the home (Tyagi et al, 2018). Patients with significant cognitive, visual and hearing impairments may also not be appropriate for telerehabilitation, hence such factors will need to be carefully considered prior to proceeding with this approach.

Responsibilities

The patient's stroke coordinator is paramount to bridge the gap between inpatient and community rehabilitation. Prior to transfer of care, the patient should have a social care assessment to identify ongoing needs, with this documented formally in a health and social care plan. This should be agreed between the patient's family members/carers. Local protocols should also be in place to ensure timely exchange of information between local health and social care providers.

Table 2 summarises essential information that should be communicated to local providers on transfer of care to the community (NICE, 2023). The information may be adjusted based on changes to the patient's personalised rehabilitation goals, home environment, access to benefits, tailored-evolving care needs over time, community participation, access to transport and available voluntary services. It is important to additionally ensure patients' families and caregivers are given the opportunity to contribute towards goal setting particularly prior to transition into the community, as this would promote ongoing patient adherence. It would also be important that families/caregivers are educated on the benefits of physical exercise, to encourage the patient to continue to engage in the rehabilitation process (García-Cabo and López-Cancio, 2020). The patient and their carers should be given access to the team's contact details should any problems arise once transitioned into the community.

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Table 2. Important information to be conveyed to local providers upon transfer of care to the community.

||Diagnosis and health status Functional abilities Care needs with daily activities Medication needs (to ensure compliance)| |---|---| |Information for transfer of care|Psychological needs Social circumstances, including carer needs Mental capacity regarding transfer decision Risk management Plans for follow-up, ongoing rehabilitation and access to services|

Therapy and Care Needs

Prior to discharge to the community, the patient's key worker is responsible for supplying any necessary information (via writing, telephone or joint visit) about home interventions and adaptations to the provider to ensure it is safe and tailored to the patient. The patient's equipment needs should also be made known to their carers and they should be provided with appropriate training on how to operate the equipment, such as hoists and chair raisers. It is advised that the rehabilitation team review the abilities of the family/carers to manage the equipment needs every 6-months to a year to reduce caregiver burden.

A further aspect of care to be considered prior to discharge is the ability of the patients to travel from their discharge destination to attend sessions or follow-up appointments at the arranged time and location to determine if this is feasible. Any further arrangements can subsequently be made to assist with this if needed.

Psychological Needs

It is important to relay to carers that the patient's psychological needs can fluctuate in the months following a stroke (Elendu et al, 2023). When new or persisting changes to mood or emotional difficulties are identified at the 6-month or annual stroke review, patients should be referred to local services for more detailed assessment and potential commencement of treatment. In the absence of cognitive impairment, depression and anxiety should be managed as per the usual guidance for these, taking into account any cultural factors that may be significant to the patient (NICE, 2022; NICE, 2024). Family/carers should be made aware they are entitled to a carer's needs assessment to ensure that they would also not struggle with the caregiver burden in the community. Details of support services, such as leisure and voluntary organisations, should subsequently be provided to patients and their carers prior to discharge.

Social Support and Integration

The integration of post-stroke patients into society is also an essential aspect to rehabilitation, as community engagement is associated with lower rates of depression, less fatigue and improvements in mobility (Shrivastav et al, 2022). This could start with wider integration into the patient's family and support networks,

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however with time it is recommended that this should extend to community and peer support groups. There are several stroke support groups that patients could be referred to, such as those provided by the Stroke Association, Chest Heart and Stroke Scotland or the Irish Heart Foundation. This would be complimented by local council groups that also facilitate social integration.

Communication

Patients with aphasia and/or dysarthria should be referred to communication aids on discharge to facilitate their ongoing rehabilitation whilst in the community, such as home-based computer therapies or mobile apps that are tailored to their individual goals (Stroke Association, 2013; Wray et al, 2019). Prior to discharge, patients and their carers should also be provided with details of community support groups and, if persistent communication difficulties are noted in the 6-month or annual stroke follow-up, they should be referred back to the speech and language therapy team for further assessment.

Returning to Work and Driving

Return-to-work issues should be identified as soon as possible after the patient has suffered a stroke and be reviewed regularly (Vestling et al, 2003). The demands of their job should be assessed as well as any issues that may affect the patient's work performance to ensure they are provided with tailored interventions (e.g., teaching the use of voice-activated software for those with difficulty typing) and information on available support (e.g., access-to-work schemes). Workplace visits and liaising with employers can be helpful to make necessary adjustments, such as the provision of equipment or a phased return to work. Referring patients to a vocational rehabilitation service or return-to-work programme should also be considered (Clarke et al, 2024; Olaoye et al, 2020).

Effective return-to-work programmes necessitate a structured approach that should encompass a comprehensive assessment and individualised action plan. It would be important to evaluate relevant work-related skills and competencies (physical, cognitive, communication etc.) to determine the patient's potential to return to work, with input from occupational health professionals. Potential barriers and facilitators to return to work, individualised to the patient's job role and demands, should also be assessed for. A personalised plan outlining strategies to overcome any barriers can subsequently be developed (Clarke et al, 2024). This may be in the form of vocational counselling and coaching, emotional and psychological support, adaptations to the work environment, compensatory strategies for functional limitations and fatigue management strategies. It may be the case that many workplaces do not yet have a formal return to work programme, however there is useful guidance to aid employers in the design of one with recommendations of important aspects to consider prior to launch (GOV.UK, 2025a).

The Driver and Vehicle Licensing Agency (DVLA) regulations should also be reviewed for patients who are reliant on driving. Car drivers and motorcyclists must not drive for a minimum of one calendar month, whilst bus and lorry drivers must stop driving for a minimum of one year (GOV.UK, 2025b; Stroke Associa-

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tion, 2023b). Some patients may be required to stop driving for longer than the minimum period, which a healthcare professional may be able to advise upon con-fidently. However, patients may also be instructed to consult a driving assessment centre who would be able to advise more formally on this. All patients must notify their motor insurance company after suffering a stroke or transient ischaemic attack (TIA). Certain car drivers and motorcyclists may also need to inform the DVLA, but all bus and lorry drivers must tell the DVLA following a stroke or TIA.

After Discharge From Stroke Services

Long-term follow-up or further reviews of post-stroke patients should regularly consider the patients' ongoing functional and neuropsychological needs. Patients should be followed up at least at the 6-month interval following a stroke, or sooner if requested by the individual and/or their caregivers. A further follow-up should be conducted at one-year post-stroke with a view to follow patients up annually thereafter, however this is dependent on the individual patient and their needs.

Following discharge from the stroke services, patients should feel empowered that they can self-refer to the services again if needed. This would usually require support from a primary care provider or named contact from the rehabilitation service. The updated guidance emphasises that it is also imperative that, prior to discharge, patients are encouraged to consult voluntary support organisations (after being signposted to particularly helpful resources), continue to participate in community activities and support their social roles (e.g., work) (NICE, 2023). This will further assist them in adapting to life and improving their general wellbeing following their stroke.

Conclusion

The impact of a stroke can be enormous, causing significant disability. However, with effective rehabilitation, facilitated by the MDT that spans the hospital and community settings, patients can experience dramatic improvements in quality of life, function and optimise their likelihood of regaining independence. This necessitates an ethos centred on effective teamwork between the MDT, the patient and their carers, as well as a rehabilitation plan that must be specifically tailored to the individual patient to ensure the best outcome. Previously, research trials surrounding stroke rehabilitation have been hampered by single centre studies using small sample sizes. This has improved dramatically in recent years, however patients with communication difficulties and significant frailty are still heavily underrepresented in clinical trials. The optimum rehabilitation guidance for these subgroups remains unclear, as well as the most appropriate psychological interventions. Furthermore, there is still significant variability in available resources for rehabilitation dependent on geographical location, however approaches such as telerehabilitation (recommended in the new guidance) may offer at least a partial solution to this. These remain much-needed focuses to continue to address in future studies and research surrounding stroke rehabilitation.

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Key Points

* Stroke affects a significant proportion of middle-aged to elderly individuals, with the number of stroke survivors set to increase further in subsequent years.

$\bullet$ Rehabilitation is an essential aspect in the care of stroke patients and the development of a personalised plan is vital for each individual patient.

* There is an increasing focus to transition patients into the community as soon as feasible, using early support discharge and telerehabilitation, to enable them to continue their rehabilitation in the home setting.

* Patients with communication difficulties or significant frailty remain underrepresented in previous research studies and should be targeted in future trials.

Availability of Data and Materials

Not applicable.

Author Contributions

AJ produced and revised the original draft. AJ, MM, SA and EW made substantial contributions to the conception and design of the work and important editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

Ethics Approval and Consent to Participate

Not applicable.

Acknowledgement

Not applicable.

Funding

This research received no external funding.

Conflict of Interest

EW was the clinical lead for the NICE stroke rehabilitation guidelines. The other authors declare no conflict of interest.

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