Stroke is the third commonest cause of death and the most frequent cause of severe adult disability in Scotland. 70,000 individuals are living with stroke and its consequences and each year, there will be approximately 15,000 new stroke events. 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 timespan. About 30% of survivors will be fully independent within three weeks, rising to nearly 50% by six months.¹ Disabling conditions such as stroke are best considered within an agreed framework of definitions. The World Health Organisation (WHO) International Classification of Impairment Disabilities and Handicaps (ICIDH) provides the following framework for considering the impact of stroke on the individual:^2,3

• pathology (disease or diagnosis): operating at level of the organ or organ system
• impairment (symptoms and signs): operating at the level of the whole body
• activity (disability): observed behaviour or function
• participation (handicap): social position and roles of the individual.

A number of contextual factors may influence this framework as recognised in the International Classification of Functioning, Disability and Health (ICF).⁴ ICF has two parts, each with two components:

• Part 1 Functioning and disability
  1. Body functions and structures
  2. Activities and participation
• Part 2 Contextual factors
  3. Environmental factors
  4. Personal factors.

The ICF also outlines nine domains of activity and participation, which can provide the focus for rehabilitation efforts:

• 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 Rehabilitation

The conventional approach to rehabilitation is a cyclical process:

• 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
• reassessment: progress is assessed against the agreed goals.

Rehabilitation goals can be considered at several levels:

• aims: often long term and referring to situation after discharge
• objectives: usually multi-professional at the level of disability
• 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.

1.2 The SIGN stroke guidelines series

Four SIGN stroke guidelines have been published:

• Management of patients with stroke part I: Assessment, investigation, immediate management and secondary prevention⁵
• Management of patients with stroke part II: Management of carotid stenosis and carotid
  endarterectomy⁶
• Management of patients with stroke part III: Identification and management of dysphagia⁷
• Management of patients with stroke part IV: Rehabilitation, prevention and management of
  complications, and discharge planning.⁸

This guideline is a complete revision of part IV and supersedes it. Part III is currently under review and is due for publication around mid 2003. Parts I and II will be reviewed jointly and a single publication is expected late 2004.

1.3 Aims of this guideline

The aim of this national guideline is to assist individual clinicians, primary care teams, hospital departments, and hospitals 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. 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. Specific aspects of assessment, secondary prevention and dysphagia are dealt with in separate guidelines from SIGN^5,7 and from the Royal College of Physicians, London.⁹

This guideline has five main sections:

• 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 commissioning and providing rehabilitation services.
• General rehabilitation principles: this section addresses general rehabilitation principles, which are relevant to the majority of stroke patients.
• Specific management and prevention strategies: this section aims to inform the assessment and management of common impairments or complications resulting from a stroke. The section is based on epidemiological studies which have identified common and important impairments, disabilities and complications following stroke. This section aims to be useful to multidisciplinary teams and individual clinicians when planning treatment of individual patients.
• Discharge planning and transfer of care: this section addresses the planned transfer of care of patients from the hospital to the home setting.
• Roles of the multidisciplinary team: this section is derived from stroke unit trials plus supporting information and aims to provide guidance on the levels of care and expertise to be provided within stroke services.

Creating regional/local consensus on the use of standardised set of assessments when patient related information is transferred from one centre to another (or the community) may be an important aspect for improving quality of care of stroke patients.

1.3.1 Terminology

“Disability” and “handicap” have been replaced with new terms of “activity limitations” and “participation restrictions”. The above terms are used interchangeably in this document.

1.4 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.

1.5 Review and updating

This guideline was issued in 2002 and will be considered for further review in 2006, or sooner if new evidence becomes available. Any updates to the guideline in the interim period will be noted on the SIGN website: http://www.sign.ac.uk