Stroke patients may experience a whole range of barriers to recovery of normal activities and participation. These can take the form of impairments directly caused by the stroke or other complications of the stroke (see Box 1).^{44, 45} This section looks at specific treatment strategies addressing commoner impairments, limitations and complications after stroke. It should be noted that not all impairments or complications have been addressed in this guideline, e.g. visual impairment has been excluded and fever is covered by the SIGN acute stroke guideline.⁵

Box 1: Common impairments, limitations and complications after stroke

4.1 Intensity of therapy

Within the stroke unit trials, patients received an average of 45 (range 30-60) minutes of physiotherapy and 40 (30-60) minutes of occupational therapy per weekday.¹⁰ Other trials have investigated the intensity of therapy.^{31, 32, 33, 34, 46, 47, 48, 49, 50} Some of these trials included small numbers of subjects, reported heterogeneous interventions and possessed possible selection bias. Most of these studies reported a small positive result. A select proportion (perhaps the fittest 10%) of the stroke population may derive moderate benefit from greater intensity of therapy. There is insufficient evidence however, to make a judgement on the cost effectiveness of this increased intensity of therapy or to make an overall recommendation. Evidence level 1++,1+,1-

See section 4.4 for details of the intensity of speech and language therapy.

4.2 Movement

4.2.1 MOTOR WEAKNESS- DIFFERENT PHYSIOTHERAPY TREATMENT APPROACHES

Different treatment approaches exist for all therapy interventions. The area with most published evidence is physiotherapy where a number of different approaches to treatment for patients with stroke have been compared. These include: Bobath (or normal movement) approach, ^{51, 52} Motor Learning (or Motor Relearning or Movement Science) approach,⁵³ Brunnstrom,⁵⁴ Rood,⁵⁵ Proprioceptive Neuromuscular Facilitation,⁵⁶ and Johnstone.⁵⁷

Questionnaire studies indicate that the Bobath approach is currently the most widely used approach in Sweden,⁵⁸ Australia⁵⁹ and the UK.^{60, 61} A lower proportion of Scottish physiotherapists (65%) use the Bobath approach than physiotherapists in England (91%), Northern Ireland (97%) and Wales (92%).⁶¹ In contrast to England, Northern Ireland and Wales, 18% of Scottish physiotherapists use the Motor Learning approach.⁶¹ Evidence level 2+

The few high quality RCTs investigating the relative efficacy of different physiotherapy treatments provide no evidence that any one treatment approach improves functional ability more effectively than any other.^{62, 63, 64, 65, 66, 67, 68} A systematic review of RCTs of exercise therapy for arm function concluded that there was no difference in the effectiveness of different types of exercise therapy.⁶⁹ There is therefore insufficient evidence to conclude that any one approach to treatment is more efficacious than others in promoting effective rehabilitation. Four heterogeneous RCTs indicate that task-specific training may result in improvement in outcomes specific to the task trained, for example training specific to reaching improves maximum reach,⁶² training specific to gait improves gait speed,^{63, 64} and training specific to strength improves strength.⁶⁵ There is limited evidence from controlled trials that approaches incorporating strength training may lead to improvements in gait speed,⁷⁰ activities of daily living⁶⁵ and strength.⁶⁵ Evidence level 1+,1-

One well-conducted but small RCT found that patients treated with a Motor Relearning Approach to physiotherapy had a shorter length of acute inpatient stay than patients treated with a Bobath approach to physiotherapy.⁷¹ Evidence level 1+

Until further evidence is available, any one approach to treatment should not be assumed to be more efficacious than others in promoting effective rehabilitation.

Task-specific training can be used in order to improve performance of selected tasks.

4.2.2 SPASTICITY

There are very few trials of the physical management of spasticity (e.g. exercise, splinting, electrotherapy) and these are too small and inconclusive to guide present practice.

Specific pharmacological measures to treat spasticity can be found in the RCP London stroke guideline (see Table 9.7).¹⁷

4.2.3 GAIT DISORDERS - TREADMILL TRAINING

There is limited evidence in this area. A small number of trials suggest that treadmill training, particularly with partial (30-40%) body weight support with a harness, may be effective in re-educating the patient in walking after stroke. There is no evidence to suggest that this method is more beneficial than conventional physiotherapy. The subgroups of subjects that benefited most were those who were non-ambulant late after severe stroke, and those with co-existing pathologies affecting cardiovascular fitness.^{72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83} Evidence level 1+,2+

Carefully selected non-ambulant patients, late after severe stroke, may benefit from treadmill training.

Patients with co-existing pathologies affecting cardiovascular fitness may benefit from training using a treadmill that offers partial bodyweight support.

4.2.4 BIOFEEDBACK

Biofeedback (BF) provides a patient with auditory or visual feedback relating to the movement or posture of their body or limbs. This feedback may relate to muscle activity (electromyographic: EMG BF) or to body position (e.g. weight distribution between the legs during standing or while rising to stand).

Four meta-analyses of trials of the benefits of BF for patients with stroke have been carried out.^{84, 85, 86, 87} Three were limited to EMG BF and the fourth⁸⁷ only looked at range of movement as an outcome, excluding the majority of non EMG BF trials. The available evidence is not sufficient to support the routine use of EMG biofeedback in the rehabilitation of movement and function after stroke, although there is no evidence that EMG BF is detrimental to outcome. Evidence level 1++,1+

EMG biofeedback need not be used routinely in the rehabilitation of function and movement following stroke.

4.2.5 ANKLE FOOT ORTHOSES

Ankle foot orthoses (AFOs) can be prescribed to patients with dropped foot following stroke with the aim of maintaining ankle dorsiflexion, reducing spasticity and improving the pattern and safety of gait.

Only one RCT investigating the efficacy of a polypropylene AFO was found; this included 60 patients and investigated the effects of thermocoagulation of the tibial nerve and an AFO.⁸⁸ This study found no evidence that AFOs were useful in the reduction of motor impairments or the improvement of function. Over 67% of patients reported a problem or harm associated with the use of the AFO. Approximately 50% of patients did not fully comply with the use of the AFO. Evidence level 1+

Although there is a lack of evidence to support an AFO having a measurable effect on gait parameters, in clinical practice there are distinct benefits in their use, particularly to allow early ambulation in patients with severe hemiplegia.

A joint assessment by a physiotherapist and an orthotist of patients for whom ankle stability can only be achieved through orthotic means, will allow a decision to be made on whether AFOs are appropriate.

Although ankle foot orthoses may help some patients with foot drop, they should not be used routinely without proper assessment prior to use and follow-up to establish their effectiveness in the individual.

4.2.6 ELECTRICAL STIMULATION

Electrical stimulation (ES) applies bursts of electrical current to a muscle or a peripheral nerve, using either surface or internal electrodes, in order to create or assist a voluntary muscle contraction.

A meta-analysis⁸⁹ of four poor quality RCTs and additional trials^{90, 91, 92} suggest that ES may improve muscle force in selected patients. There was no evidence to indicate whether or not this improvement would be sustained after the period of ES treatment had ceased. Different types and regimes of electrical stimulation (including electromyography triggered) were used in the different studies. The meta-analysis only considered muscle force as an outcome, so no conclusions can be made regarding the benefits or harm of ES relating to other outcomes. There remains limited evidence to support the use of electrical stimulation as an adjunct to physiotherapy. Electrical stimulation may improve muscle force, strength and function in selected patients. The multidisciplinary team will be able to decide which patients are likely to benefit most. Evidence level 1+,1-

Electrical stimulation (ES) should be considered for use in improving muscle force, strength and function in selected patients. ES must not be assumed to have sustained effects.

4.3 Visuospatial dysfunction

Unilateral spatial neglect is a cognitive disorder which disrupts many activities of daily living. There is limited evidence that cognitive rehabilitation may improve performance on neglect, when tested on paper and pencil tests.⁹³ However, there is no evidence that this transfers to gain in everyday function.

4.4 Communication

4.4.1 APHASIA

Aphasia is ‘an acquired impairment of the cognitive system for comprehending and formulating language, leaving other cognitive capacities relatively intact’.⁹⁴ It can co-exist with other cognitive deficits. Although a distinction had sometimes been made between aphasia and dysphasia, aphasia now tends to be used regardless of severity level. The reporting of the proportion of stroke cases demonstrating aphasia at initial assessment varies from 20%⁹⁵ to 38%.⁹⁶ In the latter study 12%, 6% and 20% have mild, moderate and severe impairment, respectively and 19% continue to have aphasia at six months. Aphasia is usually associated with left hemisphere damage, but symptoms such as subtle communication deficit, affecting communication interaction, notably non-verbal communication, and communication of non-literal or inferred information, may also occur following right hemisphere stroke.⁹⁷

The role of the speech and language therapist (SLT) in aphasia includes assessment, differentiation of aphasia from other communication difficulties, advice and education about maximising communication, counselling, provision of alternative or augmentative communication (AAC) and direct intervention.

A Cochrane review concluded that there was no RCT evidence of effectiveness, nor of ineffectiveness following speech and language therapy for people with aphasia following stroke.⁹⁸ A meta-analysis which included group quasi-experimental studies where aphasia was not necessarily of stroke origin concluded that outcomes for treated individuals are superior to those for untreated individuals in all stages of recovery, and especially in the acute stages.⁹⁹ Two additional RCTs have demonstrated the benefits of intervention for aphasia following stroke, with therapy sessions of three hours per week over six months¹⁰⁰ and five hours per week for four months.¹⁰¹ Overall, there is now good evidence that people with aphasia benefit from speech and language therapy. Evidence level 1+,2+

In a study of global aphasia where subjects were randomised to intensive therapy (daily sessions) and regular therapy (three sessions per week), more patients in the intensive group achieved significant improvement.¹⁰² The meta-analysis similarly indicated amounts of treatment and magnitude of change to be positively related, with the outcome of low intensity treatment being only slightly better than no treatment.⁹⁹ Treatment length in excess of two hours per week brought about gains exceeding those that result from shorter durations.⁹⁹

Aphasic stroke patients should be referred for speech and language therapy. Where the patient is sufficiently well and motivated, aim for minimum of two hours per week.

Where appropriate, treatments for aphasia may require a minimum period of six months to be fully effective.

Referral to the volunteer stroke service (through CHSS) should be considered as an adjunct (see section 7.4).

4.4.2 DYSARTHRIA

Dysarthria is a motor speech impairment of varying severity affecting clarity of speech, voice quality and volume, and overall intelligibility.¹⁰³ Frequencies of between 20% and 30% have been reported for dysarthria following stroke.^{44, 104, 105} It may also co-exist with other communication disorders such as aphasia. Communication and quality of life can be significantly affected. No useful information is available regarding persistence of this symptom.

SLTs offer a diagnostic and management service for this condition. A Cochrane review has determined that evidence for the effectiveness of intervention is restricted to small-group or single-case studies or to expert opinion.¹⁰⁶ At this time, expert opinion remains firmly in favour of effectiveness of SLT interventions.^{103, 107, 108, 109} Service providers will need to take into account the possible provision of prosthetic devices and of AAC systems which range from basic to highly sophisticated electronic devices.^{110, 111} Advice on the provision of AAC systems is available from the national Scottish Centre of Technology for the Communication Impaired or from local centres such as KEYCOMM (Edinburgh) and FACCT (Fife; see section 7.5 for details). Evidence level 3

Patients with dysarthria should be referred to an appropriate speech and language therapy service for assessment and management.

4.5 Cognition

Cognitive changes post stroke may be general (e.g. slowing of information processing), or may occur within specific domains (e.g. orientation, attention, memory, visuo-spatial and visuo-constructive, mental flexibility, planning and organisation and language).¹⁷ It should also be recognised that cognitive impairment may have existed before the stroke. Some patients may experience problems with reasoning or limited awareness or lack of insight into their difficulties. Around one quarter of patients may sustain severe and generalised cognitive impairment.¹⁷ With less severe impairment, recovery occurs but residual deficits may be long lasting. There is little consistent information on the frequency of these problems or their effect on everyday living, although they can be associated with slower progress in rehabilitation.¹⁷ Full assessment is important; an apparent lack of motivation in self-care could be due to a problem of initiating or planning actions or a visuo-spatial disturbance or both.

A full understanding of the patient’s cognitive strengths and weaknesses should be an integral part of the rehabilitation plan.

4.5.1 SCREENING

Short, standardised cognitive screening measures can be used by a health professional with knowledge and experience of the presentations of cognitive functioning and factors influencing it. They can be used as a broad screen to reduce the possibility that problems will be missed and as a measure of progress.¹¹² It is important for staff to understand that these screening measures will miss some of the cognitive problems which can be most important for rehabilitation and eventual functioning. These are varied but can include such issues as poor awareness of deficits or their implications, slowing of information processing, and the ability to cope with distraction.¹¹³

4.5.2 ASSESSMENT

Screening measures do not provide information about the depth and nature of the patient’s problems or strengths and therefore do not constitute an assessment sufficient for rehabilitation planning or for establishing suitability for a particular work role (e.g. operating machinery). Administering and interpreting full assessment results requires specialist training and should be carried out in the context of clinical interviews with access to background information.

In order that cognitive impairment can be assessed fully, stroke patients should have access to neuropsychological expertise.

4.5.3 COGNITIVE REHABILITATION

Cognitive rehabilitation concerns efforts to help patients understand their impairment and to restore function or to compensate for lost function (e.g. by teaching strategies) in order to assist adaptation and facilitate independence).¹¹⁴ There is not yet sufficient evidence to support or refute the benefits of cognitive rehabilitation for patients with problems of attention or memory.^{115, 116} When cognitive problems are suspected and relatives report personality change, the patient can be referred to a clinical psychologist to provide assessment and where appropriate, psychological intervention which may include carer education and support. One RCT found a trend only toward reduced carer strain when this service was provided.¹¹⁷ Assistant psychologists, not fully trained clinical psychologists were used in this study.

It is important that such approaches address how cognitive difficulties are manifest in a patient’s life and ensure that any gains made in a formal therapy setting generalise to the daily living environment. Formal neuropsychological assessment should be conducted initially in order to identify the cognitive abilities and deficits of the patient and consider these within the individual’s wider personal and social context.

4.6 Nutrition and swallowing

Careful assessment of nutritional status and of swallowing impairment, careful fluid management, and routine use of intravenous fluids are consistent features of early management for patients in stroke units. The advice of dietitians and SLTs should be sought (see the SIGN guideline on dysphagia in stroke patients which also covers nutrition).⁷

4.7 Infection

Infections are relatively common during stroke rehabilitation, with approximately 20% of patients experiencing chest infection or urinary tract infection while in hospital.⁴⁵ Staff providing rehabilitation services should be aware of the possibility of infection particularly among patients whose progress is less satisfactory than expected.

Stroke unit staff should be vigilant in recognising, investigating and treating common infections such as chest or urinary tract infections.

4.8 Continence

Incontinence of urine and faeces is dramatically increased by stroke. Reported frequency of urinary incontinence varies widely between studies due to selection biases but about 50% of all patients with acute stroke can be expected to be incontinent at some time. Faecal incontinence is a less common but more distressing problem. Unfortunately there is very little useful evidence specifically from studies of incontinent patients following stroke.¹¹⁸ Usual continence management should be appropriate for patients with stroke, although special attention should be paid to the practical problems faced by patients with stroke, e.g. functional disability, aphasia and cognitive impairment.

Every service caring for patients with stroke should have local continence guidelines including advice on appropriate referral.

4.8.1 URINARY INCONTINENCE

Urinary incontinence may have been a problem prior to the stroke, but more commonly is due to the stroke.
Every patient with urinary incontinence should be assessed in order to make an accurate diagnosis. Routine assessment should include a standard medical and nursing assessment.¹¹⁸ Evidence level 4

The medical assessment of every patient with urinary incontinence must include:

• a history of how long incontinence has been a problem
• current drug history
• obstetric history for women
• prostatic symptoms for men
• abdominal examination to help exclude palpable bladder
• rectal examination (both sexes)
• vaginal examination (to exclude prolapse, vaginitis and neoplasia)
• mental state examination
• urinalysis (for glucose, protein, blood, white cells)
• mid-stream urine if proteinuria or haematuria (for microscopy and culture)
• urea and electrolytes and a frequency and volume bladder chart.

The presence or absence of incontinence of urine should be documented for all patients after a stroke.

Although the evidence was not examined systematically, anticholingergic drugs to treat urinary incontinence must not be prescribed until post micturition urine retention has been reliably excluded by scanning or catheterisation.

4.8.2 URINARY CATHETERISATION

Urinary catheters should only be used after a diagnosis of urinary incontinence has been made. Indwelling catheters should be used to treat painful urinary retention without delay. Once precipitating causes have been removed or treated, the patient’s care plan should include a planned trial without catheter. Occasionally, urinary catheters may be considered to protect the vulnerable skin of patients with chronic urinary incontinence. The continued use of such catheterisation should be reviewed regularly and appropriate diagnosis made of the cause of the incontinence. Long term urinary catheterisation should only be considered when an accurate diagnosis of the cause of the incontinence has been documented together with a reason why a curative treatment has not been, or cannot be, offered. Stroke services should have access to urinary catheter protocols and staff who insert catheters need appropriate training and continued professional training. Sexual function needs to be recognised when long term urinary catheterisation is considered. Intermittent self (or assisted) catheterisation may be appropriate, as guided by local specialist continence advisors. Cosmetic appearances and the ease of use will guide providers in selecting the best continence aid.

4.8.3 FAECAL INCONTINENCE

The assessment of patients with faecal incontinence is very similar to that of urinary incontinence and will identify most causes of faecal problems. Constipation is also a problem and needs management. The importance of rectal examination cannot be overemphasised. Faecal incontinence after stroke can be improved in most patients and, after the simple problems of faecal loading and infective diarrhoea (e.g. due to Clostridium difficile) have been treated, there are a number of management strategies that can help achieve continence. These include:

• manipulation of the gastrocolic reflex where bowel evacuation is common after meals
• helping the patient to sit on the toilet after meals to promote voiding
• regular use of a constipating agent and bowel care with an enema.

Annex 1 has been compiled by the SIGN guideline review group as an example approach to incontinence after stroke.

4.9 Pain

Stroke patients are particularly prone to pain, most commonly associated with the musculo-skeletal ramifications of paralysis and immobility, and particularly involving the hemiplegic shoulder (see section 4.10). Age-related co-pathologies resulting from joint changes due to osteoarthritis cause added discomfort, particularly during handling and positioning procedures.

Some two to six per cent of stroke patients experience Central Post Stroke Pain (CPSP) syndrome, with an annual incidence of between 2,000 and 6,000 in the UK, and a prevalence of as many as 20,000.¹¹⁹ True CPSP, characterised by a partial or total deficit for thermal and/or sharpness sensations, is best treated initially with adrenergically active antidepressants¹²⁰ such as amitriptyline.¹²¹ Intravenous naloxone is of no value in alleviating the pain of CPSP.¹¹⁹ Stimulation of the motor cortex or spinal cord by implanted electrodes and the use of Hi–Lo Transcutaneous Electrical Stimulation may help patients resistant to medical treatment.^{122, 123} Positive relaxation, as an adjuvant therapy, should be used in most cases.¹²⁴ Evidence level 1+,2+

The presence of pain in stroke patients should be identified early and treated appropriately.

Central Post Stroke Pain may respond to the use of tricyclic antidepressants, particularly amitriptyline.

4.10 Shoulder pain

Hemiplegic Shoulder Pain (HSP) is a problem which may contribute to poor upper limb recovery, depression, sleeplessness and may be associated with adverse overall functional outcome in patients following stroke.

There is no evidence to support any particular intervention in the management of HSP. High quality systematic reviews and a number of well-conducted, methodologically sound RCTs have not provided unequivocal evidence in support of a specific intervention.^{125, 126, 127, 128, 129, 130, 131} Careful handling of the affected upper limb along with consistent, supportive positioning strategies should be practiced at all times. Education of staff, patients and carers should be provided by physiotherapists or occupational therapists as appropriate. New untested developments in the management of established HSP include Functional Electrical Stimulation, physical therapy, ultrasound, strapping and supports which reduce subluxation. Evidence level 1+,2+

The management and prevention of hemiplegic shoulder pain is an integral part of good quality physical care provided within the multidisciplinary environment of the stroke unit.

4.11 Falls

Falls are a common feature for patients undergoing rehabilitation after stroke. As some falls can lead to devastating complications, measures should be taken to minimise the risk of falling. Evidence from studies including older people support a multidisciplinary multi-factorial approach, a common feature of organised stroke unit care (see section 2.1).¹³² Individually prescribed muscle strengthening and balance retraining programme, withdrawal of psychotropic medication and home hazard assessment and modification have been shown to be of benefit in reducing falls.¹³² These interventions are likely to be a integral component of well organised stroke care. There is evidence that the use of hip protectors reduces hip fracture rate,^{133, 134, 135} although compliance with treatment may be a problem. In a stroke unit setting, good compliance can be achieved and hip protectors have a role for patients at high risk of hip injury. Evidence level 1+

Hip protectors are recommended in men and women at high risk of hip fracture (particularly older people in care homes) although problems with compliance should be recognised.

4.12 Pressure ulcer prevention

With adequate nursing resources and expertise, pressure ulcers should not develop during immobility after stroke. Risk assessment for pressure sores is a generic nursing skill and should be a part of routine hospital nursing care and community care. Guidelines from the Department of Health (England and Wales) and Nursing and Midwifery Practice Development Unit are available.^{136, 137} Evidence level 4

Hospital managers should ensure that nursing expertise, staffing and equipment levels are sufficient to prevent pressure ulcers.

Hospitals should have up to date policies on risk assessment, pressure ulcer prevention and treatment.

4.13 Therapeutic positioning

Therapeutic positioning of patients is practised by nurses and therapists to prevent complications such as contractures, pain, abnormal tone, respiratory problems and pressure sores or to assist functional recovery. To date there is no evidence from clinical trials to support or refute the practice of therapeutic positioning in the management of patients after stroke. Further work is necessary in the form of an RCT or controlled clinical trial to determine the efficacy of therapeutic positioning.

4.14 Mood disturbance

Mood disturbance is a considerable problem after stroke. Despite this, there is little clear information on just how frequent different mood problems are. Little is known about the psychosocial and physical causes of mood disturbance after stroke. Diagnosis may be complicated by the similarity of symptoms of depression or anxiety to physical and cognitive changes associated with the stroke.

Depression is particularly common and has been associated with slower progress in rehabilitation and longer stay in hospital. Anxiety, with or without panic, may be generalised or may be associated with specific issues such as fears of falling or social embarrassment, which can lead to avoidance of certain situations.

Emotionalism or emotional lability is a lessening of control over emotions leading to a greater tendency to cry or laugh. These symptoms tend to get better with time. Some patients find this acutely embarrassing and it may interfere with their rehabilitation efforts. Emotionalism can be confirmed by clinical interview by appropriately trained staff.

In the first instance, standardised screening assessments of depression and anxiety offer some indication that these mood problems exist, and also form a standardised measure of progress. Members of staff with some knowledge of depression and stroke can use these after appropriate training. A number of different measures exist and it is not possible, on the basis of current evidence, to recommend any one measure above the others. Verbal scales will be contraindicated where aphasia is present and an alternative should be sought.¹³⁸ Visual and visuospatial problems will also affect the patient’s ability to fill in forms.

All stroke patients should be screened for mood disturbance. Some form of screening should occur initially and at three month intervals or key stages of the rehabilitation process and after rehabilitation support has been lost.

All screening measures have limitations (in specificity and sensitivity) so that some patients’ problems will be missed or overestimated. Current measures may include items concerning, for example, activity or concentration, which may be directly affected by stroke. Screening does not constitute a diagnosis of depression and cannot provide insight into the complexity of the individual’s problems.

If an individual is suspected of having a mood disorder they should be referred on to an appropriately trained professional for a full assessment.

Different kinds of mood disturbance may coexist and therefore the presence of one problem should not exclude assessment for others.¹³⁹

4.14.1 PSYCHOLOGICAL INTERVENTIONS FOR TREATING MOOD DISTURBANCE POST STROKE

Studies of psychosocial approaches to treating mood disturbance post stroke have focussed on depression. Almost all studies have methodological weaknesses. Interventions are diverse which adds to problems when evaluating efficacy. There is no evidence that general support or counselling has a proven beneficial effect for clinical levels of depression.^{140, 141}

There is no evidence that the provision of information alone helps resolve clinical depression in stroke patients.¹⁴²

A systematic, evidence based review of counselling and psychological therapies has looked at the level of expertise which is required for working with patients with depression.¹⁴³ This concluded that:

• generic counselling should only be offered to those with minor degrees of psychological distress
• patients with complex psychological problems should be treated by staff with therapeutic expertise.
  Evidence level 1+

4.14.2 PHARMACOLOGICAL INTERVENTIONS FOR PREVENTING POST-STROKE DEPRESSION

A systematic review of whether antidepressant therapy should be used to prevent depression in stroke survivors appears to include trials which have excluded patients with significant communication or cognitive problems. The trials were small and had high drop out rates. Clinical impact was difficult to assess as results were analysed as depression scores. In two cases, activities of daily living scores were worse relative to placebo.¹⁴⁴ Evidence level 2+

Although pooled analysis suggested a reduction in depression scores with antidepressant treatment, major concerns exist about the small study size, uncertain trial quality, high drop out rates, and potential adverse effects. Evidence level 2+

Stroke patients should not routinely receive antidepressant drugs to prevent depression.

4.14.3 PHARMACOLOGICAL INTERVENTIONS FOR TREATING POST-STROKE DEPRESSION

The clinical impact of using antidepressants for suspected depression in stroke survivors is potentially large. Four patients would need to be treated with anti-depressants to produce one recovery from depression and one patient in every ten would drop out because of drug side effects.¹⁴⁴ The information is much less complete on quality of life and other outcomes. Given the importance of post stroke depression, the potential benefits would appear to be cost effective. Evidence level 1+,2+

One systematic review of six stroke trials reported a significant improvement in depression scores in antidepressant-treated patients, but there was significant heterogeneity between trials and high drop out rates.¹⁴⁴ These results (and problems) are broadly similar to those of a Cochrane review of treatment of depression in physical illness.¹⁴⁵ No changes in physical disease were observed and the impact on physical recovery is not known. Evidence level 1+,2+

Stroke patients with diagnosed depression should be offered a course of treatment with antidepressant drug therapy.

4.14.4 PHARMACOLOGICAL INTERVENTIONS FOR EMOTIONALISM

For many patients with emotional lability education and advice on management may suffice. Where the problem is severe, or interferes with rehabilitation and maximum functioning, drug treatment has been shown to be beneficial.^{146, 147} Evidence level 1+

Drug treatments may be used to treat emotionalism in stroke patients.

4.15 Recurrent stroke

Recurrent stroke is outside the remit of this guideline as it is included in the SIGN guideline on the assessment, investigation, immediate management and secondary prevention of stroke.⁵

4.16 Epileptic seizures

For information on treating epileptic seizures, see the SIGN guideline on epilepsy (currently under review).¹⁴⁸

4.17 Venous thromboembolism

Hospital care in an organised stroke unit (see section 2.1) is likely to reduce the incidence of thromboembolism due to:

• Early mobilisation rehabilitation policies (see section 3.3)
• Early hydration with normal saline
• Specialised nursing care (see section 6.1).

Whilst there is no direct evidence to show that early hydration prevented deep vein thrombosis (DVT), there was a non-significant reduction in DVT in an overview of haemodilution trials.¹⁴⁹

4.17.1 EARLY MEDICAL TREATMENT

Heparin treatment in the first two weeks after ischaemic stroke can cause early recurrent haemorrhagic stroke and has no net benefit.¹⁵⁰ Low dose aspirin has been shown to be safe and effective in preventing DVT and pulmonary embolism.^{5, 151, 152, 153} Evidence level 1++

Aspirin (initial starting dose 150-300mg/day and 75mg/day or more thereafter) should be given to all patients with acute ischaemic stroke in the first two weeks following stroke onset to help prevent deep vein thrombosis and pulmonary embolism (provided there are no known contraindications to aspirin therapy). Aspirin can be given by nasogastric tube or rectally (using 300mg/day suppositories) for those who are unable to swallow.

Patients at a particularly high risk of early DVT (e.g. those with a history of previous DVT, known thrombophilia or active cancer) can be given prophylactic heparin, in a low dose regimen (e.g. 5,000 units of unfractionated heparin subcutaneously twice a day).

4.17.2 MEDICAL TREATMENT TWO WEEKS FROM STROKE ONSET

It is not known when the early risk of haemorrhagic transformation of cerebral infarction returns to normal pre-stroke levels (or acceptable levels). It may be wise to wait a few weeks before re-considering the use of heparin for patients at continued risk of DVT.^{153, 154} Evidence level 4

Two weeks following acute ischaemic stroke, clinicians should reassess the patient’s risk for DVT and consider starting additional prophylactic medical treatment (e.g. heparin).

Physical methods (e.g. graduated elastic compression stockings) are preferred for patients recovering from haemorrhagic stroke.

4.17.3 GRADUATED ELASTIC COMPRESSION STOCKINGS

A Cochrane review of the use of graduated elastic compression stockings (GECS) found little data on the risks and benefits of wearing GECS for many weeks in patients participating in stroke rehabilitation.¹⁵⁵ Whilst the benefits may be similar to those seen in the perioperative period, the risks are potentially greater due to an increased prevalence of peripheral vascular disease, potential discomfort for patients who are very immobile and redirection of scarce nursing resource on stroke units. Stockings have the advantage of being applicable to patients following ischaemic and haemorrhagic stroke. A large multicentre trial (CLOTS) is currently in progress to assess the efficacy of graduated elastic compression stockings in stroke patients (see section 8.3). Evidence level 1+

Selected use of graduated elastic compression stockings may be justified for some high risk stroke patients.

4.18 Driving after a stroke

The rules regarding driving after stroke are summarised in a guide published by the Driver and Vehicle Licensing Agency.¹⁵⁶ Stroke teams should be aware of this guide as these rules are governed by law. Doctors have a duty to inform patients of the rules regarding driving. Patients have a responsibility to act on this advice. Patients need to inform their insurance company.

Patients with stroke who make a satisfactory recovery should be advised that they must not drive for at least one month after their stroke.

Patients with residual disability at one month must inform the DVLA (particularly if there are visual field defects, motor weakness or cognitive deficits) and can only resume driving after formal assessment.

Readers are directed to the DVLA document for guidance for individual patients.¹⁵⁶ Evidence level 4

If there is doubt about a patient’s ability to drive, patients should be referred to the local Disabled Drivers’ Assessment Centre (details available from the DVLA).

4.19 Sexuality

Having a stroke does not mean an end to a sex life for the patient. The wider concept of sexuality encompasses expression of attractiveness and intimacy, as well as sexual relations. The effects of stroke, such as motor or sensory impairment, urinary problems, perceptual alterations, tiredness, anxiety, depression, and changes in self image, self confidence and self worth can cause sexually-related difficulties. Medication, particularly anti-hypertensives, can also interfere with sexual function. The most common fear is that resuming sex may bring on another stroke. The evidence indicates this is not true.^{157, 158, 159} After a stroke sexual activity can be resumed as soon as the patient feels ready to do so. During sex, heart rate rises no more than in normal daily activity and blood pressure does not rise significantly. Patients with known hypertension, should be advised to take their medication as prescribed, and consult their doctor if they have any problems. Evidence level 3

It is important that health professionals talk to patients and partners about sexuality and sex after stroke, and provide advice and information to address any concerns.

4.20 Ethical dilemmas

4.20.1 CARDIOPULMONARY RESUSCITATION

Cardiopulmonary resuscitation (CPR) can be an extremely difficult ethical issue for patients with acute stroke. On one hand, some patients have a rapidly fatal course with no prospect of meaningful recovery and yet patients who were very unwell and disabled in the early phase of their stroke make remarkable recoveries. Many factors will influence the likely recovery for an individual and CPR recommendations need to take these into account, be assessed by a doctor experienced in stroke, and, as appropriate, discussed with families and patients. Recent guidelines have been produced to guide stroke unit staff.¹⁶⁰ Evidence level 4

Hospitals (or stroke units) should have a local cardiopulmonary resuscitation policy.

It is widely accepted that decisions about CPR should be confirmed by the doctor in charge of the patient at the earliest opportunity. This is likely to be the hospital consultant in most stroke units. CPR decisions should be regularly reviewed and discussed with patients as appropriate. The views of the family should be sought if the patient is mentally incompetent.

CPR status should be confirmed at every weekly multidisciplinary meeting and changed according to the patients’ progress and views.

4.20.2 FEEDING AFTER A STROKE

Dysphagia management is dealt with in the accompanying SIGN guideline on the “identification and management of post-stroke dysphagia”⁷ (currently being reviewed).

4.20.3 ANTIBIOTICS FOR PATIENTS WHO ARE TERMINALLY ILL OR SEVERELY DISABLED

Severely disabled patients, and those in the terminal phase of their stroke are at high risk of infection e.g. chest or urinary tract infections. When these infections occur it can be difficult to know what treatment to offer. Discussion with the patient, their relatives and the stroke team can help in treatment decisions. It may be considered appropriate to treat the infection aggressively or palliate with antipyretics (e.g. paracetamol) and opiates.

4.20.4 METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) INFECTION AND CARRIAGE

Many hospitals operate a strict isolation policy for patients who carry MRSA or have MRSA infections. If MRSA cannot be cleared using conventional methods and the patient is isolated for prolonged periods, there may be severe psychological consequences. Some hospitals have a less strict isolation policy which may provide a better rehabilitation setting for the MRSA affected patient but at the risk of spreading MRSA amongst the other rehabilitation patients.

Hospital policies of isolating MRSA patients can have detrimental effects on patients undergoing prolonged rehabilitation and these consequences should be considered when MRSA policies are reviewed.