Stroke is a major health problem in the UK. Each year in England, approximately 110,000 people ²³⁰, in Wales 11,000 and in Northern Ireland 4,000 people have a first or recurrent stroke ²⁵⁰. Most people survive a first stroke, but often have significant morbidity. More than 900,000 people in England are living with the effects of stroke. Stroke mortality rates in the UK have been falling steadily since the late 1960s²⁵. The development of stroke units following the publication of the Stroke Unit Trialists Collaboration meta-analysis of stroke unit care ¹, and the further reorganisation of services following the advent of thrombolysis have resulted in further significant improvements in mortality and morbidity from stroke (as documented in the National Sentinel Audit for Stroke ¹²³). However, the burden of stroke may increase in the future as a consequence of the ageing population.

Despite improvements in mortality and morbidity, stroke survivors need access to effective rehabilitation services. Over 30% of people have persisting disability and they need access to stroke services long term. Stroke rehabilitation is a multidimensional process, which is designed to facilitate restoration of, or adaptation to, the loss of physiological or psychological function when reversal of the underlying pathological process is incomplete. Rehabilitation aims to enhance functional activities and participation in society and thus improve quality of life.

A stroke rehabilitation service comprises a multidisciplinary team of people who work together towards goals for each patient, involve and educate the patient and family, have relevant knowledge and skills to help address most common problems faced by their patients²⁷⁶ Key aspects of rehabilitation care include multidisciplinary assessment, identification of functional difficulties and their measurement, treatment planning through goal setting, delivery of interventions which may either effect change or support the individual in managing persisting change, and evaluation of effectiveness.

Assessment is typically undertaken using the World Health Organisation (WHO) International Classification of Functioning, Disability and Health (ICF) which provides a bio-psychosocial model of disability. As well as supporting comprehensive assessment the ICF can be used in goal setting & treatment planning and monitoring, as well as outcome measurement. Treatments are largely delivered via physiotherapists, occupational therapists, speech and language therapists, nurses and psychologists. Other components of rehabilitation include the learning of new skills to circumvent those lost; adaptation to loss by both the patient and family; the application of new technologies, appliances and environmental modifications; and the development of new service delivery systems. The rehabilitation process aims to maximise the participation of the patient in his or her social setting, including supporting people to establish roles and occupations, and minimise the pain and distress experienced by the patient and their family carers²⁷⁶.

Clear standards exist for stroke rehabilitation, for instance as described both in the National Clinical Guideline for Stroke developed by the Intercollegiate Stroke Working Party ¹²². These are reflected in the NICE quality standards ¹⁸⁹ and the National Stroke Strategy ⁶¹. Overall there is little doubt that the rehabilitation approach is effective; what individual interventions should take place within this structure is less clear.

Advances in the neurosciences including greater understanding of the mechanisms of impairment will lead to novel treatments. There is a wealth of evidence suggesting that central nervous system reorganisation underlies much of the improvement in impairment that is frequently seen. Experiments show that some regions in the normal adult brain, particularly the cortex, have the capacity to change structure and consequently function in response to environmental change, a process described as plasticity. In addition functionally relevant adaptive changes have been demonstrated following focal damage to the brain. It is suggested that rehabilitation therapies interacts with these plastic changes, thus reducing impairment via activity dependent plastic change.²⁸⁰ Examples of such therapies already exist in rehabilitation practice such as upper or lower limb sensorimotor function by task-related training using constraint induced therapy ¹⁷³, treadmill training ¹⁰⁹, and prism adaptation (to reverse visual neglect) ^87,109.

The aim of this guideline development group was to review the structure, processes and interventions currently used in rehabilitation care, and to evaluate whether they improve outcomes for people with stroke. Such studies are complex and research methodologies need to be robust. Evaluation of clinical effectiveness needs studies that have robust theoretical underpinnings, capture changes that are relevant to the treatment evaluated and reflect what is important to patients, and be large enough to allow reliable data interpretation. This guideline reviews some of the available interventions that can be used in stroke rehabilitation, and highlights where there are gaps in the evidence. It is not intended to be comprehensive.

All interventions should take place in the context of a comprehensive stroke pathway which recognises that early management, while critical, is a component of a process which aims to ameliorate the long term consequences of living with stroke for individuals and their families and to enable them to live at home, able to participate in as many activities as they are able. At the point of discharge the person who has had a stroke may need support from a range of other agencies such as housing, Jobcentre Plus, social services and stroke voluntary organisations. Randomised controlled trial evidence, although the gold standard for intervention studies may not be available or appropriate for examining rehabilitation processes. A modified Delphi survey was conducted to obtain formal consensus around areas such as service delivery and care planning. It needs to be recognised that even where the evidence base is clear, rehabilitation interventions need to be targeted and relevant to the individual. Some individuals may decline treatment which health care professionals see as important. In such circumstances issues such as capacity and consent need to be considered ¹⁰⁸.