national-clinical-guidelines-for-stroke-fourth-edition

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etween 2 days and 7 months across a broad range of pathologies in adults and children. The majority of studies looked at stretch interventions of 0–6 weeks duration and in most instances to 4 weeks. Until the evidence base is more conclusive therapists must be analytical and critical in their practice in identifying who and when to splint and when not to splint. Splinting may be used to help manage tone, reduce pain and improve range of movement and function (passive and active). Splints should only be assessed, fitted and reviewed by appropriately skilled staff. 6.11.1 Recommendations A Any patient who has increased tone sufficient to reduce passive or active movement around a joint should have their range of passive joint movement assessed and monitored. B Splinting of the arm and hand should not be used routinely after stroke. 6.11.2 Sources A Consensus B Lannin et al 2007a 6.12 Biofeedback One key aspect of any therapist’s work is to provide the patient with feedback on their performance of an activity or exercise. One method of enhancing feedback is to use technology which can often also provide more consistent, detailed and sometimes individually adapted feedback. Performance measures monitored in this way include muscle activity (electromyography (EMG)) and balance (force platform), and the feedback may be auditory or visual. For biofeedback for dysphagia see section 6.21. Evidence to recommendations The stroke literature on biofeedback contains small to moderate sized RCTs and systematic reviews. From the current evidence it is not possible to determine which combinations or characteristics of feedback are most beneficial, but augmented visual feedback in general has added value (Molier et al 2010). When feedback is directed towards Knowledge of Performance (KP), quality of movement improves more than when Knowledge of Results (KR) feedback is given (Cirstea and Levin 2007). Many biofeedback machines are promoted for use after stroke but there remains insufficient evidence of benefit to justify their use outside the context of a clinical trial (van Dijk et al 2005; Woodford and Price 2007). 6.12.1 Recommendation 6 Recovery phase from impairments and limited activities: rehabilitation A Stroke patients should not be offered biofeedback outside the context of a clinical trial. © Royal College of Physicians 2012 89
National clinical guideline for stroke 6.12.2 Sources A Molier et al 2010; van Dijk et al 2005; Woodford and Price 2007 6.13 Neuromuscular electrical stimulation (including functional electrical stimulation) Neuromuscular electrical stimulation (NMES or ES) has been used as an adjunct treatment for stroke for many years in many forms. The principle is that, if the brain cannot control muscles, electrical stimulation of the relevant nerve(s) may generate a muscle contraction that improves function. The most common forms used to treat stroke patients are: functional electrical stimulation where the immediate effect aims to improve function, and therapeutic electrical stimulation in which longer-term use aims to improve recovery of function or reduce pain. Evidence to recommendations The stroke literature on therapeutic electrical stimulation for rehabilitation of the upper limb contains small to moderate sized RCTs and systematic reviews. Findings are inconclusive: they report reductions in impairment and improved function but these are not translated into improved activities of daily living or quality of life. Similarly, the therapeutic electrical stimulation studies of lower limb rehabilitation after stroke (small RCTs and papers) report contradictory findings at the level of impairment or activity. Overall, these findings may result from studies being underpowered and lacking internal validity. There are no cost-effectiveness studies in this area. 6.13.1 Recommendations A Functional electrical stimulation can be used for drop foot of central neurological origin provided normal arrangements are in place for clinical governance, consent and audit. B Therapeutic electrical stimulation for treatment of the upper and lower limbs following stroke should only be used in the context of a clinical trial. 6.13.2 Sources A National Institute for Health and Clinical Excellence 2009b B Consensus 6.14 Acupuncture Acupuncture has been used as a treatment for several impairments seen after stroke including loss of motor control, pain, sensory loss, and reduced balance, as well as in a more generic manner to improve function and well-being. 90 © Royal College of Physicians 2012
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National clinical guideline for str
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The Royal College of Physicians The
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The Intercollegiate Stroke Working
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Conflicts of interest All working p
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Key recommendations Number Recommen
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Acknowledgements The Intercollegiat
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Glossary ABCD2 score Prognostic sco
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2 Commissioning of stroke services
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2.1.2 Implications needed by patien
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2.4 Commissioning rehabilitation se
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3 Organisation of stroke services 3
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symptoms who screen positive using
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● nursing staff specifically trai
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3.5.1 Recommendation 3.5.2 Source A
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3.8 Transfers of care - discharge f
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B Clinicians in all settings should
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E have protocols to guide the use o
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Evidence to recommendations It is r
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evidence from randomised trials is
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4 Acute phase care 4.0 Introduction
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Page 158 and 159: C People with stroke should be offe
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Carers (informal, unpaid) (7.6.1) A
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● any continuing specialist treat
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Lipid-lowering therapy (5.6.1) B Al
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Occupational therapy concise guide
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C Bilateral arm training involving
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● be referred to a specialist in
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problems, such as using notebooks,
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Physiotherapy concise guide for str
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medically unstable, by an appropria
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numerical rating scale), the modifi
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Cognitive impairments - general (6.
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E Patients with suspected TIA who a
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Lipid-lowering therapy (5.6.1) A Al
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● ask about and identify any abso
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formal review at least every 6 mont
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Depression and anxiety (6.35.1) A A
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Perception (6.42.1) A Any person wh
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days per week, at a level that enab
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language function should be assesse
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● organising and supporting venue
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Appendix 1 Evidence table reviewers
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Appendix 2 Peer reviewers Commissio
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Dr Katerina Hilari City University
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QM7 Urgent response All patients wi
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References Abbott AL (2009) Medical
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Cirstea MC, Levin MF (2007) Improve
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Fung TT, Chiuve SE, McCullough ML,
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Koyuncu E, Nakipoglu YG, Dogan A, O
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Mitchell PH, Veith RC, Becker KJ, B
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Rothwell P, Eliasziw M, Gutnikov S,
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therapy for stroke inpatients. Clin
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