Stroke rehabilitation and secondary prevention

• After a stroke, most functional recovery comes from organised rehabilitation: a specialist multidisciplinary stroke team delivering needs-based therapy, at least 3 hours a day on at least 5 days of the week, for as long as it helps the patient meet their goals.^[1]
• Dysphagia, limb spasticity, low mood, fatigue, and memory, attention and communication problems are common and should be screened for explicitly rather than assumed.^[1][2]
• Survivorship is high-risk: up to 90% of strokes may be preventable by addressing vascular risk factors, so blood pressure, lipids, diabetes and smoking are revisited at every review.^[3][4]
• Secondary prevention is mechanism-based: non-cardioembolic stroke needs antiplatelet therapy (single agent long term, dual only for 21 to 90 days in specific early minor strokes), while atrial fibrillation and other cardioembolic causes need anticoagulation.^[4][7]
• Driving stops immediately after a stroke or TIA; many car and motorcycle licences can be resumed after 1 month if there is no residual deficit and a clinician agrees it is safe, but bus, coach and lorry driving needs at least 1 year.^[6]

By the end of this page you should be able to:

1. Describe how a stroke rehabilitation service is organised and what intensity of therapy NICE (NG236) recommends.
2. Screen for and manage common post-stroke problems: dysphagia, spasticity, depression and anxiety, fatigue, vision, hearing, communication and safe swallowing and nutrition.
3. Set movement, spasticity and shoulder-pain goals, including the place of botulinum toxin and oral baclofen.
4. State the secondary-prevention targets for blood pressure, LDL cholesterol and glucose after stroke, and the AHA/ASA 2021 recommendations on lipid therapy.
5. Choose the correct antithrombotic strategy (antiplatelet versus anticoagulant, and short-term dual antiplatelet therapy) for a given stroke mechanism.
6. Advise a stroke survivor about driving in line with DVLA guidance.

Stroke rehabilitation is the organised, patient-centred process by which a person who has had a stroke regains functional ability and adapts to impairment: assessment, goal setting, repeated practice of tasks, education and provision of aids and adaptations. Secondary prevention is everything done to stop the next stroke or vascular event, and it starts in the acute hospital and continues for life. The two are inseparable, because a drug or exercise programme only works if the patient can swallow it, tolerate it, remember it and reach the clinic. This page is a care pathway: it follows a stroke survivor from the first therapy screen through long-term review and lifelong secondary prevention. Acute diagnosis, emergency treatment and thrombolysis are not covered here; they belong to the acute stroke topic.

A stroke survivor's risk of a further stroke is highest in the days and weeks after the event, and remains substantially raised thereafter. The 2021 AHA/ASA secondary-prevention recommendations for people who have had a stroke or TIA state that up to 90% of strokes may be preventable by addressing vascular risk factors, including blood pressure control, diet, physical activity and smoking cessation, and that targeting multiple risk factors has additive effects.^[3] Control of vascular risk factors is important after every type of ischaemic stroke, but specific prevention strategies differ by stroke mechanism, so every survivor needs a clear aetiological diagnosis before the long-term plan is finalised.^[3] That is the principle behind the two halves of this pathway: rehabilitation for the impairment caused by the stroke, and mechanism-based, lifelong reduction of risk.

People who need rehabilitation after stroke should receive it from a specialist stroke service: in a stroke unit and then from a specialist stroke team in the community, or directly from a specialist team in the community through early supported discharge, or in a level 1 or 2 specialist inpatient neurorehabilitation unit followed by community specialist follow-up.^[1] An inpatient stroke unit should provide a dedicated rehabilitation environment, access to services such as continence advice, orthotics, pharmacy, podiatry and wheelchair services, and a multidisciplinary education programme.^[1]

A core multidisciplinary stroke rehabilitation team with expertise in stroke should comprise: consultant physicians specialising in stroke or rehabilitation medicine, nurses, physiotherapists, occupational therapists, speech and language therapists, dietitians, clinical psychologists or neuropsychologists, orthoptists, rehabilitation assistants and social workers.^[1] Their roles and responsibilities should be documented and communicated to the patient and family.^[1] Families and carers who are willing should be trained in moving people and helping with dressing, and their training and support needs reviewed regularly, at a minimum at the 6-month and annual reviews.^[1]

On admission, screen and act promptly on: signs of disorientation, safe positioning, swallowing function, transfers and mobility, pressure area risk, continence, communication (understanding and expression) and nutritional status and hydration.^[1] A full medical assessment should cover cognition (attention, memory, spatial awareness, apraxia of speech, perception), vision, hearing, muscle tone, strength, sensation and balance.^[1] The comprehensive assessment also includes previous functional abilities, changes in psychological and neuropsychological function, communication, impairment of body functions including pain, activity limitations and participation restrictions, and environmental factors.^[1] Valid tools such as the National Institutes of Health Stroke Scale and the Barthel Index should be used on admission and discharge and fed back to the multidisciplinary team.^[1]

Goals should be meaningful and relevant to the patient, focus on activity and participation, be challenging but achievable, and include both short- and long-term elements. Goal-setting meetings should be timetabled, regular and include the patient and family.^[1] The patient should receive a copy of the agreed goals after each meeting, and goals should be reviewed regularly.^[1] Rehabilitation plans should be reviewed in multidisciplinary team meetings timed to the stage of recovery and the patient's needs, and documentation should include diagnosis and medicines, screening assessments, goals, progress, a named key contact and discharge planning.^[1]

Needs-based rehabilitation should be offered after stroke. It should be for at least 3 hours a day, on at least 5 days of the week, and should cover a range of multidisciplinary therapy including physiotherapy, occupational therapy and speech and language therapy.^[1] Where a patient is unable or does not wish to participate in at least 3 hours a day on 5 days a week, any therapy still needed should be offered for a minimum of 5 days per week.^[1] Before rehabilitation begins, give information about the benefits of intensive therapy that starts as soon as it is safe and about what to expect from sessions.^[1] Sessions should include activities linked to goals, be tailored to ongoing medical needs including post-stroke fatigue, and take account of mood and motivation.^[1] Families and carers should be involved where appropriate, and special arrangements such as joint speech and language therapy and physiotherapy sessions should be made for patients with communication or cognitive needs.^[1]

Early supported discharge should be offered to people who can transfer from a bed to a chair, as long as a safe environment can be provided; therapy must continue at the same intensity as in hospital.^[1] Before discharge, establish a safe and enabling home environment, with adaptations and carer support in place, and provide the patient and carers with a health and social care plan.^[1] After discharge, the specialist stroke rehabilitation team should follow up within 72 hours, and care and rehabilitation should continue for as long as they help achieve the patient's goals.^[1] Health and social care needs, and carers' needs, are reviewed at 6 months and then annually.^[1]

Telerehabilitation may be considered instead of, or as well as, face-to-face therapy only if the patient agrees or prefers it and it aligns with rehabilitation goals.^[1] The person must have, or be provided with, the correct equipment, training and technical support, and should be monitored for benefit and for symptoms or signs of depression.^[1]

Dysphagia is difficulty swallowing. It is common after stroke because the swallowing motor programmes and the cranial nerves that coordinate them are often affected, and it raises the risk of aspiration pneumonia and malnutrition. Swallowing should be assessed in line with NICE's guideline on stroke in people over 16, and dysphagia support should be seen as part of rehabilitation rather than a separate problem.^[1][2]

If a patient has dysphagia and cannot take tablets, review whether each medicine is still needed; if it is, change the formulation or the route of administration.^[2] Provide information to the patient and family about what dysphagia is and its risks, and give carers information on how to help someone who is coughing or choking while eating or drinking.^[2] Effective mouth care is important because it reduces aspiration pneumonia risk, and nutrition support should follow adult nutrition support guidance.^[1]

Patients with oropharyngeal dysphagia should be supported to eat and drink as safely as possible using one or more of: changes in physical position, modified fluid intake (small sips, thickened fluids), modified diet texture, adaptation of how food and drink are served (such as different cutlery) and compensatory strategies and manoeuvres (such as the Mendelsohn manoeuvre).^[1] Behavioural exercises such as chin tuck against resistance should be offered for at least 5 days per week, and physical stimulation such as thermal or tactile stimulation should be considered for at least 5 days per week.^[1][2] Monitoring continues until swallowing is stable.^[1]

If a patient with dysphagia is at risk of aspiration but chooses to eat and drink without aids and interventions, respect that choice while discussing risks, benefits and consequences.^[1]

Physiotherapy should be provided for people with trunk or limb weakness, sensory disturbance or balance difficulties affecting movement, delivered by therapists with appropriate training, and continued until the person can maintain or progress function independently or with assistance.^[1] Strength training, fitness and walking training should be encouraged, including treadmill training and a possible group circuit training programme with an educational element and peer support.^[1] Repetitive task training over a range of activities, constraint-induced movement therapy for those with at least 20 degrees of wrist extension and 10 degrees of finger extension, and mirror therapy for upper or lower limb weakness (around 30 minutes, at least 5 times per week for 4 weeks, started within the first 6 months) are used as appropriate.^[1] Ankle-foot orthoses are considered for swing-phase clearance or stance-phase control problems, trial electrical stimulation may be offered where there is muscle contraction without movement against resistance, and wrist and hand splints should not be offered routinely, only for specific aims such as maintaining joint range or facilitating function.^[1] Robot-assisted arm training should not be offered, electromechanical gait training only in research, and functional electrical stimulation for drop foot should follow NICE interventional procedures guidance.^[1]

Shoulder pain should be prevented where possible in at-risk patients and, when present, assessed to identify its cause before a management plan is chosen.^[1] Positioning advice, taping, neuromuscular electrical stimulation, intra-articular corticosteroid injection and local anaesthetic nerve block are among the options considered, with neuropathic pain managed by the relevant guideline.^[1]

Spasticity is increased, velocity-dependent resistance to passive movement from overactive stretch reflexes; after stroke it can be focal (one limb or part) or generalised.^[2] The patient and family should be given information about what spasticity is and what makes it better or worse, its distribution should be established, and options should be discussed with the multidisciplinary team.^[2] A goal-directed plan may include stretching, splints when needed, and identifying and managing triggers of spasticity.^[2]

For focal upper limb spasticity, consider treatment with either Dysport up to 1,000 units per treatment or Xeomin up to 400 units per treatment, unless the patient is already receiving a different type or dose of botulinum toxin A, which should be continued if effective.^[2] The dose should be spread across appropriate injection sites, the patient should not receive more than one treatment every 3 months, and response should be monitored and treatment stopped if ineffective.^[2] A trial of NMES, functional electrical stimulation or TENS can be considered for focal spasticity, and oral baclofen can be considered for generalised spasticity with close monitoring for adverse effects.^[2] Refer to a specialist spasticity service if spasticity persists despite treatment, treatments are not tolerated, or needs are complex, such as injection of small muscles or spasticity-related pain.^[2]

People after stroke should be screened for cognitive impairment and, where found, assessed in detail before a treatment programme is planned, with education and support for the patient and family.^[1] Standardised assessments and behavioural observation are used for visual inattention, with functional interventions such as scanning strategies, prism glasses and sounds; memory and attention impairments are addressed with errorless learning, elaborative strategies, external aids and environmental strategies.^[1] People in hospital after stroke should be offered a specialist orthoptist assessment as soon as possible, with eye movement therapy for persisting hemianopia, and driving advice should follow DVLA rules.^[1] Screen for hearing within the first 6 weeks after stroke and refer for audiology assessment.^[1]

Psychological adjustment changes over time. Assess emotional functioning, behaviour, mental health including suicide risk (thoughts, plans, actions, attempts) and how the person is coping, and refer for detailed assessment and treatment when new or persisting mood or emotional difficulties are found, including at 6-month and annual reviews.^[1] Depression and anxiety without cognitive impairment should be managed in line with NICE depression and anxiety guidance.^[1]

Depression is common after stroke, with post-stroke anxiety in roughly 19 to 24%; rates are higher in young survivors and when assessed with rating scales rather than structured interviews.^[8] Suicide risk is high: stroke survivors have higher risks of suicidal ideation (12.2% versus 4.3%), suicide attempts and suicide death than the general population.^[8] Depression also reduces participation in rehabilitation and raises mortality, so screening and treatment are part of recovery, not an optional extra.

Treatment should be chosen by clinical factors and tolerability. Current evidence supports routine antidepressant use for post-stroke depression, with SSRIs (sertraline, citalopram or escitalopram) as first-line agents because of low anticholinergic activity, and paroxetine is less favoured.^[8] Treatment should continue for at least 6 months with careful tapering to avoid withdrawal, starting low and titrating.^[8] For patients who do not tolerate or respond to SSRIs, SNRIs (venlafaxine, duloxetine) or mirtazapine are alternatives; tricyclics and monoamine oxidase inhibitors are not first-line because of anticholinergic and cardiovascular risks.^[8] Cognitive behavioural therapy and other psychological therapies, exercise programmes and supported lifestyle change all have evidence.^[8] Fluoxetine and other SSRIs should not be given routinely to prevent post-stroke depression: trials such as FOCUS, AFFINITY and EFFECTS showed no functional benefit and an increased fracture risk.^[8] For anxiety after stroke, SSRIs and SNRIs are first-line; benzodiazepines are generally discouraged because of dependence, cognitive effects, falls and mortality risk.^[8]

Screen for communication difficulties within 72 hours, refer for detailed speech and language therapy assessment, and provide communication aids, accessible written information and training in supportive communication.^[1]

Consider standardised fatigue assessment early in rehabilitation and at the 6-month review using the Fatigue Severity Scale, Fatigue Assessment Scale or Modified Fatigue Impact Scale.^[1]

Assess oral hygiene using a national or local protocol, and encourage brushing twice daily, with electric or battery-powered toothbrushes and antibacterial or antifungal mouthwashes or gels when needed, delivered or supervised by a trained professional if the patient cannot manage.^[2]

Eight lifelong systems need attention after stroke:

• Explain self-referral for further help, usually through general practice or a named contact from the stroke service.^[1]
• Review health and social care needs, carers' needs and participation in everyday activities at 6 months and annually.^[1]
• Encourage life after stroke: information about voluntary organisations, community activities, sports, worship and stroke support groups, support for social roles in work, education, volunteering and family life, transport and driving with DVLA requirements.^[1]
• Provide participation programmes suited to rehabilitation goals, and manage incontinence using the relevant NICE guidance.^[1]
• Community participation needs reassessment when goals change.^[1]

Secondary prevention is multidisciplinary and personalised, with targets set for hypertension, diabetes, lipid levels and smoking.^[3][4] Prevention should be the same for patients with ischaemic stroke and TIA, but strategies differ by aetiological subtype, so the cause must be pursued with diagnostic tests completed as early as possible.^[4] Behaviour change for diet, exercise and medication adherence is difficult and is best delivered through structured, multidisciplinary programmes rather than simple advice.^[3]

For most stroke patients with hypertension, the goal blood pressure is under 130/80 mmHg.^[3] Aggressive medical management of this vascular risk factor is a central pillar of recurrence prevention.^[3] Ongoing adherence and reasons for non-adherence should be checked before therapy is changed if a stroke occurs while a patient is prescribed prevention medication.^[3]

In most stroke patients, atorvastatin 80 mg daily is recommended to reduce the risk of stroke recurrence, and an LDL cholesterol below 70 mg/dL is recommended to reduce cardiovascular events.^[3] If the LDL remains above 70 mg/dL on maximally tolerated statin therapy, add ezetimibe; if it is still above 70 mg/dL, a PCSK9 inhibitor can be considered.^[3]

Guidelines differ on how low to go. The ESC/EAS dyslipidaemia guideline (2019) recommends an LDL cholesterol below 55 mg/dL (1.4 mmol/L) and at least a 50% reduction from baseline in patients with established atherosclerotic cardiovascular disease, whereas AHA/ASA 2021 recommends below 70 mg/dL.^[5] Both are guideline-based; the local lipid guideline and the patient's profile should determine the target used.^[3][5]

In stroke patients with diabetes, therapy and glycaemic goals should be individualised, but for most patients a haemoglobin A1c of 7% or less is recommended; in selected patients a GLP-1 agonist or SGLT2 inhibitor can be added to metformin.^[3]

Stroke survivors should be encouraged to be physically active: at least moderate-intensity aerobic activity for at least 10 minutes four times a week, or vigorous-intensity aerobic activity for at least 20 minutes twice a week.^[3] Supervised exercise programmes help where mobility deficits exist.^[3] Limiting salt intake and following a heart-healthy Mediterranean diet are advised, together with smoking cessation.^[3] NICE NG236 also encourages healthy life after stroke and community participation.^[1]

Patients with non-cardioembolic ischaemic stroke or TIA should receive antiplatelet therapy, not anticoagulation, typically with 3 possible regimens: aspirin 50 to 325 mg daily, clopidogrel 75 mg daily, or the combination of aspirin 25 mg plus extended-release dipyridamole 200 mg twice daily, unless contraindicated.^[7][3] Combining antiplatelet and anticoagulation is generally not recommended.^[3]

Long-term dual antiplatelet therapy has no role for most stroke patients. Short-term dual therapy (aspirin plus clopidogrel, or aspirin plus ticagrelor) is reserved for specific groups and should be initiated early (ideally within 24 hours, at least within 7 days).^[4][7]

• Minor ischaemic stroke (NIHSS 3 or less; 5 or less for ticagrelor) or high-risk TIA (ABCD2 score 4 or more; 6 or more for ticagrelor): dual antiplatelet therapy for 21 to 90 days, then a single agent. The benefit is observed mainly in the first 21 days; POINT found benefit over 90 days but with more major bleeding.^[7]
• Recent (within 30 days) stroke or TIA attributable to severe (70 to 99%) intracranial atherosclerosis: aspirin 325 mg daily with clopidogrel 75 mg daily for up to 90 days, followed by aspirin alone.^[7]
• Recent (within 24 hours) minor stroke or high-risk TIA plus ipsilateral intracranial stenosis over 30%: ticagrelor 90 mg twice daily added to aspirin for up to 30 days.^[7]

Beyond these windows, single antiplatelet therapy is recommended because long-term dual therapy increases bleeding and intracranial haemorrhage.^[7] Aggressive medical management plus short-term dual antiplatelet therapy is preferred first-line over angioplasty and stenting for severe symptomatic intracranial stenosis.^[3]

Atrial fibrillation is common in stroke survivors and anticoagulation reduces recurrence; screening should be thorough, including longer-term cardiac monitoring for occult atrial fibrillation when no other cause is identified.^[3][4] Typical indications for anticoagulation arise from these sources: under 60 years with an embolic stroke of uncertain source, discussion of percutaneous patent foramen ovale closure is reasonable for high-risk patent foramen ovale; no benefit has been found for empirical anticoagulation or ticagrelor in embolic stroke of uncertain source.^[3]

Patients with a non-disabling ischaemic stroke and ipsilateral severe extracranial carotid stenosis (50 to 99%) should have carotid endarterectomy or stenting soon after the stroke, with the choice guided by anatomy and comorbidity.^[3][7] Intracranial arterial stenting for 70 to 99% stenosis has not shown benefit over aggressive medical management.^[7]

A stroke survivor must stop driving straight away.^[6] For a car or motorcycle licence they must stop driving for at least 1 month and may restart only when their doctor or healthcare professional says it is safe.^[6] If recovery is complete, there is no need to notify DVLA.^[6] Notification and medical review are needed if, after 1 month, there is weakness in the arms or legs, visual field loss or double vision, balance, memory or understanding problems, any seizure, brain surgery as part of stroke treatment, or if the clinician believes driving may be unsafe.^[6] Failure to notify a relevant condition can lead to a fine of up to £1,000.^[6] For a bus, coach or lorry licence the driver must tell DVLA and stop driving for at least 1 year, with assessment and possible tests before reapplying.^[6] NICE also advises that visual advice after stroke be checked against DVLA rules.^[1] Because licensing rules differ by country, patients everywhere should follow their own authority's guidance.^[6]

• Prioritise blood pressure control, statin therapy, one antiplatelet and simple rehabilitation over expensive interventions.^[3]
• Task-shift therapy to carers and community workers; family training in swallowing safety, positioning and movement is effective and low cost.^[1][2]
• Use basic screens for swallowing, motor weakness and mood, and arrange early referral for suspected dysphagia, spasticity requiring injections, or low mood needing medication.^[1][8]

Older adults and those with communication or cognitive impairment need adapted screening and therapy; patients with aphasia cannot use standard self-report mood screens reliably, so clinician-rated or aphasia-specific tools should be used.^[8] Pregnancy-specific management is individualised and beyond this page.

• Stroke rehabilitation is organised, goal-directed multidisciplinary care: specialist stroke service, core team, early supported discharge and 6-month and annual reviews.^[1]
• Therapy after stroke should be at least 3 hours a day on 5 days a week, with a minimum of 5 days weekly when more intensity is not possible.^[1]
• Dysphagia care includes safe positioning, modified textures and fluids, compensatory manoeuvres, behavioural exercises 5 days a week, mouth care and medicines formulation change.^[1][2]
• Spasticity is managed with goal-directed stretching and splints, focal upper limb botulinum toxin (Dysport up to 1,000 units or Xeomin up to 400 units every 3 months) and oral baclofen for generalised spasticity.^[2]
• Depression affects about one in four to one third of survivors and anxiety roughly one in five; screen and treat routinely, with SSRIs as first line and treatment for at least 6 months.^[8]
• Survivors should be physically active, eat a Mediterranean-style diet and stop smoking; up to 90% of strokes are preventable by addressing risk factors.^[3]
• Blood pressure goal for most survivors with hypertension is under 130/80 mmHg.^[3]
• LDL goal is below 70 mg/dL on atorvastatin 80 mg daily, with ezetimibe and PCSK9 inhibitors for resistant elevation; ESC/EAS recommends below 55 mg/dL in very-high-risk disease.^[3][5]
• Glucose goal for most with diabetes is an HbA1c of 7% or less.^[3]
• Non-cardioembolic stroke needs antiplatelet, not anticoagulant, therapy; dual antiplatelet is confined to early minor stroke or TIA and severe symptomatic intracranial stenosis windows.^[7]
• Screen for atrial fibrillation and anticoagulate cardioembolic stroke; do not use empirical anticoagulation or ticagrelor for embolic stroke of uncertain source.^[3]
• Driving stops at once; car and motorcycle licences often resume after 1 month, but bus, coach and lorry licences need 1 year.^[6]

Acute ischaemic stroke and TIA; Atrial fibrillation and anticoagulation; Hypertension; Dyslipidaemia and lipid-lowering therapy; Carotid artery stenosis; Intracranial atherosclerosis; Diabetes management; Shoulder pain and spasticity; Dysphagia and aspiration pneumonia; Cognitive impairment after stroke; Post-stroke depression and anxiety; Fatigue after stroke; Driving after a medical condition; Low-resource stroke care.