Synopsis
Plan needs-based multidisciplinary rehabilitation after stroke, protect nutrition and lungs through structured dysphagia care, and treat spasticity only when a goal-directed intervention is likely to improve comfort, care or function.
- Rehabilitation starts in the specialist stroke unit and is organised around the person’s own goals, impairments, activities, participation, home setting and support network rather than around a fixed package of therapies.
- NICE recommends needs-based multidisciplinary therapy for at least three hours a day on at least five days each week when the person can participate; those unable to tolerate that intensity should still receive needed therapy on five days.
- No food, drink or oral medicine should be given after acute stroke until swallowing has been screened by a trained professional using the local validated process.
- A failed screen requires specialist swallowing assessment, texture and fluid recommendations, safe medication planning, mouth care and a nutrition and hydration strategy—not simply nil by mouth without support.
- Spasticity is velocity-dependent resistance from upper motor neurone injury; distinguish it from fixed contracture, pain guarding, dystonia, rigidity and mechanical joint restriction before prescribing treatment.
- Treat the consequences that matter to the person: pain, hygiene difficulty, skin injury, sleep disturbance, impaired gait, loss of reach or barriers to care. Reducing tone without a functional goal can weaken useful compensatory activity.
- Focal upper-limb spasticity may respond to botulinum toxin A plus active rehabilitation, whereas generalised troublesome tone may justify cautious oral baclofen and specialist review.
- Recovery includes communication, cognition, mood, vision, fatigue, continence, sexuality, work and carer needs; a normal limb-power score does not mean rehabilitation is complete.
Key red flags
Coughing, choking, a wet or gurgly voice, drooling, prolonged meals, pocketing food, recurrent chest infection or unexplained weight loss suggests dysphagia, while silent aspiration may present without an obvious cough.
Sudden neurological worsening, new hypoxia, calf swelling, fever, shoulder trauma or an acutely painful limb needs medical reassessment before therapy continues because recurrence and preventable complications can mimic rehabilitation fluctuation.
Investigation priorities
Identify who can safely begin oral food, fluid and medication immediately after stroke.
Management branches
A person is admitted with acute stroke once hyperacute treatment and physiological stability are being addressed.
- 1. Admit to a specialist stroke service, screen swallowing before any oral intake and identify immediate mobility, pressure, communication and cognition risks.
- 2. Establish premorbid function, meaningful activities, home layout, work and caring roles, and involve family or advocates with consent.
- 3. Set initial multidisciplinary goals and offer needs-based practice at the highest safe intensity the person can sustain, reviewing tolerance each day.
- 4. Begin discharge planning early, including equipment, medication support, carer training and continuity with a specialist community stroke team.