Guidelines for Adult Stroke Rehabilitation and Recovery: Difference between revisions

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==Guidelines for Adult Stroke Rehabilitation and Recovery==
==Guidelines for Adult Stroke Rehabilitation and Recovery==
===Organization of Poststroke Rehabilitation Care (Levels of Care===
===Organization of Poststroke Rehabilitation Care ===
{|class="wikitable" style="width:80%"
{|class="wikitable" style="width:80%"
|-
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:A]] )'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki> It is recommended that stroke patients who are candidates for postacute rehabilitation receive organized, coordinated, interprofessional care''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:A]] )'' <nowiki>"</nowiki>
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.'''<nowiki>"</nowiki> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.'''<nowiki>"</nowiki> It is recommended that stroke survivors who qualify for and have access to IRF care receive treatment in an IRF in preference to a SNF. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.'''<nowiki>"</nowiki> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.'''<nowiki>"</nowiki> Organized community-based and coordinated interprofessional rehabilitation care is recommended in the outpatient or home-based settings. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
|}
|}
{|class="wikitable" style="width:80%"
{|class="wikitable" style="width:80%"
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|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki>.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki>ESD services may be reasonable for people with mild to moderate disability.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
|}Rehabilitation
|}Rehabilitation
===Interventions in the Inpatient Hospital Setting===
===Interventions in the Inpatient Hospital Setting===
Line 27: Line 27:
|colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:A]] )'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki> It is recommended that early rehabilitation for hospitalized stroke patients be provided in environments with organized, interprofessional stroke care. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:A]] )'' <nowiki>"</nowiki>
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.'''<nowiki>"</nowiki> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.'''<nowiki>"</nowiki> It is recommended that stroke survivors receive rehabilitation at an intensity commensurate with anticipated benefit and tolerance ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
|-
|-
|}
|}
Line 36: Line 36:
|colspan="1" style="text-align:center; background:LightCoral"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|colspan="1" style="text-align:center; background:LightCoral"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
|-
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki> ''. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:A]] )'' <nowiki>"</nowiki>
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki> High-dose, very early mobilization within 24 hours of stroke onset can reduce the odds of a favorable outcome at 3 months and is not recommended.''. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:A]] )'' <nowiki>"</nowiki>
|-
|-
|}
|}
Line 44: Line 44:
|colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki> During hospitalization and inpatient rehabilitation, regular skin assessments are recommended with objective scales of risk such as the Braden scale ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.'''<nowiki>"</nowiki> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.'''<nowiki>"</nowiki> It is recommended to minimize or eliminate skin friction, to minimize skin pressure, to provide appropriate support surfaces, to avoid excessive moisture, and to maintain adequate nutrition and hydration to prevent skin breakdown. Regular turning, good skin hygiene, and use of specialized mattresses, wheelchair
cushions, and seating are recommended until mobility returns. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.'''<nowiki>"</nowiki> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.'''<nowiki>"</nowiki> Patients, staff, and caregivers should be educated about the prevention of skin breakdown. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
|}
|}
{|class="wikitable" style="width:80%"
{|class="wikitable" style="width:80%"
Line 54: Line 55:
|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki>.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki>Positioning of hemiplegic shoulder in maximum external rotation while the patient is either sitting or in bed for 30 minutes daily is probably indicated..''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
|}
|}
{|class="wikitable" style="width:80%"
{|class="wikitable" style="width:80%"
Line 60: Line 61:
|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki>.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki> Resting hand/wrist splints, along with regular stretching and spasticity management in patients lacking active hand movement, may be considered..''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.'''<nowiki>"</nowiki>.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.'''<nowiki>"</nowiki> Use of serial casting or static adjustable splints may be considered to reduce mild to moderate elbow and wrist contractures.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.'''<nowiki>"</nowiki>.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.'''<nowiki>"</nowiki> Surgical release of brachialis, brachioradialis, and biceps muscles may be considered for substantial elbow contractures and associated pain.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.'''<nowiki>"</nowiki>.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.'''<nowiki>"</nowiki> Resting ankle splints used at night and during assisted standing may be considered for prevention of ankle contracture in the hemiplegic limb..''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
|}
|}
===Prevention of DVT===
===Prevention of DVT===
Line 73: Line 74:
|colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:A]] )'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki> In ischemic stroke, prophylactic-dose subcutaneous heparin (UFH or LMWH) should be used for the duration of the acute and rehabilitation hospital stay or until the stroke survivor regains mobility. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:A]] )'' <nowiki>"</nowiki>
|-
|-
|}
|}
Line 80: Line 81:
|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki>.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:A]] )'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki> In ischemic stroke, it is reasonable to use prophylactic-dose LMWH over prophylactic dose UFH for prevention of DVT.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:A]] )'' <nowiki>"</nowiki>
|-
|-
|}
|}
Line 87: Line 88:
|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki>.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki> In ischemic stroke, it may be reasonable to use intermittent pneumatic compression over no prophylaxis during the acute hospitalization.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.'''<nowiki>"</nowiki>.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.'''<nowiki>"</nowiki> In ICH, it may be reasonable to use prophylactic-dose subcutaneous heparin (UFH or LMWH) started between days 2 and 4 over no prophylaxis..''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.'''<nowiki>"</nowiki>.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.'''<nowiki>"</nowiki> In ICH, it may be reasonable to use prophylactic dose LMWH over prophylactic-dose UFH.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.'''<nowiki>"</nowiki>.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.'''<nowiki>"</nowiki> In ICH, it may be reasonable to use intermittent pneumatic compression devices over no prophylaxis.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
|}
|}
{|class="wikitable" style="width:80%"
{|class="wikitable" style="width:80%"
Line 99: Line 100:
|colspan="1" style="text-align:center; background:LightCoral"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|colspan="1" style="text-align:center; background:LightCoral"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
|-
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki> ''. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki> In ischemic stroke, it is not useful to use elastic compression stockings. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
|-
|-
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.'''<nowiki>"</nowiki> .([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.'''<nowiki>"</nowiki> In ICH, it is not useful to use elastic compression stockings.([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
|-
|-
|}
|}
Line 109: Line 110:
|colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki> Assessment of bladder function in acutely hospitalized stroke patients is recommended. A history of urological issues before stroke should be obtained. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.'''<nowiki>"</nowiki> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.'''<nowiki>"</nowiki> Assessment of urinary retention through bladder scanning or intermittent catheterizations after voiding while recording volumes is recommended for patients
|-
with urinary incontinence or retention. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )''  
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.'''<nowiki>"</nowiki> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
|-
|-
|<nowiki>"</nowiki>Removal of the Foley catheter (if any) within 24 hours after admission for acute stroke is recommended.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )''
|}
|}
{|class="wikitable" style="width:80%"
{|class="wikitable" style="width:80%"
Line 120: Line 121:
|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki>.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki> Assessment of cognitive awareness of need to void or having voided is reasonable.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.'''<nowiki>"</nowiki>.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.'''<nowiki>"</nowiki> It is reasonable to use the following treatment interventions to improve bladder incontinence in stroke patients:
a) Prompted voiding
 
b) Pelvic floor muscle training (after discharge home.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
|-
|-
|}
|}
Line 129: Line 133:
|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki>.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]] )'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki> It may be reasonable to assess prior bowel function in acutely hospitalized stroke patients and include the following.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]])'' <nowiki>"</nowiki>
a) Stool consistency, frequency, and timing (before stroke)
 
b) Bowel care practices before stroke
|-
|-
|}
|}
Line 137: Line 144:
|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki>.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:A]] )'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''<nowiki>"</nowiki> .''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:A]] )'' <nowiki>"</nowiki>
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.'''<nowiki>"</nowiki>.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.'''<nowiki>"</nowiki>.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]] )'' <nowiki>"</nowiki>

Revision as of 14:20, 13 December 2016


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]

Guidelines for Adult Stroke Rehabilitation and Recovery

Organization of Poststroke Rehabilitation Care

Class I
"1." It is recommended that stroke patients who are candidates for postacute rehabilitation receive organized, coordinated, interprofessional care(Level of Evidence:A ) "
"2." It is recommended that stroke survivors who qualify for and have access to IRF care receive treatment in an IRF in preference to a SNF. (Level of Evidence:B ) "
"3." Organized community-based and coordinated interprofessional rehabilitation care is recommended in the outpatient or home-based settings. (Level of Evidence:C ) "
Class IIb
"1."ESD services may be reasonable for people with mild to moderate disability.(Level of Evidence:B ) "

Rehabilitation

Interventions in the Inpatient Hospital Setting

Class I
"1." It is recommended that early rehabilitation for hospitalized stroke patients be provided in environments with organized, interprofessional stroke care. (Level of Evidence:A ) "
"2." It is recommended that stroke survivors receive rehabilitation at an intensity commensurate with anticipated benefit and tolerance (Level of Evidence:B ) "
Class III
"1." High-dose, very early mobilization within 24 hours of stroke onset can reduce the odds of a favorable outcome at 3 months and is not recommended.. (Level of Evidence:A ) "

Prevention of Skin Breakdown and Contractures

Class I
"1." During hospitalization and inpatient rehabilitation, regular skin assessments are recommended with objective scales of risk such as the Braden scale (Level of Evidence:C ) "
"2." It is recommended to minimize or eliminate skin friction, to minimize skin pressure, to provide appropriate support surfaces, to avoid excessive moisture, and to maintain adequate nutrition and hydration to prevent skin breakdown. Regular turning, good skin hygiene, and use of specialized mattresses, wheelchair

cushions, and seating are recommended until mobility returns. (Level of Evidence:C ) "

"3." Patients, staff, and caregivers should be educated about the prevention of skin breakdown. (Level of Evidence:C ) "
Class IIa
"1."Positioning of hemiplegic shoulder in maximum external rotation while the patient is either sitting or in bed for 30 minutes daily is probably indicated..(Level of Evidence:B ) "
Class IIb
"1." Resting hand/wrist splints, along with regular stretching and spasticity management in patients lacking active hand movement, may be considered..(Level of Evidence:C ) "
"2." Use of serial casting or static adjustable splints may be considered to reduce mild to moderate elbow and wrist contractures.(Level of Evidence:C ) "
"3." Surgical release of brachialis, brachioradialis, and biceps muscles may be considered for substantial elbow contractures and associated pain.(Level of Evidence:B ) "
"4." Resting ankle splints used at night and during assisted standing may be considered for prevention of ankle contracture in the hemiplegic limb..(Level of Evidence:B ) "

Prevention of DVT

Class I
"1." In ischemic stroke, prophylactic-dose subcutaneous heparin (UFH or LMWH) should be used for the duration of the acute and rehabilitation hospital stay or until the stroke survivor regains mobility. (Level of Evidence:A ) "
Class IIa
"1." In ischemic stroke, it is reasonable to use prophylactic-dose LMWH over prophylactic dose UFH for prevention of DVT.(Level of Evidence:A ) "
Class IIb
"1." In ischemic stroke, it may be reasonable to use intermittent pneumatic compression over no prophylaxis during the acute hospitalization.(Level of Evidence:B ) "
"2." In ICH, it may be reasonable to use prophylactic-dose subcutaneous heparin (UFH or LMWH) started between days 2 and 4 over no prophylaxis..(Level of Evidence:C ) "
"3." In ICH, it may be reasonable to use prophylactic dose LMWH over prophylactic-dose UFH.(Level of Evidence:C ) "
"4." In ICH, it may be reasonable to use intermittent pneumatic compression devices over no prophylaxis.(Level of Evidence:C ) "
Class III
"1." In ischemic stroke, it is not useful to use elastic compression stockings. (Level of Evidence:B ) "
"2." In ICH, it is not useful to use elastic compression stockings.(Level of Evidence:C ) "

Treatment of Bowel and Bladder Incontinence

Class I
"1." Assessment of bladder function in acutely hospitalized stroke patients is recommended. A history of urological issues before stroke should be obtained. (Level of Evidence:B ) "
"2." Assessment of urinary retention through bladder scanning or intermittent catheterizations after voiding while recording volumes is recommended for patients

with urinary incontinence or retention. (Level of Evidence:B )

"Removal of the Foley catheter (if any) within 24 hours after admission for acute stroke is recommended.(Level of Evidence:B )
Class IIa
"1." Assessment of cognitive awareness of need to void or having voided is reasonable.(Level of Evidence:B ) "
"2." It is reasonable to use the following treatment interventions to improve bladder incontinence in stroke patients:

a) Prompted voiding

b) Pelvic floor muscle training (after discharge home.(Level of Evidence:B ) "

Class IIb
"1." It may be reasonable to assess prior bowel function in acutely hospitalized stroke patients and include the following.(Level of Evidence:C) "

a) Stool consistency, frequency, and timing (before stroke)

b) Bowel care practices before stroke

Assessment, Prevention, and Treatment of Hemiplegic Shoulder Pain

Class IIa
"1." .(Level of Evidence:A ) "
"2.".(Level of Evidence:C ) "
"3.".(Level of Evidence:C ) "
"4.".(Level of Evidence:C ) "
Class IIb
"1.".(Level of Evidence:A ) "
"2.".(Level of Evidence:B ) "
"3.".(Level of Evidence:B ) "
"4.".(Level of Evidence:B ) "
"5.".(Level of Evidence:B ) "
"6.".(Level of Evidence:C ) "
Class III
"1." . (Level of Evidence:C ) "

Central Pain After Stroke

Class I
"1." (Level of Evidence:C ) "
"2." (Level of Evidence:C ) "
Class III
"1." . (Level of Evidence:B ) "
"2." . (Level of Evidence:B ) "
Class IIa
"1.".(Level of Evidence:B ) "
"2.".(Level of Evidence:C ) "
Class IIb
"1.".(Level of Evidence:B ) "
"2.".(Level of Evidence:C ) "
"3.".(Level of Evidence:B ) "

Prevention of Falls

Class I
"1." Defining TIA with a 24-hour maximum duration has the potential to delay the initiation of effective stroke therapies(Level of Evidence:B ) "
"2." Defining TIA with a 24-hour maximum duration has the potential to delay the initiation of effective stroke therapies(Level of Evidence:A ) "
Class IIa
"1.".(Level of Evidence:B ) "
"2.".(Level of Evidence:B ) "
Class IIb
"1.".(Level of Evidence:B ) "

Seizures

Class I
"1." Defining TIA with a 24-hour maximum duration has the potential to delay the initiation of effective stroke therapies(Level of Evidence:C ) "
Class III
"1." . (Level of Evidence:C ) "

Poststroke Depression, Including Emotional and Behavioral State

Class I
"1." Defining TIA with a 24-hour maximum duration has the potential to delay the initiation of effective stroke therapies(Level of Evidence:B ) "
"2." Defining TIA with a 24-hour maximum duration has the potential to delay the initiation of effective stroke therapies(Level of Evidence:B ) "
"3." Defining TIA with a 24-hour maximum duration has the potential to delay the initiation of effective stroke therapies(Level of Evidence:B ) "
Class IIb
Class IIa
"1.".(Level of Evidence:A ) "
"2.".(Level of Evidence:B ) "
"3.".(Level of Evidence:C ) "
Class IIa
"1.".(Level of Evidence:A ) "
"2.".(Level of Evidence:A ) "
"3.".(Level of Evidence:B ) "
"4.".(Level of Evidence:B ) "
"5.".(Level of Evidence:B ) "
"6.".(Level of Evidence:B ) "
Class III
"1." . (Level of Evidence:A ) "

Poststroke Osteoporosis

Class I
"1." Defining TIA with a 24-hour maximum duration has the potential to delay the initiation of effective stroke therapies(Level of Evidence:A ) "
"2." Defining TIA with a 24-hour maximum duration has the potential to delay the initiation of effective stroke therapies(Level of Evidence:B ) "
Class IIa
"1.".(Level of Evidence:B ) "

Assessment of Disability and Rehabilitation Needs

Class I
"1." (Level of Evidence:B ) "
"2." (Level of Evidence:B ) "
"3." (Level of Evidence:C ) "
"4." (Level of Evidence:C ) "
Class IIa
"1.".(Level of Evidence:B ) "
"2.".(Level of Evidence:C ) "
Class IIa
"1.".(Level of Evidence:B ) "

Assessment of Motor Impairment, Activity, and Mobility

Class IIa
"1.".(Level of Evidence:C ) "
"2.".(Level of Evidence:C ) "
"3.".(Level of Evidence:C ) "
"4.".(Level of Evidence:C ) "
"5.".(Level of Evidence:C ) "
"6.".(Level of Evidence:C ) "
"7.".(Level of Evidence:C ) "

Assessment of Communication Impairment

Class I
"1." (Level of Evidence:B ) "
Class IIa
"1.".(Level of Evidence:A ) "
Class IIb
"1.".(Level of Evidence:C ) "

Assessment of Cognition and Memory

Class I
"1." (Level of Evidence:B ) "
Class IIa
"1.".(Level of Evidence:C ) "

Sensory Impairments, Including Touch, Vision, and Hearing

Class IIa
"1.".(Level of Evidence:B ) "

Dysphagia Screening, Management, and Nutritional Support

Class I
"1." (Level of Evidence:B ) "
"2." (Level of Evidence:B ) "
"3." (Level of Evidence:B ) "
"4." (Level of Evidence:A ) "
"5." (Level of Evidence:B ) "
"6." (Level of Evidence:B ) "
Class IIa
"1.".(Level of Evidence:C ) "
"2.".(Level of Evidence:B ) "
"3.".(Level of Evidence:B ) "
"4.".(Level of Evidence:C ) "
Class IIb
"1.".(Level of Evidence:C ) "
"2.".(Level of Evidence:A ) "
"3.".(Level of Evidence:B ) "
Class III
"1." . (Level of Evidence:A ) "

Nondrug Therapies for Cognitive Impairment, Including Memory

Class I
"1." (Level of Evidence:A ) "
Class IIb
"1.".(Level of Evidence:B ) "
"2.".(Level of Evidence:B ) "
Class IIb
"1.".(Level of Evidence:C ) "
"2.".(Level of Evidence:C ) "
"3.".(Level of Evidence:A ) "
"4.".(Level of Evidence:B ) "
"5.".(Level of Evidence:B ) "
"6.".(Level of Evidence:B ) "

Use of Drugs to Improve Cognitive Impairments, Including Attention

Class IIb
"1.".(Level of Evidence:B ) "
"2.".(Level of Evidence:B ) "
"3.".(Level of Evidence:B ) "
"4.".(Level of Evidence:C ) "

Limb Apraxia

Class IIb
"1.".(Level of Evidence:B ) "
"2.".(Level of Evidence:C ) "

Hemispatial Neglect or Hemi-Inattention

Class IIa
"1.".(Level of Evidence:B ) "
Class IIb
"1.".(Level of Evidence:B ) "
"2.".(Level of Evidence:B ) "

Cognitive Communication Disorders

Class IIa
"1.".(Level of Evidence:B ) "

Aphasia

Class I
"1." (Level of Evidence:A ) "
"2." (Level of Evidence:B ) "
Class IIa
"1.".(Level of Evidence:B ) "
Class IIb
"1.".(Level of Evidence:A ) "
"2.".(Level of Evidence:B ) "
"3.".(Level of Evidence:B ) "
"4.".(Level of Evidence:B ) "
Class III
"1." . (Level of Evidence:B ) "

Motor Speech Disorders:Dysarthria and Apraxia of Speech

Class I
"1." (Level of Evidence:A ) "
"2." (Level of Evidence:B ) "
Class IIa
"1.".(Level of Evidence:A ) "
Class IIb
"1.".(Level of Evidence:C ) "
"2.".(Level of Evidence:C ) "

Spasticity

Class I
"1." (Level of Evidence:A ) "
"2." (Level of Evidence:A ) "
Class IIa
"1.".(Level of Evidence:A ) "
Class IIb
"1.".(Level of Evidence:A ) "
"2.".(Level of Evidence:A ) "
"3.".(Level of Evidence:A ) "
"4.".(Level of Evidence:C ) "
Class III
"1." . (Level of Evidence:B ) "

Balance and Ataxia

Class I
"1." (Level of Evidence:A ) "
"2." (Level of Evidence:A ) "
"3." (Level of Evidence:C ) "
Class IIb
"1.".(Level of Evidence:C ) "

Mobility

Class I
"1." (Level of Evidence:A ) "
"2." (Level of Evidence:A ) "
Class IIa
"1.".(Level of Evidence:B ) "
"2.".(Level of Evidence:B ) "
"3.".(Level of Evidence:B ) "
Class IIb
"1.".(Level of Evidence:B ) "
"2.".(Level of Evidence:B ) "
"3.".(Level of Evidence:B ) "
"4.".(Level of Evidence:B ) "
"5.".(Level of Evidence:B ) "
"6.".(Level of Evidence:B ) "
"7.".(Level of Evidence:B ) "
"8.".(Level of Evidence:B ) "
"9.".(Level of Evidence:B ) "
"10.".(Level of Evidence:A ) "
"11.".(Level of Evidence:A ) "
"12.".(Level of Evidence:A ) "
Class III
"1." . (Level of Evidence:B ) "

Upper Extremity Activity, Including ADLs, IADLs, Touch, and Proprioception

Class I
"1." (Level of Evidence:A ) "
"2." (Level of Evidence:A ) "
"3." (Level of Evidence:B ) "
Class IIa
"1.".(Level of Evidence:A ) "
"2.".(Level of Evidence:A ) "
"3.".(Level of Evidence:A ) "
"4.".(Level of Evidence:A ) "
"5.".(Level of Evidence:B ) "
"6.".(Level of Evidence:B ) "
Class IIb
"1.".(Level of Evidence:B ) "
"2.".(Level of Evidence:A ) "
Class III
"1." . (Level of Evidence:A ) "

Adaptive Equipment, Durable Medical Devices, Orthotics, and Wheelchairs

Class I
"1." (Level of Evidence:B ) "
"2." (Level of Evidence:B ) "
"3." (Level of Evidence:C ) "
"4." (Level of Evidence:C ) "

Chronic Care Management: Home- and Community-Based Participation

Class I
"1." (Level of Evidence:A ) "
"2." (Level of Evidence:A ) "

Treatments/Interventions for Visual Impairments

Class I
"1." (Level of Evidence:B ) "
Class IIb
"1.".(Level of Evidence:B ) "
"2.".(Level of Evidence:B ) "
"3.".(Level of Evidence:B ) "
"4.".(Level of Evidence:B ) "
"5.".(Level of Evidence:B ) "
"6.".(Level of Evidence:C ) "
"7.".(Level of Evidence:C ) "
Class III
"1." . (Level of Evidence:B ) "

Hearing Loss

Class IIa
"1.".(Level of Evidence:C ) "
"2.".(Level of Evidence:C ) "
"3.".(Level of Evidence:C ) "
"4.".(Level of Evidence:C ) "

Ensuring Medical and Rehabilitation Continuity Through the Rehabilitation Process and Into the Community

Class IIa
"1.".(Level of Evidence:B ) "
"2.".(Level of Evidence:B ) "

Social and Family Caregiver Support

Class IIb
"1.".(Level of Evidence:A ) "
"2.".(Level of Evidence:A ) "
"2.".(Level of Evidence:B ) "

Referral to Community Resources

Class I
"1." (Level of Evidence:C ) "
"2." (Level of Evidence:C ) "
"3." (Level of Evidence:C ) "
"4." (Level of Evidence:C ) "
"5." (Level of Evidence:C ) "

Rehabilitation in the Community

Class I
"1." (Level of Evidence:A ) "
Class IIa
"1.".(Level of Evidence:B ) "
Class IIb
"1.".(Level of Evidence:B ) "

Sexual Function

Class IIb
"1.".(Level of Evidence:B ) "

Recreational and Leisure Activity

Class IIa
"1.".(Level of Evidence:B ) "
"2.".(Level of Evidence:B ) "
"3.".(Level of Evidence:B ) "

Return to Work

Class IIa
"1.".(Level of Evidence:C ) "
Class IIb
"1.".(Level of Evidence:C ) "

Return to Driving

Class I
"1." (Level of Evidence:C ) "
Class IIa
"1.".(Level of Evidence:B ) "
"1.".(Level of Evidence:B ) "
Class IIb
"1.".(Level of Evidence:C ) "

References

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