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
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| "1." It is recommended that stroke patients who are candidates for postacute rehabilitation receive organized, coordinated, interprofessional care(Level of Evidence:A ) "
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| "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 ) "
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| "3." Organized community-based and coordinated interprofessional rehabilitation care is recommended in the outpatient or home-based settings. (Level of Evidence:C ) "
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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 ) "
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| "2." It is recommended that stroke survivors receive rehabilitation at an intensity commensurate with anticipated benefit and tolerance (Level of Evidence:B ) "
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| Class III
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| "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 ) "
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| 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 ) "
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| "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 ) "
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| "3." Surgical release of brachialis, brachioradialis, and biceps muscles may be considered for substantial elbow contractures and associated pain.(Level of Evidence:B ) "
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| "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 ) "
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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 ) "
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| Class IIa
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| "1." In ischemic stroke, it is reasonable to use prophylactic-dose LMWH over prophylactic dose UFH for prevention of DVT.(Level of Evidence:A ) "
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| Class IIb
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| "1." In ischemic stroke, it may be reasonable to use intermittent pneumatic compression over no prophylaxis during the acute hospitalization.(Level of Evidence:B ) "
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| "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 ) "
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| "3." In ICH, it may be reasonable to use prophylactic dose LMWH over prophylactic-dose UFH.(Level of Evidence:C ) "
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| "4." In ICH, it may be reasonable to use intermittent pneumatic compression devices over no prophylaxis.(Level of Evidence:C ) "
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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 ) "
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| "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 ) "
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| "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 ) "
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| 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
Central Pain After Stroke
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 ) "
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| "2." Defining TIA with a 24-hour maximum duration has the potential to delay the initiation of effective stroke therapies(Level of Evidence:A ) "
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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 ) "
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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 ) "
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| "2." Defining TIA with a 24-hour maximum duration has the potential to delay the initiation of effective stroke therapies(Level of Evidence:B ) "
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| "3." Defining TIA with a 24-hour maximum duration has the potential to delay the initiation of effective stroke therapies(Level of Evidence:B ) "
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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 ) "
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| "2." Defining TIA with a 24-hour maximum duration has the potential to delay the initiation of effective stroke therapies(Level of Evidence:B ) "
|
Assessment of Disability and Rehabilitation Needs
Assessment of Motor Impairment, Activity, and Mobility
Assessment of Communication Impairment
Assessment of Cognition and Memory
Sensory Impairments, Including Touch, Vision, and Hearing
Dysphagia Screening, Management, and Nutritional Support
Nondrug Therapies for Cognitive Impairment, Including Memory
Use of Drugs to Improve Cognitive Impairments, Including Attention
Limb Apraxia
Hemispatial Neglect or Hemi-Inattention
Cognitive Communication Disorders
Aphasia
Motor Speech Disorders:Dysarthria and Apraxia of Speech
Spasticity
Balance and Ataxia
Mobility
Upper Extremity Activity, Including ADLs, IADLs, Touch, and Proprioception
Adaptive Equipment, Durable Medical Devices, Orthotics, and Wheelchairs
Chronic Care Management: Home- and Community-Based Participation
Treatments/Interventions for Visual Impairments
Hearing Loss
Ensuring Medical and Rehabilitation Continuity Through the Rehabilitation Process and Into the Community
Social and Family Caregiver Support
Sexual Function
Recreational and Leisure Activity
Return to Work
Return to Driving
References
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