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
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| "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 ) "
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Prevention of Skin Breakdown and Contractures
| Class I
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| "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 ) "
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| "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 ) "
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| "3." Patients, staff, and caregivers should be educated about the prevention of skin breakdown. (Level of Evidence:C ) "
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| Class IIa
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| "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
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| "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
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| "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
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| "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 )
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| "Removal of the Foley catheter (if any) within 24 hours after admission for acute stroke is recommended.(Level of Evidence:B )
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| Class IIa
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| "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
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| "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
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Assessment, Prevention, and Treatment of Hemiplegic Shoulder Pain
| Class Ia
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| "1." Patient and family education (ie, range of motion, positioning) is recommended for shoulder pain and shoulder care after stroke, particularly before discharge or transitions in care.(Level of Evidence:C) "
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| Class IIa
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| "1." Botulinum toxin injection can be useful to reduce severe hypertonicity in hemiplegic shoulder muscles.(Level of Evidence:A ) "
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| "2." A trial of neuromodulating pain medications is reasonable for patients with hemiplegic shoulder pain who have clinical signs and symptoms of neuropathic pain manifested as sensory change in the shoulder region, allodynia, or hyperpathia.(Level of Evidence:A) "
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| "3." It is reasonable to consider positioning and use of supportive devices and slings for shoulder subluxation.(Level of Evidence:C ) "
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| "4." A clinical assessment can be useful, including:
a) Musculoskeletal evaluation
b) Evaluation of spasticity
c) Identification of any subluxation
d) Testing for regional sensory changes.(Level of Evidence:C ) "
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| Class IIb
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| "1." NMES may be considered (surface or intramuscular) for shoulder pain.(Level of Evidence:A ) "
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| "2." Ultrasound may be considered as a diagnostic tool for shoulder soft tissue injury.(Level of Evidence:B ) "
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| "3." Usefulness of acupuncture as an adjuvant treatment for hemiplegic shoulder pain is of uncertain value.(Level of Evidence:B ) "
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| "4." Usefulness of subacromial or glenohumeral corticosteroid injection for patients with inflammation in these locations is not well established.(Level of Evidence:B ) "
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| "5." Suprascapular nerve block may be considered as an adjunctive treatment for hemiplegic shoulder pain.(Level of Evidence:B ) "
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| "6." Surgical tenotomy of pectoralis major, lattisimus dorsi, teres major, or subscapularis may be considered for patients with severe hemiplegia and restrictions in shoulder range of motion.(Level of Evidence:C ) "
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Central Pain After Stroke
| Class I
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| "1." The diagnosis of central poststroke pain should be based on established diagnostic criteria afterother causes of pain have been excluded. (Level of Evidence:C ) "
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| "2." The choice of pharmacological agent for the treatment of central poststroke pain should be individualized to the patient’s needs and response to therapy and any side effects. (Level of Evidence:C ) "
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| Class IIa
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| "1." Amitriptyline and lamotrigine are reasonable first-line pharmacological treatments.(Level of Evidence:B ) "
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| "2." Interprofessional pain management is probably useful in conjunction with pharmacotherapy.(Level of Evidence:C )"
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| Class IIb
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| "1." Motor cortex stimulation might be reasonable for the treatment of intractable central poststroke pain that is not responsive to other treatments in carefully selected patients.(Level of Evidence:B ) "
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| "2." Standardized measures may be useful to monitor response to treatment.(Level of Evidence:C ) "
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| "3." Pregabalin, gabapentin, carbamazepine, or phenytoin may be considered as second-line treatments..(Level of Evidence:B ) "
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Prevention of Falls
| Class I
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| "1." It is recommended that individuals with stroke discharged to the community participate in exercise programs with balance training to reduce falls. (Level of Evidence:B ) "
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| "2." It is recommended that individuals with stroke be provided a formal fall prevention program during hospitalization.(Level of Evidence:A ) "
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| Class IIa
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| "1." It is reasonable that individuals with stroke be evaluated for fall risk annually with an established instrument appropriate to the setting.(Level of Evidence:B ) "
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| "2." It is reasonable that individuals with stroke and their caregivers receive information targeted to home and environmental modifications designed to reduce falls.(Level of Evidence:B ) "
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Seizures
| Class I
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| "1." Any patient who develops a seizure should be treated with standard management approaches, including a search for reversible causes of seizure in addition to potential use of antiepileptic drugs.(Level of Evidence:C ) "
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Poststroke Depression, Including Emotional and Behavioral State
| Class I
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| "1." Administration of a structured depression inventory such as the Patient Health Questionnaire-2 is recommended to routinely screen for poststroke depression.(Level of Evidence:B ) "
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| "2."Patient education about stroke is recommended. Patients should be provided with information, advice, and the opportunity to talk about the impact of the illness on their lives.(Level of Evidence:B ) "
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| "3." Patients diagnosed with poststroke depression should be treated with antidepressants in the absence of contraindications and closely monitored to verify effectiveness.(Level of Evidence:B ) "
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| Class IIa
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| "1." A therapeutic trial of an SSRI or dextromethorphan/quinidine is reasonable for patients with emotional lability or pseudobulbar affect causing emotional distress.(Level of Evidence:A ) "
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| "2." Periodic reassessment of depression, anxiety, and other psychiatric symptoms may be useful in the care of stroke survivors..(Level of Evidence:B ) "
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| "3." Consultation by a qualified psychiatrist or psychologist for stroke survivors with mood disorders causing persistent distress or worsening disability can be useful.(Level of Evidence:C ) "
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Poststroke Osteoporosis
| Class I
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| "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 ) "
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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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