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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| Class IIb
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| "1." The usefulness of routine use of prophylactic antidepressant medications is unclear.(Level of Evidence:A ) "
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| "2." Combining pharmacological and nonpharmacological treatments of poststroke depression may be considered.(Level of Evidence:A ) "
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| "3." The efficacy of individual psychotherapy alone in the treatment of poststroke depression is unclear.(Level of Evidence:B ) "
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| "4." Patient education, counseling, and social support may be considered as components of treatment for poststroke depression.(Level of Evidence:B ) "
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| "5." An exercise program of at least 4 weeks duration may be considered as a complementary treatment for poststrok depression.(Level of Evidence:B ) "
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| "6." Early effective treatment of depression may have a positive effect on the rehabilitation outcome.(Level of Evidence:B ) "
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| Class III
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| "1." No recommendation for the use of any particular class of antidepressants is made. SSRIs are commonly used and generally well tolerated in this patient population. (Level of Evidence:A ) "
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Poststroke Osteoporosis
| Class I
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| "1." It is recommended that individuals with stroke residing in long-term care facilities be evaluated for calcium and vitamin D supplementation.(Level of Evidence:A ) "
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| "2." It is recommended that US Preventive Services Task Force osteoporosis screening recommendations be followed in women with stroke. (Level of Evidence:B ) "
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| Class IIa
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| "1." Increased levels of physical activity are probably indicated to reduce the risk and severity of poststroke osteoporosis.(Level of Evidence:B ) "
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Assessment of Disability and Rehabilitation Needs
| Class I
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| "1." It is recommended that all individuals with stroke be provided a formal assessment of their ADLs and IADLs, communication abilities, and functional mobility before discharge from acute care hospitalization and the findings be incorporated into the care transition and the discharge planning process.(Level of Evidence:B ) "
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| "2." It is recommended that all individuals with stroke discharged to independent community living from postacute rehabilitation or SNFs receive ADL and IADL assessment directly related to their discharge living setting. (Level of Evidence:B ) "
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| "3." A functional assessment by a clinician with expertise in rehabilitation is recommended for patients with an acute stroke with residual functional deficits. (Level of Evidence:C ) "
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| "4." Determination of postacute rehabilitation needs should be based on assessments of residual neurological deficits; activity limitations; cognitive, communicative, and psychological status; swallowing ability; determination of previous functional ability and medical comorbidities; level of family/caregiver support; capacity of family/ caregiver to meet the care needs of the stroke survivor; likelihood of returning to community living; and ability to participate in rehabilitation. (Level of Evidence:C ) "
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| Class IIa
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| "1." It is reasonable that individuals with stroke discharged from acute and postacute hospitals/centers receive formal follow-up on their ADL and IADL status, communication abilities, and functional mobility within 30 days of discharge.(Level of Evidence:B ) "
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| "2." The routine administration of standardized measures can be useful to document the severity of stroke and resulting disability, starting in the acute phase and progressing over the course of recovery and rehabilitation.(Level of Evidence:C ) "
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| Class IIa
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| "1." A standardized measure of balance and gait speed (for those who can walk) may be considered for planning postacute rehabilitation care and for safety counseling with the patient and family.(Level of Evidence:B ) "
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Assessment of Motor Impairment, Activity, and Mobility
| Class IIb
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| "1." Motor impairment assessments (paresis/muscle strength, tone, individuated finger movements, coordination) with standardized tools may be useful.(Level of Evidence:C ) "
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| "2." Upper extremity activity/function assessment with a standardized tool may be useful.(Level of Evidence:C ) "
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| "3." Balance assessment with a standardized tool may be useful.(Level of Evidence:C ) "
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| "4." Mobility assessment with a standardized tool may be useful.(Level of Evidence:C ) "
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| "5." The use of standardized questionnaires to assess stroke survivor perception of motor impairments, activity limitations, and participation may be considered.(Level of Evidence:C ) "
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| "6." The use of technology (accelerometers, stepactivity monitors, pedometers) as an objective means of assessing real-world activity and participation may be considered.(Level of Evidence:C ) "
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| "7." Periodic assessments with the same standardized tools to document progress in rehabilitation may be useful.(Level of Evidence:C ) "
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Assessment of Communication Impairment
| Class I
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| "1." Communication assessment should consist of interview, conversation, observation, standardized tests, or nonstandardized items; assess speech, language, cognitive communication, pragmatics, reading, and writing; identify communicative strengths and weaknesses; and identify helpful compensatory strategies. (Level of Evidence:B ) "
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| Class IIb
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| "1." Communication assessment may consider the individual’s unique priorities using the ICF framework, including quality of life.(Level of Evidence:C ) "
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Assessment of Cognition and Memory
| Class I
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| "1." Screening for cognitive deficits is recommended for all stroke patients before discharge home. (Level of Evidence:B ) "
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| Class IIa
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| "1." When screening reveals cognitive deficits, a more detailed neuropsychological evaluation to identify areas of cognitive strength and weakness may be beneficial.(Level of Evidence:C ) "
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Sensory Impairments, Including Touch, Vision, and Hearing
| Class IIa
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| "1." Evaluation of stroke patients for sensory impairments, including touch, vision, and hearing, is probably indicated.(Level of Evidence:B ) "
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Dysphagia Screening, Management, and Nutritional Support
| Class I
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| "1." Early dysphagia screening is recommended for acute stroke patients to identify dysphagia or aspiration, which can lead to pneumonia, malnutrition, dehydration, and other complications. (Level of Evidence:B ) "
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| "2." Assessment of swallowing before the patient begins eating, drinking, or receiving oral medications is recommended. (Level of Evidence:B ) "
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| "3." Oral hygiene protocols should be implemented to reduce the risk of aspiration pneumonia after stroke. (Level of Evidence:B ) "
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| "4." Enteral feedings (tube feedings) should be initiated within 7 days after stroke for patients who cannot safely swallow. (Level of Evidence:A ) "
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| "5." Nasogastric tube feeding should be used for short term (2–3 weeks) nutritional support for patients who cannot swallow safely. (Level of Evidence:B ) "
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| "6." Percutaneous gastrostomy tubes should be placed in patients with chronic inability to swallow safely. (Level of Evidence:B ) "
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| Class IIa
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| "1." Dysphagia screening is reasonable by a speech-language pathologist or other trained healthcare provider.(Level of Evidence:C ) "
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| "2." An instrumental evaluation is probably indicated for those patients suspected of aspiration to verify the presence/absence of aspiration and to determine the physiological reasons for the dysphagia to guide the treatment plan.(Level of Evidence:B ) "
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| "3." Nutritional supplements are reasonable to consider for patients who are malnourished or at risk of malnourishment.(Level of Evidence:B ) "
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| "4." Incorporating principles of neuroplasticity into dysphagia rehabilitation strategies/interventions is reasonable.(Level of Evidence:C ) "
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| Class IIb
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| "1." Selection of instrumental study (fiberoptic endoscopic evaluation of swallowing, videofluoroscopy, fiberoptic endoscopic evaluation of swallowing with sensory
testing) may be based on availability or other considerations.(Level of Evidence:C ) "
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| "2." Behavioral interventions may be considered as a component of dysphagia treatment.(Level of Evidence:A ) "
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| "3." Acupuncture may be considered as a adjunctive treatment for dysphagia.(Level of Evidence:B ) "
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| Class III
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| "1." Drug therapy, NMES, pharyngeal electrical stimulation, physical stimulation, tDCS, and transcranial magnetic stimulation are of uncertain benefit and not currently recommended. (Level of Evidence:A ) "
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Nondrug Therapies for Cognitive Impairment, Including Memory
| Class IIb
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| "1." Use of cognitive rehabilitation to improve attention, memory, visual neglect, and executive functioning is reasonable.(Level of Evidence:B ) "
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| "2." Use of cognitive training strategies that consider practice, compensation, and adaptive techniques for increasing independence is reasonable.(Level of Evidence:B ) "
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| Class IIb
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| "1." Virtual reality training may be considered for verbal, visual, and spatial learning, but its efficacy is not well established.(Level of Evidence:C ) "
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| "2." Exercise may be considered as adjunctive therapy to improve cognition and memory after stroke.(Level of Evidence:C ) "
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| "3." Compensatory strategies may be considered to improve memory functions, including the use of internalized strategies (eg, visual imagery, semantic organization, spaced practice) and external memory assistive technology (eg, notebooks, paging systems, computers, other prompting devices).(Level of Evidence:A ) "
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| "4." Some type of specific memory training is reasonable such as promoting global processing in visual-spatial memory and constructing a semantic framework for
language-based memory.(Level of Evidence:B ) "
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| "5." Errorless learning techniques may be effective for individuals with severe memory impairments for learning specific skills or knowledge, although there is limited transfer to novel tasks or reduction in overall functional memory problems.(Level of Evidence:B ) "
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| "6." Music therapy may be reasonable for improving verbal memory.(Level of Evidence:B ) "
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| Class III
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| "1." Use of cognitive rehabilitation to improve attention, memory, visual neglect, and executive functioning is reasonable.(Level of Evidence:B ) "
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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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