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
|
| "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
|
| "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 ) "
|
| "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
|
| "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
|
| "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 )
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| 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 Ia
|
| "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
|
| "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 ) "
|
| Class IIb
|
| "1." NMES may be considered (surface or intramuscular) for shoulder pain.(Level of Evidence:A ) "
|
| "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
|
| "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
|
| "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
|
| "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 ) "
|
| "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
|
| "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
|
| "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
|
| "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
|
| "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
|
| "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 ) "
|
| Class IIa
|
| "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
|
| "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 ) "
|
Assessment of Motor Impairment, Activity, and Mobility
| Class IIb
|
| "1." Motor impairment assessments (paresis/muscle strength, tone, individuated finger movements, coordination) with standardized tools may be useful.(Level of Evidence:C ) "
|
| "2." Upper extremity activity/function assessment with a standardized tool may be useful.(Level of Evidence:C ) "
|
| "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
|
| "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
|
| "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
|
| "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
|
| "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 ) "
|
| "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." Anodal tDCS over the left dorsolateral prefrontal cortex to improve language-based complex attention (working memory) remains experimental.(Level of Evidence:B ) "
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Use of Drugs to Improve Cognitive Impairments, Including Attention
| Class IIb
|
| "1." The usefulness of donepezil in the treatment of poststroke cognitive deficits is not well established.(Level of Evidence:B ) "
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| "2." The usefulness of rivastigmine in the treatment of poststroke cognitive deficits is not well established.(Level of Evidence:B ) "
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| "3." The usefulness of antidepressants in the treatment of poststroke cognitive deficits is not well established.(Level of Evidence:B ) "
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| "4." The usefulness of dextroamphetamine, methylphenidate, modafinil, and atomoxetine in the treatment of poststroke cognitive deficits is unclear.(Level of Evidence:C ) "
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Limb Apraxia
Hemispatial Neglect or Hemi-Inattention
| Class IIa
|
| "1." It is reasonable to provide repeated top-down and bottom-up interventions such as prism adaptation, visual scanning training, optokinetic stimulation, virtual reality, limb activation, mental imagery, and neck vibration combined with prism adaptation to improve neglect symptoms.(Level of Evidence:B ) "
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Cognitive Communication Disorders
| Class IIa
|
| "1." Interventions for cognitive-communication disorders are reasonable to consider if they are individually tailored and target:
a) The overt communication deficit affecting prosody, comprehension, expression of discourse, and pragmatics.
b) The cognitive deficits that accompany or underlie the communication deficit, including attention, memory, and executive functions.(Level of Evidence:B ) "
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Aphasia
| Class IIa
|
| "1." Intensive treatment is probably indicated, but there is no definitive agreement on the optimum amount, timing, intensity, distribution, or duration of treatment.(Level of Evidence:B ) "
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| Class IIb
|
| "1." Computerized treatment may be considered to supplement treatment provided by a speech language pathologist.(Level of Evidence:A ) "
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| "2." A variety of different treatment approaches for aphasia may be useful, but their relative effectiveness is not known.(Level of Evidence:B ) "
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| "3." Group treatment may be useful across the continuum of care, including the use of community-based aphasia groups.(Level of Evidence:B ) "
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| "4." Pharmacotherapy for aphasia may be considered on a case-by-case basis in conjunction with speech and language therapy, but no specific regimen is recommended for routine use at this time.(Level of Evidence:B ) "
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| Class III
|
| "1." Brain stimulation techniques as adjuncts to behavioral speech and language therapy are considered experimental and therefore are not currently recommended for routine use. (Level of Evidence:B ) "
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Motor Speech Disorders:Dysarthria and Apraxia of Speech
| Class I
|
| "1." Interventions for motor speech disorders should be individually tailored and can include behavioral techniques and strategies that target:
a) Physiological support for speech, including respiration, phonation, articulation, and resonance.(Level of Evidence:A ) "
b) Global aspects of speech production such as loudness, rate, and prosody.
|
| "2." Augmentative and alternative communication devices and modalities should be used to supplement speech. (Level of Evidence:B ) "
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| Class IIb
|
| "1." Environmental modifications, including listener education, may be considered to improve communication effectiveness.(Level of Evidence:C ) "
|
| "2." Activities to facilitate social participation and promote psychosocial well-being may be considered.(Level of Evidence:C ) "
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Spasticity
| Class I
|
| "1." Targeted injection of botulinum toxin into localized upper limb muscles is recommended to reduce spasticity, to improve passive or active range of motion, and to improve dressing, hygiene, and limb positioning. (Level of Evidence:A ) "
|
| "2." Targeted injection of botulinum toxin into lower limb muscles is recommended to reduce spasticity that interferes with gait function. (Level of Evidence:A ) "
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| Class IIa
|
| "1." Oral antispasticity agents can be useful for generalized spastic dystonia but may result in dose-limiting sedation or other side effects.(Level of Evidence:A ) "
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| Class IIb
|
| "1." Physical modalities such as NMES or vibration applied to spastic muscles may be reasonable to improve spasticity temporarily as an adjunct to rehabilitation therapy.(Level of Evidence:A ) "
|
| "2." Intrathecal baclofen therapy may be useful for severe spastic hypertonia that does not respond to other interventions.(Level of Evidence:A ) "
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| "3." Postural training and task-oriented therapy may be considered for rehabilitation of ataxia.(Level of Evidence:A ) "
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| Class III
|
| "1." The use of splints and taping are not recommended for prevention of wrist and finger spasticity after stroke.. (Level of Evidence:B ) "
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Balance and Ataxia
| Class I
|
| "1." Individuals with stroke who have poor balance, low balance confidence, and fear of falls or are at risk for falls should be provided with a balance training program. (Level of Evidence:A ) "
|
| "2." Individuals with stroke should be prescribed and fit with an assistive device or orthosis if appropriate to improve balance. (Level of Evidence:A ) "
|
| "3." Individuals with stroke should be evaluated for balance, balance confidence, and fall risk. (Level of Evidence:C ) "
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Mobility
| Class I
|
| "1." Intensive, repetitive, mobility- task training is recommended for all individuals with gait limitations after stroke. (Level of Evidence:A ) "
|
| "2." An AFO after stroke is recommended in individuals with remediable gait impairments (eg, foot drop) to compensate for foot drop and to improve mobility and paretic ankle and knee kinematics, kinetics, and energy cost of walking. (Level of Evidence:A ) "
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| Class IIa
|
| "1." Group therapy with circuit training is a reasonable approach to improve walking.(Level of Evidence:B ) "
|
| "2." Incorporating cardiovascular exercise and strengthening interventions is reasonable to consider for recovery of gait capacity and gait related mobility tasks.(Level of Evidence:B ) "
|
| "3." NMES is reasonable to consider as an alternative to an AFO for foot drop.(Level of Evidence:B ) "
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| Class IIb
|
| "1." The effectiveness of TENS in conjunction with everyday activities for improving mobility, lower extremity strength, and gait speed is uncertain.(Level of Evidence:B ) "
|
| "2." The effectiveness of rhythmic auditory cueing to improve walking speed and coordination is uncertain.(Level of Evidence:B ) "
|
| "3." The usefulness of electromyography biofeedback during gait training in patients after stroke is uncertain.(Level of Evidence:B ) "
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| "4." Virtual reality may be beneficial for the improvement of gait.(Level of Evidence:B ) "
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| "5." The effectiveness of neurophysiological approaches (ie, neurodevelopmental therapy, proprioceptive neuromuscular facilitation) compared with other treatment approaches for motor retraining after an acute stroke has not been established.(Level of Evidence:B ) "
|
| "6." The effectiveness of water-based exercise for motor recovery after an acute stroke is unclear.(Level of Evidence:B ) "
|
| "7." The effectiveness of fluoxetine or other SSRIs to enhance motor recovery is not well established.(Level of Evidence:B ) "
|
| "8." The effectiveness of levodopa to enhance motor recovery is not well established.(Level of Evidence:B ) "
|
| "9." Practice walking with either a treadmill (with or without body-weight support) or overground walking exercise training combined with conventional rehabilitation may be reasonable for recovery of walking function.(Level of Evidence:B ) "
|
| "10." Robot-assisted movement training to improve motor function and mobility after stroke in combination with conventional therapy may be considered.(Level of Evidence:A ) "
|
| "11." Mechanically assisted walking (treadmill, electromechanical gait trainer, robotic device, servo-motor) with body weight support may be considered for patients who are nonambulatory or have low ambulatory ability early after stroke.(Level of Evidence:A ) "
|
| "12." There is insufficient evidence to recommend acupuncture for facilitating motor recovery and walking mobility.(Level of Evidence:A ) "
|
Upper Extremity Activity, Including ADLs, IADLs, Touch, and Proprioception
| Class I
|
| "1." Functional tasks should be practiced; that is, task-specific training, in which the tasks are graded to challenge individual capabilities, practiced repeatedly, and progressed in difficulty on a frequent basis. (Level of Evidence:A ) "
|
| "2." All individuals with stroke should receive ADL training tailored to individual needs and eventual discharge setting. (Level of Evidence:A ) "
|
| "3." All individuals with stroke should receive IADL training tailored to individual needs and eventual discharge setting. (Level of Evidence:B ) "
|
| Class IIa
|
| "1." CIMT or its modified version is reasonable to consider for eligible stroke survivors.(Level of Evidence:A ) "
|
| "2." Robotic therapy is reasonable to consider to deliver more intensive practice for individuals with moderate to severe upper limb paresis.(Level of Evidence:A ) "
|
| "3." NMES is reasonable to consider for individuals with minimal volitional movement within the first few months after stroke or for individuals with shoulder subluxation.(Level of Evidence:A ) "
|
| "4." Mental practice is reasonable to consider as an adjunct to upper extremity rehabilitation services.(Level of Evidence:A ) "
|
| "5." Strengthening exercises are reasonable to consider as an adjunct to functional task practice.(Level of Evidence:B ) "
|
| "6." Virtual reality is reasonable to consider as a method for delivering upper extremity movement practice.(Level of Evidence:B ) "
|
| Class IIb
|
| "1." Somatosensory retraining to improve sensory discrimination may be considered for stroke survivors with somatosensory loss.(Level of Evidence:B ) "
|
| "2." Bilateral training paradigms may be useful for upper limb therapy.(Level of Evidence:A ) "
|
Adaptive Equipment, Durable Medical Devices, Orthotics, and Wheelchairs
| Class I
|
| "1." Ambulatory assistive devices (eg, cane, walker) should be used to help with gait and balance impairments, as well as mobility efficiency and safety, when needed. (Level of Evidence:B ) "
|
| "2." AFOs should be used for ankle instability or dorsiflexor weakness. (Level of Evidence:B ) "
|
| "3." Wheelchairs should be used for nonambulatory individuals or those with limited walking ability. (Level of Evidence:C ) "
|
| "4." Adaptive and assistive devices should be used for safety and function if other methods of performing the task/activity are not available or cannot be learned or if the patient’s safety is a concern. (Level of Evidence:C ) "
|
Chronic Care Management: Home- and Community-Based Participation
| Class I
|
| "1." After successful screening, an individually tailored exercise program is indicated to enhance cardiorespiratory fitness and to reduce the risk of stroke
recurrence. (Level of Evidence:A ) "
|
| "2." After completion of formal stroke rehabilitation, participation in a program of exercise or physical activity at home or in the community is recommended (Level of Evidence:A ) "
|
Treatments/Interventions for Visual Impairments
| Class I
|
| "1." Multimodal audiovisual spatial exploration training appears to be more effective than visual spatial exploration training alone and is recommended to improve visual scanning. (Level of Evidence:B ) "
|
| "2.The use of behavioral optometry approaches involving eye exercises and the use of lenses and colored filters to improve eye movement control, eye focusing, and eye coordination is not recommended.(Level of Evidence:A )
|
| Class IIb
|
| "1." There is insufficient evidence to support or refute any specific intervention as effective at reducing the impact of impaired perceptual functioning..(Level of Evidence:B ) "
|
| "2." The use of virtual reality environments to improve visual-spatial/perceptual functioning may be considered.(Level of Evidence:B ) "
|
| "3." The use of behavioral optometry approaches involving eye exercises and the use of lenses and colored filters to improve eye movement control, eye focusing, and eye coordination is not recommended.(Level of Evidence:B ) "
|
| "4." Compensatory scanning training may be considered for improving functional ADLs.(Level of Evidence:B ) "
|
| "5." Compensatory scanning training may be considered for improving scanning and reading outcomes.(Level of Evidence:B ) "
|
| "6." Yoked prisms may be useful to help patients compensate for visual field cuts.(Level of Evidence:B ) "
|
| "7." Compensatory scanning training may be considered for improving functional deficits after visual field loss but is not effective at reducing visual field deficits.(Level of Evidence:B ) "
|
| "8."Computerized vision restoration training may be considered to expand visual fields, but evidence of its usefulness is lacking.(Level of Evidence:C)
|
| Class III
|
| "1." The use of behavioral optometry approaches involving eye exercises and the use of lenses and colored filters to improve eye movement control, eye focusing, and eye coordination is not recommended. (Level of Evidence:B ) "
|
Hearing Loss
| Class IIa
|
| "1." If a patient is suspected of a hearing impairment, it is reasonable to refer to an audiologist for audiometric testing.(Level of Evidence:C ) "
|
| "2." It is reasonable to use some form of amplification (eg, hearing aids).(Level of Evidence:C ) "
|
| "3." It is reasonable to use communication strategies such as looking at the patient when speaking.(Level of Evidence:C ) "
|
| "4." It is reasonable to minimize the level of background noise in the patient’s environment.(Level of Evidence:C ) "
|
Ensuring Medical and Rehabilitation Continuity Through the Rehabilitation Process and Into the Community
| Class IIa
|
| "1." It is reasonable to consider individualized discharge planning in the transition from hospital to home.(Level of Evidence:B ) "
|
| "2." It is reasonable to consider alternative methods of communication and support (eg, telephone visits, telehealth, or Web-based support), particularly for patients in rural settings.(Level of Evidence:B ) "
|
Social and Family Caregiver Support
| Class IIb
|
| "1." It may be useful for the family/caregiver to be an integral component of stroke rehabilitation.(Level of Evidence:A ) "
|
| "2." It may be reasonable that family/caregiver support include some or all of the following on a regular basis:
a) Education
b) Training
c) Counseling
d) Development of a support structure
e) Financial assistance(Level of Evidence:A ) "
|
| "3." It may be useful to have the family/caregiver involved in decision making and treatment planning as early as possible and throughout the duration of the rehabilitation process.(Level of Evidence:B ) "
|
| Class I
|
| "1." It is recommended that acute care hospitals and rehabilitation facilities maintain up-to-date inventories of community resources. (Level of Evidence:C ) "
|
| "2." Patient and family/caregiver preferences for resources should be considered. (Level of Evidence:C ) "
|
| "3." It is recommended that information about local resources be provided to the patient and family. (Level of Evidence:C ) "
|
| "4." It is recommended that contact with community resources be offered through formal or informal referral. (Level of Evidence:C ) "
|
| "5." Follow-up is recommended to ensure that the patient and family receive the necessary services. (Level of Evidence:C ) "
|
| Class I
|
| "1." Patients with stroke receiving comprehensive ADL, IADL, and mobility assessments, including evaluation of the discharge living setting, should be considered candidates for communityor home-based rehabilitation when feasible. Exclusions include individuals with stroke who require daily nursing services, regular medical interventions, specialized equipment, or interprofessional expertise. (Level of Evidence:A ) "
|
| Class IIa
|
| "1." It is reasonable that caregivers, including family members, be involved in training and education related directly to home-based rehabilitation programs and be included as active partners in the planning and implementation or treatment activities under the supervision of professionals.(Level of Evidence:B ) "
|
| Class IIb
|
| "1." A formal plan for monitoring compliance and participation in treatment activities may be useful for individuals with stroke referred for home- or community-based rehabilitation services. A case manager or professional staff person should be assigned to oversee implementation of the plan.(Level of Evidence:B ) "
|
Sexual Function
| Class IIb
|
| "1." An offer to patients and their partners to discuss sexual issues may be useful before discharge home and again after transition to the community. Discussion topics may include safety concerns, changes in libido, physical limitations resulting from stroke, and emotional consequences of stroke.(Level of Evidence:B ) "
|
Recreational and Leisure Activity
| Class IIa
|
| "1." It is reasonable to promote engagement in leisure and recreational pursuits, particularly through the provision of information on the importance of maintaining an active and healthy lifestyle.(Level of Evidence:B ) "
|
| "2." It is reasonable to foster the development of self-management skills for problem solving for overcoming barriers to engagement in active activities.(Level of Evidence:B ) "
|
| "3." It is reasonable to start education and selfmanagement skill development about leisure/recreation activities during and in conjunction with in-patient rehabilitation.(Level of Evidence:B ) "
|
Return to Work
| Class IIa
|
| "1." Vocationally targeted therapy or vocational rehabilitation is reasonable for individuals with stroke considering a return to work.(Level of Evidence:C ) "
|
| Class IIb
|
| "1." An assessment of cognitive, perception, physical, and motor abilities may be considered for stroke survivors considering a return to work.(Level of Evidence:C ) "
|
Return to Driving
| Class I
|
| "1." Individuals who appear to be ready to return to driving, as demonstrated by successful performance on fitness-to-drive tests, should have an on-the-road test administered by an authorized person. (Level of Evidence:C ) "
|
| Class IIa
|
| "1." It is reasonable that individuals be assessed for cognitive, perception, physical, and motor abilities to ascertain readiness to return to driving according to safety and local laws.(Level of Evidence:B ) "
|
| "2." It is reasonable that individuals who do not pass an on-the-road driving test be referred to a driver rehabilitation program for training.(Level of Evidence:B ) "
|
References
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