This is the current release of the guideline.

This guideline updates a previous version: Veterans Health Administration, Department of Defense. VA/DoD clinical practice guideline for the management of stroke rehabilitation in the primary care setting. Washington (DC): Department of Veteran Affairs; 2003 Feb. Various p. [331 references]

Adult patients (18 years or older) with post-stroke functional disability who may require rehabilitation in the Veterans Health Administration (VHA) or Department of Defense (DoD) healthcare system

Evaluation/Risk Assessment

1. Initial assessment of complications, impairment, and rehabilitation needs including medical status, risk for complications, and function
2. Medical history and physical examination
3. Assessment of stroke severity using standardized assessment instruments
4. Prevention of complications with special emphasis on the following:
   • Swallowing problems (risk of aspiration)
   • Risk factors for stroke recurrence
   • Malnutrition and dehydration
   • Risk of deep vein thrombosis (initiation of early mobilization; low-dose unfractionated heparin; low-molecular-weight heparin and heparinoids; graduated compression stockings)
   • Skin assessment and risk for pressure ulcers
   • Bowel and bladder function
   • Sensation and pain
   • Risk of falling
   • Osteoporosis
   • Seizures
5. Assessment of comorbidities (e.g., diabetes, hypertension, cardiac co-morbidities, substance use disorders, depression)
6. Assessment of impairment (communication, motor impairment, cognitive function, sensory impairment, emotional state)
7. Assessment of activity and function
8. Assessment of support systems

Rehabilitation Program

1. Determining rehabilitation needs and services
2. Determining rehabilitation setting (inpatient rehabilitation, home-based rehabilitation)
3. Patient and family education
4. Detailed treatment plan
5. Transfer to community living
6. Function/social support
7. Return to work
8. Discharge from rehabilitation
9. Long-term management

Treatment/Management

1. Management of dysphagia including modification of food texture, education regarding swallowing postures, training patients and care givers in feeding techniques and the use of thickening agents
2. Management of cognitive impairment including non-drug therapies (e.g., cognitive re-training) and drug therapies (e.g., acetylcholinesterase inhibitors, N-methyl D-aspartate [NMDA] receptor inhibitor memantine, short-term atypical antipsychotics)
3. Management of speech and language impairment
4. Management of motor impairment including motor recovery program; strength training; active and passive range of motion prolonged stretching program; spasticity management with tizanidine, baclofen, or botulinum toxin; treadmill training, ankle foot orthoses, functional electrical stimulation (FES), transcutaneous electrical nerve stimulation, and virtual reality for lower extremities; constraint-induced movement therapy, robot-assisted movement therapy, and FES for upper extremities
5. Management of sensory impairment (cutaneous electrical stimulation, visual field stimulation, prisms, eye exercises, hearing aids)
6. Training for activities of daily life (e.g., mobility, self-care, shopping, meal preparation, cleaning, driving)
7. Family and community support

After orientation to the guideline scope and to goals that had been identified, the Working Group (WG) developed a set of 35 researchable questions within the focus area of the guideline and identified associated key terms. This ensured that the guideline development work outside of meetings focused on issues that practitioners considered important. This also produced criteria for the literature search and selection of included studies that formed the body of evidence for this guideline update. The questions specified (adapted from the Evidence-Based Medicine toolbox, Centre for Evidence-Based Medicine, [http://www.cebm.net ]):

• Population – Characteristics of the target patient population
• Intervention – Exposure, diagnostic, or prognosis
• Comparison – Intervention, exposure, or control used for comparison
• Outcome – Outcomes of interest

These specifications served as the preliminary criteria for selecting studies. See PICO Questions to Guide Literature Search in Appendix A of the original guideline document for a complete listing and categorization of the questions.

Literature Search

The searches for these questions covered the period since the last Department of Veterans Affairs/Department of Defense (VA/DoD) clinical practice guideline (CPG) on Stroke (published after January 1, 2003 and before March 2008 but ran in PubMed most recently on March 2009). The terms cerebrovascular disorders and rehabilitation or rehab were used. Adding a stroke text word did not appear to be useful in that sensitivity was not enhanced but specificity was decreased. Electronic searches were supplemented by reference lists and additional citations suggested by the WG.

An initial global literature search (using cerebrovascular disorders as a MeSH term crossed with stroke as a text term) yielded 5,612 abstracts which were reviewed, resulting in 832 references being selected for further analysis (199 randomized clinical trials [RCTs], 19 meta-analyses [MAs], 58 systematic reviews [SRs], 541 reviews/observational studies, and 5 guidelines). Refinement of the review process with input from the WG members resulted in 301 studies being identified that met the baseline criteria for inclusion, addressed one or more of the researchable questions, and covered topic areas that had either not been addressed in the previous version of this guideline or had been included but not fully developed. A more detailed (full) search was conducted on each question, supplemented by hand searches and cross-referencing to search for relevant articles.

Selection of Evidence

The evidence selection process was designed to identify the best available evidence to address each key question and ensure maximum coverage of studies at the top of the hierarchy of study types. Published, peer-reviewed RCTs, as well as MSs and SRs that included randomized controlled studies, were considered to constitute the strongest level of evidence in support of guideline recommendations. This decision was based on the judgment that RCTs provide the clearest, most scientifically sound basis for judging comparative efficacy. The WG also recognized the limitations of RCTs, particularly considerations of generalizability with respect to patient selection and treatment quality. When available, the search sought out critical appraisals already performed by others that described explicit criteria for deciding what evidence was selected and how it was determined to be valid. The sources that have already undergone rigorous critical appraisal include Cochrane Reviews, Best Evidence, Technology Assessment, Agency for Healthcare Research and Quality (AHRQ) systematic evidence reports, and other published Evidence-based Clinical Practice Guidelines.

In addition to Medline/PubMed, the following databases were searched: Database of Abstracts of Reviews of Effectiveness (DARE), CINAHL/Medline/Embase/PsycINFO (OVID), and Cochrane Central Register of Controlled Trials. For Medline/PubMed searches, limits were set for language (English), and type of research (RCT, SRs and MAs). For prognostic and diagnostic questions (e.g., does test improve outcome?), cohort or other prospective non-RCT designs were considered.

The following inclusion criteria were used to select the articles identified in the literature search for possible inclusion:

• Published in United States, United Kingdom, Europe, Australia, Japan, New Zealand
• Full articles only published in English
• Study populations: age limited to adults 18 years of age or older; all races, ethnicities, and cultural groups
• Relevant outcomes able to be abstracted from the data presented in the articles
• Sample sizes appropriate for the study question addressed in the paper. RCTs were included if they were initiated with 30 or more participants.

Not stated

Level of Evidence

Overall Quality

Net Effect of the Intervention

Preparation of Evidence Tables (Reports) and Evidence Rating

The results of the searches were organized in evidence reports, and copies of the original studies were provided to the Working Group (WG) for further analysis. Each reference was appraised for scientific merit, clinical relevance, and applicability to the populations served by the Department of Veterans Affairs (VA) and Department of Defense (DoD) healthcare systems.

Recommendation and Quality Rating

Evidence-based practice involves integrating clinical expertise with the best available clinical evidence derived from systematic research.

A group of research analysts read and coded each article that met inclusion criteria. The articles were assessed for methodological rigor and clinical importance. Clinical experts from the VA and DoD WG reviewed the results and evaluated the strength of the evidence, considering quality of the body of evidence (made up of the individual studies) and the significance of the net benefit (potential benefit minus possible harm) for each intervention.

The overall strength of each body of evidence that addresses a particular Key Question was assessed using methods adapted from the U.S. Preventive Services Task Force (USPSTF). To assign an overall quality (QE) of the evidence (good, fair, or poor), the number, quality, and size of the studies; consistency of results between studies; and directness of the evidence were considered. Consistent results from a number of higher-quality studies (LE) across a broad range of populations supports with a high degree of certainty that the results of the studies are true and therefore the entire body of evidence would be considered "good" quality. A "fair" quality was assigned to the body of evidence indicating that the results could be due to true effects or to biases present across some or all of the studies. For a "poor" quality body of evidence, any conclusion is uncertain due to serious methodological shortcomings, sparse data, or inconsistent results (see the "Rating Scheme for the Strength of the Evidence" field).

The Strength of Recommendation (SR) was then determined based on the QE, and the clinical significance of the net benefit (NE) for each intervention, as demonstrated by the body of evidence. Thus, the grade (i.e., A, B, C, D or I) assigned to guideline recommendations reflect both variables, the quality of the evidence and the potential clinical benefit that the intervention may provide to patients (see the "Rating Scheme for the Strength of the Recommendations" field).

The update of the Department of Veterans Affairs/Department of Defense (VA/DoD) Clinical Practice Guideline for Management of Stroke Rehabilitation was developed following the steps described in "Guideline for Guidelines," an internal working document of the VA/DoD Evidence Based Practice Working Group that requires an ongoing review of guideline works in progress.

The Offices of Quality and Performance and Patient Care Services of the VA, and the Army Medical Command of the DoD identified clinical leaders to champion the guideline development process. During a preplanning conference call, the clinical leaders defined the scope of the guideline and identified a group of clinical experts from the VA and DoD to form the Management of Stroke Rehabilitation Working Group (WG). For this guideline, these WG participants were drawn from the fields of physical medicine and rehabilitation, internal medicine, primary care, neurology, geriatric medicine, social work, and rehabilitation (physical therapy, exercise physiology, occupational therapy, speech/language therapy, nursing, recreation therapy, and exercise therapy), were from diverse geographic regions, and were selected from both VA and DoD healthcare systems. Experts representing the American Heart Association (AHA) were also part of the WG.

The WG participated in 3 face-to-face meetings to reach consensus about the guideline algorithm and evidence-based recommendations and to prepare a draft update document. The draft continued to be revised by the WG through numerous conference calls and individual contributions to the document.

Recommendations for the Stroke Rehabilitation Guideline were derived through a rigorous methodological approach that included the following:

• Determining appropriate criteria such as effectiveness, efficacy, population benefit, or patient satisfaction
• Reviewing literature to determine the strength of the evidence in relation to these criteria
• Formulating the recommendations and grading the level of evidence supporting the recommendation

Lack of Evidence – Consensus of Experts

Where existing literature was ambiguous or conflicting, or where scientific data was lacking on an issue, recommendations were based on the clinical experience of the WG.

This update of the Stroke Rehabilitation Guideline is the product of many months of diligent effort and consensus building among knowledgeable individuals from the VA, DoD, and academia, as well as guideline facilitators from the private sector. An experienced moderator facilitated the multidisciplinary WG. The list of participants is included in Appendix D of the original guideline document.

Final Grade of Recommendation

Strength of Recommendation Rating

The draft document was discussed in three face-to-face group meetings. The content and validity of each section was thoroughly reviewed in a series of conference calls. The final document is the product of those discussions and has been approved by all members of the Working Group.

Note from the Department of Veterans Affairs and the Department of Defense (VA/DoD) and the National Guideline Clearinghouse (NGC): The recommendations for the management of stroke rehabilitation in the primary care setting are presented in 3 algorithms. The accompanying recommendations are presented below. See the original guideline document  for the algorithms and evidence tables associated with selected recommendations, including level and quality of evidence, strength of recommendation, and supporting evidence citations.

The strength of recommendation grading (A, B, C, D, I) is defined at the end of the "Major Recommendations" field.

Assessment

1. Rehabilitation during the Acute Phase

Annotation A. Patient with Stroke during the Acute Phase

The Agency for Health Care Policy and Research (AHCPR) (1995) defines "acute care" as the period immediately following the onset of an acute stroke. Patients with an acute stroke are typically treated in a medical service or in a specialized stroke unit, and rehabilitation interventions are normally begun during the acute phase.

Because of the nature of the neurological problems and the propensity for complications, most patients with acute ischemic stroke are admitted to a hospital. Outcomes can be improved if a patient is admitted to a facility that specializes in the care of stroke. The goals of early supportive care after admission to the hospital are to:

1. Observe changes in the patient's condition that might prompt different medical or surgical interventions.
2. Facilitate medical and surgical measures aimed at improving outcome after stroke.
3. Institute measures to prevent complications.
4. Begin planning for therapies to prevent recurrent stroke.
5. Begin efforts to restore function through rehabilitation or other techniques.

After stabilization of the patient's condition the following can be initiated when appropriate: rehabilitation, measures to prevent long-term complications, chronic therapies to lessen the likelihood of recurrent stroke, and family support.

Annotation B. Initial Assessment of Complications, Impairment and Rehabilitation Needs

1.2 Brief Assessment

Recommendations

1. The initial assessment should have special emphasis on the following:

   Medical Status

   1. Level of consciousness and cognitive status
   2. Risk factors for stroke recurrence
   3. History of previous antiplatelet or anticoagulation use, especially at the time of stroke
   4. Medical co-morbidities (see Annotation E)

   Risk of Complications

   5. Screening for aspiration risk (Brief swallowing assessment) (see Screening for Aspiration Risk section below)
   6. Malnutrition and dehydration (see Annotation E)
   7. Skin assessment and risk for pressure ulcers (see Annotation E)
   8. Risk of deep vein thrombosis (DVT) (see Annotation E)
   9. Bowel and bladder dysfunction (see Annotation E)
   10. Sensation and pain (see Annotation E)

   Function

   11. Motor function and muscle tone
   12. Mobility, with respect to the patient's needs for assistance in movement
   13. Emotional support for the family and caregiver

1.3 Screening for Aspiration Risk

Recommendations

1. Strongly recommend that all acute/newly diagnosed stroke patients be screened for swallowing problems prior to oral intake of any medication, foods, or fluids to determine risk for aspiration.
2. Screening should be performed by an appropriately trained provider within the first 24 hours of admission to determine the risk of aspiration:
   • Low risk for aspiration: Patients who are cooperative, able to talk, voluntarily cough, swallow saliva and pass a simple swallowing screening test (water)
   • High risk for aspiration: Patients who are non-cooperative, failed the simple swallowing screening test (wet hoarse voice or coughing are noted, or volume of water consumed is below population norms), or have a history of swallowing problems, aspiration or dysphagia

3. Patients who are not alert should be monitored closely and swallowing screening performed when clinically appropriate.
4. If screening results indicate that the patient is at high risk for dysphagia, oral food and fluids should be withheld from the patient (i.e., the patient should be Nil per os [NPO]) and a comprehensive clinical evaluation of swallowing food and fluids be performed within 24 hours by a clinician trained in the diagnosis and management of swallowing disorders.

Annotation C. Assessment of Stroke Severity

1.4 Use of Standardized Assessments

Recommendations

1. Strongly recommend that the National Institutes of Health Stroke Scale (NIHSS) be used at the time of presentation/hospital admission, or at least within the first 24 hours following presentation. [A]
2. Recommend that all patients should be screened for depression and motor, sensory, cognitive, communication, and swallowing deficits by appropriately trained clinicians, using standardized and valid screening tools. [C]
3. If depression or motor, sensory, cognitive, communication, or swallowing deficits are found on initial screening assessment, patients should be formally assessed by the appropriate clinician from the coordinated rehabilitation team. [C]
4. Recommend that the clinician use standardized, validated assessment instruments to evaluate the patient's stroke-related impairments, functional status, and participation in community and social activities. [C]
5. Recommend that the standardized assessment results be used to assess probability of outcome, determine the appropriate level of care, and develop interventions.
6. Recommend that the assessment findings should be shared and the expected outcomes discussed with the patient and family/caregivers.

Annotation D. Initiate Secondary Prevention and Early Interventions

1.5 Secondary Stroke Prevention

For specific evidence-based recommendations for secondary prevention of stroke refer to the American Health Association/American Stroke Association (AHA/ASA) 'Guidelines for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack' (http://stroke.ahajournals.org/cgi/content/full/37/2/577 ).

1.6 Early Intervention of Rehabilitation Therapy

Recommendations

1. Strongly recommend that rehabilitation therapy should start as early as possible, once medical stability is reached. [A]
2. Recommend that the patient receive as much therapy as "needed" and tolerated to adapt, recover, and/or reestablish the premorbid or optimal level of functional independence.

Annotation E. Assessment and Prevention of Complications

Recommendations

1. Recommend that risk of complications should be assessed in the initial phase and throughout the rehabilitation process and followed by intervention to address the identified risk. Areas of assessment include:
   1. Swallowing problems (risk of aspiration)
   2. Malnutrition and dehydration
   3. Skin assessment and risk for pressure ulcers
   4. Risk of DVT
   5. Bowel and bladder dysfunction
   6. Sensation and pain
   7. Risk of falling
   8. Osteoporosis
   9. Seizures

Annotation F. Obtain Medical History and Physical Examination

Recommendations

1. A thorough history and physical examination should be completed on all patients and should include, at a minimum:
   1. Chief complaint and history of present illness
   2. Past medical and psychiatric history
   3. Past surgical history
   4. Medications
   5. Allergies
   6. Family history
   7. Social history
   8. Functional history
   9. Review of systems
   10. Physical examination
   11. Imaging studies

2. The assessment should cover the following areas:
   1. Risk of Complications (swallowing problems, malnutrition, skin breakdown, risk for DVT, bowel and bladder dysfunction, falls, and pain)
   2. Determination of Impairment (communication, cognition, motor, psychological, and safety awareness) (see Annotation G) and assessment of prior and current functional status (e.g., Functional Independence Measure [FIM™]) (see Annotation G)
   3. Assessment of participation in community and social activities, and a complete psychosocial assessment (family and caregivers, social support, financial, and cultural support) (see Annotation G)

2. Prevention of Complications

2.1 Swallowing Problems, Aspiration Risk

Recommendations

Assessment

1. Recommend all patients receive evaluation of nutrition and hydration status as soon as possible after admission. Food and fluid intake should be monitored daily in all patients and body weight should be determined regularly.
2. Recommend that if screening for swallowing problems indicates that the patient is at risk for dysphagia, the patient should be Nil per os (NPO) and a comprehensive clinical evaluation of swallowing of food and fluid be performed within 24 hours by a professional trained in the diagnosis and management of swallowing disorders. Documentation of this exam should include information about signs and symptoms of dysphagia, likelihood of penetration and aspiration, and specific recommendations for follow-up including need for a dynamic instrumental assessment, treatment, and follow-up. [I]
3. Recommend patients who are diagnosed as having dysphagia based on comprehensive clinical evaluation of swallowing should have a dynamic instrumental evaluation to specify swallowing anatomy and physiology, mode of nutritional intake, diet, immediate effectiveness of swallowing compensations and rehabilitative techniques, and referral to specialist. The optimal diagnostic procedure (Videofluoroscopy Swallowing Study [VFSS], Fiberoptic Endoscopic Examination of Swallowing [FEES]) should be determined by the clinician based on patient needs and clinical setting.

2.2 Malnutrition and Dehydration

Recommendations

1. Recommend all patients receive evaluation of nutrition and hydration as soon as possible after admission. Food and fluid intake should be monitored in all patients, and body weight should be determined regularly.
2. Recommend that a variety of methods be used to maintain and improve intake of food and fluids. This will require treating the specific problems that interfere with intake, providing assistance in feeding if needed, consistently offering fluid by mouth to patients with dysphagia, and catering to the patient's food preferences. If intake is not maintained, feeding by a feeding gastrostomy may be necessary.
3. Patients at high risk for, or problems with, nutrition and their family/caregiver should receive counseling by a Registered Dietitian upon discharge regarding healthy diet and food choices.

2.3 Prevention of Skin Breakdown

Recommendations

Assessment

1. Recommend a thorough assessment of skin integrity be completed upon admission and monitored at least daily, thereafter. [C]
2. Risk for skin breakdown should be assessed using a standardized assessment tool (such as the Braden Scale). [I]

Treatment

3. Recommend the use of proper positioning, turning, and transferring techniques and judicious use of barrier sprays, lubricants, special mattresses, and protective dressings and padding to avoid skin injury due to maceration, friction or excessive pressure. [C]

2.4 Risk for DVT

Recommendations

Assessment

1. Concurrent risk factors that increase the risk of DVT should be assessed in all patients post stroke to determine the choice of therapy. These risk factors include mobility status, congestive heart failure (CHF), obesity, prior DVT or pulmonary embolism (PE), limb trauma or long bone fracture.

Treatment

2. Recommend all patients be mobilized, as soon as possible.
3. Recommend the use of subcutaneous low-dose low-molecular-weight heparin (LMWH) to prevent DVT/PE for patients with ischemic stroke or hemorrhagic stroke and leg weakness with impaired mobility.
4. Attention to a history of heparin-induced thrombocytopenia will affect treatment choice. A platelet count obtained 7-10 days after initiation of heparin therapy should be considered.
5. Consider the use of graduated compression stockings or an intermittent pneumatic compression device as an adjunct to heparin for non-ambulatory patients or as an alternative to heparin for patients in whom anticoagulation is contraindicated.
6. Consider inferior vena cava filters (IVCF) if patients at risk for PE, in whom anticoagulation is contraindicated.

2.5 Bowel and Bladder

Recommendations

Assessment

1. Recommend a structured assessment of bladder function in acute stroke patients, as indicated. Assessment should include:
   • Assessment of urinary retention through the use of a bladder scanner or an in-and-out catheterization
   • Measurement of urinary frequency, volume, and control
   • Presence of dysuria

2. There is insufficient evidence to recommend for or against the use of urodynamics over other methods of assessing bladder function.

Treatment

3. Consider removal of the indwelling catheter within 48 hours to avoid increased risk of urinary tract infection; however, if a catheter is needed for a longer period, it should be removed as soon as possible.
4. Recommend the use of silver alloy-coated urinary catheters, if a catheter is required.
5. Consider an individualized bladder training program (such as pelvic floor muscle training in women) be developed and implemented for patients who are incontinent of urine.
6. Recommend the use of prompted voiding in stroke patients with urinary incontinence.
7. Recommend a bowel management program be implemented in patients with persistent constipation or bowel incontinence. [I]

2.6 Pain

Recommendations

Assessment

1. Recommend pain assessment using the 0 to 10 scale. [C]
2. Recommend a pain management plan that includes assessment of the following: likely etiology (i.e., musculoskeletal and neuropathic), pain location, quality, quantity, duration, intensity, and aggravating and relieving factors. [C]

Treatment

3. Recommend balancing the benefits of pain control with possible adverse effects of medications on an individual's ability to participate in and benefit from rehabilitation. [I]
4. When practical, utilize a behavioral health provider to address psychological aspects of pain and to improve adherence to the pain treatment plan. [C]
5. When appropriate, recommend use of non-pharmacologic modalities for pain control such as biofeedback, massage, imaging therapy, and physical therapy. [C]
6. Recommend that the clinician tailor the pain treatment to the type of pain. [C]
7. Musculoskeletal pain syndromes can respond to correcting the underlying condition such as reducing spasticity or preventing or correcting joint subluxation.
8. Non-steroidal anti-inflammatory drugs (NSAIDs) may also be useful in treating musculoskeletal pain.
9. Neuropathic pain can respond to agents that reduce the activity of abnormally excitable peripheral or central neurons.
10. Opioids and other medications that can impair cognition should be used with caution.
11. Recommend use of lower doses of centrally acting analgesics, which may cause confusion and deterioration of cognitive performance and interfere with the rehabilitation process. [C]
12. Shoulder mobility should be monitored and maintained during rehabilitation. Subluxation can be reduced and pain decreased using functional electrical stimulation (FES) applied to the shoulder girdle. [B]

2.7 Fall Prevention

Recommendations

1. Recommend that all patients be assessed for fall risk during the inpatient phase, using an established tool. [B]
2. Recommend that fall prevention precautions be implemented for all patients identified to be at risk for falls while they are in the hospital.
3. Refer to the falls prevention toolkit on the National Center for Patient Safety (NCPS) for specific interventions.
4. Recommend regular reassessments for risk of falling including at discharge, ideally in the patient's discharge environment. [B]
5. Recommend that patient and family/caregiver be provided education on fall prevention both in the hospital setting and in the home environment. [B]

2.8 Osteoporosis

Recommendations

1. Early mobilization and movement of the paretic limbs will reduce the risk of bone fracture after stroke. [A]
2. Consider medications to reduce bone loss which will reduce the development of osteoporosis. [B]
3. Consider assessing bone density for patients with known osteoporosis who have been mobilized for 4 weeks before having the patient bear weight.
4. Assess for level of Vitamin D and consider supplemental Vitamin D in patients with insufficient levels. [B]

2.9 Seizures

Recommendations

Assessment

1. Obtain an electroencephalogram (EEG) of individuals who have a clinical seizure or manifest in a prolonged or intermittent stage of consciousness.

Treatment

2. Treat patients with post-stroke epilepsy with anti-epileptic medications (AEDs). [B]
3. Consider the side effect profile of AEDs when choosing a chronic anticonvulsant. [B]
4. Levetiracetam and lamotrigine are the first-line anticonvulsants for post-stroke seizure and epilepsy in elderly patients or in younger patients requiring anticoagulants. [B]
5. Extended-release carbamazepine might be a reasonable and less expensive option in patients under 60 years of age with appropriate bone health who do not require anticoagulation. [C]
6. Prophylactic treatment with an AED is not indicated in patients without a seizure after a stroke. [A]

3. Medical Co-Morbidities

3.1 Diabetes/Glycemic Control

Recommendations

1. Recommend obtaining clinical information for a history of diabetes or other glycemic disorder and including a blood test with admission labs in a patient with suspected stroke. [A]
2. Recommend monitoring blood glucose (BG) levels for a minimum of 72 hours post-stroke. [B]
3. Insulin should be adjusted to maintain a BG <180 mg/dL with the goal of achieving a mean glucose around 140 mg/dL. Evidence is lacking to support a lower limit of target blood glucose but based on a recent trial suggesting that blood glucose <110 mg/dL may be harmful, blood glucose levels <110 mg/dL are not recommended. [A]
4. Insulin therapy should be guided by local protocols and preferably "dynamic" protocols that account for varied and changing insulin requirements. A nurse-driven protocol for the treatment of hypoglycemia is highly recommended to ensure prompt and effective correction of hypoglycemia. [I]
5. To minimize the risk of hypoglycemia and severe hyperglycemia after discharge it is reasonable to provide hospitalized patients who have diabetes mellitus (DM) and knowledge deficits, or patients with newly discovered hyperglycemia, basic education in "survival skills." [I]
6. Patients who experienced hyperglycemia during hospitalization but who are not known to have DM should be re-evaluated for DM after recovery and discharge. [B]
7. Recommend maintenance of near-normoglycemic levels (80-140 mg/dL) for long-term prevention of microvascular and macrovascular complications. [A]

3.2 Cardiac

Recommendations

1. Monitor vital signs at the time of physical therapy interventions, particularly in patients with coronary heart disease (CHD).
2. Consider modifying or discontinuing therapy for significant changes in heart rate, blood pressure, temperature, pulse-oximetry, or if symptoms develop including excessive shortness of breath, syncope, or chest pain.
3. Management of heart disease and cardiac rehabilitation should follow AHA, VA/DoD, and AHCPR guidelines. 

3.3 Hypertension

Recommendations

1. Blood pressure should be carefully monitored following stroke.
2. The type of stroke (ischemic, hemorrhagic, aneurysmal), the clinical situation, and co-morbidities must be considered in blood pressure management. (See the VA/DoD Clinical Practice Guideline for Diagnosis and Management of Hypertension in the Primary Care Setting .)

3.4 Substance Use Disorders (SUDs)

Recommendations

1. People who have survived a stroke should be educated about the risks associated with excessive alcohol usage, substance abuse, and the risk for stroke recurrence.
2. Patients who are smokers should be counseled about the benefits of smoking cessation on reducing the risk for a future stroke, and they should be considered for nicotine replacement therapy and other interventions that promote smoking cessation.

3.5 Post-Stroke Depression

Recommendations

1. There are several treatment options for the patient with stroke and mild depression that can be used alone or in combination based on the patient's individual need and preference for services. (See the NGC summary, VA/DoD Clinical Practice Guideline for Management of Major Depressive Disorder [MDD].)
2. Patients diagnosed with moderate to severe depression after stroke should be referred to Mental Health specialty for evaluation and treatment.
3. There is conflicting evidence regarding the use of routine pharmacotherapy or psychotherapy to prevent depression or other mood disorders following stroke.
4. Patients with stroke who are suspected of wishing to harm themselves or others (suicidal or homicidal ideation) should be referred immediately to Mental Health for evaluation.
5. Recommend that patients with stroke should be given information, advice, and the opportunity to talk about the impact of the illness upon their lives.

Other Mood Disorders

6. Patients following stroke exhibiting extreme emotional lability (i.e., pathological crying/tearfulness) should be given a trial of antidepressant medication, if no contraindication exists. Selective serotonin reuptake inhibitors (SSRIs) are recommended in this patient population. [A]
7. Patients with stroke who are diagnosed with anxiety related disorders should be evaluated for pharmacotherapy options. Consider psychotherapy intervention for anxiety and panic. Cognitive Behavioral Therapy has been found to be a more efficacious treatment for anxiety and panic disorder than other therapeutic interventions.
8. Recommend skills training regarding Activities of Daily Living (ADLs), and psychoeducation regarding stroke recovery with the family.
9. Encourage the patient with stroke to become involved in physical and/or other leisure activities.

4. Assessment of Impairments

Annotation G. Determine Nature and Extent of Impairments and Disabilities

4.1 Global Assessment of Stroke Severity

Recommendations

1. Strongly recommend the patient be assessed for stroke severity using the NIHSS at the time of presentation/hospital admission, or at least within the first 24 hours following presentation. [A]
2. Strongly recommend that all professionals involved in any aspect of the stroke care be trained and certified to perform the NIHSS. [A]
3. Consider reassessing severity using the NIHSS at the time of acute care discharge to validate the first assessment or identify neurological changes.
4. If the patient is transferred to rehabilitation and there are no NIHSS scores in the record, the rehabilitation team should complete an NIHSS.

4.2 Assessment of Communication Impairment

Recommendations

1. Assessment of communication ability should address the following areas: listening, speaking, reading, writing, gesturing, and pragmatics. Problems in communication can be language-based (as with aphasia), sensory/motor based (as with dysarthria), or cognitive-based (as with dementia).
2. Assessment should include standardized testing and procedures. [B]

4.3 Assessment of Motor Impairment and Mobility

Recommendations

Motor Assessment

1. Motor function should be assessed at the impairment level (ability to move in a coordinated manner in designated patterns), and at the activity level (performance in real life or simulated real life tasks), using assessments with established psychometric properties.
2. The following components should be considered in assessment of motor function: muscle strength for all muscle groups, active and passive range of motion available, muscle tone, ability to isolate the movements of one joint from another, gross and fine motor coordination.
3. The daily use of the paretic extremity should be assessed using a self-report measure (e.g., the Motor Activity Log), and with accelerometry.
4. Balance should be assessed using a standardized assessment tool (e.g., Berg Balance Scale).
5. Apraxia should be assessed using an established apraxia measure (e.g., Florida Apraxia Screen).

Mobility

6. Stroke survivors with impaired mobility should be referred to a mobility-training program (physical therapy and/or occupational therapy) where specific and individualized goals can be established.

4.4 Assessment of Cognitive Function

Objective

Identify areas of cognitive impairment.

Recommendations

1. Assessment of arousal, cognition, and attention should address the following areas:
   1. Arousal
   2. Attention deficits
   3. Visual neglect
   4. Learning and memory deficits
   5. Executive function and problem-solving difficulties

2. There is insufficient evidence to recommend for the use of any specific tools to assess cognition. Several screening and assessment tools exist. (See Appendix B of the original guideline document for standard screening instruments for cognitive assessment.)

4.5 Assessment of Sensory Impairment: Touch, Vision and Hearing

Recommendations

1. Recommend that all patients be screened for sensory deficits by appropriately trained clinicians. This assessment should include an evaluation of sharp/dull, temperature, light touch, vibratory and position sensation.
2. Consider using Semmes-Weinstein monofilament to assess cutaneous sensation.
3. Recommend that all individuals with stroke should have a vision exam that includes visual acuity, contrast sensitivity (using Pelli chart), perimetry for visual field integrity, eye movements (including diplopia) and visual scanning.
4. Recommend that a careful history related to hearing impairment be elicited from the patient and/or family and that a hearing evaluation be completed for patients who demonstrate difficulty with communication where hearing impairment is suspected. 

4.6 Assessment of Emotional and Behavioral State

Recommendations

1. Initial evaluation of the patient should include a psychosocial history that covers pre-morbid personality characteristics, psychological disorders, pre-morbid social roles, and level of available social support.
2. Brief, continual assessments of psychological adjustment should be conducted to quickly identify when new problems occur. These assessments should also include ongoing monitoring of suicidal ideation and substance abuse. Other psychological factors deserving attention include: level of insight, level of self-efficacy/locus of control, loss of identity concerns, social support, sexuality, and sleep.
3. Review all medications and supplements including over the counter (OTC) medications that may affect behavior and function.
4. Inclusion of collateral information (e.g., spouse, children) is recommended to obtain a comprehensive picture of the patient's pre-morbid functioning and psychological changes since the stroke.
5. There is insufficient evidence to recommend the use of any specific tools to assess psychological adjustment. Several screening and assessment tools exist. (See Appendix B of the original guideline document for standard instruments for psychological assessment.)
6. Post-stroke patients should be assessed for other psychiatric illnesses, including anxiety, bipolar illness, SUD, and nicotine dependence. Refer for further evaluation by mental health if indicated.

5. Assessment of Activity and Function

5.1 ADL, Instrumental Activities of Daily Living (IADL)

Recommendations

1. Recommend that a standardized assessment tool be used to assess functional status (ADL/IADL) of stroke patients. [B]
2. Consider the use of the FIM^™ as the standardized functional assessment. (See Appendix B – FIM^™ Instrument, and a list of other standard instruments for assessment of function and impact of stroke in the original guideline document)

6. Assessment of Support Systems

6.1 Patient, Family Support, and Community Resources

Recommendations

1. Recommend all stroke patients and family caregivers receive a thorough psychosocial assessment with psychosocial intervention and referrals as needed.
2. The psychosocial assessment of both the patient with stroke and the primary family caregiver should include the following areas:
   1. History of pre-stroke functioning of both the patient and the primary family caregiver (e.g., demographic information, past physical conditions and response to treatment, substance use and abuse, psychiatric, emotional and mental status and history, education and employment, military, legal, and coping strategies)
   2. Capabilities and care giving experiences of the person identified as the primary caregiver
   3. Caregiver understanding of the patient's needs for assistance and caregiver's ability to meet those needs
   4. Family dynamics and relationships
   5. Availability, proximity, and anticipated involvement of other family members
   6. Resources (e.g., income and benefits, housing, and social network
   7. Spiritual and cultural activities
   8. Leisure time and preferred activities
   9. Patient/family/caregiver understanding of the condition, treatment, and prognosis, as well as hopes and expectations for recovery
   10. Patient/family/caregiver expectations of stroke-related outcomes and preferences for follow-up care

3. Recommend a home assessment for all patients who will be discharged home with functional impairments.

Annotation H. Does the Patient Have a Severe Stroke and/or Maximum Dependence and Poor Prognosis for Functional Recovery?

Recommendations

1. Families and caregivers should be educated in the care of patients who have experienced a severe stroke, who are maximally dependent in ADL, or have a poor prognosis for functional recovery; as these patients are not candidates for rehabilitation intervention.
2. Families should receive counseling on the benefits of nursing home placement for long-term care.

7. The Rehabilitation Program

Annotation I. Does the Patient Need Rehabilitation Intervention?

7.1 Determine Rehabilitation Needs

Objective

Identify the patient who requires rehabilitation intervention.

Recommendations

1. Once the patient is medically stable, the primary physician should consult with rehabilitation services (i.e., physical therapy, occupational therapy, speech and language pathology, kinesiotherapy, and Physical Medicine) to assess the patient's impairments as well as activity and participation deficiencies to establish the patient's rehabilitation needs and goals.
2. A multidisciplinary assessment should be undertaken and documented for all patients. [A]
3. Patients with no residual disability postacute stroke who do not need rehabilitation services may be discharged back to home.
4. Strongly recommend that patients with mild to moderate disability in need of rehabilitation services have access to a setting with a coordinated and organized rehabilitation care team that is experienced in providing stroke services. [A]
5. Post-acute stroke care should be delivered in a setting where rehabilitation care is formally coordinated and organized.
6. If an organized rehabilitation team is not available in the facility, patients with moderate or severe disability should be offered a referral to a facility with such a team. Alternately, a physician or rehabilitation specialist with some experience in stroke should be involved in the patient's care.
7. Post-acute stroke care should be delivered by a variety of treatment disciplines which are experienced in providing post-stroke care, to ensure consistency and reduce the risk of complications.
8. The multidisciplinary team may consist of a physician, nurse, physical therapist, occupational therapist, kinesiotherapist, speech and language pathologist, psychologist, recreational therapist, social worker, patient, and family/caregivers.
9. Patients who are severely disabled and for whom prognosis for recovery is poor may not benefit from rehabilitation services and may be discharged to home or nursing home in coordination with family/care giver.

Annotation J: Are Early Supportive Discharge Rehabilitation Services Appropriate?

7.2 Determine Rehabilitation Setting

Recommendations

1. The medical team, including the patient and family, must analyze the patient's medical and functional status, as well as expected prognosis in order to establish the most appropriate rehab setting. [I]
2. The severity of the patient's impairment, the rehabilitation needs, the availability of family/social support and resources, the patient/family goals and preferences and the availability of community resources will determine the optimal environment for care. [I]
3. Where comprehensive interdisciplinary community rehabilitation services and caregiver support services are available, early supported discharge services may be provided for people with mild to moderate disability. [B]
4. Recommend that patients remain in an inpatient setting for their rehabilitation care if they are in need of daily professional nursing services, intensive physician care, and/or multiple therapeutic interventions.
5. Inconclusive evidence to recommend the superiority of one type of rehabilitation setting over another.
6. Patients should receive as much therapy as they are able to tolerate in order to adapt, recover, and/or reestablish their premorbid or optimal level of functional independence. [B]

Annotation K. Discharge Patient from Rehabilitation

See Discharge section under subtitle Discharge from Rehabilitation below.

Annotation L. Arrange For Medical Follow-Up

See Follow-up section under subtitle Discharge from Rehabilitation below.

Annotation M. Post-Stroke Patient in Inpatient Rehabilitation

Inpatient rehabilitation is defined as rehabilitation performed during an inpatient stay in a free standing rehabilitation hospital or a rehabilitation unit of an acute care hospital. The term inpatient is also used to refer generically to programs where the patient is in residence during treatment, whether in an acute care hospital, a rehabilitation hospital, or a nursing facility.

Patients typically require continued inpatient services if they have significant functional deficits and medical and/or nursing needs that require close medical supervision and 24 hour availability of nursing care. Inpatient care may be appropriate if the patient requires treatment by multiple other rehabilitation professionals (e.g., physical therapists, occupational therapists, speech language pathologists, and psychologists).

Annotation N. Educate Patient/Family; Reach Shared Decision Regarding Rehabilitation Program; Determine and Document Treatment Plan

7.3 Treatment Plan

Objective

Assure the understanding of common goals among staff, family, and caregivers in the stroke rehabilitation process, and therefore optimize the patient's functional recovery and community re-integration.

Recommendations

1. Patients and/or their family members should be educated in order to make informed decisions and become good advocates.
2. The patient/family member's learning style must be assessed (through questioning or observation) and supplemental materials (including handouts) must be available when appropriate.
3. The following list includes topics that (at a minimum) must be addressed during a patient's rehabilitation program:
   1. Etiology of stroke
   2. Patient's diagnosis and any complications/co-morbidities
   3. Prognosis
   4. Expectations for what to expect during recovery and rehabilitation
   5. Secondary prevention
   6. Discharge plan
   7. Follow-up care including medications

4. The clinical team and family/caregiver should reach a shared decision regarding the rehabilitation program.
5. The rehabilitation program should be guided by specific goals developed in consensus with the patient, family, and rehabilitation team.
6. Document the detailed treatment plan in the patient's record to provide integrated rehabilitation care.
7. The patient's family/caregiver should participate in the rehabilitation sessions, and should be trained to assist patient with functional activities, when needed.
8. As patients progress, additional important educational topics include subjects such as the resumption of driving, sexual activity, adjustment and adaptation to disability, patient rights/responsibilities, and support group information.

Annotation O. Initiate/Continue Rehabilitation Programs and Interventions

7.4 Treatment Interventions

Recommendations

1. Initiate/continue rehabilitation program and interventions indicated by patient status, impairment, function, activity level and participation. (See Rehabilitation Interventions below)

   Impairments

   1. Dysphagia
   2. Muscle Tone
   3. Emotional, Behavioral
   4. Cognitive
   5. Communication
   6. Motor
   7. Sensory

   Activity

   1. ADL/IADL
   2. Mobility
   3. Sexuality
   4. Fitness endurance

   Support System

   1. Psychosocial needs/resources
   2. Family/Community Support
   3. Caregiver

Annotation P. Reassess Progress, Future Needs and Risks. Refer/Consult Rehabilitation Team

7.5 Assessment of Progress and Adherence

Objective

Evaluate progress toward the common goals of patient, family, and staff, and care-givers using both formal and informal measures as indicated. Continue or modify treatment plans and goals based upon these assessments.

Recommendations

1. Patients should be re-evaluated intermittently during their rehabilitation progress. Particular attention should be paid to interval change and progress towards stated goals.
2. Patients who show a decline in functional status may no longer be candidates for rehabilitation interventions. Considerations about the etiology of the decline and its prognosis can help guide decisions about when/if further rehabilitation evaluation should occur.
3. Psychosocial status and community integration needs should be re-assessed, particularly for patients who have experienced a functional decline or reached a plateau.

Annotation Q. Is Patient Ready for Community Living?

7.6 Transfer to Community Living

Objective

Determine if patient is ready for discharge to a community setting.

Recommendations

1. Recommend that all patients planning to return to independent community living should be assessed for mobility, ADL and IADL prior to discharge (including a community skills evaluation and home assessment).
2. Recommend that the patient, family, and caregivers are fully informed about, prepared for, and involved in all aspects of healthcare and safety needs. [I]
3. Recommend that case management be put in place for complex patient and family situations. [I]
4. Recommend that acute care hospitals and rehabilitation facilities maintain up-to-date inventories of community resources, provide this information to stroke patients and their families and caregivers, and offer assistance in obtaining needed services. Patients should be given information about, and offered contact with, appropriate local statutory and voluntary agencies. [I]

7.7 Function/Social Support

Recommendations

1. Patients and family caregivers should have their individual psychosocial and support needs reviewed on a regular basis post-discharge.
2. Referrals to family counseling should be offered. Counseling should focus on psychosocial and emotional issues and role adjustment.
3. Caregivers should be screened for high levels of burden and counseled in problem solving and adaptation skills as needed.
4. Caregivers and patients should be screened for depressive symptoms and referred to appropriate treatment resources as needed.
5. Health and social services professionals should ensure that patients and their families have information about the community resources available specific to these needs.
6. Provide advocacy and outreach to patients and families living in the community to help them adapt to changes and access community resources.

7.8 Recreational and Leisure Activity

Recommendations

1. Recommend that leisure activities should be identified and encouraged and the patient enabled to participate in these activities. [I]
2. Therapy for individuals with stroke should include the development of problem solving skills for overcoming the barriers to engagement in physical activity and leisure pursuits.
3. Individuals with stroke and their caregivers should be provided with a list of resources for engaging in aerobic and leisure activities in the community prior to discharge.
4. Recommend that the patient participates in a regular strengthening and aerobic exercise program at home or in an appropriate community program that is designed with consideration of the patient's co-morbidities and functional limitations. (See Intervention – Physical Activity below) [B]

7.9 Return to Work

Recommendations

1. Recommend that all patients, if interested and their condition permits, be evaluated for the potential of returning to work. [C]
2. Recommend that all patients who were previously employed, be referred to vocational counseling for assistance in returning to work. [C]
3. Recommend that all patients who are considering a return to work, but who may have psychosocial barriers (e.g., motivation, emotional, and psychological concerns) be referred for supportive services, such as vocational counseling or psychological services. [C]

7.10 Return to Driving

Recommendations

1. Recommend all patients be given a clinical assessment of their physical, cognitive, and behavioral functions to determine their readiness to resume driving. In individual cases, where concerns are identified by the family or medical staff, the patient should be required to pass the state road test as administered by the licensing department. Each medical facility should be familiar with their state laws regarding driving after a stroke. [I]
2. Consider referring patients with residual deficits to adaptive driving instruction programs to minimize the deficits, eliminate safety concerns, and optimize the chances that the patient will be able to pass the state driving test. [I]

7.11 Sexual Function

Recommendations

1. Sexual issues should be discussed during rehabilitation and addressed again after transition to the community when the post-stroke patient and partner are ready.

Annotation R. Address Adherence to Treatments and Barriers to Improvement: If Medically Unstable, Refer to Acute Services, If There Are Mental Health Factors, Refer to Mental Health Services

Recommendations

1. When an encountered barrier, such as a medical illness, makes participation difficult, referral to the appropriate service for treatment is warranted.
2. When the issue is related to mental health factors, assessment of these factors by a psychiatrist/psychologist and intervention/treatment is appropriate.

8. Discharge from Rehabilitation

Annotation K. Discharge Patient from Rehabilitation

Objective

Ensure that the patient's medical and functional needs are addressed after discharge from rehabilitation services.

Recommendations

1. Recommend that the rehabilitation team ensure that a discharge plan is complete for the patient's continued medical and functional needs prior to discharge from rehabilitation services.
2. Recommend that every patient participate in a secondary prevention program (see Annotation D above and in the original guideline document). [A]
3. Recommend post-acute stroke patients be followed by a primary care provider to address stroke risk factors and continue treatment of co-morbidities.
4. Recommend patient and family are educated regarding pertinent risk factors for stroke.
5. Recommend that the family and caregivers receive all necessary equipment and training prior to discharge from rehabilitation services. [I]
6. Family counseling focusing on psychosocial and emotional issues and role adjustment should be encouraged and made available to patients and their family members upon discharge.

Annotation L. Arrange For Medical Follow-up

8.1 Long-Term Management

Recommendations

1. Recommend post-discharge telephone follow-up with patients and caregivers be initiated and include problem solving and educational information.
2. If available, asynchronous and real-time tele-health, video, and web-based technologies, (e.g., web-based support groups, tele-rehabilitation), should be considered for patients who are unable to travel into the facility for care and services.

Follow-up

3. Ongoing monitoring of anticoagulant or antiplatelet therapy, treatment of hypertension and hypercholesterolemia, and other secondary prevention strategies are lifelong needs of patients after stroke and should normally be performed by the patient's primary healthcare provider.
4. Recommend post-acute stroke patients be followed up by a primary care provider to address stroke risk factors and continue treatment of co-morbidities.
5. Patient and family should be educated regarding pertinent risk factors for stroke.
6. Provide patient information about, and access to community based resources.

Treatment Intervention for Rehabilitation of Stroke

Rehabilitation Intervention

This section includes recommendations for intervention and treatment that address possible impairments in patients recovering from stroke. In general, patients should receive the intensity and duration of clinically relevant therapy defined in their individualized rehabilitation plan and appropriate to their needs and tolerance levels. All patients with stroke should begin rehabilitation therapy as early as possible once medical stability is reached. The rehabilitation interventions described in this section should apply regardless of the specific rehabilitation setting and may be applicable during inpatient as well as after discharge and follow-up in community outpatient rehabilitation.

9. Dysphagia Management

Recommendations

1. An oral care protocol should be implemented for patients with dysphagia and dentures to promote oral health and patient comfort.
2. Patients with persistent dysphagia should be offered an individualized treatment program guided by a dynamic instrumental swallowing assessment. The treatment program may include:
   1. Modification of food texture and fluids to address swallowing on an individual basis
   2. Education regarding swallowing postures and maneuvers on an individual basis following instrumental assessment to verify the treatment effect
   3. Addressing appropriate method of medication administration for patients with evidence of pill dysphagia on clinical or instrumental assessment
   4. Training patients and care givers, in feeding techniques and the use of thickening agents
   5. Patients with chronic oropharyngeal dysphagia should be seen for regular reassessment to ensure effectiveness and appropriateness of long-standing diet, continued need for compensations, and/or modification of rehabilitative techniques.

10. Nutrition Management

Recommendations

1. The nutritional and hydration status of stroke patients should be assessed within the first 48 hours of admission.
2. Stroke patients with suspected nutritional and/or hydration deficits, including dysphagia, should be referred to a dietitian.
3. Consider the use of feeding tubes to prevent or reverse the effects of malnutrition in patients who are unable to safely eat and those who may be unwilling to eat.
4. Oral supplementation may be considered for patients who are safe with oral intake, but do not receive sufficient quantities to meet their nutritional requirements.

11. Cognitive Rehabilitation

11.1 Non-Drug Therapies for Cognitive Impairment

Recommendations

1. Recommend that patients be given cognitive re-training, if any of the following conditions are present:
   1. Attention deficits [A]
   2. Visual neglect [B]
   3. Memory deficits [B]
   4. Executive function and problem-solving difficulties [C]

2. Patients with multiple areas of cognitive impairment may benefit from a variety of cognitive re-training approaches that may involve multiple disciplines. [C]
3. Recommend the use of training to develop compensatory strategies for memory deficits in post-stroke patients who have mild short term memory deficits. [B]

11.2 Use of Drugs to Improve Cognitive Impairment

Recommendations

1. Consider using acetylcholinesterase inhibitors (AChEIs), specifically galantamine, donepezil, and rivastigmine, in patients with vascular dementia or vascular cognitive impairment in the doses and frequency used for Alzheimer's disease.
2. Consider using the NMDA (N-methyl D-aspartate) receptor inhibitor memantine (Namenda) for patients with vascular dementia (VaD) or vascular cognitive impairment (VCI). [B]
3. The use of conventional or atypical antipsychotics for dementia-related psychosis or behavioral disturbance should be used with caution for short term, acute changes.
4. Recommend against centrally acting α2-adrenergic receptor agonists (such as clonidine and others) and α1-receptor antagonists (such as prazosin and others) as antihypertensive medications for stroke patients because of their potential to impair recovery. [D]
5. Recommend against the use of amphetamines to enhance motor recovery following stroke. [D]

11.3 Apraxia

Recommendations

1. Insufficient evidence to support specific therapeutic interventions for apraxia following stroke. [I]

11.4 Hemispatial Neglect/Hemi-inattention

Recommendations

1. Recommend cognitive rehabilitation for patients with unilateral spatial neglect such as cueing, scanning, limb activation, aids and environmental adaptations. [B]
2. Nursing and therapy sessions (e.g., for shoulder pain, postural control, feeding) need to be modified to cue attention to the impaired side in patient with impaired spatial awareness. [I]

12. Communication

Recommendations

1. If the communication assessment indicates impairment in speech, language, and/or cognition, treatment should be considered for those affected components. Treatment can be provided individually, in groups, or by computer or trained volunteer under the supervision of a clinician.
2. Maximum restoration of the impaired ability should initially be considered:
   • For dysarthria (and other impairments of speech), treatment can include techniques to improve articulation, phonation, fluency, resonance, and/or respiration.
   • For aphasia (and other impairments of language), treatment can include models designed to improve comprehension (e.g., stimulation/facilitation) and/or expression (e.g., word retrieval strategies) of language. It is recommended that the rate of treatment ("intensity", "dosage") should be higher rather than lower.
   • For dementia (and other impairments of cognitive aspects of communication), treatment can include techniques to maximize attention, memory, problem-solving, and executive functions.

3. Once maximum restoration is achieved, compensation of the remaining impairment should be considered:
   • For dysarthria, compensatory approaches include prostheses (e.g., palatal lift for hypernasality), alternate modalities (e.g., writing or gesturing), and augmentative/alternative communication (AAC) devices (e.g., a portable typing device that generates synthesized speech).
   • For aphasia, compensatory approaches include alternate modalities (e.g., gesturing) and AAC devices (e.g., a portable electronic pointing board).
   • For dementia, compensatory approaches include memory books, portable alarms, Personal Digital Assistants (PDAs), and similar devices to provide reminders and other information as needed.

4. Once maximum restoration and maximum benefits of compensation are achieved, counsel and educate those closest to the patient to modify the patient's environment to minimize and eliminate obstacles to communication, assisting them in such activities as helping them pay their bills or recording a message on their phone answering machine instructing callers to leave a message.

13. Motor Impairment and Recovery

13.1 Treatment Approach

Recommendations

1. Strongly recommend a comprehensive motor recovery program early on in stroke rehab.
2. There is insufficient evidence to recommend for or against using neurodevelopmental training (NDT) in comparison to other treatment approaches for motor retraining following an acute stroke. [I]
3. Recommend that motor recovery program should incorporate multiple interventions, emphasizing progressive difficulties, repetition, and functional task practice. [B]
4. Interventions for motor recovery (including improving ambulation) should include cardiovascular exercise fitness and strengthening. [A] (see Strengthening and Exercise and Cardiovascular Conditioning and Fitness below)

13.1.5 Strengthening and Exercise

Recommendations

1. Consider using strength training as a component of the therapeutic approach in paretic patients. [B]

13.2 Range of Motion (ROM)

Recommendations

1. Consider active and passive ROM prolonged stretching program to decrease risk of contracture development (night splints, tilt table) in early period following stroke. [C]
2. Joint movement and positioning needs to be carefully monitored during rehabilitation to prevent the development of maladaptive activity patterns.

13.3 Spasticity

Recommendations

1. Consider deterring spasticity with antispastic positioning, ROM exercises, stretching and splinting. Contractures may need to be treated using splinting, serial casting, or surgical correction. [C]
2. Consider use of oral agents such as tizanidine and oral baclofen for spasticity especially if the spasticity is associated with pain, poor skin hygiene, or decreased function. Tizanidine should be used specifically for chronic stroke patients. [B]
3. Diazepam and other benzodiazepines should be avoided during the stroke recovery period because this class of medication may interfere with cerebral functions associated with recovery of function after stroke, and these agents are likely to produce sedation which will compromise an individual's ability to participate effectively in rehabilitation. [D]
4. Consider use of botulinum toxin, on its own, or in conjunction with oral medication for patients with spasticity that is painful, impairs function, reduces the ability to participate in rehabilitation or compromises proper positioning or skin care. [B]
5. Intrathecal baclofen treatments may be considered for stroke patients with chronic lower extremity spasticity that cannot be effectively managed by oral medication or botulinum toxin. [B]
6. Consider neurosurgical procedures, such as selective dorsal rhizotomy or dorsal root entry zone lesion, for spasticity that cannot be managed by non-surgical modalities. [I]

13.4 Balance and Posture

Recommendations

1. Recommend that patients demonstrating balance impairments following stroke should be provided a balance training program. [C]

13.5 Lower Extremities

Gait Training Strategies

Recommendations

1. Consider using treadmill training in conjunction with other task specific practice and exercise training techniques in individuals with gait impairments post stroke without known cardiac risks for treadmill exercise. [B]
2. Consider the use of partial bodyweight support for treadmill training (partial BWSTT) (up to 40% of individuals' weight) in conjunction with other task specific and exercise training techniques for individuals with gait impairments post stroke without known cardiac risks for treadmill exercise. [B]
3. Recommend for patient with foot drop, ankle foot orthoses (AFO) to prevent foot drop and improve knee stability during walking. [B]
4. Recommend FES as an adjunctive treatment for patients with impaired muscle contraction, specifically for patients with impaired gait due to ankle/knee motor impairment. FES can be utilized for individuals with acute or chronic deficits after stroke. [B]
5. Consider transcutaneous electrical nerve stimulation (TNS or TENS) as an adjunctive treatment for enhancing recovery of gait function after stroke. [C]
6. Consider rhythmic auditory cueing as a modality to include in multimodal interventions to improve walking speed. [B]
7. There is no sufficient evidence supporting use of robotic devices during gait training in patients post stroke. [D]
8. Consider using virtual reality (VRT) to enhance gait recovery following stroke. [B]

13.6 Upper Extremities (UE)

Recommendations

1. Recommend that UE functional recovery should consist of the practice of functional tasks, emphasizing progressive difficulty and repetition.
2. Recommend that treatment should be tailored to the individual patients considering the intervention that are most appropriate, engaging the patient, and are accessible and available.
3. Recommend constraint-induced movement therapy (CIMT) for individuals with at least 10 degrees of extension in two fingers, the thumb and the wrist. [A]
4. Recommend robot-assisted movement therapy as an adjunct to conventional therapy in patients with deficits in arm function to improve motor skill at the joints trained. [B]
5. Recommend bilateral practice to improve UE function. [B]
6. Recommend treatment with FES for patients who have impaired UE muscle contraction, specifically with patients with elbow/wrist motor impairment. [B]
7. Recommend FES for patients who have shoulder subluxation. [B]
8. Consider FES and mental practice combined with repetitive and intense motor practice of functional tasks. [B]
9. Consider strengthening exercises in addition to functional task practice. [C]
10. Consider virtual reality as practice context. [C]
11. Insufficient evidence to recommend Mirror therapy. [I]
12. Do NOT use repetitive practice of movements in rehabilitation of UE.

13.7 Cardiovascular Conditioning and Fitness

Recommendations

1. Strongly recommend that patients participate in a regular aerobic exercise program at home or in an appropriate community program that is designed with consideration of the patient's co-morbidities and functional limitations. [A]

13.8 Adaptive Equipment, Durable Medical Devices, Orthotics, and Wheelchairs

Objective

Minimally necessary assistive technology and training in its use should be available for individuals recovering from stroke to facilitate maximum independence in activity and participation.

Recommendations

1. Recommend adaptive devices be used for safety and function if other methods of performing the task are not available or cannot be learned or if the patient's safety is a concern. [C]
2. Recommend lower extremity orthotic devices be considered, if ankle or knee stabilization is needed to improve the patient's gait and prevent falls. [C]
3. Recommend that a prefabricated brace be initially used and only patients who demonstrate long-term need for bracing have customized orthoses made. [C]
4. Recommend wheelchair prescriptions be based on careful assessment of the patient and the environment in which the wheelchair will be used. [C]
5. Recommend walking assistive devices be used to help with mobility efficiency and safety, when needed. [C]

14. Sensory Impairment

14.1 Sensory Impairment - Touch

Recommendations

1. Consider that all patients with sensory impairments be provided sensory-specific training.
2. Consider that patients with sensory impairments be provided a trial of cutaneous electrical stimulation in conjunction with conventional therapy when appropriate.

14.2 Sensory Impairment - Vision (Seeing)

Recommendations

1. Patients who have visual field cuts/hemianopsia or eye motility impairments after stroke should be provided with an intervention program for that visual impairment or compensatory strategies. [I]
2. Consider scanning training, visual field stimulation, prisms, and eye exercises as restorative intervention strategies.
3. Consider prisms and/or patching as compensatory intervention strategies.

14.3 Sensory Impairment - Hearing

Recommendations

1. Recommend appropriate hearing aids be obtained and used, for patients with known hearing loss.

15.  Activities (ADL, IADL)

Recommendations

1. Recommend all patients receive ADL training. [A]
2. Recommend all patients receive IADL training in areas of need. [C]
3. Recommend those individuals with stroke who exhibit ADL/IADL deficits should be given a training program that is tailored to the individual needs and anticipated discharge setting. [I]

16. Adjunctive Treatment

16.1 Complementary Alternative Medicine (CAM) - Acupuncture

Recommendations

1. There is insufficient evidence to recommend acupuncture to improve stroke rehabilitation outcomes. [D]

16.2 Hyperbaric Oxygen (HBO)

Recommendations

1. The use of HBO therapy is not recommended. [D]

17. Family/Community Support

Recommendations

1. Patients and caregivers should be educated throughout the rehabilitation process to address patient's rehabilitation needs, expected outcomes, procedures and treatment as well as appropriate follow-up in the home/community. [B]
2. Patient and caregiver education should be provided in both interactive and written formats. [B]
3. Caregivers should be provided with a variety of methods of training based on their specific needs, cognitive capability, and local resources; training may be provided in individual or group format, and in community-based programs. [B]

Definitions:

Level of Evidence

Overall Quality

Net Effect of the Intervention

Final Grade of Recommendation

Strength of Recommendation Rating

Algorithms are provided in the original guideline document  for:

• Algorithm A: Assessment
• Algorithm B: Inpatient Rehabilitation
• Algorithm C: Community Based Rehabilitation

The type of supporting evidence is identified for selected recommendations (see "Major Recommendations").

The guideline is based on an exhaustive review of the literature. Where existing literature was ambiguous or conflicting, or where scientific data were lacking on an issue, recommendations were based on the clinical experience of the Working Group.

Possible contraindications to electrical stimulation and thermal tactile stimulation include pregnancy and presence of pacemaker.

The guideline and algorithms are designed to be adapted by individual facilities in consideration of local needs and resources. The algorithms serve as a guide that providers can use to determine best interventions and timing of care for their patients in order to optimize quality of care and clinical outcomes.

Although this guideline represents the state of the art practice on the date of its publication, medical practice is evolving and this evolution requires continuous updating of published information. New technology and more research will improve patient care in the future. The clinical practice guideline can assist in identifying priority areas for research and optimal allocation of resources. Future studies examining the results of clinical practice guidelines such as these may lead to the development of new practice-based evidence.

This guideline update builds on the 1996 Department of Veterans Affairs (VA) Stroke/Lower Extremity Amputee Algorithms Guide and the 2003 VA/Department of Defense (DoD) Guideline for the Management of Stroke Rehabilitation in the Primary Care Setting. The guideline also incorporates information from the following existing evidence-based guidelines/reports:

• The Evidence-Based Review of Stroke Rehabilitation – Update 2009 (www.ebrsr.com ) .
• Royal College of Physicians (RCP). National clinical guidelines for stroke: second edition. June 2004.
• Canadian best practice recommendations for stroke care (update 2008) guidelines 2006.

United States Government

Management of Stroke Rehabilitation Working Group

Working Group Members (VA): Barbara Bates*, MD, MBA (Co-Chair); Jonathan Glasberg, MA, PT; Karen Hughes, BS, PT; Richard Katz, PhD; Beverly Priefer, RN; Lori Richards*, PhD, OTR/L; Robert Ruff*, MD, PhD; Paula Sullivan*, MS, CCC-SLP, BRS-S; Andrea L. Zartman, PhD

Working Group Members (DoD): Amy Bowles*, MD (Co-Chair); Shannon Crumpton, M.Ed., HFI, CSCS; Karen Lambert, CPT

Working Group Members (AHA): David N. Alexander*, MD; Pamela W. Duncan*, PhD, PT, FAPTA; Barbara Lutz, PhD, RN, CRRN, FAHA

Office of Quality and Performance, VHA: Carla Cassidy, RN, MSN, NP

Quality Management Division, US Army Medical Command: Ernest Degenhardt, MSN, RN, ANP-FNP; Angela V. Klar, MSN, RN, ANP-CS

Facilitator: Oded Susskind*, MPH

Research Team – Evidence Appraisal RTI International North Carolina: Linda Lux, MPA; Meera Viswanathan, PhD; Kathleen Lohr, PhD

Healthcare Quality Informatics: Martha D'Erasmo, MPH; Rosalie Fishman, RN, MSN, CPHQ

*Members of the Editorial Panel

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Veterans Health Administration, Department of Defense. VA/DoD clinical practice guideline for the management of stroke rehabilitation in the primary care setting. Washington (DC): Department of Veteran Affairs; 2003 Feb. Various p. [331 references]

Electronic copies: Available from the Department of Veterans Affairs Web site .

Print copies: Department of Veterans Affairs, Veterans Health Administration, Office of Quality and Performance (10Q) 810 Vermont Ave. NW, Washington, DC 20420.

The following are available:

• VA/DoD clinical practice guideline for the management of stroke rehabilitation. Guideline summary. Washington (DC): Department of Veterans Affairs (U.S.); 2010. 44 p. Electronic copies: Available in Portable Document Format (PDF) from the Department of Veterans Affairs Web site .

Print copies: Department of Veterans Affairs, Veterans Health Administration, Office of Quality and Performance (10Q) 810 Vermont Ave. NW, Washington, DC 20420.

None available

This summary was completed by ECRI on May 5, 2004. This summary was updated by ECRI on February 11, 2005, following the release of a public health advisory from the U.S. Food and Drug Administration regarding Adderall and related products. This summary was updated by ECRI on August 15, 2005, following the U.S. Food and Drug Administration advisory on antidepressant medications. This summary was updated by ECRI on March 6, 2007 following the FDA advisory on Coumadin (warfarin sodium). This summary was updated by ECRI Institute on May 8, 2007, following the U.S. Food and Drug Administration advisory on Zanaflex (tizanidine hydrochloride). This summary was updated by ECRI Institute on June 22, 2007 following the U.S. Food and Drug Administration (FDA) advisory on heparin sodium injection. This summary was updated by ECRI Institute on September 7, 2007 following the revised U.S. Food and Drug Administration (FDA) advisory on Coumadin (warfarin). This summary was updated by ECRI Institute on November 6, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs. This summary was updated by ECRI Institute on March 13, 2008 following the updated FDA advisory on heparin sodium injection. This summary was updated by ECRI Institute on December 26, 2008 following the FDA advisory on Innohep (tinzaparin). This summary was updated by ECRI Institute on May 26, 2009, following the U.S. Food and Drug Administration advisory on Botox, Botox Cosmetic (Botulinum toxin Type A), and Myobloc (Botulinum toxin Type B). This summary was updated by ECRI Institute on April 12, 2011. The updated information was verified by the guideline developer on May 20, 2011.

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