1. When possible, treat the acute stroke patient in a setting that provides coordinated, multidisciplinary stroke-related evaluation and services

Such settings include acute stroke units, well-staffed neurology or rehabilitation departments, or other acute hospital settings with coordinated stroke services. Studies have found improved survival and greater likelihood of returning home when acute stroke care is coordinated and multidisciplinary. This may be related to better organization of services, with an emphasis on early mobilization of the patient, and early implementation of rehabilitation interventions.

2. Fully document the patient's condition and clinical course in the medical record

Thorough documentation of clinical information during the acute hospitalization is essential to making appropriate rehabilitation decisions. Included are:

• Stroke etiology and areas of the brain involved.

• Type(s), severity, and trajectory of neurological deficits.

• Type(s) and severity of comorbid diseases.

• Complications and abnormal health patterns.

• Changes in clinical status (over time).

• Functional status prior to stroke.

3. Begin rehabilitation-oriented care immediately, and increase the patient's activity as soon as medically feasible during the acute phase

Position changes (to prevent skin breakdown) and careful range of motion exercises (to prevent contractures) should begin shortly after admission. Further mobilization should begin when medical stability is achieved, preferably within the first 24 to 48 hours. Transfer techniques should be followed closely and taught to the patient and family. As early as possible, the patient should be encouraged to participate in personal care activities and to communicate and interact with staff and other patients. Benefits of early mobilization include:

• Prevention of deep vein thrombosis (DVT), skin breakdown, contracture formation, constipation, and pneumonia.

• Better orthostatic tolerance.

• Earlier return of mental and motor function and ability to perform ADL.

• Improved morale of both patient and family.

Indications for delaying mobilization or approaching it with caution include:

• Coma or severe obtundation.

• Progressing neurological signs or symptoms.

• Subarachnoid or intracerebral hemorrhage.

• Severe orthostatic hypotension.

• Acute myocardial infarction.

• Acute DVT (until adequate anticoagulation has been achieved).

4. Manage general health functions throughout all stages of treatment

5. Take steps to prevent complications throughout all stages of treatment

Preventive measures should be initiated during acute care and continued throughout rehabilitation and after the return to the community. Potential complications include:

• Deep vein thrombosis (DVT) and pulmonary embolism.

• Preventive measures include early mobilization, low-dose heparin or low-molecular-weight heparin. Warfarin, intermittent pneumatic compression, and elastic stockings are also effective.

• Dysphagia and aspiration.

• Depending on the type of swallowing deficit, treatment includes training to relearn swallowing, compensatory approaches such as changes in food texture and, if necessary, a gastrostomy tube. Dysphagia frequently resolves spontaneously; however, the condition should be reassessed periodically during rehabilitation and treatments continued or adjusted as necessary.

• Skin breakdown.

• Preventive measures include daily skin inspection, gentle routine cleansing, minimizing exposure to moisture, avoidance of friction, reduction of pressure, upright sitting posture, proper nutrition/hydration, and early mobility.

• Prevention of urinary tract infections.

• If indwelling catheters are used, they should be removed as soon as possible.

• Seizures.

• Anticonvulsant medications are recommended for preventing recurrent seizures in patients with stroke who have had one or more seizures, but not for use with patients who have not had seizures.

• Falls.

• Stroke survivors are at increased risk of falls. Risk factors include problems with perceptual deficits, visual impairments, impaired communication, confusion, drug side effects, environmental hazards, mobility, balance, and coordination. The risk is increased by rehabilitation treatments aimed at increasing mobility. Risk prevention includes supervision of high-risk patients, proper seating and wheelchair modification, regular toileting, supervised transfer and ambulation, nurse call systems suited to a patient's abilities, institution-wide fall prevention programs addressing both patient and environmental risk factors, and patient and family education about preventing falls and getting up after a fall. Adequate supervision and environmental precautions should continue after the patient returns to the community.

• Spasticity and contractures.

• Methods of prevention and treatment include antispastic pattern positioning, range of motion exercises, stretching, splinting, and nerve blocks.

• Shoulder injury.

• This is a frequent cause of pain in stroke patients. Prevention emphasizes proper positioning and support as well as avoidance of overly vigorous range of motion exercises.

6. Take steps to prevent recurrent stroke throughout all stages of treatment

Individuals who have had a stroke are at increased risk of another stroke. Preventive measures should be taken throughout acute care and rehabilitation and after the patient returns to the community. They include:

• Identification and control of risk factors such as hypertension, cigarette smoking, diabetes mellitus, high serum cholesterol, and heavy alcohol consumption.

• Oral anticoagulants to prevent embolic strokes in patients with atrial fibrillation or prosthetic cardiac valves. These are not currently recommended for ischemic stroke not attributed to embolism from the heart.

• Aspirin or ticlopidine for prevention of recurrent stroke secondary to arterial diseases.

• Carotid endarterectomy to prevent recurrent strokes following nondisabling strokes or transient ischemic attacks (TIAs) in selected patients with carotid artery stenosis of greater than 70 percent. The effectiveness of this procedure has been demonstrated to reduce the risk of stroke in patients without previous stroke warning signs, but with greater than 60 percent stenosis of the carotid endarterectomy. The effectiveness of this procedure has not been demonstrated for lesser degrees of stenosis.

• Surgery to clip an intracranial aneurysm or resect an arteriovenous malformation.

7. Systematically evaluate the patient at key stages throughout acute care and rehabilitation

A patient should be examined on admission to acute care and whenever there are questions about the person's condition. In addition, assessments should be made at the following times:

• At the time of screening for rehabilitation.

• On admission to a rehabilitation program.

• During rehabilitation (to monitor progress).

• After discharge from rehabilitation and return to a community residence.

8. Use well-validated standardized measures

This guideline strongly recommends the use of well-validated, standardized instruments in evaluating stroke patients. These instruments help to ensure reliable documentation of a patient's neurological condition, levels of disability or functional independence, family support, quality of life, and progress over time. Table 1 lists recommended standardized instruments, the approximate time each requires for administration, and their major strengths and weaknesses.

Table

Table 1. Preferred standard instruments for patient assessment in stroke.

9. Screen the patient for formal rehabilitation during the acute hospitalization

Screening for rehabilitation should be performed during the acute hospitalization, as soon as the patient's neurological and medical conditions permit. Its purposes are:

• To identify patients who may benefit from a formal rehabilitation program or from individual rehabilitation services.

• To guide selection of the appropriate rehabilitation program.

Table

Table 2. Screening for rehabilitation.

10. Recommend whether the patient should receive further rehabilitation and whether this should consist of individual services or an interdisciplinary program

The decision whether to recommend rehabilitation--and whether the choice should be individual services or an interdisciplinary program--is based on information obtained during the acute hospitalization and the rehabilitation screening examination. The most important patient considerations are:

• Medical stability.

• Nature and extent of functional disabilities.

• Ability to learn.

• Physical activity endurance.

Referral criteria are:

• Patients are potential candidates for formal rehabilitation if they have one or more significant disabilities, are at least moderately stable medically, are able to learn, have enough physical endurance to sit supported for 1 hour, and are able to participate to at least some extent in active rehabilitation treatments.

• Patients are candidates for an interdisciplinary rehabilitation program if they meet the above criteria and also have significant disabilities in at least two of the following areas of function: mobility, basic ADL, bowel or bladder control, cognition, emotional functioning, pain management, swallowing, or communication.

• Patients with only a single area of disability are candidates for individual rehabilitation services but do not require an interdisciplinary program.

• Patients too impaired to participate in rehabilitation should receive appropriate supportive services, and their families should receive thorough education regarding their care.

Some patients, at first, may not be recommended for rehabilitation. With time, however, they may recover sufficiently to become candidates for rehabilitation. Providers should be alert to such opportunities.

11. Be familiar with local rehabilitation programs and their capabilities

Rehabilitation programs should maintain and make available information on staffing patterns, services offered, and performance. Programs vary widely, and physicians and other medical personnel who refer patients for rehabilitation should be knowledgeable about the capabilities of programs in their community. Basic rehabilitation settings are as follows:

• Hospital inpatient rehabilitation programs

• may be located in freestanding rehabilitation hospitals or may be distinct units in acute care hospitals. They are staffed by the full range of rehabilitation professionals and an interdisciplinary team provides a comprehensive rehabilitation program for each patient. Hospital inpatient rehabilitation is generally more intense than rehabilitation in other settings and requires greater physical and mental effort from the patient.

• Rehabilitation programs in nursing facilities

• vary widely in the spectrum of services they provide. Hospital-based nursing facilities are located in or adjacent to acute care hospitals. They provide rehabilitation designed primarily for patients who have the potential to improve enough during 2 or 3 weeks of treatment to become candidates for inpatient, home, or outpatient rehabilitation. Programs in community-based nursing facilities vary. Some are as comprehensive as hospital inpatient programs though usually less intense, while others are very limited.

• Outpatient rehabilitation programs

• are offered by hospital outpatient departments and freestanding outpatient facilities. They can provide either a comprehensive rehabilitation program or individual rehabilitation services. An advantage of outpatient programs is that they enable the patient to live at home while still having access to an interdisciplinary program and to rehabilitation equipment. There are also opportunities for the patient to make social contacts and obtain peer support. Though frequently more intense, day hospital programs are similar to outpatient programs. The patient spends several hours, 3 to 5 days a week, in a typical day hospital program. Availability of transportation is a prerequisite for both outpatient and day hospital programs.

• Home rehabilitation programs

• usually provide physical therapy, occupational therapy, and nursing services. Some of these programs can also provide speech therapy and social work services. Programs are expanding their capabilities, and some now provide comprehensive services including home visits by physicians and intense rehabilitation. An advantage of home rehabilitation programs is that new skills are learned in the same environment where they will be applied. An additional advantage is that many patients function better in a familiar environment.

12. If the patient is a candidate for interdisciplinary rehabilitation, choose an appropriate program in consultation with the patient and family

Criteria for program choice. Figure 2 shows the step-by-step process of arriving at rehabilitation recommendations on the basis of clinical and social/environmental factors. For patients who have been identified as candidates for interdisciplinary rehabilitation (see No. 10), the most important patient characteristics in choosing a program are:

• Medical stability.

• Nature and extent of functional disabilities.

• Physical activity endurance.

• Needs for assistance.

• Extent of support by family or caregivers.

• Patient and family wishes.

Figure

Figure 2. Selection of setting for rehabilitation program after hospitalization for acute stroke. Figure 2. Selection of setting for rehabilitation program after hospitalization (more...)

The following are criteria for program choice:

• Patients who meet threshold criteria for an interdisciplinary program (see No. 10) and need moderate to total assistance with mobility or basic ADL are candidates for an intense rehabilitation program, if they can tolerate 3 or more hours of physically demanding rehabilitation activity each day. Otherwise, a less intense program is usually more appropriate.

• Patients who can benefit from intense rehabilitation but have complex medical problems should be treated in inpatient hospital programs that have 24-hour coverage by physicians and nurses skilled in acute medical care and rehabilitation.

• Patients who need only supervision or minimal assistance can usually be managed in home or outpatient rehabilitation programs--if the home environment and support are adequate. If not, a nursing facility program should be considered.

Need for consensus with the patient and family. In order to succeed, rehabilitation must have the full support and active participation of the patient and family. Hence, rehabilitation decisions need to be agreed on by the patient, family, treating physician, and accepting rehabilitation program to the maximum extent possible. To this end, health care providers should:

• Explain clearly the reasons for their recommendations concerning rehabilitation.

• Listen carefully to any concerns of the patient or family that might dictate a different choice.

• Point out the possibility of transfer to a different program in the future (if the patient's condition changes).

13. Perform a baseline assessment on admission to rehabilitation

The purposes of baseline assessment are to:

• Reaffirm the referral decision.

• Provide the information needed to develop rehabilitation goals and a rehabilitation management plan.

• Provide a baseline for monitoring progress.

• A broad-based disability/ADL scale for all patients.

• Specific measures targeting the patient's identified neurological impairments.

• A scale for assessing family functioning (if applicable).

Table

Table 3. Baseline assessment on admission to a rehabilitation program.

The baseline assessment can be performed by the treating physician,nurse, and other rehabilitation professionals. It should be fully documented in the medical record.

14. Develop explicit rehabilitation goals and a plan for achieving them

Rehabilitation goals are derived from the baseline assessment and from the goals of the patient and family. This information then forms the basis of the rehabilitation management plan (see Figure 3). The goals should be:

• Realistic in terms of current levels of disability. Unrealistically ambitious goals set the patient up for failure and lead to excessive use of services, while goals that underestimate a patient's potential will fail to achieve the best outcome.

• Mutually agreed on by the patient, family, and rehabilitation clinicians.

• Stated in explicit, measurable terms, and documented in the medical record.

Figure

Figure 3. Development of a rehabilitation management plan.

The management plan addresses both rehabilitation needs and medical problems such as complications of stroke or comorbidities. The plan includes:

• Treatment goals.

• Interventions planned to achieve the goals.

• The frequency, duration, sequencing, and intensity of interventions.

15. Involve the patient and family actively in rehabilitation

Patients and family members (or involved others) should participate in rehabilitation from the beginning. During formal rehabilitation programs, they should be encouraged to:

• Learn about the causes and consequences of stroke and stroke prevention.

• Learn about the goals, process, and prognosis of rehabilitation.

• Participate in setting rehabilitation goals and developing and modifying the rehabilitation management plan.

• Communicate their questions, concerns, and ideas.

• Participate in therapy sessions.

16. Provide remedial treatment for sensorimotor deficits

Patients who have some voluntary control over movements of a weakened limb should be offered exercise and functional training activities to increase strength and motor control, relearn sensorimotor relationships, and improve functional performance.

Training should emphasize independent functioning with or without the assistance of a caregiver. Patients and their families need to accept responsibility for practice aimed at maintaining and increasing function outside scheduled therapy sessions.

Research evidence is inadequate to support recommendations regarding the following:

• Superiority of one type of exercise regimen over another.

• Use of biofeedback or functional electrical stimulation as adjuncts to functional therapy.

• Sensory retraining.

17. Provide compensatory training for disabilities

Patients with persistent functional deficits should be taught compensatory methods for performing important tasks and activities--using the affected limb when possible--and the unaffected limb if necessary. Compensatory treatment teaches patients to improve their mobility, perform ADL, communicate, and conduct other valued activities despite persisting motor, sensory, or other deficits.

Compensatory techniques for mobility and task performance can be supplemented by adaptive devices. Examples include:

• Lower extremity orthotic devices.

• These are needed if the ankle or knee requires stabilization.

• Other adaptive devices.

• These are needed when compensatory methods of performing a task cannot be learned or are too fatiguing.

• Wheelchairs.

• These devices should be used when deficits are too severe to permit ambulation or when the patient's physical exercise tolerance is insufficient. Wheelchair selection should be a joint decision of the patient and rehabilitation team. The selection is based on the patient's body measurements, specific needs for wheelchair modification, safety, comfort, maneuverability, and environmental considerations (e.g., door widths in the home).

18. Identify and, when possible, treat cognitive and perceptual deficits

Cognitive and perceptual problems affect achievement of treatment goals and the selection of interventions for other types of deficits. Deficits that preclude effective learning are a contraindication to rehabilitation. Managing less severe deficits is an intrinsic part of the rehabilitation management plan.

19. Maintain a high index of suspicion for depression and provide treatment

Patient depression is common after stroke:

• Minor symptoms of depression may represent a normal grieving response to the losses caused by the stroke; however, patients may respond to encouragement from others or to simple environmental changes.

• Major depression occurs in 10 to 27 percent of patients following stroke. It has been associated with higher mortality, greater disability in ADL, lower socialization and sexual functioning, and higher rates of institutionalization.

• The patient persistently appears depressed.

• There is evidence of diminished interest in activities, loss of energy, loss of appetite, sleep disturbances, or agitated states.

• The patient expresses feelings of worthlessness, impaired concentration, or suicidal thoughts.

Before treating depression, the clinician should ensure that depressive symptoms are not due to medications. Choice of treatment depends on the cause of depression and may involve psychotherapy, an antidepressant medication, or both. Risks of medication side effects are high in patients with strokes. Initial doses should be small when medications are used, and the patient should be monitored closely for side effects.

Other emotional disturbances noted less commonly following stroke include emotional lability, mania, delusions, hallucinations, personality changes, and obsessive-compulsive disorders. Treatment relies on behavioral approaches or medications.

20. Identify and treat speech and language disorders

Communication disorders occur in as many as 40 percent of stroke patients; frequently, they resolve spontaneously. If not, they need to be thoroughly evaluated so that treatment can be tailored to the underlying deficit. Persistent problems with communication can have pervasive effects on the ability to participate in rehabilitation and the quality of life.

Communication disorders include:

• Aphasia.

• This is a disorder of language comprehension, retrieval, and formulation. Patients may respond to retraining targeted at the identified deficits and to compensatory strategies for circumventing remaining problems.

• Right hemisphere communication disorders.

• These disorders include a variety of difficulties in organizing and using language. The effectiveness of treatment has not been adequately studied.

• Dysarthria and apraxia of speech.

• These are disorders that impede production of intelligible speech. Treatment is directed at the specific speech mechanisms that are disturbed. Effectiveness of treatment has not been adequately studied.21. Educate the patient, family, and caregivers.

Patients and family members or other caregivers need education about stroke and thorough training in the management of residual disabilities and general health. Topics should include:

• The etiology and effects of stroke.

• Potential complications with preventive measures, signs, and treatments.

• Prevention of recurrent strokes.

• Medications, side effects, and medication regimen.

• Exercises and task-performance techniques.

• Social and emotional functioning of patient and family or caregivers.

• Reintegration into the community after rehabilitation.

Education should be adapted to the educational and cultural background of the patient and family, the mental status of the patient, and emotional factors that may interfere with learning. Experiential learning is often more effective than didactic learning, and repetition is important.

22. Monitor progress

The patient's progress should be assessed regularly during rehabilitation and the results used to adjust the treatment plan.

• During an intense rehabilitation program, evaluations should be performed at least weekly in an inpatient rehabilitation facility, a nursing facility, or at home. They should be performed at least every other week during less intense nursing facility, outpatient, or home programs.

• A subset of the standardized measures administered at baseline assessment (see Table 3) should be chosen, targeting those impairments and disabilities that have been the focus of treatments during the preceding period.

• Absence of progress between two evaluations should lead to a change in regimen, transfer, or discharge (unless specific circumstances have interfered with rehabilitation).

23. Plan for discharge

Discharge from a rehabilitation program or transfer to a different type of program should be considered when reasonable treatment goals have been achieved or when no measurable progress is found on two successive evaluations. Discharge planning should begin on the day of admission and should be a systematic, interdisciplinary process, coordinated by only one health provider. Decisions should reflect a consensus among the patient, family/caregivers, and rehabilitation staff.

Goals of discharge planning are to identify a safe place of residence, ensure that the patient and family/caregivers are adequately trained in essential skills, and arrange for continued medical, rehabilitation, and other services.

• The ability of a stroke survivor to return home depends on the person's needs and the availability of caregiver support. If patient needs exceed caregiver capabilities, an alternative long-term placement should be considered. The proposed residence should be evaluated for safety (e.g., furniture placement, scatter rugs, and pets), accessibility, and assistance provided in making needed modifications.

• Patient and family education should focus on tasks that need to be performed by the patient and the family or caregivers after discharge and on any concerns or questions they may have.

• Continuity of services after discharge should be the responsibility of a single clinician. This individual may be the patient's previous health care provider or a rehabilitation specialist. A full report of the patient's medical condition, disability status, present treatment, and recommendations for further treatment (see Table 4) should be given to the health care provider and also to the patient or primary caregiver.

Table

Table 4. Information to be included in discharge summary following rehabilitation.

Shortly before discharge, an assessment should be performed including evaluation of the patient's living environment, family/caregiver support, and other issues of concern to the patient and family. These issues may include concerns over financial resources and insurance coverage, disability entitlements, ability to drive a car, and potential for vocational rehabilitation.

24. Arrange for continued services

Routine followup care after discharge should give high priority to preventing recurrent stroke and complications, lowering cardiovascular risk, and preventing falls or other injuries. Continued rehabilitation services should be considered in order to:

• Help the patient maintain the gains made during the rehabilitation program.

• Build on patient and family strengths and interests to help the patient become reintegrated into the home and community.

• Identify and address any problem areas that were not evident in the rehabilitation setting.

• Valued hobbies or recreational activities.

• Social relationships.

• Preexisting family roles.

• Vocational or volunteer activities.

25. Continue regular monitoring of progress

The period following return to the community is a high-risk one for the stroke survivor and family alike. One goal of postdischarge assessment is to identify problem areas. Types of information to be obtained are identified in Table 5. Important issues are measures of:

• Success in adapting to the living environment and functioning independently.

• Adherence to medical and rehabilitation regimens.

• Ability of the family or other caregivers to provide needed support.

Table

Table 5. Assessment after return to the community.

The first postdischarge assessment should take place within a month after the patient's return to a community residence. Assessments should be repeated at regular intervals during at least the first year, consistent with the patient's condition, and patient and family preferences.

Assessment and followup should be the responsibility of the clinician who is coordinating medical care.

26. Provide support and assistance to caregivers

Help from family members or other caregivers is often critical to achieving successful long-term outcomes in individuals with disabilities; however, the burden of caregiving may be considerable and can have adverse effects on family functioning and the health of the caregiver. These effects need to be detected as early as possible so that steps can be taken to address them. To these ends:

• Evaluation of family and caregiver functioning is important. Clinicians need to be sensitive to potential problems.

• Interventions include providing practical assistance as well as counseling to treat emotional problems. Continuity with previous education or counseling services should be maintained whenever possible.

• The principal physician either should be familiar with local support groups and community social services or should refer the stroke survivor or caregiver to someone who can provide guidance to these resources. Table 6 lists major national organizations that can provide information or assistance to stroke patients and families; several of these provide assistance through local offices in many communities.

Table

Table 6. Resources for stroke survivors and families/caregivers.