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## Complete Summary

#### GUIDELINE TITLE

VA/DoD clinical practice guideline for the management of stroke
rehabilitation in the primary care setting.

#### BIBLIOGRAPHIC SOURCE(S)

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. \[331 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [February 28, 2008, Heparin Sodium
    Injection](http://www.fda.gov/medwatch/safety/2008/safety08.htm#HeparinInj2):
    The U.S. Food and Drug Administration (FDA) informed the public that
    Baxter Healthcare Corporation has voluntarily recalled all of their
    multi-dose and single-use vials of heparin sodium for injection and
    their heparin lock flush solutions. Alternate heparin manufacturers
    are expected to be able to increase heparin production sufficiently
    to supply the U.S. market. There have been reports of serious
    adverse events including allergic or hypersensitivity-type
    reactions, with symptoms of oral swelling, nausea, vomiting,
    sweating, shortness of breath, and cases of severe hypotension.

-   [August 16, 2007, Coumadin
    (Warfarin)](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Warfarin):
    Updates to the labeling for Coumadin to include pharmacogenomics
    information to explain that people\'s genetic makeup may influence
    how they respond to the drug.

-   [May 2, 2007, Antidepressant
    drugs](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Antidepressant):
    Update to the existing black box warning on the prescribing
    information on all antidepressant medications to include warnings
    about the increased risks of suicidal thinking and behavior in young
    adults ages 18 to 24 years old during the first one to two months of
    treatment.

-   [April 11, 2007, Zanaflex (tizanidine
    hydrochloride)](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Zanaflex):
    Changes to the product labeling for Zanaflex, a drug used to treat
    spasticity, to warn against its hypotensive and sedative effects
    when administered with fluvoxamine or ciprofloxacin (CYP1A2
    inhibitors).

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Stroke

-   Conditions and complications resulting from stroke

#### GUIDELINE CATEGORY

Evaluation\
Management\
Prevention\
Rehabilitation\
Risk Assessment\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Geriatrics\
Internal Medicine\
Neurology\
Nursing\
Pharmacology\
Physical Medicine and Rehabilitation\
Psychology\
Speech-Language Pathology

#### INTENDED USERS

Advanced Practice Nurses\
Nurses\
Occupational Therapists\
Pharmacists\
Physical Therapists\
Physician Assistants\
Physicians\
Psychologists/Non-physician Behavioral Health Clinicians\
Social Workers\
Speech-Language Pathologists

#### GUIDELINE OBJECTIVE(S)

-   To provide a scientific evidence-base for practice interventions and
    evaluations related to stroke rehabilitation designed to achieve
    maximum functionality and independence and improve patient/family
    quality of life

-   To serve as a guide that clinicians can use to determine best
    interventions and timing of care for their patients, better stratify
    stroke patients, reduce re-admission, and optimize healthcare
    utilization.

#### TARGET POPULATION

Veterans who suffer a stroke

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Assessment and Coordination of Care**

1.  Coordinated, multidisciplinary stroke-related evaluation and
    interventions, including organized and coordinated post-acute
    inpatient rehabilitation care, interdisciplinary team approach,
    coordination with the patient and family members/caregivers

2.  Post-stroke assessment using standardized assessment instruments

    -   Level-of consciousness scale (Glasgow Coma Scale)

    -   Stroke deficit scales (National Institutes of Health Stroke
        Scale \[NIHSS\]; Canadian Neurological Scale)

    -   Global disability scale (Rankin Scale)

    -   Measures of disability/activities of daily living (Barthel
        Index; Functional Independence Measure \[FIM™\])

    -   Mental status screening (Folstein Mini-Mental State Examination;
        Neurobehavioral Cognition Status Exam \[NCSE\])

    -   Assessment of motor function (Fugl-Meyer; Motor Assessment
        Scale; Motricity Index)

    -   Balance assessment (Berg Balance Assessment)

    -   Mobility assessment (Rivermead Mobility Index)

    -   Assessment of speech and language functions (Boston Diagnostic
        Aphasia Examination; Porch Index of Communicative Ability
        \[PICA\]; Western Aphasia Battery)

    -   Depression scales (Beck Depression Inventory \[BDI\]; Center for
        Epidemiologic Studies Depression \[CES-D\]; Geriatric Depression
        Scale \[GDS\])

    -   Measures of instrumental ADL (PGC Instrumental Activities of
        Daily Living; Frenchay Activities Index)

    -   Family Assessment Device (FAD)

    -   Health status/quality of life measures (Medical Outcomes Study
        \[MOS\] Item Short-Form Health Survey; Sickness Impact Profile
        \[SIP\])

3.  Patient and family/caregiver education

**Rehabilitation During The Acute Phase**

1.  Initial assessment during the acute phase, including a complete
    history and physical examination, with special emphasis on the
    following:

    -   Risk factors for stroke recurrence

    -   Medical comorbidities

    -   Level of consciousness and cognitive status

    -   Brief swallowing assessment

    -   Skin assessment and risk for pressure ulcers

    -   Bowel and bladder function

    -   Mobility, with respect to the patient´s needs for assistance in
        movement

    -   Risk of deep vein thrombosis (DVT)

    -   History of previous antiplatelet or anticoagulation use,
        especially at the time of stroke

    -   Emotional support for the family and caregiver

    -   Measures to prevent skin breakdown (use of proper positioning,
        turning, and transferring techniques and judicious use of
        barrier sprays, lubricants, special mattresses, and protective
        dressings and padding)

2.  Measures to prevent deep vein thrombosis (early mobilization;
    low-dose unfractionated heparin \[LDUH\]; low molecular weight
    heparin \[LMWH\] and heparinoids; alternating compression machines;
    graduated compression stockings)

3.  Assessment of stroke severity using the National Institutes of
    Health Stroke Scale (NIHSS) in order to stratify patients according
    to severity and likely outcome

4.  Measures to prevent complications and reduce the risk for stroke
    recurrence (carotid endarterectomy; warfarin for cardiogenic stroke;
    antiplatelet therapy; angiotensin-converting-enzyme \[ACE\]
    inhibitor; statin therapy; lifestyle modification)

**Post-Stroke Rehabilitation**

1.  Assessment of post-acute stroke patient for rehabilitation services,
    such as inpatient rehabilitation, nursing facility rehabilitation,
    outpatient rehabilitation, home-based rehabilitation

2.  Obtain medical history and physical examination, including risk of
    complications (skin breakdown, risk for deep vein thrombosis
    \[DVT\], swallowing problems, bowel and bladder dysfunction,
    malnutrition, falls, and pain), determination of impairment
    (swallowing, cognition, communication, motor, psychological, and
    safety awareness, psychosocial assessment (family and caregivers,
    social support, financial, and cultural support, assessment of prior
    and current functional status)

3.  Determination of nature and extent of rehabilitation services based
    on stroke severity, functional status, and social support

4.  Assessment of risk for complications

    -   Assessment of swallowing (dysphagia) (bedside swallow screening;
        videofluoroscopy swallowing study \[VFSS\]; fiber-optic
        endoscopic examination of swallowing \[FEES\], fiber-optic
        endoscopic examination of swallowing with sensory testing
        \[FEESST\])

    -   Assessment of bowel and bladder function and treatment of bowel
        and bladder incontinence (bladder assessment/scanning;
        indwelling catheter; silver alloy-coated catheters; urodynamics;
        bladder training program; prompted voiding; bowel program)

    -   Assessment of malnutrition (nutrition and hydration evaluation;
        use of variety of methods to maintain and improve intake of food
        and fluids)

    -   Assessment and treatment of pain

5.  Assessment of cognition and communication to identify areas of
    cognitive and communication impairment

6.  Psychosocial assessment to provide comprehensive understanding of
    patient/caregiver psychosocial functioning, environment, resources,
    goals, and expectations for community integration

7.  Assessment of function to provide baseline assessment of overall
    functional status using standardized assessment tool

8.  Evaluation of need for rehabilitation interventions and
    identification of the optimal environment for providing
    rehabilitation interventions

9.  Prior to discharge, evaluation of patient for activities of daily
    living (ADL) and instrumental activities of daily living (IADL) in
    order to determine appropriate discharge environment

10. Discharging patient to prior home/community and arranging for
    medical follow-up in primary care

11. Monitoring and addressing of patient´s continued medical and
    functional needs after discharge from rehabilitation services

12. Follow up, including exercise program, adaptive equipment, durable
    medical devices, orthotics, and wheelchairs

13. Referral to vocational counseling to evaluate returning to work

14. Evaluation of readiness to return to driving and referral to
    adaptive driving program as indicated

15. Addressing sexual functioning issues

16. Patient/family education; reach shared decision regarding
    rehabilitation program; determination of treatment plan

17. Rehab programs/interventions:

    -   Treatment of dysphagia (enteral feeding for patients who are
        unable to orally maintain adequate nutrition; swallowing
        treatment and management)

    -   Treatment of acute communication disorders and long-term
        communication difficulties

    -   Motor Functioning -- Strengthening for patients with muscle
        weakness following stroke

    -   Partial body weight support for treadmill training

    -   Constraint induced (CI) movement therapy

    -   Functional electrical stimulation (FES)

    -   Neuro developmental training for motor retraining

    -   Treatment for spasticity (antispastic positioning, range of
        motion exercises, stretching, splinting, serial casting, or
        surgical correction for spasticity; medications, such as
        tizanidine, dantrolene, and oral baclofen, botulinum toxin and
        phenol/alcohol, intrathecal baclofen; use of certain
        neurosurgical procedures)

    -   Biofeedback

    -   Measures to prevent and/or treat shoulder pain (electrical
        stimulation; intra-articular injections; ROM- lateral rotation;
        exercise; positioning; strapping

    -   Cognitive remediation (training to improve attention; training
        to compensate for visual neglect; formal problem solving
        strategies; multimodal intervention for multiple cognitive
        deficits; training to develop compensatory strategies for a mild
        short-term memory deficit

    -   Treatment for mood disturbance, such as depression and
        emotionalism (pharmacotherapy; psychotherapy;
        information/advice)

    -   Assessment and treatment for visual and spatial neglect

    -   Use of pharmacologic agents to enhance stroke recovery including
        drugs to use and drugs to avoid using

18. Preparation of patient for community living (patient and
    family/caregiver education and information, equipment and training,
    vocation counseling, encouragement for leisure activities; case
    management as appropriate; resource listing)

19. Monitoring for adherence to treatments and barriers to improvement

20. Referral as appropriate (referral to acute services in medically
    unstable; referral to mental health services as indicated)

#### MAJOR OUTCOMES CONSIDERED

-   Morbidity, mortality, and complications related to stroke

-   Post-stroke functional ability and return to independent living

-   Quality of life

-   Rates of stroke recurrence and rehospitalizations

-   Validity, reliability, and sensitivity of standardized instruments
    for post-stroke assessment

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The following three guidelines were identified by the Working Group as
appropriate seed guidelines. They served as the starting point for the
development of questions and key terms.

-   Agency for Health Care Policy and Research (AHCPR) Post-Stroke
    Rehabilitation (1995)

-   Royal College of Physicians (RCP) National Clinical Guidelines for
    Stroke (2000)

-   Scottish Intercollegiate Guidelines Network (SIGN) Management of
    Patients with Stroke, 20 (1997)

Fifty-one researchable questions and associated key terms were developed
by the Working Group after orientation to the seed guidelines and to
goals that had been identified by the Working Group. The questions
specified:

-   Population -- characteristics of the target population

-   Intervention -- diagnostic, screening, therapy, and assessment

-   Control -- the type of control used for comparison

-   Outcome -- the outcome measure for this intervention (morbidity,
    mortality, patient satisfaction, and cost)

A systematic search of the literature was conducted. It focused on the
best available evidence to address each key question, and ensured
maximum coverage of studies at the top of the hierarchy of study types:
evidence-based guidelines, meta-analyses, and systematic reviews
(Cochrane, EBM, and EPC reports). The seed guidelines evidence was
carefully reviewed.

The search continued using well-known and widely available databases
that were appropriate for the clinical subject. Limits on language
(English), time (1990 through January 2002), and type of research
(randomized controlled trials \[RCTs\]) were applied. The search
included MEDLINE and additional specialty databases (DARE), depending on
the topic.

The search strategy did not cast a wide net. Once definitive clinical
studies that provided valid relevant answers to the question were
identified, the search stopped. It was extended to studies/reports of
lower quality (observational studies) only if there were no high quality
studies.

The results of the search were organized and reported using reference
manager software. At this point, additional exclusion criteria were
applied. Typical exclusions were studies with physiological endpoints or
studies of populations that were not comparable to the population of
interest (e.g., studies of rehabilitation of patients with other
diseases).

Evidence Appraisal Reports for each of the 51 questions were prepared by
the Center for Evidence-Based Practice at the State University of New
York, Upstate Medical University, Department of Family Medicine (these
reports are available by request). Each report covered:

-   Summary of findings

-   Methodology

-   Search terms

-   Resources searched

-   Articles critically appraised

-   Findings

The Working Group suggested some additional references. Copies of
specific articles were provided to participants on an as-needed basis.
This document includes references through January 2002.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

The following rating schemes are from the U.S. Preventive Services Task
Force (USPSTF) (2001).

**Quality of Evidence (QE)**

**I**: Evidence obtained from at least one properly randomized
controlled trial\
**II-1**: Evidence obtained from well-designed controlled trails without
randomization\
**II-2**: Evidence obtained from well-designed cohort or case-control
analytic studies, preferably from more than one center or research
group\
**II-3**: Evidence obtained from multiple time series studies with or
without the intervention. Dramatic results in uncontrolled experiments
(such as the results of the introduction of penicillin treatment in the
1940s) could also be regarded as this type of evidence.\
**III**: Opinions of respected authorities, based on clinical
experience; descriptive studies and case reports; or reports of expert
committees

**Overall Quality**

**Good**: High grade evidence (I or II-1) directly linked to health
outcome\
**Fair**: High grade evidence (I or II-1 linked to intermediate outcome
or Moderate grade evidence (II-2 or II-3) directly linked to health
outcome\
**Poor**: Level III evidence or no linkage of evidence to health outcome

**Net Effect of Intervention**

**Substantial**:

-   More than a small relative impact on a frequent condition with a
    substantial burden of suffering, or

-   A large impact on an infrequent condition with a significant impact
    on the individual patient level

**Moderate**:

-   A small relative impact on a frequent condition with a substantial
    burden of suffering, or

-   A moderate impact on an infrequent condition with a significant
    impact on the individual patient level

**Small**:

-   A negligible relative impact on a frequent condition with a
    substantial burden of suffering, or

-   A small impact on an infrequent condition with a significant impact
    on the individual patient level

**Zero or Negative**:

-   Negative impact on patients, or

-   No relative impact on either a frequent condition with a substantial
    burden of suffering, or

-   An infrequent condition with a significant impact on the individual
    patient level

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Evidence Appraisal Reports for each of 51 questions were prepared by the
Center for Evidence-Based Practice at the State University of New York,
Upstate Medical University, Department of Family Medicine (these reports
are available by request). Each report covered:

-   Summary of findings

-   Methodology

-   Search terms

-   Resources searched

-   Articles critically appraised

-   Findings

The clinical experts and research team evaluated the evidence for each
question according to criteria proposed by the U.S. Preventive Services
Task Force (USPSTF) (2001). See \"Rating Scheme for the Quality of the
Evidence\".

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

-   The Guideline for the Management of Stroke Rehabilitation is the
    product of many months of diligent effort and consensus building
    among knowledgeable individuals from the Veterans Administration
    (VA), Department of Defense (DoD), academia, and guideline
    facilitators from the private sector. An experienced moderator
    facilitated the multidisciplinary Working Group that included
    internists, physiatrists, neurologists, geriatricians, nurse
    practitioners, occupational therapists, physical therapists,
    recreational therapists, speech and language pathologists,
    psychologists, social workers, kinesiotherapists, pharmacists, and
    rehabilitation/clinic coordinators, as well as consultants in the
    field of guideline and algorithm development.

-   The Working Group participated in two face-to-face sessions to reach
    a consensus about the guideline recommendations and to prepare a
    draft document. The draft was revised by the experts through
    numerous conference calls and individual contributions to the
    document.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

The following rating scheme is from the U.S. Preventive Services Task
Force (USPSTF) (2001).

**Grade of Recommendation**

**A**: A strong recommendation that the intervention is always indicated
and acceptable\
**B**: A recommendation that the intervention may be useful/effective\
**C**: A recommendation that the intervention be considered\
**D**: A recommendation that a procedure may be considered not
useful/effective, or may be harmful\
**I**: Insufficient evidence to recommend for or against; clinical
judgment should be used

#### COST ANALYSIS

Published cost analyses were reviewed.

-   One systematic review included cost-effectiveness analyses that
    suggested that routine screening for dysphagia with a preliminary
    bedside evaluation followed by either a full bedside evaluation or
    videofluoroscopy swallowing study (VFSS) when the preliminary study
    is abnormal may be cost-effective, if the assumptions used in the
    analyses are correct.

-   A meta-analysis study published in 1998 concluded: \"Silver
    alloy-coated urinary catheters are significantly more effective in
    preventing urinary tract infections than are silver oxide catheters.
    They are more expensive, but may reduce overall costs of care, as
    catheter related infection is a common cause of nosocomial infection
    and bacteremia.\" This analysis covered a diverse patient
    population, and was not specific to stroke.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The final draft was reviewed by experts from the Veterans Administration
(VA) and Department of Defense (DoD) in physical medicine and neurology.
Their feedback was integrated into the final draft.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The recommendations for the management of stroke rehabilitation in the
primary care setting are organized into 3 major algorithms. The
algorithms, the objectives, annotations, and recommendations that
accompany them, and the evidence supporting the recommendations are
presented below. The quality of evidence (I, II-1, II-2, II-3, III),
overall quality (good, fair, poor), net effect of intervention
(substantial, moderate, small, zero or negative), and strength of
recommendation grading (A-D, I) are defined at the end of the \"Major
Recommendations\" field.

*Note: A list of abbreviations is provided at the end of the \"Major
Recommendations\" field.*

[Algorithm A:
Assessment](http://www.oqp.med.va.gov/cpg/STR/str_cpg/algoAframeset.htm)

[Algorithm B: Inpatient
Rehabilitation](http://www.oqp.med.va.gov/cpg/STR/str_cpg/algoBframeset.htm)

[Algorithm C: Community Based
Rehabilitation](http://www.oqp.med.va.gov/cpg/STR/str_cpg/algoCframeset.htm)

**The Provision of Rehabilitation Care**

**Organization of Post-Acute Stroke Rehabilitation Care**

1.  Better clinical outcomes are achieved when post-acute stroke
    patients who are candidates for rehabilitation receive coordinated,
    multidisciplinary evaluation and intervention.

    -   Post-acute stroke care should be delivered in a setting where
        rehabilitation care is formally coordinated and organized.
        (Evans et al., 2001; Langhorne & Duncan, 2001) (***Quality of
        the Evidence \[QE\]*: I; *Overall Quality*: Good;
        *Recommendation \[R\]*: A**)

    -   Post-acute care should be delivered by a variety of treatment
        disciplines, experienced in providing post-stroke care, to
        ensure consistency and reduce the risk of complications. (Agency
        for Health Care Policy and Research (AHCPR), 1995; Cifu &
        Stewart, 1999; Evans et al., 1995; Evans et al., 2001;
        Indredavik et al., 1997; Kalra et al., 2000; Langhorne & Duncan,
        2001; Stroke Unit Trialists, 2002) (***QE*: I; *Overall
        Quality*: Fair; *R*: B**)

    -   The multidisciplinary team may consist of a physician, nurse,
        physical therapist, occupational therapist, kinesiotherapist,
        speech and language pathologist, psychologist, recreational
        therapist, patient, and family/caregivers. (***QE*: III;
        *Overall Quality*: Poor; *R*: I**)

2.  If an organized rehabilitation team is not available in the
    facility, patients with moderate or severe symptoms should be
    offered a referral to a facility with such a team, or a physician or
    rehabilitation specialist with some experience in stroke should be
    involved in the patient´s care. (***QE*: III; *Overall Quality*:
    Poor; *R*: I**)

3.  An organized team approach should also be continued in coordinating
    the outpatient or home-based rehabilitation care. Community
    resources for stroke rehabilitation services that include an
    organized team should be identified and provided to patients and
    families/caregivers. (***QE*: III; *Overall Quality*: Poor; *R*:
    I**)

**The Use of Standardized Assessments**

1.  Strongly recommend to assess the stroke recovery using the National
    Institutes of Health Stroke Scale (NIHSS) at the time of
    presentation/hospital admission, or at least within the first 24
    hours following presentation. (Adams et al., 1999; Frankel et
    al., 2000) (***QE*: I; *Overall Quality*: Good; *R*: 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. (AHCPR, 1995; Working Group Consensus) (***QE*:
    III; *Overall Quality*: Poor; *R*: C**)

3.  If depression and motor, sensory, cognitive, communication, and
    swallowing deficits are found, all patients should be formally
    assessed by the appropriate clinician from the coordinated
    rehabilitation team. (Royal College of Physicians \[RCP\], 2000;
    Scottish Intercollegiate Guidelines Network (SIGN), 1997) (***QE*:
    III; *Overall Quality*: Poor; *R*: C**)

4.  Recommend that the clinician use standardized, valid assessments to
    evaluate the patient´s stroke-related impairments and functional
    status and participation in community and social activities. (Duncan
    et al., 1999) (***QE*: III; *Overall Quality*: Poor; *R*: 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 be discussed with the patient and
    family/caregivers.

**Intensity/Duration of Therapy**

1.  Strongly recommend that rehabilitation therapy should start as early
    as possible, once medical stability is reached. (Cifu & Stewart,
    1999 ; Ottenbacher & Jannell, 1993) (***QE*: I; *Overall Quality*:
    Good; *R*: A**)

2.  Recommend that the patient receives as much therapy as \"needed\" to
    adapt, recover, and/or reestablish the premorbid or optimal level of
    functional independence. (Kwakkel et al., 1999; Langhorne, Wagenaar,
    & Partridge, 1996; Richards et al., 1993; Sivenius et al., 1985;
    Smith et al., 1981; van der Lee & Snels, 2001) (***QE*: I; *Overall
    Quality*: Fair; *R*: B**)

**Patient´s Family and Caregivers**

1.  The family/caregiver of the stroke patient should be involved in
    decision making and treatment planning as early as possible, if
    available, and throughout the duration of the rehabilitation
    process.

2.  The providers must be alert to the stress on the family/caregiver,
    specifically recognizing the stress associated with impairments
    (e.g., cognitive loss, urinary incontinence, and personality
    changes) and providing support, as indicated.

3.  Acute care hospitals and rehabilitation facilities should maintain
    up-to-date information on community resources at the local and
    national level, provide this information to the stroke patient and
    families/caregivers, and offer assistance in obtaining needed
    services.

4.  The patient and caregivers should have their psychosocial and
    support needs reviewed on a regular basis, by a social worker or
    appropriate healthcare worker, to minimize caregiver distress.

**Patient and Family/Caregiver Education**

1.  Recommend that patient and family/caregiver education should be
    provided in an interactive and written format. (Forster et
    al., 2001) (***QE*: I; *Overall Quality*: Fair; *R*: B**)

2.  Consider identifying a specific team member to be responsible for
    providing information to the patient and family/caregiver about the
    nature of the stroke, stroke management rehabilitation and outcome
    expectations, and their roles in the rehabilitation process.
    (***QE*: III; *Overall Quality*: Poor; *R*: C**)

3.  The family conference may be considered as a useful means of
    information dissemination. (***QE*: III; *Overall Quality*: Poor;
    *R*: C**)

4.  Recommend that patient and family education should be documented in
    the patient´s medical record to prevent the occurrence of duplicate
    or conflicting information from different disciplines. (***QE*: III;
    *Overall Quality*: Poor; *R*: C**)

**Rehabilitation During The Acute Phase**

A.  **Patient with Stroke During Acute Phase**

> The Agency for Health Care Policy and Research (AHCPR) (1995) defines
> \"acute care\" as:
>
> *The period of time immediately following the onset of an acute
> stroke. A full-service hospital where patients with an acute stroke
> are treated either in a medical service or in a specialized stroke
> unit, and where 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. Outcome 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 subacute complications.

4.  Begin planning for therapies to prevent recurrent stroke.

5.  Begin efforts to restore neurological 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, family support, and treatment of depression
> (American Heart Association \[AHA\], 1994).

B.  **Obtain Medical History And Physical Examination. Initial
    Assessment of Complications, Impairment, And Rehabilitation Needs**

> *Objective*
>
> Obtain clinical data required to manage the stroke rehabilitation.
>
> *Recommendations*

1.  The National Institutes of Health Stroke Scale (NIHSS) should be
    used to assess severity of stroke in the initial stages as a
    predictor of mortality and long-term outcome (see Annotation C in
    the original guideline document).

2.  The initial assessment should include a complete history and
    physical examination, with special emphasis on the following:

    -   Risk factors for stroke recurrence

    -   Medical comorbidities

    -   Level of consciousness and cognitive status

    -   Brief swallowing assessment

    -   Skin assessment and risk for pressure ulcers (see Annotation
        B-1)

    -   Bowel and bladder function

    -   Mobility, with respect to the patient´s needs for assistance in
        movement

    -   Risk of deep vein thrombosis (DVT) (see Annotation B-2)

    -   History of previous antiplatelet or anticoagulation use,
        especially at the time of stroke

    -   Emotional support for the family and caregiver

> **B-1 Risk for Skin Breakdown**
>
> *Recommendations*

1.  Recommend that a thorough assessment of skin integrity should be
    completed upon admission and monitored, at least daily, thereafter.
    (AHCPR, 1995; Bates-Jensen & Sussman, 1998) (***QE*: III; *Overall
    Quality*: Poor; *R*: C**)

2.  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 friction or excessive pressure. (AHCPR, 1995; Working
    Group Consensus) (***QE*: III; *Overall Quality*: Poor; *R*: C**)

> **B-2 Risk for Deep Vein Thrombosis (DVT)**
>
> *Recommendations*

1.  Recommend that all patients be mobilized as soon as possible (the
    act of getting a patient to move in the bed, sit up, stand, and
    eventually walk). (Working Group Consensus) (***QE*: III; *Overall
    Quality*: Poor; *R*: C**)

2.  Strongly recommend the use of subcutaneous low-dose unfractionated
    heparin (LDUH) (5,000 units twice a day \[BID\], unless
    contraindicated) to prevent DVT/pulmonary embolism (PE) for patients
    with ischemic stroke and impaired mobility. (The International
    Stroke Trial \[IST\], 1997) (***QE*: I; *Overall Quality*: Good;
    *R*: A**) Low molecular weight heparin (LMWH) or heparinoids may be
    used as an alternative to LDUH, especially in patients with a
    history of heparin-related side effects (such as thrombocytopenia).
    (Bath, Iddenden, & Bath , 2000; Bath, Bath, & Smithard, 2001;
    Bijsterveld et al., 1999) (***QE*: I; *Overall Quality*: Poor; *R*:
    C**)

3.  Consider the use of graduated compression stockings. (Muir et
    al., 2000) (***QE*: I; *Overall Quality*: Fair; *R*: B**) or an
    intermittent pneumatic compression machine. (Kamran, Downey, &
    Ruff, 1998) (***QE*: II-3; *Overall Quality*: Fair; *R*: B**) as an
    adjunct to anticoagulation, or as an alternative to anticoagulation
    for patients with intracerebral hemorrhagic or for patients in whom
    anticoagulation is contraindicated.

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C.  **Assessment of Stroke Severity (NIHSS)**

> *Objective*
>
> Stratify patients according to severity and likely outcome.
>
> *Recommendations*

1.  Strongly recommend that 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. (Adams et
    al., 1999; Frankel et al., 2000) (***QE*: I; *Overall Quality*:
    Good; *R*: A**)

2.  Strongly recommend that all professionals involved in any aspect of
    the stroke care be trained and certified to perform the NIHSS.

3.  Recommend that patients should be reassessed using the NIHSS at the
    time of acute care discharge.

4.  Recommend that if the patient is transferred to rehabilitation and
    there are no NIHSS scores in the record, the rehabilitation team
    should complete an NIHSS.

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D.  **Initiate Secondary Prevention and Prevention of Complications**

> *Objective*
>
> Reduce the risk for recurrence of stroke.
>
> *Recommendations*

1.  Strongly recommend that patients with a symptomatic carotid stenosis
    of 70 to 99 percent who are surgical candidates and have a life
    expectancy of over 2 years should undergo carotid endarterectomy
    (CEA) if the surgical morbidity and mortality is under 5 percent at
    the treating center (\"Beneficial effect of carotid
    endarterectomy,\" 1991). CEA may be considered in selected patients
    with carotid stenosis of 50 to 69 percent (number-needed-to-treat to
    prevent one stroke over 5 years = 15) (Barnett et al., 1998).
    Antiplatelet therapy should be instituted after post-operative
    recovery from CEA. (Barnett et al., 1998) (***QE*: I; *Overall
    Quality*: Good; *R*: A**)

2.  Strongly recommend that patients with atrial fibrillation,
    mechanical heart valves, mural thrombi, or other high risk sources
    of cardiogenic emboli should be treated with warfarin at a target
    international normalized ratio (INR) of 2.5, range 2.0 to 3.0, if
    they are likely to be compliant with the required monitoring and are
    not at high risk for bleeding complications. (Albers et al., 2001).
    In cardioembolic patients who have had a large stroke,
    anticoagulation should not be started for 7 to 10 days due to the
    risk of cerebral hemorrhage. In non-cardioembolic ischemic stroke,
    warfarin has not been shown to be more effective than aspirin (Mohr
    et al., 2001). (Albers et al., 2001; Blackshear et al., 1999)
    (***QE*: I; *Overall Quality*: Good; *R*: A**)

3.  Strongly recommend that patients with non-cardioembolic ischemic
    stroke should receive antiplatelet therapy after stroke if there is
    no bleeding contraindication. Aspirin at a dose of 81 to 325 mg is
    cost-effective and is the usual first-line agent. Clopidogrel at 75
    mg/day, and the combination of 200-mg extended release dipyridamole
    with 25 mg of aspirin taken twice a day are acceptable alternatives
    to aspirin and may provide a greater degree of risk reduction than
    aspirin albeit at a higher cost. (CAPRIE Steering Committee, 1996;
    Diener et al., 1996; Zusman et al., 1999; Albers et al., 2001)
    (***QE*: I, III; *Overall Quality*: Fair, Good; *R*: A**)

4.  Strongly recommend that patients having a stroke while on aspirin be
    considered for alternative antiplatelet agents (see Appendix
    A-Antiplatelet Pharmacotherapy in the original guideline document
    and also at
    [www.vapbm.org/PBM/criteria.htm](http://www.vapbm.org/PBM/criteria.htm))

5.  Strongly recommend that treatment of hypertension should be
    instituted after the acute period in patients who have consistently
    elevated blood pressure. Even borderline hypertension conveys an
    increased stroke risk. Target blood pressure should be in accordance
    with the [VA/DoD Clinical Practice Guideline for the Diagnosis and
    Management of Hypertension in the Primary Care
    Setting](http://www.oqp.med.va.gov/cpg/HTN/HTN_Base.htm). Several
    drugs have been studied and shown to be effective in stroke
    prevention such as angiotensin-converting enzyme (ACE) inhibitors,
    beta-blockers, and thiazide diuretics. The ACE inhibitors, ramipril
    and perindopril, may exhibit beneficial effects on stroke prevention
    independent of blood pressure reduction. (Yusuf et al., 2000;
    \"Randomised trial of a perindopril-based blood-pressure-lowering
    regimen,\" 2001) (***QE*: I; *Overall Quality*: Good; *R*: A**)
    Control of hypertension remains an essential cornerstone for stroke
    prevention. Avoid sudden or excessive drops in blood pressure which
    could exacerbate cerebral hypoperfusion (especially in the acute
    phase). Do not use fast-acting antihypertensive drugs, which could
    drop blood pressure too much and too fast.

6.  Strongly recommend that patients who have had an ischemic stroke be
    treated for hypercholesterolemia according to the [VA/DoD Clinical
    Practice Guideline for the Management of
    Dyslipidemia](http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9907&nbr=5303).
    (Blauw et al., 1997; Bucher, Griffith, & Guyatt, 1998; Byington et
    al., 2001; van Mil et al., 2000; Bloomfield Rubins et al., 2001;
    Jonsson & Asplund, 2001) (***QE*: I, II-2; *Overall Quality*: Good;
    *R*: A**)

7.  Recommend that all patients after stroke should be counseled about
    smoking cessation, participation in a regular exercise program (as
    permitted by the patient´s physical limitations and general medical
    condition), maintaining a body-mass index within the desirable
    range, and avoidance of heavy alcohol use (refer to the VA/DoD
    Clinical Practice Guideline for Management of Substance Use
    Disorders in the Primary Care Setting) and the VA/DoD Clinical
    Practice Guideline To Promote Tobacco Use Cessation in the Primary
    Care Setting). (Dunbabin & Sandercock, 1990; Goldstein et al., 2001)
    (***QE*: II-2; *Overall Quality*: Fair; *R*: B**)

8.  Ongoing monitoring of anticoagulant or antiplatelet therapy,
    treatment of hypertension and hypercholesterolemia, and other
    secondary prevention strategies is a lifelong need of patients after
    stroke and should normally be performed by the patient´s primary
    healthcare provider

**Post-Stroke Rehabilitation**

E.  **Post-Acute Stroke Patient Assessed For Rehabilitation Services**

> Post-acute stroke is defined as the period of time immediately
> following discharge from acute care. The stroke patient has achieved
> medical stability and the focus of care now becomes rehabilitation.
> Stroke rehabilitation following discharge from acute care can be
> conducted in inpatient rehabilitation hospitals or rehabilitation
> units in acute care hospitals, nursing facilities, the patient´s home,
> or outpatient facilities. Some patients may recover from the acute
> phase with no need for rehabilitation services.
>
> Inpatient rehabilitation:
>
> *Rehabilitation performed during an inpatient stay in a freestanding
> 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.*
>
> Nursing facility rehabilitation:
>
> *Rehabilitation performed during a stay in a nursing facility. Nursing
> facilities vary widely in their rehabilitation capabilities, ranging
> from maintenance care to comprehensive and intense rehabilitation
> programs.*
>
> Outpatient rehabilitation:
>
> *Rehabilitation performed in an outpatient facility that is either
> freestanding or attached to an acute care or rehabilitation hospital.
> Day hospital care is a subset of outpatient rehabilitation in which
> the patient spends a major part of the day in an outpatient
> rehabilitation facility.*
>
> Home-based rehabilitation:
>
> *A rehabilitation program provided in the patient\'s place of
> residence (AHCPR, 1995).*

F.  **Obtain Medical History and Physical Examination. Determine Nature
    and Extent of Rehabilitation Services Based on Stroke Severity,
    Functional Status, and Social Support**

> *Objective*
>
> Obtain clinical data to determine the patient´s need for
> rehabilitation services.
>
> *Annotations*
>
> A thorough history and physical should be performed by the
> rehabilitation physician. The National Institute of Health Stroke
> Scale (NIHSS) score should be obtained at this time, if not previously
> determined by the referring team. The history, physical, and NIHSS
> score provides the framework to begin to determine the nature and
> extent of needed rehabilitation services.
>
> The history and physical should cover the following areas:

-   Risk of complications (skin breakdown, risk for DVT, swallowing
    problems, bowel and bladder dysfunction, malnutrition, falls, and
    pain) (see Annotations B and G)

-   Determination of impairment (swallowing, cognition, communication,
    motor, psychological, and safety awareness) (see Annotations H and
    S)

-   Psychosocial assessment (family and caregivers, social support,
    financial, and cultural support) (see Annotation I)

-   Assessment of prior and current functional status (e.g., FIM^TM^)
    (see Annotation J)

G.  **Assess Risk for Complications**

> **G-1 Assessment of Swallowing (Dysphagia)**
>
> *Recommendations*

1.  Recommend that all patients have their swallow screened prior to
    initiating oral intake of fluids or food, utilizing a simple valid
    bedside testing protocol. (ECRI, 1999; Perry & Love, 2001; Martino,
    Pron, & Diamant, 2000) (***QE*: II-2; *Overall Quality*: Fair; *R*:
    B**)

2.  Recommend that the swallow screening be performed by the Speech and
    Language Pathologist (SLP) or other appropriately trained personnel,
    if the SLP is not available. (Working Group Consensus) (***QE*: III;
    *Overall Quality*: Poor; *R*: I**)

3.  If the patient´s swallow screening is abnormal, a complete bedside
    swallow examination is recommended. The examination should be
    performed by the SLP, who will define swallow physiology and make
    recommendations regarding management and treatment. (Working Group
    Consensus) (***QE*: III; *Overall Quality*: Poor; *R*:I**)

4.  Recommend that all patients who have a positive bedside screening be
    tested using videofluoroscopy swallowing study (VFSS)/modified
    barium swallow. Patients with a high risk for aspiration and/or
    dysphagia (e.g., brainstem stroke, pseudobulbar palsy, and multiple
    strokes), regardless of screening results, should undergo VFSS.
    (Perry & Love, 2001) (***QE*: II-2: *Overall Quality*: Fair; *R*:
    B**)

5.  Consider fiber-optic endoscopic examination of swallowing (FEES) as
    an alternative to VFSS. (ECRI, 1999) (***QE*: II-2; *Overall
    Quality*: Fair; *R*: C**)

6.  There is insufficient evidence to recommend for or against
    fiber-optic endoscopic examination of swallowing with sensory
    testing (FEESST) for the assessment of dysphagia. (Aviv, 2000)
    (***QE*: II-3; *Overall Quality*: Poor; *R*: I**)

7.  Recommend that the diagnostic assessment, whether VFSS or another
    modality, include a definition of swallow physiology with
    identification of the physiologic abnormality and treatment
    strategies to directly assess their effectiveness. (Martin-Harris et
    al., 2000) (***QE*: II-2; *Overall Quality*: Fair; *R*: B**)

8.  Consider addressing food consistency with dietetics to ensure
    standardization, consistency, and palatability.

> **G-2 Treatment of Bowel and Bladder Incontinence**
>
> *Recommendations*

1.  Recommend 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

> (Nwosu et al., 1998; Working Group Consensus) (***QE*: II-2, III;
> *Overall Quality*: Poor, Fair; *R*: C, B**)

2.  Consider removal of the Foley catheter within 48 hours to avoid
    increased risk of urinary tract infection; however, if used, it
    should be removed as soon as possible. (Bjork, Pelletier, & Tight,
    1984; Sabanthan, Castelden, & Mitchell, 1985; Warren et al., 1982)
    (***QE*: II-2; *Overall Quality*: Fair; *R*: B**)

3.  Recommend the use of silver alloy-coated urinary catheters, if a
    catheter is required. (Saint et al., 1998) (***QE*: I; *Overall
    Quality*: Fair; *R*: B**)

4.  There is insufficient evidence to recommend for or against the use
    of urodynamics over other methods of assessing bladder function.
    (Ramsay et al., 1995) (***QE*: III; *Overall Quality*: Poor; *R*:
    I**)

5.  Consider an individualized bladder training program be developed and
    implemented for patients who are incontinent of urine. (Roe,
    Williams, & Palmer, 2001; Berghmans et al., 2000) (***QE*: III;
    *Overall Quality*: Poor; *R*: C**)

6.  Recommend the use of prompted voiding in stroke patients with
    urinary incontinence. (Eustice, Roe, & Patterson, 2001) (***QE*: I;
    *Overall Quality*: Fair; *R*: B**)

7.  Recommend a bowel management program be implemented in patients with
    persistent constipation or bowel incontinence. (Venn et al., 1992)
    (***QE*: III; *Overall Quality*: Poor; *R*: I**)

> **G-3 Assessment of Malnutrition**
>
> *Recommendations*

1.  Recommend that all patients receive evaluation of nutrition and
    hydration, as soon as possible after admission. Food and fluid
    intake should be monitored daily in all patients and body weight
    should be determined regularly. (Working Group Consensus) (***QE*:
    III; *Overall Quality*: Poor; *R*: I**)

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
    dysphagic patients, and catering to the patient´s food preferences.
    If intake is not maintained, feeding by a feeding gastrostomy may be
    necessary. (Working Group Consensus) (***QE*: III; *Overall
    Quality*: Poor; *R*: I**)

> **G-4 Assessment and Treatment of Pain**
>
> *Recommendations*

1.  Recommend pain assessment using the 0 to 10 scale. (Working Group
    Consensus) (***QE*: III; *Overall Quality*: Poor; *R*: I**)

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 what
    aggravates or relieves the pain.

3.  Control pain that interferes with therapy.

4.  Recommend the use of lower doses of centrally-acting analgesics,
    which may cause confusion and deterioration of cognitive performance
    and interfere with the rehabilitation process.

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H.  **Assessment of Cognition and Communication**

> *Objective*
>
> Identify areas of cognitive and communication impairment.
>
> *Recommendations*

1.  Assessment of cognition, arousal, and attention should address the
    following areas: learning and memory, visual neglect, attention,
    apraxia, and problem solving.

2.  The Working Group does not recommend for or against the use of any
    specific tools to assess cognition. Several screening and assessment
    tools exist.

3.  Assessment of communication ability should address the following
    areas: listening, speaking, reading, writing, and pragmatics.

4.  The Working Group does not recommend for or against the use of any
    specific tools to assess communication. Several screening and
    assessment tools exist. Appendix B in the original guideline
    document includes standard instruments for assessment of
    communication.

5.  Communication and cognitive problems are prevalent in stroke
    patients. Team members should be trained to recognize and manage the
    patient´s communication and cognitive problems.

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I.  **Psychosocial Assessment**

> *Objective*
>
> Provide comprehensive understanding of patient/caregiver psychosocial
> functioning, environment, resources, goals, and expectations for
> community integration.
>
> *Recommendations*

1.  Recommend that all stroke patients should receive a psychosocial
    assessment, psychosocial intervention, and referrals. (Tsouna-Hadjis
    et al., 2000) (***QE*: II-3; *Overall Quality*: Fair; *R*: B**)

2.  Recommend that families, significant others, and caregivers should
    be included in the assessment process. (Tsouna-Hadjis et al., 2000)
    (***QE*: II-3; *Overall Quality*: Fair; *R*: B**)

3.  Recommend that all stroke patients should be referred to a social
    worker for a comprehensive psychosocial assessment and intervention.
    (Working Group Consensus) (***QE*: III; *Overall Quality*: Poor;
    *R*: I**)

4.  The psychosocial assessment should include the following areas:

    -   History of pre-stroke functioning (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)

    -   Family/caregiver situation and relationships

    -   Resources (e.g., income and benefits, housing, and social
        network)

    -   Spiritual and cultural activities

    -   Leisure time and preferred activities

    -   Patient/family/caregiver understanding of the condition,
        treatment, and prognosis, as well as hopes and expectations for
        care

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J.  **Assessment of Function**

> *Objective*
>
> Provide baseline assessment of overall functional status.
>
> *Recommendations*

1.  Recommend that a standardized assessment tool be used to assess
    functional status of stroke patients.

2.  Consider the use of the Functional Independence Measure (FIM™) as
    the standardized functional assessment (see Appendix D -- Functional
    Independence Measure \[FIM™\] Instrument in the original guideline
    document).(Lin, 2001; Ottenbacher et al., 1996) (***QE*: II-2;
    *Overall Quality*: Fair; *R*: B**)

> Appendix B includes the list of other standard instruments for
> assessment of function and impact of stroke.

K.  **Does Patient Need Rehabilitation Interventions?**

> *Objective*
>
> Identify the patient who requires rehabilitation intervention.
>
> *Recommendations*

1.  Strongly recommend that once the patient is medically stable, the
    primary physician consult rehabilitation services (i.e., physical
    therapy, occupational therapy, speech and language pathology,
    kinesiotherapy, and Physical Medicine), as indicated, to assess the
    patient´s rehabilitation needs and to recommend the most appropriate
    setting to meet those needs.

2.  A multidisciplinary assessment, using a standard procedure, should
    be undertaken and documented for all patients. Patients with need of
    rehabilitation intervention should be referred to a specialist
    stroke rehabilitation team, as soon as possible.

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L.  **Is Inpatient Rehabilitation Indicated?**

> *Objective*
>
> Identify the optimal environment for providing rehabilitation
> interventions.
>
> *Recommendations*

1.  Strongly recommend that patients in need of rehabilitation services
    have access to a setting with a coordinated and organized
    rehabilitation care team, experienced in providing stroke services.
    The coordination and organization of inpatient post-acute stroke
    care will improve patient outcome. (*See Provision of Rehabilitation
    Care)* (***QE*: I; *Overall Quality*: Good; *R*: A**)

2.  No conclusive evidence was found to demonstrate the superiority of
    one type of rehabilitation setting over another. (Cifu & Stewart,
    1999; Early Supported Discharge Trialists, 2001; Evans et al., 1995;
    Rudd et al., 1997) (***QE*: I; *Overall Quality*: Fair; *R*: B**)

3.  The severity of the patient´s impairment, the availability of
    family/social support, and patient/family preferences will determine
    the optimal environment for care. (Working Group Consensus) (***QE*:
    III; *Overall Quality*: Fair; *R*: I**)

4.  Recommend that patients remain in an inpatient setting for their
    rehabilitation care if they are in need of skilled nursing services,
    regular physician care, and multiple therapeutic interventions.
    (Working Group Consensus) (***QE*: III; *Overall Quality*: Poor;
    *R*: I**)

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M.  **Is Patient Independent in Activities of Daily Living (ADL) And
    IADL (Instrumental Activities of Daily Living)?**

> *Objective*
>
> Determine appropriate discharge environment.
>
> *Recommendations*

1.  Recommend that all post-stroke patients should be reassessed for ADL
    prior to discharge. (Nourhashemi et al., 2001) (***QE*: II-2;
    *Overall Quality*: Fair; *R*: B**)

2.  Recommend that all patients planning to return to independent
    community living should be assessed for IADL prior to discharge
    (including a community skills evaluation and home assessment).
    (Ginsberg et al., 1999) (***QE*: II-3; *Overall Quality*: Fair; *R*:
    B**)

3.  Minimal IADL skills required to stay at home alone include the
    ability to: (1) prepare or retrieve a simple meal, (2) employ safety
    precautions and exhibit good judgment, (3) take medication, and (4)
    get emergency aid, if needed. Refer to Table 1 in the original
    guideline document as a guide to differentiate between ADL and IADL.

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N.  **Discharge Patient to Prior Home/Community; Arrange for Medical
    Follow-Up in Primary Care**

> *Objective*
>
> Ensure that the patient´s continued medical and functional needs are
> addressed after discharge from rehabilitation services.
>
> *Recommendations*

1.  Strongly recommend that every patient participate in a secondary
    prevention program (see Annotation D) (***QE*: I; *Overall Quality*:
    Good; *R*: A**).

2.  Recommend that post-acute stroke patients be followed up by a
    primary care provider to address stroke risk factors and continue
    treatment of comorbidities.

3.  Recommend that the patient and family be educated regarding
    pertinent risk factors for stroke.

> **N-1 Exercise Program**
>
> *Recommendations*

1.  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
    comorbidities and functional limitations. (Macko et al., 1997;
    Potempa et al., 1996; Rimmer et al., 2000; Teixeira-Salmela et
    al., 1999) (***QE*: II-2; *Overall Quality*: Fair; *R*: B**)

> **N-2 Adaptive Equipment, Durable Medical Devices, Orthotics, and
> Wheelchairs**
>
> *Recommendations*

1.  Recommend that 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. (AHCPR, 1995;
    Working Group Consensus) (***QE*: III; *Overall Quality*: Poor; *R*:
    C**)

2.  Recommend that lower extremity orthotic devices be considered, if
    ankle or knee stabilization is needed to improve the patient´s gait
    and prevent falls. (AHCPR, 1995; Working Group Consensus) (***QE*:
    III; *Overall Quality*: Poor; *R*: C**)

3.  Recommend that a prefabricated brace be initially used and only
    patients who demonstrate long-term need for bracing have customized
    orthoses made. (AHCPR, 1995; Working Group Consensus) (***QE*: III;
    *Overall Quality*: Poor; *R*: C**)

4.  Recommend that wheelchair prescriptions be based on careful
    assessment of the patient and the environment in which the
    wheelchair will be used. (AHCPR, 1995; Working Group Consensus)
    (***QE*: III; *Overall Quality*: Poor; *R*: C**)

5.  Recommend that walking assistive devices be used to help with
    mobility efficiency and safety, when needed.

> **N-3 Return to Work**
>
> *Recommendations*

1.  Recommend that all patients, if their condition permits, should be
    encouraged to be evaluated for the potential of returning to work.
    (AHCPR, 1995) (***QE*: III; *Overall Quality*: Poor; *R*: C**)

2.  Recommend that all patients who were previously employed be referred
    to vocational counseling for assistance in returning to work.
    (AHCPR, 1995; American Stroke Association) (***QE*: III; *Overall
    Quality*: Poor; *R*: 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. (AHCPR,
    1995; American Stroke Association) (***QE*: III; *Overall Quality*:
    Poor; *R*: C**)

> **N-4 Return to Driving**
>
> *Recommendations*

1.  Recommend that 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. (Working Group
    Consensus). (***QE*: III; *Overall Quality*: Poor; *R*: I**)

2.  Consider referring patients with residual deficits to adaptive
    driving instruction programs to minimize the deficits, eliminate
    safety concerns, and ensure that patients will be able to pass the
    state driving test. (Working Group Consensus) (***QE*: III; *Overall
    Quality*: Poor; *R*: I**)

> **N-5 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.

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O.  **Patient with Severe Stroke And/Or Maximum Dependence And Poor
    Prognosis For Functional Recovery**

> *Annotation*
>
> Patients who have had a severe stroke or who are maximally dependent
> in ADL and have a poor prognosis for functional recovery are not
> candidates for rehabilitation intervention. Families and caregivers
> should be educated in the care of these patients. The family and
> caregiver education may include preventing recurrent stroke; signs and
> symptoms of potential complications and psychological dysfunction;
> medication administration; assisted ADL tasks (e.g., transfers,
> bathing, positioning, dressing, feeding, toileting, and grooming);
> swallowing techniques; nutrition and hydration; care of an indwelling
> bladder catheter; skin care; contractures; use of a feeding tube; home
> exercises (range of motion); and sexual functioning. Families should
> receive counseling on the benefits of nursing home placement long-term
> care.

P.  **Post-Stroke Patient in Inpatient Rehabilitation**

> *Inpatient rehabilitation* is defined as rehabilitation performed
> during an inpatient stay in a freestanding 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.

Q.  **Determine Level of Care**

> *Objective*
>
> Provide the optimal environment for rehabilitation care.
>
> *Recommendations*

1.  Strongly recommend that rehabilitation services be provided in an
    environment with organized and coordinated post-acute stroke
    rehabilitation care. (*See Provision of Rehabilitation Care*)
    (***QE*: I; *Overall Quality*: Good; *R*: A**)

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R.  **Educate Patient/Family; Reach Shared Decision Regarding
    Rehabilitation Program; Determine Treatment Plan**

> *Objective*
>
> Assure the understanding of common goals among staff, patient, and
> family/caregivers in the stroke rehabilitation process, and therefore,
> optimize the patient´s functional recovery and community
> reintegration.
>
> *Recommendations*

1.  Recommend that the rehabilitation team and family/caregiver should
    reach a shared decision regarding the rehabilitation program.

    -   The rehabilitation team proposes the preferred environment for
        rehabilitation and treatments based on expectations for
        recovery.

    -   The rehabilitation team describes to the patient and
        family/caregiver the treatment options, including the
        rehabilitation and recovery process, prognosis, estimated length
        of stay, frequency of therapy, and discharge criteria.

    -   The patient, family/caregiver, and rehabilitation team should
        determine the optimal environment for rehabilitation and
        preferred treatment.

2.  The rehabilitation program should be guided by specific goals
    developed in consensus with the patient, family, and rehabilitation
    team. (Working Group Consensus) (***QE*: III; *Overall Quality*:
    Poor; *R*: I**)

3.  Recommend that the patient´s family/caregiver should participate in
    the rehabilitation sessions, and be trained to assist the patient
    with functional activities, when needed.

4.  Patient and family/caregiver education should be provided in an
    interactive and written format. Provide the patient and
    family/caregiver with an information packet that may include printed
    material on subjects such as the resumption of driving, patient
    rights/responsibilities, support group information, and audio/visual
    programs on stroke. (*See Provision of Rehabilitation Care*)
    (***QE*: I; *Overall Quality*: Fair; *R*: B**)

5.  Document the detailed treatment plan in the patient´s record to
    provide integrated rehabilitation care.

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S.  **Initiate Rehabilitation Programs and Interventions**

> *Objective*
>
> Provide the most appropriate interventions to optimize patient
> function and quality of life after an acute stroke.
>
> **S-1 Dysphagia Treatment**
>
> *Recommendations*

1.  Recommend considering enteral feeding for the stroke patient who is
    unable to orally maintain adequate nutrition or hydration.
    (Finestone et al., 2001) (***QE*: II-2; *Overall Quality*: Fair;
    *R*: B**)

2.  Consider the use of a feeding tube; however, there is no evidence to
    recommend the use of one feeding route over another.

3.  Recommend that the dysphagic stroke patient receive both direct
    swallowing treatment and management by the speech and language
    pathologist (SLP), when available, when a treatable disorder in
    swallow anatomy or physiology is identified. (Hinds & Wiles, 1998;
    Martin-Harris et al., 2000; Perry & McLaren, 2000) (***QE*: II-3;
    *Overall Quality*: Fair; *R*: B**)

> **S-2 Acute Communication Disorders**
>
> *Recommendations*

1.  Recommend that patients with communication disorders receive early
    treatment and monitoring of change in communication abilities in
    order to optimize recovery of communication skills, develop useful
    compensatory strategies, when needed, and facilitate improvements in
    functional communication. (American Speech-Language Hearing
    Association \[ASHA\], 2001, 2002; Robey, 1994; Robey, 1998) (***QE*:
    II-2; *Overall Quality*: Fair; *R*: B**)

2.  Recommend that the SLP educate the rehabilitation staff and
    family/caregivers in techniques to enhance communication with
    patients who have communication disorders. (ASHA, 2001; Working
    Group Consensus) (***QE*: III; *Overall Quality*: Poor; *R*: I**)

> **S-3 Long-Term Communication Difficulties**
>
> *Recommendations*

1.  Strongly recommend that all patients should be evaluated and treated
    by the SLP for residual communication difficulties (i.e., speaking,
    listening, reading, writing, and pragmatics). (Elman &
    Bernstein-Ellis, 1999; Katz & Wertz, 1997; Robey, 1994; Robey, 1998;
    Wertz et al., 1986; Whurr, Lorch, & Nye, 1997; Whurr, Lorch, &
    Nye, 1992) (***QE*: I; *Overall Quality*: Good; *R*: A**)

> **S-4 Motor Functioning - Strengthening**
>
> *Recommendations*

1.  Recommend that strengthening be included in the acute rehabilitation
    of patients with muscle weakness following stroke. (Working Group
    Consensus). (***QE*: III; *Overall Quality*: Poor; *R*: I**)

> **S-5 Partial Body Weight Support for Treadmill Training**
>
> *Recommendations*

1.  Recommend that treadmill training with partial body weight support
    be used as an adjunct to conventional therapy in patients with mild
    to moderate dysfunction resulting in impaired gait. (Kosak & Reding,
    2000; Teixeira et al., 2001; Visintin et al., 1998) (***QE*: I;
    *Overall Quality*: Fair; *R*: B**)

> **S-6 Constraint Induced (CI) Movement Therapy**
>
> *Recommendations*

1.  Consider the use of constraint induced (CI) therapy for a select
    group of patients (i.e., patients with 20 degrees of wrist extension
    and 10 degrees of finger extension, who have no sensory and
    cognitive deficits). To date the only demonstrated benefit occurs in
    individuals who received 6 to 8 hours of daily training for at least
    2 weeks. (Kunkel et al., 1999; van der Lee et al., 1999) (***QE*: I;
    *Overall Quality*: Poor; *R*: C**)

> **S-7 Functional Electrical Stimulation (FES)**
>
> *Recommendations*

1.  Recommend treatment with FES for patients who have demonstrated
    impaired muscle contraction, specifically with patients with
    ankle/knee/wrist motor impairment. (Glanz et al., 1996) (***QE*: I,
    *Overall Quality*: Fair; *R*: B**)

2.  Recommend FES for patients who have shoulder subluxation. (Price &
    Pandyan, 2001) (***QE*: I; *Overall Quality*: Fair; *R*: B**)

3.  There is insufficient evidence to recommend for or against using
    multi-channel FES for severe hemiplegic patients with gait
    impairment. (Bogataj et al., 1995) (***QE*: I; *Overall Quality*:
    Fair; *R*: B**)

4.  Recommend FES for gait training following stroke. (Daly et al.,
    1993; Daly & Ruff, 2000; Daly et al., 2000, 2001) (***QE*: II-2;
    *Overall Quality*: Fair; *R*: B**)

> **S-8 Neuro Developmental Training (NDT) for Motor Retraining**
>
> *Recommendations*

1.  There is insufficient evidence to recommend for or against using NDT
    in comparison to other treatment approaches for motor retraining
    following an acute stroke. (Bruhnam & Snow, 1992; Mulder, Hulstijn,
    & van der Meer, 1986; Wagenaar et al., 1990) (***QE*: I; *Overall
    Quality*: Fair: *R*: I**)

> **S-9 Spasticity**
>
> *Recommendations*

1.  Recommend that spasticity and contractures be treated with
    antispastic positioning, range of motion exercises, stretching,
    splinting, serial casting, or surgical correction. (AHCPR, 1995;
    RCP, 2000; Working Group Consensus) (***QE*: III; *Overall Quality*:
    Poor; *R*: C**)

2.  Consider use of tizanidine, dantrolene, and/or oral baclofen for
    spasticity resulting in pain, poor skin hygiene, or decreased
    function. Tizanidine should be used specifically for chronic stroke
    patients (refer to Annotation S-15). (Gelber et al., 2001; Ketel &
    Kolb, 1984; Milanov, 1992) (***QE*: II-1; *Overall Quality*: Fair;
    *R*: B**)

3.  Recommend *against* diazepam or other benzodiazepines during the
    stroke recovery period due to possible deleterious effects on
    recovery (refer to Annotation S-15), in addition to deleterious
    sedation side effects. (Goldstein, 1995, 1998; Graham et al., 1999;
    Troisi et al., 2002) (***QE*: II-2; *Overall Quality*: Fair; *R*:
    D**)

4.  Consider use of botulinum toxin or phenol/alcohol for selected
    patients with disabling or painful spasticity or spasticity
    resulting in poor skin hygiene or decreased function. (Bakheit et
    al., 2000; Kirazli et al., 1998; Kong & Chua, 1999; On et al., 1999;
    Richardson et al., 2000; Simpson et al., 1996) (***QE*: I; *Overall
    Quality*: Fair; *R*: B**)

5.  Consider intrathecal baclofen for chronic stroke patients for
    spasticity resulting in pain, poor skin hygiene, or decreased
    function. (Meythaler et al., 2001) (***QE*: ll-1; *Overall Quality*:
    Fair; *R*: C**)

6.  Consider neurosurgical procedures, such as selective dorsal
    rhizotomy or dorsal root entry zone lesion, for spasticity resulting
    in pain, poor skin hygiene, or decreased function. (Working Group
    Consensus) (***QE*: III; *Overall Quality*: Poor; *R*: I**)

> **S-10 Biofeedback**
>
> *Recommendations*

1.  The Working Group makes no recommendation for or against routine use
    of biofeedback for post-stroke patients. The use of biofeedback is
    left to the consideration of the individual provider. (Schleenbaker
    & Mainous, 1993; Glanz et al., 1995; Moreland et al., 1998) (***QE*:
    I; *Overall Quality*: Poor; *R*: C**)

> **S-11 Shoulder Pain**
>
> *Recommendations*

1.  Consider the following interventions to prevent shoulder pain in the
    involved upper extremity, following a stroke:

    -   Electrical stimulation to improve shoulder lateral
        rotation(Price & Pandyan, 2001 (***QE*: I; *Overall Quality*:
        Good; *R*: B**)

    -   Shoulder strapping (sling)

    -   Staff education to prevent trauma to the hemiplegic shoulder
        (Dean, Mackey, & Katrak, 2000) (***QE*: I; *Overall Quality*:
        Fair; *R*: B**)

2.  Recommend avoiding the use of overhead pulleys which encourage
    uncontrolled abduction. (Kumar et al., 1990)(***QE*: I; *Overall
    Quality*: Fair; *R*: D**)

3.  Consider the following interventions to treat shoulder pain:

    -   Intra-articular injections (Triamcinolone) (Dekker et al., 1997)
        (***QE*: I; *Overall Quality*: Poor; *R*: B**)

    -   Shoulder strapping (Ancilffe, 1992; Hanger et al., 2000)
        (***QE*: II-2; I; *Overall Quality*: Fair; *R*: C**)

    -   Improve range of motion (ROM) through stretching and
        mobilization techniques focusing especially on external rotation
        and abduction, as a means of preventing frozen shoulder and
        shoulder-hand-pain syndrome (Bohannon et al., 1986) (***QE*:
        II-2; *Overall Quality*: Fair; *R*: B**)

    -   Modalities: ice, heat, and soft tissue massage

    -   Functional electrical stimulation (FES)

    -   Strengthening

> **S-12 Cognitive Remediation**
>
> *Recommendations*

1.  Recommend that patients be assessed for cognitive deficits and be
    given cognitive retraining, if any of the following conditions are
    present:

    -   Attention deficits(Cicerone et al., 2000; Gray et al., 1992;
        Niemann, Ruff, & Baser, 1990; Sohlberg & Mateer, 1987;
        Strache, 1987) (***QE*: I, II; *Overall Quality*: Good; *R*:
        A**)

    -   Visual neglect (Cicerone et al., 2000) (***QE*: I; *Overall
        Quality*: Good; *R*: B**)

    -   Memory deficits

    -   Executive function and problem-solving difficulties (Cicerone et
        al., 2000) (***QE*: II; *Overall Quality*: Fair; *R*: C**)

2.  Patients with multiple areas of cognitive impairment may benefit
    from a variety of cognitive retraining approaches that may involve
    multiple disciplines. (Cicerone et al., 2000) (***QE*: III; *Overall
    Quality*: Fair; *R*: 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. (Cicerone et al., 2000; Ryan & Ruff, 1988) (***QE*:
    I; *Overall Quality*: Good; *R*: B**)

> **S-13 Mood Disturbance: Depression and Emotionalism**
>
> *Recommendations*
>
> Assessment

1.  The Working Group makes no recommendation for the use of one
    specific diagnostic tool over another.

2.  Recommend using a structured inventory to assess specific
    psychiatric symptoms and monitor symptom change over time.

3.  Recommend assessing post-stroke patients for other psychiatric
    illnesses, including anxiety, bipolar illness, and pathological
    affect.

> Treatment

4.  Strongly recommend that patients with a diagnosed depressive
    disorder be given a trial of antidepressant medication, if no
    contraindication exists. (Andersen, 1995; Cole et al., 2001; Gill &
    Hatcher, 2000; Kimura, Robinson, & Kosier, 2000; Miyai & Reeding,
    1998; RCP, 2000; Robinson et al., 2000; Wiart et al., 2000) (***QE*:
    I; *Overall Quality*: Good; *R*: A**)

5.  The Working Group makes no recommendation for the use of one class
    of antidepressants over another; however, side effect profiles
    suggest that selective serotonin reuptake inhibitors (SSRIs) may be
    favored in this patient population.

6.  Recommend that patients with severe, persistent or troublesome
    tearfulness be given a trial on antidepressant medications. (Brown,
    Sloan, & Pentland, 1998; Burns et al., 1999; Cole et al., 2001;
    Gordon, 1992; RCP, 2000; Robinson et al., 1993) (***QE*: I; *Overall
    Quality*: Good; *R*: A**)

7.  Strongly recommend SSRIs as the antidepressant of choice in patients
    with severe, persistent, or troublesome tearfulness.

8.  There is insufficient evidence to recommend for or against the use
    of individual psychotherapy alone in the treatment of post-stroke
    depression. (Grober et al., 1993; Lincoln et al., 1997) (***QE*: II;
    *Overall Quality*: Fair; *R*: C**)

9.  Recommend that patients be given information, advice, and the
    opportunity to talk about the impact of the illness upon their
    lives. (RCP, 2000) (***QE*: I; *Overall Quality*: Fair; *R*: B**)

10. Routine use of prophylactic antidepressants is not recommended in
    post-stroke patients. (Dam et al., 1996; Palomaki et al., 1999;
    Raffaele et al., 1996; Robinson et al., 2000) (***QE*: I; *Overall
    Quality*: Good; *R*: D**)

11. Recommend that mood disorders causing persistent distress or
    worsening disability be managed by or with the advice of an
    experienced clinical psychologist or psychiatrist.

> **S-14 Visual and Spatial Neglect**
>
> *Recommendations*

1.  Recommend that stroke patients be assessed for visual and spatial
    neglect, as indicated. (Agrell, Dehlin, & Dahlgren, 1997; Halligan,
    Marshall, & Wade, 1989; Jehkonen et al., 1998; Schubert & Spatt,
    2001; Stone et al., 1991; Wilson, Cockburn, & Halligan, 1987;
    Working Group Consensus) (***QE*: III; *Overall Quality*: Poor; *R*:
    C**)

2.  Recommend that treatment for stroke patients with visual/spatial
    neglect focuses on functional adaptation (e.g., visual scanning,
    environmental adaptation, environmental cues, and patient/family
    education). (Antonucci et al., 1995; Beis et al., 1999; Fanthome et
    al., 1995; Paolucci et al., 1996; Rossetti et al., 1998; Wiart et
    al., 1997) (***QE*: I; *Overall Quality*: Poor; *R*: B**)

> **S-15 Use of Pharmacologic Agents**
>
> *Recommendations*

1.  Recommend against the use of neuroleptics, benzodiazepines,
    phenobarbital, and phenytoin during the stroke recovery period.
    These pharmaceutical agents should be used cautiously in stroke
    patients, weighing the likely benefit of these drugs against the
    potential for adverse effects on patient outcome. (Goldstein, 1995
    & 1998) (***QE*: II-2; *Overall Quality*: Fair; *R*: D**)

2.  Recommend against centrally acting alpha~2~-adrenergic receptor
    agonists (such as clonidine and others) and alpha~1~-receptor
    antagonists (such as prazosin and others) as antihypertensive
    medications for stroke patients because of their potential to impair
    recovery (see Annotation D). (Goldstein, 1995, 1998; Graham et
    al., 1999) (***QE*: II-2; *Overall Quality*: Fair; *R*: D**)

3.  There is insufficient evidence regarding optimal dose and safety use
    of neurotransmitter-releasing agents and central nervous system
    stimulants. Consider stimulants/neurotransmitter-releasing agents in
    selected patients to improve participation in stroke rehabilitation
    or to enhance motor recovery. Dextroamphetamine has been the most
    tested stimulant at 10 mg per day, but insufficient evidence is
    available regarding optimal dosing and safety to support the routine
    use of central nervous system (CNS) stimulants during
    rehabilitation. Data remains sparse to consider routine use of
    neurotransmitter-releasing agents in stroke recovery. (Crisostomo et
    al., 1988; Dam et al., 1996; Grade et al., 1998; Nishino et al.,
    2001; Scheidtmann et al., 2001; Walker-Batson et al., 1995, 2001)
    (***QE*: I; *Overall Quality*: Fair; *R*: B**)

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T.  **Is Patient Ready For Community Living?**

> *Objective*
>
> Provide smooth transition back to community living following stroke.
>
> *Recommendations*

1.  Recommend that the patient and family/caregivers are fully informed
    about, prepared for, and involved in all aspects of healthcare and
    safety needs. (Working Group Consensus) (***QE*: III; *Overall
    Quality*: Poor; *R*: I**)

2.  Recommend that the family/caregivers receive all necessary equipment
    and training in moving and handling, in order to position and
    transfer the patient safely in the home environment. (Working Group
    Consensus) (***QE*: III; *Overall Quality*: Poor; *R*: I**)

3.  Recommend that the patient have appropriate vocational and income
    support opportunities. Stroke patients who worked prior to their
    strokes should be encouraged to be evaluated for the potential to
    return to work, if their condition permits. Vocational counseling
    should be offered when appropriate. (Working Group Consensus)
    (***QE*: III; *Overall Quality*: Poor; *R*: I**)

4.  Recommend that leisure activities should be identified and
    encouraged and the patient enabled to participate in these
    activities. (Working Group Consensus) (***QE*: III; *Overall
    Quality*: Poor; *R*: I**)

5.  Recommend that case management be put in place for complex patient
    and family situations. (Working Group Consensus) (***QE*: III;
    *Overall Quality*: Poor; *R*: I**)

6.  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. (Working Group Consensus)
    (***QE*: III; *Overall Quality*: Poor; *R*: I**)

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U.  **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**

V.  **Does Patient Need Community-Based Rehabilitation Services?**

> Nursing facility rehabilitation:\
> Rehabilitation performed during a stay in a nursing facility. Nursing
> facilities vary widely in their rehabilitation capabilities, ranging
> from maintenance care to comprehensive and intense rehabilitation
> programs.
>
> Outpatient rehabilitation:\
> Rehabilitation performed in an outpatient facility that is either
> freestanding or attached to an acute care or rehabilitation hospital.
> Day hospital care is a subset of outpatient rehabilitation in which
> the patient spends a major part of the day in an outpatient
> rehabilitation facility.
>
> Home-based rehabilitation:\
> A rehabilitation program provided in the patient´s place of residence
> (AHCPR, 1995).

W.  **Determine Optimal Environment for Community-Based Rehabilitation
    Services**

> *Objective*
>
> Determine if therapy following hospital discharge should be provided
> on an outpatient basis or in the home environment by home health
> services.
>
> *Recommendations*

1.  Strongly recommend continuing outpatient rehabilitation services in
    the setting where they can most appropriately and effectively be
    carried out. This is based on medical status, function, social
    support, and access to care. (Weir, 1999) (***QE*: I; *Overall
    Quality*: Good; *R*: A**)

**Definitions**:

**Quality of Evidence (QE)**

**I**: Evidence obtained from at least one properly randomized
controlled trial\
**II-1**: Evidence obtained from well-designed controlled trails without
randomization\
**II-2**: Evidence obtained from well-designed cohort or case-control
analytic studies, preferably from more than one center or research
group\
**II-3**: Evidence obtained from multiple time series studies with or
without the intervention. Dramatic results in uncontrolled experiments
(such as the results of the introduction of penicillin treatment in the
1940s) could also be regarded as this type of evidence.\
**III**: Opinions of respected authorities, based on clinical
experience; descriptive studies and case reports; or reports of expert
committees

**Overall Quality**

**Good**: High grade evidence (I or II-1) directly linked to health
outcome\
**Fair**: High grade evidence (I or II-1 linked to intermediate outcome
or Moderate grade evidence (II-2 or II-3) directly linked to health
outcome\
**Poor**: Level III evidence or no linkage of evidence to health outcome

**Net Effect of Intervention**

**Substantial**:

-   More than a small relative impact on a frequent condition with a
    substantial burden of suffering, or

-   A large impact on an infrequent condition with a significant impact
    on the individual patient level

**Moderate**:

-   A small relative impact on a frequent condition with a substantial
    burden of suffering, or

-   A moderate impact on an infrequent condition with a significant
    impact on the individual patient level

**Small**:

-   A negligible relative impact on a frequent condition with a
    substantial burden of suffering, or

-   A small impact on an infrequent condition with a significant impact
    on the individual patient level

**Zero or Negative**:

-   Negative impact on patients, or

-   No relative impact on either a frequent condition with a substantial
    burden of suffering, or

-   An infrequent condition with a significant impact on the individual
    patient level

**Grade of Recommendation (R)**

**A**: A strong recommendation that the intervention is always indicated
and acceptable\
**B**: A recommendation that the intervention may be useful/effective\
**C**: A recommendation that the intervention be considered\
**D**: A recommendation that a procedure may be considered not
useful/effective, or may be harmful\
**I**: Insufficient evidence to recommend for or against; clinical
judgment should be used

**Abbreviations**

ACE -- Angiotensin-Converting-Enzyme\
ADL - Activities of Daily Living\
AFO - Ankle-Foot-Orthoses\
AHCPR - Agency for Healthcare Policy and Research\
ASHA - American Speech and Hearing Association\
BI -- Barthel Index\
CAD - Coronary Artery Disease\
CCC -- SLP Certificate of Clinical Competence-Speech and Language
Pathology\
CEA - Carotid Endarterectomy\
CI - Constraint Induced\
CNS - Central Nervous System\
CVA - Cerebrovascular Accident\
DME - Durable Medical Devices\
DoD - Department of Defense\
DVT - Deep Vein Thrombosis\
EMG -- Electromyographic\
FAI - Frenchay Activities Index\
FDA - Federal Drug Administration\
FEES - Fiber optic Endoscopic Examination of Swallowing\
FEESST - Fiber optic Endoscopic Examination of Swallowing with Sensory
Testing\
FES - Functional Electrical Stimulation\
FIM ™ - Functional Independence Measure\
GAD - Generalized Anxiety Disorder\
HDL - High-Density Lipoproteins\
IADL - Instrumental Activities of Daily Living\
KAFO - Knee-Ankle Foot-Orthoses\
LDL - Low-Density-Lipoproteins\
LDUH - Low-Dose Unfractionated Heparin\
LMWH - Low Molecular Weight Heparin\
MCA - Middle-Cerebral-Artery\
NDT - Neuro Developmental Training\
NHP -Nottingham Health Profile\
NHSTA - National Highway Safety and Traffic Administration\
NIH - National Institutes of Health\
NIHSS - National Institutes of Health Stroke Scale\
NOMS - National Outcomes Measurement System\
PE - Pulmonary Embolism\
PSD - Post-Stroke Depression\
RBU - Rehabilitation Bed Units\
RCP - Royal College of Physicians\
RCT - Randomized Controlled Trial\
ROM - Range of Motion\
SIGN - Scottish Intercollegiate Guidelines Network\
SLP - Speech and Language Pathologist\
SSRI - Selective Serotonin Reuptake Inhibitor\
TBI - Traumatic Brain Injury\
USPTSF - U.S. Preventive Services Task Force\
VA - Veterans Affairs\
VAMC - Veterans Affairs Medical Center\
VFSS -Videofluoroscopy Swallowing Study\
VHA -- Veterans Health Administration

#### CLINICAL ALGORITHM(S)

Algorithms are provided in the original guideline document for the
management of stroke rehabilitation:

-   [Algorithm A:
    Assessment](http://www.oqp.med.va.gov/cpg/STR/str_cpg/algoAframeset.htm)

-   [Algorithm B: Inpatient
    Rehabilitation](http://www.oqp.med.va.gov/cpg/STR/str_cpg/algoBframeset.htm)

-   [Algorithm C: Community Based
    Rehabilitation](http://www.oqp.med.va.gov/cpg/STR/str_cpg/algoCframeset.htm)

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=3846)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

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

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

**Overall Benefits**

-   Guideline implementation is intended to help clinicians determine
    best intervention and timing of care for their patients, better
    stratify stroke patients, reduce readmission, and optimize
    healthcare utilization.

-   Goals of rehabilitation are to prevent complications, minimize
    impairments, maximize function, and improve patient/family quality
    of life.

-   Secondary prevention is fundamental to preventing stroke recurrence.

-   Standardized evaluations and valid assessment tools are essential to
    the development of a comprehensive treatment plan.

-   Patient and family education improves informed decision-making,
    social adjustment, and maintenance of rehabilitation gains.

-   Ongoing medical management of risk factors and comorbidities is
    essential to ensure survival.

**Specific Benefits**

-   A considerable body of evidence indicates that better clinical
    outcomes are achieved when patients with acute stroke are treated in
    a setting that provides coordinated, multidisciplinary
    stroke-related evaluation and services.

-   The National Institute of Health Stroke Scale (NIHSS) score strongly
    predicts the likelihood of a patient´s recovery after stroke.

#### POTENTIAL HARMS

-   *Side effects and adverse effects of medication*. For example,
    anticoagulants used to prevent deep vein thrombosis (DVT) can cause
    hemorrhagic complications.

    -   The development of thrombocytopenic purpura with clopidogrel
        therapy has been reported. The background rate is thought to be
        about four cases per million person-years.

    -   If a patient is to undergo elective surgery and an antiplatelet
        effect is not desired, therapy with irreversible antiplatelet
        agents (aspirin and clopidogrel) should be discontinued 7 days
        prior to surgery. Since dipyridamole is a reversible
        antiplatelet agent, the immediate release product could be given
        until 24 hours prior to surgery.

    -   In CAPRIE (1996), clopidogrel was associated with a rate of
        gastrointestinal bleeding of 2.0 percent, versus 2.7 percent on
        aspirin.

    -   In a 1996 study, aspirin-extended release dipyridamole was
        associated with a rate of bleeding at any site of 8.7 percent,
        placebo 4.5 percent, aspirin alone 8.2 percent and extended
        release dipyridamole alone 4.7 percent.

-   *False positive or false negative results of some standard
    instruments for post-stroke assessment*. For example, The Beck
    Depression Inventory (BDI) has a high rate of false positives, while
    the Geriatric Depression Scale (GDS0 has a high rate of false
    negative in minor depression (*see Appendix B titled \"Standard
    Instruments for Post-Stroke Assessment\" in the original guideline
    document for a list of weaknesses related to each test*)

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

There are contraindications to specific medications used to prevent
complications of stroke or recurrence of stroke. For example,
antiplatelet pharmacotherapy is contraindicated in active pathological
bleeding or most intracranial hemorrhage. Diazepam is relatively
contraindicated in stroke patients, at least in the stroke recovery
period, as reviewed in Annotation S15 of the guideline.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   *Antiplatelet pharmacotherapy*: Recommendations for antiplatelet
    pharmacotherapy are dynamic and will be revised as new clinical data
    become available.

-   These guidelines are not intended to interfere with clinical
    judgment. Rather, they are intended to assist practitioners in
    providing cost effective, consistent, high quality care.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

**Outcome Measures**

Effective rehabilitation improves functional outcome. An indicator for
improvement is the positive change in the Functional Independence
Measures (FIM™) score over a period of time in the post-acute care
period. Within the Veterans Health Administration (VHA) this measure is
captured in the Functional Status and Outcomes Database for
rehabilitation. All stroke patients should be entered into the database,
as directed by VHA Directive 2000-016 (dated June 5, 2000; Medical
Rehabilitation Outcomes for Stroke, Traumatic Brain, and Lower Extremity
Amputee Patients).

Additional indicators that should be measured at three months following
the acute stroke episode may include the following:

-   Functional status (including activities of daily living \[ADL\] and
    instrumental activities of daily living \[IADL\])

-   Rehospitalizations

-   Community dwelling status

-   Mortality

The primary outcome measure for assessment of functional status is the
FIM™ (see Appendix D in the original guideline document). The FIM™ has
been tested extensively in rehabilitation for reliability, validity, and
sensitivity, and is by far the most commonly used outcome measure. A
return to independent living requires not only the ability to perform
basic ADL, but also the ability to carry out more complex activities
(i.e., IADL), such as shopping, meal preparation, use of the phone,
driving a car, and money management. These functions should be evaluated
as the patient returns to the community. New stroke-specific outcome
measures, such as the Stroke Impact Scale, may be considered for a more
comprehensive assessment of functional status and quality of life.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Pocket Guide/Reference Cards\
Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

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. \[331 references\]

#### ADAPTATION

The development process of the guideline incorporated information from
several sources into a format intended to maximally facilitate clinical
decision-making. The effort drew heavily from the following sources:
1996 Veterans Affairs Stroke/Lower Extremity Amputee Algorithms Guide,
Agency for Health Care Policy and Research (AHCPR) Post --Stroke
Rehabilitation (1995), Royal College of Physicians (RCP) National
Clinical Guidelines for Stroke (2000), and Scottish Intercollegiate
Guidelines Network (SIGN) Management of Patients with Stroke, 20 (1997).

#### DATE RELEASED

2003 Feb

#### GUIDELINE DEVELOPER(S)

Department of Defense - Federal Government Agency \[U.S.\]\
Department of Veterans Affairs - Federal Government Agency \[U.S.\]\
Veterans Health Administration - Federal Government Agency \[U.S.\]

#### SOURCE(S) OF FUNDING

United States Government

#### GUIDELINE COMMITTEE

Stroke Rehabilitation Working Group

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Editorial Panel of the Working Group*: Barbara Bates, MD, Acting
Director, PM&RS, Albany VAMC, Crystal Barker, MS, RN, BC, PHN, CRRN,
Rehabilitation Case Manager, Greater Los Angeles Health Care System; MAJ
John Choi, MD, Neurologist, Walter Reed Army Medical Center, Pamela W.
Duncan, PhD, PT, FAPTA, Director of VA Rehabilitation Outcomes Research
Center for Excellence, Professor, Department of Health Services
Administration, College of Health Professions, Director of Brooks Center
for Rehabilitation Studies, University of Florida; LTC Jane Freund, MS,
PT, NCS, Physical Therapist, Walter Reed Army Medical Center; Glenn
Graham, MD, PhD, Director Stroke Program, Staff Neurologist, New Mexico
VA Healthcare System; Richard Katz, PhD, Chair, Audiology and Speech
Pathology, Carl T. Hayden VA Medical Center; Kerri Lamberty, PhD, Staff
Psychologist, Minneapolis VAMC; Clifford Marshall, MS, Rehabilitation
Planning Specialist, Memphis VAMC; MAJ Charles Walters, MEd, OTR/L,
Occupational Therapy, Evans Army Community Hospital; Oded Susskind, MPH,
(Facilitator), Medical Education Consultant; Joanne Marko, MS, CCC-SLP
(Coordinator), Senior Consultant, ACS Federal Healthcare, Inc.

*Members of the Working Group*: Laura Barrett, MEd, CTRS, Recreational
Therapist, Minneapolis VAMC; Sandra Brake MSW, Social Work Program
Manager, VHA Headquarters, John Brehm, MD, Internal Medicine, West
Virginia Medical Institute; LTC Carla Cassidy, MSN, ANP, Clinical
Coordinator Outcomes Management, Walter Reed Army Medical Center; Cathy
Cruise, MD, Physiatrist, VA New York Harbor Healthcare System; Katherine
Dolter, RN, PhD, LTC, USA, Chief, Outcome Management, Medical Command,
US Army; Michell Cramer, RKT, BA, Rehabilitation Coordinator, Northern
Arizona VA Healthcare System; Lori Danzl, BS, PT, GCS, Physical
Therapist, Minneapolis VAMC; LTC Jeffrey Gambel, MD, MSW, MPH, Staff
Physiatrist, Walter Reed Army Medical Center; Jonathan Glasberg, MA, PT,
VISN 3 FSOD Coordinator, PM&R Assistant Clinical Coordinator, VA New
York Harbor Healthcare System; Glenn Graham, MD, PhD, Director Stroke
Program, Staff Neurologist, New Mexico VA Healthcare System; Helen
Hoenig, MD, Associate Professor of Medicine/Geriatrics,Duke University
Medical School, Chief of Physical Medicine and Rehabilitation, Durham
VAMC; Susan Holme, MS, OTR/L, Business Manager, Rehabilitation Care
Service, VA Puget Sound Health Care System; Ashish Jha, MD,
Undersecretary´s Fellow for Quality, San Francisco VAMC; Jeri Logemann,
PhD, Professor, Communication Sciences and Disorders, Northwestern
University; Susan Parker, MS, OTR, Supervisor, Occupational Therapy,
Hunter Holmes McGuire VAMC; Traci Piero, MSN, NP-C, Nurse Practitioner,
Cleveland Louis Stokes VAMC; Dean Reker, PhD, RN, Research Scientist,
Kansas City VAMC, Assistant Professor, Health Policy and Management,
University of Kansas Medical Center; Donna Schoonover, RN, EdD, Project
Manager, Employee Education System; James Schumacher, MS, CCC-SLP,
Speech and Language Pathologist, Minneapolis VAMC; Dale Strasser, MD,
Atlanta Site Director, Atlanta VAMC; Kathryn Tortorice, PharmD, BCPS,
Clinical Specialist, Pharmacy Benefits Management, Strategic Healthcare
Group; Debby Walder, RN, MSN, Director of Quality and Performance,
Department of Veterans Affairs; Marilyn Weber, MD, Associate Professor
of Physical Medicine & Rehabilitation, University of Minneapolis,
Director of Stroke Rehabilitation, Minneapolis VAMC; Carolee Winstein,
PhD, Associate Professor Biokinesiology & PT, University of Southern CA;
Steven Wolf, PhD, Professor of Rehabilitation Medicine, Emory University
School of Medicine; Richard Zorowitz, MD, Associate Professor of
Rehabilitation Medicine, University of Pennsylvania Health System

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Department of Veterans Affairs
Web site](http://www.oqp.med.va.gov/cpg/STR/STR_base.htm).

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

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Management of stroke rehabilitation care. Washington (DC): National
    CPG Council; 2003. Various p.

-   VHA/DoD clinical practice guideline for the management of stroke
    rehabilitation. Guideline summary. Washington (DC): Department of
    Veterans Affairs (U.S.); 2002 Oct. 27 p. See the related QualityTool
    summary on the [Health Care Innovations Exchange Web
    site](http://innovations.ahrq.gov/content.aspx?id=1129).

-   VHA/DoD clinical practice guideline for the management of stroke
    rehabilitation. Pocket guide. Washington (DC): National CPG Council;
    2002 Oct. 2 p. See the related QualityTool summary on the [Health
    Care Innovations Exchange Web
    site](http://innovations.ahrq.gov/content.aspx?id=1121).

-   VHA/DoD clinical practice guideline for the management of stroke
    rehabilitation. Key points. Washington (DC): National CPG Council;
    2002 Oct. 2 p. See the related QualityTool summary on the [Health
    Care Innovations Exchange Web
    site](http://innovations.ahrq.gov/content.aspx?id=766).

-   Management of stroke rehabilitation care algorithm: module A:
    initial assessment. Washington (DC): National CPG Council; 2002 Oct.
    See the related QualityTool summary on the [Health Care Innovations
    Exchange Web
    site](http://innovations.ahrq.gov/content.aspx?id=1116).

-   Management of stroke rehabilitation care algorithm: module B:
    inpatient rehabilitation. Washington (DC): National CPG Council;
    2002 Oct. See the related QualityTool summary on the [Health Care
    Innovations Exchange Web
    site](http://innovations.ahrq.gov/content.aspx?id=1117).

-   Management of stroke rehabilitation care algorithm: module C:
    community based rehabilitation. Washington (DC): National CPG
    Council; 2002 Oct. See the related QualityTool summary on the
    [Health Care Innovations Exchange Web
    site](http://innovations.ahrq.gov/content.aspx?id=1137).

Electronic copies available from the [Department of Veterans Affairs
(VA) Web site](http://www.oqp.med.va.gov/cpg/STR/STR_base.htm).

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

The following is also available:

-   Putting clinical practice guidelines to work \[online tutorial\].
    Available from the [Department of Veterans Affairs Web
    site](http://www.oqp.med.va.gov/Training/WWW/010000000010.html).

#### PATIENT RESOURCES

None available

#### NGC STATUS

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.

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

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