Chinese Stroke Association guidelines for clinical management of cerebrovascular disorders: executive summary and 2019 update of clinical management of stroke rehabilitation

Stroke is the third leading cause of long-term disability. Effective stroke rehabilitation should be provided to patients with a moderate or severe stroke so as to achieve functional recovery. Also, stroke rehabilitation is moving towards more intense therapy models that incorporate technologies such as robotics and computer games. Evidence-based guidelines are useful for promoting the best possible clinical practices. This guideline summarises the modes of stroke rehabilitation in China-three-stage rehabilitation network, rehabilitation of stroke dysfunction, training for activities of daily living, stroke complications and rehabilitation care. The aim of this guideline was to provide a synopsis of best clinical practices in the stroke rehabilitation of adult patients in China.
There are about 2 million new stroke cases in China each year, and 70% to 80% of patients who had a stroke cannot live independently due to disability. Despite advances in modern medicine, medications and medical technology, stroke diseases impose a substantial mortality and morbidity risk to the individual with increased economic burden to the society. As such, there is an urgent need to develop an optimal stroke disease management plan, incorporating a comprehensive stroke rehabilitation programme. What is more, stroke rehabilitation is moving towards more intense therapy models that incorporate technologies such as robotics and computer games.
The purpose of the Stroke Rehabilitation Guideline is to provide scientific evidence and basis for the implementation and evaluation of rehabilitation therapy, standardise the rehabilitation treatment post-stroke, help the medical institutions follow the evidence-based rehabilitation methodology and improve the rehabilitation results.
Mode of sTroke rehAbiliTATion-Three-sTAge rehAbiliTATion neTwork A large number of studies have shown that three-stage rehabilitation after stroke (figure 1) can improve motor function and reduce complications. This implies early rehabilitation in stroke units and neurological wards, subacute rehabilitation in medical wards or rehabilitation hospital followed by long-term rehabilitation at a rehabilitation centre or the community or at home. recommendations 1. Three-stage rehabilitation network should be promoted, so that patients can continue lifelong rehabilitation (Grade I recommendation, Level A evidence). 2. Stroke rehabilitation units should be established in general hospitals and rehabilitation centres (Grade I recommendation, Level A evidence). [bib_ref] guidelines for the early management of patients with acute ischemic stroke: a..., Powers [/bib_ref]. Patients with chronic stroke should be recommended to transfer to the tertiary rehabilitation institution for subsequent rehabilitation with unified rehabilitation programme (Grade I recommendation, Level B evidence).

## Early rehabilitation early rehabilitation and rehabilitation teams
Early rehabilitation is generally performed within 1 month after stroke onset. The Stroke Unit should provide rehabilitation, which includes training for improvement of extremity dysfunction, language use, cognition and so on.

## Early rehabilitation intervention time and rehabilitation intensity
In 2011, the Chinese stroke rehabilitation guidelines recommended that patients who had a stroke should be rehabilitated as soon as stable (stable vital signs, no signs of progression). [bib_ref] Guidelines for stroke rehabilitation in China, Zhang [/bib_ref] Rehabilitation that starts within 2 weeks following stroke can achieve better outcome.A Very Early Rehabilitation Trial (AVERT) explored the effectiveness and safety of superearly activities within 24 hours after stroke onset. The results showed that the super-early activity programme could reduce the benefit at 3 months. [bib_ref] guidelines for the early management of patients with acute ischemic stroke: a..., Powers [/bib_ref] rehAbiliTATion of sTroke dysfunCTion rehabilitation of dyskinesia Recommendations 1. A patient who had a stroke should be kept on the bed in a normal limb position. Lateral position on the affected side is recommended (Grade I recommendation, Level C evidence). 2. It is reasonable that normal limb position can effectively reduce limb spasticity and improve the rehabilitation outcomes (Grade IIa recommendation, Level B evidence). 3. Transfer training should be performed with patients who had a stroke on-bed with the help of attendant or rehabilitation therapist as soon as possible (Grade I recommendation, Level B evidence). 4. Range of motion training is recommended for patients who had a stroke on-bed, and mechanical injury of the affected limbs should be avoided (Grade I recommendation, Level B evidence). 5. Transferring and range of motion training is reasonable to implement as early as possible and could prevent complications, such as hypostatic pneumonia, deep venous thrombosis (DVT) and bedsores (Grade IIa recommendation, Level B evidence). 6. When clinically stable, patients with acute stroke with paralysis should get out of the bed as soon as possible, and start training standing and walking (Grade I recommendation, Level B evidence). 7. In the acute stroke phase, the muscle strength training for the paralysed limbs should be emphasised (Grade I recommendation, Level B evidence). 8. Functional electrical stimulation and electromyography biofeedback for the corresponding muscles, combined with conventional rehabilitation, can improve the muscle strength and the function of paralysed limbs (Grade I recommendation, Level B evidence). 9. It is reasonable for patients who had a stroke with hemiplegia to train standing and walking actively to regain basic walking ability as soon as possible (Grade IIa recommendation, Level B evidence). 10. Analysis of the hemiplegic gait with an integrative gait analysis system is an effective way to make an elaborate walking programme and improve the quality of walking (Grade I recommendation, Level B evidence). 11. Lower-limb robots, weight-supporting devices and orthoses is reasonable to assist with walking recovery (Grade IIa recommendation, Level B evidence).

## Recommendations

## The modified ashworth scale and modified tardieu
Scale are recommended for the evaluation of spasticity (Grade I recommendation, Level B evidence). 13. Although the electromyography operation is time consuming and complicated, it may lead to some advantages (Grade IIb recommendation, Level B evidence). 14. The principle of post-stroke spasticity treatment is to improve functional ability (Grade I recommendation, Level C evidence Open access Flowchart of rehabilitation of swallowing dysfunction after stroke.
3. It is reasonable to use TENS in patients with sensory impairment after stroke (Grade IIa recommendation, Level B evidence). 4. Virtual reality may be considered to improve sensory perception function (Grade IIb recommendation, Level C evidence). 5. Compensatory saccade training is reasonable to improve functional deficits after visual field loss and improve functional ADL. However, this approach cannot reduce visual impairment effectively (Grade IIa recommendation, Level B evidence). 6. Prisms is reasonable to be used as a complementary therapy to help patients compensate for visual field defects (Grade IIa recommendation, Level B evidence). 7. Virtual reality is reasonable to be considered to improve the visual-spatial function (Grade IIa recommendation, Level B evidence).
rehabilitation of swallowing dysfunction Overview Dysphagia after stroke affects 42% to 67% of patients within 3 days after the onset of stroke, where 50% tend to have aspiration (including occult aspiration) and 1/3 pneumonia. [bib_ref] Influence of dysphagia on short-term outcome in patients with acute stroke, Maeshima [/bib_ref] shows the assessment and rehabilitation flowchart of the swallowing function in patients who had a stroke. Early screening for swallowing function after stroke is recommended; however, currently, there are no randomised controlled studies on the optimal timing of screening for swallowing function. [bib_ref] Functional outcomes of standard dysphagia treatment in first time documented stroke patients, Mcmicken [/bib_ref] Screening for dysphagia Commonly used assessments include the Eating Assessment Tool-10 (EAT-10), the Clinical Swallowing Function Assessment Form, the Standardised Swallowing Assessment (SSA) and so on. The inspection methods include repeated saliva swallowing test, Watian drinking water test, dye test and so on. [bib_ref] Objective measures of swallowing function applied to the dysphagia population: a one..., Kendall [/bib_ref] [bib_ref] Bedside screening to detect oropharyngeal dysphagia in patients with neurological disorders: an..., Kertscher [/bib_ref] [bib_ref] Cough reflex testing in dysphagia following stroke: a randomized controlled trial, Miles [/bib_ref] [bib_ref] Factors predicting recovery of oral intake in stroke survivors with dysphagia in..., Ikenaga [/bib_ref] [bib_ref] Usefulness of the volume-viscosity swallow test for screening dysphagia in subacute stroke..., Guillen-Sola [/bib_ref] [bib_ref] Oropharyngeal dysphagia after stroke: incidence, diagnosis, and clinical predictors in patients admitted..., Falsetti [/bib_ref] Recommendations 1. All patients with acute stroke are recommended to undergo screening for the swallowing function before oral feeding and drinking water by a speech therapist or other trained healthcare people (Grade I recommendation, Level A evidence). 2. It is reasonable for patients with suspected aspiration to be further examined with flexible endoscopic examination of swallowing (FEES) or/and videofluoroscopic swallowing study (VFSS) (Grade IIa recommendation, Level B evidence). 3. FEES or/and VFSS, which are supplementary to each other, is reasonable to be used for instrumental examination of dysphagia (Grade IIa recommendation, Level B evidence). 4. All patients with dysphagia is reasonable to be evaluated for nutrition and water supply within 48 hours (Grade IIa recommendation, Level B evidence). 5. Behavioural intervention is considered a part of swallowing treatment; oral hygiene management can reduce the risk of post-stroke aspiration pneumonia (Grade I recommendation, Level B evidence). 6. Acupuncture treatment is reasonable to be considered as a potentially adjuvant treatment for dysphagia (Grade IIa recommendation, Level B evidence). 7. Currently, there is no sufficient evidence on beneficial effects of medication, NMES, pharyngeal electrical stimulation, physical stimulation, transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (Grade IIb recommendation, Level B evidence). 8. Patients who had a stroke who could not eat safely and effectively should start enteral nutrition (tube feeding) within 7 days after stroke (Grade I recommendation, Level A evidence). 9. Patients who had a stroke who could not eat safely and effectively for more than 4 weeks were suggested percutaneous gastrostomy tube insertions (Grade IIa recommendation, Level B evidence). dysarthria Overview Dysarthria can individually or simultaneously affect any speech production subsystem, including the respiratory, larynx, pharynx and oral pronunciation subsystems. Open access 6. Computer therapy is reasonable to be used as an addition to speech and language therapy (SLT) (Class IIa recommendation, Level B evidence). 7. Group therapy for aphasia is reasonable at each stage of treatment, including the application of community aphasia groups (Class IIa recommendation, Level B evidence). 8. Brain stimulation may be considered as an adjunct experimental therapy to behavioural SLT, thus regular use is not recommended (Class IIb recommendation, Level B evidence). 9. Acupuncture is reasonable for aphasia treatment (Class IIa recommendation, Level B evidence). 10. Use of music is reasonable for aphasia rehabilitation (Class IIa recommendation, Level B evidence).

## Rehabilitation of cognitive impairment introduction
Existing studies have shown that post-stroke cognitive impairment after stroke within 3 months ranges from 6% to 27%. Assessment of cognitive impairment Minimum Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) could be used to screen post-stroke cognitive impairment. Previous studies have found that MMSE has a ceiling effect and low sensitivity, while MoCA is more sensitive with lower specificity. [bib_ref] Comparison of the mini-mental state examination and Montreal cognitive assessment executive subtests..., Fu [/bib_ref] It is recommended to be assessed once a week (Class IIa recommendation, Level C evidence). 4. Serotonin reuptake inhibitors can be used to treat PSD (Class I recommendation, Level A evidence). 5. For patients with emotional distress or pseudobulbar affect, selective serotonin reuptake inhibitor or dextromethorphan/quinidine should be considered (Class IIa recommendation, Level A evidence). 6. It is reasonable to provide a professional mental or psychiatrist consultation for stroke survivors with a persistent affective disorder or disability deterioration (Class IIa recommendation, Level C evidence). 7. Patient education, counselling services and social support may be considered as part of PSD treatment (Class IIb recommendation, Level B evidence). 8. It is recommended to use mindfulness decompression and mindfulness cognitive therapy for PSD (Class I recommendation, Level A evidence).
Open access 9. Combined drugs and transcranial electromagnetic stimulation, hyperbaric oxygen therapy, exercise therapy and music therapy should be considered for the treatment of PSD (Class IIa recommendation, Level B evidence). 10. It is reasonable to use the Baker Anxiety Scale to assess post-stroke anxiety (Class IIa recommendation, Level C evidence). 11. It is recommended to use serotonin reuptake inhibitors to treat post-stroke anxiety (Class I recommendation, Level A evidence). 12. It is recommended to use mindfulness decompression and mindfulness cognitive therapy for PSD (Class I recommendation, Level A evidence).
Adl, soCiAl pArTiCipATion bArriers And voCATionAl TrAining Adl and social engagement disorder Recommendations 1. It is recommended to use Barthel Index and Modified Barthel Index to assess ADL in patients with stroke (Class I recommendation, Level B evidence). 2. Because of high reliability and sensitivity, functional independence measure is recommended (Class I recommendation, Level A evidence). 3. Early rehabilitation, occupational therapy, constraintinduced movement therapy, virtual reality rehabilitation training, functional electrical stimulation, repetitive transcranial magnetic stimulation and other methods are recommended for improvement of ADL (Class I recommendation, Level A evidence).

## Vocational training and guidance
In a study with 8 years of follow-up, the risk of unemployment in young patients who had a stroke increased two to three times. 31

## Recommendations
Semi-structured interviews should be used to understand influencing factors and needs of patients to return to work; assessment and training in the workplace can increase the probability of returning to work (Class I recommendation, Level B evidence).
CoMpliCATions skin damage Recommendations 1. In patients who had a stroke, maintaining sufficient nutrient intake, water supply and dynamic position management can effectively reduce the risk of skin damage (Class I recommendation, Level A evidence). 2. Special air bed is recommended to use to avoid skin friction (Class I recommendation, Level B evidence).

## Contracture
A prospective cohort study found that the probability of multiple joint contractures has been estimated to be 12% to 28%. [bib_ref] Half of the adults who present to hospital with stroke develop at..., Kwah [/bib_ref] In a broad retrospective analysis of 328 stroke survivors, the health score of the patients with spasm were significantly lower than those in non-spasm patients (p<0.05 intestinal and bladder incontinence Age, aphasia, impaired urinary awareness and dyskinesia are the leading causes of urinary incontinence. [bib_ref] Management of faecal incontinence and constipation in adults with central neurological diseases, Coggrave [/bib_ref] Pizzi et al, who monitored the urodynamic pattern in 84 patients with post-stroke urinary incontinence, suggested that post-stroke urinary incontinence was associated with different changes in urodynamic patterns, and each urodynamic model may require different treatment strategies. [bib_ref] Urinary incontinence after ischemic stroke: clinical and urodynamic studies, Pizzi [/bib_ref] which leads to secondary hyperthyroidism.

## Recommendations
It is reasonable to develop individualised aerobic exercise and strength training for patients who had a stroke, which can reduce the risk of osteoporosis and fracture after stroke (Class IIa recommendation, Level B evidence).
rehAbiliTATion CAre Early implementation of acute stroke rehabilitation care can reduce or prevent further complications.
recommendations It is recommended to implement comprehensive rehabilitation care interventions during rehabilitation to meet the specific needs of patients with stroke (Class I recommendation, Level B evidence).
health education and psychological care Recommendations 1. It is recommended to provide health education for patients with mild stroke to improve their awareness of changes in their health status, initiative and confidence in the rehabilitation, and improve the overall rehabilitation quality (Class I recommendation, Level C evidence). 2. It is reasonable to conduct inspiring interviews and personalised education for patients so as to define individual risk factors, which may be beneficial for the long-term control of stroke risk factors (Class IIa recommendation, Level B evidence).

## Respiratory management recommendations
In patients who had a stroke with declined respiratory function and intrapulmonary infection, the bedside respiratory management and pulmonary function rehabilitation should be strengthened (Class IIa recommendation, Level B evidence).

## Fall prevention
Studies have shown that about 40% of patients who had a stroke have experienced a fall within 6 months after stroke. [bib_ref] Falls after stroke: results from the Auckland Regional Community Stroke (ARCOS) Study, Kerse [/bib_ref] The fall prevention programme should be implemented in the early intervention of stroke, and it is important to timely identify the high-risk patients. It is necessary to carry out proper inpatient facility environmental transformation and safety education. Disposal and prevention of falls should be addressed by the multidisciplinary team.
Open access Recommendations 1. During the hospitalisation period, each patient with a stroke should be assessed for fall risks and provided with an individualised fall prevention programme. Patients who are in the community are recommended to participate in balance training, such as Tai Chi, to prevent falls (Class I recommendation, Level B evidence). 2. Patients with poor balance, low self-confidence, fear of falling or risks of falling should receive balance function training (Class IIa recommendation, Level C evidence). 3. An annual assessment of the risk of falls should be conducted to improve the life and home environment in patients who had a stroke, and to reduce the accident (Class IIa recommendation, Level B evidence).
position management and oropharyngeal care Recommendations 1. It is recommended to perform oropharyngeal care and health assessment in patients who had a stroke, as well as a routine assessment of swallowing ability before oral intake (Class I recommendation, Level B evidence). 2. It is reasonable to raise the head of the bed by 2045 to reduce reflux aspiration caused by improper position (Class IIa recommendation, Level C evidence).
[fig] Figure 1: Flowchart of three-stage rehabilitation after stroke. ADL, activities of daily living. [/fig]