New Guidelines for Adult Stroke Rehabilitation and Recovery

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New Guidelines for Adult Stroke Rehabilitation and Recovery
New Guidelines for Adult Stroke Rehabilitation and Recovery

The American Heart Association/American Stroke Association (AHA/ASA) released guidelines on adult stroke rehabilitation and recovery. A panel formed from both organizations reviewed relevant literature on adults with stroke through 2014 and published their findings on best clinical practices in Stroke.

They developed classes and levels of evidence on organization of post-stroke rehabilitation care, rehabilitation interventions in the inpatient hospital setting, prevention of skin breakdown and contractures, prevention of deep vein thrombosis, treatment of bowel and bladder incontinence, central and other pain, post-stroke depression, assessment of disability, motor and cognitive function, and more.

Current treatment gaps and future directions for research were identified: development of multimodal interventions (eg, drug and therapy, brain stimulation, and therapy); consideration of multiple outcomes such as patient-centered, self reported outcomes in intervention effectiveness trials; development of computer-adapted assessments for personalized interventions; effective models of care that consider stroke a chronic condition vs a single acute event; capitalization of newer technologies (eg, virtual reality, body-worn sensors, and communication resources), development of interventions for individuals with severe stroke; and development of better predictor models to identify responders and nonresponders to different therapies.

“Rehabilitation services are the primary mechanism by which functional recovery and the achievement of independence are promoted in patients with acute stroke,” the authors wrote. “The array of rehabilitation services delivered to stroke patients in the United States is broad and highly heterogeneous, varying in the type of care settings used; in the duration, intensity, and type of interventions delivered; and in the degree of involvement of specific medical, nursing, and other rehabilitation specialists.”

The panel reviewed different settings of stroke rehabilitation care. They noted that, ideally, rehabilitation services are supplied by an “interprofessional team of healthcare providers with training in rehabilitation nursing, occupational therapy (OT), PT [physical therapy], and speech and language therapy (SLT).” There are data that strongly suggest that starting these therapies as soon as possible will benefit the patient, according to the authors. However, regardless of when therapy begins, patients should undergo a formal assessment of their needs prior to discharge.

Early discharge to a “community setting” for continuing rehabilitation may achieve outcomes similar to an inpatient rehabilitation unit. In a 2012 review, the early supported discharge (ESD) model was evaluated for efficacy and it concluded that “appropriately resourced ESD services provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as reducing the length of hospital stay.”

However, the ESD model has been primarily studied in Europe and Australia/New Zealand. Systems of care are different than in the United States and the lengths of hospital stay are often longer. Therefore, clinicians should be mindful when implementing practices in US systems.

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