VA/DoD clinical practice guideline for the management of stroke rehabilitation in the primary care setting.
VA/DoD clinical practice guideline for the management of stroke rehabilitation in the primary care setting.
27 October 2008
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.]
Summary,
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 [FIMâ„¢])
* 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
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.]
Summary,
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 [FIMâ„¢])
* 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
