AHA/ASA Issues First-Ever Stroke Rehabilitation Guidelines

May 04, 2016

The American Heart Association/American Stroke Association (AHA/ASA) has issued guidelines for the first time on rehabilitation after stroke, calling for intensive, multidisciplinary treatment.

The guidelines, published online in Stroke on May 4, have been endorsed by the American Academy of Neurology, American Academy of Physical Medicine and Rehabilitation; American Physical Therapy Association; American Occupational Therapy Association; American Society of Neurorehabilitation; and American Congress of Rehabilitation Medicine.

Lead author of the guidelines, Carolee J. Winstein, PhD, professor of biokinesiology and physical therapy at the University of Southern California Los Angeles, commented to Medscape Medical News that this is the first time AHA/ASA has commissioned guidelines on stroke rehabilitation and recovery.

"It has previously been more focused on the medical management of acute stroke," Dr Winstein said. "These new guidelines are significant in that they show the AHA/ASA recognizes the importance of good care in the period after the initial event and that this is an important contributor to quality of life after a stroke."

She explained that stroke has previously been considered by many as primarily an acute event, with little recognition that it is a chronic condition and that patients often live with a disability for the rest of their lives. "But these new guidelines show this attitude is changing. They represent a huge effort to expand care of stroke patients into the chronic phase, which should help people lead the fullest of lives."

She added: "While many of the recommendations make sense intuitively, we have evaluated the evidence and found many interventions that have level 1A evidence — ie, strong evidence that they do have a beneficial impact on outcomes. Many professionals involved in stroke care may not have been aware of this before, and we hope publication of these guidelines will encourage greater efforts to make these interventions happen."

Dr Winstein noted that many of the recommendations made depend on rehabilitation exercise and educational programs, which need to be delivered by trained personnel from different specialities. "A multidisciplinary team effort is required. This is most easily delivered at an inpatient facility specializing in stroke aftercare — and one of the top recommendations in the new guidelines is that patients should be admitted to such a facility after a stroke."

In the guidelines publication in Stroke, the authors conclude that: "Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others.

"Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline," the authors write. "Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential."

The guidelines document includes hundreds of different recommendations on every aspect of rehabilitation care for a patient after they have sustained a stroke, from the early actions taken in the acute care hospital through reintegration into the community.

The guidelines rely on a mixture of evidence and consensus. The main recommendations with Level IA evidence include the following:

  • Inpatient rehabilitation facilities produce better outcomes than nursing homes

Dr Winstein explained that at inpatient rehabilitation facility patients would receive at least 3 hours each day of specific rehabilitation tailored to their needs by a dedicated coordinated team of professionals. This would include physical therapy, occupational therapy, speech therapy, medical management, and a visit from a social worker, whereas at a nursing home the intensity of rehabilitation is normally lower and there is less of an emphasis on recovery, with the focus more on maintenance and medical management.

She said: "There is considerable evidence that patients benefit from the team approach in a facility that understands the importance of rehabilitation during the early period after a stroke. So if relatives are trying to decide what type of establishment would be best for aftercare for a patient following a stroke, then they should choose an inpatient rehabilitation facility if possible. At such facilities the various specialists can also meet with the relatives and explain the various therapies and how they can be continued when the patient leaves."

However, according to information in the guidelines document quoting 2006 Medicare data, 42% of stroke patients are not referred to any post-acute care.

  • Formal fall prevention programs during hospitalization

Dr Winstein reported that there is a very high probability of mobility issues after a stroke, and a large proportion of patients have a fall once they go home.

"Once a patient falls and has a bad injury, then recovery is stalled and deterioration accelerates," she said. "Many of these falls could be prevented with better education for both the patient and their families. This would include advice on side effects of drug treatments that may affect balance, removing obstacles at home, the need for good lighting, and proper training on how best to use mobility aids such as walkers, wheelchairs and canes."

"This recommendation will probably change medical practice. Even the top stroke centers may not have a formal falls-prevention program," she added.

  • Intensive repetitive mobility exercises for all patients with gait issues

The guidelines document notes that loss or difficulty with ambulation is one of the most devastating sequelae of stroke, and restoration of gait is often one of the primary goals of rehabilitation. Gait-related activities include such tasks as mobility during rising to stand, sitting down, stair climbing, turning, transferring (eg, wheelchair to bed or bed to chair), using a wheelchair after stroke, walking quickly, and walking for specified distances.

Limitations in gait and gait-related activities are associated with an increase in fall risk, and a number of systematic reviews have demonstrated enhanced outcomes of gait-related activities after intensive, repetitive task training.

Dr Winstein added: "These repetitive exercises are focused on generally improving people's mobility and ability to get around. This would normally be included in programs run at intensive rehabilitation facilities."

  • Screening of calcium/vitamin D levels in patients in long-term care facilities

The guidelines document points out that bone mineral density and lean tissue mass commonly decline after stroke, and changes on the paretic side are more profound, where bone mineral density can decrease by more than 10% in less than a year. This coupled with balance deficits resulting from stroke, increases fracture risk.

  • Tailored exercise programs

The guidelines emphasize the need for active participation in exercise early after stroke to minimize the detrimental effects of bed rest and inactivity, to capitalize on heightened neuroplasticity present in the early poststroke period, "and to begin the important process of fostering exercise self efficacy and self-monitoring."

While the recent AVERT randomized trial suggested that high-dose, very early mobilization may be detrimental, the document notes growing evidence that the initiation of aerobic exercise in the subacute period (ie, a mean of 11 to 78 days after stroke) is safe and effective in improving exercise capacity and walking endurance.

"People need to be kept active and engaged in their lives," Dr Winstein commented. "Taking exercise and remaining active is very important. Patients should undergo screening and then be given an individual tailored exercise program so they can safely improve their cardiovascular fitness. Everything possible should be done to prevent patients from falling into the trap of going home and feeling that because they have had a stroke they can't do anything apart from sit on the sofa and eat."

She added: "The thought of exercise can be scary after a stroke. Patients need to be assessed carefully and then encouraged to participate in an appropriate exercise program. Ideally this would take place at a community class where they would experience socialization as well."

"Patients and families need to know that just because an individual has had a stroke and is finding it more difficult to get around, they still have the capacity to move and they have to invest in that. There are multiple benefits of staying active, including improved cardiovascular fitness, less depression, and improved cognitive function. It is a win-win situation. You just have to get over the initial ignorance and fear of how to do this."

  • Engaging in cognitive activities

Another level 1A recommendation is to provide an "enriched environments to increase engagement with cognitive activities."

Dr Winstein said this could include encouraging the patient to read books, listen to music, play computer games, or do puzzles; "anything that challenges the brain is good."

The guidelines document cites a study in which listening to self-selected music for 1 to 2 hours every day improved verbal memory, focused attention, and depressive symptoms, and another in which 4 weeks of playing virtual reality games for 30-minute sessions 3 times weekly improved visual attention and short-term visuospatial memory.

  • Balance training programs

The guidelines document recommends that individuals with stroke who have poor balance, low balance confidence, and fear of falls or are at risk for falls should be provided with a balance training program.

It notes that balance impairment is common after stroke because stroke can affect 1 or more of the sensory and motor networks. Impaired balance makes it difficult to safely move about the home and community and to live independently. "If left undetected or untreated, balance impairments can result in a cascade of serious, undesirable, and expensive events," it states.

The guidelines document states that balance training programs have been shown to be beneficial after stroke. While no specific approach or program has been demonstrated to be superior, the training typically includes balance-specific activities, and more general strengthening activities, and progression to more challenging training activities over the course of training is recommended.

This new scientific statement on rehabilitation is the 8th set of stroke guidelines from the American Stroke Association, completing the association's recommendations for the continuum of care for stroke patients and their families.

Stroke. Published online May 4, 2016. Abstract.

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