Stroke Rehabilitation—An Overview of Existing Guidelines and Standards of Care

In the US, the incidence rate of new or recurrent stroke is approximately 795,000 per year, and stroke prevalence for individuals over the age of 20 years is estimated at seven million.¹ Mortality rates in the first 30 days post-stroke have decreased owing to advances in emergency medicine and acute stroke care. There is also strong evidence that organized post-acute, inpatient stroke care delivered within the first four weeks by an interdisciplinary healthcare team results in an absolute reduction of deaths.^2,3 Despite these achievements, 25–74 % of stroke survivors require some assistance or are fully dependent on caregivers for activities of daily living (ADLs).^4,5 Thus, stroke continues to represent a leading cause of long-term disability and long-term care placement.

Despite the publication of the Agency for Healthcare Policy and Research (AHCPR) Guideline for Post-Stroke Rehabilitation in 1995,⁶ many healthcare providers are unaware not only of stroke survivors’ potential for motor recovery, but also common secondary complications of stroke. Since this time, a number of clinical practice guidelines have attempted to educate interdisciplinary stroke rehabilitation teams about many of these issues. This article summarizes the best available evidence-based recommendations for interdisciplinary management of the stroke survivor and caregivers. The recommendations emanate from the work of the US Departments of Veterans Affairs and Defense (VA/DoD),⁷ the American Heart Association (AHA) Councils on Stroke and Cardiovascular Nursing,⁸ the Canadian Stroke Strategy (CSS),⁹ the Scottish Intercollegiate Guideline Network (SIGN),¹⁰ and the National Institute for Health and Clinical Excellence (NICE).¹¹ The article is organized into the two major sections of unique characteristics of the guidelines and common clinical recommendations.

Unique Characteristics of the Guidelines
Each of the guidelines has its own methodology for developing its guideline. A set of researchable questions and associated key terms were developed within a number of focus areas. Inclusion criteria were developed for the literature search. The literature search resulted in a body of evidence that was critically reviewed for the strength of its findings. Each panel reviewed the body of evidence that addressed a particular question using an established method, formulated recommendations, and graded the evidence supporting each recommendation.

Department of Veterans Affairs and Defense Guideline
The VA/DoD Clinical Practice Guideline for the Management of Stroke Rehabilitation is divided into seven sections, including topics in rehabilitation in the acute phase, medical rehabilitation problems (e.g. bowel, bladder, stroke prevention), medical comorbidities (e.g. hypertension, cardiac, depression), impairments (e.g. motor, sensory, communication, cognitive), basic and instrumental activities of daily living, the rehabilitation program (e.g. needs, setting, interventions, community re-entry), and discharge from the rehabilitation program (e.g. medical follow-up). The guideline offers three algorithms for the assessment of inpatient rehabilitation, the re-assessment of inpatient rehabilitation, and the assessment for community services. The first algorithm provides a framework for the evaluation of impairments and activity limitations and participation restrictions, medical comorbidities, potential secondary complications, and triage of rehabilitation services. The second algorithm assesses functional progress and whether the stroke survivor in inpatient rehabilitation still requires inpatient services. The final algorithm assesses the need and environment for community-based rehabilitation services. All of the algorithms include the stroke survivor and caregiver in education and decision-making that are central to the patient-centered process.

American Heart Association Council on Stroke and Cardiovascular Nursing Guideline
The AHA Councils on Stroke and Cardiovascular Nursing guideline divides up rehabilitation care using two classification schemes. First, the guideline considers rehabilitation care in inpatient and outpatient environments, in chronic care, and at end-of-life. Each of the environments is defined, and the services provided to the stroke survivor are described. Second, the guideline uses the World Health Organization’s (WHO) International Classification of Functioning, Disability, and Health (ICF)¹² as an organizational framework to provide an overview of the interdisciplinary team approach to rehabilitation. The ICF model acknowledges that stroke recovery is a multifaceted process encompassing the interplay of the pathophysiologic processes directly related to the stroke and its associated comorbidities, the impact that stroke has on the stroke survivor, and contextual factors such as personal and environmental resources. As a result, the impact of stroke is described in terms of loss of body functions and structures; activity limitations that stroke survivors experience in basic and instrumental ADLs; and participation restrictions that stroke survivors encounter when re-establishing previous or developing new life roles and societal involvement. Personal factors may include internal attributes (e.g. gender, comorbidities, ethnocultural background), whereas environmental factors include external attributes (e.g. family support, social attitudes, architectural barriers, healthcare resources).

Canadian Stroke Strategy Guideline
The CSS guideline draws its evidence from the web-based Evidence- Based Review of Stroke Rehabilitation.¹³ Like the AHA guideline, the CSS guideline attempts to make recommendations based upon the environment in which stroke rehabilitation takes place. In addition, it organizes guidance into sections on best practices, rationale, system implications, and performance measures. For example, the best practice for prophylaxis of deep venous thrombosis (DVT) states: “Patients at high risk of venous thromboembolism should be started on venous thromboembolism prophylaxis immediately…” While the rationale for DVT prophylaxis is obvious, the system implication suggests: “standardized evidence-based protocols for optimal inpatient care of all acute stroke patients, regardless of where they are treated in the healthcare facility…” The related performance measure is defined as the: “percentage of patients with stroke who experience complications (such as venous thromboembolism) during [their] inpatient stay…” As a result, this recommendation scheme proposes potential solutions to operationalize and monitor guideline implementation.

Scottish Intercollegiate Guideline Network Guideline
The SIGN guideline also bases its recommendations on the WHO ICF classification scheme. It is divided into five sections: organization of services; management and prevention strategies; transfer from hospital to home; roles of the multidisciplinary team; and provision of information. The section on transfer from hospital to home takes into account community re-entry issues, such as post-discharge support, driving, and follow-up by a primary care provider. The section on roles of the multidisciplinary team emphasizes the need for collaboration and communication. The section on provision of information emphasizes active education and counseling techniques that take into account the needs, values, and preferences of the stroke survivor and his caregivers. The section concludes with a list of Scottish stroke advocacy and caregiver websites.

National Institute for Health and Clinical Excellence Guideline
Finally, the NICE guideline is the oldest of the guidelines, having been issued in July, 2008. The guideline encompasses comprehensive stroke care, of which rehabilitation comprises two sections: recovery phase from impairments and limited activities; and long-term management after recovery. The recovery phase sections consist of 52 sub-sections that cover general topics, a number of specific treatments, common impairments seen after stroke, activity limitations, and personal and environmental adaptations and equipment. The long-term management section discusses monitoring disability and episodes of further rehabilitation, long-term support and care at home, management in nursing homes and residential care, and caregiver support. Following these recommendations, the guideline organizes recommendations that are pertinent to nurses, physical therapists, occupational therapists, speech-language pathologists, and nutritionists. The guideline is scheduled for updating in December, 2011.

Common Clinical Recommendations
According to the VA/DoD Clinical Practice Guideline for the Management of Stroke Rehabilitation,⁷ the primary goal of rehabilitation is to prevent complications, minimize impairments, and maximize function. A number of key points influence the types of recommendations on which the guidelines are based:

• Early assessment and intervention is critical to optimize rehabilitation.
• Secondary prevention is fundamental for preventing stroke recurrence.
• Every candidate for rehabilitation should have access to an experienced and coordinated rehabilitation team in order to ensure optimal outcome.
• The patient and family and/or caregiver are essential members of the rehabilitation team.
• Standardized evaluations and valid assessment tools are essential to the development of a comprehensive treatment plan.
• Evidence-based interventions should be based on functional goals.
• Patient and family education improves informed decision-making, social adjustment, and maintenance of rehabilitation gains.
• The rehabilitation team should use community resources for community reintegration.
• Ongoing medical management of risk factors and comorbidities is essential to ensure survival.

Based upon this paradigm, a number of recommendations made by most or all of the guidelines are summarized. To simplify the recommendations from the different clinical practice guidelines, the recommendations and classification scheme described by the CSS guideline is used (see Table 1).⁹ The summary of recommendations can be seen in Table 2.

Conclusion
A number of well-organized clinical practice guidelines in stroke rehabilitation have been published over the past three years. They all are updated from previous editions, have established methods for collecting and rating the scientific evidence, have established techniques for reaching professional consensus, and have clear structure in stating and justifying each recommendation.

However, the publication of these updated guidelines emphasizes a major shortcoming. Despite the advances in stroke rehabilitation since the publication of the AHCPR Guideline for Post-Stroke Rehabilitation in 1995, the reader should note that many of the recommendations still carry an evidence level C rather than an evidence level A. There are still many questions to be answered to improve the level of evidence in stroke rehabilitation. As researchers continue to answer many of these questions, stroke survivors will be able to benefit from proven tools that decrease impairments, increase activity limitations and participation restrictions, and ultimately improve quality of life.