American Heart Association/American Stroke Association Release 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.

In the United States, approximately 70% of Medicare beneficiaries are discharged for acute stroke with Medicare-covered postacute stroke care. After hospitalization, the largest proportion of patients are first referred to a skilled nursing facility (SNF; 32%), 22% to an inpatient rehabilitation facility (IRF), and 15% to a home healthcare agency (HHCA). The authors point out that policy makers and researchers should strive for a better understanding of patient outcomes in different rehabilitation settings, specifically relative to use and cost.

In their review of the medical literature, the panelists found that there were substantial baseline differences in patients between rehabilitation settings. For example, IRF patients had a more favorable prognostic outlook because of their younger age, lower prestroke disability, fewer comorbidites, and greater caregiver or family support.

In their recommendations for levels of care in organization of post-stroke rehabilitation care, the panel recommended the following: patients who are candidates for postacute rehabilitation should receive organized, coordinated, interprofessional care (class I, level of evidence A); stroke survivors who qualify for and have access to IRF care should receive treatment in that setting vs an SNF (class I, level of evidence B); organized community-based and coordinated interprofessional rehabilitation care should occur in outpatient or home-based settings (class I, level of evidence C); and finally, ESD services may be reasonable for patients with mild to moderate disability (class IIb, level of evidence B).

In their recommendations for rehabilitation interventions in the inpatient hospital setting, the panel recommended that early rehabilitation for hospitalized patients be provided in environments with organized, interprofessional stroke care (class I, level of evidence A), and stroke survivors should receive rehabilitation at an intensity commensurate with anticipated benefit and tolerance (class I, level of evidence B). They also found that high-dose, very early mobilization within 24 hours of stroke onset can reduce odds of favorable outcomes at 3 months, and therefore is not recommended (class III, level of evidence A).

According to the authors, postacute stroke care and rehabilitation are often considered expensive healthcare costs, and as systems of care evolve, adequate resources should remain a priority to prevent further “downstream medical morbidity.”

“Stroke rehabilitation requires a sustained and coordinated effort from a large team,” the panel concluded. “Communication and coordination among these team members [eg, physicians, nurses, physical and occupational therapists, family, and other caregivers] are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline.”

“Without communication and coordination,” they stressed, “isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.”

Reference

Winstein CJ, Stein J, Arena R, et al; on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Quality of Care and Outcomes Research. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016. doi: 10.1161/STR.0000000000000098.