In our most recent edition of the Guidelines Timelines, we will be exploring the topic of stroke rehabilitation. In August 2024, the Department of Veterans Affairs (VA) and the Department of Defense (DoD) jointly released an updated clinical practice guideline (CPG) for the management of stroke rehabilitation for their healthcare providers. This new guideline serves as an update to the 2019 VA/DoD Stroke Rehabilitation CPG.

Stroke is a prevalent medical condition, impacting nearly 800,000 individuals annually in the United States (US), with 75% being first-time occurrences and 25% being recurrent strokes. It is noteworthy that around 3% of the US population has experienced a stroke, with projections indicating a potential 1% increase by 2030. Moreover, stroke significantly contributes to long-term disability, with about 45% of individuals experiencing at least moderate disability post-stroke. It ranks as the fifth leading cause of mortality for individuals assigned male at birth and the third leading cause for those assigned female at birth.

Each year, approximately 6,000 Veterans are admitted to VA facilities due to stroke, with around 60,000 stroke-related outpatient visits, underscoring the substantial impact on the Veteran population. While stroke is less common in the VA population, it does occur in active duty, retiree, and other beneficiary populations served by the DoD. 

Effective management of stroke can reduce disability severity, lower the risk of complications, and alleviate potential lifelong deficits. Today, we will explore the key takeaways and differences between the 2024 and 2019 CPGs. While we won’t cover every aspect within these guidelines, we will touch on the highlights. Without further delay, let’s proceed!

VA/DoD Stroke Rehabilitation Guidelines

Major Changes & Key Takeaways: 2024 vs 2019

The most significant change in the 2024 Clinical Practice Guidelines (CPG) is the incorporation of 24 new recommendations, the revision and replacement of 19 recommendations, the review and amendment of 3 recommendations, the review without alteration of 1 recommendation, and the deletion of 16 recommendations from the 2019 VA/DoD Stroke Rehabilitation CPG. These updates reflect the latest advancements in stroke rehabilitation practices and aim to enhance the quality of care provided to stroke patients.

  • Transitions to Community
    • The 2024 CPG introduced a new section titled “Transitions to Community,” which was absent in the 2019 version. This new addition provides guidance on utilizing case management services upon discharge, along with implementing behavioral health and psychosocial interventions to address patient and caregiver depression.
    • It is important to note that the 2024 CPG emphasizes the significance of caregivers and the interconnectedness between patients and caregivers, with mental health affecting both parties.
  • Motor Therapy
    • Both the 2024 and 2019 CPG feature the topic of “Motor Therapy,” with both editions strongly recommending task-specific practice to enhance motor function, gait, posture, and activities of daily living. Task-specific practice, also known as task-oriented practice or repetitive task practice, has been identified as a key strategy for improving overall motor skills and functional abilities.  
    • In the 2024 CPG, there is a focus on the lack of sufficient evidence for many recommendations in this area. However, one notable change is the endorsement of mirror therapy to enhance motor outcomes and address unilateral spatial neglect. Conversely, the 2019 CPG did not find any significant benefits associated with mirror therapy. The 2024 CPG now presents a slightly beneficial stance on mirror therapy due to the incorporation of new research findings.  
    • A notable change in the 2024 CPG is the absence of a recommendation regarding body-weight support treadmill training for improving motor outcomes. In contrast, the 2019 CPG took a more favorable position on this intervention. The 2024 Work Group determined that the evidence supporting this type of training was insufficient and raised concerns about potential discomfort and anxiety experienced by patients, which could diminish the value of such an approach.
  • Mental Health
    • The 2024 CPG advise against the use of antidepressants for preventing post-stroke depression, while the 2019 CPG states that there is insufficient evidence to support or refute the universal use of selective serotonin reuptake inhibitors or serotonin norepinephrine reuptake inhibitors due to the risk of fractures. The 2024 CPG acknowledges the lack of evidence and the stigma surrounding mental health treatment with antidepressants. Many Service members and Veterans are hesitant to take medication, especially for a mental health condition they are not currently experiencing or may never experience.
    • Interestingly, both CPGs recommend the use of a selective serotonin reuptake inhibitor or a serotonin norepinephrine reuptake inhibitor for managing depression symptoms. It has been determined that the potential benefits outweigh the risks.
  • Telehealth
    • The 2024 CPG has incorporated the topic of telehealth, encompassing a recommendation for either face-to-face therapy or telerehabilitation based on patient characteristics and preferences. This addition is particularly noteworthy, as the field of telehealth is anticipated to evolve significantly over time, with the development of new technologies aimed at enhancing the experience for both patients and healthcare providers.

Thank you for your interest in our Guidelines Timelines Series on stroke rehabilitation. By gaining a better understanding of these Clinical Practice Guidelines (CPGs) that advocate for shared decision-making, a collaborative process involving healthcare providers, patients, and patient care partners (such as family members, friends, and caregivers), we can ensure the best treatment and outcomes for each patient.

We appreciate your continued interest and support, and we encourage you to sign up for alerts and stay informed on the latest published guidelines and future installments of our Guidelines Timelines.

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