Adult Stroke Rehabilitation and Recovery
Publication Date: May 4, 2016
Last Updated: March 14, 2022
Recommendations
Organization of Poststroke Rehabilitation Care (Levels of Care)
It is recommended that stroke patients who are candidates for postacute rehabilitation receive organized, coordinated, interprofessional care. (AI)
701
It is recommended that stroke survivors who qualify for and have access to IRF care receive treatment in an IRF in preference to a SNF. (BI)
701
Organized community-based and coordinated interprofessional rehabilitation care is recommended in the outpatient or home-based settings. (CI)
701
ESD services may be reasonable for people with mild to moderate disability. (BIIb)
701
Prevention of Skin Breakdown and Contractures
During hospitalization and inpatient rehabilitation, regular skin assessments are recommended with objective scales of risk such as the Braden scale. ( C , I )
701
It is recommended to minimize or eliminate skin friction, to minimize skin pressure, to provide appropriate support surfaces, to avoid excessive moisture, and to maintain adequate nutrition and hydration to prevent skin breakdown. Regular turning, good skin hygiene, and use of specialized mattresses, wheelchair cushions, and seating are recommended until mobility returns. (CI)
701
Patients, staff, and caregivers should be educated about the prevention of skin breakdown. (CI)
701
Positioning of hemiplegic shoulder in maximum external rotation while the patient is either sitting or in bed for 30 minutes daily is probably indicated. (BIIa)
701
Resting hand/wrist splints, along with regular stretching and spasticity management in patients lacking active hand movement, may be considered. (CIIb)
701
Use of serial casting or static adjustable splints may be considered to reduce mild to moderate elbow and wrist contractures. (CIIb)
701
Surgical release of brachialis, brachioradialis, and biceps muscles may be considered for substantial elbow contractures and associated pain. (BIIb)
701
Resting ankle splints used at night and during assisted standing may be considered for prevention of ankle contracture in the hemiplegic limb. ( B , IIb )
701
Prevention of DVT
In ischemic stroke, prophylactic-dose subcutaneous heparin (UFH or LMWH) should be used for the duration of the acute and rehabilitation hospital stay or until the stroke survivor regains mobility. (AI)
701
In ischemic stroke, it is reasonable to use prophylactic-dose LMWH over prophylactic-dose UFH for prevention of DVT. (AIIa)
701
In ischemic stroke, it may be reasonable to use intermittent pneumatic compression over no prophylaxis during the acute hospitalization. (BIIb)
701
In intracerebral hemorrhage (ICH), it may be reasonable to use prophylactic-dose subcutaneous heparin (UFH or LMWH) started between days 2 and 4 over no prophylaxis. (CIIb)
701
In ICH, it may be reasonable to use prophylactic-dose LMWH over prophylactic-dose UFH. (CIIb)
701
In ICH, it may be reasonable to use intermittent pneumatic compression devices over no prophylaxis. (CIIb)
701
In ischemic stroke, it is not useful to use elastic compression stockings. (BIII (no benefit))
701
In ICH, it is not useful to use elastic compression stockings. (CIII (no benefit))
701
Treatment of Bowel and Bladder Incontinence
Assessment of bladder function in acutely hospitalized stroke patients is recommended. (BI)
701
A history of urological issues before stroke should be obtained. (BI)
701
Assessment of urinary retention through bladder scanning or intermittent catheterizations after voiding while recording volumes is recommended for patients with urinary incontinence or retention. (BI)
701
Assessment of cognitive awareness of need to void or having voided is reasonable. (BIIa)
701
Removal of the Foley catheter (if any) within 24 hours after admission for acute stroke is recommended. (BI)
701
It is reasonable to use the following treatment interventions to improve bladder incontinence in stroke patients:
- Prompted voiding
- Pelvic floor muscle training (after discharge home)
701
It may be reasonable to assess prior bowel function in acutely hospitalized stroke patients and include the following:
- Stool consistency, frequency, and timing (before stroke)
- Bowel care practices before stroke
701
Assessment, Prevention, and Treatment of Hemiplegic Shoulder Pain
Patient and family education (ie, range of motion, positioning) is recommended for shoulder pain and shoulder care after stroke, particularly before discharge or transitions in care. (CI)
701
Botulinum toxin injection can be useful to reduce severe hypertonicity in hemiplegic shoulder muscles. (AIIa)
701
A trial of neuromodulating pain medications is reasonable for patients with hemiplegic shoulder pain who have clinical signs and symptoms of neuropathic pain manifested as sensory change in the shoulder region, allodynia, or hyperpathia. (AIIa)
701
It is reasonable to consider positioning and use of supportive devices and slings for shoulder subluxation. (CIIa)
701
A clinical assessment can be useful, including:
- Musculoskeletal evaluation
701
- Evaluation of spasticity
701
- Identification of any subluxation
701
- Testing for regional sensory changes
701
Neuromuscular electrical stimulation (NMES) may be considered (surface or intramuscular) for shoulder pain. (AIIb)
701
Ultrasound may be considered as a diagnostic tool for shoulder soft tissue injury. (BIIb)
701
Usefulness of acupuncture as an adjuvant treatment for hemiplegic shoulder pain is of uncertain value. (BIIb)
701
Usefulness of subacromial or glenohumeral corticosteroid injection for patients with inflammation in these locations is not well established. (BIIb)
701
Suprascapular nerve block may be considered as an adjunctive treatment for hemiplegic shoulder pain. (BIIb)
701
Surgical tenotomy of pectoralis major, lattisimus dorsi, teres major, or subscapularis may be considered for patients with severe hemiplegia and restrictions in shoulder range of motion. (CIIb)
701
The use of overhead pulley exercises is not recommended. (CIII (no benefit))
701
Central Pain After Stroke
The diagnosis of central poststroke pain should be based on established diagnostic criteria after other causes of pain have been excluded. (CI)
701
The choice of pharmacological agent for the treatment of central poststroke pain should be individualized to the patient’s needs and response to therapy and any side effects. (CI)
701
Amitriptyline and lamotrigine are reasonable first-line pharmacological treatments. (BIIa)
701
Interprofessional pain management is probably useful in conjunction with pharmacotherapy. (CIIa)
701
Standardized measures may be useful to monitor response to treatment. (CIIb)
701
Pregabalin, gabapentin, carbamazepine, or phenytoin may be considered as second-line treatments. (BIIb)
701
Transcutaneous electrical nerve stimulation (TENS) has not been established as an effective treatment. (BIII (no benefit))
701
Motor cortex stimulation might be reasonable for the treatment of intractable central poststroke pain that is not responsive to other treatments in carefully selected patients. (BIIb)
701
Deep brain stimulation has not been established as an effective treatment. (BIII (no benefit))
701
Prevention of Falls
It is recommended that individuals with stroke discharged to the community participate in exercise programs with balance training to reduce falls. (BI)
701
It is recommended that individuals with stroke be provided a formal fall prevention program during hospitalization. (AI)
701
It is reasonable that individuals with stroke be evaluated for fall risk annually with an established instrument appropriate to the setting. (BIIa)
701
It is reasonable that individuals with stroke and their caregivers receive information targeted to home and environmental modifications designed to reduce falls. (BIIa)
701
Tai Chi training may be reasonable for fall prevention. (BIIb)
701
Seizures
Any patient who develops a seizure should be treated with standard management approaches, including a search for reversible causes of seizure in addition to potential use of antiepileptic drugs. (CI)
701
Routine seizure prophylaxis for patients with ischemic or hemorrhagic stroke is not recommended. (CIII (no benefit))
701
Poststroke Depression, Including Emotional and Behavioral State
Administration of a structured depression inventory such as the Patient Health Questionnaire-2 is recommended to routinely screen for poststroke depression. (BI)
701
Patient education about stroke is recommended. Patients should be provided with information, advice, and the opportunity to talk about the impact of the illness on their lives. (BI)
701
Patients diagnosed with poststroke depression should be treated with antidepressants in the absence of contraindications and closely monitored to verify effectiveness. (BI)
701
A therapeutic trial of an SSRI or dextromethorphan/quinidine is reasonable for patients with emotional lability or pseudobulbar affect causing emotional distress. (AIIa)
701
Periodic reassessment of depression, anxiety, and other psychiatric symptoms may be useful in the care of stroke survivors. (BIIa)
701
Consultation by a qualified psychiatrist or psychologist for stroke survivors with mood disorders causing persistent distress or worsening disability can be useful. (CIIa)
701
The usefulness of routine use of prophylactic antidepressant medications is unclear. (AIIb)
701
Combining pharmacological and nonpharmacological treatments of poststroke depression may be considered. (AIIb)
701
The efficacy of individual psychotherapy alone in the treatment of poststroke depression is unclear. (BIIb)
701
Patient education, counseling, and social support may be considered as components of treatment for poststroke depression. (BIIb)
701
An exercise program of at least 4 weeks duration may be considered as a complementary treatment for poststroke depression. (BIIb)
701
Early effective treatment of depression may have a positive effect on the rehabilitation outcome. (BIIb)
701
No recommendation for the use of any particular class of antidepressants is made. SSRIs are commonly used and generally well tolerated in this patient population. (AIII (no benefit))
701
Poststroke Osteoporosis
It is recommended that individuals with stroke residing in long-term care facilities be evaluated for calcium and vitamin D supplementation. (AI)
701
It is recommended that US Preventive Services Task Force osteoporosis screening recommendations be followed in women with stroke. (BI)
701
Increased levels of physical activity are probably indicated to reduce the risk and severity of poststroke osteoporosis. (BIIa)
701
Assessment of Disability and Rehabilitation Needs
It is recommended that all individuals with stroke be provided a formal assessment of their ADLs and IADLs, communication abilities, and functional mobility before discharge from acute care hospitalization and the findings be incorporated into the care transition and the discharge planning process. (BI)
701
It is recommended that all individuals with stroke discharged to independent community living from postacute rehabilitation or SNFs receive ADL and IADL assessment directly related to their discharge living setting. (BI)
701
A functional assessment by a clinician with expertise in rehabilitation is recommended for patients with an acute stroke with residual functional deficits. (CI)
701
Determination of postacute rehabilitation needs should be based on assessments of residual neurological deficits; activity limitations; cognitive, communicative, and psychological status; swallowing ability; determination of previous functional ability and medical comorbidities; level of family/caregiver support; capacity of family/caregiver to meet the care needs of the stroke survivor; likelihood of returning to community living; and ability to participate in rehabilitation. (CI)
701
It is reasonable that individuals with stroke discharged from acute and postacute hospitals/centers receive formal follow-up on their ADL and IADL status, communication abilities, and functional mobility within 30 days of discharge. (BIIa)
701
The routine administration of standardized measures can be useful to document the severity of stroke and resulting disability, starting in the acute phase and progressing over the course of recovery and rehabilitation. (CIIa)
701
A standardized measure of balance and gait speed (for those who can walk) may be considered for planning postacute rehabilitation care and for safety counseling with the patient and family. (BIIb)
701
Assessment of Motor Impairment, Activity, and Mobility
Motor impairment assessments (paresis/muscle strength, tone, individuated finger movements, coordination) with standardized tools may be useful. (CIIb)
701
Upper extremity activity/function assessment with a standardized tool may be useful. (CIIb)
701
Balance assessment with a standardized tool may be useful. (CIIb)
701
Mobility assessment with a standardized tool may be useful. (CIIb)
701
The use of standardized questionnaires to assess stroke survivor perception of motor impairments, activity limitations, and participation may be considered. (CIIb)
701
The use of technology (accelerometers, step-activity monitors, pedometers) as an objective means of assessing real-world activity and participation may be considered. (CIIb)
701
Periodic assessments with the same standardized tools to document progress in rehabilitation may be useful. (CIIb)
701
Assessment of Communication Impairment
Communication assessment should consist of interview, conversation, observation, standardized tests, or nonstandardized items; assess speech, language, cognitive-communication, pragmatics, reading, and writing; identify communicative strengths and weaknesses; and identify helpful compensatory strategies. (BI)
701
Telerehabilitation is reasonable when face-to-face assessment is impossible or impractical. (AIIa)
701
Communication assessment may consider the individual’s unique priorities using the ICF framework, including quality of life. (CIIb)
701
Assessment of Cognition and Memory
Screening for cognitive deficits is recommended for all stroke patients before discharge home. (BI)
701
When screening reveals cognitive deficits, a more detailed neuropsychological evaluation to identify areas of cognitive strength and weakness may be beneficial. (CIIa)
701
Sensory Impairments, Including Touch, Vision, and Hearing
Evaluation of stroke patients for sensory impairments, including touch, vision, and hearing, is probably indicated. (BIIa)
701
Dysphagia Screening, Management, and Nutritional Support
Early dysphagia screening is recommended for acute stroke patients to identify dysphagia or aspiration, which can lead to pneumonia, malnutrition, dehydration, and other complications. (BI)
701
Dysphagia screening is reasonable by a speech-language pathologist or other trained healthcare provider. (CIIa)
701
Assessment of swallowing before the patient begins eating, drinking, or receiving oral medications is recommended. (BI)
701
An instrumental evaluation is probably indicated for those patients suspected of aspiration to verify the presence/absence of aspiration and to determine the physiological reasons for the dysphagia to guide the treatment plan. (BIIa)
701
Selection of instrumental study (fiberoptic endoscopic evaluation of swallowing, videofluoroscopy, fiberoptic endoscopic evaluation of swallowing with sensory testing) may be based on availability or other considerations. (CIIb)
701
Oral hygiene protocols should be implemented to reduce the risk of aspiration pneumonia after stroke. (BI)
701
Enteral feedings (tube feedings) should be initiated within 7 days after stroke for patients who cannot safely swallow. (AI)
701
Nasogastric tube feeding should be used for short term (2–3 weeks) nutritional support for patients who cannot swallow safely. (BI)
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Percutaneous gastrostomy tubes should be placed in patients with chronic inability to swallow safely. (BI)
701
Nutritional supplements are reasonable to consider for patients who are malnourished or at risk of malnourishment. (BIIa)
701
Incorporating principles of neuroplasticity into dysphagia rehabilitation strategies/interventions is reasonable. (CIIa)
701
Behavioral interventions may be considered as a component of dysphagia treatment. (AIIb)
701
Acupuncture may be considered as a adjunctive treatment for dysphagia. (BIIb)
701
Drug therapy, NMES, pharyngeal electrical stimulation, physical stimulation, tDCS, and transcranial magnetic stimulation are of uncertain benefit and not currently recommended. (AIII (no benefit))
701
Nondrug Therapies for Cognitive Impairment, Including Memory
Enriched environments to increase engagement with cognitive activities are recommended. (AI)
701
Use of cognitive rehabilitation to improve attention, memory, visual neglect, and executive functioning is reasonable. (BIIa)
701
Use of cognitive training strategies that consider practice, compensation, and adaptive techniques for increasing independence is reasonable. (BIIa)
701
Compensatory strategies may be considered to improve memory functions, including the use of internalized strategies (eg, visual imagery, semantic organization, spaced practice) and external memory assistive technology (eg, notebooks, paging systems, computers, other prompting devices). (AIIb)
701
Some type of specific memory training is reasonable such as promoting global processing in visual-spatial memory and constructing a semantic framework for language-based memory. (BIIb)
701
Errorless learning techniques may be effective for individuals with severe memory impairments for learning specific skills or knowledge, although there is limited transfer to novel tasks or reduction in overall functional memory problems. (BIIb)
701
Music therapy may be reasonable for improving verbal memory. (BIIb)
701
Exercise may be considered as adjunctive therapy to improve cognition and memory after stroke. (CIIb)
701
Virtual reality training may be considered for verbal, visual, and spatial learning, but its efficacy is not well established. (CIIb)
701
Anodal tDCS over the left dorsolateral prefrontal cortex to improve language-based complex attention (working memory) remains experimental. (BIII (no benefit))
701
Use of Drugs to Improve Cognitive Impairments, Including Attention
The usefulness of donepezil in the treatment of poststroke cognitive deficits is not well established. (BIIb)
701
The usefulness of rivastigmine in the treatment of poststroke cognitive deficits is not well established. (BIIb)
701
The usefulness of antidepressants in the treatment of poststroke cognitive deficits is not well established. (BIIb)
701
The usefulness of dextroamphetamine, methylphenidate, modafinil, and atomoxetine in the treatment of poststroke cognitive deficits is unclear. (CIIb)
701
Limb Apraxia
Strategy training or gesture training for apraxia may be considered. (BIIb)
701
Task practice for apraxia with and without mental rehearsal may be considered. (CIIb)
701
Hemispatial Neglect or Hemi-Inattention
It is reasonable to provide repeated top-down and bottom-up interventions such as prism adaptation, visual scanning training, optokinetic stimulation, virtual reality, limb activation, mental imagery, and neck vibration combined with prism adaptation to improve neglect symptoms. (AIIa)
701
Right visual field testing may be considered. (BIIb)
701
Repetitive transcranial magnetic stimulation of various forms may be considered to ameliorate neglect symptoms. (BIIb)
701
Cognitive Communication Disorders
Interventions for cognitive-communication disorders are reasonable to consider if they are individually tailored and target:
- The overt communication deficit affecting prosody, comprehension, expression of discourse, and pragmatics
- The cognitive deficits that accompany or underlie the communication deficit, including attention, memory, and executive functions
701
Aphasia
Speech and language therapy is recommended for individuals with aphasia. (AI)
701
Treatment for aphasia should include communication partner training. (BI)
701
Intensive treatment is probably indicated, but there is no definitive agreement on the optimum amount, timing, intensity, distribution, or duration of treatment. (AIIa)
701
Computerized treatment may be considered to supplement treatment provided by a speech-language pathologist. (AIIb)
701
A variety of different treatment approaches for aphasia may be useful, but their relative effectiveness is not known. (BIIb)
701
Group treatment may be useful across the continuum of care, including the use of community-based aphasia groups. (BIIb)
701
Pharmacotherapy for aphasia may be considered on a case-by-case basis in conjunction with speech and language therapy, but no specific regimen is recommended for routine use at this time. (BIIb)
701
Brain stimulation techniques as adjuncts to behavioral speech and language therapy are considered experimental and therefore are not currently recommended for routine use. (BIII (no benefit))
701
Motor Speech Disorders: Dysarthria and Apraxia of Speech
Interventions for motor speech disorders should be individually tailored and can include behavioral techniques and strategies that target:
- Physiological support for speech, including respiration, phonation, articulation, and resonance
- Global aspects of speech production such as loudness, rate, and prosody
701
Augmentative and alternative communication devices and modalities should be used to supplement speech. (CI)
701
Telerehabilitation may be useful when face-to-face treatment is impossible or impractical. (CIIa)
701
Environmental modifications, including listener education, may be considered to improve communication effectiveness. (CIIb)
701
Activities to facilitate social participation and promote psychosocial well-being may be considered. (CIIb)
701
Spasticity
Targeted injection of botulinum toxin into localized upper limb muscles is recommended to reduce spasticity, to improve passive or active range of motion, and to improve dressing, hygiene, and limb positioning. (AI)
701
Targeted injection of botulinum toxin into lower limb muscles is recommended to reduce spasticity that interferes with gait function. (AI)
701
Oral antispasticity agents can be useful for generalized spastic dystonia but may result in dose-limiting sedation or other side effects. (AIIa)
701
Physical modalities such as NMES or vibration applied to spastic muscles may be reasonable to improve spasticity temporarily as an adjunct to rehabilitation therapy. (AIIb)
701
Intrathecal baclofen therapy may be useful for severe spastic hypertonia that does not respond to other interventions. (AIIb)
701
Postural training and task-oriented therapy may be considered for rehabilitation of ataxia. (CIIb)
701
The use of splints and taping are not recommended for prevention of wrist and finger spasticity after stroke. (BIII (no benefit))
701
Balance and Ataxia
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. (AI)
701
Individuals with stroke should be prescribed and fit with an assistive device or orthosis if appropriate to improve balance. (AI)
701
Individuals with stroke should be evaluated for balance, balance confidence, and fall risk. (CI)
701
Postural training and task-oriented therapy may be considered for rehabilitation of ataxia. (CIIb)
701
Mobility
Intensive, repetitive, mobility- task training is recommended for all individuals with gait limitations after stroke. (AI)
701
An ankle-foot orthosis (AFO) after stroke is recommended in individuals with remediable gait impairments (eg, foot drop) to compensate for foot drop and to improve mobility and paretic ankle and knee kinematics, kinetics, and energy cost of walking. (AI)
701
Group therapy with circuit training is a reasonable approach to improve walking. (AIIa)
701
Incorporating cardiovascular exercise and strengthening interventions is reasonable to consider for recovery of gait capacity and gait-related mobility tasks. (AIIa)
701
NMES is reasonable to consider as an alternative to an AFO for foot drop. (AIIa)
701
Practice walking with either a treadmill (with or without body-weight support) or overground walking exercise training combined with conventional rehabilitation may be reasonable for recovery of walking function. (AIIb)
701
Robot-assisted movement training to improve motor function and mobility after stroke in combination with conventional therapy may be considered. (AIIb)
701
Mechanically assisted walking (treadmill, electromechanical gait trainer, robotic device, servo-motor) with body weight support may be considered for patients who are nonambulatory or have low ambulatory ability early after stroke. (AIIb)
701
There is insufficient evidence to recommend acupuncture for facilitating motor recovery and walking mobility. (BIIb)
701
The effectiveness of TENS in conjunction with everyday activities for improving mobility, lower extremity strength, and gait speed is uncertain. (BIIb)
701
The effectiveness of rhythmic auditory cueing to improve walking speed and coordination is uncertain. (BIIb)
701
The usefulness of electromyography biofeedback during gait training in patients after stroke is uncertain. (BIIb)
701
Virtual reality may be beneficial for the improvement of gait. (BIIb)
701
The effectiveness of neurophysiological approaches (ie, neurodevelopmental therapy, proprioceptive neuromuscular facilitation) compared with other treatment approaches for motor retraining after an acute stroke has not been established. (BIIb)
701
The effectiveness of water-based exercise for motor recovery after an acute stroke is unclear. (BIIb)
701
The effectiveness of fluoxetine or other SSRIs to enhance motor recovery is not well established. (BIIb)
701
The effectiveness of levodopa to enhance motor recovery is not well established. (BIIb)
701
The use of dextroamphetamine or methylphenidate to facilitate motor recovery is not recommended. (BIII (harm))
701
Upper Extremity Activity, Including ADLs, IADLs, Touch, and Proprioception
Functional tasks should be practiced; that is, task-specific training, in which the tasks are graded to challenge individual capabilities, practiced repeatedly, and progressed in difficulty on a frequent basis. (AI)
701
All individuals with stroke should receive ADL training tailored to individual needs and eventual discharge setting. (AI)
701
All individuals with stroke should receive IADL training tailored to individual needs and eventual discharge setting. (BI)
701
Constraint-induced movement therapy (CIMT) or its modified version is reasonable to consider for eligible stroke survivors. (AIIa)
701
Robotic therapy is reasonable to consider to deliver more intensive practice for individuals with moderate to severe upper limb paresis. (AIIa)
701
NMES is reasonable to consider for individuals with minimal volitional movement within the first few months after stroke or for individuals with shoulder subluxation. (AIIa)
701
Mental practice is reasonable to consider as an adjunct to upper extremity rehabilitation services. (AIIa)
701
Strengthening exercises are reasonable to consider as an adjunct to functional task practice. (BIIa)
701
Virtual reality is reasonable to consider as a method for delivering upper extremity movement practice. (BIIa)
701
Somatosensory retraining to improve sensory discrimination may be considered for stroke survivors with somatosensory loss. (BIIb)
701
Bilateral training paradigms may be useful for upper limb therapy. (AIIb)
701
Acupuncture is not recommended for the improvement of ADLs and upper extremity activity. (AIII (no benefit))
701
Adaptive Equipment, Durable Medical Devices, Orthotics, and Wheelchairs
Ambulatory assistive devices (eg, cane, walker) should be used to help with gait and balance impairments, as well as mobility efficiency and safety, when needed. (BI)
701
AFOs should be used for ankle instability or dorsiflexor weakness. (BI)
701
Wheelchairs should be used for nonambulatory individuals or those with limited walking ability. (CI)
701
Adaptive and assistive devices should be used for safety and function if other methods of performing the task/activity are not available or cannot be learned or if the patient’s safety is a concern. (CI)
701
Chronic Care Management: Home- and Community-Based Participation
After successful screening, an individually tailored exercise program is indicated to enhance cardiorespiratory fitness and to reduce the risk of stroke recurrence. (I)
A (for improved fitness); B (for reduction of stroke risk)
701
After completion of formal stroke rehabilitation, participation in a program of exercise or physical activity at home or in the community is recommended. (AI)
701
Treatments/Interventions for Visual Impairments
For deficits in eye movements:
- Eye exercises for treatment of convergence insufficiency are recommended.
701
- Compensatory scanning training may be considered for improving functional ADLs.
701
- Compensatory scanning training may be considered for improving scanning and reading outcomes.
701
For deficits in visual fields:
- Yoked prisms may be useful to help patients compensate for visual field cuts.
701
- Compensatory scanning training may be considered for improving functional deficits after visual field loss but is not effective at reducing visual field deficits.
701
- Computerized vision restoration training may be considered to expand visual fields, but evidence of its usefulness is lacking.
701
For visual-spatial/perceptual deficits:
- Multimodal audiovisual spatial exploration training appears to be more effective than visual spatial exploration training alone and is recommended to improve visual scanning
701
- There is insufficient evidence to support or refute any specific intervention as effective at reducing the impact of impaired perceptual functioning.
701
- The use of virtual reality environments to improve visual-spatial/perceptual functioning may be considered.
701
- The use of behavioral optometry approaches involving eye exercises and the use of lenses and colored filters to improve eye movement control, eye focusing, and eye coordination is not recommended.
701
Hearing Loss
If a patient is suspected of a hearing impairment, it is reasonable to refer to an audiologist for audiometric testing. ( C , IIa )
701
It is reasonable to use some form of amplification (eg, hearing aids). (CIIa)
701
It is reasonable to use communication strategies such as looking at the patient when speaking. (CIIa)
701
It is reasonable to minimize the level of background noise in the patient’s environment. (CIIa)
701
Ensuring Medical and Rehabilitation Continuity Through the Rehabilitation Process and Into the Community
It is reasonable to consider individualized discharge planning in the transition from hospital to home. (BIIa)
701
It is reasonable to consider alternative methods of communication and support (eg, telephone visits, telehealth, or Web-based support), particularly for patients in rural settings. (BIIa)
701
Social and Family Caregiver Support
It may be useful for the family/caregiver to be an integral component of stroke rehabilitation. (AIIb)
701
It may be reasonable that family/caregiver support include some or all of the following on a regular basis:
- Education
- Training
- Counseling
- Development of a support structure
- Financial assistance
701
It may be useful to have the family/caregiver involved in decision making and treatment planning as early as possible and throughout the duration of the rehabilitation process. (BIIb)
701
Referral to Community Resources
It is recommended that acute care hospitals and rehabilitation facilities maintain up-to-date inventories of community resources. (CI)
701
Patient and family/caregiver preferences for resources should be considered. (CI)
701
It is recommended that information about local resources be provided to the patient and family. (CI)
701
It is recommended that contact with community resources be offered through formal or informal referral. (CI)
701
Follow-up is recommended to ensure that the patient and family receive the necessary services. (CI)
701
Rehabilitation in the Community
Patients with stroke receiving comprehensive ADL, IADL, and mobility assessments, including evaluation of the discharge living setting, should be considered candidates for community- or home-based rehabilitation when feasible. Exclusions include individuals with stroke who require daily nursing services, regular medical interventions, specialized equipment, or interprofessional expertise. (AI)
701
It is reasonable that caregivers, including family members, be involved in training and education related directly to home-based rehabilitation programs and be included as active partners in the planning and implementation or treatment activities under the supervision of professionals. (BIIa)
701
A formal plan for monitoring compliance and participation in treatment activities may be useful for individuals with stroke referred for home- or community-based rehabilitation services. A case manager or professional staff person should be assigned to oversee implementation of the plan. (BIIb)
701
Sexual Function
An offer to patients and their partners to discuss sexual issues may be useful before discharge home and again after transition to the community. Discussion topics may include safety concerns, changes in libido, physical limitations resulting from stroke, and emotional consequences of stroke. (BIIb)
701
Recreational and Leisure Activity
It is reasonable to promote engagement in leisure and recreational pursuits, particularly through the provision of information on the importance of maintaining an active and healthy lifestyle. (BIIa)
701
It is reasonable to foster the development of self-management skills for problem solving for overcoming barriers to engagement in active activities. (BIIa)
701
It is reasonable to start education and self-management skill development about leisure/recreation activities during and in conjunction with in-patient rehabilitation. (BIIa)
701
Return to Work
Vocationally targeted therapy or vocational rehabilitation is reasonable for individuals with stroke considering a return to work. (CIIa)
701
An assessment of cognitive, perception, physical, and motor abilities may be considered for stroke survivors considering a return to work. (CIIb)
701
Return to Driving
Individuals who appear to be ready to return to driving, as demonstrated by successful performance on fitness-to-drive tests, should have an on-the-road test administered by an authorized person. (CI)
701
It is reasonable that individuals be assessed for cognitive, perception, physical, and motor abilities to ascertain readiness to return to driving according to safety and local laws. (BIIa)
701
It is reasonable that individuals who do not pass an on-the-road driving test be referred to a driver rehabilitation program for training. (BIIa)
701
A driving simulation assessment may be considered for predicting fitness to drive. (CIIb)
701
Rehabilitation Interventions in the Inpatient Hospital Setting
It is recommended that early rehabilitation for hospitalized stroke patients be provided in environments with organized, interprofessional stroke care. (AI)
701
It is recommended that stroke survivors receive rehabilitation at an intensity commensurate with anticipated benefit and tolerance. (BI)
701
High-dose, very early mobilization within 24 hours of stroke onset can reduce the odds of a favorable outcome at 3 months and is not recommended. (AIII (harm))
701
Recommendation Grading
Overview
Title
Adult Stroke Rehabilitation and Recovery
Authoring Organization
American Heart Association
Publication Month/Year
May 4, 2016
Last Updated Month/Year
June 23, 2022
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.
Inclusion Criteria
Female, Male, Adult, Older adult
Health Care Settings
Ambulatory, Home health, Hospital, Long term care, Outpatient
Intended Users
Speech language pathologist, physician, physical therapist, nurse, nurse practitioner, physician assistant
Scope
Rehabilitation
Diseases/Conditions (MeSH)
D000066530 - Neurological Rehabilitation, D000071939 - Stroke Rehabilitation, D000072038 - Cardiac Rehabilitation
Keywords
stroke, Stroke Rehabilitation