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(CPG) for the Management of Stroke Rehabilitation

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(CPG) for the Management of Stroke Rehabilitation VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF STROKE REHABILITATION Department of Veterans Affairs Department of Defense QUALIFYING STATEMENTS The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best information available at the time of publication. They are designed to provide information and assist decision making. They are not intended to define a standard of care and should not be construed as one. Neither should they be interpreted as prescribing an exclusive course of management. This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical relationships between various care options and health outcomes while rating both the quality of the evidence and the strength of the recommendation. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation. These guidelines are not intended to represent Department of Veterans Affairs or TRICARE policy. Further, inclusion of recommendations for specific testing and/or therapeutic interventions within these guidelines does not guarantee coverage of civilian sector care. Additional information on current TRICARE benefits may be found at www.tricare.mil or by contacting your regional TRICARE Managed Care Support Contractor. Version 4.0 – 2019 VA/DoD Clinical Practice Guideline for the Management of Stroke Rehabilitation Prepared by: The Management of Stroke Rehabilitation Work Group With support from: The Office of Quality, Safety and Value, VA, Washington, DC & Office of Evidence Based Practice, U.S. Army Medical Command Version 4.0 – 2019 Based on evidence reviewed through July 5, 2018 July 2019 Page 2 of 170 VA/DoD Clinical Practice Guideline for the Management of Stroke Rehabilitation Table of Contents I. Introduction ..................................................................................................................................... 5 II. Background...................................................................................................................................... 5 A. Stroke Epidemiology and Impact in the General Population ............................................................. 5 B. Stroke Rehabilitation in the Department of Veterans Affairs Population ......................................... 6 C. Stroke Rehabilitation in the Department of Defense Population ...................................................... 6 III. About this Clinical Practice Guideline ............................................................................................... 7 A. Methods ............................................................................................................................................... 7 a. Grading Recommendations ......................................................................................................... 8 b. Reconciling 2010 Clinical Practice Guideline Recommendations ............................................. 10 c. Peer Review Process .................................................................................................................. 11 B. Summary of Patient Focus Group Methods and Findings ................................................................ 11 C. Conflicts of Interest ........................................................................................................................... 12 D. Scope of this Clinical Practice Guideline ........................................................................................... 13 E. Highlighted Features of this Clinical Practice Guideline ................................................................... 13 F. Patient-centered Care ....................................................................................................................... 13 G. Shared Decision Making .................................................................................................................... 14 H. Co-occurring Conditions .................................................................................................................... 14 I. Implementation ................................................................................................................................. 14 IV. Guideline Work Group ................................................................................................................... 15 V. Algorithm ...................................................................................................................................... 17 A. Module A: Rehabilitation Disposition of the Inpatient with Stroke................................................. 18 B. Module B: Outpatient/Community-Based Rehabilitation ............................................................... 19 VI. Recommendations ......................................................................................................................... 23 A. Approach and Timing......................................................................................................................... 27 B. Motor Therapy ................................................................................................................................... 30 a. Upper and Lower Limbs Rehabilitation ..................................................................................... 30 b. Technology-Assisted Physical Rehabilitation ............................................................................ 37 c. Pharmacological Treatment in Motor Therapy ........................................................................ 45 C. Dysphagia Therapy ............................................................................................................................ 48 D. Cognitive, Speech, and Sensory Therapy .......................................................................................... 55 a. Cognitive Therapy ...................................................................................................................... 55 b. Speech Therapy .......................................................................................................................... 56 c. Spatial Neglect Therapy ............................................................................................................ 57 d. Visual Therapy ........................................................................................................................... 59 July 2019 Page 3 of 170 VA/DoD Clinical Practice Guideline for the Management of Stroke Rehabilitation E. Mental Health Therapy ...................................................................................................................... 61 a. Prevention of Post-Stroke Depression ....................................................................................... 61 b. Treatment of Post-Stroke Depression ....................................................................................... 63 c. Treatment of Post-Stroke Anxiety ............................................................................................. 66 d. Adjunctive Treatment ................................................................................................................ 69 F. Other Functions ................................................................................................................................. 72 VII. Research Priorities ......................................................................................................................... 74 Appendix A: Identifying Patient Rehabilitation Goals.......................................................................... 77 Appendix B: Additional Information on Management of Stroke .......................................................... 80 A. Education ........................................................................................................................................... 80 B. Communication ................................................................................................................................. 80 C. Dysphagia ........................................................................................................................................... 81 D. Driving ................................................................................................................................................ 82 E. Pseudobulbar Affect .......................................................................................................................... 83 Appendix C: Patient Focus Group Methods and Findings .................................................................... 84 A. Methods ............................................................................................................................................. 84 B. Patient Focus Group Findings ............................................................................................................ 84 Appendix D: Evidence Review Methodology ....................................................................................... 87 A. Developing the
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