VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF STROKE REHABILITATION Department of Veterans Affairs Department of Defense And The American Heart Association/ American Stroke Association Prepared by: THE MANAGEMENT OF STROKE REHABILITATION Working Group With support from: The Office of Quality and Performance, VA, Washington, DC & Quality Management Division, United States Army MEDCOM QUALIFYING STATEMENTS The Department of Veterans Affairs (VA) and The Department of Defense (DoD) guidelines are based on the best information available at the time of publication. They are designed to provide information and assist in decision-making. They are not intended to define a standard of care and should not be construed as one. Also, they should not be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriately occur when providers 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 any particular clinical situation. Version 2.0 2010 TABLE OF CONTENTS INTRODUCTION ................................................................................................................................................ 2 Guideline Update Working Group Participants ......................................................................................... 7 Key Points ...................................................................................................................................................... 8 Outcome Measures ........................................................................................................................................ 8 THE PROVISION OF REHABILITATION CARE Algorithm .................................................................................................................................................... 12 Annotations .................................................................................................................................................. 15 Rehabilitation Interventions ....................................................................................................................... 69 APPENDICES Appendix A: Guideline Development Process ........................................................................................... 112 Appendix B: Standard Instruments for Post-Stroke Assessment .............................................................. 121 Appendix C: Acronym List ......................................................................................................................... 127 Appendix D: Participant List...................................................................................................................... 129 Appendix E: Bibliography .......................................................................................................................... 131 Version 2.0 VA/DoD Clinical Practice Guideline for the October, 2010 Management of Stroke Rehabilitation INTRODUCTION This update of the Clinical Practice Guideline for the Management of Stroke Rehabilitation was developed under the auspices of the Veterans Health Administration (VHA) and the Department of Defense (DoD) pursuant to directives from the Department of Veterans Affairs (VA). VHA and DoD define clinical practice guidelines as: “Recommendations for the performance or exclusion of specific procedures or services derived through a rigorous methodological approach that includes: • Determination of appropriate criteria such as effectiveness, efficacy, population benefit, or patient satisfaction; and Literature review to determine the strength of the evidence in relation to these criteria.” This VA/DoD Stroke Rehabilitation guideline update builds on the 1996 VA Stroke/Lower Extremity Amputee Algorithms Guide and the 2003 VA/DoD Guideline for the Management of Stroke Rehabilitation in the Primary Care Setting. The 2003 version of this guideline focused on stroke rehabilitation, utilizing a team model of intervention and interactions with patients and families (caregivers & support systems). Algorithms: This guideline has been developed using an algorithmic approach to guide the clinician in determining care and the sequencing of interventions on a patient specific basis. The clinical algorithm incorporates the information presented in the guideline in a format that maximally facilitates clinical decision-making. The use of the algorithmic format was chosen because such a format improves data collection, facilitates diagnostic and therapeutic decision-making, and changes in patterns of resource use. However, this should not prevent providers from using their own clinical expertise in the care of an individual patient. Guideline recommendations are intended to support clinical decision-making and should never replace sound clinical judgment. The VA developed an algorithm for the Stroke/Lower Extremity Amputee Algorithms Guide (1996) and the results of implementation of this guideline demonstrated the utility of the algorithm, as well as the feasibility of implementing a standard algorithm of rehabilitation care in a large healthcare system (Bates & Stineman, 2000). The algorithm of the 2003 version of the guideline was modified to emphasize early decision-making regarding discharge to home/community. The key decisions in early stages of the assessment and management of a patient recovering from stroke include assessment of rehabilitation needs and the appropriateness of providing these interventions in both community and outpatient rehabilitation settings. The interventions module on this 2010 update has been reorganized, and the recommendations are formulated to address possible impairment regardless of care setting. Target Population: This guideline applies to adult patients (18 years or older) with post-stroke functional disability who may require rehabilitation in the VHA or DoD health care system. Audiences: The guideline is relevant to all healthcare professionals providing or directing treatment services to patients recovering from a stroke, in any healthcare setting (primary care, specialty care, and long-term care) and in community programs. Introduction Page - 2 Version 2.0 VA/DoD Clinical Practice Guideline for the October, 2010 Management of Stroke Rehabilitation Stroke Rehabilitation: Stroke is a leading cause of disability in the United States. (AHA, 1999) Forty percent of stroke patients are left with moderate functional impairment and 15% to 30% with severe disability. Effective rehabilitation interventions initiated early after stroke can enhance the recovery process and minimize functional disability. Improved functional outcomes for patients also contribute to patient satisfaction and can reduce potentially costly long-term care expenditures. Substantial evidence indicates that patients do better with a well-organized, multidisciplinary approach to post-acute stroke care. The highest priorities of early stroke rehabilitation are to prevent recurrence of stroke, manage comorbidities and prevent complications. In addition to facilitating mobilization and resumption of self care activities, ensuring proper management of general health functions and providing emotional support to the patient and family are important. Following the "acute" phase of stroke care, the focus of care turns to recovery of physical and cognitive deficits, as well as compensation for residual impairment. There is a growing body of evidence that indicates patients do better with a well-organized, multidisciplinary approach to post-acute stroke care (Cifu & Stewart, 1999; Evans et al., 1995; Stroke Unit Trialists’ Collaboration, 2002). For this Guideline update, the VA/DoD Stroke Rehabilitation Working Group only focused on the rehabilitation phase of the post-acute care. Secondary Prevention of Stroke will not be addressed in this update. Providers may refer to the revised AHA/ASA Guideline for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack (http://stroke.ahajournals.org/cgi/content/full/37/2/577).. Duncan, Horrner and colleagues (2002) found that greater adherence to post-acute stroke rehabilitation guidelines was associated with improved patient outcomes and concluded that “compliance with guidelines may be viewed as a quality of care indicator with which to evaluate new organizational and funding changes involving post-acute stroke rehabilitation." Stroke in VA population: The Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) estimates that 15,000 veterans are hospitalized for stroke-related diagnoses each year (VA HSR&D, 1997). In 2006, the number of new stroke patients at the VA was 5766 with an additional 5920 being identified in 2007. Although a significant percentage of these patients (87.60% & 83.89% respectively) received an initial assessment, the percentage who received comprehensive rehabilitation (22.30% &22.50%) was quite low. There are only 45 rehabilitation bed units (RBU) in the VA today. Many veterans, who are admitted to a VA Medical Center after suffering a stroke, will find themselves in a facility that does not offer comprehensive, integrated, coordinated care. In a VA rehabilitation field survey published in December 2000, over half of the respondents reported that the “rehabilitative care of stroke