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Stroke rehab should start with inpatient multidisciplinary team: guideline

November 20, 2019

By Will Boggs MD

NEW YORK (Reuters Health) - Rehabilitation of stroke patients works best when it begins in an inpatient stroke unit with a multidisciplinary team of physicians, nurses and therapists, according to updated guidelines from the Department of Veterans Affairs and the U.S. Department of Defense.

"With improved stroke survival, an aging population, and increasing numbers of older workers, it is critical to identify best practices to guide decision making in these areas," Dr. James Sall from Department of Veterans Affairs, in Washington, D.C., told Reuters Health by email.

To update recommendations from 2010, Dr. Sall and colleagues reviewed the evidence on benefits and harms of rehabilitation interventions for motor deficits and treatment of poststroke mood disorders.

The guidelines include 42 recommendations in six key areas, as well as two algorithms - one for rehabilitation disposition of the inpatient with stroke and one for outpatient/community-based rehabilitation.

Evidence supporting motor therapy is lacking, the authors say. But the guideline recommends task-specific practice for improving upper- and lower-extremity motor function, gait, posture and activities of daily living, as well as the use of cardiovascular exercise (walking, aquatics, and rowing).

Information is also sparse regarding the optimal treatment of dysphagia, memory deficits, aphasia and spatial neglect, though some therapies appear to be beneficial and are recommended by the guideline.

Mixed results suggest that antidepressants and cognitive behavioral therapy (CBT) can be useful for treating poststroke depression, so the guidelines recommend their judicious use, although they caution against using tricyclic antidepressants as first-line treatment because of their side effects.

"There is a distinct lack of scientifically rigorous studies evaluating many community reintegration topics that are important to our patient population," Dr. Sall said. "Specifically, we identified few studies evaluating return to driving or return to work."

The work group determined that it is reasonable for all patients to have a clinical assessment of their physical, cognitive and behavioral function to determine their readiness to resume driving.

"There may be a tendency to delay rehabilitation for a variety of reasons; however, evidence suggests that it should begin as soon as the patient is stable," Dr. Sall said.

"There have been many advances in stroke rehabilitation care," he concluded. "The utilization of shared decision making with patients, their family members, and their caregivers is important in the identification of rehabilitation goals and the identification of the interventions to help them meet those goals."

Dr. Kristen E. D'Anci and colleagues from ECRI Institute, in Plymouth Meeting, Pennsylvania, prepared the systematic review of treatments for poststroke motor deficits and mood disorders that supported the updated guideline.

The review appears with the guideline in the November 19 issue of the Annals of Internal Medicine. The guideline can also be found on the VA website at

Dr. D'Anci told Reuters Health by email, "Although we looked at a number of interventions intended to improve recovery of motor function following stroke, relatively few interventions that we covered in this review showed benefit over standard physiotherapies. Additionally, we had hoped to review more comparative effectiveness studies, and this represents an area of future research."

"About a third of patients who have experienced stroke will develop depression," she said "While the evidence for interventions for addressing poststroke depression was generally low, I think it's important to keep in mind that CBT, with or without use of antidepressant medication, is useful for treating poststoke depression. However, exercise or mind-body activities, such as yoga or tai chi, are also helpful in patient with poststroke depression."

"Despite the prevalence of depression following stroke, the current evidence does not support the use of antidepressant medication to prevent depression or to treat motor deficits," Dr. D'Anci added.

Dr. Anita D. Mountain of Dalhousie University Division of Physical Medicine and Rehabilitation and Nova Scotia Rehabilitation Center, in Halifax, Canada, who was not involved in the new work, told Reuters Health by email, "The identification of mental health therapy as a key area, as well as the inclusion of identifying and treating poststroke depression in the algorithms, helps to specifically highlight this important issue for clinicians."

Dr. Gert Kwakkel, chair of neurorehabilitation at VU University Medical Center, in Amsterdam, said, "It has been shown that about 20% to 30% of all patients with severe strokes fail to show spontaneous neurological recovery. Evidence-based therapies are lacking for this unfavorable prognostic group."

"Moving stroke rehabilitation trials forward, there is an urgent need for high-quality, explanatory trials in the first 3 months post stroke," Dr. Kwakkel, who also was not involved in the guideline work, told Reuters Health by email.


Ann Intern Med 2019.

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