Number 16 Post-Stroke Rehabilitation Post-Stroke Rehabilitation Guideline Panel Glen E. Gresham, MD (Chair) Pamela W. Duncan, PhD, PT (Co-Chair) William B. Stason, MD (Project Director) Harold P. Adams, Jr., MD Alan M. Adelman, MD, MS Duane S. Bishop, MD Nancy E. Donaldson, RN, DNSC Carl V. Granger, MD Audrey L. Holland, PhD Margaret Kelly-Hayes, EdD, RN, CRRN Fletcher H. McDowell, MD Larry Myers, MD Marion A. Phipps, RN, MS, CRRN, FAAN Elliot J. Roth, MD Hilary C. Siebens, MD Gloria A. Tarvin, MSW, LSW Catherine Anne Trombly, SCD, OTR/L, FAOTA U.S. Department of Health and Human Services Public Health Service Agency for Health Care Policy and Research AHCPR Publication No. 95-0662 May 1995 Guideline Development and Use Guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical conditions. This guideline was written by an independent multidisciplinary panel of private-sector clinicians and other experts convened by the Agency for Health Care Policy and Research (AHCPR). The panel employed explicit, science-based methods and expert clinical judgment to develop specific statements on patient assessment and management for the clinical condition selected. Extensive literature searches were conducted and critical reviews and syntheses were used to evaluate empirical evidence and significant outcomes. Peer review and field review were undertaken to evaluate the validity, reliability, and utility of the guideline in clinical practice. The panel's recommendations are primarily based on the published scientific literature. When the scientific literature was incomplete or inconsistent in a particular area, the recommendations reflect the professional judgment of panel members and consultants. The guideline reflects the state of knowledge, current at the time of publication, on effective and appropriate care. Given the inevitable changes in the state of scientific information and technology, periodic review, updating, and revision will be done. We believe that the AHCPR-assisted clinical guidelines will make positive contributions to the quality of care in the United States. We encourage practitioners and patients to use the information provided in this Clinical Practice Guideline. The recommendations may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made by the practitioner in light of available resources and circumstances presented by individual patients. Clifton R. Gaus, ScD Administrator Agency for Health Care Policy and Research Publication of this guideline does not necessarily Foreword A3 855 no. 16 This guideline was developed to assist primary care providers and PUBL rehabilitation specialists in the care of patients with disabilities from stroke and to help patients and their families become better informed consumers of rehabilitation services. The guideline seeks to increase awareness of the value and limitations of rehabilitation treatments after stroke and to encourage appropriate use of services. Stroke is a leading cause of disability in the elderly and a significant cause of disability in younger people. Nearly 3 million Americans have some degree of disability from strokes, and the estimated annual economic burden is more than $30 billion. Rehabilitation attempts to reduce levels of disability and facilitate return to active and productive lives through a combination of educational, counseling, physical, and technology-based interventions. Prevention of recurrent strokes and prevention of complications from stroke are additional objectives. Rehabilitation combines a medical/scientific orientation with a social service orientation. Caring, support, and advocacy for the disabled are intrinsic components. This guideline focuses primarily on the patient with a first stroke who has some degree of hemiparesis, with or without other neurological deficits, and is a candidate for treatment in an interdisciplinary rehabilitation program. Many recommendations also apply, however, to people with multiple strokes and those with limited disabilities who require care by a single rehabilitation discipline. Recommendations cover the period from the time of admission to an acute care hospital through any rehabilitation program and the transition to a community residence. The benefits of rehabilitation must be distinguished from spontaneous neurological recovery after a stroke. For this reason, the natural history of recovery from stroke is emphasized. Recommendations address rehabilitation interventions during acute care, assessment strategies throughout acute care and rehabilitation, the choice of a rehabilitation setting, goal setting and management during rehabilitation, and issues that arise after the patient returns to a community residence. Recommendations are explicit where this is possible; otherwise, they imply a sense of priority or direction. Recommendations are supported by direct evidence from controlled trials where this is available. However, the sparsity of good scientific evidence has necessitated heavy reliance on expert opinion to support most recommendations. The guideline was developed by the Center for Health Economics Research in Waltham, Massachusetts, under a contract with the Agency for Health Care Policy and Research (AHCPR). Development was led by a multidisciplinary panel of experts. Inputs included an extensive review of relevant literature, public testimony at a national public forum, and thorough review by a wide array of additional experts, professional |