Management of Stroke Rehabilitation

Transitions to Community

• 1

  We suggest using case management services at time of discharge from the acute care hospital or post-acute care facility to improve activities of daily living and functional independence.

  Weak forEvidence: LowIntervention
• 2

  We suggest the following interventions for patients and their caregivers: Behavioral health/psychosocial interventions to improve patient and caregiver depression; Psychoeducation to improve family function, patient functional independence, and quality of life.

  Weak forEvidence: LowIntervention
• 3

  There is insufficient evidence to recommend for or against implementing transitional care rehabilitation interventions (e.g., home-based services after hospital discharge) or early supported discharge to improve activities of daily living or functional disability following stroke.

  Neither for nor againstEvidence: Very LowIntervention
• 4

  There is insufficient evidence to recommend for or against community participation interventions to improve community engagement for survivors of stroke.

  Neither for nor againstEvidence: Very LowIntervention

Motor Therapy (General)

• 5

  We recommend task-specific practice (also known as task-oriented practice or repetitive task practice) to improve motor function, gait, posture, and activities of daily living.

  Strong forEvidence: ModerateIntervention
• 6

  We suggest mirror therapy to improve motor outcomes and activities of daily living.

  Weak forEvidence: Very LowIntervention
• 7

  We suggest mirror therapy to improve unilateral spatial neglect.

  Weak forEvidence: Very LowIntervention
• 8

  There is insufficient evidence to recommend for or against body-weight support treadmill training to improve motor outcomes.

  Neither for nor againstEvidence: LowIntervention
• 9

  We suggest rhythmic auditory stimulation as an adjunct intervention to improve motor outcomes.

  Weak forEvidence: LowIntervention
• 10

  There is insufficient evidence to recommend for or against the use of high intensity interval training over moderate intensity continuous training to enhance gait recovery.

  Neither for nor againstEvidence: Very LowIntervention
• 11

  There is insufficient evidence to recommend for or against constraint-induced movement therapy to improve upper extremity motor outcomes for individuals with some movement in the paretic limb.

  Neither for nor againstEvidence: Very LowIntervention
• 12

  There is insufficient evidence to recommend for or against selective serotonin reuptake inhibitors to improve motor outcomes in patients with or without depression.

  Neither for nor againstEvidence: Very LowPharmacotherapy
• 13

  There is insufficient evidence to recommend for or against aquatic therapy, as compared with land-based therapy, to improve mobility, balance, and activities of daily living.

  Neither for nor againstEvidence: Very LowIntervention
• 14

  There is insufficient evidence to recommend for or against biofeedback as an adjunct intervention to improve motor outcomes.

  Neither for nor againstEvidence: Very LowIntervention
• 15

  There is insufficient evidence to recommend for or against motor imagery to improve motor function.

  Neither for nor againstEvidence: Very LowIntervention
• 16

  There is insufficient evidence to recommend for or against acupuncture to improve motor function.

  Neither for nor againstEvidence: Very LowIntervention

Technology Assisted Physical Rehabilitation

• 17

  We suggest neuromuscular electrical stimulation to improve motor outcomes.

  Weak forEvidence: Very LowIntervention
• 18

  There is insufficient evidence to recommend for or against robot-assisted therapy to improve upper or lower extremity motor outcomes.

  Neither for nor againstEvidence: Very LowIntervention
• 19

  There is insufficient evidence to recommend for or against virtual reality to improve balance or enhance gait recovery.

  Neither for nor againstEvidence: LowIntervention
• 20

  There is insufficient evidence to recommend for or against the use of virtual reality/serious gaming to improve upper extremity motor outcomes, activities of daily living, or quality of life.

  Neither for nor againstEvidence: Very LowIntervention
• 21

  There is insufficient evidence to recommend for or against contralaterally controlled functional electrical stimulation to improve upper extremity motor outcomes and activities of daily living.

  Neither for nor againstEvidence: LowIntervention
• 22

  There is insufficient evidence to recommend for or against non-invasive brain-computer interface to improve upper extremity motor outcomes and activities of daily living.

  Neither for nor againstEvidence: Very LowIntervention
• 23

  There is insufficient evidence to recommend for or against vagus nerve stimulation as an adjunct intervention for rehabilitation of acute and chronic motor deficits.

  Neither for nor againstEvidence: LowIntervention

Spasticity

• 24

  We suggest botulinum toxin for patients with focal spasticity depending on patient characteristics and preferences.

  Weak forEvidence: Very LowPharmacotherapy
• 25

  There is insufficient evidence to recommend for or against the use of acupuncture or dry needling for spasticity management.

  Neither for nor againstEvidence: Very LowIntervention
• 26

  There is insufficient evidence to recommend for or against whole body or localized muscle vibration for spasticity management.

  Neither for nor againstEvidence: LowIntervention
• 27

  There is insufficient evidence to recommend for or against extracorporeal shock wave therapy for spasticity management.

  Neither for nor againstEvidence: LowIntervention

Dysphagia, Cognition, and Aphasia

• 28

  We suggest chin tuck against resistance exercises for patients with dysphagia.

  Weak forEvidence: ModerateIntervention
• 29

  We suggest respiratory muscle strength training for dysphagia in patients without a tracheostomy.

  Weak forEvidence: LowIntervention
• 30

  There is insufficient evidence to recommend for or against tongue pressure resistance training for dysphagia.

  Neither for nor againstEvidence: Very LowIntervention
• 31

  There is insufficient evidence to recommend for or against neuromuscular electrical stimulation and pharyngeal electrical stimulation for dysphagia.

  Neither for nor againstEvidence: Very LowIntervention
• 32

  There is insufficient evidence to recommend for or against surface electromyography for dysphagia.

  Neither for nor againstEvidence: Very LowIntervention
• 33

  There is insufficient evidence to recommend for or against the use of selective serotonin reuptake inhibitors to improve cognitive outcomes.

  Neither for nor againstEvidence: LowPharmacotherapy
• 34

  There is insufficient evidence to recommend for or against computer assisted cognitive rehabilitation to improve cognitive outcomes.

  Neither for nor againstEvidence: Very LowIntervention
• 35

  There is insufficient evidence to recommend for or against a specific intensity of language therapy for aphasia.

  Neither for nor againstEvidence: LowIntervention
• 36

  There is insufficient evidence to recommend for or against hemifield eye patching in addition to traditional therapy to improve functional outcomes in patients with unilateral spatial neglect.

  Neither for nor againstEvidence: Very LowIntervention
• 37

  There is insufficient evidence to recommend for or against the use of prism adaptation therapy for patients with unilateral spatial neglect.

  Neither for nor againstEvidence: Very LowIntervention

Mental Health

• 38

  There is insufficient evidence to recommend for or against solution-focused psychological interventions (e.g., motivational interviewing, problem-solving therapy) to prevent the development of depression.

  Neither for nor againstEvidence: Very LowIntervention
• 39

  We suggest against the use of antidepressants for the prevention of post-stroke depression.

  Weak againstEvidence: Very LowPharmacotherapy
• 40

  We suggest a selective serotonin reuptake inhibitor or a serotonin norepinephrine reuptake inhibitor for depression symptoms.

  Weak forEvidence: Very LowPharmacotherapy
• 41

  We suggest psychotherapy (e.g., cognitive behavioral therapy) for depression following stroke.

  Weak forEvidence: Very LowIntervention
• 42

  We suggest mindfulness-based therapies for treatment of depression following stroke.

  Weak forEvidence: Very LowIntervention
• 43

  There is insufficient evidence to recommend for or against acupuncture, either alone or as an adjunct to pharmacotherapy, for depression following stroke.

  Neither for nor againstEvidence: Very LowIntervention

Telehealth

• 44

  We suggest either face-to-face therapy or telerehabilitation, depending on patient characteristics and preferences.

  Weak forEvidence: LowIntervention
• 45

  There is insufficient evidence to recommend for or against the use of telerehabilitation and technology-based interventions to improve stroke-related dysphagia or aphasia outcomes or both.

  Neither for nor againstEvidence: Very LowIntervention
• 46

  There is insufficient evidence to recommend for or against technology-based caregiver support/education interventions to improve caregiver quality of life.

  Neither for nor againstEvidence: Very LowIntervention

Non-invasive Brain Stimulation

• 47

  There is insufficient evidence to recommend for or against non-invasive brain stimulation (e.g., repetitive transcranial magnetic stimulation, transcranial direct current stimulation, and continuous theta burst stimulation) for patients in stroke rehabilitation.

  Neither for nor againstEvidence: Very LowIntervention

Therapeutic Area

Guideline Scope

Inclusion Criteria

• Adult patients 18 years and older
• Experienced a stroke
• Eligible for care in the VA or DoD health care delivery systems

Exclusion Criteria

• Patients under 18 years of age

Care Settings

Special Populations

Evidence Levels

Recommendation Strength

Related

• VA/DoD Clinical Practice Guideline for Management of Major Depressive Disorder

Comparable guidelines from other societies

• 2019 VA/DoD Stroke Rehabilitation CPG
• 2019 Update to the 2018 AHA/ASA Guidelines for the Early Management of Patients with Acute Ischemic Stroke
• 2021 AHA/ASA Guidelines for the Prevention of Stroke in Patients with Stroke and Transient Ischemic Attack
• 2022 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage
• VA/DoD Clinical Practice Guideline for Management of Major Depressive Disorder