VA/DoD Clinical Practice Guideline (CPG) For The .

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VA/DoD CLINICAL PRACTICE GUIDELINE FORTHE MANAGEMENT OF STROKEREHABILITATIONDepartment of Veterans AffairsDepartment of DefenseQUALIFYING STATEMENTSThe Department of Veterans Affairs and the Department of Defense guidelines are based upon the bestinformation available at the time of publication. They are designed to provide information and assistdecision 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 epidemiologicalevidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logicalrelationships between various care options and health outcomes while rating both the quality of theevidence and the strength of the recommendation.Variations in practice will inevitably and appropriately occur when clinicians take into account the needs ofindividual patients, available resources, and limitations unique to an institution or type of practice. Everyhealthcare professional making use of these guidelines is responsible for evaluating the appropriateness ofapplying 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 theseguidelines does not guarantee coverage of civilian sector care. Additional information on currentTRICARE benefits may be found at www.tricare.mil or by contacting your regional TRICARE ManagedCare Support Contractor.Version 4.0 – 2019

VA/DoD Clinical Practice Guideline for the Management of Stroke RehabilitationPrepared by:The Management of Stroke Rehabilitation Work GroupWith support from:The Office of Quality, Safety and Value, VA, Washington, DC&Office of Evidence Based Practice, U.S. Army Medical CommandVersion 4.0 – 2019Based on evidence reviewed through July 5, 2018July 2019Page 2 of 170

VA/DoD Clinical Practice Guideline for the Management of Stroke RehabilitationTable of ContentsI.Introduction. 5II.Background. 5A.Stroke Epidemiology and Impact in the General Population . 5B.Stroke Rehabilitation in the Department of Veterans Affairs Population . 6C.Stroke Rehabilitation in the Department of Defense Population . 6III. About this Clinical Practice Guideline . 7A.Methods . 7a. Grading Recommendations . 8b. Reconciling 2010 Clinical Practice Guideline Recommendations . 10c. Peer Review Process . 11B.Summary of Patient Focus Group Methods and Findings. 11C.Conflicts of Interest . 12D.Scope of this Clinical Practice Guideline . 13E.Highlighted Features of this Clinical Practice Guideline . 13F.Patient-centered Care . 13G.Shared Decision Making . 14H.Co-occurring Conditions . 14I.Implementation . 14IV. Guideline Work Group . 15V.Algorithm . 17A.Module A: Rehabilitation Disposition of the Inpatient with Stroke. 18B.Module B: Outpatient/Community-Based Rehabilitation . 19VI. Recommendations . 23A.Approach and Timing. 27B.Motor Therapy . 30a. Upper and Lower Limbs Rehabilitation . 30b. Technology-Assisted Physical Rehabilitation . 37c. Pharmacological Treatment in Motor Therapy . 45C.Dysphagia Therapy . 48D.Cognitive, Speech, and Sensory Therapy . 55a. Cognitive Therapy . 55b. Speech Therapy . 56c. Spatial Neglect Therapy . 57d. Visual Therapy . 59July 2019Page 3 of 170

VA/DoD Clinical Practice Guideline for the Management of Stroke RehabilitationE.Mental Health Therapy. 61a. Prevention of Post-Stroke Depression . 61b. Treatment of Post-Stroke Depression . 63c. Treatment of Post-Stroke Anxiety . 66d. Adjunctive Treatment . 69F.Other Functions . 72VII. Research Priorities . 74Appendix A:Identifying Patient Rehabilitation Goals. 77Appendix B: Additional Information on Management of Stroke . 80A.Education . 80B.Communication . 80C.Dysphagia . 81D.Driving . 82E.Pseudobulbar Affect . 83Appendix C:Patient Focus Group Methods and Findings . 84A.Methods . 84B.Patient Focus Group Findings. 84Appendix D: Evidence Review Methodology. 87A.Developing the Key Questions . 87B.Conducting the Systematic Review . 98C.Convening the Face-to-face Meeting. 103D.Grading Recommendations. 103E.Recommendation Categorization . 107F.Drafting and Submitting the Final Clinical Practice Guideline. 109Appendix E:Evidence Table . 111Appendix F:2010 Recommendation Categorization Table . 116Appendix G: Participant List . 140Appendix H: Literature Review Search Terms and Strategy . 142Appendix I:Alternative Text Descriptions of Algorithms. 154Appendix J:Abbreviation List. 157References . 160July 2019Page 4 of 170

VA/DoD Clinical Practice Guideline for the Management of Stroke RehabilitationI.IntroductionThe Department of Veterans Affairs (VA) and Department of Defense (DoD) Evidence-Based Practice WorkGroup (EBPWG) was established and first chartered in 2004, with a mission to advise the Health ExecutiveCommittee (HEC) “ on the use of clinical and epidemiological evidence to improve the health of thepopulation ” across the Veterans Health Administration (VHA) and Military Health System (MHS), byfacilitating the development of clinical practice guidelines (CPGs) for the VA and DoD populations.[1] ThisCPG is intended to provide healthcare providers with a framework by which to evaluate, treat, andmanage the individual needs and preferences of patients rehabilitating from stroke, thereby leading toimproved clinical outcomes.In 2010, the VA and DoD published a CPG for the Management of Stroke Rehabilitation (2010 StrokeRehabilitation CPG), which was based on evidence reviewed through March 2009. Since the release of thatguideline, a growing body of research has expanded the general knowledge and understanding of strokerehabilitation.Consequently, a recommendation to update the 2010 Stroke Rehabilitation CPG was initiated in 2018. Theupdated CPG, which includes objective, evidence-based information, is intended to assist healthcareproviders in all aspects of stroke rehabilitation (e.g., assessment, treatment, follow-up). The system-widegoal of evidence-based guidelines is to improve the patient’s health and well-being by guiding healthproviders who are taking care of patients recovering from stroke along management pathways that aresupported by evidence. The expected outcomes of successful implementation of this guideline is include: Assessing the patient’s condition and determining, in collaboration with the patient, family, andcaregivers, the optimal treatment and rehabilitation method Optimizing each individual’s health outcomes and improve quality of life Minimizing preventable complications and morbidity Emphasizing the use of patient-centered care (PCC)II.BackgroundA.Stroke Epidemiology and Impact in the General PopulationStroke is a condition that affects nearly 800,000 individuals annually in the United States (U.S.).Approximately 75% of these are first-time strokes, while the remaining 25% are recurrent strokes.[2] Whileoften viewed as a disease of the elderly, stroke can occur at any age. Approximately 10% of all strokesoccur in individuals aged 18-50.[2] Currently, stroke is the fifth most common cause of death in the U.S.and a leading cause of long-term disability.[2] While younger patients may be more physically capable ofrecovering from stroke than older patients, poor functional outcomes are commonplace. Approximately44% of individuals aged 18-50 experience moderate disability after stroke, requiring at least someassistance with activities of daily living (ADL) and/or mobility (modified Rankin Scale score 2).[3] Even inpatients with so-called “mild” or “improving” stroke, a recent study found that only 28% were dischargedto home, 16% required admission to acute rehabilitation facilities, and 11% were admitted to skillednursing facilities.[4]July 2019Page 5 of 170

VA/DoD Clinical Practice Guideline for the Management of Stroke RehabilitationDisability from stroke can present in a myriad of ways depending on the affected area(s) of the centralnervous system. The most common presentations include focal weakness and sensory disturbances,speech and swallowing impairments, vision loss or neglect, cognitive problems with inattention or memoryloss, as well as emotional difficulties with mood or anxiety. The early management of stroke in the form ofmedical, surgical, or rehabilitation interventions is essential to help reduce disability severity, decrease therisk of further complications, and lessen potentially life-long deficits.[5,6]Unfortunately, in approximately 30% of ischemic stroke cases, the cause of the stroke remainsunknown.[7] Ischemic strokes with no obvious cause are labelled as “cryptogenic” strokes and are morecommon in younger patients than in the elderly.[8] This is largely due to the lack of comorbiditiesassociated with stroke risk more commonly seen in the older population (e.g., uncontrolled hypertension,atrial dysrhythmias, cerebrovascular disease). Research is ongoing to try to identify patients with thehighest risk of cryptogenic stroke recurrence; however, risk factors are difficult to quantify given the lack ofa clearly identifiable primary etiology. This is of particular importance in the active duty militarypopulation, in which both residual disability and the likelihood of recurrence can directly impact dutyrestrictions, deployability, and/or disability ratings.B.Stroke Rehabilitation in the Department of Veterans Affairs PopulationThe Veterans Health Administration (VHA) estimates that 15,000 Veterans are hospitalized for strokerelated diagnoses each year. In 2017, just over 8,000 unique patients with stroke were admitted to the VA.The number of new patients with stroke at the VA was 8,125. Approximately 15-30% of survivors of strokeare left with severe disability, while 40% experience functional impairments.[9] In 2019, there are 33Primary Stroke Centers, 32 limited hours Stroke Centers, 43 supporting stroke facilities, and over 45 acuterehabilitation units (ARU) in the VA. Comprehensive outpatient neurorehabilitation programs are alsolocated throughout the VA, but many Veterans who are admitted to a VA medical center after surviving astroke will find themselves in a facility that does not offer comprehensive, integrated, and coordinatedcare. Additionally, Veterans may receive acute treatment for stroke in facilities outside the VHA and laterpresent for follow-up care at their local VA facility.C.Stroke Rehabilitation in the Department of Defense PopulationWhile less common than in the VA population, stroke does occur in active duty, retiree, and otherbeneficiary populations served by the DoD. Comprehensive acute management of stroke is accomplishedat military treatment facilities (MTFs) unless the patient meets criteria for transfer to the nearest certifiedstroke center. At this time, the DoD has no certified stroke centers. The DoD has limited inpatientrehabilitation beds and often partners with VA or civilian network providers when these services areneeded. At some of the larger MTFs, comprehensive outpatient stroke rehabilitation services may beavailable. Some military medical facilities may offer these services through their traumatic brain injury(TBI) rehabilitation clinics. Survivors of stroke who live outside of military medical center catchment areasare able to access community stroke resources through the TRICARE network.July 2019Page 6 of 170

VA/DoD Clinical Practice Guideline for the Management of Stroke RehabilitationIII. About this Clinical Practice GuidelineThis guideline is aimed at improving the management of stroke rehabilitation in the VA and DoD. As withother CPGs, however, challenges remain, including evidence gaps, the need to develop effective strategiesfor guideline implementation and the need to evaluate the effect of guideline adherence on clinicaloutcomes. This guideline is intended for use by VA and DoD healthcare practitioners including physicians,nurses, nurse practitioners, physician assistants, psychologists and other mental health providers, socialworkers, pharmacists, physical therapists, occupational therapists, case managers, speech languagepathologists, vision therapists, vocational rehabilitation specialists, recreation therapists, and othersinvolved in the care of Service Members or Veterans undergoing stroke rehabilitation.As elaborated in the qualifying statement on page one, this CPG is not intended to serve as a standard ofcare. Standards of care are determined on the basis of all clinical data available for an individual patientand are subject to change as scientific knowledge and technology advance and patterns evolve. This CPG isbased on information available on or before July 5, 2018 (see Appendix D for additional information on theevidence review methodology; note, discussion of topics related to Key Questions 3 and 9 [see Table D-2]is based on information available on or before December 18, 2018 [see General Criteria for Inclusion inSystematic Review]) and is intended to provide a general guide to best leading evidence-based practices.While this guideline can assist care providers, the use of a CPG must always be considered as arecommendation, within the context of a provider’s clinical judgment and patient values and preferences,for the care of an individual patient. Additional materials including an a

rehabilitation. Consequently, a recommendation to update the 2010 Stroke Rehabilitation CPG was initiated in 2018. The updated CPG, which includes objective, evidence-based information, is intended to assist healthcare providers in all aspects of stroke rehabilitation (

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