An Evidence Map of Clinical Practice Guideline Recommendations on Stroke Rehabilitation

American Journal of Physical Medicine & Rehabilitation

Wei, L., Shang, W., et al. (2024).

American Journal of Physical Medicine & Rehabilitation, Advance online publication. https://doi.org/10.1097/phm.0000000000002413.

<div>This umbrella review of clinical practice guidelines (CPGs) summarizes recommendations for management of swallowing and communication function for individuals post-stroke. Details about the included articles may be found in the Notes on this Article section.</div>

Not stated

<div>Two of the twelve articles published in this review are available elsewhere in the Evidence Maps. Please see the Associated Article(s) section below for more details.&nbsp;</div> <div> <div> <ul> <li>Umay, E., Eyigor, S., et al. (2021). Best Practice Recommendations for Stroke Patients With Dysphagia: A Delphi-Based Consensus Study of Experts in Turkey-Part II: Rehabilitation.&nbsp;<em>Dysphagia</em>,&nbsp;<em>36</em>(5), 800&ndash;820. https://doi.org/10.1007/s00455-020-10218-8</li> <li>Winstein, C. J., Stein, J., et al. (2016). Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. <em>Stroke</em>,&nbsp;<em>47</em>(6), e98&ndash;e169. https://doi.org/10.1161/STR.0000000000000098</li> </ul> <div>&nbsp;</div> <div>The ten remaining articles are not included in the Evidence Maps. Please contact ASHA&rsquo;s National Center for Evidence-Based Practice in Communication Disorders (N-CEP) for the full list of articles.</div> <div> <ul> <li>Fan, Y., Yu, J., et al. (2020). Chinese Stroke Association Guidelines for Clinical Management of Cerebrovascular Disorders: Executive Summary and 2019 Update of Clinical Management of Cerebral Venous Sinus Thrombosis.&nbsp;<em>Stroke and Vascular Neurology</em>,&nbsp;<em>5</em>(2), 152&ndash;158. https://doi.org/10.1136/svn-2020-000358</li> <li>Sall, J., Eapen, B. C., et al. (2019). The Management of Stroke Rehabilitation: A Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline. <em>Annals of Internal Medicine</em>,&nbsp;<em>171</em>(12), 916&ndash;924. https://doi.org/10.7326/M19-1695</li> <li>Brosseau, L., Wells, G. A., et al. (2006). Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation. <em>Topics in Stroke Rehabilitation</em>,&nbsp;<em>13</em>(2), 1-269. https://doi.org/10.1310/3TKX-7XEC-2DTG-XQKH</li> </ul> </div> </div> </div>

From database inception to March 2022

<div>Clinical practice guidelines&nbsp;</div>

12

<div>The following were recommendations regarding organizational management:</div> <div> <ul> <li>"All patients admitted to the hospital with acute stroke should have an initial assessment conducted by rehabilitation professionals immediately after admission" (p. 10; strong [4 CPGs], not mentioned [2 CPGs]).</li> <li>"Within 24h of admission, rehabilitation professionals in direct contact with the patient should start initial screening and assessment" (p. 10; strong [2 CPGs], not mentioned [2 CPGs]).</li> <li>"A standard and effective scale can be applied for the rehabilitation assessment before developing an individualized program for rehabilitation" (p. 10; strong [2 CPGs], not mentioned [1 CPG]).</li> <li>"Initial assessment would include evaluating the function, safety, physical readiness, and learning and participation ability of the patient in rehabilitation therapies" (p. 10; strong [1 CPG], not mentioned [2 CPGs]).</li> <li>"All the patients requiring inpatient rehabilitation after a stroke should be treated in a specialized stroke rehabilitation unit (p. 10; strong [1 CPG], not mentioned [2 CPGs]).</li> <li>"In the interprofessional team, additional members may include pharmacists, discharge planners or case managers, (neuro) psychologists, palliative care&nbsp;specialists, recreation and vocational therapists, therapy assistants, spiritual care providers, peer supporters, and stroke recovery group liaisons" (p. 10; strong [3 CPGs], weak [1 CPG], not mentioned [4 CPGs]).</li> </ul> </div>

<div>The following were recommendations regarding timing and intensity:</div> <div> <ul> <li>"All stroke patients should receive rehabilitation therapy as early as possible once they are deemed ready and can medically participate in active rehabilitation within an active and complex stimulating environment" (p. 11; strong [7 CPGs], not mentioned [3 CPGs]).</li> <li>"Patients should receive rehabilitation therapies of appropriate intensity and duration. The therapies should be individually designed to meet their needs for optimal recovery and tolerance levels" (p. 11; strong [1 CPG], weak [3 CPGs], not mentioned [2 CPGs]).</li> </ul> </div>

<div>The following were recommendations regarding rehabilitation and management of dysphagia:</div> <div> <ul> <li>"All stroke patients should undergo a standard clinical bedside evaluation of swallowing function by a clinician, rehabilitation nurse, or speech therapist" (p. 11; strong [2 CPGs], weak [2 CPGs], not mentioned [1 CPG]).</li> <li>"According to the results from the bedside swallowing assessment, all the patients at risk for pharyngeal dysphagia or poor airway protection should undergo a Videofluoroscopic swallow study (VSS, VFSS, MBS) or fiberoptic endoscopic examination of swallowing (FEES)" (p. 11; strong [1 CPG], weak [1 CPG], not mentioned [1 CPG]).</li> <li>"Behavioral intervention is a part of swallowing treatment. Oral hygiene management can reduce the risk of post-stroke aspiration pneumonia" (p. 11; strong [3 CPGs], not mentioned [1 CPG]).</li> <li>Neuromuscular electrical stimulation (NMES), pharyngeal electrical stimulation (PES), physical/sensory stimulation, transcranial direct current stimulation (tDCS), and transcranial magnetic stimulation (TMS) are not recommended due to uncertain benefits (weak [1 CPG], not mentioned [3 CPGs]).</li> </ul> </div>

<div>The following were recommendations regarding return-to-work:</div> <div> <ul> <li>"Vocationally targeted therapy or vocational rehabilitation can be reasonable for stroke patients considering a return to work" (p. 12; weak [1 CPG], not mentioned [2 CPGs]).</li> <li>"Assessing cognitive, perception, physical, and motor abilities may be implemented in stroke survivors considering a return to work" (p. 12; strong [1 CPG], weak [1 CPG], not mentioned [3 CPGs]).</li> </ul> </div>

<div>The following were recommendations regarding communication, speech, and language function:</div> <div> <div> <ul> <li>"Stroke patients should be screened for communication disorders with a simple, reliable, and validated tool" (p. 12; not mentioned [1 CPG]).</li> <li>"All stroke patients should be evaluated by a speech and language pathologist to uncover subtle communication disorders" (p. 12; strong [1 CPG], not mentioned [1 CPG]).</li> <li>"Communication assessment must include an interview, conversation, observation, standardized tests, or non-standardized items such as speech assessment, language, cognitive-communication, pragmatics, reading, and writing; identification of communicative strengths and weaknesses, and identification of helpful compensatory strategies" (p. 12; strong [1 CPG], weak [1 CPG], not mentioned [1 CPG]).</li> </ul> </div> </div>

<div>The following is recommended in adults with post-stroke aphasia:</div> <div> <ul> <li>"All professional team members should be trained in supportive conversation to interact with patients suffering from communication limitations like aphasia" (p. 13; not mentioned [2 CPGs]).</li> <li>"Patients with aphasia should have early access to a combination of intensive language and communication therapy based on their needs, goals, and impairment severity" (p. 13; not mentioned [1 CPG]).</li> </ul> </div>