http://journals.lww.com/neurotodayonline/blog/breakingnews/pages/post.aspx?PostID=547
BY SARAH OWENS
Citing a number of "unmet needs" in rehabilitative stroke care, a new guideline from the American Heart Association and the American Stroke Association said the best evidence supports offering stroke patients these among other services:
1. a formal fall prevention program during hospitalization,
2. a balance training program,
3. assessments for calcium and vitamin D supplementation for stroke survivors living in long-term care facilities, and
4. speech and language therapy for individuals with aphasia.
The impetus for the evidence-based guideline, which was published online May 4 ahead of the June print issue of Stroke, was a "lack of clear guidelines regarding the efficacy of various interventions," guideline author Joel Stein, MD, Simon Baruch professor and chair of the department of rehabilitation and regenerative medicine at Columbia University College of Physicians and Surgeons, professor and chief of the division of rehabilitation medicine at Weill Cornell Medical College, and physiatrist-in-chief at New York-Presbyterian Hospital, told Neurology Today. A comprehensive guideline is particularly necessary because of the increasing array of therapeutic interventions for stroke, Dr. Stein said.
One of the guideline's most important new recommendations is that patients who have residual deficits after a stroke should receive a functional assessment from a clinician with expertise in rehabilitation, Dr. Stein said. Currently, "some people who have a stroke are not necessarily evaluated by an expert, especially if their symptoms are relatively mild. This can lead to rehabilitation at a lesser level of intensity than is appropriate, or for not as long as required, or that is not as focused on their specific needs as they deserve."
The guideline authors pointed out that stroke care in the US has become very heterogeneous, and is best when delivered by a multidisciplinary team that includes stroke neurologists, physiatrists, nurses, physical and occupational therapies, speech-language pathologists, as well as psychologists, nutritionists, social workers, and others.
The panel conducted computerized searches of available medical literature, including systematic reviews through 2014, and organized data and studies using the joint American Heart Association/American College of Cardiology classification system — dividing findings by level of certainty, the class of each trial, and the level of evidence.
It found that between 1996 and 2003 the proportion of patients who had not been referred for any post-acute rehabilitation increased from 26 to 31 percent. One analysis of 2006 Medicare data found the level had increased to 42 percent.
The guideline authors noted that stroke "has been managed medically as a temporary or transient condition," and that a comprehensive approach was needed to ensure a continuum of care, including social reintegration, health-related quality of life, and self-efficacy.
Dr. Stein also stressed the importance – noted for the first time in this guideline – of recognizing post-stroke depression. "It's extraordinarily common after a stroke – estimates range up to 40 percent for people who have significant depression after stroke. And there's an attitude that [depression] is an unavoidable consequence of stroke. That's very unfortunate, because, in fact, it's very disabling to be depressed; people withdraw socially, they are less active, and their mobility deteriorates. But this type of depression responds well to standard treatments for depression."
The guideline also includes an analysis of inpatient and outpatient rehabilitation treatment; in particular, it emphasizes the importance of impatient rehabilitation for patients with significant deficits. "This guideline, for the first time, clearly states that patients who qualify for inpatient rehabilitation facility care, which is high-level hospital rehabilitation, and who have access to it, really should receive that type of care in preference to lower levels of rehabilitation," said Dr. Stein. Inpatient rehabilitation offers the added benefit that it "supports strong teamwork among caregivers," Dr. Stein added. For patients who receive outpatient stroke treatment, it's important to have a physician who serves as "a central command center for a caregiving team to make sure that referrals go to physical therapy, occupational therapy, speech therapy, psychology, psychiatry, et cetera, as appropriate," said Dr. Stein.
Above all, communication and coordination are "paramount" in achieve the best possible outcomes for people who have suffered a stroke, the study's authors concluded. Without such coordination, they added, "isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential."
Look for a more in-depth analysis of the stroke rehabilitation guideline in the June 9 issue of Neurology Today.
LINK UP FOR MORE INFORMATION:
Citing a number of "unmet needs" in rehabilitative stroke care, a new guideline from the American Heart Association and the American Stroke Association said the best evidence supports offering stroke patients these among other services:
1. a formal fall prevention program during hospitalization,
2. a balance training program,
3. assessments for calcium and vitamin D supplementation for stroke survivors living in long-term care facilities, and
4. speech and language therapy for individuals with aphasia.
The impetus for the evidence-based guideline, which was published online May 4 ahead of the June print issue of Stroke, was a "lack of clear guidelines regarding the efficacy of various interventions," guideline author Joel Stein, MD, Simon Baruch professor and chair of the department of rehabilitation and regenerative medicine at Columbia University College of Physicians and Surgeons, professor and chief of the division of rehabilitation medicine at Weill Cornell Medical College, and physiatrist-in-chief at New York-Presbyterian Hospital, told Neurology Today. A comprehensive guideline is particularly necessary because of the increasing array of therapeutic interventions for stroke, Dr. Stein said.
One of the guideline's most important new recommendations is that patients who have residual deficits after a stroke should receive a functional assessment from a clinician with expertise in rehabilitation, Dr. Stein said. Currently, "some people who have a stroke are not necessarily evaluated by an expert, especially if their symptoms are relatively mild. This can lead to rehabilitation at a lesser level of intensity than is appropriate, or for not as long as required, or that is not as focused on their specific needs as they deserve."
The guideline authors pointed out that stroke care in the US has become very heterogeneous, and is best when delivered by a multidisciplinary team that includes stroke neurologists, physiatrists, nurses, physical and occupational therapies, speech-language pathologists, as well as psychologists, nutritionists, social workers, and others.
The panel conducted computerized searches of available medical literature, including systematic reviews through 2014, and organized data and studies using the joint American Heart Association/American College of Cardiology classification system — dividing findings by level of certainty, the class of each trial, and the level of evidence.
It found that between 1996 and 2003 the proportion of patients who had not been referred for any post-acute rehabilitation increased from 26 to 31 percent. One analysis of 2006 Medicare data found the level had increased to 42 percent.
The guideline authors noted that stroke "has been managed medically as a temporary or transient condition," and that a comprehensive approach was needed to ensure a continuum of care, including social reintegration, health-related quality of life, and self-efficacy.
Dr. Stein also stressed the importance – noted for the first time in this guideline – of recognizing post-stroke depression. "It's extraordinarily common after a stroke – estimates range up to 40 percent for people who have significant depression after stroke. And there's an attitude that [depression] is an unavoidable consequence of stroke. That's very unfortunate, because, in fact, it's very disabling to be depressed; people withdraw socially, they are less active, and their mobility deteriorates. But this type of depression responds well to standard treatments for depression."
The guideline also includes an analysis of inpatient and outpatient rehabilitation treatment; in particular, it emphasizes the importance of impatient rehabilitation for patients with significant deficits. "This guideline, for the first time, clearly states that patients who qualify for inpatient rehabilitation facility care, which is high-level hospital rehabilitation, and who have access to it, really should receive that type of care in preference to lower levels of rehabilitation," said Dr. Stein. Inpatient rehabilitation offers the added benefit that it "supports strong teamwork among caregivers," Dr. Stein added. For patients who receive outpatient stroke treatment, it's important to have a physician who serves as "a central command center for a caregiving team to make sure that referrals go to physical therapy, occupational therapy, speech therapy, psychology, psychiatry, et cetera, as appropriate," said Dr. Stein.
Above all, communication and coordination are "paramount" in achieve the best possible outcomes for people who have suffered a stroke, the study's authors concluded. Without such coordination, they added, "isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential."
Look for a more in-depth analysis of the stroke rehabilitation guideline in the June 9 issue of Neurology Today.
LINK UP FOR MORE INFORMATION:
- Winstein CJ, Stein J, Arena R, et al, on behalf of the American heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Quality of Care and Outcomes Research. Guidelines for adult stroke rehabilitation and recovery. A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2016; Epub 2016 May 4.
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