Stroke Rehabilitation: Synopsis of the 2024 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

 Notice this is guidelines; NOT PROTOCOLS! so, they really don't know what they are doing to get you recovered. Isn't incompetence wonderful when your stroke medical 'professionals' have NO consequences from it, but it affects you!

Stroke Rehabilitation: Synopsis of the 2024 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

Authors: Blessen C. Eapen, MD, Johanna Tran, MD, Jennifer Ballard-Hernandez, DNP, NP https://orcid.org/0000-0003-1657-1476, Andrew Buelt, DO, DNP, Carrie W. Hoppes, PT, PhD https://orcid.org/0000-0001-5104-7448, Christine Matthews, CScD, Svetlana Pundik, MD, MSc, James Reston, PhD, MPH, MAJ Zahari Tchopev, MD, MBA https://orcid.org/0000-0003-1829-3190, Lisa M. Wayman, PhD, RN, and MAJ Tyler Koehn, MDAuthor, Article, & Disclosure Information

Publication: Annals of Internal Medicine

https://doi.org/10.7326/ANNALS-24-02205

Eligible for CME Point-of-Care

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• Abstract
• Guideline Development Process
• Highlighted 2024 Guideline Updates
• Comparison With Other Guidelines
• Research Recommendations
• Conclusion
• Supplemental Material
• References
• Comments

• Information & Authors
• Metrics & Citations
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Abstract

Description:

In July 2024, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DOD) released a joint update of their 2019 clinical practice guideline (CPG) for the management(NOT RECOVERY!) of stroke rehabilitation. This synopsis is a condensed version of the 2024 CPG, highlighting the key aspects of the guideline development process and describing the major recommendations.

Methods:

The VA/DOD Evidence-Based Practice Work Group convened a joint VA/DOD guideline development work group (WG) that included clinical stakeholders and conformed to the Institute of Medicine’s tenets for trustworthy CPGs. The guideline WG conducted a patient focus group, developed key questions, and systematically searched and evaluated the literature (English-language publications from 1 July 2018 to 2 May 2023). The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to evaluate the evidence. The WG developed 47 recommendations along with algorithms for stroke rehabilitation in the inpatient and outpatient settings. Stakeholders outside the WG reviewed the CPG before approval by the VA/DOD Evidence-Based Practice Work Group.

Recommendations:

This synopsis summarizes where evidence is strongest to support guidelines in crucial areas relevant to primary care physicians: transition to community (case management, psychosocial or behavioral interventions); motor therapy (task-specific practice, mirror therapy, rhythmic auditory stimulation, electrical stimulation, botulinum toxin for spasticity); dysphagia, aphasia, and cognition (chin tuck against resistance, respiratory muscle strength training); and mental health (selective serotonin reuptake inhibitor use, psychotherapy, mindfulness-based therapies for treatment but not prevention of depression).

Stroke is a major cause of morbidity, mortality, and disability worldwide. It is a pervasive medical condition affecting nearly 800 000 persons annually in the United States; approximately 75% of cases are first-time occurrences and the remaining 25% are recurrent strokes (1). Roughly 3% of the U.S. population has experienced a stroke, with a projected increase to 4% by 2030 (1). Stroke is the fifth most prevalent cause of death in the United States, accounting for 1 out of every 21 deaths in the nation; alarmingly, a stroke-related death occurs approximately every 3 minutes 17 seconds (1). Stroke is a leading contributor to long-term disability, with approximately 45% of persons aged 15 to 50 years having at least moderate disability after a stroke (2).

The spectrum of disability resulting from stroke manifests diversely. Typical presentations may include motor weakness and sensory disturbances, impairments in speech and swallowing, vision loss or neglect, cognitive challenges involving inattention or memory loss, and emotional difficulties, such as mood disorders or anxiety. Stroke survivors consequently require tailored and timely rehabilitative interventions aligning with their individualized needs (3, 4). Tailored rehabilitative efforts should start as soon as clinically feasible to maximize functional outcomes. These guidelines are relevant for health care professionals across a stroke patient’s continuum of care, including primary care providers, specialists (physiatry, neurology, and cardiology), nurses, and allied health professionals.

The patient population of interest for the 2024 VA/DOD Clinical Practice Guideline for Management of Stroke Rehabilitation (5) is adult patients with poststroke deficits (motor, cognitive, speech, or sensory) who are candidates for rehabilitation. These guidelines can be found at www.healthquality.va.gov/guidelines/rehab/stroke/index.asp.

The focus and scope of the 2024 clinical practice guideline (CPG) is to provide primary care providers in the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DOD) with recommendations and tools for the rehabilitation management of adult patients (aged ≥18 years) who have had a stroke, with an emphasis on an interdisciplinary care approach. The guideline also provides stroke rehabilitation specialist providers with guidelines for evidence-based practice. It is intended to improve quality of care and clinical outcomes; however, it is not intended to define a standard of care. The 2024 guideline is an update to the 2019 VA/DOD Clinical Practice Guideline for Management of Stroke Rehabilitation (6).

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