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).

More at link.

Treatment Effects of Upper Limb Action Observation Therapy and Mirror Therapy on Rehabilitation Outcomes after Subacute Stroke: A Pilot Study

 Using Fugl-Meyer as a measurement tool means this is not objectively measured so not repeatable.  Your doctor will need to get the protocol for this anyway.  See the email for how to contact. There is absolutely no fucking excuse for your doctor to not accomplish this.  Or, I suppose you could let your doctor continue to be incompetent with no consequences.

Treatment Effects of Upper Limb Action Observation Therapy and Mirror Therapy on Rehabilitation Outcomes after Subacute Stroke: A Pilot Study

 Yu-Wei Hsieh ,1,2,3 Yu-Hsuan Lin,4 Jun-Ding Zhu ,1 Ching-Yi Wu ,1,2,3 Yun-Ping Lin,5 and Chih-Chi Chen3,6 1Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan 2Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan 3Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkou, Taiwan 4Department of Physical Medicine and Rehabilitation, Cathay General Hospital, Taipei, Taiwan 5Division of Occupational Therapy, Department of Physical Medicine and Rehabilitation, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan 6School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
Correspondence should be addressed to Yu-Wei Hsieh; ywhsieh@mail.cgu.edu.tw Received 19 July 2019; Revised 18 November 2019; Accepted 12 December 2019; Published 2 January 2020
Academic Editor: Luigi Trojano
Copyright © 2020 Yu-Wei Hsieh et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background. 
Action observation therapy and mirror therapy, two promising rehabilitation strategies, are aimed at enhancing the motor learning and functional improvement of stroke patients through different patterns of visual feedback and observation.
Objective. 
This study investigated and compared the treatment effects of the action observation therapy, mirror therapy, and active control intervention on motor and functional outcomes of stroke patients. Methods. 
Twenty-one patients with subacute stroke were recruited in this study. All patients were randomly assigned to the action observation therapy, mirror therapy, or active control intervention for 3 weeks. Outcome measures were conducted at baseline, immediately after treatment, and at 3-month follow-up. The primary outcome was the Fugl-Meyer Assessment, and secondary outcomes included the Box and Block Test, Functional Independence Measure, and Stroke Impact Scale. Descriptive analyses and the number of patients whose change score achieved minimal clinically important difference were reported.
Results. 
Both the action observation therapy and active control intervention showed similar improvements on the Fugl-Meyer Assessment, Box and Block Test, and Stroke Impact Scale. Moreover, the action observation therapy had a greater improvement on the Functional Independence Measure than the other 2 groups did. However, the mirror therapy group gained the least improvements on the outcomes.
Conclusion. 
The preliminary results found that the patients in the action observation therapy and active control intervention groups had comparable benefits, suggesting that the 2 treatments might be used as an alternative to each other. A further large-scale study with at least 20 patients in each group to validate the study findings is needed. This trial is registered with NCT02871700.

Pre-hospital Triage of Acute Ischemic Stroke Patients—Importance of Considering More Than Two Transport Options

Once again you have to have the proper stroke with the correct presentations to be treated properly.   This leaves vast numbers of strokes left behind. NOT ACCEPTABLE. Do you think you can accomplish that? No consequences to the doctors for not having prepared for all eventualities. But severe consequences to the stroke survivors, if they survive.

Pre-hospital Triage of Acute Ischemic Stroke Patients—Importance of Considering More Than Two Transport Options

Ludwig Schlemm^1,2,3*, Eckhard Schlemm^4,5, Christian H. Nolte^1,2,3,6,7 and Matthias Endres^1,2,3,6,7

• ¹Department of Neurology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
• ²Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin, Berlin, Germany
• ³Berlin Institute of Health (BIH), Berlin, Germany
• ⁴Medizinische Fakultät, Universität Hamburg, Hamburg, Germany
• ⁵Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
• ⁶DZHK (German Center for Cardiovascular Research), Partner Site, Berlin, Germany
• ⁷DZNE (German Center for Neurodegenerative Diseases), Partner Site, Berlin, Germany

Background: Patients with acute ischemic stroke (AIS) and large vessel occlusion benefit from rapid access to mechanical thrombectomy in addition to intravenous thrombolysis. Prehospital triage algorithms to determine the optimal transport destination for AIS patients with unknown vessel status have so far only considered two alternatives: the nearest comprehensive (CSC) and the nearest primary stroke center (PSC).

Objective: This study explores the importance of considering a larger number of PSCs during pre-hospital triage of AIS patients.

Methods: Analysis was performed in random two-dimensional abstract geographic stroke care infrastructure environments and two models based on real-world geographic scenarios. Transport times to CSCs and PSCs were calculated to define sub-regions with specific triage properties. Possible transport destinations included the nearest CSC, the nearest PSC, and any of the remaining PSCs that are not closest to the scene, but transport to which would imply a shorter total time-to-CSC-via-PSC.

Results: In abstract geographic environments, the median relative size of the sub-region where a triage decision is required ranged from 34 to 92%. The median relative size of the sub-region where more than two triage options need to be considered ranged from 0 to 56%. The achievable reduction in time-to-thrombectomy (“benefit”) exceeded the increase in time-to-thrombolysis (“harm”) by a factor of 2 in 30.5–37.0% of the sub-region where more than two triage options need to be considered. Results were confirmed in geographic environments based on real-world urban and rural stroke care infrastructures.

Conclusion: Pre-hospital triage algorithms for AIS patients that only take into account the nearest CSC and the nearest PSC as transport destinations may be unable to identify the optimal transport destination for a significant proportion of patients.

Introduction

Background

International guidelines recommend early administration of intravenous thrombolysis for eligible patients with acute ischemic stroke (AIS); in addition, patients with proximal large vessel occlusion (LVO) should receive mechanical thrombectomy (MT) as quickly as possible (1). As the clinical benefit of both thrombolysis (2–4) and MT (5–7) diminishes over time, research efforts in recent years have focused on improving clinical outcome by reducing pre-hospital (8–10) and intra-hospital delays (11, 12). With regard to pre-hospital delays, directly transporting AIS patients to an MT-capable comprehensive stroke center (CSC) instead of a nearer non-MT-capable primary stroke center (PSC) has been suggested as one strategy to reduce time to MT for patients with LVO (13). Given that information about the vessel status of patients is typically not available to emergency medical personnel in the field, patients that are likely to benefit from direct transportation to a CSC need to be selected based on clinical and demographic variables. Several clinical pre-hospital stroke severity scales with similar accuracies to estimate the likelihood of LVO exist (14); however, the optimal instruments as well as the most appropriate cutoff values to inform pre-hospital triage decisions and to select patients for direct transportation to a CSC are not currently known (1). Previous studies that explored the impact of triage algorithms to determine the most adequate transport destination for AIS patients only allowed for a decision between two alternatives, namely transport to the nearest CSC, bypassing all PSCs; and transport to the nearest PSC (15–17). However, clinical experience as well as fundamental geographic observations suggest that oftentimes a PSC that is not nearest to the scene, but from which a patient could be transferred quickly to a CSC if necessary, might be a better primary transport destination option than the nearest PSC.

ESJ Comment: Therapeutic hypothermia for acute ischaemic stroke. Results of a European multicenter, randomized, phase III clinical trial

All my previous research posts on this suggested no useful intervention. Obviously no protocols were ever written on hypothermia so everyone is still shooting in the dark. The result being that survivors are still screwed with no consequences to the doctors who haven't written up protocols on this. Don't you just love incompetence?

• hypothermia (43)

 

ESJ Comment: Therapeutic hypothermia for acute ischaemic stroke. Results of a European multicenter, randomized, phase III clinical trial

by ESO | 24.4.2019 | Stroke Research | 0 comments

Comment by Nicolas Martinez-Majander, Department of Neurology, Helsinki University Hospital, Finland

Original Article: H Bart van der Worp, Malcolm R Macleod, Philip MW Bath et al, 2019. Therapeutic hypothermia for acute ischaemic stroke. Results of a European multicenter, randomized, phase III clinical trial https://journals.sagepub.com/doi/10.1177/2396987319844690

Previous systematic reviews and meta-analyses of animal studies have shown that therapeutic hypothermia is highly effective in reducing infarct size and improving neurological outcome. Hypothermia can affect several ongoing processes in the penumbra, such as counteracting edema, reducing lactacidosis, and inhibiting free radical formation and apoptosis. However, there is only little evidence of therapeutic hypothermia in human stroke.

In this paper of ESJ, van der Worp and colleagues reported results of EuroHYP-1, a European multicentre, randomized, phase III clinical trial which aimed to assess whether modest systemic cooling started within 6 hours of symptom onset could improve functional outcome at three months in awake patients with acute ischaemic stroke. These patients were allocated to hypothermia (target body temperature of 34-35°C either with intravenous infusion or a pre-specified surface cooling method) within 6 h after onset of stroke. Hypothermia was maintained for 12 to 24 hours. The primary outcome was mRS score at 91 days, assessed by independent blinded adjudicators. Although the target sample size was 1500 patients, the trial was stopped after inclusion of 98 patients, at 23 study sites, because of slow recruitment. Of these, 49 were randomized to hypothermia and 49 to control arm. The intention-to-treat analysis showed no difference between the groups (OR for good outcome, 1.01; 95% CI, 0.48-2.13; p=0.97). 38% in the hypothermia group and 29% controls had at least one serious adverse event, such as pneumonia and symptomatic intracranial haemorrhage. Unfortunately however, the final sample was underpowered to detect any benefit or harm of therapeutic hypothermia. Furthermore, in about two thirds of patients randomized to hypothermia, it was not possible to achieve cooling target of body temperature of 34-35 °C, mainly because of shivering and discomfort. As the authors conclude, despite of a well-balanced and robust study protocol, the feasibility of cooling needs to be improved before launching any new trials.

Reference

H Bart van der Worp, Malcolm R Macleod, Philip MW Bath et al, 2019. Therapeutic hypothermia for acute ischaemic stroke. Results of a European multicenter, randomized, phase III clinical trial. European Stroke Journal. DOI: 10.1177/2396987319844690 https://journals.sagepub.com/doi/10.1177/2396987319844690