Purpose—The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke. Methods—Writing group members were nominated by th...

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association

ContextSingle-site studies suggest that a 2-week program of constraint-induced movement therapy (CIMT) for patients more than 1 year after stroke who maintain some hand and wrist movement can improve upper extremity function that persists for at least 1 year.ObjectiveTo compare the effects of a 2-week multisite program of CIMT vs usual and customary care on improvement in upper extremity function among patients who had a first stroke within the previous 3 to 9 months.Design and SettingThe Extremity Constraint Induced Therapy Evaluation (EXCITE) trial, a prospective, single-blind, randomized, multisite clinical trial conducted at 7 US academic institutions between January 2001 and January 2003.ParticipantsTwo hundred twenty-two individuals with predominantly ischemic stroke.InterventionsParticipants were assigned to receive either CIMT (n = 106; wearing a restraining mitt on the less-affected hand while engaging in repetitive task practice and behavioral shaping with the hemiplegic hand) or usual and customary care (n = 116; ranging from no treatment after concluding formal rehabilitation to pharmacologic or physiotherapeutic interventions); patients were stratified by sex, prestroke dominant side, side of stroke, and level of paretic arm function.Main Outcome MeasuresThe Wolf Motor Function Test (WMFT), a measure of laboratory time and strength-based ability and quality of movement (functional ability), and the Motor Activity Log (MAL), a measure of how well and how often 30 common daily activities are performed.ResultsFrom baseline to 12 months, the CIMT group showed greater improvements than the control group in both the WMFT Performance Time (decrease in mean time from 19.3 seconds to 9.3 seconds [52% reduction] vs from 24.0 seconds to 17.7 seconds [26% reduction]; between-group difference, 34% [95% confidence interval {CI}, 12%-51%]; P<.001) and in the MAL Amount of Use (on a 0-5 scale, increase from 1.21 to 2.13 vs from 1.15 to 1.65; between-group difference, 0.43 [95% CI, 0.05-0.80]; P<.001) and MAL Quality of Movement (on a 0-5 scale, increase from 1.26 to 2.23 vs 1.18 to 1.66; between-group difference, 0.48 [95% CI, 0.13-0.84]; P<.001). The CIMT group achieved a decrease of 19.5 in self-perceived hand function difficulty (Stroke Impact Scale hand domain) vs a decrease of 10.1 for the control group (between-group difference, 9.42 [95% CI, 0.27-18.57]; P=.05).ConclusionAmong patients who had a stroke within the previous 3 to 9 months, CIMT produced statistically significant and clinically relevant improvements in arm motor function that persisted for at least 1 year.Trial Registrationclinicaltrials.gov Identifier: NCT00057018

https://jamanetwork.com/journals/jama/articlepdf/203876/joc60147_2095_2104.pdf

Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial.

Context Single-sitestudiessuggestthata2-weekprogramofconstraint-inducedmove-ment therapy (CIMT) for patients more than 1 year after stroke who maintain somehand and wrist movement can improve upper extremity function that persists for atleast 1 year.Objective To compare the effects of a 2-week multisite program of CIMT vs usualandcustomarycareonimprovementinupperextremityfunctionamongpatientswhohad a first stroke within the previous 3 to 9 months.Design and Setting The Extremity Constraint Induced Therapy Evaluation(EXCITE) trial, a prospective, single-blind, randomized, multisite clinical trial con-ducted at 7 US academic institutions between January 2001 and January 2003.Participants Twohundredtwenty-twoindividualswithpredominantlyischemicstroke.Interventions Participants were assigned to receive either CIMT (n=106; wearinga restraining mitt on the less-affected hand while engaging in repetitive task practiceandbehavioralshapingwiththehemiplegichand)orusualandcustomarycare(n=116;rangingfromnotreatmentafterconcludingformalrehabilitationtopharmacologicorphysiotherapeutic interventions); patients were stratified by sex, prestroke dominantside, side of stroke, and level of paretic arm function.Main Outcome Measures The Wolf Motor Function Test (WMFT), a measure oflaboratory time and strength-based ability and quality of movement (functional abil-ity),andtheMotorActivityLog(MAL),ameasureofhowwellandhowoften30com-mon daily activities are performed.Results From baseline to 12 months, the CIMT group showed greater improve-ments than the control group in both the WMFT Performance Time (decrease inmean time from 19.3 seconds to 9.3 seconds [52% reduction] vs from 24.0 sec-onds to 17.7 seconds [26% reduction]; between-group difference, 34% [95% con-fidence interval {CI}, 12%-51%];

Effect of Constraint-Induced Movement Therapy on Upper Extremity Function 3 to 9 Months After Stroke

Published version made available following 12 month embargo from the date of publication [12 Feb 2015] according to publisher policy. Accessed 10/03/2015. Published version available from 13 February 2016.

/pdf/virtual-reality-for-stroke-rehabilitation-4evwp7ler3.pdf

Virtual reality for stroke rehabilitation

In the United States, the incidence rate of new or recurrent stroke is approximately 795 000 per year, and stroke prevalence for individuals over the age of 20 years is estimated at 6.5 million.1 Mortality rates in the first 30 days after stroke have decreased because of advances in emergency medicine and acute stroke care. In addition, there is strong evidence that organized postacute, inpatient stroke care delivered within the first 4 weeks by an interdisciplinary healthcare team results in an absolute reduction in the number of deaths.2,3 Despite these positive achievements, stroke continues to represent the leading cause of long-term disability in Americans: An estimated 50 million stroke survivors worldwide currently cope with significant physical, cognitive, and emotional deficits, and 25% to 74% of these survivors require some assistance or are fully dependent on caregivers for activities of daily living (ADLs).4,5

Notwithstanding the substantial progress in acute stroke care over the past 15 years, the focus of stroke medical advances and healthcare resources has been on acute and subacute recovery phases, which has resulted in substantial health disparities in later phases of stroke care. Additionally, healthcare providers (HCPs) are often unaware of not only patients’ potential for improvement during more chronic recovery phases but also common issues that stroke survivors and their caregivers experience. Furthermore, even with evidence that documents neuroplasticity potential regardless of age and time after stroke,6 the mean lifetime cost of ischemic stroke (which accounts for 87% of all strokes) in the United States is an estimated $140 000 (for inpatient, rehabilitation, and follow-up costs), with 70% of first-year stroke costs attributed to acute inpatient hospital care1; therefore, fewer financial resources appear to be dedicated to providing optimal care during the later phases of stroke recovery.

Because there remains a …

Comprehensive Overview of Nursing and Interdisciplinary Rehabilitation Care of the Stroke Patient A Scientific Statement From the American Heart Association

Stroke is a leading cause of disability in the United States.1 The Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) estimates that 15 000 veterans are hospitalized for stroke each year (VA HSR&D, 1997).

Forty percent of stroke patients are left with moderate functional impairments and 15% to 30% with severe disability.2 Effective rehabilitation interventions initiated early after stroke can enhance the recovery process and minimize functional disability. Improved functional outcomes for patients also contribute to patient satisfaction and reduce potential costly long-term care expenditures.

There are only 45 rehabilitation bed units (RBUs) in the VA today. Many veterans who have a stroke and are admitted to a VA Medical Center will find themselves in a facility that does not offer comprehensive, integrated, multidisciplinary care. In a VA rehabilitation field survey published in December 2000, more than half of the respondents reported that the “rehabilitative care of stroke patients was incomplete, fragmented, and not well coordinated” at sites lacking a RBU (VA Stroke Medical Rehabilitation Questionnaire Results, 2000).

In Department of Defense (DoD) medical treatment facilities, approximately 20 000 active-duty personnel and dependents were seen in 2002 for stroke and stroke-related diagnoses according to ICD-9 coding.3 Comprehensive treatment for stroke patients in DoD medical facilities is given primarily at medical centers. Smaller DoD community hospitals may have limited resources to see both inpatients and outpatients, relying more on the TRICARE network for ongoing stroke rehabilitation services.

A growing body of evidence indicates that patients do better with a well-organized, multidisciplinary approach to post-acute rehabilitation after a stroke.4–6 The VA/DoD Stroke Rehabilitation Working Group only focused on the post–acute stroke rehabilitation care.

Duncan and colleagues7 found that greater adherence to post-acute stroke rehabilitation guidelines was associated with improved patient outcomes and concluded “compliance …

/pdf/management-of-adult-stroke-rehabilitation-care-a-clinical-55zu3naq5e.pdf

Management of Adult Stroke Rehabilitation Care: a clinical practice guideline.

Background— A panel of experts developed stroke rehabilitation guidelines for the Veterans Health Administration and Department of Defense Medical Systems. Methods— Starting from previously established guidelines, the panel evaluated published literature through 2002, using criteria developed by the US Preventive Services Task Force. Recommendations were based on evidence from randomized clinical trials, uncontrolled studies, or consensus expert opinion if definitive data were lacking. Results— Recommendations with Level I evidence include the delivery of poststroke care in a multidisciplinary rehabilitation setting or stroke unit, early patient assessment via the NIH Stroke Scale, early initiation of rehabilitation therapies, swallow screening testing for dysphagia, an active secondary stroke prevention program, and proactive prevention of venous thrombi. Standardized assessment tools should be used to develop a comprehensive treatment plan appropriate to each patient’s deficits and needs. Medical therap...

/pdf/veterans-affairs-department-of-defense-clinical-practice-4eqcicyhll.pdf

Kerri Lamberty

Papers

Management of Adult Stroke Rehabilitation Care: a clinical practice guideline.

Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care: executive summary.