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Stroke Rehabilitation and Recovery Guideline – A Major Milestone for Comprehensive Stroke Care

Disclosure: Dr. Feng receives research grant support from the American Heart Association and the National Institute of Health.
Pub Date: Wednesday, May 4, 2016
Authors: Wuwei Feng MD, MS
Affiliation: Department of Neurology, College of Medicine, Medical University of South Carolina; and Department of Health Science and Research, College of Health Professions, Medical University of South Carolina

Citation

Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, Deruyter F, Eng JJ, Fisher B, Harvey RL, Lang CE, MacKay-Lyons M, Ottenbacher KJ, Pugh S, Reeves MJ, Richards LG, Stiers W, Zorowitz RD; 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 [published online ahead of print May 4, 2016]. Stroke. doi: 10.1161/STR.0000000000000098

Article Text

More stroke victims survive from the indexed event due to improved control of vascular risk factors and widespread dedicated stroke care units.1, 2 However, stroke is still a leading cause of deficit and disability worldwide, demanding optimized and systemic recovery and rehabilitation cares in order to improve post-stroke outcomes.

The 18-member writing committee, led by Dr. Carolee Winstein, is a multidisciplinary team comprising vascular neurologists, physical medicine & rehabilitation physicians, physical therapists, occupational therapists, speech pathologists, nurses, biostatisticians, and rehabilitation scientists. In this issue of Stroke Journal, the committee released the first version of Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professional from American Heart Association/American Stroke Association.3 This collaborative work has received endorsements and affirmations from four professional rehabilitation societies - the American Academy of Physical Medicine and Rehabilitation; American Society of Neurorehabilitation; American Congress of Rehabilitation Medicine; and American Academy of Neurology. Compared with the 2005 Management of Adult Stroke Rehabilitation Care: a Clinical Practice Guideline,4 this guideline is significantly more comprehensive and represents more inter-professional consensus of various issues across the entire stroke recovery course. The total of 229 recommendations address 41 rehabilitation topics. These recommendations were presented and organized into 5 primary categories (the rehabilitation program; prevention and medical management of comorbidities; assessment; sensorimotor impairments and treatments/interventions; transitions in care and community rehabilitation). The guideline covers long-sought and previously inadequately addressed topics, such as, sexual dysfunction, return to work, return to driving and rehabilitation in the community, etc.

Although the guideline is comprehensive, evidence for practice in stroke recovery and rehabilitation is still lacking in general – only 22 (9.6%) out 229 recommendations in this guideline are classified as Class I and Level A. This highlights the urgent needs for recovery research at basic, translational and clinical levels. The priorities should be: to better understand the pathophysiology underlying the stroke recovery trajectory, especially the first 90 days after event; to identify the target(s) and to harness brain plasticity to maximally preserve, protect and recover brain function; to assure basic and translational science research addresses clinical needs; and to translate restorative post-stroke therapeutics through collaborative, rigorous, transparent research efforts. It is hoped that more stroke recovery studies can be catalyzed and translated to the bedside care through the governmental NIH-funded stroke trials network as well as nongovernmental research funding organizations, like the American Heart Association/American Stroke Association (AHA/ASA) funded Strategically Focused Research Networks. It is also the time to incorporate recovery and rehabilitation trainings into vascular neurology fellowship program where recovery and rehabilitation components are insufficiently mentioned in the current version of milestone evaluation.5 The new generation of stroke physicians will then better equipped to handle post-stroke deficits and complications.

Despite the hurdle and challenges, the stroke recovery field is dynamic and fast growing. Several recent major studies disclosed scientific findings but were not included in this guideline yet. Another botulinum toxin product is demonstrated to be safe to inject and lead to significantly reduced upper extremity muscle tone for up to 3 months after stroke or traumatic brain injury.6 Patients have more treatment options to alleviate post-stroke limb spasticity – a very disabling complication. The ICARE study7, somewhat unexpected and disappointing, showed that use of a 12-month, structured, task-oriented upper extremity rehabilitation program did not significantly improve motor function or recovery beyond either an equivalent or a lower dose of customary occupational therapy. At least 256 studies are ongoing and actively recruiting subjects by a searching for “stroke recovery” through the clinicaltrial.gov website.8 Many promising new stroke rehabilitation modalities are on the horizon, for example, non-invasive brain stimulations( transcranial direct current stimulation and repetitive transcranial magnetic stimulation),9, 10 cell-based therapy,11 brain-computer interface,12 etc. We remain optimistic that many of evidence gaps in stroke recovery and rehabilitation field will be reduced in the not-too-distant future.

Fortunately, improving post-stroke outcomes is clearly a priority item on the agenda of policy makers at various levels of medical research funding and healthcare delivery. World Stroke Organization (WSO) issued an11-item post-stroke checklist to assist health care professionals to identify post-stroke problems amenable to treatments and/or referrals. Now the guidelines on acute stroke treatment13, 14, secondary stroke prevention,15 and stroke rehabilitation and recovery are all in one place, it is the time to implement them simultaneously in order to achieve optimal outcomes after stroke.

References

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  3. Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, Deruyter F,  Eng JJ, Fisher B,  Harvey RL, Lang CE, MacKay-Lyons M, Ottenbacher KJ,  Pugh S, Reeves MJ, Richards LG, Stiers W,  Zorowitz RD; 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;47:XXX–XXX. DOI:  10.1161/STR.0000000000000098
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  8. Https://clinicaltrials.Gov/ct2/results?Term=stroke+recovery&recr=open. 2016
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  15. Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45:2160-2236.