Brain Trauma Stroke
re-entry), and discharge from the rehabilitation program (e.g. medical follow-up). The guideline offers three algorithms for the assessment of inpatient rehabilitation, the re-assessment of inpatient rehabilitation, and the assessment for community services. The first algorithm provides a framework for the evaluation of impairments and activity limitations and participation restrictions, medical comorbidities, potential secondary complications, and triage of rehabilitation services. The second algorithm assesses functional progress and whether the stroke survivor in inpatient rehabilitation still requires inpatient services. The final algorithm assesses the need and environment for community-based rehabilitation services. All of the algorithms include the stroke survivor and caregiver in education and decision-making that are central to the patient-centered process.
American Heart Association Council on Stroke and Cardiovascular Nursing Guideline
The AHA Councils on Stroke and Cardiovascular Nursing guideline divides up rehabilitation care using two classification schemes. First, the guideline considers rehabilitation care in inpatient and outpatient environments, in chronic care, and at end-of-life. Each of the environments is defined, and the services provided to the stroke survivor are described. Second, the guideline uses the World Health Organization’s (WHO) International Classification of Functioning, Disability, and Health (ICF)12
as an
organizational framework to provide an overview of the interdisciplinary team approach to rehabilitation. The ICF model acknowledges that stroke recovery is a multifaceted process encompassing the interplay of the pathophysiologic processes directly related to the stroke and its associated comorbidities, the impact that stroke has on the stroke survivor, and contextual factors such as personal and environmental resources. As a result, the impact of stroke is described in terms of loss of body functions and structures; activity limitations that stroke survivors experience in basic and instrumental ADLs; and participation restrictions that stroke survivors encounter when re-establishing previous or developing new life roles and societal involvement. Personal factors may include internal attributes (e.g. gender, comorbidities, ethnocultural background), whereas environmental factors include external attributes (e.g. family support, social attitudes, architectural barriers, healthcare resources).
Canadian Stroke Strategy Guideline
The CSS guideline draws its evidence from the web-based Evidence- Based Review of Stroke Rehabilitation.13
Like the AHA guideline, the
CSS guideline attempts to make recommendations based upon the environment in which stroke rehabilitation takes place. In addition, it organizes guidance into sections on best practices, rationale, system implications, and performance measures. For example, the best practice for prophylaxis of deep venous thrombosis (DVT) states: “Patients at high risk of venous thromboembolism should be started on venous thromboembolism prophylaxis immediately...” While the rationale for DVT prophylaxis is obvious, the system implication suggests: “standardized evidence-based protocols for optimal inpatient care of all acute stroke patients, regardless of where they are treated in the healthcare facility...” The related performance measure is defined as the: “percentage of patients with stroke who experience complications (such as venous thromboembolism) during [their] inpatient stay...” As a result, this recommendation scheme proposes potential solutions to operationalize and monitor guideline implementation.
42
Table 1: Strength of Recommendation Rating (from the Canadian Stroke Strategy)9
A B
Strong recommendation. Evidence from randomized controlled trials or meta-analyses of randomized controlled trials. Desirable effects clearly outweigh undesirable effects, or vice versa
Single randomized controlled trial or well-designed observational study with strong evidence; or well-designed cohort or case-control analytic study; or multiple time series or dramatic results of uncontrolled experiment. Desirable effects closely balanced with undesirable effects
C
At least one well-designed, non-experimental descriptive study (e.g. comparative studies, correlation studies, case studies), or expert committee reports, opinions and/or experience of respected authorities, including consensus from development and/or reviewer groups
Based on Guyatt GH, et al.14
Scottish Intercollegiate Guideline Network Guideline The SIGN guideline also bases its recommendations on the WHO ICF classification scheme. It is divided into five sections: organization of services; management and prevention strategies; transfer from hospital to home; roles of the multidisciplinary team; and provision of information. The section on transfer from hospital to home takes into account community re-entry issues, such as post-discharge support, driving, and follow-up by a primary care provider. The section on roles of the multidisciplinary team emphasizes the need for collaboration and communication. The section on provision of information emphasizes active education and counseling techniques that take into account the needs, values, and preferences of the stroke survivor and his caregivers. The section concludes with a list of Scottish stroke advocacy and caregiver websites.
National Institute for Health and Clinical Excellence Guideline
Finally, the NICE guideline is the oldest of the guidelines, having been issued in July, 2008. The guideline encompasses comprehensive stroke care, of which rehabilitation comprises two sections: recovery phase from impairments and limited activities; and long-term management after recovery. The recovery phase sections consist of 52 sub-sections that cover general topics, a number of specific treatments, common impairments seen after stroke, activity limitations, and personal and environmental adaptations and equipment. The long-term management section discusses monitoring disability and episodes of further rehabilitation, long-term support and care at home, management in nursing homes and residential care, and caregiver support. Following these recommendations, the guideline organizes recommendations that are pertinent to nurses, physical therapists, occupational therapists, speech-language pathologists, and nutritionists. The guideline is scheduled for updating in December, 2011.
Common Clinical Recommendations According to the VA/DoD Clinical Practice Guideline for the Management of Stroke Rehabilitation,7
the primary goal of rehabilitation is to prevent
complications, minimize impairments, and maximize function. A number of key points influence the types of recommendations on which the guidelines are based:
• Early assessment and intervention is critical to optimize rehabilitation. • Secondary prevention is fundamental for preventing stroke recurrence.
US NEUROLOGY
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