Brain Trauma Stroke
Table 2 (cont.): Recommendation
Evidence Level
5) Upper limb: A Exercise and functional training should be directed towards enhancing motor control for restoring sensorimotor and functional abilities A B Engage in repetitive and intense use of novel tasks that challenge the patient to acquire necessary motor skills to use the involved limb during functional tasks and activities
A
C An upper limb program should include strength training to improve impairment and function after stroke for upper extremity. Spasticity is not a contraindication to strength training;
A
therapists should provide a graded repetitive arm supplementary program for patients to increase activity on the rehabilitation unit and at home A D Following appropriate cognitive and physical assessment, mental imagery should be used to enhance sensory-motor recovery in the upper limb
Early-level A, late-level B
E Functional electrical stimulation (FES) should be used for the wrist and forearm to reduce motor impairment and improve functional motor recovery A F Intensive constraint-induced movement therapy (CIMT) should not be used for individuals in the first month post stroke until further research is completed
It can be used in a select group of patients with specific inclusion criteria15 G Electromyography (EMG) biofeedback systems should not be used on a routine basis
H There is insufficient evidence to recommend for or against neurodevelopmental treatment in comparison to other treatment approaches for motor retraining following an acute stroke
6) Lower limb: A Task-oriented training (i.e. training that is progressively adapted, salient, and involves active participation) is recommended to improve transfer skills and mobility
B Lower extremity orthotic devices may be helpful if ankle or knee stabilization is needed to help the patient walk. Prefabricated bracing can be used initially, and more expensive customized bracing reserved for patients who demonstrate a long-term need
C FES should be considered for use in improving muscle force, strength and function (gait) in selected patients. FES must not be assumed to have sustained effects
7) Spasticity/Contracture: A Spasticity and contractures should be treated or prevented by anti-spastic pattern positioning, range-of-motion exercises, stretching and/or splinting
B For stroke survivors with focal and/or symptomatically distressing spasticity, consider use of chemodenervation using botulinum toxin to increase range of motion and decrease pain
D Recommend against prescription of benzodiazepines during stroke recovery period due to possible deleterious effects on recovery, in addition to deleterious sedation side effects
8) Depression: A Stroke survivors with post-stroke depression should be considered for antidepressant treatment, with decisions made on an individual basis. Clinicians should monitor response to treatment, plan regular reviews and should be vigilant to the possible occurrence of unwanted side effects, issues of adherence to medication and the possibility of symptom relapse B Routine prescription of antidepressants is not recommended to prevent post-stroke depression
9) Falls:
Stroke survivors who are identified as high risk for falls in the community should have a comprehensive set of interventions implemented, such as an individually prescribed exercise program, in order to prevent or reduce the number and severity of fallsA
10) Dysphagia: Stroke survivors with dysphagia should be offered swallowing therapy and the opportunity for reassessment as required 11) Cardiovascular fitness:
Stroke survivors should be provided with a cardiovascular fitness program to maximize functional outcomes after stroke (and as part of overall vascular risk reduction)
Education (Specific Areas of Education are Addressed in Each of the Guidelines) 1) As integral parts of the stroke rehabilitation team, the stroke survivor, family and caregiver must be addressed at all stages across the continuum and at all transition points of stroke care for both adult and pediatric patients Patient and family education should include information sharing, teaching patients self-management skills, and training of caregivers
2) Educational content should be specific to the phase of care or recovery and appropriate to the readiness and needs of the stroke survivor, family, and caregiver
3) The scope of the educational content should cover all aspects of stroke care and recovery
4) Education should be interactive, up to date, ongoing, and provided in a variety of languages and formats (e.g., written, oral, group counseling approach), and ensure communicative accessibility for stroke survivors
B A
A A A
B I Use adaptive devices for safety and function if other methods of performing specific tasks are not available or cannot be learned C C C C
D There is no conclusive evidence that body weight-supported treadmill training (BWSTT) is superior to overground training to enhance walking abilities. BWSTT could be considered when other strategies for walking practice are unsuccessful in those patients with low ambulatory function B
C
Early-level C, late-level A
C Consider use of tizanidine for spasticity in patients with generalized, disabling spasticity resulting in poor skin hygiene, poor Early-level C, positioning, increased caregiver burden or decreased function
late-level B B
A A
A
B A
B
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