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SPREAD V Ed. | |
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Rehabilitation |
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R 15.1 Grade C |
All specific interventions targeted to the recovery of impairments are recommended for planning the rehabilitation treatment in individual patients. The rehabilitation programme has to be regularly updated according to the course of recovery. | ||||||||||||
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R 15.2 Grade D |
Pre- and post-rehabilitation assessment of disability is recommended by means of valid and widely used scales such as the Barthel Index and the Functional Independence Measure (FIM). | ||||||||||||
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R 15.3 Grade D |
Assessment of clinical, functional and socio-economic status of a patient with stroke should be performed soon after the admission in a rehabilitation unit. Both disability and impairment (motor and/or cognitive) should be measured. | ||||||||||||
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R 15.4 Grade D |
A comprehensive cognitive and mood assessment is recommended in patients with communication, cognitive and emotional disturbances. | ||||||||||||
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R 15.5 Grade D |
Identification
of significant and achievable rehabilitation goals according to a
definite temporal sequence is recommended. The assessment of obtained vs. targeted improvement may be helpful. The goals should be identified at team level, but also assigned as target to the individual professionals. |
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R 15.6 *GPP |
In planning the rehabilitation programme, the identification of goal priority is recommended according to the functional hierarchy of recovery and to the care needs. | ||||||||||||
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R 15.7 Grade C |
The active involvement of patients and carers
together with the multidisciplinary team, co-ordinated by a stroke
rehabilitation expert, is recommended in the rehabilitation
process. The team should regularly conduct meetings to identify the patient's problems, set the rehabilitation goals, monitor the progress and plan the discharge. |
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R 15.8 *GPP |
The assessment of the available resources is recommended before planning the rehabilitation programme, to ensure the long-term feasibility of interventions. | ||||||||||||
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R 15.9 Grade D |
Evaluation of possible use of orthoses and aids is recommended when planning a rehabilitation programme based on compensatory strategies. | ||||||||||||
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R 15.10 Grade D |
Regular follow-up is recommended to verify the achievement of the goals and to assess the patient’s functional independence in the activities of daily living by means of standardised scales (Barthel Index or Functional Independence Measure). | ||||||||||||
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R 15.11 *GPP |
Rehabilitative services are recommended to adopt a system of quality assessment, preferably ISO (International Organization for Standardization) certification or accreditation procedures, to improve quality, efficiency and appropriateness of rehabilitative interventions. | ||||||||||||
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R 15.12 Grade B |
 Clear
information
should be given to patients and carers, accounting for the
individual needs of each person. Patients and caregivers should
receive educational training to facilitate their co-operation in the
rehabilitation programme. |
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R 15.13 Grade D |
The discharge plan form the hospital after the acute phase of stroke should supply to the rehabilitation hospital or the territorial services that will receive the patients an estimate of the functional prognosis and all documentation useful for transfer of care. | ||||||||||||
| S 15-1 | Pharmacological interventions possibly helping in recovery after stroke are under investigation. Possible detrimental effects of drug treatments on recovery should also be taken into account. | ||||||||||||
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R 15.14 Grade A |
The use of psychostimulant or dopaminergic agents to favour recovery is, to date, not recommended. | ||||||||||||
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R 15.15 Grade A |
Professionals working in services (hospital or territorial) dedicated to stroke care should be expert in both cerebrovascular diseases and rehabilitation. They should be trained in the use of standardised treatment protocols and continuing education programmes for health professionals, patients and caregivers. | ||||||||||||
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R 15.16 *GPP |
The specific age-related care needs should be considered by the services involved in the management of patients with stroke. | ||||||||||||
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R 15.17 Grade D |
Assessment of progress against the agreed short- and long-term rehabilitative goals is recommended, in relation to the activity of the whole team and of the individual professionals. | ||||||||||||
| S 15-2 | Immobility and functional deficits in the acute phase of stroke may be the cause of a number of physical and functional impairments that negatively interfere with recovery. | ||||||||||||
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R 15.18 Grade C |
The early rehabilitation programmes should consider state of consciousness, cognitive problems, swallowing impairment, efficiency in communicating, nutritional status, risk of pressure sores and mobility. | ||||||||||||
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R 15.19 Grade A |
The involvement of the rehabilitative staff is recommended within the first week of hospitalisation. | ||||||||||||
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R 15.20 Grade A |
The rehabilitation treatment of stroke patients is recommended to be intensive, compatibly with patient’s conditions and service characteristics, structuring the programme based on the available operators (physiotherapists, occupational therapists, therapists of superior functions and of speech, nurses). | ||||||||||||
| S 15-3 | The functional recovery of stroke patients is based upon motor recovery and compensatory strategies. The available evidence is not sufficient to consider any one approach to treatment more efficacious than others in promoting effective rehabilitation. Controlled trial are needed to investigate the effectiveness of each single approach. | ||||||||||||
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R 15.21 Grade C |
It is recommended that carers are kept fully and clearly informed on the problems associated with stroke, in first instance motorial but especially cognitive and behavioural as well as of urinary incontinence. They should also be given information on the services provided by local and national agencies. | ||||||||||||
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R 15.22 Grade C |
The involvement of social workers is recommended to organise and support the appropriate care resources, thus reducing the family distress. | ||||||||||||
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R 15.23 Grade C |
Reassessment of patients with residual disability
lasting longer than 6 months after stroke
is recommended to set
further rehabilitation goals. |
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R 15.24 Grade C |
Careful evaluation of patients with severe stroke is recommended to identify potential recovery and plan the most efficacious care pathway. | ||||||||||||
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R 15.25 Grade B |
Therapeutic positioning and segmental limb mobilisation are recommended to prevent contractures, respiratory infections, shoulder pain and pressure sores. | ||||||||||||
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R 15.26 Grade B |
Patients should be encouraged to participate in daily activities and to leave the bed early (possibly within the third day) unless contraindicated. | ||||||||||||
| S 15-4 | Early rehabilitation treatment promotes the recovery of postural control and gait. No specific approach was proven to be better than any other. Some evidence suggests a benefit of the task-specific training. | ||||||||||||
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R 15.27 Grade C |
A rehabilitation programme for the plegic upper limb should be initiated within the first 3 months after stroke. | ||||||||||||
| S 15-5 | Functional recovery of the upper limb is a short- and medium-term goal of the rehabilitation of stroke patients. An integrated behavioural-physical approach is suggested as beneficial to recovery, but evidence is insufficient to conclude that any one approach is more effective than another. Intensive protocols and/or task-oriented approaches appear to have an added value, according to some studies. | ||||||||||||
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R 15.28 Grade D |
Motor imagery is complementary to the traditional neuro-motor techniques for the functional recovery of the upper limb. | ||||||||||||
| S 15-6 | Rehabilitation programmes that included motor imagery effectively improved the motor performance of the upper limb but the evidence is limited. There is insufficient evidence to recommend motor imagery in the rehabilitation of postural control and gait. | ||||||||||||
| S 15-7 | Integration of robots in the techniques for motory rehabilitation of the upper limb increases the treatment intensity but with limited evidence, requiring additional studies. There are no estimates of the cost-benefit ratio. | ||||||||||||
| S 15-8 | Speech and language therapy is aimed
at:
Most common treatments for aphasia are:
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R 15.29 *GPP |
When starting speech and language rehabilitation, the therapist should secure motivation and constant cooperation of patients and carers. | ||||||||||||
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R 15.30 Grade D |
A careful
evaluation by the speech therapist is recommended for patients with communication
disturbances following stroke to ensure an adequate treatment. |
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R 15.31 Grade B |
Speech and language interventions should be adequately tailored to the individual patient's communication disturbances and defined according to the therapist's expertise. | ||||||||||||
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R 15.32 Grade C |
In patients with selective communication disturbances, a targeted specific rehabilitation treatment is recommended. | ||||||||||||
| S 15-9 | Visuospatial and attention disturbances are
associated with a poorer functional outcome of stroke patients. Therapy of unilateral visuospatial neglect is aimed at improving exploration of personal and peripersonal space. Treatments of hemineglect are based on specific strategy training and on approaches directed to improve general attention. |
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R 15.33 Grade A |
Specific strategy training
is recommended to treat
visuospatial attention disturbances. Further evidence on effectiveness of prism adaptation and vestibular stimulation approaches is needed. |
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| S 15-10 | Treatment of apraxia aims at restoring the ability of gesture-programming with stimulus-response exercises or gesture reintegration, according to classical cognitive models, or ecologic approaches. | ||||||||||||
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R 15.34 Grade C |
Specific treatment of oral or limb apraxia is recommended in patients with apraxic disorders persisting after the acute phase of stroke. | ||||||||||||
| S 15-11 | Evidence from two Cochrane reviews does not consent to support or reject the effectiveness of cognitive rehabilitation for attention deficits or for memory problems following stroke. | ||||||||||||
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R 15.35 *GPP |
Strategies to increase attention performance are recommended if attention disturbances are present in the acute stroke phase. | ||||||||||||
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R 15.36 *GPP |
The use of aids (agendas, clocks, etc) that can facilitate the daily activities and drug intake, is recommended in presence of memory disorders after a stroke. Structured rehabilitation of the memory deficit appears not justified. | ||||||||||||
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R 15.37 *GPP |
Patient's compliance and motivation, appropriate carer training and efficient cooperation between all members of the rehabilitative team are recommended to carry out programmes for neuropsychological assessment and rehabilitation. | ||||||||||||
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R 15.38 *GPP |
In presence of dysarthria, phoniatric and logopedic evaluations should be performed for diagnostic classification and to set goals and treatment strategies. | ||||||||||||
| S 15-12 | Data from reviews do not permit to conclude whether the logopedic treatment of dysarthria is effective. Further trials are needed, also to identify the timing of intervention, the effectiveness of rehabilitation technique, the qualitative impact of treatment and an appropriate psychometric measurement of outcome, including the extent of participation, to assess communication limits. | ||||||||||||
| S 15-13 |
The use of
sensory-motor integration methods, acupuncture and transcutaneous
electrical nerve stimulation (TENS) is supported more by
experimental data than by clinical evidence. There are no additional
benefits from the combination of functional electrical stimulation (FES)
or TENS plus acupuncture or other physiotherapy approaches. These
techniques may be used in selected cases for the treatment of
painful syndromes. |
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R 15.39 *GPP |
Acupuncture or transcutaneous electrical nerve stimulation (TENS), alone or in combination with physiotherapy, for the treatment of painful syndromes other than shoulder pain, are recommended only within controlled clinical trial. | ||||||||||||
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R 15.40 Grade C |
Transcutaneous electrical nerve stimulation (TENS) is recommended for the treatment of hemiplegic painful shoulder only in selected cases. | ||||||||||||
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R 15.41 Grade C |
The assessment of factors that may be responsible for upper limb pain is recommended in both the acute and post-acute phase. | ||||||||||||
| S 15-14 | There is insufficient evidence supporting the role of physiotherapy in the treatment of shoulder pain following stroke. Electrical stimulation increases articular range of motion without obtaining a persisting improvement of focal disability. | ||||||||||||
| R 14.42 a Grade B |
It is recommended that the risk of aspiration is timely screened by trained personnel within the first few days after stroke. In case of swallowing disturbances, speech and language therapists should be involved and appropriate interventions should be programmed. | ||||||||||||
| R 14.42 b Grade D |
Prevention of malnutrition due to dysphagia is recommended by enteral nutrition approaches, such as naso-gastric tube and percutaneous endoscopic gastrostomy. | ||||||||||||
| R 14.42 c Grade D |
Weaning from enteral nutrition should be considered in patients with positive prognostic factors and performed by specialized personnel, following a standardised approach based on clinical, videofluoroscopic and/or endoscopic monitoring. | ||||||||||||
| R 14.42 d Grade D |
During all phases of weaning from enteral feeding, an appropriate energy (mainly protein) and water intake is recommended. | ||||||||||||
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R 15.43 *GPP |
Units dedicated to stroke care should implement protocols for the management of urinary and faecal incontinence or retention. Assessment of patients with incontinence is a nursing practice that should be started at time of admission together with all the specific care activities. The protocols should provide indications about the use of urinary catheter or the need of urodynamic or anorectal function assessment, and on the most adequate continence aids to be selected during hospital stay and after discharge, considering also possible limitation of sexual activity. | ||||||||||||
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R 15.44 Grade C |
In patients with urinary incontinence, a specialised, clinical and functional assessment, including an urodynamic assessment, is recommended to plan re-education to voluntary micturition. | ||||||||||||
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R 15.45 Grade B |
Thee need for aids should be assessed based on the individual rehabilitation programme. Aids should be selected according to the needs and expectations of patient and carer and should be provided timely. | ||||||||||||
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R 15.46 *GPP |
It is recommended that appropriate environment adaptations are set up before patients return home from hospital. | ||||||||||||
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R 15.47 *GPP |
It
is recommended that, at the time of discharge
from the hospital, all territorial resources and outpatient
facilities be activated to promote a successful social
reintegration of the patient, according to the indications
provided by the stroke care team after the acute phase. |
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R 15.48 Grade B |
Encouraging stroke
survivors who had a job prior to the event, to return to work
is recommended if allowed by
their functional status. Whenever necessary, counselling regarding actual job options should be offered to patients. |
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| S 15-15 | Beside impairments following stroke, patients may be also affected by previous comorbidities and by stroke complications (spasticity, depression, malnutrition, articular painful syndromes, falls...). All these ailments ought to be carefully assessed and treated because they negatively affect the rehabilitative processes. | ||||||||||||
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R 15.49 Grade B |
Injection of Botulinum Toxin, associated to physiotherapy, is recommended as a strategy for the treatment of focal spasticity, usually of upper or lower limbs, in patients who exhibit poor response or tolerability to oral antispasmodic drugs. | ||||||||||||
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R 15.50 Grade B |
To improve the motor performance after stroke, it is recommended to suggest progressive-resistance reinforcement exercises. | ||||||||||||
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R 15.51 Grade D |
Among stroke survivors who are able to walk, it
is
recommended to:
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R 15.52 Grade B |
The rehabilitation programme should include interventions to improve the cardiovascular fitness. | ||||||||||||
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R 15.53 *GPP |
There is not sufficient evidence yet to support or refute the benefits of cognitive rehabilitation for patients with problems of attention or memory, nevertheless, considering the negative functional impact of cognitive impairment on stroke patients, approaches directed at exploiting the residual abilities and at providing appropriate caregiver education are recommended. | ||||||||||||
| R 14.54 a *GPP |
Early after stroke, appropriate shoulder positioning, using soft supports and avoiding traction manoeuvres on plegic shoulder is recommended. | ||||||||||||
| R 14.54 b *GPP |
After the acute phase of stroke, radiological examination of shoulder is recommended if a subluxation occurs. | ||||||||||||
| R 14.54 c Grade D |
Shoulder slings and functional electrical stimulation (FES) of the deltoid are recommended to manage shoulder subluxation. This should be applied early to avoid the impairment of subluxation and persistence of pain. | ||||||||||||
| R 14.54 d Grade D |
Local infiltrations with corticosteroids may be recommended for severe shoulder pain. | ||||||||||||
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R 15.55 Grade C |
Analgesic treatment of persistent central pain
is
recommended by using antiepileptic drugs (gabapentin,
carbamazepine or pregabalin.) or
tricyclic antidepressants (amitriptyline), to be individually
titrated. |
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R 15.56 *GPP |
Assessments of nutritional status should be recorded in the patients' clinical documents that are transferred within the different phases of hospital stay, because nutritional needs may change along the time. Data from nutritional documents should be studied as possible prognostic indicators. | ||||||||||||
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R 15.57 Grade D |
Evaluation of pulse oximetry and polysomnography
is
recommended to diagnose a sleep apnoea syndrome in patients with
stroke who are obese or affected by heart diseases. Interventions for weight reduction, alcohol cessation, nasal cavity widening as well as avoiding sleeping in supine position should be applied. If sleep apnoea persists nevertheless, Continuous Positive Airway Pressure (CPAP) during the night should be suggested, if tolerated. |
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