For the first time, guidelines have been developed by the American Heart
Association/American Stroke Association for rehabilitation after a stroke
and released in May 2016.
"Previous guidelines have focused on the medical issues involved in
the initial management of stroke, but many people survive a stroke with
some level of disability. There is increasing evidence that rehabilitation
can have a big impact on the survivors’ quality of life, so the
time is right to review the evidence in this complex field and highlight
effective and important aspects of rehabilitation," said Carolee
J. Winstein, Ph.D., P.T., lead author of the new scientific statement
published in the American Heart Association journal
Whenever possible, the American Stroke Association strongly recommends
that stroke patients be treated at an in-patient rehabilitation facility
rather than a skilled nursing facility. While in an in-patient rehabilitation
facility, a patient participates in at least three hours of rehabilitation
a day from physical therapists, occupational therapists, and speech therapists.
Nurses are continuously available and doctors typically visit daily. An
in-patient rehabilitation facility may be a free-standing facility or
a separate unit of a hospital.
"If the hospital suggests sending your loved one to a skilled nursing
facility after a stroke, advocate for the patient to go to an in-patient
rehabilitation facility instead – unless there is a good reason
not to – such as being medically unable to participate in rehab.
There is considerable evidence that patients benefit from the team approach
in a facility that understands the importance of rehabilitation during
the early period after a stroke," said Winstein, who is a professor
of biokinesiology and physical therapy at the University of Southern California
in Los Angeles, California.
Caregivers should also insist that a stroke survivor not be discharged
from the hospital until they have participated in a structured program
on preventing falls. This includes education about changes to make the
home safer (such as removing throw rugs and improving lighting), minimizing
the fall risk resulting from the side effects of medication, and safely
using assistive devices such as wheelchairs, walkers and canes.
"This recommendation will probably change medical practice. Even the
top stroke centers may not have a formal falls-prevention program, but
it is very important because a high percentage of patients end up falling
after a stroke," Winstein said.
Other recommendations include:
- Intense mobility-task training after stroke for all survivors with walking
limitations to relearn activities such as climbing stairs.
- Individually tailored exercise program so survivors can safely continue
to improve their cardiovascular fitness through the proper exercise and
physical activity after formal rehabilitation is complete.
- An enriched environment (which might include a computer, books, music and
virtual reality games) to increase engagement and cognitive activities
during rehabilitation. There is not yet enough research to determine whether
specific promising new techniques, such as activity monitors and virtual
reality games, are effective at helping patients.
- Speech therapy for those with difficulty speaking following a stroke.
- Eye exercises for survivors with difficulty focusing on near objects.
- Balance training program for survivors with poor balance, or who are at
risk for falls.
"For a person to fulfill their full potential after stroke, there
needs to be a coordinated effort and ongoing communication between a team
of professionals as well as the patient, family and caregivers,"
The new scientific statement is the eighth set of stroke guidelines from
the American Stroke Association, completing the association’s recommendations
for the continuum of care for stroke patients and their families.
Co-authors are Joel Stein, M.D., vice-chair; Ross Arena, Ph.D., P.T.; Barbara
Bates, M.D., M.B.A.; Leora R. Cherney, Ph.D.; Steven C. Cramer, M.D.;
Frank Deruyter, Ph.D.; Janice J. Eng, Ph.D., B.Sc.; Beth Fisher, Ph.D.,
P.T.; Richard L. Harvey, M.D.; Catherine E. Lang, Ph.D., P.T.; Marilyn
MacKay-Lyons, B.Sc.; M.Sc.P.T., Ph.D.; Kenneth J. Ottenbacher, Ph.D.,
O.T.R.; Sue Pugh, M.S.N., R.N., C.N.S.-B.C.; Mathew J. Reeves, Ph.D.,
D.V.M.; Lorie G. Richards, Ph.D., O.T.R./L.; William Stiers, Ph.D., A.B.P.P.
(R.P.); Richard D. Zorowitz, M.D.; 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. Author disclosures are on the manuscript.
The American Heart Association/American Stroke Association receives funding
mostly from individuals. Foundations and corporations donate as well,
and fund specific programs and events. Strict policies are enforced to
prevent these relationships from influencing the association’s science
content. Financial information for the American Heart Association, including
a list of contributions from pharmaceutical companies and device manufacturers,
is available at www.heart.org/corporatefunding.