A new American Stroke Association guideline on adult stroke rehabilitation and recovery emphasizes early, individualized rehabilitation and coordinated care from a multidisciplinary team.

The first update in a decade recommends beginning rehabilitation as soon as patients are medically stable, ideally within 48 hours of stroke, with ongoing attention to physical, cognitive, communication, and mental health needs.

“It’s important to provide rehabilitation for people who have impairments that are impacting their function because there is a lot we can do to help them out,” lead guideline author Lorie Gage Richards, PhD, chair of the volunteer guideline writing group, and associate professor of occupational therapy, University of Utah, Salt Lake City, told Medscape Medical News.

Patients with moderate-to-severe stroke should be transferred to an inpatient rehabilitation facility when feasible, Richards said, noting that outcomes are generally better with inpatient rehabilitation.

However, she cautioned against starting intensive rehabilitation too early. Moderate- to high-intensity exercise and task practice within the first 24 hours after stroke may worsen outcomes and neurologic function.

The new guideline was published online on August 27 in Stroke.

Beyond Physical Recovery

Stroke is now the fourth leading cause of death in the US and a leading cause of serious long-term disability, with nearly 800,000 Americans experiencing a stroke each year.

The wide-ranging guideline reflects the latest evidence and expands recommendations on mental health and cognition, while adding a new section addressing poststroke sleep and fatigue.

The guideline emphasizes mental health as an important part of stroke recovery, recommending early and repeated screening for depression and anxiety and treatment as needed.

“It’s amazing how often depression is missed after a stroke,” Richards said, noting that untreated depression can worsen outcomes. She emphasized that poststroke depression is treatable and should be identified and addressed.

The guideline also expands recommendations for cognitive assessment and rehabilitation, including the use of brief, multidomain performance-based tools to assess overall cognitive function, executive function, and perception.

It also recommends broader use of nonpharmacologic approaches to cognitive rehabilitation. Richards noted that executive dysfunction is common after stroke and may respond to interventions such as computer-based games.

The guideline also includes a new section on poststroke sleep and fatigue. It recommends cognitive-behavioral therapy as a potentially beneficial intervention and discusses light therapy, although research on the latter remains in the early stages, Richards said.

For physical rehabilitation, the guideline recommends individually tailored exercise programs, including moderate- to high-intensity exercise, to improve overall health, cardiorespiratory fitness, and mobility and reduce the risk for future vascular events.

Returning to Work

Return-to-work recommendations are particularly timely as stroke rates rise among younger adults and more older adults delay retirement. The guideline recommends assessing whether job modifications are feasible and working with employers to help patients return to work, Richards said.

The guideline also emphasizes technology-based approaches to rehabilitation. Telehealth should be considered for patients unable to travel to a clinic, while other options include virtual reality, robotic-assisted rehabilitation, and brain stimulation, Richards said.

For central poststroke pain, the guideline recommends duloxetine, lamotrigine, or amitriptyline as first-line treatments, with pregabalin or gabapentin as second-line options. Richards cautioned that these medications can cause adverse effects and noted that treatment is complicated by the lack of a universally accepted definition of central poststroke pain.

For patients with stroke-related arm and hand impairment, hemiplegic shoulder pain may be a concern. The guideline recommends a multimodal treatment approach that may include neuromodulation and botulinum toxin injections. It advises against overhead pulleys for arm stretching because they can pinch soft tissue in the shoulder and potentially worsen pain, Richards said.

For bladder and bowel dysfunction, the guideline expands assessment and management strategies to include bladder scanning, timed voiding, pelvic floor training, and electrical stimulation.

The guideline also expands recommendations for fall prevention, including structured programs, dual-task training, and tai chi.

Where the Evidence Falls Short

Richards noted that the new guideline is more user-friendly than previous versions but said that important research gaps remain.

One of the biggest research gaps, she said, is the lack of evidence on optimal dosing for rehabilitation interventions.

The field also lags behind other areas of medicine in precision or personalized approaches to care. The goal, Richards said, is to tailor both the intervention and its dose to the individual patient. Progress has been challenging, in part because poststroke rehabilitation is complex and involves multiple disciplines.

The guideline also includes recommendations addressing:

• Prevention of skin breakdown and contractures
• Prevention of venous thromboembolism
• Poststroke osteoporosis
• Assessment of sensory impairments, including touch, vision, and hearing
• Management of spasticity, balance, and ataxia
• Lifestyle modification and management
• Dysphagia screening and management

Richards reported no relevant disclosures.