STROKE Guideline - Philippine Academy of Rehabilitation Medicine

278 Pages·2013·2.88 MB·English

Stroke rehabilitation guideline
FOREWORD

The formulation of this clinical practice guideline in stroke/low back pain is the answer to the
clamour of standardizing our approach to these common Physiatric problems.
We are proud to say that these work comply with the highest standard based on evidence based
medicine appropriate for the Philippine setting.
Every reference in that was examined and summarized has the most up to date quality evidence
the current data on prevention, diagnosis and prognosis. Therapy formulation is the highest
risk/benefit cost effective that is available in our setup. The other purpose of this manuscript is
to standardize physiatric care that can be recommended to the Philippine Health insurance
Corporation (PHIC) and HMO.
This will be made available to each Physiatrist and will be coordinated with other members of
the medical team concern in the treatment of low back pain and stroke.
It is the goal of the proponent of this study to update accordingly to meet the changes in time.
The Philippine Academy of Rehabilitation Medicine CPG Committee will commit to update and
revise this CPG so as to set standard locally and internationally.
Mabuhay ang PARM!

Sylvan Lorenzo, MD, FPARM
President
Philippine Academy of Rehabilitation Medicine 2011

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FOREWORD

“Much of outcomes research is a systematic attempt to exploit what is known and make it
better.” – Kevin Kelly

Recognizing the need to make clinical practice guidelines for two of the most common cases
Filipino Physiatrists see in their respective institutions, the Philippine Academy of Rehabilitation
(PARM) has poured its time and resources in research. After two years of data gathering,
brainstorming, drafting and editing, it is with great pleasure and pride to present to you the
PARM Clinical Practice Guidelines for Stroke Rehabilitation and Low Back Pain.

The brainchild of the indefatigable Dr. Consuelo Suarez together with the collaborative effort of
the members of the Academy, this would not have been possible without the invaluable
contribution of Prof. Karen Grimmer-Somers who acted as our resource speaker and workshop
moderator. Long flights from Australia, horrendous traffic in Manila and modest
accommodations were never a hindrance for her to pursue this noteworthy endeavour with
us. Maraming salamat Prof. Somers sa lahat ng iyong tulong.

This project started during the term of my predecessor, Dr. Sylvan Lorenzo, who was as
passionate as the rest of the incumbent Executive Board to see this project to its implementation
stage. We believe that this milestone will create a positive and lasting mark in the medical
community both locally and internationally. PARM-funded, both clinical practice guidelines
boasts of being independent, unbiased and at its core, the true essence of research.

Research creates new knowledge and new knowledge we gained. All of these in pursuit of the
best care we can give our patients. In the end, they are the reason why we are called doctors.

The vocation we have chosen demands continuous education. Learning goes beyond after we got
our licenses and passed our specialty board exams. Physiatry involves a diverse group of patients
applying evolving means of treatment and using the basic, to the innovative, to the most
advanced modality and equipment there is available. This is to achieve the Academy’s mission -

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to promote and advance the field of rehabilitation medicine and elevate the standards of practice
through training, education, research and service thereby improving the quality of life of the
Filipino people.

The PARM’s vision to be a nationally-recognized and globally-accepted society of dynamic,
compassionate and highly competent rehabilitation medicine specialists is in our horizon. The
PARM Clinical Practice Guidelines for Stroke Rehabilitation and Low Back Pain are just some
of the tools in making it a reality. We therefore challenge each and every member of the
Academy to make a commitment to further their education, develop their skills, dream big and
be at the forefront of comprehensive healthcare of the Filipino people.

Mabuhay tayong lahat! Mabuhay ang PARM!

Bonifacio S. Rafanan Jr., MD, FPARM
President
Philippine Academy of Rehabilitation Medicine 2012

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Contents
1 Introduction 1
1.1 The need for a guideline 1
1.1.1 Clinical guidelines supporting evidence based practice 2
1.1.2 Getting guidelines into practice 3
1.2 Care pathways 4
1.2.1 Inpatient 5
1.2.2 Outpatient 6
2 Methodology 7
2.1 Purpose and scope 7
2.2 Guideline search process 7
2.3 Critical appraisal 8
2.4 Extraction of relevant data for care pathways 8
2.5 Contextualization 9
2.6 PARM endorsements 11
2.7 PARM context points 12
2.8 Guidelines 12
2.9 Filling the gaps 14
2.10 Guideline developers 14
2.11 Public consultation 15
2.12 Implementation plans 15
3 Inpatient and outpatient stroke rehabilitation 18
3.1 Timing, intensity, frequency and duration of rehabilitation 18
3.2 PARM context points 22
3.2.1 Inpatient rehabilitation 22
3.2.2 Outpatient rehabilitation 22
4 Secondary prevention of stroke 23
4.1 Recommendations for identification of risk factors 24
4.2 Lifestyle measures 25

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4.2.1 Recommendations for smoking 25
4.2.2 Recommendations for diet 27
4.2.3 Recommendations for physical activity 30
4.2.4 Recommendations for weight maintenance 33
4.2.5 Recommendations for alcohol consumption 35
4.3 Recommendations for blood pressure 37
4.4 Recommendations for antiplatelet use 41
4.5 Recommendations for lipid lowering 44
4.6 Recommendations for carotid stenosis 47
4.7 Recommendations for oral contraception 51
4.8 Recommendations for diabetes 51
4.9 Recommendations for patent foramen ovale 55
4.10 Recommendations for hormone replacement therapy 56
4.11 PARM context points 57
5 Lower extremity interventions 58
5.1 Approach to therapy 58
5.2 Gait training 60
5.2.1 Other treatment modalities for gait training 62
5.3 Spasticity 64
5.4 Contractures 66
5.5 Cardiorespiratory fitness 67
5.6 Balance and falls 68
5.7 PARM context points 69
6 Upper extremity interventions 71
6.1 Intensity of training 71
6.2 Theraputic approaches 72
6.2.1 Constraint induced movement therapy 72
6.2.2 Imagery / mental practice / mental imagery 74
6.2.3 Electromechanical / robotic devices / robot-assisted therapy / mechanical-
assisted training 74
6.2.4 Repetitive task training 75
6.2.5 Routine electromyographic biofeedback 76

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6.2.6 Virtual reality 79
6.2.7 Bilateral practice 80
6.2.8 Neurodevelopmental technique 81
6.2.9 Upper extremity strengthening exercises 81
6.2.10 Mirror therapy 82
6.3 Upper extremity splinting 83
6.4 PARM context points 83
7 Post-stroke shoulder pain 85
7.1 Assessment and monitoring 85
7.2 Prevention 86
7.3 Treatment 88
7.4 Non-pharmacologic management 89
7.5 Pharmacologic management 91
7.6 PARM context points 92
8 Cognitive, perceptual disorders and apraxia 93
8.1 Cognitive impairment 93
8.1.1 Assessment and management of cognitive impairment 93
8.1.2 Treatment of cognitive impairment 97
8.2 Limb apraxia 98
8.3 Neglect 98
8.4 Executive functioning 99
8.5 PARM context points 100
9 Aphasia 101
9.1 Aphasia screening 101
9.2 Aphasia management 103
9.3 Dyspraxia 105
9.4 Dysarthria 106
9.5 PARM context points 108
10 Dysphagia and aspiration post stroke 109
10.1 Screening 109
10.2 Bedside assessment 112

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10.3 Instrumental assessment 113
10.4 Management 114
10.5 PEG / NGT insertion 116
10.6 PARM context points 118
10.6.1 Dysphagia assessment 118
10.6.2 Dysphagia management 119
11 Post-stroke medical complications 120
11.1 Central post-stroke pain 120
11.2 Deep venous thromboembolism / pulmonary embolism 123
11.3 Incontinence 125
11.3.1 Urinary incontinence 125
11.3.2 Fecal incontinence 129
11.4 Decubitus ulcer 131
11.5 Temperature management/ infection 132
11.6 Sleep apnea 133
11.7 PARM context points 133
12 Depression in stroke 135
12.1 Identification 135
12.2 Prevention 136
12.3 Intervention 137
12.4 Good practice points 138
13 Community-based rehabilitation and reintegration 139
13.1 Self-management 139
13.2 Driving 140
13.3 Leisure/physical activity 144
13.4 Return to work 146
13.5 Sexuality 147
13.6 Support 148
13.7 PARM context points 153
Abbreviations 154
Indeces 156

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Appendices 160
References 209

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1 Introduction
1.1 THE NEED FOR A GUIDELINE

According to the Department of Health, vascular disease is the second highest cause of
morbidity in the Philippines (Department of Health 2005). The prevalence of stroke in
the Philippines has increased in recent years, affecting more people at younger ages, and
causing a large burden on the Filipino health care system. Furthermore, due to the low
socio-economic status of most Filipinos, it is important that stroke patients be able to
return to work to support their families. If stroke patients are unable to continue their
occupation, issues of family burden and independence in daily activities need to be
addressed.

It was previously thought that the majority of functional recovery after a stroke is a
result of spontaneous natural recovery from neurological impairment (Dobkin 1989;
Lind 1982). However, studies have since shown that rehabilitation has an independent
role in improving function beyond that explained by neurological recovery alone (Roth
et al. 1998). Elements of a stroke rehabilitation program shown to contribute to a
patient’s functional recovery include: patient participation and motivation; early patient
mobilization; intensity and timing of physiotherapy; and compliance with stroke
rehabilitation guidelines. Functional recovery gained from a stroke rehabilitation
program has likewise been shown to have both short-term and long-term effects.
Although the cost of a stroke rehabilitation program in a stroke unit may initially seem
to pose a significant economic burden, even in developed countries, studies have shown
that participation in a rehabilitation program substantially reduces the length of a
patient’s stay in a stroke unit and is more effective in minimizing disability, thereby
proving to be more cost-effective in the long term (Kalva et al. 2005; Van Exel et al.
2003).

The application of evidence to guide clinical practice has been a global challenge for
almost all health professionals (Grol & Grimshaw 2003), more so in developing
countries such as the Philippines, where scant resources and sometimes even out of date
practices are still being delivered (Agarwal et al. 2008). Evidence-based healthcare
practices are not well established, particularly in terms of understanding evidence-based
practice (EBP), development of guidelines, or application of guidelines in making
decisions regarding patient care (McDonald et al. 2010; Short et al. 2010). However,
there have been some pioneering initiatives done in this area by medical societies in the
Philippines such as the Philippine Rheumatological Association (Guidelines for gout,
osteoarthritis and osteoporosis) and the Stroke society (Guidelines for stroke) within the

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