2024 VA/DOD Clinical Practice Guideline for Stroke Rehabilitation
26 Jan, 2025 | 17:07h | UTCIntroduction:
This document summarizes the updated 2024 clinical practice guideline (CPG) jointly developed by the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DOD). It addresses stroke rehabilitation across inpatient, outpatient, and community settings, emphasizing an interdisciplinary approach. The main objective is to provide evidence-based recommendations to guide clinical decision-making and improve functional outcomes and quality of life for adult stroke survivors.
Key Recommendations:
- Transition to Community
- Case Management: Suggest using case management services at discharge to enhance activities of daily living (ADLs) and functional independence (“weak for”).
- Behavioral/Psychosocial Interventions: Recommend psychosocial supports, such as stress management and motivational interviewing, to improve patient and caregiver depression, family function, and overall quality of life (“weak for”).
- Psychoeducation: Encourage structured education on stroke care and self-management for patients and their caregivers to boost functional independence and social support.
- Motor Therapy
- Task-Specific Practice: Strongly recommend repetitive or task-oriented practice to improve motor function, gait, posture, and ADLs (“strong for”).
- Mirror Therapy: Suggest mirror therapy to improve motor outcomes, ADLs, and unilateral spatial neglect (“weak for”).
- Rhythmic Auditory Stimulation: Suggest adding external auditory cues (e.g., music or metronome) to assist in gait training (“weak for”).
- Neuromuscular Electrical Stimulation: Suggest neuromuscular electrical stimulation for enhancing upper- or lower-extremity motor recovery (“weak for”).
- Botulinum Toxin for Spasticity: Suggest botulinum toxin for focal spasticity, considering patient-specific characteristics and preferences, though evidence shows comparable efficacy to oral baclofen except in ankle spasticity (“weak for”).
- Dysphagia, Aphasia, and Cognition
- Dysphagia Rehabilitation:
- Chin tuck against resistance for swallowing impairment (“weak for”).
- Respiratory muscle strength training (for those without tracheostomy) to reduce aspiration risk (“weak for”).
- Aphasia Rehabilitation:
- No specific intensity level of language therapy is proven superior; tailor therapy duration and frequency to individual needs (“neither for nor against”).
- Cognitive Outcomes:
- Current evidence does not support or refute SSRIs for cognitive recovery; consider other individualized cognitive rehabilitation strategies (“neither for nor against”).
- Unilateral Spatial Neglect:
- Mirror therapy may help address neglect and improve ADLs (“weak for”).
- Dysphagia Rehabilitation:
- Mental Health
- Depression Treatment:
- Suggest SSRIs or SNRIs for patients with established poststroke depression (“weak for”).
- Recommend psychotherapy (e.g., cognitive behavioral therapy) and consider mindfulness-based therapies for depression following stroke (“weak for”).
- Prevention of Depression:
- Suggest against prophylactic antidepressants for preventing poststroke depression due to risk of adverse effects, such as fractures (“weak against”).
- Depression Treatment:
- Telehealth
- Consider telerehabilitation as an alternative or adjunct to in-person therapy if it aligns with patient preferences and clinical feasibility (“weak for”).
- Evidence is inconclusive regarding telerehabilitation for dysphagia, aphasia, or caregiver support; use individualized judgment (“neither for nor against”).
- Noninvasive Brain Stimulation
- Insufficient evidence to recommend for or against repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), or continuous theta burst stimulation to enhance motor recovery (“neither for nor against”).
Conclusion:
These updated 2024 VA/DOD stroke rehabilitation guidelines underscore the importance of an interdisciplinary and patient-centered approach that integrates medical, psychological, and rehabilitative strategies. Adopting these recommendations—particularly around early case management, targeted motor therapies (task-specific practice, mirror therapy, neuromuscular electrical stimulation), dysphagia interventions, and tailored mental health treatments—can improve functional outcomes, optimize quality of life, and reduce poststroke morbidity.
Reference:
- Eapen BC, Tran J, Ballard-Hernandez J, et al. Stroke Rehabilitation: Synopsis of the 2024 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines. Annals of Internal Medicine. 2025. DOI: https://doi.org/10.7326/ANNALS-24-02205
- Cramer SC. Moving Stroke Rehabilitation Forward and Into the Future. Annals of Internal Medicine. 2025. DOI: https://doi.org/10.7326/ANNALS-24-03568