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Recreational Therapy Evidence Based Practice Day ConferenceTemple University, Department of Rehabilitation Sciences, Recreational Therapy ProgramApril 24, 2019Clinical Practice Guidelines for RT Treatment of Adult StrokeKayla Fili, BSRT Student; kfili@temple.eduHeather R. Porter, PhD, CTRS; Associate Professor; hporter@temple.eduCitation of Guideline Reviewed: Winstein, C., Stein, J., Arena, R., Bates, B., Cherney, L., Cramer, S.,…Zorowitz, R. (2016). Guidelines for adult stroke rehabilitation and recovery: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 47(6), e98-e169. INCLUDEPICTURE "" \* MERGEFORMATINET Usefulness/efficacy is less well established by evidence or opinion. Things that MAY be reasonable to consider.The weight of evidence or opinion is in favor of the procedure or treatment…OR… Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. Things that ARE reasonable.Conditions for which there is evidence for and/or general agreement that the procedure or treatment is useful and effective. Things that are recommended.CognitionKeywordRecommendationCompensatory strategiesCompensatory strategies may be considered to improve memory functions, including the use of internalized strategies (e.g., visual imagery, semantic organization, spaced practice) and external memory assistive technology (e.g., notebooks, paging systems, computers, other prompting devices).Memory trainingSome type of specific memory training is reasonable such as promoting global processing in visual-spatial memory and constructing a semantic framework for language-based memory.Errorless learningErrorless learning techniques may be effective for individuals with severe memory impairments for learning specific skills or knowledge, although there is limited transfer to novel tasks or reduction in overall functional memory problems.Music therapyMusic therapy may be reasonable for improving verbal memory.ExerciseExercise may be considered as adjunctive therapy to improve cognition and memory after stroke.Virtual reality trainingVirtual reality training may be considered for verbal, visual, and spatial learning, but its efficacy is not well established.Cognitive rehabilitationUse of cognitive rehabilitation to improve attention, memory, visual neglect, and executive functioning is reasonable.Cognitive training strategiesUse of cognitive training strategies that consider practice, compensation, and adaptive techniques for increasing independence is reasonable.Enriched environmentsEnriched environments to increase engagement with cognitive activities are recommended.Limb ApraxiaKeywordRecommendationStrategy training/gesture trainingStrategy training or gesture training for apraxia may be considered.Task practiceTask practice for apraxia with and without mental rehearsal may be considered.AphasiaKeywordRecommendationsComputerized treatmentComputerized treatmentGroup treatmentGroup treatment may be useful across the continuum of care, including the use of community-based aphasia munication partner trainingCommunication partner trainingMotor Speech Disorders: Dysarthria and Apraxia of SpeechKeywordRecommendationEnvironmental modificationsEnvironmental modifications, including listener education, may be considered to improve communication effectiveness.ActivitiesActivities to facilitate social participation and promote psychosocial well-being may be considered.Augmentative and alternative communication devicesAugmentative and alternative communication devices and modalities should be used to supplement speech.Balance and AtaxiaKeywordRecommendationPostural training and task-oriented therapyPostural training and task-oriented therapy may be considered for rehabilitation of ataxia.Balance training programIndividuals with stroke who have poor balance, low balance confidence, and fear of falls or are at risk for falls should be provided with a balance training programEvaluated for…Individuals with stroke should be evaluated for balance, balance confidence, and falls risk.MobilityKeywordRecommendationPractice walkingPractice walking with either a treadmill (with or without body-weight support) or over-ground walking exercise training combined with conventional rehabilitation may be reasonable for recovery of walking function.Rhythmic auditory cueingThe effectiveness of rhythmic auditory cueing to improve walking speed and coordination is uncertain.Virtual realityVirtual reality may be beneficial for the improvement of gait.Water-based exerciseThe effectiveness of water-based exercise for motor recovery after an acute stroke is unclear.Group therapy with circuit trainingGroup therapy with circuit training is a reasonable approach to improve walking.Cardiovascular exercise and strengthening interventionsIncorporating cardiovascular exercise and strengthening interventions is reasonable to consider for recovery of gait capacity and gait-related mobility tasks.Intensive, repetitive, mobility-task trainingIntensive, repetitive, mobility-task training is recommended for all individuals with gait limitations after stroke.Upper Extremity ActivityKeywordRecommendationBilateral trainingBilateral training paradigms may be useful for upper limb therapy.CIMT or mCIMTCIMT or its modified version is reasonable to consider for eligible stroke survivors.Mental practiceMental practice is reasonable to consider as an adjunct to upper extremity rehabilitation services.Strengthening exercisesStrengthening exercises are reasonable to consider as an adjunct to functional task practice.Virtual realityVirtual reality is reasonable to consider as a method for delivering upper extremity movement practice.Task-specific trainingFunctional tasks should be practiced; that is, task-specific training, in which the tasks are graded to challenge individual capabilities, practiced repeatedly, and progressed in difficulty on a frequent basis.Visual ImpairmentsKeywordRecommendationFor deficits in eye movementsCompensatory scanningCompensatory scanning training may be considered for improving scanning and reading outcomes.For deficits in visual fieldsCompensatory scanningCompensatory scanning training may be considered for improving functional deficits after visual field loss but it is not effective at reducing visual field deficits.For visual-spatial/perceptual deficitsVirtual reality environmentsThe use of virtual reality environments to improve visual-spatial/perceptual functioning may be considered.Hemi-spatial Neglect or Hemi-inattentionKeywordRecommendationVisual scanning training, virtual reality, limb activation, mental imageryVisual scanning training, virtual reality, limb activation, mental imageryHearing LossKeywordRecommendationRefer to audiologistIf a patient is suspected of a hearing impairment, it is reasonable to refer to an audiologist for audiometric testing.AmplificationIt is reasonable to use some form of amplification (i.e. hearing aids).Communication strategiesIt is reasonable to use communication strategies such as looking at the patient when speaking.Background noiseIt is reasonable to minimize the level of background noise in the patient’s environment.Social and Family Caregiver SupportKeywordRecommendationFamily/caregiver componentIt may be useful for the family/caregiver to be an integral component of stroke rehabilitation Family/caregiver supportIt may be reasonable that family/caregiver support include some or all of the following on a regular basis: education, training, counseling, development of a support structure, financial assistanceFamily/caregiver involvement It may be useful to have the family/caregiver involved in decision making and treatment planning as early as possible and throughout the duration of the rehabilitation processChronic Care Management: Home-and Community-Based ParticipationKeywordRecommendationTailored exercise programAfter successful screening, an individually tailored exercise program is indicated to enhance cardiorespiratory fitness and to reduce the risk of stroke recurrence.Engagement in home/community exercise programAfter completion of formal stroke rehabilitation, participation in a program of exercise or physical activity at home or in the community is recommended.Sexual FunctionKeywordRecommendationDiscussionAn offer to patients and their partners to discuss sexual issues may be useful before discharge home and again after transition to the community. Discussion topics may include safety concerns, changes in libido, physical limitations resulting from stroke, and emotional consequences of stroke.Recreational and Leisure ActivityKeywordRecommendationsActive and healthy lifestyleIt is reasonable to promote engagement in leisure and recreational pursuits, particularly through the provision of information on the importance of maintaining an active and healthy lifestyle.Barrier problem solvingIt is reasonable to foster the development of self-management skills for problem solving for overcoming barriers to engagement in active activities.Begin during in-patient rehabIt is reasonable to start education and self-management skill development about leisure/recreation activities during and in conjunction with in-patient rehabilitation.Rehabilitation in the CommunityKeywordRecommendationMonitoring complianceA formal plan for monitoring compliance and participation in treatment activities may be useful for individuals with stroke referred for home- or community-based rehabilitation services. A case manager or professional staff person should be assigned to oversee implementation of the munity/home-based rehabPatients with stroke receiving comprehensive ADL, IADL, and mobility assessments, including evaluation of the discharge living setting, should be considered candidates for community or home-based rehabilitation when feasible. Exclusions include individuals with stroke who require daily nursing services, regular medical interventions, specialized equipment, or interprofessional expertise.Family/caregiver involvementIt is reasonable that caregivers, including family members, be involved in training and education related directly tohome-based rehabilitation programs and be included as active partners in the planning and implementation or treatment activities under the supervision of professionals.Referral to Community ResourcesKeywordRecommendationInventory of community resourcesIt is recommended that acute care hospitals and rehabilitation facilities maintain up-to-date inventories of community resources.Preferences for resourcesPatient and family/caregiver preferences for resources should be considered.Local resourcesIt is recommended that information about local resources be provided to the patient and family.ReferralIt is recommended that contact with community resources be offered through formal or informal referral.Ensuring Medical and Rehabilitation Continuity Through the Rehabilitation Process and into the CommunityKeywordRecommendationIndividualized discharge planningIt is reasonable to consider individualized discharge planning in the transition from hospital to home.Mixed communication methodsIt is reasonable to consider alternative methods of communication and support (i.e. telephone visits, telehealth, or Web-based support), particularly for patients in rural settings.Recommended Standardized Assessment TypeConstruct/ MeasureComments~Time to Administer in MinutesActivityUE FunctionBox and Block TestScore is the number of blocks moved in 1 min; higher scores equal better performance; normative data are available for comparison.<5BalanceBerg Balance ScaleCriterion-based assessment of static and dynamic balance; widely used in multiple settings15BalanceFunctional Reach TestA single-item test that measures how far one can reach in standing; normative data are available for comparison<5MobilityTimed Up and GoQuantifies more than straight walking, including sit/stand and a turn; scored by time to complete; criterion values available for comparison<5Mobility6-Min walk testQuantifies walking endurance; normative and criterion values for community ambulation distances available<10ParticipationSelf-reported impairments, limitations, and restrictionsStroke Impact Scale: Strength, Mobility, ADL, and Hand Function subscalesThese 4 subscales measure different aspects of physical performance; people rate their perceived ability to do different items; each subscale ranges from 0-100, with higher scores indicating better abilities5 per subscaleSelf-reported impairments, limitations, and restrictionsActivities-specific Balance Confidence Scale16 questions in which people with stroke rate their balance confidence during routine activities; scores range from 0-100, with higher scores indicating more confidence20Technology for monitoring activity and participationAccelerometers, step activity monitors, pedometersNumerous commercially available options; issues to consider when purchasing: cost, expected wear and tear, accompanying software, ease of use, wearing comfort; pedometers are the most economic option but need to be checked for ability to register steps of individuals with slow walking speeds<5 to don/doff; additional processing timeLinks to additional content reviewed within the PowerPoint PresentationRehab Measures Database ................
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