Nonpharmaceutical interventions have strongest evidence support for poststroke rehab

Recently updated Veterans Affairs guidelines on rehabilitation after stroke were based on this review of pharmacologic and nonpharmacologic therapies for motor deficits or mood disorders after stroke.

Cardiorespiratory training, repetitive task training, and transcranial direct current stimulation (tDCS) may improve activities of daily living in adults who have had a stroke, according to a review that supported recent Veterans Affairs (VA) guidelines.

Cognitive behavioral therapy, exercise, and selective serotonin reuptake inhibitors (SSRIs) may reduce symptoms of poststroke depression, but SSRIs were not found to prevent depression or improve motor function, according to the systematic review.

Researchers from ECRI Institute reviewed 19 systematic reviews and 37 randomized controlled trials addressing pharmacologic and nonpharmacologic therapies for motor deficits or mood disorders in adults with stroke as part of an update to recommendations from the VA and Department of Defense. Their findings were published Nov.19 by Annals of Internal Medicine.

The quality of evidence was low to very low for most interventions for improving poststroke motor deficits, the review found. Most interventions did not improve motor function. High-quality evidence did not support use of fluoxetine to improve motor function. Moderate-quality evidence supported using cardiorespiratory training to improve maximum walking speed and using repetitive task training or tDCS to improve functional movement. Low-quality evidence supported robotic arm training to improve activities of daily living.

Low-quality evidence showed a positive effect of SSRIs or serotonin-norepinephrine reuptake inhibitors on symptoms of poststroke depression, but the review stated that the frequency and severity of antidepressant-related adverse effects were unclear. Nonpharmacologic approaches such as cognitive behavioral therapy, exercise, and mind-body approaches also seemed to safely reduce symptoms of depression and anxiety.

More studies are needed, the authors noted. “Although stroke continues to cause significant disability, much remains unknown regarding the best interventions for rehabilitation for common sequelae, such as motor deficits and impaired ambulation,” they wrote. “Although several interventions led to positive outcomes, most interventions were not different from standard physiotherapy or control.”

Members of the VA and Department of Defense Work Group also summarized their resulting guideline recommendations in six areas: timing and approach of rehabilitation; motor therapy; dysphagia; cognitive, speech, and sensory therapy; mental health therapy; and other functions such as returning to work and driving.

“Poststroke rehabilitation requires an interdisciplinary holistic approach to the management, treatment, and rehabilitation of poststroke sequelae, with the patient and family as vital members of the team,” the authors wrote. They recommended that their guidelines be used as an adjunct to those from the American Heart Association and American Stroke Association.