ICU Registered Nurse Lisa Nugent, foreground, talked with the “patient” during a 2022 simulation exercise at the Milwaukee VAMC as part of training for the new TeleStroke program. The program connects staff with an off-site neurologist via an iPad (visible in the background). New VA/DoD guidelines for treatment of stroke patients are designed to improve care. Photo from the Milwaukee VAMC.
LOS ANGELES — Revised treatment algorithms, 24 new recommendations and an expanded literature review on complementary and integrative health (CIH) approaches such as acupuncture, noninvasive brain stimulation, post-stroke spasticity management and technology-based rehabilitation like virtual reality (VR) are among the highlights of the newly updated VA/DOD Clinical Practice Guideline (CPG) for Management of Stroke Rehabilitation.
A leading cause of morbidity, mortality and disability, stroke affects approximately 3% of the U.S. population, a figure expected to rise to 4% by 2030. Stroke impacts motor function, speech, cognition, vision and emotional well-being, requiring timely, tailored rehabilitation for optimal recovery, stated the authors of a paper summarizing the guidelines in the Annals of Internal Medicine.1
The 2024 CPG, and update of the 2019 guideline, provides VA and DOD primary care providers (PCPs) with recommendations for adult stroke rehabilitation, emphasizing an interdisciplinary approach. It also offers guidance to stroke rehabilitation specialists. The guideline aims to improve quality of care and clinical outcomes but does not define a standard of care, the authors noted.
The guideline was developed through the VA/DOD Evidence-Based Practice Guideline Work Group process, said Blessen C. Eapen, MD, chief of physical medicine and rehabilitation at VA Greater Los Angeles Health Care, who co-chaired the Guideline Work Group and Development Team. The team, which included clinicians from various specialties, formulated 12 key questions using the PICOTS framework, focusing on rehabilitation strategies such as motor recovery, speech and swallowing, spasticity, mental health and caregiver support.
A systematic literature review (July 2018-May 2023) identified 179 relevant studies, prioritizing systematic reviews, meta-analyses and randomized controlled trials. The GRADE methodology was used to classify recommendations as “strong for,” “weak for,” “neutral,” “weak against” or “strong against.”
Patient focus groups, composed of VA and DOD patients, played a vital role in shaping the guidelines by identifying patient priorities and influencing recommendation strength, Eapen said. “A patient focus group is convened for every CPG and is conducted prior to the Key Question development,” he said. “The [Grading of Recommendations Assessment, Development and Evaluation] which was used to evaluate evidence, allows the work group to discuss if recommendations would be acceptable to patients and to modify the strength of the recommendations to reflect patient preferences. Finally, patient focus group participants are invited to review the final draft of the CPG and provide feedback. Patient feedback is a highly valued aspect of all CPGs.”
Key updates from the 2019 guideline included:
- Updated clinical algorithm and sidebars for streamlined decision-making.
- 24 new recommendations added, 19 replaced, 3 amended, and 16 removed.
- Greater emphasis on early rehabilitation, ensuring PCPs quickly identify and address cognitive, physical and emotional challenges post-stroke.
- Expanded role for PCPs in managing long-term recovery, adjusting rehabilitation plans and preventing secondary complications.
- Increased focus on mental health, recognizing the prevalence of post-stroke depression and anxiety and integrating psychological support into rehabilitation plans.
Eapen emphasized the guidelines’ role in helping PCPs identify early rehabilitation needs, even in the acute phase after a stroke. “Early intervention is critical for improving functional outcomes and reducing long-term disability,” he said.
He noted that stroke recovery is often a long-term process, with some patients requiring ongoing rehabilitation for months or years. “The guidelines help PCPs manage long-term care, including monitoring progress, adjusting rehabilitation plans as needed, and preventing complications like secondary strokes or cardiovascular issues.” They also focus on coordination of care with other specialists, Eapen said, noting that many stroke patients have comorbid conditions such as hypertension, diabetes, and cardiovascular disease, which need to be managed alongside rehabilitation.
Further, the guidelines stress the importance of educating patients and their families about stroke recovery, the rehabilitation process and lifestyle modifications. “By following these guidelines, PCPs can improve recovery outcomes, enhance stroke survivors’quality of life, and reduce the risk of further complications while addressing the unique needs of veterans and service members,” Eapen explained.
The guideline’s clear, evidence-based recommendations help clinicians determine the most effective interventions for stroke recovery. “Post-stroke depression and other mental health challenges are common, and these guidelines emphasize recognizing and addressing mental health issues during rehabilitation,” Eapen told U.S. Medicine. “This helps PCPs provide holistic care by incorporating psychological support and mental health resources into treatment plans.”
“Rehabilitation isn’t just about physical recovery—it’s also about reintegrating stroke survivors into their social and professional lives,” he said.
- Eapen BC, Tran J, Ballard-Hernandez J, Buelt A, Hoppes CW, Matthews C, Pundik S, Reston J, Tchopev Z, Wayman LM, Koehn T. Stroke Rehabilitation: Synopsis of the 2024 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines. Ann Intern Med. 2025 Feb;178(2):249-268. doi: 10.7326/ANNALS-24-02205. Epub 2025 Jan 21. PMID: 39832369.
