Stroke: Clinical Guidelines

Original Editor - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Abiodun Adedotun and Amrita Patro  

Introduction

The momentum for evidence-based healthcare has been gaining ground rapidly, motivated by clinicians, and management concerned about quality, consistency and costs of healthcare intervention. The use of Clinical Guidelines, based on standardised best practice, have been shown to be capable of supporting improvements in quality and consistency in healthcare and is considered one of the main ways that evidence-based medicine can be implemented. Clinical Practice Guidelines was defined by Field and Lohr (1990) as "systematically developed statements to assist practitioners and patient decisions about appropriate health care for specific circumstances".[1] [2]

According to Woolf et al (2012) Clinical Guidelines have become one of the foundation of efforts to improve healthcare and health care management. Methods of guideline development have progressed both in terms of process and necessary procedures and the context for guideline development has changed with the emergence of Guideline Clearinghouses and large scale guideline production organisations e.g National Institute for Health and Clinical Excellence [3].

Purpose

Clinical guidelines provide recommendations on how healthcare professionals should care for people with specific conditions. They can cover any aspect of a condition and may include recommendations about providing information and advice, prevention, diagnosis, treatment and longer-term management and are designed to support the decision-making processes in patient care. The content of a guideline is based on a systematic review of research literature and clinical evidence - the main source for evidence-based care.[4]

"The aim of clinical guidelines is to improve quality of care by translating new research findings into practice. There is evidence that the following characteristics contribute to their use: inclusion of specific recommendations, sufficient supporting evidence, a clear structure and an attractive lay out. In the process of formulating recommendations, implicit norms of the target users should be taken into account. Guidelines should be developed within a structured and coordinated programme by a credible central organisation. To promote their implementation, guidelines could be used as a template for local protocols, clinical pathways and interprofessional agreements". [5]

  • To describe appropriate care based on the best available scientific evidence and broad consensus;
  • To reduce inappropriate variation in practice;
  • To provide a more rational basis for referral;
  • To provide a focus for continuing professional education;
  • To promote efficient use of resources;
  • To act as focus for quality control, including audit;
  • To highlight shortcomings of existing literature and suggest appropriate future research. [4]

Limitations & Controversy

But Clinical Guidelines can have their limitations and there is controversy surrounding some recommendations within some guidelines e.g. controvery around use of tPA in Acute Stroke. Not every patient or situation fits neatly into a guideline. Guidelines to not always cover every eventuality and each patient's circumstance needs to be taken into consideration when a treatment is decided upon. Recommendations should be viewed as statements that inform the clinician, the patient and any other user, and not as rigid rules.

" The problems of getting people to act on evidence based guidelines are widely recognised. An overview of 41 systematic reviews found that the most promising approach was to use a variety of interventions including audit and feedback, reminders, and educational outreach. The effective interventions often involved complicated procedures and were always an addition to the provision of guidelines. None of the studies used the simplest intervention-that is, changing the wording of the guidelines. We examine the importance of precise behavioural recommendations and suggest how some current guidelines could be improved. ... "[6][7]

For a fuller discussion on the pros and cons of Clinical Guidelines, see the original series of articles written in the British Medical Journal followed by an updated and extended series with further recent considerations in the development of Clinical Guidelines. 

Development and Use of Clinical Guidelines Series 1:

  1. Potential Benefits, Limitations, and Harms of Clinical Guidelines [8]
  2. Developing Guidelines [9][9][9][9]
  3. Legal and Political Considerations of Clinical Practice Guidelines[10] [10][10][10]
  4. Using Clinical Guidelines[11] [11][11][11][11]

Developing Clinical Practice Guidelines Series 2 - Updated & Extended:

  1. Target Audiences, Identifying Topics for Guidelines, Guideline Group Composition and Functioning and Conflicts of Interest [12]
  2. Types of Evidence and Outcomes; Values and Economics, Synthesis, Grading, and Presentation and Deriving Recommendations [13]
  3. Reviewing, Reporting, and Publishing Guidelines; Updating Guidelines; and the Emerging Issues of Enhancing Guideline Implementability and Accounting for Comorbid Conditions in Guideline Development [14]

Guideline Organisations

Stroke Clinical Guidelines

While the evidence base for stroke managament and rehabilitation is increasing, substantial gaps still remain with an ongoing need for more research to improve both service delivery and more importantly patient outcomes.

Acute

Acute Clinical Guidelines fo Stroke tend to focus on the Medical Management covering interventions for Stroke or TIA during the acute phase, when the diagnosis is made, medical stability is achieved and early complications prevented, which approximates to the first 72 hours of care but in some instances extends into the rehabilitation phase when an individual has ongoing needs around their medical managament and stabilisation of Stroke. Principally it covers interventions at the level of individual patients and their family/carers with recommendations related to diagnosis and management of the underlying disease based on the WHO-ICF framework level of pathology, over the course of the first few days while clinical stability is being achieved, complications prevented and rehabilitation can begin in earnest. [15] 

Secondary Prevention

Research shows a substantially increased risk for further Stroke or TIA as 26% within the first 5 years of a first stroke and 39% at 10 years, with the greatest risk for further event within the first three months post Stroke[16]. Guidelines for Secondary Prevention therefore focus on identification and reduction of risk for futher event that are specific to each individual with priority being early implmenetation of secondary prevention occurring as soon as possible post stroke.[17][18]

Recommendations incorporate medical management such as use of aspirin post Ischemic Stroke but also incorporate changes in lifestyle factors such as nutrition, physical activity, smoking tha also address longer term secondary prevention that as physiotherapists we can play a large role in.[17][19]

Rehabilitation

This phase of the Stroke Recovery process focuses on the common issues that people with stroke will encounter as they recover from their stroke and is focused on person-centred outcomes of activities and participation rather than interventions aimed at pathology or impairments. [20] [19]

Guidelines highlight the importance of the stroke specialist multidisciplinary team but both timeframe and pathway for this process is not restrictuied and often overlaps with the into the long-term management phase. This phase can cover a range of settings including an acute stroke units, stroke rehabilitation units, early supported discharge services and other community rehabilitation services.[20]

Guidelines for this phase tend to focus initially on restoritive approaches then changing towards compensatory and adaptive approaches towards the end of this phase as the patient moves into the long term managament phase. Although a natural plateau should not preclude access to ongoing rehabilitation.[20][19]

Recommendations during this phase include management of specific losses and limitations that arise following a stroke and include cognition, communication, continence) which contain recommendations for specific impairments (e.g. spasticity), activity limitations (e.g. driving), restricted social participation and quality of life (e.g. sex).[20][19] 

Long Term

Studies that have followed up people with stroke at varying times post stroke indicate that many people continue to make functional gains following interventions, months and years post stroke, across a range of functional abilities [21]. Guidelines for this phase focuse on the long-term management of individuals with stroke in relation to stroke-specific issues, combining long-term medical management, principally around secondary vascular prevention and the treatment of less common causes of stroke, with aspects of social participation and is concerned with person-centred and family-centred care.[22][17]

Long Term Management can be very complex in nature  as a result of the wide variety of individual circumstance that each individual post stroke is faced with. This creates a challenge for research and as a consequence, the evidence to guide recommendations here are more difficult to interpret, and often more sprase but this should not reduce the importance of this phase and the need for further research in this area in order to develop expert guidance on best practice. [22][17]

References

  1. Field MJ, Lohr KN (Eds). Clinical Practice Guidelines: Directions for a New Program, Institute of Medicine, Washington, DC: National Academy Press, 1990.
  2. Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999 Feb 20;318(7182):527-30.
  3. Woolf S, Schünemann HJ, Eccles MP, Grimshaw JM, Shekelle P. Developing clinical practice guidelines: types of evidence and outcomes; values and economics, synthesis, grading, and presentation and deriving recommendations. Implementation Science. 2012 Jul 4;7(1):61.
  4. 4.0 4.1 Open Clinical. Clinical Practice Guidelines. http://www.openclinical.org/guidelines#refs (accessed 2 May 2017).
  5. Wollersheim H, Burgers J, Grol R. Clinical guidelines to improve patient care. Neth J Med. 2005 Jun;63(6):188-92.
  6. Michie S, Johnston M. Changing clinical behaviour by making guidelines specific. BMJ. 2004 Feb 7;328(7435):343-5.
  7. Jackson R, Feder G. Guidelines for Clinical Guidelines: A Simple, Pragmatic Strategy for Guideline Development. British Medical Journal. 1998 Aug 15;317(7156):427-9.
  8. Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Potential benefits, limitations, and harms of clinical guidelines. British Medical Journal. 1999 Feb 20;318(7182):527.
  9. Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Developing Guidelines. Bmj. 1999 Feb 27;318(7183):593-6.
  10. Hurwitz B. Legal and Political Considerations of Clinical Practice Guidelines. BMJ: British Medical Journal. 1999 Mar 6;318(7184):661.
  11. Feder G, Eccles M, Grol R, Griffiths C, Grimshaw J. Using Clinical Guidelines. British Medical Journal. 1999 Mar 13;318(7185):728.
  12. Eccles MP, Grimshaw JM, Shekelle P, Schünemann HJ, Woolf S. Developing Clinical Practice Guidelines: Target Audiences, Identifying Topics for Guidelines, Guideline Group Composition and Functioning and Conflicts of Interest. Implementation Science. 2012 Dec;7(1):60.
  13. Woolf S, Schünemann HJ, Eccles MP, Grimshaw JM, Shekelle P. Developing Clinical Practice Guidelines: Types of Evidence and Outcomes; Values and Economics, Synthesis, Grading, and Presentation and Deriving Recommendations. Implementation Science. 2012 Dec;7(1):61.
  14. Shekelle P, Woolf S, Grimshaw JM, Schünemann HJ, Eccles MP. Developing Clinical Practice Guidelines: Reviewing, Reporting, and Publishing Guidelines; Updating Guidelines; and the Emerging Issues of Enhancing Guideline Implementability and Accounting for Comorbid Conditions in Guideline Development. Implementation Science. 2012 Dec;7(1):62.
  15. Section 3 Acute Care in Intercollegiate Stroke Working Party. National Clinical Guideline for Stroke Fifth Edition. 2016 pp. 34 - 52
  16. Mohan KM, Wolfe CD, Rudd AG, Heuschmann PU, et al, 2011. Risk and cumulative risk of stroke recurrence: a systematic review and meta-analysis. Stroke, 42, 1489-94.
  17. 17.0 17.1 17.2 17.3 Section 5 Long Term Management and Secondary Prevention in Intercollegiate Stroke Working Party. National Clinical Guideline for Stroke Fifth Edition. 2016 pp. 89 - 113
  18. Coutts SB, Wein TH, Lindsay MP, Buck B, Cote R, Ellis P, Foley N, Hill MD, Jaspers S, Jin AY, Kwiatkowski B. Canadian Stroke Best Practice Recommendations: Secondary Prevention of Stroke Guidelines, Update 2014. International Journal of Stroke. 2015 Apr;10(3):282-91.
  19. 19.0 19.1 19.2 19.3 J.M. Veerbeek et al. Clinical Practice Guideline for Physical Therapy in Patients with Stroke. Royal Dutch Society for Physical Therapy (KNGF), 2014.
  20. 20.0 20.1 20.2 20.3 Section 4 Recovery & Rehabilitation in Intercollegiate Stroke Working Party. National Clinical Guideline for Stroke Fifth Edition. 2016 pp. 53-88
  21. Doig E, Amsters D. Community Rehabilitation Needs Of Stroke Survivors - Short and long term. Community Rehabilitation Workforce Project: Queensland Health, 2006.
  22. 22.0 22.1 Stroke Rehabilitation: Long-term Rehabilitation After Stroke. NICE Guidelines, 2014.