2022+BAN实践指南：卒中康复—第Ⅰ部分

https://doi.org/10.1590/0004-282X-ANP-2021-0354
BRAZILIAN ACADEMY OF NEUROLOGY
Brazilian Academy of Neurology practice
guidelines for stroke rehabilitation: part I
Diretrizes da Academia Brasileira de Neurologia para reabilita??o do acidente vascular
cerebral: parte I
1,2 3 4,5,6,7,8 9
Cesar MINELLI , Rodrigo BAZAN , Marco Túlio Araújo PEDATELLA , Luciana de Oliveira NEVES ,
10 3 11
Roberta de Oliveira CACHO , Sheila Cristina Sayuri Abe MAGALH?ES , Gustavo José LUVIZUTTO ,
12,13,14 15 3
Carla Heloísa Cabral MORO , Marcos Christiano LANGE , Gabriel Pinheiro MODOLO , Bruna Correia
16 16 3 2
LOPES , Elisandra Leites PINHEIRO , Juli Thomaz de SOUZA , Guilherme Riccioppo RODRIGUES ,
17 18 18
Soraia Ramos Cabette FABIO , Gilmar Fernandes do PRADO , Karla CARLOS , Juliana Junqueira
8 4,6 4,6
Marques TEIXEIRA , Clara Monteiro Antunes BARREIRA , Rodrigo de Souza CASTRO , Thalita Dayrell
4,6 5,6,7,19 20
Leite QUINAN , Eduardo DAMASCENO , Kelson James ALMEIDA , Octávio Marques PONTES-
2 21 2
NETO , Marina Teixeira Ramalho Pereira DALIO , Millene Rodrigues CAMILO , Michelle Hyczy de Siqueira
22,23 22 22
TOSIN , Bianca Campos OLIVEIRA , Beatriz Guitton Renaud Baptista de OLIVEIRA , Jo?o José Freitas
24,25 26,27,28
de CARVALHO , Sheila Cristina Ouriques MARTINS
ABSTRACT
The Guidelines for Stroke Rehabilitation are the result of a joint effort by the Scientific Department of Neurological Rehabilitation of the
Brazilian Academy of Neurology aiming to guide professionals involved in the rehabilitation process to reduce functional disability and increase
individual autonomy. Members of the group participated in web discussion forums with predefined themes, followed by videoconference
meetings in which issues were discussed, leading to a consensus. These guidelines, divided into two parts, focus on the implications of
recent clinical trials, systematic reviews, and meta-analyses in stroke rehabilitation literature. The main objective was to guide physicians,
physiotherapists, speech therapists, occupational therapists, nurses, nutritionists, and other professionals involved in post-stroke care.
Recommendations and levels of evidence were adapted according to the currently available literature. Part I discusses topics on rehabilitation
in the acute phase, as well as prevention and management of frequent conditions and comorbidities after stroke.
Keywords: Stroke; Guideline; Neurological Rehabilitation; Practice Guidelines as Topic.
RESUMO
As Diretrizes Brasileiras para Reabilita??o do AVC s?o fruto de um esfor?o conjunto do Departamento Científico de Reabilita??o Neurológica
da Academia Brasileira de Neurologia com o objetivo de orientar os profissionais envolvidos no processo de reabilita??o para a redu??o da
incapacidade funcional e aumento da autonomia dos indivíduos. Membros do grupo acima participaram de fóruns de discuss?o na web com
pré-temas, seguidos de reuni?es por videoconferência em que as controvérsias foram discutidas, levando a um consenso. Essas diretrizes,
divididas em duas partes, focam as implica??es de recentes ensaios clínicos, revis?es sistemáticas e metanálises sobre reabilita??o do AVC.
O objetivo principal é servir de orienta??o a médicos, fisioterapeutas, fonoaudiólogos, terapeutas ocupacionais, enfermeiros, nutricionistas
e demais profissionais envolvidos no cuidado pós-AVC. As recomenda??es e níveis de evidência foram adaptados de acordo com a literatura
disponível atualmente. Aqui é apresentada a Parte I sobre tópicos de reabilita??o na fase aguda, preven??o e tratamento de doen?as e
comorbidades frequentes após o AVC.
Palavras-chave: Acidente Vascular Cerebral; Guia; Reabilita??o Neurológica; Guias de Prática Clínica como Assunto.
1
Hospital Carlos Fernando Malzoni, Mat?o SP, Brazil.
2
Universidade de S?o Paulo, Faculdade de Medicina de Ribeir?o Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeir?o Preto SP,
Brazil.
3
Universidade Estadual Paulista, Faculdade de Medicina de Botucatu, Botucatu SP, Brazil.
4
Hospital Israelita Albert Einstein, Unidade Goiania, Goiania GO, Brazil.
5
Hospital Santa Helena, Goiania GO, Brazil.
6
Hospital Encore, Goiania GO, Brazil.
7
Hospital Geral de Goiania, Goiania GO, Brazil.
8
Hospital de Urgência de Goiania, Goiania GO, Brazil.
9
Universidade de Fortaleza, Hospital S?o Carlos, Fortaleza CE, Brazil.
10
Universidade Federal do Rio Grande do Norte, Faculdade de Ciências da Saúde do Trairi, Santa Cruz RN, Brazil.
11
Universidade Federal do Triangulo Mineiro, Departamento de Fisioterapia Aplicada, Uberaba MG, Brazil.
12
Neurológica Joinville, Joinville SC, Brazil.
63413
Hospital Municipal de Joinville, Joinville SC, Brazil.
14
Associa??o Brasil AVC, Joinville SC, Brazil.
15
Universidade Federal do Paraná, Complexo Hospital de Clínicas, Curitiba PR, Brazil.
16
Hospital Moinhos de Vento, Porto Alegre RS, Brazil.
17
Hospital UNIMED Ribeir?o Preto, Ribeir?o Preto SP, Brazil.
18
Universidade Federal de S?o Paulo, Escola Paulista de Medicina, S?o Paulo SP, Brazil.
19
Hospital Orion, Goiania GO, Brazil.
20
Universidade Federal do Piauí, Departamento de Neurologia, Teresina PI, Brazil.
21
Universidade de S?o Paulo, Hospital das Clínicas, Faculdade de Medicina de Ribeir?o Preto, Centro de Cirurgia de Epilepsia de Ribeir?o Preto, Ribeir?o Preto
SP, Brazil.
22
Universidade Federal Fluminense, Niterói RJ, Brazil.
23
Rush University, Chicago IL, USA.
24
Faculdade de Medicina Unichristus, Fortaleza CE, Brazil.
25
Hospital Geral de Fortaleza, Fortaleza CE, Brazil.
26
Rede Brasil AVC, Porto Alegre RS, Brazil.
27
Hospital Moinhos de Vento, Departamento de Neurologia, Porto Alegre RS, Brazil.
28
Hospital de Clínicas de Porto Alegre, Departamento de Neurologia, Porto Alegre RS, Brazil.
CM https://orcid.org/0000-0002-3969-6629; RB https://orcid.org/0000-0003-3872-308X; MTAP https://orcid.org/0000-0003-1295-5536;
? ? ?
LON https://orcid.org/0000-0002-8524-4308; ROC https://orcid.org/0000-0002-0440-8594; SCSAM https://orcid.org/0000-0003-4629-2849;
? ? ?
GJL https://orcid.org/0000-0002-6914-7225; CHCM https://orcid.org/0000-0001-6346-939X; MCL https://orcid.org/0000-0002-0405-7157;
? ? ?
GPM https://orcid.org/0000-0003-1057-5089; BCL https://orcid.org/0000-0003-0470-813X; ELP https://orcid.org/0000-0003-4698-5303;
? ? ?
JTS https://orcid.org/0000-0003-2227-7505; GRR https://orcid.org/0000-0003-1475-1908; SRCF https://orcid.org/0000-0002-8789-5796;
? ? ?
GFP https://orcid.org/0000-0002-3383-8198; KC https://orcid.org/0000-0002-6600-4587; JJMT https://orcid.org/0000-0003-0213-5905;
? ? ?
CMAB https://orcid.org/0000-0003-4422-9969; RSC https://orcid.org/0000-0003-0960-5797; TDLQ https://orcid.org/0000-0001-5663-6778;
? ? ?
ED https://orcid.org/0000-0003-4042-0192; KJA https://orcid.org/0000-0002-6299-7323; OMPN https://orcid.org/0000-0003-0317-843X;
? ? ?
MTRPD https://orcid.org/0000-0002-5990-3306; MRC https://orcid.org/0000-0002-0310-6033; MHST https://orcid.org/0000-0001-7309-1407;
? ? ?
BCO https://orcid.org/0000-0002-6348-3287; BGRBO https://orcid.org/0000-0001-7494-7457; JJFC https://orcid.org/0000-0002-1070-5552;
? ? ?
SCOM https://orcid.org/0000-0002-8452-712X
?
Correspondence: Cesar Minelli; Email: [e-mail].
Conflict of interest: There is no conflict of interest to declare.
Authors’ contributions: RB, GJL, CM: Introduction, recommendation ratings, and levels of evidence – conceptualization, writing, review, editing, and validation
of the original draft; MCL: participation as reviewer; CHCM, CM: Rehabilitation in the acute phase and the Stroke Unit – conceptualization, writing, review,
editing, and validation of the original draft; MCL: participation as reviewer; GPM: Contractures – conceptualization, writing, review, editing, and validation
of the original draft; CM: Physical deconditioning – conceptualization, writing, review, editing, and validation of the original draft; CM: Central Pain –
conceptualization, writing, review, editing, and validation of the original draft; KJA: participation as reviewer; CM: Painful Shoulder – conceptualization,
writing, review, editing, and validation of the original draft; KJA: participation as reviewer; BCL, ELP: Pressure Injury – conceptualization, writing, review,
editing, and validation of the original draft; JTS: Nutritional Support – conceptualization, writing, review, editing, and validation of the original draft; GRR:
Mood Disorders – conceptualization, writing, review, editing, and validation of the original draft; SRCF: Deep Vein Thrombosis – conceptualization, writing,
review, editing, and validation of the original draft; SRCF: Secondary Stroke Prevention – conceptualization, writing, review, editing, and validation of the
original draft; GFP, KC: Sleep Disorders – conceptualization, writing, review, editing, and validation of the original draft; MTAP, JJMT, CMAB, RSC, TDLQ, ED:
Falls – conceptualization, writing, review, editing, and validation of the original draft; MTAP, JJMT, CMAB, RSC, TDLQ: Osteoporosis – conceptualization, writing,
review, editing, and validation of the original draft; MRC, MTRPD, OMPN: Epilepsy – conceptualization, writing, review, editing, and validation of the original
draft; MHST, BCO, BGRBO: Neurogenic Lower Urinary Tract Dysfunction and Fecal Incontinence – conceptualization, writing, review, editing, and validation
of the original draft; CM, LON: Sexual Dysfunction – conceptualization, writing, review, editing, and validation of the original draft; JJF, SCOM: participation
as reviewers; CM: General Coordinator; CM, RB, LON, MTP, SCSAB, ROC, GJL: Coordinating Nucleus; RB: Standardization and Guidelines Coordinator; RB, CM,
LON, MTP, SCSAM, ROC, GJL: Standards and Guidelines Council; Scientific Department of Neurological Rehabilitation of the Brazilian Academy of Neurology:
Execution.
Received on August 27, 2021; Received in its final form on December 21, 2021; Accepted on January 18, 2022.
stroke patients are referred to a rehabilitation center by the
INTRODUCTION
time of discharge; however, in most parts of the country stroke
Stroke is the second leading cause of death and disability
survivors have few opportunities to initiate or continue reha-
1,2
worldwide . It is estimated that in 2016, there were almost
bilitation after the acute phase. This data is lacking in Brazil
260,000 stroke cases, approximately 107,000 deaths, and more
and has been evaluated by the Access to Rehabilitation Study
than 2.2 million adjusted life years lost due to disability fol- across 17 public health centers in Brazilian cities in the North,
3,4 7
lowing a stroke in Brazil . Worldwide, stroke is the most
Northeast, West, Southeast and South of Brazil . Therefore, the
prevalent neurological disease that needs rehabilitation, with
need for effective rehabilitation of stroke patients remains an
5
86 million disabled individuals . More than two-thirds of indi- essential part of the continuum of stroke treatment.
viduals after stroke receive rehabilitation services after hos- Considering this premise, the Scientific Department
6
pitalization . Despite the development and support of stroke
of Neurological Rehabilitation of the Brazilian Academy of
centers and national societies in Brazil to raise awareness of Neurology made efforts to draft the first Brazilian Guidelines
stroke symptoms, only a minority of stroke patients in the for Stroke Rehabilitation to guide professionals involved in
acute phase receive thrombolytic therapy or thrombectomy. the rehabilitation process to reduce functional disability and
Consequently, many stroke survivors have residual functional increase the autonomy of individuals. The members of the
deficits. Stroke rehabilitation differs in many regions in Brazil group participated in discussion forums on the web with pre-
according to socio-economic conditions. In large urban centers defined themes, followed by videoconference meetings in which
Minelli C, et al. Brazilian practice guidelines for stroke rehabilitation: part I.
635controversies were discussed, leading to a consensus. For the for all ages. Therefore, the Recommendations of this guideline
preparation of the Brazilian Guidelines for Stroke Rehabilitation, can be applied to all individuals after a stroke. In addition,
several national co-authors, with prior knowledge in their areas these guidelines also aim to highlight the issues of accessibil-
of expertise, were asked to write the suggested topics follow- ity and palliative care. The guidelines have been divided into
ing criteria defined by the coordinators of these guidelines. two groups. Part I includes topics on rehabilitation in the acute
The original texts were adapted to follow a format in which, phase as well as prevention and management of the most fre-
after the general information, the Recommendations for each quent conditions and comorbidities after stroke. A section on
intervention were added. Secondary Stroke Prevention was included in Part I because
The present work focuses on recent clinical trials, meta- the incidence of stroke recurrence is higher in the first months
9
analyses, and systematic reviews in stroke rehabilitation lit- after stroke and it is a potential and preventable complica-
erature. The main objective of this paper is to guide physicians, tion that impairs the process of rehabilitation as do falls, deep
physiotherapists, speech therapists, occupational therapists, vein thrombosis and others. More detailed information about
nurses, nutritionists, and other professionals involved in post- Secondary Stroke Prevention is available at https://www.aha-
stroke care. Recommendations and levels of evidence have been journals.org/doi/pdf/10.1161/STR.0000000000000375. Table 1
adapted according to currently available literature. shows daily doses, adverse effects, and duration of follow-up
We have sought to provide visibility to broader rehabilita- during the study periods of drugs used in the management of
tion aspects based on the intervention concepts proposed in central pain, mood disorder, sleep disorder, and epilepsy after
the International Classification of Functioning, Disability, and stroke. Part II covers the topics on rehabilitation of neurologi-
8
Health . The rehabilitation strategies included in this guideline cal deficits and disabilities after stroke, and transitions to com-
cover the different stroke phases: hyper-acute (0-24 hours), munity rehabilitation and palliative care. A table with validated
acute (1-7 days), early subacute (7 days-3 months), late subacute scales to assess neurological impairment, disability, and qual-
9
(3-6 months), and chronic phases (> 6 months) . Most studies ity of life is included in Part II. At the end of Part II, support-
in stroke rehabilitation include participants over the age of 18 ing material includes suggestions for patients, caregivers, and
10
years . In clinical practice, the same interventions are used other health professionals, including legal rights after stroke,
Table 1. Daily doses, adverse effects, and duration of follow-up during the study periods of drugs used in the management of
central pain, mood disorder, sleep disorder, and epilepsy after stroke.
Daily Duration of study Adverse
Comorbidities Drug
dose follow-up effects
Dry mouth, urinary retention,
39
Amitriptyline Start with 25 mg, up to 75 mg 4 weeks
drowsiness, and confusion
39
Lamotrigine Start with 25 mg, up to 200 mg 8 weeks Rash and severe headache
42
Duloxetine Start with 30 mg, up to 60 mg 3 weeks Nausea, agitation, and drowsiness
Central Pain
43
Pregabalin Start with 150 mg, up to 600 mg 12 weeks Somnolence, and peripheral edema
39
Gabapentin Start with 900 mg, up to 2400 mg 8 weeks Dizziness and drowsiness
Drowsiness, insomnia, and
44
Fluvoxamine Start with 50 mg, up to 125 mg 2 to 4 weeks
restlessness
Dry mouth, urinary retention,
79
Nortriptyline Start with 25 mg, up to 100 mg 6 weeks
drowsiness, and confusion
Dry mouth, urinary retention,
79
Trazodone Start with 25 mg, up to 200 mg 32 days
drowsiness, and confusion
Nausea, drowsiness, weakness,
79
Mood disorder Citalopram Start with 5 mg, up to 10 mg 6 weeks dizziness, anxiety, trouble sleeping,
and sexual dysfunction
6 weeks to 3 Nausea headaches, insomnia,
79
Fluoxetine Start with 10 mg, up to 10 mg
months diarrhea, weakness, and anxiety
Dry mouth, constipation, and sexual
79
Reboxetine 4 mg 16 weeks
dysfunction
Dry mouth, urinary retention,
110
Sleep disorders Trazodone 100 mg 1 week
somnolence, and confusion
Fatigue, drowsiness, skin eruptions
157
Levetiracetam Start with 500 mg up to 300 mg 52 weeks
or allergies
157
Epilepsy Lamotrigine Start with 25 mg up to 200 mg 52 weeks Dizziness and rash
Controlled release Confusion, skin eruptions or allergies,
Start with 200 mg up to 1600 mg 52 weeks
157
carbamazepine nausea, and vomiting
Arq Neuropsiquiatr 2022;80(6):634-652
636as well as functional accessibility laws and the care network. communication, cognition, alertness and engagement, vision,
We have also included a chapter on the possibilities of paths hearing, perception, behavior, emotional, need for assistance,
11
and social engagement .
to be followed in the future, based on promising approaches
The level of care after stabilization of the acute phase will
to rehabilitation after stroke.
depend on the degree of dependence in activities of daily living,
We hope that this pioneering Brazilian work will soon be
status of comorbidities and neurological impairments and dis-
followed by new versions that can improve and update the
abilities. It is suggested that the Assessment for Rehabilitation
content presented here.
12
Tool (ART) , a pathway and decision tool that considers
individual particularities, such as age, prognosis, neurologi-
RECOMMENDATION RATING AND LEVEL OF
cal impairment and disability domains, level of function, and
EVIDENCE
management level available, i.e., inpatient, home or outpatient
The recommendation rating and level of evidence used in rehabilitation. ART also considers exceptions where there is
these guidelines is an adaptation of the framework established no need to initiate rehabilitation, such as the patient return-
10
by the American Heart Association . ing to pre-morbid function, coma and/or unresponsiveness
or palliative care.
Recommendations
Recommendation
Class I: There is evidence and/or consensus that interven-
tion is effective.
? Organized, coordinated, and multidisciplinary
care should be available to patients after stroke.
Class II: There is conflicting evidence and/or divergence
(Recommendation I-A).
of opinions about the effectiveness and usefulness of
intervention.
a) Although there is divergent evidence on the usefulness REHABILITATION IN THE ACUTE PHASE
and effectiveness of intervention, the Recommendations
This topic will address themes of relevance to rehabilitation
are in favor of intervention;
in the acute phase of stroke that do not involve reperfusion or
b) Utility and effectiveness are less established by the
clinical stabilization interventions, as there are specific guide-
evidence or opinions.
13,14
lines for that purpose .
Class III: There is evidence and/or consensus that interven-
All patients must be evaluated by a multidisciplinary team
tion is not useful or effective and may cause harm.
using an objective framework, through the application of scales
to assess the risk of pulmonary aspiration, malnutrition, pres-
Levels of evidence
sure ulcers, deep vein thrombosis, neurological deficits, focal
A: Data are obtained from multiple randomized clinical
9
and global disabilities, and psychiatric disorders . A multi-
trials or meta-analyses.
disciplinary team should include physicians, physical, occu-
B: Data are obtained from a single randomized or non-
pational, speech and language therapists, physical educators,
randomized study. 11
social workers, psychologists, and psychiatrists .
C: Consensus and expert opinion, case studies, or usual
All rehabilitative interventions should be initiated as soon
(standardized) treatments.
as the impairments and disabilities after stroke are diagnosed
and should be continued as outpatient rehabilitation in the
11,15
ORGANIZATION OF POST-STROKE REHABILITATION community . Some conditions are contraindications to the
CARE (LEVELS OF CARE) commencement of rehabilitation: early deterioration, immedi-
ate surgery, another serious medical illness or unstable coro-
The ideal organization of post-stroke rehabilitation care
nary condition, systolic blood pressure lower than 110 mm Hg
includes rehabilitation during the acute phase in stroke units,
or higher than 220 mm Hg, oxygen saturation lower than 92%
nursing home facilities, inpatient, home-based and outpatient
with oxygen supplementation, resting heart rate of less than 40
11
rehabilitation services . The level of care to which patients will
beats per min or more than 110 beats per min, and tempera-
16
be referred depends on the status of clinical conditions and
ture higher than 38·5°C . Mobilization out of bed or any other
the degree of neurological impairment and disability. These
intervention should be initiated only if the patient’s blood pres-
services should be delivered by a multidisciplinary team with sure does not drop by more than 30 mm Hg on achievement
16
physicians, physical, occupational, speech and language ther- of an upright position .
16
apists, physical educators, social workers, psychologists, and Regarding mobilization in the acute phase, the AVERT
10
psychiatrists . Integration within the whole system of health multicenter trial showed that the group that received very
and social community care is necessary. At all levels of care, early mobilization, within 24 hours of stroke onset, had a lower
specific needs should be assessed, such as swallowing, hydration chance of favorable results at three months. Mobilization to
and nutrition, continence, mobility, activities of everyday life, maintain range of motion, sensory stimulation and body posture
Minelli C, et al. Brazilian practice guidelines for stroke rehabilitation: part I.
63716
change is not considered intensive rehabilitation . A multi-
CONTRACTURES
17
center study (HeadPoST) did not find differences between
Contractures are defined as the shortening or stiffening
outcomes when comparing a group that rested with the head
of muscles, skin, or connective tissue resulting in decreased
in the horizontal position, without elevation (i.e., 0o) in the first
23
movement and range of motion . Observational studies have
24 hours post-randomization and another group in which the
shown the incidence of contractures to be between 15% and
head was elevated to at least 30o.
24
60%, mainly in patients with greater motor impairment . The
predictors of contractures include spasticity, muscle weakness,
COMPREHENSIVE STROKE CENTER
23
upper limb dysfunction, impaired dexterity, and pain .
Few studies have addressed the treatment of contractures
The Comprehensive Stroke Center (CSC), a combined and
after stroke. Systematic reviews and randomized studies eval-
integrated service for acute-phase care and rehabilitation, offers
uating passive movement and positioning with limb resting
18
the best outcomes . Care in a CSC reduces deaths by two and
orthoses have shown little evidence of benefits in prevention
dependence by six in every 100 patients and promotes the
25-29
and treatment of contracture . A dynamic, progressive ortho-
18
return home of six individuals . It is a cost-effective interven-
sis fixed in the forearm to lengthen the wrist in extension in
15,18,19
tion . The benefits of CSCs apply to all stroke cases, regard-
post-stroke hemiplegic patients improved the range of motion
less of severity, age, sex, and whether the stroke is ischemic,
and resistance to passive movement, but this benefit was not
18
hemorrhagic, or a transient ischemic attack .
30
sustained . A recent meta-analysis of several neurological
Despite the limited number of CSCs in Brazil, patients
conditions, including those found in post-stroke patients, for
must be admitted to these units in the acute phase, preferably
interventions to reduce muscle contractures, did not find con-
20
within the first hours of the stroke . A suspicious case evalu-
vincing evidence in favor of non-surgical interventions, such
ated in a service not dedicated to stroke must be immediately
as stretching, botulinum toxin, electrical stimulation, physical
31
transferred to the nearest qualified unit. All services must offer
activity, and robot-assisted therapies . Surgical release of the
protocols for managing fever, blood pressure, blood glucose,
brachial, brachioradialis, and biceps muscles improved pain,
20
and dysphagia . Additionally, patients must have their reha-
passive range of motion, and decreased spasticity of the elbow
32
bilitation needs assessed within 24-48 hours of admission by
with a contracture .
11,15
members of a multidisciplinary team .
There is evidence that individuals with mild stroke may have Recommendations
impairments neglected by professionals in multidisciplinary
? Progressive casting and adjustable orthotics may be
21
teams . On the other hand, severely affected patients are not
considered to reduce mild to moderate contractures
22
referred to rehabilitation services . To avoid these situations
of the elbow joints. (Recommendation IIb-B);
12
the ART can be used to provide an appropriate course of post-
? Resting ankle and wrist orthotics may be used to pre-

stroke rehabilitation.
vent contractures. (Recommendation IIb-B);
? The effects of stretching, botulinum toxin, electrical
Recommendations
stimulation, physical activity, and robot-assisted thera-
? All patients in the acute stroke phase must be admitted
pies have not been well established. (Recommendation
to specialized stroke care units where they can receive IIb-B);
care from a multidisciplinary team. (Recommendation
? Surgical interventions in the brachial, brachioradialis,
I-A);
and biceps muscles in elbow contractures might be
considered. (Recommendation IIb-B).
? All patients in the acute stroke phase must be seen
by specialized professionals and objectively assessed,
PHYSICAL DECONDITIONING
with the use of scales, for risk of pulmonary aspiration,
malnutrition, pressure ulcers, deep vein thrombosis,
People who have had a stroke spend 81% of the day in sed-
neurological deficits, focal and global disabilities, and
entary time, increasing the risk of glucose intolerance, diabetes,
psychiatric disorders. (Recommendation I-A);
heart disease, mood disorders, cognitive decline, decreased
? Very early and high-intensity mobilization within
muscle mass, increased dependency for daily activities, stroke
24 hours of stroke onset is not recommended.
recurrence, and death. Physical activity (PA) plays a central role
(Recommendation III-A);
in reducing these risks and improving cardiovascular perfor-
33
? Keeping the head in the horizontal position, without
mance . PA also has benefits for bone structure, fatigue, cog-
elevation, did not show benefit in the acute post-stroke nition, mood, wellness, sensation, gait speed, social isolation,
34
and has the potential to reduce treatment costs .
phase. (Recommendation III-A).
Arq Neuropsiquiatr 2022;80(6):634-652
638The Recommendations below are based on the American
CENTRAL PAIN
33,35
and Canadian guidelines .
Central pain after stroke is defined as neuropathic pain
resulting from spinothalamic or thalamocortical tract lesions
Recommendations
in the central nervous system (CNS), affecting patients in the
? It is recommended that all post-stroke individuals
36
acute or chronic phase after a stroke . As a diagnostic criterion,
participate in PA interventions once they are clinically
it is necessary that the pain that occurs after a stroke should
stable. (Recommendation I-A);
be located in a body area corresponding to the CNS lesion
? Assessment of PA must be performed by qualified pro-
and not caused by peripheral neuropathic pain or nociceptive
fessionals. (Recommendation I-B);
37
stimuli . Numbness, tingling, or needling sensations may also
? Monitoring of heart rate, blood pressure, and rating of
be present. The onset of symptoms is always gradual, coincid-
perceived exertion before, during, and after comple-
ing with improvement in sensory perception and the onset of
tion of the test is recommended. Cardiac monitor-
38
dysesthesia . The pain can be intermittent or constant and
ing is recommended if stress testing is performed.
36
can manifest as hyperalgesia or allodynia .
(Recommendation I-A);
Amitriptyline and lamotrigine can be first-line pharmaco-
? Aerobic training is recommended in a rehabilitation 39-41
logical treatments . Duloxetine, as an adjuvant treatment,
program with the addition of muscle strengthening,
42
has shown positive effects in pain reduction . Pregabalin and
task-oriented activities of motor control, balance, gait,
gabapentin can be considered second-line medications, and
and functional use of the upper limb. (Recommendation
pregabalin has a favorable secondary effect of reducing anxiety
I-C);
43
and improving sleep . Fluvoxamine reduced pain in an open
44
? It is recommended that a PA program be developed
observational study . Levetiracetam and carbamazepine do not
39
and supervised by physical therapists or cardiovascu-
improve post-stroke neuropathic pain symptoms . There is no
lar rehabilitation specialists. (Recommendation I-C);
evidence for the use of opioids in the treatment of central post-
45
stroke pain . Table 1 shows the drugs with favorable outcomes.
? Exercises to activate a large group of muscles for a
sufficient period to produce aerobic effort are recom- Steroids, intravenous infusions of lidocaine, ketamine pro-
mended. (Recommendation I-B); pofol, repetitive transcranial magnetic stimulation (rTMS), deep
brain stimulation, and spinal electrical stimulation showed
? A minimum period of eight weeks is recommended to
46,47
favorable results . However, they should be reserved for
obtain significant effects, followed by PA being main-
48
refractory cases .
tained indefinitely. (Recommendation I-B);
? A frequency of three times a week of PA and lighter
Recommendations
physical activities on other days is recommended.
? Amitriptyline and lamotrigine should be used as first-
(Recommendation I-B);
line treatments for neuropathic pain. (Recommendation
? Sessions lasting more than 20 minutes are recom-
I-A);
mended, with a period of five minutes of warm-
? Duloxetine can be considered as an adjuvant treat-
up and relaxation before and after each session.
ment. (Recommendation IIa-B);
(Recommendation I-B);
? Pregabalin and gabapentin can be used as second-line
? It is recommended that exercise intensity has individ-
medication. (Recommendation IIa-B);
ualized parameter values based on the percentage of
heart rate reserve, percentage of maximum heart rate,
? Fluvoxamine can be considered. (Recommendation
and individual perceived exertion. (Recommendation
IIb-B);
I-B);
? rTMS, deep brain, or spinal electrical stimulation may
? It is recommended that the effects of PA be monitored
be considered in refractory cases. (Recommendation
by measures of cardiovascular capacity, blood pressure,
IIb-B);
lipid profile, fasting blood glucose, waist circumference,
? Levetiracetam, carbamazepine, and opioids are not
medication adherence, tobacco use, cognition, mood,
recommended. (Recommendation III-B).
and sleep quality. (Recommendation I-B);
? A PA program is recommended to be continued by
PAINFUL SHOULDER
the patient so that he/she can practice on their own.
(Recommendation I-B);
Painful shoulder (PS) after stroke has an incidence range
? Clinical dates and stress tests with sub-maximal limits of 9% to 73%, depending on the diagnostic criteria used in the
49
of tolerance should be used for prior evaluation of PA studies . It can appear in the first two weeks but is more fre-
50
as a reference. (Recommendation IIa-C). quent between the second and fourth months after stroke .
Minelli C, et al. Brazilian practice guidelines for stroke rehabilitation: part I.
639The most frequent causes are spasticity, adhesive capsulitis,
PRESSURE INJURY
49
and glenohumeral subluxation .
Evidence for the use of shoulder orthoses to prevent dislo- Pressure injury (PI) is defined as localized injury to the
50,51
cation, decrease pain, and improve function is conflicting . skin and/or underlying tissues, usually over a bony promi-
51
These orthoses can improve gait efficiency . Placing an orthosis nence, resulting from pressure or pressure in combination with
61
on an already dislocated shoulder can reduce vertical sublux- shear . Its etiology is multifactorial and can include advanced
age, cognitive, physical, and sensory impairment, comorbid
ation on imaging examinations, but the improvement is not
52
conditions, malnutrition, and limited mobility.
maintained after removing the orthosis .
The PI classification of the Associa??o Brasileira de
Gentle joint alignment movements and mobilization with
49
Estomatoterapia (SOBEST) and Associa??o Brasileira de
external rotation and abduction may be beneficial . Analgesics,
Enfermagem em Dermatologia (SOBENDE) is recomended
such as acetaminophen and ibuprofen, and neuromodulators
49 62
can be used . Botulinum toxin has positive effects on pain in these guidelines .
reduction and functional improvement and increases the Although not specific to patients after stroke, the Braden
53
range of motion . Subacromial corticosteroid injections can Scale is a widely used tool for assessing pressure injury risk
63
be used if the pain is caused by trauma or inflammation of the and had moderate predictive validity . The Sunderland Scale
54
subacromial region . Suprascapular nerve blocks, with and and the Cubbin & Jackson Revised Scale can also be used and
55 64
without corticosteroids, increased passive range of motion . have been translated and validated in Portuguese .
A functional bandage reduced shoulder subluxation, improved The Recommendations for the prevention and care of PI
upper limb motor function and activities of everyday life, and after stroke are based on an adaptation of the latest version
56,57
reduced pain when compared to placebo . of the Prevention and Treatment of Pressure Ulcers/Injuries
Conventional acupuncture and electroacupuncture have
Quick Reference Guide published by the European Pressure
58
shown uncertain benefits . Electrical functional stimulation
Ulcer Advisory Panel, National Pressure Injury, Advisory Panel,
65
can be beneficial in reducing pain and regaining indepen-
and Pan Pacific Pressure Alliance .
59
dence in activities of everyday life . The pulley system should
60
not be used .
Recommendations
? Skin assessment for the risk of pressure injuries over
Recommendations
pressure points is recommended in subjects with
? Functional bandages are recommended for PS after
impaired mobility, sensory perception, older age, and
stroke. (Recommendation I-A);
diabetes. (Recommendation I-A);
? Botulinum toxin injection in the subscapular and pec-
? Structured PI risk assessment and PI classification are
toral muscles is recommended, mainly if PS is associ-
recommended. (Recommendation I-C);
ated with spasticity. (Recommendation I-A);
? The skin of individuals at risk of PI should be inspected
? Arm position and support during rest, arm protec-
to identify the presence of erythema. (Recommendation
tion, and support during functional movements can
I-A);
be considered to prevent PS. (Recommendation IIa-C);
? The skin of individuals at risk of PI should be kept clean
? Functional electrical stimulation can be considered in
and appropriately hydrated. (Recommendation I-C);
the prevention of PS. (Recommendation IIa-A);
? Full-thickness excision of pressure sores, including
? PS can be treated with gentle alignment movements
abnormal skin as well as granulation and necrotic
and mobilization with external rotation and abduc-
tissues, should be performed. (Recommendation I-B);
tion. (Recommendation IIa-B);
? The following factors should be considered for PI sur-
? Analgesics, such as acetaminophen and ibuprofen,
gery: comorbidities, surgical risk, the individual’s clinical
and neuromodulators, can be used. (Recommendation
condition, and the likelihood of healing with non-sur-
IIa-A);
gical versus surgical interventions. (Recommendation
I-C);
? Subacromial corticosteroid injections and suprascapu-
lar nerve block are reasonable options for hemiplegic
? Airflow mattresses can be considered for stroke patients
PS. (Recommendation IIb-B);
at risk of developing PI. (Recommendation IIa-B);
? Acupuncture, as an adjunctive treatment, has an uncer-
? Pulsed current electrical stimulation to facilitate
tain value. (Recommendation IIb-B);
wound healing in recalcitrant PI should be consid-
? The use of orthotics to prevent dislocations is uncer- ered. (Recommendation IIa-A);
tain. (Recommendation IIb-B);
? High absorbency incontinence products can be used
? The pulley system should not be used for the preven- to protect the skin in stroke patients with urinary
tion of PS. (Recommendation III-A). incontinence at risk of PI. (Recommendation IIa-B);
Arq Neuropsiquiatr 2022;80(6):634-652
64071
? Post-stroke individuals at risk of PI can undergo nutri- in the limb affected by the brain injury . The instrument rec-
tional assessment. (Recommendation IIa-B); ommended for identifying the risk of developing sarcopenia
is the SARC-F (sluggishness, requiring assistance in walking,
? Stroke patients with, or at risk of, pressure injuries
72
rising from a chair, climbing stairs, falls) questionnaire . It
can be repositioned on an individualized schedule.
assesses muscle strength, muscle quantity/quality, and physi-
(Recommendation IIa-B);
cal performance.
? Hydrogels, hydrocolloids, and polymeric wound dress-
ings for non-infected stage II PI can be considered.
Recommendations
(Recommendation IIa-B);
? Screening for the risk of malnutrition is highly recom-
? Wound dressing with calcium alginate for stages III
mended within the first 48 hours of hospital admission.
and IV PI with moderate exudates can be considered.
(Recommendation I-C);
(Recommendation IIa-B);
? If oral feeding is not possible, feeding by a nasogastric/
? Hydrogel for stage III and IV non-infected PI with
enteric tube is recommended. (Recommendation I-A);
minimal exudate is recommended. (Recommendation
? Every patient with dysphagia who needs food texture
IIa-B);
modification or fluid thickening should be referred for
? Subjects at risk of PI may be encouraged to sit out
nutritional assessment to ensure adequate nutrition
of bed for limited periods. (Recommendation IIb-B);
and water intake. (Recommendation I-C);
? Offering high-calorie, high-protein fortified foods or
? Percutaneous endoscopic gastrostomy is recommended
nutritional supplements in addition to the usual diet
when there has been a need for enteral nutrition for
might be considered for stroke individuals at risk of
more than three weeks. (Recommendation I-A);
PI. (Recommendation IIb-C);
? Patients should be screened for the risk of sarcopenia
? The benefits of topical antiseptics that are active against
using the SARC-F questionnaire. (Recommendation
biofilms are uncertain. (Recommendation IIb-C).
I-C);
? The use of oral nutritional supplements is probably
NUTRITIONAL SUPPORT
recommended for individuals who are able to eat
and have been diagnosed with malnutrition or were
After a stroke, individuals are susceptible to nutritional
at risk of malnutrition during hospital admission.
changes due to a variety of symptoms and sequelae. The risk
(Recommendation IIa-C);
factors for nutritional changes after stroke are dysphagia,
? For patients with severe dysphagia lasting longer than
immobility, impaired cognition, as well as reduced food and
66
seven days, early enteral nutrition is probably recom-
macro- and micronutrient intake . Approximately 50% of
67
mended. (Recommendation IIa-C);
stroke patients suffer from malnutrition .
For individuals without dysphagia and who are not mal-
? The use of oral nutritional supplements is not recom-
nourished or at risk of malnutrition, the use of oral nutritional
mended for patients without dysphagia and those
66
supplements is not indicated . Oral supplements are indicated
who are not malnourished or at risk of malnutrition.
for individuals who are able to eat and have been diagnosed
(Recommendation III-C).
with malnutrition or were at risk of malnutrition during hos-
66
pital admission .
MOOD DISORDERS
Individuals with dysphagia who need food texture modi-
fication or fluid thickening should be referred to a dietitian to
Post-stroke depressive disorder (PSDD) is defined by the
66
ensure adequate nutrition and water intake . If oral feeding is
presence of a significantly depressed mood or a marked decrease
73
not possible, feeding by a nasogastric/enteric tube is recom-
in interest or pleasure that occurs as a consequence of a stroke .
67
mended . Patients with severe dysphagia, probably lasting It occurs in approximately 30% of patients in the first five years
74
longer than seven days, should receive early enteral nutrition, after stroke . The risk of developing PSDD is proportional to
67 75
preferably in the first 72 hours . If enteral nutrition is needed the severity of the stroke , and social, genetic, and epigenetic
76
for a period longer than three weeks, a percutaneous endo- factors . However, the association with the topography of the
67 76
scopic gastrostomy is recommended . stroke is not clear . The presence of PSDD increases the risk of
Sarcopenia is a complication of malnutrition after stroke, death threefold over a 10-year period, particularly in patients
77
and it is associated with an increased risk of falls, fractures, with less social support . PSDD is associated with fewer feelings
68
functional disability, rehabilitation difficulties, and mortality . of guilt and a high risk of suicide, and this should be specifi-
Sarcopenia is caused by increased inactivity, muscle atrophy, cally monitored in younger patients with a history of depres-
69,70 78
sive episodes before the stroke .
neural loss, and bed rest . The most severe muscle loss occurs
Minelli C, et al. Brazilian practice guidelines for stroke rehabilitation: part I.
64179,80
Adequate social support is necessary to prevent PSDD . For the prevention of DVT or PTE in patients with ischemic
87
A systematic review and meta-analysis of low quality showed
stroke, a meta-analysis concluded that: 1) intermittent pneu-
that prophylactic use of selective serotonin reuptake inhibi- matic compression should be used in immobilized patients; 2)
tors (SSRI) in nondepressed stroke patients for one year may
elastic compression stockings are not indicated; 3) prophylac-
81
reduce the odds for development of post stroke depression .
tic anticoagulation with unfractionated heparin (UFH) or low
Non-pharmacological treatment of PSDD involves family sup-
molecular weight heparin (LMWH) or heparinoids should
79
port, cognitive behavioral therapy, and lifestyle interventions .
be considered in immobilized post-stroke patients for whom
79
Patient education about stroke has a positive effect . Physical
the benefits of reducing the risk of DVT outweigh the risk of
79
exercise training is a potential treatment option for PSDD .
intra- or extracranial bleeding; 4) if anticoagulation is chosen,
82
Transcranial magnetic stimulation is a promising treatment .
LMWH or heparinoids should be prioritized over UFH due to
Pharmacological treatment with antidepressants, especially
the greater reduction in the risk of DVT, better ease of use, cost
SSRIs, has been shown to be effective in improving post-
reduction, and patient comfort; and 5) LMWH is associated
79
stroke survival and in cases of emotional lability (Table 1).
with a higher risk of extracranial bleeding, with the risk being
Neuroleptics, anticonvulsants, and lithium have been used for
higher in elderly patients with renal dysfunction.
79
post-stroke manic symptoms .
A double-blind randomized study showed that in critically
ill patients, including 15% of patients with ischemic stroke, after
Recommendations
hospital discharge, rivaroxaban at a dose of 10 mg/day for 45
? Pharmacological treatment with antidepressants, such
days reduced the combined risk of fatal and severe thrombo-
as SSRIs, can be recommended for the treatment of
embolism by approximately 28%, without a significant increase
PSDD. (Recommendation IIa-A);
88
in bleeding tendencies .
? Selective serotonin reuptake inhibitors may be used
Regarding hemorrhagic stroke, a prophylactic dose of
prophylactically after stroke. (Recommendation IIb-B);
heparin between the second or fourth day did not increase
? Family support, cognitive behavioral therapy, and lifestyle the risk of intracranial bleeding, despite the low quality of the
89-91
interventions can be considered. (Recommendation
evaluated studies .
IIa-B); In patients with ischemic stroke and DVT or PTE, the anti-
coagulation maintenance period will be three months, unless
? Exercise training may be used as a complementary
another overlapping medical condition increases the risk of
treatment option in cases of PSDD. (Recommendation
92
recurrence .
IIb-B);
Literature lacks studies using the inferior vena cava filter
? The combination of pharmacological and non-
(IVCF) in cases of hemorrhagic stroke. However, considering
pharmacological treatments may be considered.
its use in other conditions with contraindications for the use of
(Recommendation IIb-B);
anticoagulants, the use of inferior vena cava filters in patients
? Transcranial magnetic stimulation has unclear ben-
93,94
with hemorrhagic stroke can be considered .
efits. (Recommendation III-B).
Recommend dose of unfractionated heparin: < 15.000 UI/
day. Recommended dose for low molecular weight heparin:
DEEP VEIN THROMBOSIS
30 to 60 mg/day.
Acute stroke survivors are at high risk of deep vein throm-
Recommendations
bosis (DVT) and pulmonary thromboembolism (PTE), with
83
incidence ranging from 10% to 75% in this population The
? Intermittent pneumatic compression is recommended
.
main risk factors for post-stroke DVT are advanced age, atrial in immobilized post-stroke patients to prevent DVT.
84
fibrillation, limb paresis, or plegia . DVT may be present on
(Recommendation I-A);
the second day, with a peak incidence from the second to the
? In ischemic stroke, prophylactic doses of UFH or
seventh day and may persist during the rehabilitation phase in
LMWH should be used during the hospital stay or
83
30% of patients with severe paresis . The main complications
even after discharge until the patient regains mobility.
of DVT in post-stroke patients are post-thrombotic syndrome
(Recommendation I-A);
and PTE, which can occur in 15% of cases with proximal DVT
? In ischemic stroke, a prophylactic dose of LMWH over
85
and account for approximately 3% of post-stroke deaths .
UFH can be used to prevent DVT. (Recommendation
Non-pharmacological interventions have been effective
IIa-A);
in preventing DVT and PTE. The randomized CLOTS 3 study
showed that in patients with ischemic or hemorrhagic stroke, ? Rivaroxaban at a dose of 10 mg/day for 45 days can
intermittent pneumatic compression was effective in reducing be considered as prophylaxis for thromboembolism.
86
DVT and possibly improved survival . (Recommendation IIa-B);
Arq Neuropsiquiatr 2022;80(6):634-652
642? IVCF can be considered in immobilized hemorrhagic or pronounced right-to-left shunt, without other concomi-
105
stroke patients if anticoagulation is contraindicated. tant etiologies .
(Recommendation IIa-B); Severe symptomatic intracranial stenosis or occlusion
should be treated with antiplatelet agents, and the combina-
? In hemorrhagic stroke, it may be reasonable to use a
105
tion of clopidogrel with aspirin for 90 days may be reasonable .
prophylactic dose of UFH or LMWH to start between
The approach to stroke rehabilitation does not differ in the
the second and fourth days of hospitalization rather
presence of comorbidities.
than no prophylaxis. (Recommendation IIb-C);
? The use of elastic compression stockings is not recom-
Recommendations
mended. (Recommendation III-B).
? Antiplatelet agents are recommended in patients with
non-cardioembolic stroke or TIA for secondary stroke
SECONDARY STROKE PREVENTION
prevention. (Recommendation I-A);
After an ischemic stroke or a transient ischemic attack ? Anticoagulation with warfarin or DOACs is rec-
(TIA), the risk of recurrence without treatment was 10% in ommended for stroke or TIA with a cardioembolic
95
the first week, 15% at one month, and 18% at three months . source, with a preference for DOACs over warfarin.
In the long term, it was 10% in one year, 25% in five years, and (Recommendation I-A);
96
40% in ten years .
? Patients with diabetes should control their blood
Meta-analysis of individuals with cardiovascular disease
glucose with physical activity, lifestyle modifications,
through long-term follow-up identified that a reduction of 1
and glucose-lowering agents with proven effective-
g/d sodium (2.5 g/d salt) was associated with a decrease in car-
ness in reducing risk for major cardiovascular events.
97
diovascular events . Another study established the efficacy of
(Recommendation I-A);
physical activity compared with usual care to reduce risk factors
? In severe symptomatic intracranial stenosis or occlu-
98
after stroke . Some evidence suggests that smoking cessation
sion, a combination of clopidogrel and aspirin should
99,100
and reduced alcohol consumption reduce recurrent events .
be used. (Recommendation I-A);
Antihypertensive therapy reduces the risk of ischemic or
101 ? An exercise program by a health care professional,
hemorrhagic stroke . All classes of antihypertensive drugs have
in addition to routine rehabilitation, is beneficial for
been shown to be equally effective, to the detriment of beta-
secondary stroke prevention. (Recommendation I-A);
101
blockers, due to their permissiveness in pressure variability .
? Blood pressure control with a goal of systolic pressure
The use of statins is recommended regardless of the initial LDL
102
less than 140 mmHg and diastolic pressure less than
cholesterol level . The target for maximum secondary preven-
90 mmHg is recommended. (Recommendation I-A);
tion is an LDL< 70 mg/dl, preferably using high-potency statins,
such as rosuvastatin or atorvastatin.
? It is recommended that LDL values be kept below 70
Prediabetes and diabetes are associated with increased risk
mg/dl. (Recommendation I-A);
103
of initial ischemic stroke . The American Diabetes Association
? Quitting smoking and reducing alcohol consumption
and European Association for the Study of Diabetes recommend
are recommended. (Recommendation I-B);
104
metformin and lifestyle optimization as first-line therapies .
? Reducing sodium intake is recommended to reduce
To prevent vascular events, including ischemic stroke, GLP-1
the risk of stroke. (Recommendation II-A);
104
receptor agonists should be added .
? PFO closure is recommended for cryptogenic stroke
Antiplatelet agents should be prescribed to patients with
patients aged < 60 years. (Recommendation IIa-B);
non-cardiac-embolic stroke or TIA. Short-term use of aspirin
plus clopidogrel for up to 21 days is recommended in patients
? For severe symptomatic intracranial stenosis or occlu-
105
with acute minor stroke or high-risk TIA . In the long term,
sion, the combination of clopidogrel and aspirin for 90
agent selection must be individualized based on the risk pro-
days should be considered. (Recommendation IIa-B).
105
file, cost, and tolerance .
Patients with cardiac embolism, particularly those with
SLEEP DISORDERS
105
atrial fibrillation, should be treated with anticoagulants .
Options include warfarin with an adjusted dose INR between Post-stroke patients experience insomnia, excessive day-
2 and 3 or direct oral anticoagulants (DOACs: apixaban, dabi- time sleepiness, fatigue, non-restorative sleep, nocturia, and
106
gatran, edoxaban, or rivaroxaban). The safety profile of DOACs sleep fragmentation, often present even before the stroke .
is superior to that of warfarin, with equal or superior efficacy It is important that conventional polysomnography be per-
105
in preventing new events . formed in this population, as stroke can cause respiratory
Patent foramen ovale (PFO) closure is recommended for changes that are undetectable by the screening devices avail-
107
patients with cryptogenic stroke aged < 60 years, large PFO, able on the market .
Minelli C, et al. Brazilian practice guidelines for stroke rehabilitation: part I.
643Obstructive sleep apnea syndrome (OSAS) affects 50% of 25% to 37% between one and six months, and 40% to 50% at
six to 12 months. After one year, falls continue to occur in 73%
stroke patients, and there is a strong interrelationship between
121
108-112
the two conditions . OSAS exacerbates post-stroke deficits of patients . Falls are most frequent in the first three weeks
122
by impairing the consolidation of neuroplastic synaptic pro- of rehabilitation .
113
cesses involving cognition and praxis . Falls are associated with motor, sensory, or visual impair-
ment, cognitive dysfunction, hemineglect, and stroke in the
Muscle relaxants, including benzodiazepines, are known to
123,124
106
posterior circulation . The causes of falls include cardiac
worsen OSAS . Continuous positive airway pressure (CPAP)
arrhythmias; orthostatic hypotension; vasovagal syncope;
treatment of OSAS must be performed with a positive pressure
sufficient to eliminate the apnea events. The device must be psychological factors, such as depression and fear of falling;
seizures; and some drugs, such as antihypertensives, diuret-
worn in an uninterrupted fashion during sleep, every day of the
124-128
114
ics, anticholinergics, antidepressants, and antiepileptics .
week, with an appropriate nosepiece . A meta-analysis has
Prevention of falls can be achieved by supervision, strength
shown that the use of CPAP can be beneficial for post-stroke
115
training, improvement of balance and cognition, less use of
neurological recovery . Whether OSAS treatment also reduces
116
sedative drugs and diuretics, and counseling to avoid risky
the recurrence of stroke remains controversial .
129,130
situations . Physical activity showed positive outcomes in
Fully-fledged insomnia or symptoms of insomnia affect one-
106
long-term stroke patients, mainly with specific tasks to improve
third to nearly half of all post-stroke patients . Antidepressants
postural stability, walking in challenging situations, and agility
should be taken in the morning, so avoiding the conditioning
131-133
training programs for effective fall prevention . A systematic
effect associated with the idea that night-time use of these drugs
108
review with meta-analysis showed a reduction in falls in post-
is intended to induce sleep . Trazodone has been shown to
134
stroke patients with the practice of ancient tai chi .
improve sleep and blood pressure parameters in post-ischemic
110
stroke patients . (Table 1). Cognitive-behavioral therapy is
111 Recommendations
beneficial and positively impacts neurofunctional outcomes .
Excessive daytime sleepiness is frequent in post-stroke ? Exercises aimed at preventing falls, with training to
patients and is associated with higher mortality and less suc-
improve balance, are recommended. (Recommendation
117
cessful rehabilitation . Restless leg syndrome can have a nega- I-B);
118
tive impact on the prognosis of post-stroke patients .
? Prevention of falls through patient supervision, reduc-
tion of the use of sedatives and diuretics, and restriction
Recommendations
of activities with a risk of falling should be instituted.
? CPAP is recommended in individuals with post-stroke (Recommendation I-C);
OSAS. (Recommendation I-A);
? Tai chi can be considered for fall prevention.
(Recommendation IIa-B);
? Excessive daytime sleepiness and restless leg syn-
drome should be investigated and treated if present.
? Agility training programs for fall prevention is reason-
(Recommendation I-B);
able. (Recommendation IIa-C).
? Trazodone can be considered in individuals with isch-
emic stroke and OSAS. (Recommendation IIa-A); OSTEOPOROSIS
? Conventional polysomnography is probably recom-
Osteoporosis is a metabolic bone disease characterized
mended in individuals with a history of stroke or TIA.
by an imbalance between bone resorption and accumula-
(Recommendation IIa-B);
tion, leading to changes in the bone microarchitecture and a
? Antidepressants should be taken in the morning.
135,136
reduction in bone mineral density (BMD) . In addition to
(Recommendation IIa-B);
spasticity, changes in geometric bone properties on the paretic
? Cognitive behavioral therapy can be considered
side, increased skeletal fragility, and accelerated bone loss that
135
in individuals with post-stroke sleep disorders.
occurs after a stroke, result in osteoporosis due to disuse .
(Recommendation IIa-B);
This loss of bone mass as well as reduction in bone structure
? Benzodiazepines and muscle relaxants should not be is greater on the paretic side than on the non-paretic side and
135
used in the management of post-stroke sleep disorders. affects the upper limbs more than the lower limbs . The risk
of fractures in stroke patients is seven times higher than that
(Recommendation III-C).
136
in the same population according to sex and age . Eighty per-
cent of fractures occur on the paretic side.
FALLS
The evidence for drug treatment strategies for osteoporosis
137
Falls are one of the most common causes of post-stroke com- in stroke patients is limited . It is not known who is eligible,
119,120
plications. They can occur in the acute or chronic phases . the best timing, which drug is better, and the best duration of
138
Approximately 7% of falls occur in the first week after stroke, treatment . Further studies are needed to recommend calcium
Arq Neuropsiquiatr 2022;80(6):634-652
644139,140 155
and vitamin D supplements . However adequate supple- the guidelines end with generalized Recommendations . In
141,142
practice, clinicians consider the risk of clinical worsening fol-
mentation of both can be used in all post-stroke patients .
Bisphosphonates such as zoledronic acid are a therapeutic lowing seizure. It is therefore reasonable to base the decision
143,144
option for both oral and intravenous administration . on stroke severity, injury location, stroke subtypes (intracere-
Hormonal therapy, tibolone, and selective estrogen receptor bral hemorrhage/subarachnoid hemorrhage), and electroen-
145 150,156
cephalogram findings . If ASM is used for some reason, it
modulators have cardiovascular risks .
155
should be limited to the acute phase .
Some medications, such as warfarin, pioglitazone, enzyme-
146
Conversely, the risk of recurrence after an unprovoked
inducing anticonvulsant drugs and selective serotonin reup-
seizure is approximately 70%, which defines epilepsy. In this
take inhibitors, are associated with an increased risk of frac-
147
situation, the use of ASM as secondary prophylaxis should
ture . There are clinical studies showing the potential benefits
148
be considered. The decision of a possible future suspension
of statins in preventing osteoporosis and fractures .
of ASM must be individualized since the risk of seizures after
Physical activity with gait training and resistance exercises
155
ASM withdrawal is high in patients with structural damage .
may have some beneficial effects on BMD loss, but there is
149
Most patients with post-stroke epilepsy have seizure con-
limited evidence .
156
trol with monotherapy alone . The drugs that have proved to
be effective in controlling focal epilepsy are carbamazepine,
Recommendations
levetiracetam, phenytoin, and zonisamide for adults, with
? Vitamin D and calcium supplementation can be recom-
157
lamotrigine and gabapentin for the elderly . However, there
mended for stroke patients. (Recommendation IIa-C);
is no current evidence for ASM choice in stroke patients. The
? Bisphosphonates can be used. (Recommendation IIa-B);
newer ASMs seem to be better tolerated, with fewer drug inter-
150
? Statins can be beneficial in preventing osteoporosis
actions and better side effect profiles . In a systematic review
after stroke. (Recommendation IIa-B);
with network meta-analysis, levetiracetam and lamotrigine
were better tolerated than controlled-release carbamazepine
? Physical activity with gait training and resistance exer-
for post-stroke epilepsy, with no significant differences in sei-
cises can be useful. (Recommendation IIa-C);
157
zure control (Table 1).
? Selective estrogen receptor modulators, warfarin, pio-
glitazone, enzyme-inducing anticonvulsants, and selec-
Recommendations
tive serotonin reuptake inhibitors can be used with
? Long-term use of antiseizure medication after an unpro-
caution. (Recommendation IIb-B);
voked seizure is recommended. (Recommendation I-B);
? Tibolone should be avoided. (Recommendation III-B).
? Recurrent post-stroke seizures must be treated, and
the selection of antiseizure medication should consider
SEIZURE MANAGEMENT
the patient′s characteristics. (Recommendation I-B);
Stroke is the leading cause of epilepsy among individuals
? Use of antiseizure medication after an acute symptom-
150
over 60 years of age . The incidence of post-stroke epileptic
atic seizure is generally not recommended, but it can be
seizures is 7% and may be higher in cases with cortical involve-
considered during the acute phase. (Recommendation
ment, greater severity of the vascular event, and hemorrhagic IIa-B);
151
stroke . Epilepsy is associated with increased mortality, pro-
? Use of antiseizure medication as primary prophy-
152
longed hospitalization, and higher rates of disability . In stroke
laxis of post-stroke seizures is not recommended.
patients, the risk of subsequent seizures after an unprovoked
(Recommendation III-B).
153
seizure is approximately 70% . A single unprovoked seizure
is sufficient for the diagnosis of epilepsy.
NEUROGENIC LOWER URINARY TRACT
The risk of acute symptomatic seizures or unprovoked
DYSFUNCTION AND FECAL INCONTINENCE
seizures is low. Even in patients with hemorrhagic stroke and
cortical involvement, the risk does not exceed 35%. Therefore,
Post-stroke neurogenic lower urinary tract dysfunction
the use of antiseizure medication (ASM) as primary prophy-
(NLUTD) is defined as a dysfunctional condition of the muscles
154
laxis is not justified . Likewise, since the risk of seizure recur-
of the bladder, urethra, urethral sphincter, and pelvic floor, and
rence within seven days of stroke is less than 20%, initiation of is related to the topography of the damage caused by the stroke,
ASM after a first symptomatic seizure is generally not recom-
leading to abnormal or difficult control in voluntary and/or
155
mended . Nevertheless, no adequately powered randomized
involuntary muscle contraction and/or relaxation during the
156 158
trial results are available, and this issue is still being debated . storage and voiding phases of the bladder .
In addition, there is a lack of data to determine the differences Approximately one-third of adult stroke survivors have
159
between ischemic and hemorrhagic stroke-related seizures in symptoms related to NLUTD with a prevalence ranging from
150
terms of risk factors and treatment approaches . Therefore, 11.1% to 70%. Detrusor hyperactivity is the most prevalent
Minelli C, et al. Brazilian practice guidelines for stroke rehabilitation: part I.
645160
symptom (64.7%) and urinary incontinence is associated and comorbid conditions that may affect sexual function.
161
with a high risk of death after a new stroke . Orientation to reduce anxiety related to sexual problems
Fecal incontinence (FI) is the inability to control bowel involves discussions regarding the ideal timing for sexual activ-
movements, causing stool to unexpectedly leak from the rectum. ity (in the morning when the person is not tired), dealing with
bladder and bowel issues, and working around the weakness
The prevalence of FI is approximately 40% in the post-stroke
(physical support with pillows), thus helping stroke survivors
acute phase and 20% during rehabilitation. The risk factors are
162
and their partners. Pharmacological interventions include
age and functional limitations .
phosphodiesterase‐5 inhibitors, intracavernosal injections,
Due to the low quality of the studies, no significant effects
and intraurethral suppositories to assist erectile function. Non-
on NLUTD in post-stroke individuals have been shown by
pharmacological interventions, such as mechanical devices,
behavioral interventions, assistance from specialized profes-
lubricating gels, and psycho‐educational interventions, are
sionals, complementary therapies such as acupuncture (elec-
169,170
also components of sexual rehabilitation .
troacupuncture and moxibustion), transcutaneous electrical
The effectiveness of interventions to treat sexual dysfunction
stimulation, physical therapy techniques, pharmacotherapy with
163
is limited. According to a recent meta-analysis, data indicat-
oxybutynin or estrogen, and a combination of interventions .
ing the benefits or risks of using sertraline to treat premature
There are few studies in the literature on interventions for
ejaculation, pelvic floor physiotherapy and sexual rehabilita-
FI in post-stroke individuals, and they show that educational
171
164 tion to treat sexual dysfunction after stroke are insufficient .
actions and dietary control have inconclusive effects .
Recommendations
Recommendations
? It is recommended that stroke subjects be asked about
? For post-stroke NLUTD, behavioral interventions,
their sexual function. (Recommendation I-C);
specialized professional care, complementary thera-
? Mood disorders and fears should be addressed in sexual
pies such as acupuncture (electroacupuncture and
dysfunction after stroke.
moxibustion), transcutaneous electrical stimulation,
physical therapy techniques, pharmacotherapy, and a
? If ED is present in men after stroke, antihypertensive
combination of interventions have uncertain benefits.
drug use, anxiety, and depression should be investi-
(Recommendation IIb-B);
gated. (Recommendation I-B);
? For post-stroke FI, educational actions and dietary con- ? The benefits of sertraline in treating premature ejacu-
trol have inconclusive effects. (Recommendation IIb-B). lation are uncertain. Recommendation IIb-B);
? The effects of sexual rehabilitation for treating sex-
SEXUAL DYSFUNCTION
ual dysfunction after stroke are not well established.
(Recommendation IIb-B).
Sexual dysfunction after stroke is underrecognized. It affects
over half of stroke survivors and it is not solely attributed to
CONCLUSION
165
the physical effects of stroke .?Fewer than 10% of patients
receive any advice, despite 90% of patients hoping for advice
The Brazilian Guideline for Stroke Rehabilitation – Part I
relating to sexual dysfunction in stroke. Symptoms are char-
presents Recommendations on interventions to manage and
acterized by changes in sexual activity, sexual dissatisfaction,
prevent complications and comorbidities after stroke. However,
decreased libido, problems in achieving orgasm, and erectile
this guideline is open to criticism for potential issues in the
166
dysfunction (ED) .
Recommendations: 1) the variety of topics covered; 2) the diverse
Sexual dysfunction is associated with depression, fear of
effects of a single intervention in recovery from neurological
recurrence of a new stroke, and self-perception of impaired deficits and disabilities; 3) the low methodological quality of the
167
motor function . Antihypertensive drugs, depression, and studies evaluated in systematic reviews and meta-analyses; 4)
anxiety are associated with ED168.
the personal experience of each professional; and 5) the com-
Sexual rehabilitation involves counseling and non-pharma-
plexity of the theme of stroke rehabilitation. We hope that Part I
169,170
cological and pharmacological interventions . Counseling of this guideline helps the multidisciplinary team in offering the
may address sexual performance related to medication issues best care of the most frequent clinical conditions after stroke.
Arq Neuropsiquiatr 2022;80(6):634-652
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