1 Kelly Payares Álvarez Médica Fisiatra Docente Titular Grupo Rehabilitación en Salud Universidad de Antioquia

2 GUÍA DE PRÁCTICA CLÍNICA DE DIAGNÓSTICO, TRATAMIENTO Y REHABILITACIÓN DEL EPISODIO AGUDO DEL ATAQUE CEREBRO VASCULAR ISQUÉMICO EN POBLACIÓN MAYOR DE 18 AÑOS CONVOCATORIA 637 DE 2013

3 ¿CUÁLES SON LAS INTERVENCIONES MÁS EFECTIVAS Y SEGURAS PARA LA REHABILITACIÓN DEL PACIENTE CON ATAQUE CEREBRO-VASCULAR ISQUÉMICO DE ORIGEN ARTERIAL DURANTE LOS PRIMEROS 15 DÍAS POSTERIORES AL INICIO DE LOS SÍNTOMAS?

4 DEBERÍA LA ALIMENTACIÓN TEMPRANA (MENOS DE 7 DIAS) V/S LA TARDÍA SER UTILIZADA EN PACIENTES CON DIAGNOSTICO DE ATAQUE CEREBROVASCULAR (ISQUÉMICO O HEMORRAGICO EN LOS PRIMEROS 6 MESES DE INICIO Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other considerations Feeding earlier (less than one week) Later Relative (95% CI) Absolute Case fatality at the end of the trial (follow-up 1 to 6 months; assessed with: Death) 1randomised trialsserious 1 no serious inconsistency serious 2 very serious 3 none 182/429 (42.4%) 207/430 (48.1%) OR 0.79 (0.61 to 1.04) 58 fewer per 1000 (from 120 fewer to 10 more) ÅÅOO LOW CRITICAL 40% 55 fewer per 1000 (from 111 fewer to 9 more) 56% 59 fewer per 1000 (from 123 fewer to 10 more) Death or dependency at the end of the trial (follow-up 1 to 6 months; assessed with: Death or Barthel Index of 0 to 55 or Rankin score of 3 to 5) 1randomised trialsserious 1 no serious inconsistency serious 2 very serious 3 none 339/429 (79%) 344/430 (80%) OR 0.94 (0.68 to 1.31) 10 fewer per 1000 (from 69 fewer to 40 more) ÅÅOO LOW CRITICAL 70% 13 fewer per 1000 (from 87 fewer to 53 more) 90% 6 fewer per 1000 (from 40 fewer to 22 more) Rate of institutionalisation (follow-up 1 to 6 months; assessed with: institutionalisation) 1randomised trialsserious 1 no serious inconsistency serious 2 very serious 3 none 94/429 (21.9%) 86/430 (20%) OR 1.12 (0.81 to 1.56) 19 more per 1000 (from 32 fewer to 81 more) ÅÅOO LOW IMPORTANT 15% 15 more per 1000 (from 25 fewer to 66 more) 25% 22 more per 1000 (from 37 fewer to 92 more) Systematic review: Amstar 10/11 33 trials with a total of 6779 participants Date: 2014-09-14 Question: Should Feeding earlier (less than one week) vs later be used for patients with clinical diagnosis of stroke (Ischemic or hemorrhagic) within six months of onset.? Settings: Any setting Bibliography: Geeganage C, Beavan J, Ellender S, Bath PMW. Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD000323 1 Some limitations on sequence generation, blinding and incomplete data outcome. 2 Some limitation according to the intervention access, some included participants with haemorrhagic stroke. 3 Not OIS, low rate of events, CI appreciable damage or benefit.

5 ALIMENTACIÓN DEL PACIENTE CON ATAQUE CEREBROVASCULAR ISQUÉMICO AGUDO DE ORIGEN ARTERIAL: SÍNTESIS DE LA EVIDENCIA Tipo de estudio: Revisión sistemática con 33 ensayos clínicos controlados para un total de 6779 participantes Pacientes incluidos: Pacientes con ACV isquémico agudo Intervención: Inicio temprano alimentación (antes de siete días desde el inicio de los síntomas) Comparación: Inicio tardío (> 7 días) Desenlaces: Los participantes asignados a inicio temprano de la alimentación no experimentaron una menor mortalidad OR 0.79 (IC 95% 0.61 a 1.04), una menor mortalidad o dependencia OR 0.94 (IC 95% 0.68 a 1.31) o una menor necesidad de cuidado intrahospitalario al término del seguimiento OR 1.12 (IC 95% 0.81 a 1.56). Geeganage C, Beavan J, Ellender S, Bath PMW. Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD000323.

6 Recomendación: Fuerte o Débil?

7 Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other consideration s Percutaneous endoscopic gastrostomy Nasogastric tube feeding Relative (95% CI) Absolute Treatment failures (follow-up 1 to 6 months; assessed with: Feeding failures) 3 randomised trials serious 1 no serious inconsistency 2 serious 3 very serious 4 none 0/36 (0%) 11/36 (30.6%) OR 0.09 (0.01 to 0.51) 267 fewer per 1000 (from 122 fewer to 301 fewer) ÅÅOO LOW IMPORTANT 25% 221 fewer per 1000 (from 105 fewer to 247 fewer) 35% 304 fewer per 1000 (from 135 fewer to 345 fewer) Gastrointestinal bleeding (follow-up 1 to 6 months; assessed with: Bleeding) 1 randomised trials serious 1 no serious inconsistency serious 3 very serious 4 none 5/162 (3.1%) 18/159 (11.3%) OR 0.25 (0.09 to 0.69) 82 fewer per 1000 (from 32 fewer to 102 fewer) ÅÅOO LOW CRITICAL 7% 52 fewer per 1000 (from 21 fewer to 63 fewer) 15% 108 fewer per 1000 (from 41 fewer to 134 fewer) Systematic review: Amstar 10/11 33 trials with a total of 6779 participants Date: 2014-09-13 Question: Should Percutaneous endoscopic gastrostomy vs nasogastric tube feeding be used for patients with clinical diagnosis of stroke (Ischemic or hemorrhagic) within six months of onset.? Settings: Any setting Bibliography: Geeganage C, Beavan J, Ellender S, Bath PMW. Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Data base of Systematic Reviews 2012, Issue 10. Art. No.: CD000323 GASTROSTOMIA PERCUTANEA V/S SONDA NASOGASTRICA

8 Pressure sores (follow-up 1 to 6 months; assessed with: Pressure sores) 1 randomised trials serious 1 no serious inconsistency serious 3 very serious 4 none 12/162 (7.4%) 4/159 (2.5%) OR 3.10 (0.98 to 9.83) 49 more per 1000 (from 0 fewer to 177 more) ÅÅOO LOW CRITICAL 1% 20 more per 1000 (from 0 fewer to 80 more) 3% 57 more per 1000 (from 1 fewer to 203 more) Death or dependency at the end of the trial (follow-up 1 to 6 months; assessed with: Death or Barthel Index of 0 to 55 or Rankin score of 3 to 5) 3 randomised trials serious 1 serious 5 serious 3 no serious imprecision none 178/203 (87.7%) 165/197 (83.8%) OR 0.80 (0.12 to 5.55) 33 fewer per 1000 (from 455 fewer to 129 more) ÅÅOO LOW CRITICAL 75% 44 fewer per 1000 (from 485 fewer to 193 more) 91% 20 fewer per 1000 (from 362 fewer to 72 more) Length of stay in hospital (follow-up 1 to 6 months; measured with: days; range of scores: 0-100; Better indicated by lower values) 2randomised trials serious 1 serious 6 serious 3 serious 4 none194190-MD 14.32 higher (12.04 lower to 40.68 higher) ÅÅOO LOW IMPORTANT

9 Pneumonia (follow-up 1 to 6 months; assessed with: clinical, radiologically) 2 randomised trials serious 1 no serious inconsistency serious 3 serious 4 none 14/48 (29.2%) 17/45 (37.8%) OR 0.65 (0.23 to 1.86) 95 fewer per 1000 (from 255 fewer to 153 more) ÅÅOO LOW CRITICAL 32% 86 fewer per 1000 (from 222 fewer to 147 more) 42% 100 fewer per 1000 (from 277 fewer to 154 more) Weight at end of trial (follow-up 1 to 6 months; measured with: Kg; range of scores: 0-100; Better indicated by higher values) 2randomised trials serious 1 no serious inconsistency serious 3 very serious 4 none1915-MD 4.08 higher (4.32 lower to 12.48 higher) ÅÅOO LOW IMPORT ANT 1 Some limitations on sequence generation, blinding and incomplete data outcome. 2 Heterogeneity: Tau2 = 0.0; Chi2 = 0.02, df = 2 (P = 0.99); I2 =0.0% 3 Some limitation according to the intervention access, some included participants with hemorrhagic stroke. 4 Not OIS, low rate of events, CI appreciable damage or benefit. 5 Heterogeneity: Tau2 = 1.58; Chi2 = 4.84, df = 1 (P = 0.03); I2 =79% 6 Heterogeneity: Tau2 = 287.08; Chi2 = 4.71, df = 1 (P = 0.03); I2 =79% GASTROSTOMIA PERCUTANEA V/S SONDA NASOGASTRICA

10 VIA DE ALIMENTACION GASTROSTOMIA ENDOSCOSCOPICA PERCUTANEA V/S SONDA NASOGASTRICA Desenlaces: Gastrostomía endoscópica presentaron: Una menor probabilidad de falla terapéutica OR 0.09 (IC 95% 0.01 a 0.51) Una menor frecuencia de sangrado de origen gastrointestinal OR 0.25 (IC 95% 0.09 a 0.69), No presentaron menor frecuencia de: Ulceras por presión OR 3.10 (IC 95% 0.98 a 9.83) Mortalidad o dependencia OR 0.80 (IC 95% 0.12 a 5.55) Neumonías OR 0.65 (IC 95% 0.23 a 1.86) No se asocio con una mayor estancia hospitalaria (Diferencia de medias (DM)14.32 en días, IC 95% -12.04 a 40.68) Ni con un mayor peso en kilogramos al término del seguimiento (DM4.08 en kilogramos, IC 95% -4.32 a 12.48) cuando se comparó frente al uso de la sonda nasogástrica.

11 VIA DE ALIMENTACION GASTROSTOMIA ENDOSCOSCOPICA PERCUTANEA VS/ SONDA NASOGASTRICA Desenlaces: Gastrostomía endoscópica : Una menor probabilidad de falla terapéutica Una menor frecuencia de sangrado de origen gastrointestinal Sin diferencias significativas en: Menor frecuencia de úlceras por presión Mortalidad o dependencia Neumonías Una mayor estancia hospitalaria Un mayor peso en kilogramos cuando se comparó frente al uso de la Sonda nasogástrica.

12 Se recomienda el uso de la sonda nasogástrica convencional para la alimentación de los pacientes con ataque cerebrovascular isquémico de origen arterial en etapa aguda en quienes no sea factible el inicio de la vía oral Calidad de la Evidencia Baja   En los pacientes que no tengan vo y no sea posible la alimentación por sonda nasogastrica se tendría esta como alternativa la gastrostomía endoscópica percutánea, se sugiere su uso como una alternativa para la alimentación de los pacientes con ataque cerebrovascular isquémico de origen arterial en quienes no sea factible el inicio de la vía oral Calidad de la Evidencia Baja   Recomendación: Fuerte o Débil? RecomendaciónResumen En los pacientes que se detecte falla terapeútica

13 Comparación Tipos de sonda: SNG curva v/s SNG convencional Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other considerations Looped nasogastric tube Conventional nasogastric tube Relative (95% CI) Absolute Feed delivery (follow-up 1 to 6 months; measured with: Porcentual ; range of scores: 0-100; Better indicated by higher values) 1 randomised trials serious 1 no serious inconsistency serious 2 very serious 3 none51 %53 %- MD 18.0 higher (6.66 to 29.34 higher) ÅÅOO LOW CRITICAL Death or dependency at the end of trial (follow-up 1 to 6 months; assessed with: Death or Barthel Index of 0 to 55 or Rankin score of 3 to 5) 1 randomised trials serious 1 no serious inconsistency serious 2 very serious 3 none 41/51 (80.4%) 47/53 (88.7%) OR 0.52 (0.18 to 1.57) 84 fewer per 1000 (from 302 fewer to 38 more) ÅÅOO LOW CRITICAL 80% 125 fewer per 1000 (from 381 fewer to 63 more) 96% 34 fewer per 1000 (from 148 fewer to 14 more) Length of stay in hospital (follow-up 1 to 6 months; measured with: Days; range of scores: 0-100; Better indicated by lower values) 1randomised trials serious 1 no serious inconsistency serious 2 very serious 3 none5153-MD 7.0 higher (8.48 lower to 22.48 higher) ÅÅOO LOW IMPORTANT

14 Pneumonia (follow-up 1 to 6 months; assessed with: clinical, radiologically) 1 randomised trials serious 1 no serious inconsistency serious 2 very serious 3 none 20/51 (39.2%) 23/53 (43.4%) OR 0.84 (0.39 to 1.84) 42 fewer per 1000 (from 204 fewer to 151 more) ÅÅOO LOW CRITICAL 40% 41 fewer per 1000 (from 194 fewer to 151 more) 46% 43 fewer per 1000 (from 211 fewer to 151 more) Gastrointestinal bleeding (follow-up 1 to 6 months; assessed with: Gastrointestinal bleeding) 1 randomised trials serious 1 no serious inconsistency serious 2 very serious 3 none 6/51 (11.8%) 4/53 (7.5%) OR 1.63 (0.43 to 6.17) 42 more per 1000 (from 42 fewer to 259 more) ÅÅOO LOW CRITICAL 5% 29 more per 1000 (from 28 fewer to 195 more) 9% 49 more per 1000 (from 49 fewer to 289 more) 1 Some limitations on sequence generation, blinding and incomplete data outcome. 2 Some limitation according to the intervention access, some included participants with haemorrhagic stroke. 3 Not OIS, low rate of events, CI appreciable damage or benefit. Comparación Tipos de sonda: SNG curva v/s SNG convencional

15 Comparación: SNG curva v/s SNG convencional Desenlaces: Los participantes que recibieron nutrición mediante el uso de SNG curva presentaron una menor falla terapéutica (DM 18.0% porcentaje de alimento entregado, IC 6.66% a 29.34%) sin que esto se acompañase de una menor frecuencia de mortalidad o dependencia OR 0.52 (IC 95% 0.18 a 1.57), ni de neumonía OR 0.84 (IC 95% 0.39 a 1.84) o sangrado de origen gastrointestinal OR 1.63 (IC 95% 0.43 a 6.17), ni se asoció con una mayor estancia hospitalaria (DM 7.0 en días, IC 95% -8.48 a 22.48).

16 Comparación: SNG curva v/s SNG convencional Desenlaces: SNG curva Una menor falla terapéutica medido por porcentaje de alimento entregado Sin diferencias significativas en: Menor frecuencia de mortalidad o dependencia Neumonía Sangrado de origen gastrointestinal Mayor estancia hospitalaria

17 Se recomienda el uso de la sonda nasogástrica convencional comparado a la SNG curva para la alimentación de los pacientes con ataque cerebrovascular isquémico de origen arterial en etapa aguda en quienes no sea factible el inicio de la vía oral Calidad de la Evidencia Baja   fuerte a favor Recomendación: Fuerte o Débil? Recomendación Resumen

18 Debería la suplementación nutricional ser utilizada en pacientes con diágnostico clínico de ACV (isquemico y hemorragico) dentro de los primeros 6 meses de inicio ? Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other considerations Nutritional supplementati on Control Relative (95% CI) Absolute Pressure sores (follow-up 1 to 6 months; assessed with: Pressure sores) 2 randomised trials serious 1 no serious inconsistency serious 2 very serious 3 none 22/2067 (1.1%) 38/2058 (1.8%) OR 0.56 (0.32 to 0.96) 8 fewer per 1000 (from 1 fewer to 12 fewer) ÅÅOO LOW CRITICAL 1.6% 7 fewer per 1000 (from 1 fewer to 11 fewer) 2.0% 9 fewer per 1000 (from 1 fewer to 14 fewer) Energy intake (follow-up 1 to 6 months; measured with: kcal/day; range of scores: 0-2500000; Better indicated by higher values) 3 randomised trials serious 1 serious 4 serious 2 serious 3 none9183- MD 430.18 higher (141.61 to 718.75 higher) ÅÅOO LOW IMPORTANT Protein intake (follow-up 1 to 6 months; measured with: g/day; range of scores: 0-1000; Better indicated by higher values) 3randomised trials serious 1 serious 5 serious 2 very seriousnone9183-MD 17.28 higher (1.99 to 32.56 higher) ÅÅOO LOW IMPORTANT

19 Debería la suplementación nutricional ser utilizada en pacientes con diágnostico clínico de ACV (isquémico y hemorragico) dentro de los primeros 6 meses de inicio ? Case fatality at the end of trial (follow-up 1 to 6 months; assessed with: Death) 7 randomised trials serious 1 no serious inconsistency serious 2 serious 3 none 253/2187 (11.6%) 273/2156 (12.7%) OR 0.58 (0.28 to 1.21) 49 fewer per 1000 (from 88 fewer to 23 more) ÅÅOO LOW CRITICAL 8% 32 fewer per 1000 (from 56 fewer to 15 more) 16% 61 fewer per 1000 (from 109 fewer to 27 more) Death or dependency at the end of trial (follow-up 1 to 6 months; assessed with: Death or Barthel Index of 0 to 55 or Rankin score of 3 to 5) 1 randomised trials serious 1 no serious inconsistency serious 2 serious 3 none 953/2016 (47.3%) 918/2007 (45.7%) OR 1.06 (0.94 to 1.2) 14 more per 1000 (from 15 fewer to 45 more) ÅÅOO LOW CRITICAL 40% 14 more per 1000 (from 15 fewer to 44 more) 50% 15 more per 1000 (from 15 fewer to 45 more) Albumin (follow-up 1 to 6 months; measured with: g/L; range of scores: 1-100; Better indicated by higher values) 2randomised trials serious 1 no serious inconsistency serious 2 very serious 3 none72 -MD 0.29 higher (0.65 lower to 1.24 higher) ÅÅOO LOW IMPORTANT 1 Some limitations on sequence generation, blinding and incomplete data outcome. 2 Some limitation according to the intervention access, some included participants with hemorrhagic stroke. 3 Low rate of events, not OIS, CI appreciable damage or benefit. 4 Heterogeneity: Tau2 = 58886.43; Chi2 = 23.12, df = 2 (P

20 INTERVENCIÓN: SUPLEMENTACIÓN NUTRICIONAL FRENTE A GRUPO CONTROL Desenlaces: La suplementación nutricional se asoció con: Una menor frecuencia de úlceras por presión OR 0.56 (IC 95% 0.32 a 0.96) Con una mayor cantidad de aporte calórico (DM 430.18 kilocalorías/día, IC 95% 141.61 a 718.75)y proteico(DM 17.28gramos/día, IC 95% 1.99 a 32.56). No incrementó los niveles de albúmina en sangre (DM 0.29 en gramos/litro, IC 95% -0.65 a 1.24) No disminuyó la mortalidad OR 0.58 (IC 95% 0.28 a 1.21) ó dependencia OR 1.06 (IC 95% 0.94 a 1.2) al término del seguimiento.

21 INTERVENCIÓN: SUPLEMENTACIÓN NUTRICIONAL FRENTE A GRUPO CONTROL Desenlaces: La suplementación nutricional : Menor frecuencia de úlceras por presión Mayor cantidad de aporte calórico y protéico Sin diferencias significativas: No incrementó los niveles de albúmina en sangre No disminuyó la mortalidad o dependencia al término del seguimiento frente al grupo control

22 Se recomienda la suplementación nutricional en lo los pacientes con ataque cerebrovascular isquémico de origen arterial en etapa aguda en quienes no tienen VO para disminuir la frecuencia de ulceras por presión y mejorar el aporte calórico y proteico Calidad de la Evidencia Baja   FUERTE A FAVOR Recomendación: Fuerte o Débil? RecomendaciónResumen

23 INTERVENCIONES EN DISFAGIA Desenlaces: Mortalidad al término del seguimiento Mortalidad o dependencia Proporción de pacientes con disfagia Frecuencia de neumonía Estancia hospitalaria y el índice nutricional posterior a la intervención (evaluado mediante niveles de albúmina, el peso en kilogramos y la circunferencia media del brazo).

24 Debería ser la Intervención comportamental parte de la terapia de deglución en pacientes con Disfagia ? Quality assessmentNo of patientsEffect No of studiesDesignRisk of biasInconsistencyIndirectnessImprecisionOther considerations Behavioural interventions as swallowing therapy for dysphagia Control Relative (95% CI) Absolute Death or dependency at the end of the trial (follow-up 1 to 6 months; assessed with: Death or Barthel Index of 0 to 55 or Rankin score of 3 to 5) 2randomised trialsserious 2 no serious inconsistency 3 serious 4 no serious imprecisionnone 107/153 (69.9%) 106/153 (69.3%) OR 1.05 (0.63 to 1.75) 10 more per 1000 (from 106 fewer to 105 more) 65% 11 more per 1000 (from 111 fewer to 115 more) 73% 10 more per 1000 (from 100 fewer to 96 more) Case fatality at the end of the trial. (follow-up 1 to 6 months; assessed with: Death) 2randomised trialsserious 2 no serious inconsistency 5 serious 4 serious 6,7 none 27/153 (17.6%) 33/153 (21.6%) OR 0.83 (0.46 to 1.51) 30 fewer per 1000 (from 103 fewer to 78 more) 16% 23 fewer per 1000 (from 79 fewer to 63 more) 26% 34 fewer per 1000 (from 121 fewer to 87 more) Proportion with dysphagia at the end of the trial (follow-up 1 to 6 months; assessed with: Proportion with dysphagia at the end of the trial) 5randomised trialsserious 2 no serious inconsistency 8 serious 4 serious 6 none 69/211 (32.7%) 105/212 (49.5%) OR 0.52 (0.3 to 0.88) 157 fewer per 1000 (from 32 fewer to 268 fewer) 40% 143 fewer per 1000 (from 30 fewer to 233 fewer) 58% 162 fewer per 1000 (from 31 fewer to 287 fewer)

25 Debería ser la Intervención comportamental parte de la terapia de deglución en pacientes con Disfagia ? 1 Diagnosed clinically (water swallow tests, modified diet and fluid assessments, swallowing test scores) by a range of clinicians, or using videofluoroscopy, or using flexible endoscopic evaluation of swallowing (FEES). 2 Some limitations on sequence generation, blinding and incomplete data outcome. 3 Heterogeneity: Tau2 = 0.0; Chi2 = 0.28, df = 1 (P = 0.60); I2 =0.0% 4 Some limitation according to the intervention access, some included participants with haemorrhagic stroke. Heterogeneity: Tau2 = 0.0; Chi2 = 0.00, df = 1 (P = 0.97); I2 =0.0% 6 CI appreciable damage or benefit. 7 Not OIS. 8 Heterogeneity: Tau2 = 0.08; Chi2 = 5.14, df = 4 (P = 0.27); I2 =22% 9 Heterogeneity: Tau2 = 0.22; Chi2 = 6.10, df = 4 (P = 0.19); I2 =34% 10 Heterogeneity: Tau2 = 0.0; Chi2 = 0.00, df = 1 (P = 1.00); I2 =0.0% 11 Heterogeneity: Tau2 = 1.77; Chi2 = 3.68, df = 3 (P = 0.30); I2 =19% Pneumonia (follow-up 1 to 6 months; assessed with: clinical, radiologically) 5 randomised trials serious 2 no serious inconsistency 9 serious 4 no serious imprecision none 43/211 (20.4%) 75/212 (35.4%) OR 0.50 (0.24 to 1.04) 139 fewer per 1000 (from 238 fewer to 9 more) ÅÅOO LOW CRITICAL 30% 124 fewer per 1000 (from 207 fewer to 8 more) 40% 150 fewer per 1000 (from 262 fewer to 9 more) Nutritional measures (follow-up 1 to 6 months; measured with: weight, albumin, mid-arm circumference (MAC); range of scores: 0-100; Better indicated by higher values) 2 randomised trials serious 2 no serious inconsistency 1 0 serious 4 serious 7 none2935- MD 0.20 higher (4.77 lower to 5.17 higher) ÅÅOO LOW IMPORTANT Length of hospital stay (follow-up 1 to 6 months; measured with: days; range of scores: 0-100; Better indicated by lower values) 4randomised trials serious 2 no serious inconsistency 1 1 serious 4 serious 7 none182188-MD 2.70 lower (5.68 lower to 0.28 higher) ÅÅOO LOW IMPORTANT

26 Desenlaces: La terapia comportamental se asoció con una menor proporción de pacientes con disfagia posterior a la terapia OR 0.52 (IC 95% 0.3 a 0.88) más no de una menor frecuencia de muerte OR 0.83 (IC 95% 0.46 a 1.51), dependencia OR 1.05 (IC 95% 0.63 a 1.75) o de pacientes con neumonía OR 0.50 (IC 95% 0.24 a 1.04). No se asocio con una mayor o menor estancia hospitalaria (DM -2.70 en días, IC 95% -5.68 a 0.28) ó con un mejor índice nutricional (DM 0.20, IC 95% 4.77 a 5.17). Debería ser la Intervención comportamental parte de la terapia de deglución en pacientes con Disfagia?

27 Desenlaces: La terapia comportamental Menor proporción de pacientes con disfagia Sin diferencias significativas : No generó una menor frecuencia de muerte o dependencia Neumonía Mayor o menor estancia hospitalaria Mejor índice nutricional

28 RecomendaciónResumen Se RECOMIENDA el uso de intervenciones comportamentales como parte de la terapia para la deglución en los pacientes con ataque cerebrovascular isquémico de origen arterial en etapa aguda Calidad de la Evidencia Baja   FUERTE A FAVOR Recomendación: Fuerte o Débil?

29 Debería indicarse la Acupuntura como terapia para la deglución en Disfagia ? 1 Some limitations on sequence generation, blinding and incomplete data outcome. 2 Some limitation according to the intervention access, some included participants with haemorrhagic stroke. 3 Heterogeneity: Tau2 = 0.88; Chi2 = 21.72, df = 2 (P = 0.00002); I2 =91% 4 Low rate of events, not OIS. Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other considerations Acupuncture as swallowing therapy for dysphagia Control Relative (95% CI) Absolute Proportion with dysphagia at the end of the trial (follow-up 1 to 6 months; assessed with: Proportion with dysphagia at the end of the trial) 4 randomised trials serious 1 no serious inconsistency serious 2 no serious imprecision none 52/144 (36.1%) 74/112 (66.1%) OR 0.24 (0.13 to 0.46) 342 fewer per 1000 (from 188 fewer to 459 fewer) ÅÅOO LOW CRITICAL 56% 326 fewer per 1000 (from 191 fewer to 418 fewer) 76% 328 fewer per 1000 (from 167 fewer to 468 fewer) Dysphagia (follow-up 1 to 6 months; measured with: Water swallow test; range of scores: 0-100; Better indicated by lower values) 3randomised trials serious 1 serious 3 serious 2 serious 4 none9085-MD 0.41 lower (1.53 lower to 0.72 higher) ÅÅOO LOW CRITICAL

30 Desenlaces: El uso de acupuntura disminuyó la proporción de pacientes con disfagia al final del tratamiento OR 0.24 (IC 95% 0.13 a 0.46) sin que esto se viera reflejado en un menor índice de disfagia (DM -0.41 Prueba de deglución de agua, IC 95% -1.53 a 0.72). Debe indicarse la acupuntura como terapia deglutoria en Disfagia

31 RecomendaciónResumen No se recomienda el uso de la acupuntura como parte de la terapia para la deglución en los pacientes con ataque cerebrovascular isquémico de origen arterial en etapa aguda FUERTE EN CONTRA Calidad de la Evidencia Baja   Recomendación: Fuerte o Débil?

32 Debería la terapia medicamentosa ser parte del tratamiento para la deglución en Disfagia ? 1 Some limitations on sequence generation, blinding and incomplete data outcome. 2 Some included participants with haemorrhagic stroke 3 Not OIS, low rate of events, CI appreciable damge or benefit Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other considerations Drug therapy as swallowing therapy for dysphagia Control Relative (95% CI) Absolute Case fatality at the end of trial (follow-up 1 to 6 months; assessed with: Death) 1randomised trialsserious 1 no serious inconsistency serious 2 very serious 3 none 1/8 (12.5%) 1/9 (11.1%) OR 1.14 (0.06 to 21.87) 14 more per 1000 (from 104 fewer to 621 more) ÅÅOO LOW CRITICAL 6% 8 more per 1000 (from 56 fewer to 523 more) 16% 18 more per 1000 (from 149 fewer to 646 more) Pneumonia (follow-up 1 to 6 months; assessed with: clinical, radiologically) 1randomised trialsserious 1 no serious inconsistency serious 2 very serious 3 none 1/25 (4%) 6/33 (18.2%) OR 0.19 (0.02 to 1.67) 141 fewer per 1000 (from 177 fewer to 89 more) ÅÅOO LOW CRITICAL 12% 95 fewer per 1000 (from 117 fewer to 65 more) 24% 183 fewer per 1000 (from 234 fewer to 105 more) Proportion with dysphagia at the end of the trial (follow-up 1 to 6 months; assessed with: Proportion with dysphagia at the end of the trial) 1randomised trialsserious 1 no serious inconsistency serious 2 very serious 3 none 3/8 (37.5%) 5/9 (55.6%) OR 0.48 (0.07 to 3.35) 181 fewer per 1000 (from 475 fewer to 252 more) ÅÅOO LOW CRITICAL 50% 176 fewer per 1000 (from 435 fewer to 270 more) 60% 181 fewer per 1000 (from 505 fewer to 234 more)

33 Debería la estimulación eléctrica neuromuscular ser usada como terapia para la deglución en Disfagia ? 1 Some limitations on sequence generation, blinding and incomplete data outcome. 2 Some included participants with haemorrhagic stroke. 3 Not OIS, low rate of events, CI appreciable damage or benefit. Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other considerations Neuromuscula r electrical stimulation as swallowing therapy for dysphagia Control Relative (95% CI) Absolute Proportion with dysphagia at the end of the trial (follow-up 1 to 6 months; assessed with: Proportion with dysphagia at the end of the trial) 1 randomised trials serious 1 no serious inconsistency serious 2 very serious 3 none 6/13 (46.2%) 6/9 (66.7%) OR 0.43 (0.07 to 2.5) 204 fewer per 1000 (from 544 fewer to 167 more) ÅÅOO LOW CRITICAL 60% 208 fewer per 1000 (from 505 fewer to 189 more) 72% 195 fewer per 1000 (from 567 fewer to 145 more)

34 Terapia farmacológica y Estimulación eléctrica neuromuscular Desenlaces: Con la terapia farmacológica y la estimulación eléctrica neuromuscular como parte de la terapia deglutoria en pacientes con disfagia, no encontró diferencias estadísticamente significativas en cuanto a la proporción de pacientes con disfagia al final del tratamiento OR 0.43 (IC 95% 0.07 a 2.5)con el uso de la estimulación eléctrica neuromuscular y OR 0.48 (IC 95%0.07 a 3.35) con la terapia farmacológica. Ni disminuyó el riesgo de mortalidad OR 1.14 (IC 95% 0.06 a 21.87) ni la frecuencia de neumonía OR 0.19 (IC 95% 0.02 a 1.67) cuando ambas intervenciones se compararon frente al control.

35 No se recomienda el uso de intervenciones farmacológicas como parte de la terapia para la deglución en los pacientes con ataque cerebrovascular isquémico de origen arterial en etapa aguda FUERTE EN CONTRA Calidad de la Evidencia Baja   No se recomienda el uso de estimulación eléctrica neuromuscular como parte de la terapia para la deglución en los pacientes con ataque cerebrovascular isquémico de origen arterial en etapa aguda FUERTE EN CONTRA Calidad de la Evidencia Baja   Recomendación: Fuerte o Débil? RecomendaciónResumen

36 Debería usarse la estimulación eléctrica faríngea como terapia de deglución en Disfagia? 1 Some limitations on sequence generation, blinding and incomplete data outcome. 2 Some included participants with haemorrhagic stroke. 3 Not OIS, low rate of events, CI appreciable damage or benefit. Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other consideration s Pharyngeal electrical stimulation as swallowing therapy for dysphagia Control Relative (95% CI) Absolute Case fatality at the end of trial (follow-up 1 to 6 months; assessed with: Death) 1 randomised trials serious 1 no serious inconsistency serious 2 very serious 3 none 2/16 (12.5%) 0/12 (0%) OR 4.31 (0.19 to 98.51) - ÅÅOO LOW CRITICAL 0.1% 3 more per 1000 (from 1 fewer to 89 more) 1.0% 32 more per 1000 (from 8 fewer to 489 more) Pneumonia (follow-up 1 to 6 months; assessed with: clinical, radiologically) 1 randomised trials serious 1 no serious inconsistency serious 2 very serious 3 none 2/16 (12.5%) 3/12 (25%) OR 0.43 (0.06 to 3.09) 125 fewer per 1000 (from 230 fewer to 257 more) ÅÅOO LOW CRITICAL 20% 103 fewer per 1000 (from 185 fewer to 236 more) 30% 144 fewer per 1000 (from 275 fewer to 270 more)

37 Debería usarse la estimulación Física (térmica o táctil) como terapia de deglución en Disfagia ? 1 Some limitations on sequence generation, blinding and incomplete data outcome. 2 Some included participants with haemorrhagic stroke. 3 Not OIS, low rate of events, CI appreciable damage or benefit. Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other consideration s Physical stimulation (thermal, tactile) as swallowing therapy for dysphagia Control Relative (95% CI) Absolute Case fatality at the end of trial (follow-up 1 to 6 months; assessed with: Death) 1 randomised trials serious 1 no serious inconsistency serious 2 very serious 3 none 7/11 (63.6%) 5/8 (62.5%) OR 1.05 (0.16 to 6.92) 11 more per 1000 (from 414 fewer to 295 more) ÅÅOO LOW CRITICAL 56% 12 more per 1000 (from 391 fewer to 338 more) 68% 11 more per 1000 (from 426 fewer to 256 more) Proportion with dysphagia at the end of the trial (follow-up 1 to 6 months; assessed with: Proportion with dysphagia at the end of the trial) 1 randomised trials serious 1 no serious inconsistency serious 2 very serious 3 none 3/4 (75%) 3/3 (100%) OR 0.33 (0.01 to 11.34) - ÅÅOO LOW CRITICAL 80% 231 fewer per 1000 (from 762 fewer to 178 more) 100%- Dysphagia (follow-up 1 to 6 months; measured with: Water swallow test; range of scores: 0-100; Better indicated by lower values) 1randomised trials serious 1 no serious inconsistency serious 2 very serious 3 none88-MD 1.40 higher (2.58 lower to 5.38 higher) ÅÅOO LOW CRITICAL

38 Estimulación eléctrica faríngea y estimulación física (térmica o táctil) como terapias para deglución Desenlaces: cuando se evaluó la efectividad de la estimulación Eléctrica Faríngea y de la estimulación física (térmica o táctil) estas no incrementaron la frecuencia de desenlaces favorables en salud comparadas frente a no intervención. La estimulación eléctrica faríngea no disminuyó la mortalidad OR 4.31 (IC 95% 0.19 a 98.51) o la frecuencia de neumonía OR 0.43 (IC 95% 0.06 a 3.09) La estimulación física tampoco disminuyó la mortalidad OR 1.05 (IC 95% 0.16 a 6.92), la frecuencia de pacientes con disfagia OR 0.33 (IC 95% 0.01 a 11.34) o los índices de disfagia (DM 1.40 Prueba de deglución de agua, IC 95% -2.58 a 5.38)

39 Estimulación eléctrica faríngea y estimulación física (térmica o táctil) como terapias para deglución Desenlaces: No incrementaron la frecuencia de desenlaces favorables en Salud El uso de la estimulación eléctrica faríngea: No disminuyó la mortalidad No disminuyó la frecuencia de Neumonía La estimulación física térmica o táctil: No disminuyó la mortalidad No disminuyó la frecuencia de pacientes con disfagia o los índices de disfagia al término del tratamiento.

40 No se RECOMIENDA el uso de la estimulación eléctrica faríngea como parte de la terapia para la deglución en los pacientes con ataque cerebrovascular isquémico de origen arterial en etapa aguda FUERTE EN CONTRA Calidad de la Evidencia Baja   Se recomienda el uso de la estimulación física (térmica o táctil) como parte de la terapia para la deglución en los pacientes con ataque cerebrovascular isquémico de origen arterial en etapa aguda FUERTE A FAVOR Calidad de la Evidencia Baja   Recomendación: Fuerte o Débil? RecomendaciónResumen

41 Debería usarse la estimulación con corriente directa transcraneal como terapia de deglución en Disfagia ? 1 Some limitations on sequence generation, blinding and incomplete data outcome. 2 Some included participants with hemorrhagic stroke. 3 Not OIS, low rate of events, CI appreciable damage or benefit. Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other considerations Transcranial direct current stimulation as swallowing therapy for dysphagia Control Relative (95% CI) Absolute Proportion with dysphagia at the end of the trial (follow-up 1 to 6 months; assessed with: Proportion with dysphagia at the end of the trial) 1 randomised trials serious 1 no serious inconsistency serious 2 very serious 3 none 6/7 (85.7%) 7/7 (100%) OR 0.29 (0.01 to 8.39) - ÅÅOO LOW CRITICAL 80% 263 fewer per 1000 (from 762 fewer to 171 more) 100%- Dysphagia (follow-up 1 to 6 months; measured with: Water swallow test; range of scores: 0-100; Better indicated by lower values) 1randomised trials serious 1 no serious inconsistency serious 2 very serious 3 none77-MD 1.0 higher (0.5 lower to 2.5 higher) ÅÅOO LOW CRITICAL

42 Debería utilizarse la estimulación magnetica transcraneal como terapia de deglución en Disfagia ? 1 Some limitations on sequence generation, blinding and incomplete data outcome. 2 Some included participants with haemorrhagic stroke. 3 Not OIS, low rate of events, CI appreciable damage or benefit. Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other considerations Transcranial magnetic stimulation as swallowing therapy for dysphagia Control Relative (95% CI) Absolute Case fatality at the end of trial (follow-up 1 to 6 months; assessed with: Death) 1 randomised trials serious 1 no serious inconsistency serious 2 very serious 3 none 0/14 (0%) 1/12 (8.3%) OR 0.26 (0.01 to 7.12) 60 fewer per 1000 (from 82 fewer to 310 more) ÅÅOO LOW CRITICAL 6% 44 fewer per 1000 (from 59 fewer to 252 more) 10% 72 fewer per 1000 (from 99 fewer to 342 more)

43 Estimulación transcraneal de corriente directa y Estimulación transcraneal magnética como terapia para disfagia Desenlaces: Con base en esta revisión sistemática se pudo establecer que los pacientes asignados a recibir estimulación transcraneal de corriente directa no experimentaron una menor frecuencia de disfagia OR 0.29 (IC 95% 0.01 a 8.39) Ni un menor índice de disfagia (DM 1.0 Prueba de deglución de agua, IC 95% -0.5 a 2.5) La estimulación transcraneal magnética, no disminuyó la frecuencia de muerte OR 0.26 (0.01 a 7.12) cuando se comparó frente al grupo control.

44 Recomendación: Fuerte o Débil? No se recomienda el uso de la estimulación con corriente directa transcraneal como parte de la terapia para la deglución en los pacientes con ataque cerebrovascular isquémico de origen arterial en etapa aguda FUERTE EN CONTRA Calidad de la Evidencia Baja   No se recomienda el uso de la estimulación magnética transcraneal como parte de la terapia para la deglución en los pacientes con ataque cerebrovascular isquémico de origen arterial en etapa aguda PARA REVISAR Calidad de la Evidencia Baja   RecomendaciónResumen

45 REHABILITACIÓN FÍSICA Systematic review: Amstar 9/11 96 trials with a total of 10401 participants Date: 2014-09-15 Question: Should Physical rehabilitation v/s no intervention or usual care be used for patients with clinical diagnosis of stroke (Ischemic or hemorrhagic) within 30 days of onset.? 1 Settings: Any setting Bibliography: Pollock A, Baer G, Campbell P, Choo PL, Forster A,Morris J, Pomeroy VM, Langhorne P. Physical rehabilitation approaches for the recovery of function and mobility following stroke. Cochrane Database of Systematic Reviews 2014, Issue 4. Art.No.: CD001920. DOI: 10.1002/14651858.CD001920.pub3. Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other considerations Physical rehabilitation No intervention or usual care Relative (95% CI) Absolute Independence in activities of daily living at the time of discharge (follow-up mean 30 days; measured with: Barthel Activities of Daily Living Index or Functional Independence Measure or Modified Rankin Scale, Katz Index of of Daily Living and Rehabilitation Activities Profile; range of scores: 0-100; Better indicated by higher values) 13 randomised trials serious 2 very serious 3 serious 4 no serious imprecision none590605- SMD 0.86 higher (0.61 to 1.11 higher) 5 ÅÅOO LOW CRITICAL Motor function at the time of discharge (follow-up mean 30 days; measured with: Motor Assessment scale or Fugl-Meyer Assessment or Rivermead Mobility Index or Rivermead Motor Assessment ; range of scores: 0-100%; Better indicated by higher values) 16 randomised trials serious 2 very serious 6 serious 4 no serious imprecision none13541281- SMD 0.68 higher (0.47 to 0.89 higher) 5 ÅÅOO LOW CRITICAL Balance at the time of discharge (follow-up mean 30 days; measured with: Berg Balance Scale; range of scores: 0-100; Better indicated by higher values) 5randomised trials serious 2 no serious inconsistency 7 no serious indirectness serious 8 none123 -SMD 0.31 higher (0.05 to 0.56 higher) 9 ÅÅOO LOW CRITICAL

46 REHABILITACIÓN FÍSICA 1 Treatment components were categorized as functional task training, musculoskeletal intervention (active),musculoskeletal intervention (passive), neurophysiological intervention, cardiopulmonary intervention, assistive device or modality. 2 Some limitations on sequence generation, allocation concealment, blinding, selective reporting, incomplete data outcome and other risk of bias domains. 3 Heterogeneity: Tau2 = 0.15; Chi2 = 48.04, df = 12 (P

47 REHABILITACIÓN FÍSICA Una revisión sistemática de la literatura con 96 estudios clínicos y 10.401 participantes evaluó la seguridad y la efectividad de la rehabilitación física frente a la no intervención o tratamiento habitual para el tratamiento de los pacientes con ACV isquémico agudo de origen arterial. Desenlaces: La independencia en las actividades durante la vida diaria (medida mediante el uso de la escala de Ranking modificada, el índice de Barthel, el índice de independencia funcional o el índice de Katz), la función motora (medida con la escala de evaluación motora, la evaluación de Fugl-Meyer o el índice de movilidad de Rivermead), el equilibrio al egreso (escala de Berg), la velocidad de la marcha y la estancia hospitalaria en días.

48 REHABILITACIÓN FÍSICA Desenlaces: Rehabilitación física versus no intervención,. los pacientes asignados al brazo de intervención experimentaron una mayor independencia durante las actividades diarias (Diferencia de Medias Estandarizada (DME 0.86, IC 95% 0.61 a 1.11) y una mejor función motora al momento del alta (DME 0.68, IC 95% 0.47 a 0.89) sin que la estancia hospitalaria se viera modificada (DM 2.85 en días, IC 95% -10.47 a 4.76). Se asoció con un mejor equilibrio al momento del alta (DME 0.31, IC 95% 0.05 a 0.56) al igual que con una mayor velocidad durante la marcha (DME 0.46, IC 95% 0.32 a 0.6).

49 Recomendación: Fuerte o Débil? RecomendaciónResumen Se recomienda el uso de la rehabilitación física para el tratamiento de los pacientes con ataque cerebrovascular isquémico de origen arterial en etapa aguda para mejorar la independencia en las actividades de la vida diaria, la función motora, el equilibrio y la velocidad de la marcha. FUERTE A FAVOR Calidad de la Evidencia Baja  

50 INICIO DE LA REHABILITACIÓN FÍSICA Se analizaron los riesgos y beneficios del inicio de la rehabilitación durante las primeras 24 horas como parte del tratamiento recibido al interior de las unidades especializadas para la atención de ACV frente al tratamiento habitual. Se comparó la seguridad y la efectividad del inicio de esta misma intervención dentro de los tres frente a los siete primeros días desde el inicio de los síntomas.

51 INICIO DE LA REHABILITACION FISICA TEMPRANA 24 HORAS V/S USUAL CARE Systematic review: Amstar 6/11 4 trials with a total of 240 participants Date: 2014-09-15 Question: Should Early physical rehabilitation (within 24 h) on SU v/s SU usual care be used for patients with definite clinical diagnosis of stroke within 7 to 14 days after onset? 1,2 Settings: Any setting Bibliography: Lynch E, Hillier S, Cadilhac D. When should physical rehabilitation commence after stroke: a systematic review. International Journal of Stroke, Vol 9, June 2014, 468–478. Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other considerations Early physical rehabilitation (within 24 h) on SU SU usual care Relative (95% CI) Absolute Case fatality (follow-up mean 3 months; assessed with: death) 3 randomised trials no serious risk of bias 3 no serious inconsistency no serious indirectness very serious 4 none 15/81 (18.5%) 6/78 (7.7%) RR 2.58 (0.98 to 6.79) 122 more per 1000 (from 2 fewer to 445 more) ÅÅOO LOW CRITICAL 5% 79 more per 1000 (from 1 fewer to 289 more) 9% 142 more per 1000 (from 2 fewer to 521 more) Non-serious adverse events (follow-up mean 3 months; assessed with: Not mentioned 5 ) 3 randomised trials no serious risk of bias 3 no serious inconsistency no serious indirectness very serious 4 none 21/81 (25.9%) 22/78 (28.2%) OR 0.92 (0.46 to 1.87) 17 fewer per 1000 (from 129 fewer to 141 more) ÅÅOO LOW CRITICAL 24% 15 fewer per 1000 (from 113 fewer to 131 more) 32% 18 fewer per 1000 (from 142 fewer to 148 more)

52 REHABILITACION FISICA TEMPRANA 24 HORAS V/S CUIDADO USUAL Functional independence (follow-up mean 3 months; measured with: using the BI ; range of scores: -100-100; Better indicated by higher values) 3 randomised trials no serious risk of bias 3 serious 6 no serious indirectness very serious 4 none6260- MD 1.20 higher (0.77 lower to 3.18 higher) ÅÅOO LOW CRITICAL ‘Good outcome’ (follow-up mean 3 months; assessed with: indicated by a modified Rankin Score (mRS) of 0–2) 3 randomised trials no serious risk of bias 3 serious 6 no serious indirectness very serious 4 none 37/79 (46.8%) 34/77 (44.2%) OR 1.16 (0.61 to 2.18) 37 more per 1000 (from 116 fewer to 191 more) ÅÅOO LOW CRITICAL 40% 36 more per 1000 (from 111 fewer to 192 more) 48% 37 more per 1000 (from 120 fewer to 188 more) 1 (defined as physical therapy, occupational therapy and physical exercises aimed at preserving or restoring physical function) 2 which was within 48 h of stroke. 3 Risk of bias of each study was assessed using the Critical Appraisal Skills Program (CASP) criteria for RCTs and cohort study designs 4 Not OIs, low rate of events, CI appreciable damage or benefit. 5 Non-serious adverse events included adverse events that were not life threatening, incapacitating, led to prolonged hospital admission or an increase in patient acuity. 6 Some limitations and differences on punctual estimation of effect with some heterogeneity> 30%

53 REHABILITACIÓN FÍSICA A LOS 3 DIAS V/S 7 DIAS Systematic review: Amstar 6/11 1 trials with a total of 42 participants Date: 2014-09-15 Question: Should Physical rehabilitation at 3 days (early) vs 7 days (delayed) be used for patients with definite clinical diagnosis of stroke within 7 to 14 days after onset? Settings: Any setting Bibliography: Lynch E, Hillier S, Cadilhac D. When should physical rehabilitation commence after stroke: a systematic review. International Journal of Stroke, Vol 9, June 2014, 468–478 1 Non-serious adverse events included adverse events that were not life threatening, incapacitating, led to prolonged hospital admission or an increase in patient acuity. 2 Risk of bias of each study was assessed using the Critical Appraisal Skills Program (CASP) criteria for RCTs and cohort study designs 3 Not OIs, low rate of events, CI appreciable damage or benefit. Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other consideration s Physical rehabilitation at 3 days (early) 7 days (delayed) Relative (95% CI) Absolute Non-serious adverse events (follow-up mean 30 days; assessed with: Not mentioned 1 ) 1 randomised trials no serious risk of bias 2 no serious inconsistency no serious indirectness very serious 3 none 18/25 (72%) 9/17 (52.9%) OR 0.43 (0.12 to 1.59) 203 fewer per 1000 (from 410 fewer to 112 more) ÅÅOO LOW CRITICAL 48% 196 fewer per 1000 (from 380 fewer to 115 more) 56% 206 fewer per 1000 (from 428 fewer to 109 more) "Good outcome" (follow-up mean 30 months; assessed with: indicated by a modified Rankin Score (mRS) of 0–2) 1 randomised trials no serious risk of bias 2 no serious inconsistency no serious indirectness very serious 3 none 10/25 (40%) 6/17 (35.3%) OR 0.81 (0.22 to 2.93) 47 fewer per 1000 (from 246 fewer to 262 more) ÅÅOO LOW CRITICAL 30% 42 fewer per 1000 (from 214 fewer to 257 more) 40% 49 fewer per 1000 (from 272 fewer to 261 more)

54 INICIO DE LA REHABILITACIÓN FÍSICA Desenlaces: Se evaluó la mortalidad, la frecuencia de eventos adversos no serios, la independencia funcional (medida mediante el índice de Barthel) y la frecuencia de un buen desenlace funcional (mediante puntaje de Rankin modificado de 0–2). La rehabilitación física dentro de las primeras 24 horas No experimentaron una menor mortalidad OR 2.58 (IC 95% 0.98 a 6.79), Ni una mayor proporción de un buen desenlace funcional OR 1.16 (IC 95% 0.61 a 2.18) Una mayor independencia funcional (DM 1.20, IC 95% -0.77 a 3.18). Una mayor frecuencia de eventos adversos no serios OR 0.92 (IC 95% 0.46 a 1.87).

55 INICIO DE LA REHABILITACIÓN FÍSICA Se comparó el inicio de la rehabilitación física dentro de los tres frente a los siete primeros días desde el inicio de los síntomas, el inicio temprano de la rehabilitación no incrementó la frecuencia de un buen desenlace funcional OR 0.81 (IC 95% 0.22 a 2.93) o de eventos adversos catalogados como no serios derivados de la intervención OR 0.43 (IC 95% 0.12 a 1.59).

56 Recomendación: Fuerte o Débil? RecomendaciónResumen Se recomienda el inicio temprano (en los primeras 72 horas) de la rehabilitación física en los pacientes con ataque cerebrovascular isquémico de origen arterial en etapa aguda FUERTE A FAVOR Calidad de la Evidencia Baja  

57 DONDE INICIAR LA REHABILITACIÓN FÍSICA Una revisión sistemática de la literatura con 14 estudios clínicos y un total de 1957 participantes comparó la estrategia de alta temprana con rehabilitación en casa frente al cuidado convencional (rehabilitación hospitalaria acompañada de alta convencional). Se analizaron los riesgos y beneficios de la intervención en términos de la frecuencia de muerte, la mortalidad o dependencia, el desempeño en las actividades de la vida diaria (puntaje Barthel ADL), la satisfacción del paciente con el cuidado médico proporcionado, la estancia hospitalaria y la probabilidad de reingreso posterior al alta.

58 DONDE INICIAR LA REHABILITACIÓN FÍSICA Systematic review: Amstar 9/11 14 trials with a total of 1957 participants Date: 2014-09-25 Question: Should Early discharge with rehabilitation at home (policy of early discharge with home-based support and rehabilitation) vs conventional care (policy of hospital rehabilitation and conventional discharge arrangements) be used for patients with acute or subacute diagnosis of stroke within the first 14 days after stroke onset? 1 Settings: Any setting Bibliography: Fearon P, Langhorne P, Early Supported Discharge Trialists. Services for reducing duration of hospital care for acute stroke patients. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD000443. DOI: 10.1002/14651858.CD000443.pub3. Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other considerations Early discharge with rehabilitation at home (policy of early discharge with home-based support and rehabilitation) Conventional care (policy of hospital rehabilitation and conventional discharge arrangements) Relative (95% CI) Absolute Death (follow-up 3 to 12 months; assessed with: death) 14 randomised trials serious 2 no serious inconsistency 3 no serious indirectness 4 serious 5 none 82/988 (8.3%) 88/969 (9.1%) OR 0.91 (0.67 to 1.25) 7 fewer per 1000 (from 28 fewer to 20 more) ÅÅOO LOW CRITICAL 7% 6 fewer per 1000 (from 22 fewer to 16 more) 11% 9 fewer per 1000 (from 34 fewer to 24 more) Death or dependency (follow-up 3 to 12 months; assessed with: Death or physical dependency (i.e. dependent on help for transfers, mobility, washing, dressing or toileting)) 14 randomised trials serious 2 no serious inconsistency 6 no serious indirectness no serious imprecision none 413/988 (41.8%) 455/969 (47%) OR 0.80 (0.67 to 0.97) 55 fewer per 1000 (from 8 fewer to 97 fewer) ÅÅÅO MODERATE CRITICAL 42% 53 fewer per 1000 (from 7 fewer to 93 fewer) 52% 56 fewer per 1000 (from 8 fewer to 99 fewer)

59 DONDE INICIAR LA REHABILITACIÓN FÍSICA Activities of daily living (follow-up 3 to 12 months; measured with: Barthel ADL score; range of scores: 0-100; Better indicated by higher values) 9 randomised trials serious 2 no serious inconsistency 7 no serious indirectness no serious imprecision none571553- SMD 0.03 higher (0.08 lower to 0.15 higher) ÅÅÅO MODERATE CRITICAL Patient satisfaction (follow-up 3 to 12 months; assessed with: Not mentioned) 5 randomised trials serious 2 no serious inconsistency 8 no serious indirectness serious 5 none 184/266 (69.2%) 151/247 (61.1%) OR 1.60 (1.08 to 2.38) 104 more per 1000 (from 18 more to 178 more) ÅÅOO LOW CRITICAL 56% 111 more per 1000 (from 19 more to 192 more) 66% 96 more per 1000 (from 17 more to 162 more) Length of initial hospital stay (follow-up 3 to 12 months; measured with: Days; range of scores: 0-100; Better indicated by lower values) 13 randomised trials serious 2 serious 9 no serious indirectness no serious imprecision none858837- MD 7.10 lower (10.03 to 4.17 lower) ÅÅOO LOW IMPORTANT Hospital readmissions (follow-up 3 to 12 months; assessed with: readmissions) 7 randomised trials serious 2 no serious inconsistency 10 no serious indirectness serious 5 none 155/463 (33.5%) 130/455 (28.6%) OR 1.26 (0.94 to 1.67) 49 more per 1000 (from 12 fewer to 115 more) ÅÅOO LOW IMPORTANT 23% 43 more per 1000 (from 11 fewer to 103 more) 33% 53 more per 1000 (from 14 fewer to 121 more) 1 The ESD service comprised a multidisciplinary team which co-ordinated discharge from hospital, post discharge care and provided rehabilitation and patient care at home. the multidisciplinary team met on a regular basis to plan patient care. 2 Some limitations on blinding, allocation concealment and incomplete data outcome. 3 Heterogeneity: Chi2 = 13.15, df = 13 (P = 0.44); I2 =1% 4 up to four weeks post stroke 5 Some limitations on OIS, low rate of events and CI appreciable harm and benefit. 6 Heterogeneity: Chi2 = 11.77, df = 13 (P = 0.55); I2 =0.0% 7 Heterogeneity: Chi2 = 4.39, df = 8 (P = 0.82); I2 =0.0% 8 Heterogeneity: Chi2 = 1.81, df = 4 (P = 0.77); I2 =0.0% 9 Heterogeneity: Tau2 = 12.38; Chi2 = 33.77, df = 12 (P = 0.00073); I2 =64% 10 Heterogeneity: Chi2 = 3.00, df = 6 (P = 0.81); I2 =0.0%

60 DONDE INICIAR LA REHABILITACIÓN FÍSICA La estrategia de alta temprana con rehabilitación en casa, se asoció con una menor frecuencia de mortalidad o dependencia OR 0.80 (IC 95% 0.67 a 0.97), con una mayor satisfacción de los pacientes con el cuidado recibido OR 1.60 (IC 95% 1.08 a 2.38) y con una menor estancia hospitalaria (DM -7.10 días,IC 95% -10.03 a -4.17). La estrategia de alta temprana no modificó la mortalidad al término del seguimiento OR 0.91 (IC 95% 0.67 a 1.25), o la frecuencia de reingresos posterior al alta OR 1.26 (IC 95% 0.94 a 1.67) o el desempeño en las actividades de la vida diaria (DME 0.03 IC 95% -0.08 a 0.15).

61 Recomendación: Fuerte o Débil? RecomendaciónResumen Se recomienda la rehabilitación temprana en casa para el tratamiento de los pacientes con ataque cerebrovascular isquémico de origen arterial en etapa aguda para disminuir la muerte o dependencia, incrementar la satisfacción en los pacientes y asociarse con una menor estancia hospitalaria. FUERTE A FAVOR Calidad de la Evidencia Moderada  

62 TIPO DE REHABILITACION FÍSICA Se analizaron los riesgos y beneficios de diferentes intervenciones tales como el entrenamiento en tareas funcionales, la terapia neurofisiológica y musculo esquelética, el entrenamiento en tareas repetitivas y la estimulación transcraneal con corriente directa. La revisión incluyó 96 ensayos clínicos aleatorios para un total de 10401 participantes con un seguimiento promedio a 30 días y en donde se evaluó la independencia en las actividades de la vida diaria al momento del alta (Barthel ADL, escala de Rankin modificada, índice de Katz), la función motora al egreso (evaluación de Fugl-Meyer o índice de movilidad de Rivermead Mobility), la velocidad durante la marcha, la función de las extremidades superior e inferior, la calidad de vida (perfil de salud de Nottingham o SF-36 o Dartmouth Cooperative Chart), la frecuencia de eventos adversos (caídas) y la estancia hospitalaria en días.

63 TIPO DE REHABILITACION FÍSICA Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other considerations Includes functional task training Does not includes Relative (95% CI) Absolute Independence in activities of daily living at the time of discharge (follow-up mean 30 days; measured with: Barthel Activities of Daily Living Index or Functional Independence Measure or Modified Rankin Scale, Katz Index of of Daily Living and Rehabilitation Activities Profile; range of scores: -100-100; Better indicated by higher values) 4 randomised trials serious 1 no serious inconsistency serious 2 very serious 3 none0-- SMD 0.03 lower (0.37 lower to 0.32 higher) ÅÅOO LOW CRITICAL Motor function at the time of discharge (follow-up mean 30 days; measured with: Motor Assessment scale or Fugl-Meyer Assessment or Rivermead Mobility Index or Rivermead Motor Assessment ; range of scores: -100-100; Better indicated by higher values) 3 randomised trials serious 1 serious 4 serious 2 very serious 3 none0-- SMD 0.16 lower (0.59 lower to 0.28 higher) ÅÅOO LOW CRITICAL Gait velocity at the time of discharge (follow-up mean 30 days; measured with: velocity; range of scores: -100-100; Better indicated by higher values) 3randomised trials serious 1 serious 4 serious 2 very serious 3 none0--SMD 0.43 lower (0.37 lower to 1.22 higher) ÅÅOO LOW CRITICAL Systematic review: Amstar 9/11 96 trials with a total of 10401 participants Date: 2014-09-22 Question: Should Includes functional task training vs does not includes be used for patients with clinical diagnosis of stroke (Ischemic or hemorrhagic) within 30 days of onset.? Settings: Any setting Bibliography: Pollock A, Baer G, Campbell P, Choo PL, Forster A,Morris J, Pomeroy VM, Langhorne P. Physical rehabilitation approaches for the following stroke. Cochrane Database of Systematic Reviews 2014, Issue 4. Art.No.: CD001920. DOI: 10. recovery of function and mobility 1002/14651858.CD001920.pub3 1 Some limitations on sequence generation, allocation concealment, blinding, selective reporting, incomplete data outcome and other risk of bias domains. 2 38 of the 99 studies, the time since stroke was 30 days or less 3 Not OIS, low rate of events. 4 Substantial heterogeneity (i.e >30%).

64 TIPO DE REHABILITACION FÍSICA Systematic review: Amstar 9/11 96 trials with a total of 10401 participants Date: 2014-09-22 Question: Should Includes neurophysiological vs dos not includes be used for patients with clinical diagnosis of stroke (Ischemic or hemorrhagic) within 30 days of onset.? Settings: Any setting Bibliography: Pollock A, Baer G, Campbell P, Choo PL, Forster A,Morris J, Pomeroy VM, Langhorne P. Physical rehabilitation approaches for the recovery of function and mobility following stroke. Cochrane Database of Systematic Reviews 2014, Issue 4. Art.No.: CD001920. DOI: 10.1002/14651858.CD001920.pub3. 1 Some limitations on sequence generation, allocation concealment, blindign, selective repoting, incomplete data outcome and other irsk of bias domains. 2 38 of the 99 studies, the time since stroke was 30 days or less 1 Some limitations on sequence generation, allocation concealment, blinding, selective reporting, incomplete data outcome and other irsk of bias domains. 2 38 of the 99 studies, the time since stroke was 30 days or less 3 Not OIS, low rate of events. 4 Substantial heterogeneity (i.e. > 30%) Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other considerations Includes neurophysiolo gical Dos not includes Relative (95% CI) Absolute Independence in activities of daily living at the time of discharge (follow-up mean 30 days; measured with: Barthel Activities of Daily Living Index or Functional Independence Measure or Modified Rankin Scale, Katz Index of of Daily Living and Rehabilitation Activities Profile; range of scores: -100-100; Better indicated by higher values) 7 randomised trials serious 1 no serious inconsistency serious 2 serious 3 none0-- SMD 0.02 lower (0.26 lower to 0.22 higher) ÅÅOO LOW CRITICAL Motor function at the time of discharge (follow-up mean 30 days; measured with: Motor Assessment scale or Fugl-Meyer Assessment or Rivermead Mobility Index or Rivermead Motor Assessment ; range of scores: -100-100; Better indicated by higher values) 8 randomised trials serious 1 no serious inconsistency serious 2 very serious 3 none0-- SMD 0.17 higher (0.05 lower to 0.39 higher) ÅÅOO LOW CRITICAL Gait velocity at the time of discharge (follow-up mean 30 days; measured with: velocity; range of scores: -100-100; Better indicated by higher values) 7 randomised trials serious 1 serious 4 serious 2 very serious 3 none0-- SMD 0.12 lower (0.95 lower to 0.7 higher) ÅÅOO LOW CRITICAL Length of stay at the time of discharge (follow-up mean 30 days; measured with: days; range of scores: 0-100; Better indicated by lower values) 3randomised trials serious 1 serious 4 serious 2 very serious 3 none0--MD 11.36 higher (1.52 to 21.19 higher) ÅÅOO LOW IMPORTANT

65 TIPO DE REHABILITACION FÍSICA Comparado frente a su exclusión, el uso del entrenamiento en tareas funcionales no incrementó los índices de independencia en las actividades de la vida diaria (DME - 0.03; IC 95% -0.37 a 0.32), la función motora al alta (DME - 0.16; IC 95% -0.59 a 0.28) o la velocidad durante la marcha (DME -0.43; IC 95% -0.37 a 1.22). Con respecto a la intervención neurofisiológica, no se asoció con una mejor independencia en las actividades de la vida diaria (DME -0.02; IC 95% -0.26 a 0.22), ni tampoco con una mayor función motora al egreso (DME 0.17; IC 95% -0.05 a 0.39) o con una mayor velocidad durante la marcha (DME - 0.12; IC 95% -0.95 a 0.7), pero incrementó la estancia hospitalaria (DM 11.36; IC 95% 1.52 a 21.19).

66 Recomendación: Fuerte o Débil? RecomendaciónResumen No se sugiere el entrenamiento en tareas funcionales como parte de la rehabilitación física para el tratamiento de los pacientes con ataque cerebrovascular isquémico de origen arterial en etapa aguda Calidad de la Evidencia Baja   No se sugiere el uso de intervenciones neurofisiológicas como parte de la rehabilitación física para el tratamiento de los pacientes con ataque cerebrovascular isquémico de origen arterial en etapa aguda Calidad de la Evidencia Baja  

67 TIPO DE REHABILITACION FÍSICA Systematic review: Amstar 9/11 96 trials with a total of 10401 participants Date: 2014-09-22 Question: Should Includes musculoskeletal vs does not includes be used for patients with clinical diagnosis of stroke (Ischemic or hemorrhagic) within 30 days of onset.? Settings: Any setting Bibliography: Pollock A, Baer G, Campbell P, Choo PL, Forster A,Morris J, Pomeroy VM, Langhorne P. Physical rehabilitation approaches for the recovery of function and mobility following stroke. Cochrane Database of Systematic Reviews 2014, Issue 4. Art.No.: CD001920. DOI: 10.1002/14651858.CD001920.pub3. 1 Some limitations on sequence generation, allocation concealment, blinding, selective reporting, incomplete data outcome and other risks of bias domains. 2 Substantial heterogeneity (i.e. >30%) 3 38 of the 99 studies, the time since stroke was 30 days or less 4 Not OIS, low rate of events. Quality assessmentNo of patientsEffect QualityImportance No of studies DesignRisk of biasInconsistencyIndirectnessImprecision Other consideration s Includes musculoskele tal Does not includes Relative (95% CI) Absolute Independence in activities of daily living at the time of discharge (follow-up mean 30 days; measured with: Barthel Activities of Daily Living Index or Functional Independence Measure or Modified Rankin Scale, Katz Index of of Daily Living and Rehabilitation Activities Profile; range of scores: -100-100; Better indicated by higher values) 3 randomised trials serious 1 no serious inconsistency 2 serious 3 very serious 4 none0-- SMD 0.12 lower (0.58 lower to 0.34 higher) ÅÅOO LOW CRITICAL Motor function at the time of discharge (follow-up mean 30 days; measured with: Motor Assessment scale or Fugl-Meyer Assessment or Rivermead Mobility Index or Rivermead Motor Assessment ; range of scores: -100-100; Better indicated by higher values) 4 randomised trials serious 1 no serious inconsistency serious 3 very serious 4 none0-- SMD 0.08 lower (0.53 lower to 0.36 higher) ÅÅOO LOW CRITICAL Gait velocity at the time of discharge (follow-up mean 30 days; measured with: velocity; range of scores: -100-100; Better indicated by higher values) 3 randomised trials serious 1 serious 2 serious 3 very serious 4 none0-- SMD 0.47 lower (1.67 lower to 0.74 higher) ÅÅOO LOW CRITICAL Length of stay at the time of discharge (follow-up mean 30 days; measured with: days; range of scores: 0-100; Better indicated by lower values) 2randomised trials serious 1 serious 2 serious 3 very serious 4 none0--MD 8.71 higher (12.92 lower to 30.34 higher) ÅÅOO LOW IMPORTANT

68 Terapia musculoesquelética Desenlaces: C uando se evaluó la efectividad y la seguridad de incluir el entrenamiento musculo esquelético, su uso no incrementó la independencia durante las actividades de la vida diaria (DME -0.12; IC 95% -0.58 a 0.34), los índices de función motora al alta (DME -0.08; IC 95% -0.53 a 0.36), la velocidad durante la marcha (DME -0.47; IC 95% -1.67 a 0.74) o la estancia hospitalaria (MD 8.71; IC 95% -12.92 a 30.34).

69 Recomendación: Fuerte o Débil? Se sugiere el uso de intervenciones musculo esqueléticas como parte de la rehabilitación física para el tratamiento de los pacientes con ataque cerebrovascular isquémico de origen arterial en etapa aguda Calidad de la Evidencia Baja   RecomendaciónResumen

70 TIPO DE REHABILITACION FÍSICA Systematic review: Amstar 9/11 4 trials with a total of 339 participants Date: 2014-09-27 Question: Should Repetitive task training vs compared against usual practice (including ’no treatment’), or an attention control group be used for patients with diagnosis of stroke within the first 14 days after stroke onset? 1 Settings: Any setting Bibliography: French B, Thomas LH, Leathley MJ, Sutton CJ, McAdam J, Forster A, Langhorne P, Price CIM, Walker A, Watkins CL, Connell L, Coupe J,McMahon N. Repetitive task training for improving functional ability after stroke. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD006073. DOI: 10.1002/14651858.CD006073.pub2. Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other considerations Repetitive task training Compared against usual practice (including ’no treatment’), or an attention control group Relative (95% CI) Absolute Upper limb function (follow-up mean 3 months; measured with: Arm function or Hand function or Sitting balance/reach scales.; range of scores: 0-100; Better indicated by higher values) 4 randomised trials serious 2 no serious inconsistency 3 no serious indirectness serious 4 none118121- SMD 0.21 higher (0.04 lower to 0.47 higher) ÅÅOO LOW CRITICAL Lower limb function (follow-up mean 3 months; measured with: Lower limb function or Standing balance/reach scales; range of scores: 0-100; Better indicated by higher values) 3randomised trials serious 2 no serious inconsistency 5 no serious indirectness very serious 4 none96101-SMD 0.24 higher (0.04 lower to 0.52 higher) ÅÅOO LOW CRITICAL

71 TIPO DE REHABILITACION FÍSICA 1 Intervention where an active motor sequencewas performed repetitivelywithin a single training session, and where the practice was aimed towards a clear functional goal. Functional goals could involve complex whole tasks, or pre-task movements for a whole limb or limb segment such as grasp, grip, or movement in a trajectory to facilitate an ADL-type activity. 2 Some limitations on blinding, incomplete data outcome and other risk of bias domains. 3 Heterogeneity: Chi2 = 1.87, df = 3 (P = 0.60); I2 =0.0% 4 Not OIS, low rate of events, CI appreciable damage or benefit. 5 Heterogeneity: Chi2 = 2.45, df = 2 (P = 0.29); I2 =18% 6 Heterogeneity: Chi2 = 0.02, df = 1 (P = 0.89); I2 =0.0% 7 Heterogeneity: Chi2 = 0.70, df = 2 (P = 0.71); I2 =0.0% 8 For this outcome some studies included population after 2 weeks stroke onset. Global motor function (follow-up mean 3 months; measured with: any global motor function scale; range of scores: 0-100; Better indicated by higher values) 2 randomised trials serious 2 no serious inconsistency 6 no serious indirectness very serious 4 none7167- SMD 0.32 higher (0.01 lower to 0.66 higher) ÅÅOO LOW CRITICAL Quality of life (follow-up mean 3 months; measured with: Nottingham Health Profile or SF36 or Dartmouth Cooperative Chart; range of scores: 0-100; Better indicated by higher values) 3 randomised trials serious 2 no serious inconsistency 7 serious 8 very serious 4 none7969- SMD 0.08 higher (0.24 lower to 0.41 higher) ÅÅOO LOW CRITICAL Adverse events (follow-up mean 3 months; assessed with: number of falls) 1 randomised trials serious 2 no serious inconsistency serious 8 very serious 4 none 3/25 (12%) 4/23 (17.4%) OR 0.65 (0.13 to 3.27) 54 fewer per 1000 (from 147 fewer to 234 more) ÅÅOO LOW CRITICAL 12% 39 fewer per 1000 (from 103 fewer to 188 more) 22% 65 fewer per 1000 (from 185 fewer to 260 more)

72 TIPO DE REHABILITACION FÍSICA Systematic review: Amstar 9/11 3 trials with a total of 146 participants Date: 2014-09-29 Question: Should Transcranial direct current stimulation (tDCS) vs placebo or control intervention be used for patients with diagnosis of stroke within the first 14 days after stroke onset? 1 Settings: Any setting Bibliography: Elsner B, Kugler J, Pohl M, Mehrholz J. Transcranial direct current stimulation (tDCS) for improving function and activities of daily living in patients after stroke. Cochrane Database of Systematic Reviews 2013, Issue 11. Art. No.: CD009645. DOI: 10.1002/14651858.CD009645.pub2. 1 Defined active tDCS as the longer-lasting (lasting longer than one minute) application of a direct current to the brain to stimulate the affected hemisphere 2 Some limitations on blinding, incomplete data outcome and save reporting domains. 3 Heterogeneity: Tau2 = 26.73; Chi2 = 3.39, df = 2 (P = 0.18); I2 =41% 4 Not OIS, low rate of events, CI appreciable damage or benefit. Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other considerations Transcranial direct current stimulation (tDCS) Placebo or control intervention Relative (95% CI) Absolute ADLs at the end of the intervention phase (follow-up mean 3 months; measured with: Frenchay Activities Index (FAI) or Barthel ADL Index (BI) or Rivermead ADL Assessment or Modified Rankin Scale (mRS) or Functional Independence Measure; range of scores: 0-100; Better indicated by higher values) 3randomised trials serious 2 serious 3 no serious indirectness very serious 4 none10244-SMD 5.23 higher (3.74 lower to 14.21 higher) ÅÅOO LOW CRITICAL

73 El entrenamiento en tareas repetitivas no se asoció con una mayor función de las extremidades superior e inferior, ni con la función motora global (DME 0.32; IC 95% -0.01 a 0.66) o con una mejor calidad de vida (DME 0.08; IC 95% -0.24 a 0.41) pero tampoco incrementó la frecuencia de eventos adversos derivados de la terapia OR 0.65 (IC 95% 0.13 a 3.27). Una revisión sistemática de la literatura que evaluó la efectividad de la estimulación transcraneal con corriente directa comparada con placebo o tratamiento habitual, no mejoró los niveles de independencia durante las actividades de la vida diaria (DME 5.23; IC 95% -3.74 a 14.21). TIPO DE REHABILITACION FÍSICA

74 MOVILIZACIÓN TEMPRANA V/S TARDIA Systematic review: Amstar 9/11 1 trials with a total of 71 participants Date: 2014-09-14 Question: Should Very early vs delayed mobilization be used for patients with definite clinical diagnosis of stroke within 7 to 14 days after onset? 1,2 Settings: Any setting Bibliography: Bernhardt J, Thuy MNT, Collier JM, Legg LA. Very early versus delayed mobilization after stroke. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD006187. DOI: 10.1002/14651858.CD006187.pub2. 1 within 48 hours of symptom onset 2 Very early mobilisation was defined as any intervention delivered with the aim of reducing the time from stroke onset to first mobilisation (first out of bed episode), and increasing the amount of out of bed physical activity (e.g. participation in activities of daily living (ADLs) such as walking to toilet, transferring on/off toilet, sitting out of bed, standing and walking). Any form of very early mobilisation was considered irrespective of the number and discipline of staff assisting; and dose or duration of intervention. Conventional care was defined as usual mobilisation practice. 3 Not OIs, low rate of events, CI appreciable damage or benefit. 4 including deep vein thrombosis (DVT), non fatal pulmonary embolism (PE), incidence and grade of pressure sores (using standardised grading scale), number of incontinent episodes over 24 hours, severity of incontinence, chest infection, falls and physiological variables (blood pressure, oxygen, temperature) recorded. 5 (experimental group 61, control group 76, P = 0.04). Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other considerations Very early Delayed mobilisation Relative (95% CI) Absolute Death or a poor outcome (follow-up 3 to 12 months; assessed with: death or remained dependent (Barthel score < 15 or equivalent and/or ormodified Rankin Score 3 to 6)) 1randomised trials no serious risk of bias no serious inconsistency no serious indirectness very serious 3 none 23/38 (60.5%) 23/33 (69.7%) OR 0.67 (0.25 to 1.79) 91 fewer per 1000 (from 332 fewer to 108 more) ÅÅOO LOW CRITICAL 60% 99 fewer per 1000 (from 327 fewer to 129 more) 78% 76 fewer per 1000 (from 310 fewer to 84 more) Death (follow-up mean 3 months; assessed with: number of deaths from any cause.) 1randomised trials no serious risk of bias no serious inconsistency no serious indirectness very serious 3 none 3/38 (7.9%) 3/33 (9.1%) OR 2.67 (0.64 to 11.03) 120 more per 1000 (from 31 fewer to 434 more) ÅÅOO LOW CRITICAL 6% 86 more per 1000 (from 21 fewer to 353 more) 12% 147 more per 1000 (from 40 fewer to 481 more) Potential adverse events (follow-up mean 3 months; assessed with: number and/or severity of adverse effects 4 ) 1randomised trials no serious risk of bias no serious inconsistency no serious indirectness very serious 3 none 15/38 (39.5%) 14/33 (42.4%) OR 1.42 (0.55 to 3.69) 87 more per 1000 (from 136 fewer to 307 more) ÅÅOO LOW CRITICAL 38% 85 more per 1000 (from 128 fewer to 313 more) 46% 87 more per 1000 (from 141 fewer to 299 more) Non-serious adverse events - not reported 5 1-----3-3 none61/0 (0%) 76/0 (0%) --ÅÅOO LOW CRITICAL

75 MOVILIZACIÓN TEMPRANA VS/TARDIA Movilización temprana (antes de 48 horas) frente a la movilización tardía. Se definió movilización temprana como las actividades realizadas fuera de la cama: caminar hasta el baño, transferencia para sentarse y levantarse del inodoro, sentarse fuera de la cama, ponerse de pie y caminar. Desenlaces: Mortalidad, la frecuencia de dependencia o pobre resultado y la frecuencia de eventos adversos (tromboembolismo pulmonar, trombosis venosa profunda, úlceras por presión, caídas e infección).

76 MOVILIZACIÓN TEMPRANA VS/TARDIA La revisión incluyó un ensayo clínico aleatorio para un total de 71 participantes con un seguimiento promedio a 90 días. Cuando se comparó frente al grupo control, la estrategia de movilización temprana no redujo la mortalidad OR 2.67 (IC 95% 0.64 a 11.03), la frecuencia de muerte o pobre resultado OR 0.67 (IC 95% 0.25 a 1.79) pero tampoco incrementó la frecuencia de eventos adversos derivados de la intervención OR 1.42 (IC 95% 0.55 a 3.69).

77 Recomendación: Fuerte o Débil? Recomendación Resumen Se sugiere la movilización temprana ( caminar hasta el baño, sentarse fuera de la cama, las transferencias para sentarse y levantarse del inodoro, ponerse de pie o caminar en las primeras 48 horas) de los pacientes con ataque cerebrovascular isquémico de origen arterial en etapa aguda Calidad de la Evidencia Baja  

78 Una revisión sistemática de la literatura puntaje AMSTAR 7/11 evaluó la seguridad y la efectividad de la terapia de movimiento inducida por restricción para el miembro parético. La revisión incluyó 5 ensayos clínicos aleatorios para un total de 106 participantes con un seguimiento a 90 días. Desenlaces: La deficiencia y la función del miembro superior (evaluación motora de Fugl–Meyer y la prueba de investigación de la acción del brazo (ARAT) respectivamente), el índice de destreza (prueba Grooved Pegboard) y la percepción de la función del miembro superior (evaluada por el registro de actividad motora y la escala de calidad de movimiento). REHABILITACIÓN FÍSICA DEL MIEMBRO SUPERIOR

79 REHABILITACIÓN FÍSICA DEL MIEMBRO SUPERIOR Systematic review: Amstar 7/11 5 trials with a total of 106 participants Date: 2014-09-22 Question: Should Constraint-induced movement therapy for the upper paretic limb be used for patients with acute or subacute diagnosis of stroke within the first 14 days after stroke onset? 1 Settings: Any setting Bibliography: Nijland R, Kwakkel G, Bakers J and van Wegen E. Constraint-induced movement therapy for the upper paretic limb in acute or sub-acute stroke: a systematic review. World Stroke Organization Vol 6, October 2011, 425–433. Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other considerations Constraint- induced movement therapy for the upper paretic limb Control Relative (95% CI) Absolute Upper limb impairment (follow-up 0 to 90 days; measured with: measured with the Fugl–Meyer motor assessment of the arm (FMA); range of scores: 0-100; Better indicated by higher values) 3 randomised trials serious 2 serious 3 no serious indirectness very serious 4 none1815- MD 11.0 higher (2.5 to 19.49 higher) 5 ÅÅOO LOW CRITICAL Upper limb function (follow-up 0 to 90 days; measured with: measured with the Action Research Arm Test (ARAT); range of scores: 0-100; Better indicated by higher values) 3randomised trials serious 2 serious 3 no serious indirectness very serious 4 none5131-MD 7.88 higher (1.09 to 14.66 higher) 6 ÅÅOO LOW CRITICAL

80 REHABILITACIÓN FÍSICA DEL MIEMBRO SUPERIOR Dexterity (follow-up 0 to 90 days; measured with: measuredwith the Grooved Pegboard Test (GPT); range of scores: 0-100; Better indicated by higher values) 2 randomised trials serious 2 no serious inconsistency no serious indirectness very serious 4 none14 - MD 0.05 higher (0.02 to 0.09 higher) ÅÅOO LOW CRITICAL Perceived upper limb function (follow-up 0 to 90 days; measured with: measured with the Motor Activity Log (MAL) for Amount of Use (AOU) ; range of scores: 0-100; Better indicated by higher values) 3 randomised trials serious 2 serious 3 no serious indirectness very serious 4 none1920- MD 1.15 higher (0.33 lower to 2.62 higher) 7 ÅÅOO LOW CRITICAL Perceived upper limb function (follow-up 0 to 90 days; measured with: meassure with Quality of Movement (QOM); range of scores: 0-100; Better indicated by higher values) 3randomised trials serious 2 no serious inconsistency no serious indirectness very serious 4 none1920-MD 1.11 higher (0.81 to 1.41 higher) 8 ÅÅOO LOW CRITICAL 1 HI CIMTwas defined as three-hours or more of shaping therapy per day in combinationwith restraining of the less affected limb for 90% of waking hours, whereas LO CIMT was defined as less than three-hours of shaping therapy per day and constraining of the less affected limb for less than 90% of waking hours. 2 Methodological quality of the included trials, assessed with the 10-item PEDro scale. Some limitations on allocation concealment, blinding and other risk of bias domains. 3 Substantial heterogeneity. 4 Low rate of events, not OIS, CI appreciable damage or benefit. 5 The two studies that used High Intensity (HI) CIMTyielded a nonsignificant (MD: 9.36; 95% CI: -7.12 to 25.84). The study that used Low Intensity (LI) CIMT yielded a significant difference in favor of the experimental group (difference: 13.20; 95% CI: 6.52 – 19.88). 6 The study that used HI CIMT yielded a nonsignificant difference(difference: -2.27; 95% CI: -13.65 to 9.11). The three studies that used LOCIMT yielded a significant MD in favor of the experimental group (MD: 11.25; 95% CI: 6.49 – 16.01). 7 The two studies that used HI CIMTyielded a nonsignificant MD (MD: 0.36; 95% CI: -0.68 to 1.40). The study that used LO CIMT yielded a significant difference in favor of the experimental group (difference: 2.18; 95% CI: 1.82 – 2.54) 8 Pooling the two studies assessing QOM with a HI CIMT application resulted in a nonsignificant MD (MD: 0.30; 95% CI: -0.60 to 1.21). The study that used LO CIMT yielded a significant difference in favor of the experimental group (difference: 1.21; 95% CI: 0.89 – 1.53).

81 REHABILITACIÓN FÍSICA DEL MIEMBRO SUPERIOR Cuando se comparó la terapia de movimiento inducido con Restricción, frente al grupo control, los pacientes asignados a la intervención experimentaron una menor deficiencia y una mayor función de la extremidad superior (DM 11.0; IC 95% 2.5 a 19.49 y DM 7.88; IC 95% 1.09 a 14.66) junto con un mayor índice de destreza(DM 0.05; IC 95% 0.02 a 0.09). Se incremento la percepción de la función del miembro superior medido con la escala de calidad del movimiento (DM 1.11; IC 95% 0.81 a 1.41) más no cuando se evaluó con el uso de el registro de actividad motora (DM 1.15; IC 95% -0.33 a 2.62).

82 Recomendación: Fuerte o Débil? RecomendaciónResumen Se recomienda la terapia de movimiento inducido por restricción para el miembro parético como parte del tratamiento para los pacientes con ataque cerebro vascular isquémico agudo de origen arterial en etapa aguda para mejorar la función y la destreza de la extremidad superior Calidad de la Evidencia Baja  

83 Uso de dispositivos de soporte Systematic review: Amstar 8/11 4 trials with a total of 142 participants Date: 2014-09-22 Question: Should Supportive devices for preventing and treating subluxation of the shoulder vs no supportive device be used for patients with acute or subacute diagnosis of stroke within the first 14 days after stroke onset? 1 Settings: Any setting Bibliography: Ada L, Foongchomcheay A, Canning CG. Supportive devices for preventing and treating subluxation of the shoulder after stroke. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD003863. DOI: 10.1002/14651858.CD003863.pub2. Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other consideration s Supportive devices for preventing and treating subluxation of the shoulder No supportive device Relative (95% CI) Absolute Pain (follow-up mean 4 weeks; assessed with: number of participants with pain) 1 randomised trials serious 2 no serious inconsistency no serious indirectness very serious 3 none 6/7 (85.7%) 2/7 (28.6%) OR 8.7 (1.14 to 67.13) 491 more per 1000 (from 27 more to 678 more) ÅÅOO LOW CRITICAL 20% 485 more per 1000 (from 22 more to 744 more) 36% 470 more per 1000 (from 31 more to 614 more) Pain (number of pain free days after admission to study) (follow-up mean 2 weeks; measured with: days; range of scores: 0-100; Better indicated by lower values) 2randomised trials serious 2 no serious inconsistency 4 no serious indirectness very serious 3 none1316-MD 13.76 higher (9.7 to 17.8 higher) ÅÅOO LOW CRITICAL

84 Uso de dispositivos de soporte 1 slings (such as Bobath sling or triangular sling), wheelchair attachments (such as lap-trays or arm troughs), and external shoulder orthoses (such as strapping or the Functional ShoulderOrthosis). 2 the methodological quality of the included studies using the 11-item PEDro scale, which is based on : specification of eligibility criteria; random allocation to groups; concealed allocation; groups similar at baseline; blinding of participants, therapists and assessors; at least one outcome measurement obtained from more than 85% of participants initially allocated to groups; reporting of between-group statistical comparisons; reporting of point measures and measures of variability. 3 Not OIS, low rate of events, CI appreciable damage or benefit. 4 Heterogeneity: Chi2 = 1.39, df = 1 (P = 0.24); I2 =28% 5 Some limitations on sequence generation, allocation concealment and blinding. Increasing function (follow-up mean 2 weeks; measured with: summation of Items 6, 7, 8 of the Motor Assessment Scale (score 0-18) post intervention; range of scores: 0-100; Better indicated by higher values) 1 randomised trials serious 5 no serious inconsistency no serious indirectness very serious 3 none4142- MD 0.83 higher (1.46 lower to 3.12 higher) ÅÅOO LOW CRITICAL Increasing contracture (assessed with: number of participants who had more than 30 degrees loss of shoulder external rotation) 1 randomised trials serious 5 no serious inconsistency no serious indirectness very serious 3 none 2/7 (28.6%) OR 1.00 (0.11 to 9.34) 0 fewer per 1000 (from 244 fewer to 503 more) ÅÅOO LOW CRITICAL 20% 0 fewer per 1000 (from 173 fewer to 500 more) 36% 0 fewer per 1000 (from 302 fewer to 480 more)

85 Uso de dispositivos de soporte Una revisión sistemática de la literatura puntaje AMSTAR 8/11 en 4 ensayos clínicos aleatorios para un total de 106 participantes con un rango de seguimiento de 2 a 4 semanas, evaluó la seguridad y la efectividad del uso de dispositivos de soporte para prevenir y tratar la subluxación del hombro. Desenlaces: L a frecuencia de dolor (escala visual análoga), el número de días libres de dolor, el índice de funcionalidad (escala de evaluación motora) y la presencia de contracturas (más de 30º de pérdida en la rotación externa del hombro).

86 Cuando se comparó frente al grupo control, el uso de dispositivos de soporte se asoció con un menor número de días libres de dolor (DME 14; IC 95% 9.7 a 17.8) y con una mayor intensidad del dolor en la escala visual análoga OR 8.7 (IC 95% 1.14 a 67.13). El uso del dispositivo de soporte no mejoró los índices de funcionalidad(DM 0.8; IC 95% -1.46 a 3.12) ni redujo la frecuencia de contracturas OR 1.00 (IC 95% 0.11 a 9.34). Uso de dispositivos de soporte

87 Recomendación: Fuerte o Débil? No se sugiere el uso de dispositivos de soporte para prevenir o tratar la subluxación del hombro en pacientes con ataque cerebrovascular isquémico de origen arterial en etapa aguda Calidad de la Evidencia Baja   RecomendaciónResumen

88 HIGIENE ORAL Systematic review: Amstar 9/11 3 trials with a total of 470 participants Date: 2014-09-25 Question: Should Staff-led oral care interventions vs standard care for ensuring oral hygiene be used for patients with acute or subacute diagnosis of stroke within the first 14 days after stroke onset? 1 Settings: Any setting Bibliography: BradyMC, FurlanettoD,Hunter R, Lewis SC,Milne V. Staff-led interventions for improving oral hygiene in patients following stroke. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD003864. DOI: 10.1002/14651858.CD003864.pub2. Quality assessmentNo of patientsEffect QualityImportance No of studiesDesignRisk of biasInconsistencyIndirectnessImprecision Other considerations Staff-led oral care interventions Standard care for ensuring oral hygiene Relative (95% CI) Absolute Pneumonia (follow-up mean 30 days; assessed with: Not mentioned) 1randomised trialsserious 2 no serious inconsistency no serious indirectness very serious 3 none 1/103 (0.97%) 7/100 (7%) OR 0.20 (0.05 to 0.84) 55 fewer per 1000 (from 11 fewer to 66 fewer) ÅÅOO LOW CRITICAL 2% 16 fewer per 1000 (from 3 fewer to 19 fewer) 12% 93 fewer per 1000 (from 17 fewer to 113 fewer) Septicaemia (follow-up mean 30 days; assessed with: Septicaemia and/or respiratory tract infections during hospital stay) 1randomised trialsserious 2 no serious inconsistency no serious indirectness very serious 3 none 3/103 (2.9%) 3/100 (3%) OR 0.97 (0.19 to 4.91) 1 fewer per 1000 (from 24 fewer to 102 more) ÅÅOO LOW CRITICAL 1% 0 fewer per 1000 (from 8 fewer to 37 more) 5% 1 fewer per 1000 (from 40 fewer to 155 more) Acquired aerobic Gram-negative bacilli (follow-up mean 30 days; assessed with: Carriage of AGNB on two or more consecutive samples) 1randomised trialsserious 2 no serious inconsistency no serious indirectness very serious 3 none 14/103 (13.6%) 23/100 (23%) OR 0.53 (0.26 to 1.09) 93 fewer per 1000 (from 158 fewer to 16 more) ÅÅOO LOW CRITICAL 20% 83 fewer per 1000 (from 139 fewer to 14 more) 26% 103 fewer per 1000 (from 176 fewer to 17 more) 1 Assessment tool. Equipment (for example, toothbrush). Agent (for example, mouthwash). Staff training. Oral hygiene promotion. 2 Some limitations on incomplete data outcome 3 Not OIS, low rate of events, CI appreciable damage or benefit.

89 HIGIENE ORAL Una revisión sistemática de la literatura puntaje AMSTAR 9/11 evaluó la seguridad y la efectividad de las intervenciones en higiene incluyo 3 ensayos clínicos aleatorios para un total de 470 participantes con un seguimiento a 30 días. La intervención consistió en el uso de cepillo de dientes, enjuague bucal y el entrenamiento del equipo en promoción y cuidado de la higiene oral. Desenlaces: Fueron la frecuencia de neumonía, septicemia y el aislamiento de bacilos gram negativos aerobios.

90 HIGIENE ORAL Cuando se comparó frente a la terapia convencional, el uso de intervenciones en higiene oral se asoció con una menor frecuencia de neumonía OR 0.20 (IC 95% 0.05 a 0.84), pero no de septicemia OR 0.97 (IC 95% 0.19 a 4.91) o de aislamiento positivo de bacilos gram negativos aerobios OR 0.53 (IC 95% 0.26 a 1.09).

91 Recomendación: Fuerte o Débil? RecomendaciónResumen Se recomienda el uso de intervenciones de cuidado oral para el tratamiento de los pacientes con ataque cerebrovascular isquémico de origen arterial en etapa aguda para disminuir la frecuencia de neumonía. Calidad de la Evidencia Baja  

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