Stroke affects nearly 800 000 individuals annually in the United States. Approximately 75% of these are first-ever strokes, whereas the remaining 25% are recurrent strokes (1). Although stroke is often viewed as a disease of the elderly, it can occur at any age. Approximately 10% of all strokes occur in individuals aged 18 to 50 years (1). Currently, stroke is the fifth most common cause of death in the United States and is a leading cause of long-term disability (1). While younger patients may be more physically capable of recovering from stroke than older patients, poor functional outcomes are commonplace. Approximately 44% of individuals aged 18 to 50 years experience moderate disability after stroke, requiring at least some assistance with activities of daily living (ADLs) or mobility (modified Rankin Score >2) (2). In a group of patients with ischemic stroke who were deemed as having “mild” or “improving” deficits and, therefore, not candidates for recombinant tissue-type plasminogen activator therapy, only 28% were discharged to home, whereas 16% required admission to acute rehabilitation facilities and 11% were admitted to skilled nursing facilities (3).
Disability from stroke can present in myriad ways, depending on the affected area of the brain or spinal cord. The most common presentations are motor weakness and sensory disturbances; speech and swallowing impairments; vision loss; higher-level cognitive difficulties, such as neglect or aphasia; and mental health or personality changes. The early management of stroke in the form of medical, surgical, or rehabilitation interventions to reduce severity and prevent further complications is essential to help prevent potentially lifelong deficits (4, 5).
The Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) estimates that approximately 15 000 veterans are hospitalized for stroke-related diagnoses each year. In 2017, the number of new patients with stroke at the VA was 8125. The VHA Quality Enhancement Research Initiative estimated the cost associated with caring for patients with new strokes as $111 million for acute inpatient care, $75 million for postacute inpatient care, and $88 million for follow-up care for the first 6 months poststroke. Approximately 15% to 30% of stroke survivors are left with severe disability, whereas 40% experience moderate functional impairments (6). There are over 45 acute rehabilitation units in the VHA health care system today, but many veterans who are admitted to a VA medical center after surviving a stroke will find themselves in a facility that may not offer comprehensive, integrated, and coordinated stroke rehabilitation.
Stroke is more common in the older veteran population but does occur in active-duty, retiree, and other beneficiary populations served by the DoD. Comprehensive acute management of stroke can be delivered at military hospitals unless the patient meets criteria for transfer to the nearest certified stroke center. Currently, the DoD does not have certified stroke centers for the acute management of stroke and has limited inpatient rehabilitation beds. The DoD often partners with VA or civilian network providers when these services are needed. At some of the larger military hospitals, comprehensive outpatient stroke rehabilitation services may be available. Survivors of stroke who live outside of military medical center catchment areas can access community stroke resources through the TRICARE network. Although the acute management of stroke in veterans and service members is similar to management for their civilian counterparts, this patient population may differ due to the increased number of comorbid conditions that often occur in the VA population. In addition, veterans and service members often have access to more health care resources, including rehabilitation care services through community partnerships.
The American Heart Association/American Stroke Association (AHA/ASA) Guidelines for Adult Stroke Rehabilitation and Recovery, published in 2016, focused on acute care hospitalization through community reentry (7). The focus of the current guideline is to provide VA and DoD primary care providers with recommendations and tools for the rehabilitation management of patients with stroke, with a focus on an interdisciplinary team approach. The guideline also provides stroke specialist providers with guidelines for evidence-based practice. […]