Stroke rehabilitation begins soon after the initial stroke event; once the patient is medically stable and can identify goals for rehabilitation and recovery. It can be offered in a range of settings, including acute and post-acute care, inpatient rehabilitation units, outpatient and ambulatory care clinics, community clinics, programs and recreation centers, early supported discharge (ESD) services, and outreach teams. Specially trained rehabilitation team members (e.g., physicians, physiotherapists, occupational therapists, speech-language therapists, and nurses) assist individuals in recovering from their post stroke deficits using a variety of rehabilitation interventions.3 The length of stay and services required depend on the individual and their needs, as well as the resources available within the particular setting. Although most rehabilitation and recovery occurs within the first three months after stroke onset, stroke recovery can occur over a more extended period of time, with some patients continuing to make new gains many months and even years later. Timely initiation of rehabilitation can help improve patient outcomes and allow individuals to continue to live, work and engage in their community.
Reports on stroke rehabilitation in Canada have shown that there is variability in the provision of services in terms of type of therapy, timing, and intensity.1 In Canada, stroke patients arrive to inpatient rehabilitation in a median of 12 days from stroke onset (IQR 7–25 days), with a median total admission Functional Independence Measure® (FIM®)4 score of 74 points (IQR 56–91 points). The median length of stay for inpatient rehabilitation is 31 days, with patients gaining a median of 21 points (IQR 11–33 points gained) on the FIM®, resulting in a gain of 0.67 points per day (IQR 0.33–1.13) of inpatient rehabilitation. Almost 90% of patients are discharged having met their rehabilitation goals, and 71% return directly home. There have been reports in the literature indicating that individuals with severe stroke may have limited access to rehabilitation. In Canada, examination of administrative data found that almost half of all stroke patients admitted to inpatient rehabilitation had moderate functional deficits, just over a third showed severe deficits and the remainder experienced milder degrees of deficits.
The field of research in stroke rehabilitation is very active and new evidence continues to emerge, at a rate more rapid than many other areas of stroke care. A recent study examining all randomized controlled trials published in stroke rehabilitation during 1970–2012 reported that approximately 35% had been published between 2008 and 2012.5 Moreover, interventions that aimed to improve motor outcomes accounted for nearly 60% of the total number of studies. The findings reflect the high prevalence of these issues post stroke and reflect the priority patients place on mobility and use of their upper extremities. The most current evidence supporting many stroke rehabilitation interventions and therapies have been considered for this guideline update.
This is the fifth update of the Canadian Stroke Best Practice Recommendations (CSBPR). They have been developed to provide up-to-date evidenced-based guidance across the stroke continuum of care, including separate modules for Stroke Prevention;6 Hyperacute Stroke Care;7 Acute Inpatient Stroke Management;8 Stroke Rehabilitation; Mood, Cognition and Fatigue following Stroke;9 Transitions of Care following Stroke; and Telestroke.10 The updated stroke rehabilitation recommendations apply to stroke survivors of all ages and degrees of stroke severity, and address 12 areas: initial stroke rehabilitation assessment; stroke rehabilitation units; delivery of inpatient stroke rehabilitation; outpatient and community-based rehabilitation; management of the arm and hand following stroke; mobility, balance and lower limb management; dysphagia and malnutrition; visual-perceptual deficits; central pain; language and communication; life roles and activities; and, a new section on pediatric stroke rehabilitation. The CSBPR are targeted towards all health care professionals involved in the patient’s circle of care, namely the patient, family, informal caregiver(s), working closely with the interprofessional rehabilitation team at all points along the recovery continuum. It is anticipated that disseminating and promoting the implementation of these recommendations will help to increase clinician knowledge, streamline care, reduce practice variations, optimize efficiency and ultimately improve patient outcomes after stroke within Canada and globally.
This publication describes a summary of the methodology followed to develop these recommendations and the recommendations for each of the 12 sections identified above. Additional supporting information may be found on the CSBPR website (www.strokebestpractices.ca), including a comprehensive methodology manual, detailed rationales for the recommendations with supporting evidence, health systems implications, suggested performance measures, implementation resources (i.e., evaluation, outcome measures, decision tools and templates for standing orders), a summary of the evidence, and detailed evidence tables. Readers are encouraged to access the CSBPR website for this additional information.
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