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Rehabilitation

Working Together with Stroke Survivors and their Caregivers to Achieve Optimal Outcomes is imperative within stroke rehabilitation and recovery, and applies to systems of care, healthcare providers, patients, families and caregivers, and the broader community. The primary underpinnings of ‘rehabilitation’ require these individuals and groups to work together to develop individualized treatment plans to optimize functional, cognitive and emotional recovery.

A critical concept within stroke rehabilitation is that ‘rehabilitation’ does not refer to a specific place or time where care is received. Rather, stroke rehabilitation is a goal-oriented set of therapies and activities as part of patient care post-stroke. Rehabilitation starts shortly after the stroke event occurs and continues as long as required for each individual to achieve their maximum potential recovery. Therefore, it crosses all ‘stages’ and ‘settings of care’ and a broad range of clinical experts, care providers and caregivers are included as active members of the rehabilitation ‘team’, along with the patient.

Achieving optimal outcomes in stroke rehabilitation and recovery at any age starts with early post stroke rehabilitation assessment, and the development of an individualized rehabilitation plan. The plans should incorporate patient goals, environmental factors (e.g., social supports, living arrangements), current functional, cognitive and emotional deficits, and potential for recovery. The plan clearly describes the types of therapies required based on the results of clinical assessments across all domains of rehabilitation. Throughout the rehabilitation and recovery process, the individualized plan is regularly reassessed and revised to reflect patient progress and evolving goals. These assessments happen through patient-provider interactions and are further discussed at regular meetings of the interprofessional care team.

Individualized rehabilitation plans need to be specific. Many patients with stroke will present with unique challenges such as expressive or receptive aphasia or some alteration of cognitive function. These challenges should not preclude participation in rehabilitation. In fact the individualized rehabilitation plans should clearly describe the methods and activities required to meet all rehabilitation needs using evidence-based approaches and tools validated for these subgroups. For example, including the use of specific assessment and outcome tools designed to evaluate areas such as mood or function in stroke patients with communication issues, and using supportive conversation approaches to assessments and treatment for patients with aphasia.

Working Together in stroke rehabilitation and recovery involves healthcare providers, policy makers, individuals with stroke, their families and caregivers, and the public. A critical component of stroke rehabilitation and recovery is access to specialized stroke services, ideally provided by dedicated stroke rehabilitation providers in acute care, inpatient rehabilitation and community settings.

Recent reports on the quality of stroke rehabilitation and recovery services across Canada and within provinces have shown considerable variation in access to services, availability of specific types of therapies, intensity and duration of therapy, and follow-up care after an inpatient rehabilitation stay [HSF Stroke Report 2014; EBRSR survey Meyer et al]. These reports also show limited access to rehabilitation for those with severe stroke. The disparity in access to rehabilitation is occurring in both urban areas where large volumes of patients post-stroke reside, and rural settings where there are fewer people post-stroke, and fewer rehabilitation professionals available who have stroke expertise.

Updates and Changes in Stroke Rehabilitation 2015 Update

The 2015 update of the Canadian Stroke Best Practice Recommendations Stroke Rehabilitation module reinforces the growing and changing body of research evidence available to guide assessment, diagnosis and management of stroke related impairments in the days, weeks and months following a stroke.

Highlights of the moderate and significant updates as well as new additions to the Stroke Rehabilitation module recommendations for 2015 include:

  • Many recommendations have been revised to higher levels of evidence as the evidence is strong and compelling and continues to emerge at a rapid pace.
  • The recommendations continue to evolve to become more specific to guide clinicians in tailoring their treatment to the individual based on time post stroke, severity of impairment and their goals.
  • Emphasis that rehabilitation and recovery after stroke is a dynamic and ongoing process that occurs in all settings and over time (days, weeks, months, years).
  • The recommendation sections are grouped into two parts: the first addressing organization of stroke rehabilitation within a system of care; the second part addressing specific functional areas of stroke recovery and direct clinical care.
  • Some previous recommendation sections have been combined together for comprehensiveness, as seen in the lower limb topic in Section 6. The new sections of rehabilitation recommendations provide guidance for providers to ensure a holistic approach to the rehabilitation of the person with stroke by addressing their physical, functional, cognitive and emotional status to help them return to their normal life roles.
  • Advocacy in system implications for system funders to commit to improving the stroke rehabilitation system. Analyses suggest that investing in effective and efficient rehabilitation services could actually reduce costs of taking care of stroke patients.
  • Family members and informal caregivers play a key role in post-stroke rehabilitation and recovery.
  • Development of specific recommendations for paediatric stroke rehabilitation that reflects emerging research findings. These are grouped together in a new section (Section 12) of these recommendations.

Guideline Development Methodology:

The detailed methodology and explanations for each of the steps in the development and dissemination of the Canadian Stroke Best Practice Recommendations is available in the Canadian Stroke Best Practice Recommendations Overview and Methodology manual available on the Canadian stroke best practices website at http://www.strokebestpractices.ca/wp-content/uploads/2014/08/CSBPR2014_Overview_Methodology_ENG.pdf

Citing the Stroke Rehabilitation 2015 Module

Hebert D, Teasell R, on behalf of the Stroke Rehabilitation Writing Group. Stroke Rehabilitation Module 2015. In Lindsay MP, Gubitz G, Bayley M, and Smith EE (Editors) on behalf of the Canadian Stroke Best Practices and Advisory Committee. Canadian Stroke Best Practice Recommendations, 2015; Ottawa, Ontario Canada: Heart and Stroke Foundation.

Comments

We invite comments, suggestions, and inquiries on the development and application of the Canadian Stroke Best Practice Recommendations.

Please forward comments to the Heart and Stroke Foundation’s Stroke Team at strokebestpractices@hsf.ca

Stroke Rehabilitation module contents

Part A: Organization of a Stoke Rehabilitation System for Optimal Service Delivery

1.0   Initial Stroke Rehabilitation Assessment

2.0   Stroke Rehabilitation Unit Care

3.0   Delivery of Inpatient Stroke Rehabilitation

4.0   Outpatient & Community Based Stroke Rehabilitation

Part B: Providing Stroke Rehabilitation to Address Physical, Functional, Cognitive and Emotional Issues to Maximize Participation in Usual Life Roles

5.1   Management of the Upper Extremity Following Stroke

5.2   Range of Motion and Spasticity in the Shoulder, Arm and Hand

5.3   Management of Shoulder Pain and Complex Regional Pain Syndrome Following Stroke

6.1   Mobility, Balance and Transfers

6.2   Lower Limb Spasticity Following Stroke

6.3   Falls Prevention and Management

7.0   Assessment and Management of Dysphagia and Malnutrition following Stroke

8.0   Rehabilitation of Visual Perceptual Deficits

9.0   Rehabilitation to Improve Central Pain

10.0 Rehabilitation to Improve Language and Communication

11.0 Resumption of Life Roles and Activities following Stroke

12.0 Pediatric Stroke Rehabilitation