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Initial Stroke Rehabilitation Assessment

2016 UPDATE
February, 2016

The Canadian Stroke Best Practice Recommendations for Stroke Rehabilitation, 5th Edition (2015) is published in the International Journal of Stroke (IJS) and available freely online. To access the specific recommendations for Initial Stroke Rehabilitation Assessment, and all other sections of the Stroke Rehabilitation recommendations, please click on this URL which will take you to the recommendations online in the IJS: http://journals.sagepub.com/doi/pdf/10.1177/1747493016643553

For the French version of these recommendations, open the appendix at this link :  http://wso.sagepub.com/content/suppl/2016/04/18/1747493016643553.DC1/Stroke_Rehabilitation_2015_IJS_Manuscript_FINAL_FRENCH.pdf

All other supporting information, including performance measures, implementation resources, evidence summaries and references, remain available through www.strokebestpractices.ca, and not through the IJS.  Please click on the appropriate sections on our website below for this additional content.

 

Rationale

The goal of the first interprofessional assessment a patient receives after admission for stroke is to identify impairments in physical, functional, cognitive, and communication functioning which will guide decisions on rehabilitation services and therapies required, and potential discharge needs. Early consultation with rehabilitation professionals enhances the process of discharge planning, whether patients are going to transition from acute care to specialized rehabilitation units or back to the community.

System Implications

To ensure patients receive timely stroke rehabilitation assessments, the acute care, rehabilitation,  and community organizations require:

  • An adequate complement of clinicians experienced in stroke and stroke rehabilitation.
  • A clear process referral of patients to rehabilitation professionals and programs after acute admission.
  • An interprofessional team that is resourced to provide prescribed levels of rehabilitation therapy.
  • A defined geographic area or unit where individuals with stroke are assured access to an experienced team.
  • Standardized, validated, and expert consensus-based screening assessment tools and training.
  • A process for timely referral to specialized stroke inpatient services in all centres (for example, electronic referral system and standardized assessment tools).
  • Access to a follow-up clinic for secondary stroke prevention to ensure assessment of mild stroke-related difficulties and referral to rehabilitation services and programs when deficits and issues are identified that is amenable to rehabilitation.
  • Development or expansion of stroke rehabilitation expertise in children’s hospitals and children’s treatment centres, as needed; and integration of stroke rehabilitation needs into school supports.
  • Mechanisms to periodically re-evaluate those patients with severe stroke who are admitted to nursing homes, continuing care, or other settings  to ensure that they have access to rehabilitation as appropriate, if the patient progresses sufficiently and has goals amenable to rehabilitation.
  • Coordination and development of strong partnerships in the community, and adequate resources to ensure access to comprehensive stroke rehabilitation. This is especially important in more rural and remote geographic locations where telehealth technologies should be optimized.
Performance Measures
  • Proportion of stroke patients with a rehabilitation assessment within 48 hours of hospital admission for acute stroke by at least one stroke rehabilitation specialist as appropriate to patient needs (core).
  • Median time from hospital admission for stroke to initial rehabilitation assessment for each of the rehabilitation disciplines (Target is within 48 hours of hospital admission).
  • Proportion of acute stroke patients discharged from acute care to inpatient rehabilitation (core).
  • Percentage of stroke patients discharged to the community who receive a referral for outpatient rehabilitation before discharge from acute and/or inpatient rehabilitation (either facility-based or community- based programs).
  • Median length of time between referral for outpatient rehabilitation and admission to a facility-based or community rehabilitation program.
  • Median length of time between referral for outpatient rehabilitation to commencement of therapy (Target is within 30 days).
  • Percentage of those patients with severe stroke reassessed for rehabilitation following initial assessment within one month, 3 months and six months of index stroke event.
  • Percentage of patients with severe stroke admitted to inpatient rehabilitation.
  • Percentage of Telehealth/Telestroke coverage to remote communities to support organized stroke care across the continuum, including providing rehabilitation assessments and therapies for stroke patients.

Measurement Notes

  • Referral information may be found through primary audit of inpatient charts (nurses’ notes, discharge summary notes, copies of referral forms) or through databases maintained by organizations that receive and process referrals. These community databases will vary in the amount of information included, and there may be challenges in accessing information contained in these databases.
  • Most home care organizations monitor when the first service started but cannot determine easily the onset of rehabilitation therapy.
  • For Performance Measure 3, when analyzing these data consider also looking at appropriateness of referral and location of facility.
  • Performance Measure 5, the timing being measured if from referral to acceptance into a program, and not specifically the start of therapy (Performance Measure 6 measures time to start of therapy).
  • For Performance Measure 7, this reassessment should be done at all transition points and ideally at least monthly thereafter.  This includes admission to complex care, long-term care or return to other community setting.  The denominator will be a challenge and should be clearly identified and applied consistently by all groups who adopt this measure (e.g., denominator could be all severe stroke patients admitted to a long term care facility).
Implementation Resources and Knowledge Transfer Tools

Health Care Provider Information

Health Care Provider Information

Patient Information

Summary of the Evidence

Evidence Table and Reference List

Complete stroke care delivery in the early days and weeks following an acute stroke has been shown to have a significant positive impact on stroke outcomes (Evans et al., 2002). Comprehensive assessments of a patient’s cognitive and functional status in the first few days following a stroke are essential to developing individualized plans of care and recovery. The World Health Organization’s International Classification of Functioning (ICF) model is commonly used by rehabilitation professionals to guide assessment and treatment of stroke patients in the acute and post-acute phases of care (World Health Organization, 2010). The ICF considers three perspectives: the body, the individual and societal perspectives. It also includes the two components of body function and structure and activity and participation, all within the context of one’s environment. Early rehabilitation assessments for stroke, as well as goal setting and treatment planning, should incorporate aspects of the ICF model during the short and long term recovery of stroke patients (Ustun et al., 2013; Miller et al., 2010).

Definition of functional assessment: Standardized or non-standardized method of evaluating a person’s ability to perform basic self-care activities (such as dressing, grooming, personal hygiene, feeding, functional mobility and communication) and instrumental activities of daily living (including meal preparation, home management, communication activities, financial management, shopping and community living skills). Ability to interact socially may also be a component of a functional assessment.

Benefits of early stroke rehabilitation assessment: A screening examination for rehabilitation should be performed by a person experienced in rehabilitation as soon as the patient's medical and neurological condition permits (Gresham et al., 1995). The screening examination should incorporate medical information, a neurological examination, use of a well-standardized disability instrument (e.g., activities of daily living), and a mental status-screening test. Asberg and Nydevik suggest that the optimal timing for stroke rehabilitation assessment is five to seven days post-stroke onset (Asberg and Nydevik, 1991), although recent trends have been towards completing this within 72 hours of stroke onset.

Threshold criteria for admission to a comprehensive rehabilitation program should include medical stability, the presence of a functional deficit, the ability to learn, and physical endurance to sit unsupported for at least one hour and to participate actively in rehabilitation (Gresham et al., 1995). Admission to an interprofessional program should be limited to patients who have more than one type of disability and who, therefore, require the services of two or more rehabilitation disciplines. Patients with a single disability can benefit from individual services, but generally, do not require an interprofessional program (Gresham et al., 1995).

Several studies have demonstrated the positive benefit of rehabilitation as soon as possible following stroke. Reviews by Cifu & Stewart (1999) and Ottenbacher & Jannell (1993) reported a positive correlation between early rehabilitation interventions and improved functional outcomes. However, it is not evident whether the relationship is causal. One prospective comparative trial by Paolucci et al. (2000) looked at the outcomes of stroke patients admitted to rehabilitation at differing times following stroke. They found that those stroke patients who received rehabilitation early did better functionally than those whose rehabilitation was delayed.

Interprofessional rehabilitation has also been demonstrated to be an integral component for optimal stroke recovery. Specialized nursing care promotes early recognition of complications and management of skin, bowel and bladder problems. Research suggests that physical therapy will promote better recovery through early mobilization of the patient and management of any lung problems caused by immobility. Occupational therapists focus on improving activities that are meaningful to the patient (self-care, productivity and leisure activities) by reducing stroke-related impairments. Assessment of patient’s discharge environment addresses suitability for discharge home, need for equipment and/or home modification for function and safety. Speech–language pathologists assess swallowing difficulties and provide swallowing therapy and compensatory techniques. The speech–language pathologist is also able to assess the degree of difficulty with communication, and initiate appropriate therapy. Augmentative or alternative communication devices may be introduced if necessary. Medical specialists in physical medicine and rehabilitation address complications such as pain, spasticity (increased resistance in the muscles), and bowel and bladder incontinence. Neuropsychology, social work and other allied health professionals may help with the cognitive and psychosocial sequelae of stroke (Consensus Panel on the Stroke Rehabilitation System to the Ministry of Health and Long-Term Care, 2007).

Ongoing assessment of patients is an important component of stroke care, and the initial severity of impairment has been consistently demonstrated to have a relationship with one’s ability to functionally recover (Ween et al. 1996). Interpretation of early rehabilitation assessments relies on the use of standardized assessment tools. In Canada, the FIM® Instrument is widely used within inpatient rehabilitation settings, with the AlphaFIM® Instrument becoming increasing predominant as an acute assessment tool (Oczkowski & Barreca, 1993); it serves to measure a patient’s functional status and track recovery over time (Lo et al. 2012). Ween et al. (1996) prospectively analyzed 536 consecutive stroke rehabilitation admissions to try and identify the influence of preselected factors on functional improvement and discharge destination. Nearly all patients with an admission FIM® above 80 went home following rehabilitation. It was recommended that patients with early functional independence measure (FIM®) scores greater than 80 (the mildly disabled) are best managed at home given appropriate supports are in place. Conversely, patients admitted to rehabilitation with a FIM® score of less than 40 almost always required long-term care in a nursing home facility. It was recommended that those with FIM® scores less than 40 (the more severely disabled) may be better suited to a slower paced or less intensive rehab facility, or a discharge decision should be postponed at the time of initial assessment and reassessed weekly. An admission score of 60 or more was associated with a larger FIM® improvement, but the absence of a committed caregiver at home increased the risk of nursing home discharge. Therefore, it was recommended that intensive rehabilitation units are most likely to be effective with moderately severe stroke patients with early FIM® scores between 40 and 80. These patients are generally able to participate fully, show substantial improvement during rehabilitation and have a high probability of discharge home (Alexander, 1994). A study by Lo et al. (2012) was able to demonstrate the usefulness of the AlphaFIM® Instrument, an abbreviation of the FIM® for use in acute care, as an assessment tool in predicting stroke rehabilitation outcomes in terms of functional ability to recover. The AlphaFIM® instrument was found to be significantly correlated with admission and discharge FIM® ratings at rehabilitation, but a weak correlation with FIM® gain and length of stay was reported as well as no association with FIM® efficiency.

A number of other factors have been demonstrated to correlate with the ability to make functional improvements following a stroke. Age had been shown have a strong relationship with functional recovery in a number of individual studies and systematic reviews (Ween et al., 1996; Hakkennes et al., 2011; Ones et al., 2009; Van Bragt et al. 2014; Ng et al. 2013). Other factors such as stroke type and location (Ween et al., 1996; Hakkennes et al., 2011; Ng et al. 2013), stroke severity (Van Bragt et al. 2014; Abdul-Sattar & Godab 2013), the presence of comorbidities (Ween et al., 1996), level of cognitive function (Hakkennes et al., 2011; Ones et al., 2009; Toglia et al., 2011; Abdul-Sattar & Godab 2013), and the presence of aphasia and communication deficits (Gialanella, 2011) have also shown to affect functional recovery. The presence of depressive symptoms (Gillen et al., 2001; Abdul-Sattar & Godab 2013), obesity (Kalichman et al., 2007) and a lower functional score upon admission (Van Bragt et al. 2014; Abdul-Sattar & Godab 2013) may negatively impact the recovery process. These factors may all be considered when determining candidacy for both inpatient and outpatient stroke rehabilitation.