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NEW Optimizing Activity and Community Participation following Stroke
NEW Optimizing Activity and Community Participation following Stroke

4. Health Management, and Return to Driving and Vocational Roles

Recommendations and/or Clinical Considerations
Recommendation 4.0

4.0 Individuals with stroke, their families, and caregivers should be provided with information, education, training, support and access to services throughout transitions to the community to optimize the return to life roles, activities and social participation [Strong recommendation; Moderate quality of evidence].  

4.1 Health Management Following Stroke
  1. Individuals living in the community following stroke should have access to regular and ongoing healthcare follow-up appropriate to their individual needs, which may address evaluating progress of recovery, preventing deterioration, maximizing functional and psychosocial outcomes, preventing stroke recurrence, and improving quality of life [Strong Recommendation; Moderate Quality of evidence].  
    1. Initial review with primary care providers would ideally occur within the first month following hospital discharge and address the key secondary prevention, medical and functional issues, and provide ongoing follow-up as required [Strong recommendation; Low quality of evidence]. Refer to CSBPR Secondary Prevention of Stroke module 85 for additional information and the post-stroke checklist.
  2. Individuals presenting with stroke or TIA should be screened for any changes in cognition following stroke or TIA compared to their pre-stroke cognitive status. [Strong recommendation; Moderate quality of evidence]. Note, changes can be reported by the individual, family members, caregivers or clinicians. Refer to CSBPR Vascular Cognitive Impairment module 67 Appendix Three for more information on the presenting signs and symptoms of VCI.
  3. Individuals presenting with stroke or TIA should be screened for any changes in mood and anxiety following stroke compared to their pre-stroke mental health status [Strong recommendation; Moderate quality of evidence].
  4. Secondary prevention of stroke should be optimally managed and risk factor reduction strategies optimized in all settings including long-term care [Strong recommendation; High quality of evidence]. Refer to CSBPR Secondary Prevention of Stroke module 85 for additional information.
  5. Referrals to appropriate specialists should be made to support and manage specific vascular risk factors and lifestyle behaviours and choices where required [Strong recommendation; Low quality of evidence]. Refer to CSBPR Secondary Prevention of Stroke module 85 for additional information.
4.2 Functional Health Management
  1. Individuals with stroke living in the community who experience a decline in functional status should receive targeted interventions, as appropriate [Strong recommendation; Moderate quality of evidence] even if the change occurs many months/years post-stroke. Refer to appropriate topics within this module for targeted interventions.
  2. Processes should be in place for individuals following a stroke to re-access rehabilitation or other supports and services as required based on changing needs during longer-term recovery [Strong recommendation; Moderate quality of evidence]. 
  3. Individuals with stroke should have access to evidence-based community exercise programs as appropriate [Strong recommendation; High quality of evidence]. 
4.3 Advance Care Planning
  1. The healthcare team should ensure that individual goals of care and advance care planning decisions are reviewed periodically (e.g., annually) with the individual with stroke, their family and caregivers as appropriate, and updated when needed, such as when there is a change in health status [Strong recommendation; Low quality of evidence]. Refer to CSBPR Stroke Systems of Care Module Section 8 for additional information. 
  2. Advance care planning may include a substitute decision-maker and should reflect provincial legislation [Strong recommendation; Low quality of evidence].
    1. Advance care planning discussions should be documented and reassessed regularly, including at transition points or when there is a change in health status, with the active care team and the individual with stroke or substitute decision-maker, and included on the transition (discharge) summary [Strong recommendation; Low quality of evidence].
  3. Respectful advance care planning should be integrated as part of a comprehensive care plan, taking into consideration values and preferences with information regarding the individual’s health status, understanding, prognosis, medically appropriate treatments and future medical care [Strong recommendation; Low quality of evidence].
4.4 Community-Based Palliative Care
  1. Referral and liaison with community-based hospice or palliative care services should be coordinated as appropriate based on the individual’s goals of care and condition [Strong recommendation; Low quality of evidence]. Refer to Stroke Systems of Care for additional information.
4.5 Driving following Stroke
4.5.1 Education and Screening
  1. Individuals should be advised to stop driving for at least one month after a stroke, in accordance with the Canadian Council of Motor Transport Administrators (CCMTA) Medical Standards for Drivers [Strong recommendation; Moderate quality of evidence].  
  2. The individual with stroke should be made aware whether the local licensing authority has been informed that they have had a change in their medical status that may negatively impact their ability to safely drive [Strong recommendation; Moderate quality of evidence].
  3. Individuals who have had one or multiple TIAs should be instructed to stop driving until a comprehensive neurological assessment is completed, and findings indicate no residual loss of functional ability and discloses no obvious risk of sudden recurrence that could create a hazard while driving, in accordance with the Canadian Council of Motor Transport Administrators (CCMTA) Medical Standards for Drivers [Strong recommendation; Moderate of evidence]. Refer to individual provincial and territorial laws for requirements for reporting an individual’s fitness to drive to driving authorities, and requirements to return to driving.
  4. Individuals with stroke may be screened for their interest in returning to driving at points of transitions and follow-up visits [Strong recommendation; Low quality of evidence].
4.5.2 Assessment for Fitness to Drive
  1. Individuals interested in returning to driving following stroke should be assessed for residual impairments, driving abilities and rehabilitation needs using valid and reliable methods in accordance with provincial/territorial criteria for return to driving [Strong recommendation; Moderate of evidence]. 
    1. Sensory-perceptual assessment should consider vision, visual fields, visual attention, and neglect [Strong recommendation; Moderate of evidence].
    2. Motor assessment should consider strength, range of motion, coordination and reaction time [Strong recommendation; Moderate of evidence].
    3. Cognitive assessment should consider problem solving, speed of decision making, attention, concentration, impulse control, judgment and reading/symbol comprehension [Strong recommendation; Moderate of evidence].
  2. For individuals who have residual neurological deficits impacting driving ability following stroke, a full comprehensive driving evaluation, including a government-sanctioned on-road assessment, should be considered to determine fitness to drive [Strong recommendation; Moderate quality of evidence].
4.5.3 Rehabilitation and Management for Return to Driving
  1. Following a stroke, individuals who have the functional potential and interest in returning to driving should be offered appropriate rehabilitation therapies as required to address functional, sensory-perceptual, motor and cognitive issues and increase the likelihood of being able to return to driving [Strong recommendation; Moderate quality of evidence].
  2. Individuals with stroke who have the functional potential and interest in return to driving may be referred to validated training programs to help prepare for return to driving [Strong recommendation; Moderate quality of evidence]. 
  3. Individuals with stroke unable to return to driving should be informed about and assisted to access transportation alternatives [Strong recommendation; Low quality of evidence]. 
  4. Individuals with stroke unable to return to driving should be offered support and/or counselling on coping with the loss of the ability to drive [Strong recommendation; Low quality of evidence].
4.6 Vocational Roles
  1. Following a stroke, an individual should be screened for vocational roles and interests, including both paid and unpaid work such as employment, school or volunteering [Strong recommendation; Low quality of evidence].
    1. This screening should take place early in the rehabilitation phase and be reassessed at points of transitions as appropriate [Strong recommendation; Low quality of evidence]. 
    2. Findings should be considered in planning for early and ongoing rehabilitation and included in individualized goal setting when appropriate [Strong recommendation; Low quality of evidence]. 
  2. A detailed cognitive and perceptual assessment with appropriate healthcare professionals should be considered to assist with determining the individual’s ability to meet the needs of their current or potential employment requirements and contribute to vocational planning [Strong recommendation; Low quality of evidence]. 
  3. Individuals with stroke should be encouraged to resume their vocational interests where possible and desired. A gradual resumption could occur when appropriate and adjustments made to accommodate any limitations or residual challenges (such as vision, communication) [Strong recommendation; Low quality of evidence].  
  4. Referrals to vocational or educational services, and/or counselling should be initiated and facilitated if an individual with stroke has a goal to return to work or school, to assist with the process of returning to vocational activities as part of transitions to the community [Strong recommendation; Low quality of evidence].  
    1. Individuals with stroke should be provided counselling and information about employment benefits and legal rights as required [Strong recommendation; Low quality of evidence].   
  5. Financial concerns and benefit options should be reviewed and revised, and assistance to create and implement a sustainable financial plan should be provided as needed, during admission and/or prior to discharge, and later in follow-up assessments and transitions [Strong recommendation; Low quality of evidence].   
  6. Individuals with stroke should be supported with return to work and education plans which may include engagement with employers/educators and recommendations on work modifications, accommodations and/or graduated return [Strong recommendation; Low quality of evidence].
Rationale +-

The post-discharge period is consistently reported by individuals with stroke and their families as a stressful and challenging time as they adjust to new roles and potentially altered functional and cognitive abilities. Participation in work and driving after a stroke are essential for promoting independence, improving quality of life, and enhancing overall well-being. Evidence shows that when there is coordination of care beyond the inpatient setting and community support services are provided, outcomes and satisfaction improve. Return-to-work programs tailored to the individual's abilities not only help rebuild confidence but also restore a sense of purpose and financial security. Additionally, regaining the ability to drive can significantly increase a sense of independence, allowing for greater social interaction and community participation as well as the practical aspects of being able to get to appointments and other activities. 

Individuals with stroke and their families have expressed how a follow-up visit and or other planned check-ins after returning home would be beneficial.  They describe a strong desire to regain control and independence, overcome difficulties with access to services and resources, and emphasize that health systems and services should be designed to support these positive outcomes. 

Individuals with stroke also advocated for increased access to individualized rehabilitation services and support. They highlight that the process to return to driving can be difficult and frustrating, and clear information on the process and criteria for return to driving following stroke, as well as information on who to contact for questions is especially valuable. They also stressed the importance of returning to driving when determined safe through working with the healthcare team, recognizing the impact driving can have on independence. 

It was important to individuals with stroke that conversations on educational and vocational roles and goals occur early following stroke. They discussed the significance of these goals, especially for younger individuals who experienced a stroke, and advocated for ongoing support once these roles are resumed. When return to previous vocational roles was not possible, participating in peer support programs or other volunteering activities may positively impact wellbeing and provided a sense of purpose.

Performance Measures +-

System Indicators

  1. Availability of inpatient and community-based assessment services and resources for individuals with stroke discharges from acute care and/or inpatient stroke rehabilitation. 
  2. Access to a primary care provider following discharge from hospital for an acute stroke.
  3. Number of individuals with stroke with documentation that information was given to them or their family on formal and informal educational programs, care after stroke, available services, process to access available services, and services. 
  4. Proportion of individuals with stroke who are discharged from acute care who receive health insurance.

Process Indicators

  1. Documentation of shared and collaborative decision-making between healthcare professionals and individuals with stroke regarding individualized transition plans.
  2. Proportion of individuals with stroke referred to secondary prevention services by the rehabilitation team upon discharge.
  3. Median number of visits to primary care within specified time frames for stroke-related issues following discharge from inpatient care.
  4. Median number of visits to an emergency department within specified time frames for stroke-related issues following discharge from inpatient care.
  5. Proportion of readmissions from stroke rehabilitation to acute care for stroke-related causes (e.g., medical complications, failure to thrive, decline in health status).
  6. Proportion of individuals with stroke who return home following stroke rehabilitation who require community health services (e.g., home care or respite care).
  7. Length of time from hospital discharge (whether from acute care or inpatient rehabilitation) to initiation of community health services.
  8. Frequency and duration of community health services, stratified by the type of service provided.
  9. Proportion of individuals with stroke who return to the community from acute hospital stay or following an inpatient rehabilitation stay who require admission to long-term care or a nursing home within six months or one year.
  10. Proportion of acute ischemic stroke clients admitted to acute or rehabilitation inpatient unit with diagnosis of atrial fibrillation on appropriate anticoagulant therapy at discharge (aligns with Accreditation Canada).
  11. Proportion of individuals with stroke who have been approached to participate in advance care planning and/or who have a documented conversation with a healthcare provider.
  12. Proportion of individuals with stroke who identify a substitute decision-maker.
  13. Proportion of individuals with stroke who complete a personal or advance care plan and have it documented on their chart.
  14. Proportion of individuals with stroke who had a referral to specialist palliative care services during inpatient care.
  15. Proportion of individuals with stroke who are dying following whose symptoms are routinely being assessed and monitored, and care plans adjusted as status changes.
  16. Proportion of dying individuals with stroke who were who are cared for under a palliative care approach.
  17. Proportion of individuals with stroke who die in the location specified in their palliative care plan.

Patient-Oriented Indicators   

  1. Proportion of individuals with stroke with an improvement in functional status from time of admission to inpatient rehabilitation unit to time of discharge based on a standardized measurement tool (aligns to Accreditation Canada).
  2. Measure of burden of care for family and caregivers living in the community.
  3. Proportion of individuals with stroke who report having their ongoing care needs reviewed with their primary care provider within 3 months of hospital discharge.
  4. Changes in quality of life measured at regular intervals during recovery and participation, and reassessed when changes in health status or other life events occur (e.g., at 60, 90- and 180-days following stroke). 
  5. Proportion of patients with stroke with advance care plans whose actual care was consistent with the care defined in their plan.
  6. Family and caregiver ratings on the palliative care experience following the death in hospital of a patient with stroke.
Implementation Resources and Knowledge Transfer Tools +-

Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices team or Heart & Stroke. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Health Care Provider Information

Resources for Individuals with Stroke, Families and Caregivers 

Summary of the Evidence +-

Evidence Table and Reference List 4a

Evidence Table and Reference List 4b

Functional Health Management

Functional health management is a holistic and proactive approach to maintaining and improving an individual’s ability to perform activities of daily living and to fully engage in social roles across the lifespan, particularly in the presence of chronic conditions, such as stroke and its related disability, or aging-related changes. Targeted interventions such as home-based rehabilitation 86 and exercise programs, 87,88 cardiorespiratory program or resistance training 89 can be helpful to promote independence, prevent decline, and enhance quality of life.

Community-based Palliative Care

No trials, specific to stroke have been published on the topic of palliative care. A Cochrane review 90 included the results from 4 RCTs (1,234 participants, mainly with a diagnosis of cancer) and evaluated the effectiveness of home-based end-of-life care compared to inpatient hospital or hospice care. At 6 to 24 months, individuals who received end-of-life care at home were significantly more likely to die at home (RR=1.33, 95% CI 1.14 to 1.55), aligning with many patients' preferences. However, home-based care was not associated with a significant reduction in unplanned hospital admission (RR=0.89, 95% CI 0.73 to 1.09). Pooled analyses were not conducted on any of the other outcomes (participant health outcomes, patient satisfaction, caregiver outcomes, health service resource use and cost), due to limited data availability. 

Advance Care Planning

Although no stroke-specific studies have been published that examine the effectiveness of advance care planning, several exist that include patients with mixed diagnoses, as well as those who are healthy. Malhotra et al. 91 included the results of 132 RCTs that examined the efficacy of ACP interventions in both healthy individuals and those with chronic diseases. Trials were conducted in a variety of settings, including hospitals, communities, primary care clinics, and nursing homes. While ACP interventions had limited impact on distal outcomes such as quality of life, mental health, and healthcare utilization, they consistently improved proximal outcomes, such as enhanced patient–physician communication, reduced decisional conflict, and increased alignment between patient and caregiver preferences. These findings suggest that ACP is more effective in facilitating meaningful conversations and shared understanding about end-of-life care rather than directly influencing clinical outcomes. Results from a small number of studies also suggest that interventions aimed at increasing advance care planning have been successful in significantly increasing the likelihood that end-of-life wishes are known and respected.  In a study of 309 patients admitted to internal medicine, cardiology, or respiratory medicine, Detering et al. 92 randomized patients to receive formal advance care planning from a trained facilitator or usual care. The intervention was based on the Respecting Patient Choices model, which involves reflection on goals, values, and beliefs, documentation of future health care wishes, and appointment of a surrogate decision maker. Of those who died, end-of life wishes were significantly more likely to be known and respected for participants in the intervention group compared with those in the control group (86% vs. 30%, p<0.01). Following the death of a loved one, family members of those in the intervention group reported significantly less anxiety and depression and more satisfaction with the quality of their relative’s death, compared to control group family members. Kirchhoff et al. 93 randomized 313 patients (and their surrogate decision makers) with congestive heart failure or end-stage renal disease who were expected to experience serious complication or death within 2 years, to receive a patient-centered advance care planning intervention or usual care. The intervention was composed of a 60 to 90-minute interview with a trained facilitator to discuss disease-specific end-of-life care issues and options and documentation of treatment preferences. 110 patients died within the study period, of which 26% required a surrogate decision maker at the end-of-life. Only a single patient in the intervention group and 3 in the control group received end-of-life care that was contrary to their wishes for reasons other than medical futility. With respect to resuscitation preferences, non-significantly fewer patients in the intervention group received care that was contrary to their wishes (1/62 vs. 6/48).

Return to Driving

Since driving was part of many individuals’ daily routine prior to stroke, returning to driving is often a high priority for individuals with stroke and their families; however, motor, sensory, and cognitive impairments and visual fields defects can limit an individual’s ability to drive safely. Beyond its use for completing everyday tasks and travelling to work, driving is often seen as a symbol of independence and freedom. For those who have suffered a minor stroke or TIA, temporary restrictions place on driving may be confusing and seem unwarranted. Independent predictors of successful return to driving following stroke include independence in activities of daily living and return to paid work. 94 Performance of cognitive measures such as the Trail Making Test and the Snellgrove Maze Test have been shown to predict fitness to drive. 95,96 In one recent study that included 359 participants, 26.7% returned to driving after one month. 94

Interventions to help individuals with stroke improve driving skills have not been well studied. A Cochrane review 97 included the results from 4 RCTs. The interventions examined included driving simulators (n=2) and skills development using the Dynavision device (n=1) and Useful Field of View training (n=1). No pooled analyses of the primary outcome, performance (pass/fail) during on-road assessment, were possible due to heterogeneity. Based on the results from a single trial, there was no significant difference in the mean on-road scores between groups at 6 months (MD =15.0, 95% CI -4.6 34.6, p=0.13), although participants in the intervention group had significantly higher scores on road sign recognition test (MD=1.69, 95% CI 0.51-2.87, p=0.0051).

Return to Work

Return to work (RTW) is one of the most important issues for the young individual with stroke. Following stroke, the reported rates of RTW vary widely. Using the results from 29 studies, Edwards et al. 98 reported that the overall frequency of return to either full or part-time work, assessed up to 12 years following stroke ranged from 7.3%1-74.5%. Up to 6 months following stroke, 41% of persons had returned to work, increasing to 66% at 4-6 years. Hackett et al. 99 reported that 75% of persons previously employed at the time of stroke had returned to work at one year. Hannerz et al. 100 reported that of 19,985 persons included in the Danish Occupational Hospitalization Register who were 20-57 years and had sustained a stroke, 62.1% were employed 2 years post stroke. At 4 years following stroke, Trygged et al. 101 reported that 4,867 (69%) of 7,081 Swedes who had been employed prior to stroke, aged 40-59 years had successfully returned to work. The most commonly-cited predictors of successful RTW included independence in ADLs, younger age, milder stroke severity higher cognitive functioning, fewer neurological deficits, strong family support, having realistic and flexible vocational goals, higher income and education, having a white-collar job and being male, 98,100,102,103 while hemorrhagic stroke, increasing age and stroke severity, and depression, have been citing as factors associated with a decreasing probability of RTW. 100,103

Interventions to help improve the odds of successful RTW have not been well studied. Ntsiea et al. 104 reported that a 6-week individualized workplace intervention program group was associated with an increase in the number of persons who had returned to work following a recent stroke (<8 weeks), compared with persons receiving usual care, at 6 months (60% vs. 20%, p<0.001). Baldwin & Brusco105 included the results from 6 studies, which examined rehabilitation programs that included vocational training post stroke. Vocational rehabilitation programs were defined as those that included medical, psychological, social, physical and/or occupational rehabilitation activities with the purpose to return to work. Following completion of the programs, the RTW rates varied among the studies from 12% to 49%. The pre-stroke vocation status was reported in 3 studies and ranged from 48% to 100%. Treatment with intravenous thrombolysis was also identified as a treatment that improved the odds of return to work.106

Sex & Gender Considerations

While there is limited research focused on sex differences in the areas or return to work or return to driving, the available evidence suggests that men may be more likely to retune to work and return to driving post stroke. In a recent systematic review including the results of 39 studies examining predictors of return-to-work post stroke, Orange et al. 107 reported that male sex was an independent predictor (OR=1.26, 95% CI 1.14-1.40). Using data from 1,354 participants from South Korea who had sustained a first-ever ischemic stroke, Jee et al. 108 conducted face-to-face interviews to identify predictors of return to driving within one year of stroke onset. Of the 640 pre-stroke drivers, 66.1% of participants (410) had returned to driving. In the regression model, male sex was an independent predictor of return to driving (OR=2.80, 95% CI 1.51–5.20). The generalizability of both of these estimates may be limited as they may vary between countries depending on culture and policies.

Stroke Resources
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