Definitions and descriptions
Stroke Rehabilitation is a progressive, dynamic, goal orientated process that addresses stroke-related impairments, activity limitations and participation restrictions to optimize individuals’ physical, cognitive, emotional, communicative, and social functional levels. In the chronic stage of stroke, rehabilitation may also focus on maintaining current functional abilities and preventing or slowing future functional decline and secondary health conditions (such as depression).
Rehabilitation is NOT a setting, rather, it is a process that includes a set of activities that begins soon after the initial event, once the individual with stroke is medically stable to participate and goals for rehabilitation, recovery and participation can be identified.
Rehabilitation occurs across the continuum of stroke care in a variety of formal and informal settings such as acute care or sub-acute care; rehabilitation units, on general or mixed rehabilitation units; palliative care units; in ambulatory or community settings, such as outpatient or day clinics, home-based services (includes early supported discharge and long-term care services), recreation centres, and outreach teams. Rehabilitation considers the individual’s goals of care, including integration of appropriate palliative care principles as part of the care continuum.
Palliative Rehabilitation is an integral part of this continuum by focusing on improving quality of life, helping to manage symptoms, maintain functional abilities and support independence (Refer to CSBPR Stroke Systems of Care, Section 9 Palliative Care)
Stroke Systems of Care are defined as a comprehensive, diverse and longitudinal system that addresses all aspects of stroke care within an integrated, organized and coordinated approach. A stroke system spans the continuum of care from primary prevention to end of life. A stroke system ensures access to evidence-based therapies which optimize their survival and recovery.
Integrated Stroke Systems consider all aspects of planning and delivering care, such as access, assessment, treatment, clinical evidence, data, outcomes, benchmarking, guidelines, planning, organization of services, funding, and education.
Spasticity Spasticity is manifested as velocity- and muscle length–dependent increase in resistance to externally imposed muscle stretch. It results from hyperexcitable descending excitatory brainstem pathways and from the resultant exaggerated stretch reflex responses. Other related motor impairments, including abnormal synergies, inappropriate muscle activation, and anomalous muscle coactivation, coexist with spasticity and share similar pathophysiological origins.6
Depression following stroke: There is a substantially increased prevalence of depression following stroke and has been reported in up to 24% of individuals. Within this module, we consider depression following stroke. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) category that applies is mood disorders due to another medical condition such as stroke with depressive features, major depressive-like episode, or mixed-mood features. It is often associated with large vessel infarction. 7
- An individual who is a candidate for this diagnosis would present with depressed mood or loss of interest or pleasure along with four other symptoms of depression (e.g., weight loss, insomnia, psychomotor agitation, fatigue, feelings of worthlessness, diminished concentration, suicidal ideation) lasting two or more weeks.
- Several mechanisms, including biological, behavioural, and social factors, are involved in its pathogenesis.
- Symptoms usually occur within the first three months after stroke (early onset depression following stroke); however, may occur at any time (late onset depression following stroke). Symptoms resemble those of depression triggered by other causes, although there are some differences - individuals with stroke with depression following stroke experience more sleep disturbances, vegetative symptoms, and social withdrawal.
Vascular Depression is a concept incorporating a broader range of depressive disorders. Vascular depression is related to small-vessel ischemia and people experiencing vascular depression may have white matter disease seen on brain imaging. Vascular depression also includes post-stroke depression as a sub-category. Individuals with stroke with vascular depression have later age of onset, greater cognitive impairment, less family and personal history of depression, and greater physical impairment than geriatric persons with nonvascular depression. They have been found to have different responses to treatment and different prognoses. In addition, persons with vascular depression with executive dysfunction and/or persons who show progression of white matter hyperintensities over time have a poor response to treatment with antidepressants and a more chronic and relapsing clinical course.8
Apathy is most commonly defined as a multidimensional syndrome of diminished goal-directed behavior, emotion, and cognition. 9,10 People present with loss of motivation, concern, interest, and emotional response, resulting in a loss of initiative, decreased interaction with their environment, and a reduced interest in social life. It can negatively impact recovery post-stroke. Apathy can occur as an independent syndrome, although it may also occur as a symptom of depression or dementia. 11,12 Apathy has been reported to occur in 29 – 40% of individuals with stroke.13
Anxiety following stroke is characterized by feelings of tension, extreme apprehension and worry, and physical manifestations, such as increased blood pressure. Anxiety disorders occur when symptoms become excessive or chronic. In the post-stroke literature, anxiety has been defined both by consideration of the presence and severity of symptoms using validated screening and assessment scales (such as the Hospital Anxiety and Depression Scale), or by defining syndromes using diagnostic criteria (e.g., panic disorders, general anxiety disorder, social phobia).
Pseudobulbar Affect following stroke is characterized by emotional lability – crying and/or laughing that is uncontrollable or exaggerated. The emotional expression is usually brief, lasting seconds to minutes, rather than hours. These emotional responses are incongruent with the underlying mood and are caused by the neurological condition/stroke, rather than depression. However, pseudobulbar affect can also occur with comorbid depression.14
Watchful waiting is defined as a period when the individual who has experienced a stroke displays mild depressive symptoms is monitored closely without additional therapeutic interventions to determine whether the mild depressive symptoms will improve. The timeframe for watchful waiting varies in the literature, typically between 2-4 weeks.
Sleep Health is a multidimensional pattern of sleep-wakefulness, adapted to individual, social, and environmental demands, that promotes physical and mental well-being. Good sleep health is characterized by subjective satisfaction, appropriate timing, adequate duration, high efficiency, and sustained alertness during waking hours. 15
Post-stroke Fatigue is a multidimensional motor-perceptive, emotional and cognitive experience characterized by a feeling of early exhaustion with weariness, lack of energy and aversion to effort that develops during physical or mental activity and is usually not ameliorated by rest. Fatigue can be classified as either objective or subjective. Objective fatigue is defined as the observable and measurable decrement in performance occurring with the repetition of a physical or mental task, while subjective fatigue is a feeling of early exhaustion, weariness and aversion to effort. 16-19
Characteristics of post-stroke fatigue may include overwhelming tiredness and lack of energy to perform daily activities; abnormal need for naps, rest, or extended sleep; more easily tired by daily activities than pre-stroke; unpredictable feelings of fatigue without apparent reason. Post-stroke fatigue can occur at varying stages of recovery, in both the early phase and on a longer-term basis.
Refer to CSBPR Rehabilitation, Recovery and Community Participation following Stroke Part One: Stroke Rehabilitation Planning for Optimal Care Delivery for additional definitions and descriptions.
Considerations Regarding Stroke Rehabilitation
Screening is a process for evaluating the possible presence of a particular problem. Screening is a purposeful action or query for early identification of individuals who may be at risk of developing a specific condition or disorder or problem. Screening may suggest that an issue may exist. Findings from screens can indicate the need for more comprehensive assessment. Screening is usually brief and used to identify possible concerns, not typically to diagnose. Healthcare providers may use preliminary screening measures to support clinical decision making.
Assessment is a process for defining and measuring the nature of a stroke-related health problem, informing a diagnosis, formulating a prognosis, and contributing to developing specific treatment recommendations for addressing the problem or diagnosis. Assessment may also include monitoring response to therapeutic intervention. The purpose of assessment is to gather more specific and detailed information to provide a comprehensive understanding of a potential issue. Assessments will include other information to help provide a broader context of results.
Note: Screening and assessment of individuals following stroke must take into consideration multiple factors. Ideally, both screening and assessment tools should be validated for their specific use and target population to provide the most accurate interpretation of results.
Settings: Settings for stroke rehabilitation care refers to the physical locations where rehabilitation care and services are delivered to, and received by, individuals who have experienced a stroke, their families and caregivers. Rehabilitation assessments and interventions, key components of comprehensive stroke care, are provided in a range of settings such as: acute inpatient care centres, sub-acute care settings; inpatient rehabilitation units: on stroke-specific, general or mixed rehabilitation units; in outpatient clinics, ambulatory or community settings, such as outpatient, day clinics and recreation centres; long-term care, complex care, and an individual’s home and place of residence (receiving services such as early supported discharge services and homecare rehabilitation or outreach teams). Care may be provided in person or virtually.
Duration: Length of service or stay for stroke rehabilitation varies depending upon factors such as the types of services required, accessibility of those services and the goals and needs of the individual with stroke, their families and caregivers. In some regions and local areas, the availability of staff and resources may impact duration, and all providers should strive to achieve guideline-directed therapy recommendations.
Timeframe: Stroke rehabilitation requirements often continue for many months and even years after an index stroke. Currently in Canada, publicly funded healthcare systems tend to allow for stroke rehabilitation within the first six months following stroke onset, even though many individuals with stroke will require some of these services beyond that arbitrary time frame. Rehabilitation is an ongoing process and rehabilitation needs and goals should be re-assessed periodically and plans updated as needed.
Stroke Rehabilitation Delivery: Stroke rehabilitation can be delivered in person or virtually, as both individual sessions and group activities. Decisions regarding mode of delivery of stroke rehabilitation therapies and interventions should be based on the individual with stroke’s personal factors, goals of the encounter, type of services to be provided, and the appropriateness and feasibility of each modality.
WHO International Classification of Functioning, Disability and Health 20
Impairment: Problems in body function or structure such as a significant deviation or loss
Activity limitation: Difficulties an individual may have in executing activities
Participation restrictions: Problems an individual may experience in involvement in life situations
