NEW Delivery Of Stroke Rehabilitation to Optimize Functional Recovery

Stroke is on the rise in Canada with over 108,000 strokes occur in Canada every year.² Stroke is a leading cause of adult disability, with 947,895 people 20 years of age and older estimated to be living with the effects of stroke in Canada.³ In Canada, one-third of individuals with stroke, usually with transient ischemic attack (TIA) and milder strokes, are discharged back to the community directly from the emergency department.⁴ Of those individuals admitted to acute inpatient care, 39% will be discharged to their homes without support services, and an additional 19% will be discharged to their home setting with some support service referrals, 15% will be transferred to an inpatient rehabilitation service, 8% will be transferred to long-term care or complex continuing care.⁵ For those who had access to inpatient rehabilitation, the median length of stay was 29 days, 74% were discharged home, with a median Functional Independence Measure [FIM] efficiency of 0.84 FIM points gained per day.⁵

Ultimately, most individuals who experience a stroke will return to the community, to live independently or with some degree of support. The complexity and needs of individuals living in the community following stroke and their families has been increasing with shorter lengths of hospital stay and longer waits for community services.  Several interdisciplinary team members and services are often required by individuals recovering from stroke. These individuals and their families have reported that coordination and integration of services are often major challenges as they try to navigate community healthcare services.  They report at times falling through the cracks and not being able to meet their rehabilitation goals as a result (Community Consultation and Review Panel 2024). In addition, social determinant factors such as socio-economic status, education, and geographic location can also pose additional barriers to accessing care.

The 7^th update of the Canadian Stroke Best Practice Recommendations (CSBPR) Rehabilitation, Recovery and Community Participation following Stroke module has been reorganized to better align with the International Classification of Functioning, Disability and Health (ICF) Framework.⁶ Further, due to the broad scope of topics covered in this module, this updated 7th edition has been divided into three parts: 

• Part One: Stroke Rehabilitation Planning for Optimal Care Delivery; 
• Part Two: Delivery of Stroke Rehabilitation to Optimize Functional Recovery;  
• Part Three: Optimizing Activity and Community Participation following Stroke, Update 2025. 

This module, Part Two: Delivery of Stroke Rehabilitation to Optimize Functional Recovery reflects the growing and changing body of research evidence available to guide direct rehabilitation therapies, screening, assessment, interventions, medical issues, and strategies for individuals who have experienced a stroke. Topics addressed in this module include therapy targeting upper and lower extremity function, aerobic function, balance, mobility and activities of daily living, spasticity, fall risk, communication, dysphagia, nutrition, central pain, visual and visual-perceptual issues, and bladder and bowel function. 

This module provides guidance in the delivery of coordinated and seamless systems of care that supports early access to rehabilitation therapies, build on progress achieved during the initial recovery stages, and enabling people to achieve as much independence as possible to optimize their ability to resume life roles and leisure activities (addressed in Part Three). The physical, emotional, psychological, social and environmental needs of individuals with stroke are considered throughout this set of CSBPR.  Successful planning, recovery, transitions and community participation following stroke requires integrated and coordinated people-centred efforts by all members of care teams involved with individuals who have had a stroke, their families and caregivers, and the broader community.

There is an urgent imperative for health systems of care to address the recovery needs of individuals with stroke, and ensure services and resources are in place and accessible to reduce complications and provide equitable opportunities for all individuals recovering from stroke to achieve optimal health outcomes. The physical, emotional, psychological, social and environmental needs of individuals with stroke are considered throughout this set of CSBP recommendations.  Considerations for equity in accessing and receiving needed services and facilitating linkages to resources must be addressed at all stages of recovery.  

• Reorganization of the Rehabilitation Module: The Stroke Rehabilitation, Recovery and Community Participation module has been divided into three parts, and the topics have been restructured to align with the International Classification of Functioning (ICF) framework for improved clarity and flow.
• Conversion to GRADE ratings: In moving to GRADE ratings, some consensus-based recommendations from the 6th Edition have now been moved to Clinical Considerations
• Increased Evidence: The evidence supporting multiple recommendations throughout this module was upgraded to a High Level of Evidence coupled with a Strong Recommendation. Examples include screening for swallowing impairment and referral to a trained dysphagia professional once an individual with stroke fails screening; and a trial of low-dose centrally acting analgesics for persistent Central Post-Stroke Pain. 
• New Outcomes Added: A Strong Recommendation and a High Level of Evidence was assigned to new outcomes of physical rehabilitation treatment approaches. For example, aquatic exercise is now considered effective for improving not only balance and also walking speed and mobility; and aerobic training is now considered effective for improving not only cardiovascular endurance and cognition, as well as balance and walking.
• New section (Section 10) on Bladder and Bowel Function has been added that includes recommendations for screening, assessment, and management.
• Expanded Inclusion of Healthcare Professionals: A broader scope of healthcare professionals have been engaged who have expertise to support the ongoing management of medical co-morbidities and other medical needs as part of inpatient and community rehabilitation programs.
• Utilization of validated tools: Further emphasis on the use of validated assessment tools across rehabilitation care, including recreation, leisure and social assessments.

Heart & Stroke gratefully acknowledges the Rehabilitation, Recovery and Community Participation following Stroke: Part Two: Delivery of Stroke Rehabilitation to Optimize Functional Recovery, writing group leaders and members, all of whom have volunteered their time and expertise to develop these new recommendations;  M. Patrice Lindsay RN, PhD for her expertise and efforts as senior writer and editor of these recommendations, module and manuscript; and the senior advisors Dr. Anita Mountain and Dr. Colleen O’Connell. Members of the Canadian Stroke Consortium, Can Stroke Recovery Trials Platform, Canadian Neurological Sciences Federation and the Evidence-based Review of Stroke Rehabilitation team were involved in the development of these recommendations. These recommendations (in whole or specific parts) underwent external review by Paula Barker, Joyce Chen, Jill Congram, Kenneth Curtis, Luciana de Olivera Nerves, Celina Ducroux, Hillel M Finestone, Margaret Grant, Mary Halpine, Anne Harris, Sylvie Houde, Zainab Al lawati, Dorothy Kessler, Jaylyn Leighton, Swati Mehta, Stuart Miller, Jennifer Milliken, Asha Shelton, Shamala Thilarajah, and Ankur Wadhwa.

We thank the Canadian Stroke Best Practices Committee members: Anita Mountain (Co-Chair), Dylan Blacquiere (Co-Chair), Eric E. Smith (Past Chair), Gord Gubitz, Dar Dowlatshahi, Margie Burns, Emma Ferguson, Thalia S. Field, Farrell Leibovitch, Christine Papoushek, Michael D Hill, Pascale Lavoie, Erin McHattie, Colleen O’Connell, Debbie Timpson, Theodore Wein, Manraj Heran, Katie Lin, Richard H Swartz, Adam Kirton, Ruth Whelan, Trish Helm-Neima, Kathleen McKeen, Shannon Bayluk, Janice Daitchman, and Katie White. System implications were reviewed by Mary-Lou Halabi, Leslie James, and Geoffrey Law. The performance measures were reviewed and updated by members of the Heart & Stroke health systems quality council including Patrice Lindsay, Debbie Timpson, Sacha Arsenault, Shannon MacDonald, Raed Joundi, Alison McDonald, Colleen O’Connell and Amy Yu. 

We acknowledge and thank Norine Foley and the evidence analysis team at workHORSE; Laurie Charest of Heart & Stroke for her coordination of the CSBPR teams and processes; and Francine Forget Marin and the Heart & Stroke internal teams who contributed to the development and publication of these recommendations (Translation, Communications, Knowledge Translation, Engagement, Health Policy, and Digital Solutions).

Community Consultation and Review Panel 

Heart & Stroke is especially grateful to the members of the Delivery of Stroke Rehabilitation to Optimize Functional Recovery Community Consultation and Review Panel who worked in tandem with the scientific writing group for this module and shared their personal experiences and insights on living with stroke and optimizing recovery and health outcomes. CCRP members include Allan Beaver, Suzanne Belanger, Suzanne Cady, Sheila Farrell, Katie Fung, Margie Hesom, Elizabeth Pease, Wes Reinhardt, and Kara Patterson (writing group liaison).

Nancy M. Salbach (First Author, Co-Chair), Jennifer K. Yao (Second Author, Co-Chair), M. Patrice Lindsay (Corresponding Author, Senior Editor), Michelle L.A. Nelson, Jing Shi, Colleen O’Connell, Ruth Barclay, Diana Bastasi, Mark I. Boulos, Joy Boyce, Geneviève Claveau, Heather L. Flowers, Norine Foley, Urvashy Gopaul, Esther S. Kim, Alto Lo, Alison M. McDonald, Amanda McIntyre, Colleen O’Connor, Kara K. Patterson, Tricia Shoniker, Theodore Wein, Janice Wright, Brenda Yeates, Jeanne Yiu, Chelsy Martin, Rebecca Lund (Corresponding Author), Sarvenaz Mehrabi, Dylan Blacquiere, Debbie Timpson, Benjamin Ritsma, Ada Tang, Louis-Pierre Auger, Jenna Beaumont, Rebecca Bowes, Imane Samah Chibane, Sarah J. Courtice, Rhina Delgado, Melanie Dunlop, Kimia Ghavami, Teresa Guolla, Deborah Kean, Sandra MacFayden, Jasmine Masse, Phyllis Paterson, Elyse Shumway, Alda Tee, Clinton Y.H. Tsang, Stacey Turnbull, Katie White, Anita Mountain (Senior Author) , on behalf of the Canadian Stroke Best Practice Recommendations Advisory Committee, in collaboration with the Canadian Stroke Consortium, Can Stroke Recovery Trials Platform, and the Canadian Neurological Sciences Federation. Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery and Community Participation following Stroke. Part Two: Delivery of Stroke Rehabilitation to Optimize Functional Recovery, 7^th Edition, 2025; Toronto, Ontario, Canada: Heart and Stroke Foundation.

• Rehabilitation, Recovery and Community Participation Following Stroke Module- Part Two: Delivery of Stroke Rehabilitation to Optimize Functional Recovery guideline publication
• Writing Group Members and External Reviewers (Appendices One & Two)
• Delivery of Stroke Rehabilitation to Optimize Functional Recovery Definitions and Descriptions

1. Upper Extremity Function - General Principles and Therapies

• Evidence Table and Reference List 1

2. Shoulder Pain & Complex Regional Pain Syndrome (CRPS) following Stroke

• Evidence Table and Reference List 2

3. Range of Motion and Post-Stroke Spasticity

• Evidence Table and Reference List 3a
• Evidence Table and Reference List 3b

4. Lower Extremity, Balance, Mobility and Aerobic Training

• Evidence Table and Reference List 4

5. Falls Prevention and Management

• Evidence Table and Reference List 5

6. Swallowing (Dysphagia), Nutrition and Oral Care

• Evidence Table and Reference List 6a
• Evidence Table and Reference List 6b

7. Language and Communication

• Evidence Table and Reference List 7

8. Visual and Visual-Perceptual Impairment

• Evidence Table and Reference List 8

• Evidence Table and Reference List 9

10. Bladder and Bowel Function

• Evidence Table and Reference List 10

Appendix One: Rehabilitation, Recovery and Community Participation following Stroke Writing Group 2025

Appendix Two: Delivery of Stroke Rehabilitation to Optimize Functional Recovery External Reviewers 2025

Appendix Three: References