NEW Stroke Rehabilitation Planning for Optimal Care Delivery

Stroke is on the rise in Canada with over 108,000 cases presenting to hospitals in 2017/18 in Canada.² Stroke is a leading cause of adult disability. In 2022/23, there were 969,095 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. 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 (National Ambulatory Care Reporting System [NACRS] and Discharge Abstract Database [DAD] data extracted for contributing sites, Canadian Institute of Health Information [CIHI] portal, 2024). 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 (NRS data extracted for contributing sites, CIHI portal, 2024).

Ultimately most individuals who experience a stroke will return to the community, living 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 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).

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. Further, due to the  broad scope of topics covered in this module, this updated 7^th 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; and,
• Part Three: Optimizing Activity and Community Participation following Stroke, Update 2025. 

This module, Part One: Stroke Rehabilitation Planning for Optimal Care Delivery, reflects the growing and changing body of research evidence available to guide planning, ongoing screening and assessment, management, education, and support of individuals with stroke, their families, and caregivers. This module provides guidance in the delivery of coordinated and seamless systems of care that supports progress achieved during the initial recovery stages and enables people to successfully resume life roles and leisure activities. Successful planning, recovery, transitions and community participation following stroke requires integrated and coordinated person-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 be vigilant to their recovery needs and ensure services and resources are in place to reduce complications and provide equitable opportunities for all individuals recovering from stroke to achieve optimal health outcomes. Their physical, emotional, psychological, social, spiritual and environmental needs 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. 

1. Reorganization of the Rehabilitation Module: The Stroke Rehabilitation, Recovery and Community Participation module has been divided into two parts, and the topics have been restructured to align with the International Classification of Functioning (ICF) framework for improved clarity and flow.
2. Expanded Inclusion of Healthcare Professionals: A broader scope of healthcare professionals have been engaged who have expertise to support the ongoing management of medical comorbidities and other medical needs as part of inpatient and community rehabilitation programs.
3. Virtual Rehabilitation Delivery: Expanded recommendations for the use of virtual modalities beyond therapy delivery to support rehabilitation functions such as transitions planning and education.
4. Broader Framing of Sensory Impairments: Enhanced scope of sensory impairment recommendations, specifically highlighting vision and perceptual difficulties.
5. Family Participation in Rehabilitation: Added additional recommendations regarding family meetings and utilizing virtual modalities to enhance family involvement in rehabilitation.
6. Community Engagement and Participation: Introduced new and additional recommendations focusing on strategies for community engagement and enhancing participation in community activities as part of returning to life roles.
7. Alignment of Outpatient and Inpatient Rehabilitation: Provided additional guidance to ensure outpatient and community-based rehabilitation aligns with the processes and standards of inpatient programs.
8. Utilization of validated tools: Further emphasis on the use of validated assessment tools across rehabilitation care. 
9. Early Supported Discharge: Addition of inclusion criteria when considering Early Supported Discharge.

The detailed methodology and explanations for each of these steps in the development and dissemination of the CSBPR is available in the Canadian Stroke Best Practice Recommendations Overview and Methodology manual available on the Canadian stroke best practices website at https://www.strokebestpractices.ca/recommendations/overview-methods-and-knowledge-exchange.

Conflicts of interest

All potential participants in the recommendation development and review process were required to complete confidentiality agreements and declare all actual and potential conflicts of interest prior to participation. Declared conflicts of interest were reviewed by the co-chairs of the CSBPR Advisory Committee and Heart & Stroke staff to assess the potential impact. Those with significant conflicts with respect to the module topic were not selected for writing group or reviewer roles. 

Participants who have conflicts for a particular topic area were identified at the beginning of discussions for that topic and were recused from voting. If a co-chair is in conflict, they were recused from their responsibilities for that discussion and another non-conflicted participant assumes the role for that discussion and vote. Heart & Stroke senior staff members participated in all writing group discussions and intervene if they perceived an untoward bias by a writing group member. 

Conflict of interest declarations for the Rehabilitation, Recovery and Community Participation following Stroke: Part One, Stroke Rehabilitation Planning for Optimal Care Delivery module writing group members can be found in Appendix One.

Heart & Stroke gratefully acknowledges the Rehabilitation, Recovery and Community Participation following Stroke: Part One: Stroke Rehabilitation Planning For Optimal Care Delivery writing group leaders and members, all of whom have volunteered their time and expertise to develop these new recommendations. We acknowledge M. Patrice Lindsay RN, PhD for her expertise and efforts as senior writer and editor of these recommendations, module and manuscript. We also acknowledge the additional experts involved in specific topic reviews, and 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 Ismalia De Sousa, Marika Demers, Sarah J. Donkers, Kate Hayward, Alyson Kwok, Alexander Lo, Lauren Mai, Susan Marzolini, Erin McHattie, Catherine Sackley, Lisa Sheehy, Hardeep Singh, and Ricardo Viana.  System implications were reviewed by Mary-Lou Halabi, Leslie James, and Geoff Law. The performance measures were reviewed and updated by members of the Heart & Stroke health systems quality council including Aravind Ganesh, Sacha Arsenault, and Shannon MacDonald.

We thank the Canadian Stroke Best Practices and Quality Advisory Committee members: Eric E. Smith (Co-Chair), Anita Mountain (Co-Chair), Dylan Blacquiere (Co-Chair), Gord Gubitz, Dar Dowlatshahi, Margie Burns, 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.  

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 Rehabilitation, Recovery and Community Participation following Stroke: Part One: Stroke Rehabilitation Planning For Optimal Care Delivery Community Consultation and Review Panel (CCRP) 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 Lori Beaver, Glen Brouwer, Maureen Brouwer, Janice Daitchman, Lilli Law, Ed Mitchell, Jennifer EJ Monaghan, Urainab Peerbhoy, and Alda Tee (writing group liaison).

Michelle LA Nelson (First Author, Co-Lead), Jing Shi (Second Author, Co-Lead), M Patrice Lindsay (Corresponding Author, Senior Editor), Nancy M Salbach (Co-Chair), Jennifer K Yao (Co-Chair), Debbie Timpson, Benjamin R Ritsma, Louis-Pierre Auger, Jenna Beaumont, Rebecca Bowes, Imane Samah Chibane, Sarah J Courtice, Rhina Delgado, Melanie Dunlop, Norine Foley, Kimia Ghavami, Teresa Guolla, Deborah Kean, Sandra MacFayden, Jasmine Masse, Phyllis G Paterson, Elyse Shumway, Ada Tang, Alda Tee, Clinton Y H Tsang, Stacey Turnbull, Dylan Blacquiere, Katie White, Chelsy Martin, Rebecca Lund (Corresponding Author), Elizabeth L Inness, Brodie Sakakibara, Gustavo Saposnik, Ruth Barclay, Diana Bastasi, Mark I Boulos, Joy Boyce, Geneviève Claveau,  Heather L Flowers, 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, Colleen O’Connell,  Sarvenaz Mehrabi,  and 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 One: Stroke Rehabilitation Planning for Optimal Care Delivery, 7^th Edition, 2025; Toronto, Ontario, Canada: Heart and Stroke Foundation. 

• Stroke Rehabilitation Planning for Optimal Care Delivery guideline publication 
• Writing Group Members and External Reviewers (Appendices One & Two)
• Stroke Rehabilitation Planning for Optimal Care Delivery Definitions and Descriptions 

1. Initial Stroke Rehabilitation Screening and Assessment

• Evidence Table and Reference List 1
• Box 1: Eligibility Criteria for Stroke Rehabilitation

2. Stroke Rehabilitation Unit 

• Evidence Table and Reference List 2

3. Delivery of Inpatient Stroke Rehabilitation 

• Evidence Table and Reference List 3

4. Outpatient and Community Based Rehabilitation, and Early Supported Discharge

• Evidence Table and Reference List 4
• Box 4 General Inclusion Criteria for Early Supported Discharge

5. Stroke Rehabilitation in Long-term Care and Complex Continuing Care

• Evidence Table and Reference List 5

6. Virtual Stroke Rehabilitation

• Evidence Table and Reference List 6

7. Interdisciplinary Stroke Rehabilitation Care Planning, Transitions and Communication 

• Evidence Table and Reference List 7
• Box 7 Checklist of Core Transition Summary Information

8. Supporting Individuals with Stroke, Their Family and Caregivers During Stroke Rehabilitation

• Evidence Table and Reference List 8
• Box 8 Supporting Successful Transitions of Care Checklist

9. Education for Individuals with Stroke, Their Family and Caregivers During Stroke Rehabilitation

• Evidence Table and Reference List 9
• Box 9 Education and Self-Management Checklist

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

Appendix Two: Stroke Rehabilitation Planning for Optimal Care Delivery External Reviewers 2025

Appendix Three: References