- All patients with stroke should receive rehabilitation therapy as early as possible once they are medically stable and able to participate in active rehabilitation [Evidence Level A]. Refer to Section One, Box One: Eligibility and Criteria for Stroke Rehabilitation for more information.
- Early prolonged mobilization of patients within the first fewdaysafter a stroke, especially a severe stroke, is not recommended (Evidence Level A).
- Earlier mobilization may be reasonable for select patients with acute stroke (for instance people with more mild strokes or transient ischemic attack) but caution is advised, and clinical judgement should be used (Evidence Level C)
- Once deemed to be medically and neurologically stable, patients should receive a recommended three hours per day of direct task-specific therapy, five days a week, delivered by the interdisciplinary stroke team [Evidence Level C]; more therapy results in better outcomes [Evidence Level A].
- Individualized rehabilitation plans should include a patient-centered approach, shared decision-making, culturally appropriate and agreed-upon goals and preferences of the patient, family, caregivers and the healthcare team [Evidence Level C].
- Patients should receive rehabilitation therapies of appropriate intensity and duration, individually designed to meet their needs for optimal recovery and tolerance levels [Evidence Level A].
- Therapy should include repetitive and intense use of patient-valued tasks that challenge the patient to acquire the necessary skills needed to perform functional tasks and activities [Evidence Level A].
- The team should promote the practice and transfer of skills gained in therapy into the patient’s daily routine during inpatient stay [Evidence Level A] and continue after discharge to the community [Evidence Level C].
- A pre-transition (discharge to another setting) needs assessment should be conducted to ensure a smooth transition from rehabilitation back to the community [Evidence level B].
- Elements of transition planning may include:
- A home visit by a healthcare professional, ideally conducted before discharge, for patients where the stroke rehabilitation team and/or family have concerns regarding changes in functional, communication and/or cognitive abilities that may affect patient safety [Evidence Level C].
- Assessment of the safety of the patient’s home environment and the need for equipment and home modification [Evidence Level C].
- Caregiver education, training and access to resources to assist the patient with activities of daily living and increase the patient’s level of independence [Evidence Level B].
- Patients in stroke rehabilitation should be considered for referral to transition planners (such as stroke navigators) where these roles are available [Evidence Level B]. Refer to CSBPR Transitions and Community Participation following Stroke module for additional information.
In order to obtain maximum benefit from inpatient stroke rehabilitation, a number of essential elements are required. These elements include adequate intensity of therapy, task-oriented training, excellent team coordination and early discharge planning. Both animal and human research suggests that the earlier rehabilitation starts, the better the outcome. Early, intensive rehabilitation care for patients in both the acute and subacute stage of stroke helps to improve arm and leg motor recovery, language and communication function, which in turn improves mobility, independence in self-care and participation in leisure activities. It is important that the rehabilitation therapies be tailored to the tasks that need to be retrained and developed, as well as to the activities of the patient’s choice and to their social roles. The need for a highly-coordinated, specialized team, who meet regularly to discuss the rehabilitation goals and progress, is also vital. Early discharge planning, including a home assessment and caregiver training, support and education, is required to identify and remove potential barriers to discharge and facilitate efficient transition back to the community.
People with stroke, their families and caregivers state that they really appreciate being regularly informed about their care, including the assessment tools, timelines and decision-making regarding specialist referrals.
Feedback received from people with stroke emphasized the need for support and guidance as they navigate the health care system following release from hospital. Dedicated staff members, such as stroke navigators, was considered valuable by people with stroke and family members and perceived to aid the recovery process. During the inpatient stay, people with stroke often feel the meetings regarding their care could be intimidating and stated that a dedicated staff member to support them at this stage would be helpful and improve their experience. They also note that having a peer mentor who has also experienced a stroke as an asset, specifically one that they are connected to from the beginning of their inpatient admission.
An individualized approach that focused on self-management was important to people with stroke, including inclusion of family members into therapy sessions. Teaching the family members and caregivers how to safely support and engage in exercise therapy is an important aspect of self management outside the hospital.
People with stroke have reported that the return back home after inpatient rehabilitation can be overwhelming. One step in preparing for this transition could include meeting with appropriate therapists to support the physical, emotional and mental transition, anticipating potential challenges and planning ahead for solutions.
Working together to achieve optimal functional outcomes after stroke requires the health system and organizations to ensure:
- Median length of time from stroke admission to an acute care hospital to assessment of rehabilitation potential by a rehabilitation healthcare professional.
- Median length of time from stroke onset to stroke rehabilitation referral.
- Median length of time from stroke rehabilitation referral to and admission to stroke inpatient rehabilitation.
- Percentage of stroke patients who are discharged from acute care without rehabilitation referrals in place.
- Number or percentage of patients admitted to a stroke unit — either a combined acute care and rehabilitation unit or a rehabilitation stroke unit in an inpatient rehabilitation facility — at any time during their hospital stay (acute and/or rehabilitation) (core).
- Final discharge disposition for stroke patients following inpatient rehabilitation: percentage discharged to their original place of residence, percentage discharged to a long-term care facility or nursing home, percentage discharged to supportive housing or assisted living (core).
- Percentage of patients requiring readmission to an acute care hospital for stroke-related causes (core).
- Median length of time spent on a stroke rehabilitation unit during inpatient rehabilitation.
- Average number of days spent in active rehabilitation (i.e., length of stay less days unable to participate due to service interruptions, such as illness or short-term readmission to acute care).
- Median number of days spent waiting for transfer to an inpatient rehabilitation setting (i.e. from the time a patient is ready for rehabilitation to the time of admission to inpatient rehabilitation).
- Change (improvement) in functional status scores using a standardized assessment tool from admission to an inpatient rehabilitation program to discharge (e.g., FIM® Instrument, AlphaFIM®, Modified Rankin Scale).
- Median number of hours of direct therapy for each type of service received while in inpatient rehabilitation.
- Total number of days spent in inpatient rehabilitation, by stroke type.
- Number of patients screened for cognitive impairment using valid screening tool during inpatient rehabilitation.
- Number of patients screened for depression using valid screening tool during inpatient rehabilitation.
- Time from stroke onset to mobilization: sitting, standing upright, and walking with or without assistance.
- Time from stroke onset to independence in feeding, dressing, grooming, toileting and bathing and other self-care.
- Median number of days spent in alternate level of care or inpatient rehabilitation while waiting for return to home or placement in a residential or long-term care setting.
Health Care Provider Information
- CSBPR Virtual Healthcare Tookit
- Table 1: Stroke Rehabilitation Screening and Assessment Tools
- FIM® Instrument
- AlphaFIM® Instrument
- Modified Rankin Scale
- Evidence-Based Review of Stroke Rehabilitation (Triage Module)
- Stroke Engine
Information for People with Stroke, their Families and Caregivers
- Taking charge of your stroke recovery: Rehabilitation and recovery infographic
- Taking charge of your stroke recovery: Transitions and community participation infographic
- Aphasia Institute
- Post Stroke Checklist
- Living with Stroke Program
- Stroke Resources Directory
- Your Stroke Journey
- Stroke Engine
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery
In a more recent systematic review of trials comparing additional dose of rehabilitation interventions vs. standard amount of the same rehabilitation interventions, aimed at improving upper or lower activity, or both, Schneider et al. (2016) reported that the immediate effect of additional rehabilitation was significantly improved measures of activity (SMD=0.39, 95% CI 0.07-0.71, p=0.02). Small increases in additional therapy were not associated with significant improvement in measures of activity, while large increases were.