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Rehabilitation and Recovery following Stroke

1. Initial Stroke Rehabilitation Assessment


Recommendations

1.0 All patients with acute stroke should be assessed to determine the severity of stroke and early rehabilitation needs.

  1. All patients admitted to hospital with acute stroke should have an initial assessment, conducted by rehabilitation professionals, as soon as possible after admission [Evidence Level A].
    1. The core rehabilitation professional team should include physiatrists, or other physicians with expertise/core training in stroke rehabilitation, occupational therapists, physiotherapists, speech-language pathologists, nurses, social workers and dietitians [Evidence Level A]. The patient and family are also included as part of the core team [Evidence Level C].
    2. Additional team members may include recreation therapists, psychologists, vocational therapists, educational therapists, kinesiologists, rehabilitation therapy assistants, and pharmacists. [Evidence level C].
    3. All professional members of the rehabilitation team should have specialized training in stroke care and recovery [Evidence Level A].
    4. All professional team members should be trained in supported conversation to be able to interact with patients with communication limitations such as aphasia [Evidence Level B].
  2. Initial screening and assessment should ideally be commenced within 48 hours of admission by rehabilitation professionals in direct contact with the patient [Evidence Level C].
    1. Initial assessment may include: an evaluation of patient function, safety, physical readiness, and ability to learn and participate in rehabilitation therapies [Evidence Level C].
    2. It is reasonable to consider issues related to transition planning during the initial rehabilitation assessment [Evidence Level C].
  3. Assessments of impairment, functional activity limitations, role participation restrictions and environmental factors should be conducted using standardized, valid assessment tools [Evidence Level B]; tools should be adapted for use with patients who have communication differences or limitations where required [Evidence Level B]. Refer to Table 1: Stroke Rehabilitation Screening and Assessment Tools.
  4. For patients who do not initially meet criteria for rehabilitation, weekly reassessment of  rehabilitation needs may be considered weekly during the first month, and at intervals as indicated by their health status thereafter [Evidence Level C]. Refer to Box One for more information.
  5. All patients who present with acute stroke or TIA who are not admitted to hospital should be screened for the need to undergo a comprehensive rehabilitation assessment to determine the scope of deficits from index stroke event and any potential rehabilitation requirements [Evidence level C].
    1. Priority screening areas, including evaluation of safety (cognition, fitness to drive), swallowing, communication and mobility, should be completed by a clinician with expertise in stroke rehabilitation where feasible before the patients leave the emergency department or in the  primary care setting [Evidence Level C]. Refer to CSBPR Secondary Prevention of Stroke module.
    2. Additional screening of impairments, including onset of depression, cognitive ability, functional activity limitations, role participation restrictions, environmental factors and the presence of modifiable stroke risk factors (such as lifestyle behaviours) should be considered within two weeks of stroke onset [Evidence Level C].
  6. Once a patient with stroke has undergone assessments, a standardized approach is recommended to determine the appropriate setting for rehabilitation (inpatient, outpatient, community, and/or home-based settings) [Evidence Level C].
    1. This standardized criteria for admission to any rehabilitation setting is ideally communicated to all referring centres and services [Evidence Level C]. Refer to Box One for key elements of rehabilitation admission criteria

 

Box One Eligibility and Admission Criteria for Stroke Rehabilitation +-

DETERMINING IF A PATIENT IS A CANDIDATE FOR REHABILITATION

The following criteria has been developed as part of the Canadian Stroke Best Practice Recommendations to provide guidance and increase consistency on key elements that should be considered in decision-making regarding stroke rehabilitation for individual patients. Criteria for access to rehabilitation services should be agreed upon by all relevant stakeholders in each region, be clearly stated and communicated to all referral sites to improve patient access and admission to stroke rehabilitation programs in an efficient and transparent manner. This applies to all rehabilitation settings, including inpatient rehabilitation, outpatient and community-based rehabilitation, and home-based rehabilitation. Refer to the CSBPR Transitions and Community Participation module, Section 5 for information on stroke care in long-term care settings.

General Inclusion Criteria for Stroke Rehabilitation

  • All acute or recent stroke patients:
    • Who require inpatient or outpatient interdisciplinary rehabilitation to achieve functional goals to improve independence;
    • Who would benefit from interdisciplinary rehabilitation assessment and treatment from staff with stroke expertise (including disciplines such as physiotherapy, occupational therapy, speech-language pathology, nursing, social work, psychology, and recreation therapy);
    • And whose stroke etiology and mechanisms have been clarified and appropriate prevention interventions started (exceptions noted below under ‘medically stable’).
  • Goals for rehabilitation can be established and are specific, measurable, attainable, realistic and timely.
  • The patient is medically stable:
    • A confirmed diagnosis of stroke has been identified, although the mechanism or etiology may not be initially clear, such as in cryptogenic stroke; these situations should not cause delays in access to rehabilitation;
    • All medical issues and/or co-morbidities (e.g. excessive shortness of breath, and congestive heart failure) are being managed and are not precluding active participation in the rehabilitation program
    • All key medical investigations have been completed or scheduled follow-up appointments made by time of discharge from acute care.
  • The patient demonstrates the ability to participate, which includes:
    • Stamina to participate in the program demands/schedule;
    • Ability to follow at minimum one-step commands, with communication support if required;
    • Sufficient attention, and short-term memory to progress through rehabilitation process.
  • The patient has consented to treatment in the program and demonstrates a willingness and motivation to participate in the rehabilitation program.
  • Establish and meet standards for time from receipt of referral to decision regarding intake (suggest 24-48 hours)

General Exclusion Criteria for Stroke Rehabilitation

  • Medically unstable.
  • Severe cognitive impairment preventing patient from learning and participating in therapy;
  • Behaviour is inappropriate and putting self or others at risk, such as physical and verbal aggression;
  • Not willing to participate in program.

DETERMINING IF A PATIENT IS A SUITABLE CANDIDATE FOR OUTPATIENT (HOSPITAL or HOME BASED) REHABILITATION:

  • Patient meets the criteria for rehabilitation candidacy, medical stability, and rehabilitation readiness as defined above.
  • The patient’s current medical, personal care, or rehabilitation needs can be met in the community.
  • The patient can attend therapy alone or if assistance is required a caregiver is available to attend therapy sessions.

Characteristics to Consider in Planning Rehabilitation of Stroke Patients

Stroke Characteristics:

  • Initial stroke severity
  • Location, etiology and type of stroke (ischemic versus hemorrhagic)
  • Functional deficits and functional status – using FIM ® Instrument, Alpha FIM ® Instrument scores, Barthel Index, Rankin Score, and/or Iso- Functional Autonomy Measuring System (Iso-SMAF).
  • Types of therapy required based on assessment of deficits (e.g., OT, PT, SLP, and others as required)
  • Cognitive status – patient is able to learn and actively participate in rehabilitation
  • Time from stroke symptom onset.

Additional Patient Characteristics:

  • Medical stability
  • Rehabilitation goals can be identified by patient and/or health care team in order to increase independence in all activities of daily living. Some examples of goals may include: transfer unassisted, walk independently with aids, use involved arm, improve communication skills, and provide personal self-care
  • Adequate tolerance and endurance to actively participate in stroke rehabilitation therapy
  • Age and pre-stroke frailty
  • Existing co-morbidities such as dementia, palliative care status for another medical condition/terminal illness
  • Caregiver availability for patients with severe impairment is important

System Characteristics:

  • Efficient referral process for rehabilitation.
  • Rehabilitation professionals knowledgeable about stroke should be responsible for reviewing intake applications.
  • Family members and informal caregivers should be included as part of the rehabilitation process, including decisions regarding inpatient and/or outpatient rehabilitation.
  • Standards for time from receipt of referral to decision regarding intake (suggest 24-48 hours).
  • Available services and resources at different inpatient rehabilitation sites within a geographic region; types and levels of rehabilitation services available at those sites.
  • Presence of an early supported discharge (ESD) program and criteria for patient appropriateness for ESD.
Rationale +-

The goal of the first interdisciplinary assessment a patient receives after admission for stroke is to identify impairments in physical, functional, cognitive, and communication functioning which will guide decisions on rehabilitation services and therapies required, and potential discharge needs. Early consultation with rehabilitation professionals enhances the process of discharge planning, whether patients are going to transition from acute care to specialized rehabilitation units or back to the community.

 

People with stroke express that their experiences with inpatient rehabilitation admission and eligibility assessment reflect what is within these recommendations. However, people with stroke also discuss concerns about the potential for people to be excluded from inpatient rehabilitation based on the criteria presented.  It is essential that people with stroke who do not meet the criteria for inpatient rehabilitation are appropriately referred to other services to meet post-stroke rehabilitation needs.

System Implications +-

To ensure patients receive timely stroke rehabilitation assessments, the acute care, rehabilitation, and community organizations require:

  • An adequate complement of clinicians experienced in stroke and stroke rehabilitation.
  • A clear process referral of patients to rehabilitation professionals and programs after acute admission.
  • An interdisciplinary team that is resourced to provide prescribed levels of rehabilitation therapy.
  • A defined geographic area or unit where individuals with stroke are assured access to an experienced team.
  • Standardized, validated, and expert consensus-based screening assessment tools and training.
  • A process for timely referral to specialized stroke inpatient services in all centres (for example, electronic referral system and standardized assessment tools).
  • Access to a follow-up clinic for secondary stroke prevention to ensure assessment of mild stroke-related difficulties and referral to rehabilitation services and programs when deficits and issues are identified that are amenable to rehabilitation.
  • Development or expansion of stroke rehabilitation expertise in children’s hospitals and children’s treatment centres, as needed; and integration of stroke rehabilitation needs into school supports.
  • Mechanisms to periodically re-evaluate those patients with severe stroke who are admitted to nursing homes, continuing care, or other settings to ensure that they have access to rehabilitation as appropriate, if the patient progresses sufficiently and has goals amenable to rehabilitation.
  • Coordination and development of strong partnerships in the community, and adequate resources to ensure access to comprehensive stroke rehabilitation. This is especially important in more rural and remote geographic locations where telehealth technologies should be optimized.
Performance Measures +-
  1. Proportion of stroke patients with a rehabilitation assessment within 48 hours of hospital admission for acute stroke by at least one stroke rehabilitation specialist as appropriate to patient needs (core).
  2. Median time from hospital admission for stroke to initial rehabilitation assessment for each of the rehabilitation disciplines (Target is within 48 hours of hospital admission).
  3. Proportion of acute stroke patients discharged from acute care to inpatient rehabilitation (core).
  4. Percentage of stroke patients discharged to the community who receive a referral for outpatient rehabilitation before discharge from acute and/or inpatient rehabilitation (either facility-based or community- based programs).
  5. Median length of time between referral for outpatient rehabilitation and admission to a facility-based or community rehabilitation program.
  6. Median length of time between referral for outpatient rehabilitation to commencement of therapy (Target is within 30 days).
  7. Percentage of those patients with severe stroke reassessed for rehabilitation following initial assessment within one month, 3 months and six months of index stroke event.
  8. Percentage of patients with severe stroke admitted to inpatient rehabilitation (as a change in patterns that may be directly result of implementation of endovascular thrombectomy).
  9. Percentage of Telehealth/Telestroke coverage to remote communities to support organized stroke care across the continuum, including providing rehabilitation assessments and therapies for stroke patients.
  10. Number of severe strokes and change in volume potentially as a direct result of EVT.

Measurement Notes:

  • Referral information may be found through primary audit of inpatient charts (nurses’ notes, discharge summary notes, copies of referral forms) or through databases maintained by organizations that receive and process referrals. These community databases will vary in the amount of information included, and there may be challenges in accessing information contained in these databases.
  • Most home care organizations monitor when the first service started but cannot determine easily the onset of rehabilitation therapy.
  • For Performance Measure 3, when analyzing these data consider also looking at appropriateness of referral and location of facility.
  • Performance Measure 5, the timing being measured if from referral to acceptance into a program, and not specifically the start of therapy (Performance Measure 6 measures time to start of therapy).
  • For Performance Measure 7, this reassessment should be done at all transition points and ideally at least monthly thereafter. This includes admission to complex care, long-term care or return to other community setting. The denominator will be a challenge and should be clearly identified and applied consistently by all groups who adopt this measure (e.g., denominator could be all severe stroke patients admitted to a long term care facility).
Summary of the Evidence +-

Evidence Table and Reference List

 

Comprehensive assessment of a patient’s cognitive and functional status conducted within the first few days following a stroke is essential to guide the development of individualized care plans. These assessments should be conducted using a standardized approach with validated tools.  Areas of evaluation should include a person’s ability to perform basic self-care activities (such as dressing, grooming, personal hygiene, feeding, functional mobility and communication) and instrumental activities of daily living (including meal preparation, home management, communication activities, financial management, shopping and community living skills). 

 

Admission to an interprofessional program should be limited to patients who have more than one type of disability and who, require the services of two or more rehabilitation disciplines. Patients with a single disability can usually benefit from outpatient or community-based services, and generally do not require an interprofessional program. Hakkennes et al. (2013) surveyed 14 clinicians responsible for assessing the suitability of patients for inpatient rehabilitation. A questionnaire was administered to assess factors that were used to assess a patient’s suitability for rehabilitation. Potentially relevant items included 15 patient-related factors (e.g. age, pre-morbid mobility) and 2 organization factors (bed availability and funding source).  Using data from 8,783 Veterans admitted to a Veterans Affairs Medical Center with a primary diagnosis of stroke, Stineman et al. (2013) reported that 11.2% of veterans were selected for comprehensive-level rehabilitation. Patients at the lowest grades of physical independence and the middle cognitive stages had significantly higher odds of admission to a comprehensive rehabilitation unit. Other independent factors associated with higher odds of admission for comprehensive rehabilitation included patients who were age <70 years, married, living at home pre-stroke and the presence of a comprehensive rehabilitation unit at admitting hospital. In the CERISE study (Putman et al. 2007), the presence of pre-morbid cognitive disability, depression and severe behavioral problems were identified as factors where the probability of being admitted for inpatient rehabilitation was lowered.

Stroke Resources