Previous Section 10. Rehabilitation to Improve Language and Communication
Rehabilitation and Recovery following Stroke

11. Virtual Stroke Rehabilitation

7th Edition, Interim* Consensus Statement 2022

Definitions and descriptions

Virtual care

Virtual care encompasses all the methods that healthcare providers use to interact with people with stroke remotely, when they are not in the same location or connecting at the same time (i.e., interactions can be synchronous or asynchronous). The goal is to maximize the quality and effectiveness of the care provided to the person with stroke. These interactions, called virtual encounters, are electronic exchanges using teleconferencing, videoconferencing, secure messaging, or audio digital tools, where one or more healthcare providers deliver healthcare services to a patient. Virtual care may include encounters between healthcare providers and people with a health condition and/or family members, and also between providers to discuss the care of the person they are treating.

Related virtual care services may also include telemonitoring and digital self-care tools that collect biometric data that are usually referred to during virtual encounters.

Virtual stroke rehabilitation

Virtual stroke rehabilitation (also known as telerehabilitation), refers to the use of information and communication technologies to deliver rehabilitation services from a distance. Services can include prevention, evaluation, assessment, monitoring, intervention, supervision, education, consultation, and coaching. Virtual stroke rehabilitation can be delivered in many settings and at many stages of care and recovery and can be delivered by health providers from any stroke rehabilitation and recovery-related health discipline. Technologies such as video calls, phone calls, text, or email may be used as part of virtual stroke rehabilitation.

Hybrid model

A hybrid model of care is a combination of in-person and virtual care.

*This interim Consensus Statement was undertaken to address the pandemic-related shift to virtual care. This consensus statement will be fully integrated into the Rehabilitation and Recovery following Stroke module when that module undergoes full review in the CSBPR update process.

Section 2: Technology and planning

2.1 Technology  

2.1 Recommendations  

  1. Virtual stroke rehabilitation–enabling technologies, including Internet, video-conferencing tools, and remote monitoring devices, can be used to enable consultations and/or service delivery [Strong recommendation; Low quality of evidence]. 
  2. Asynchronous modalities, such as email and text, may be considered where appropriate for communication related to sharing educational resources, scheduling, and planning of care [Conditional recommendation; Low quality of evidence].
  3. Technologies and processes should be in place to ensure timely documentation and transfer of relevant health record information to and from the virtual stroke rehabilitation provider and the referring source and/or other members of the stroke care team for virtual care encounters in accordance with clinical care processes, organizational requirements, jurisdictional legislation, and regulatory bodies [Strong recommendation; Moderate quality of evidence].

Section 2.1 Clinical considerations 

  1. Recommendations for specific virtual stroke rehabilitation platforms or technologies are beyond the scope of this document; however, efforts should be made to ensure the platforms and/or equipment used for virtual rehabilitation support ease of use, efficacy, privacy, and reliability, and follow local and provincial regulations.

2.2 Planning delivery of virtual stroke rehabilitation 

2.2 Recommendations 

  1. Preparations for implementing virtual stroke rehabilitation should involve a clear identification of program goals, a needs assessment to identify local barriers and enablers, an implementation plan to address barriers and incorporate enablers, and a process for continuous quality improvement [Strong recommendation; Low quality of evidence].

Section 2.2 Clinical considerations 

  1. Virtual stroke rehabilitation services should be overseen and directed through a governance structure that may include establishing an executive steering committee, a project team, and a change management team to engage clinicians, people with stroke, families, and caregivers to continually evaluate and update the approach.  
  2. As part of transition planning, the inpatient interdisciplinary rehabilitation team should discuss the option of using virtual stroke rehabilitation early during the inpatient stay, in consultation with the outpatient team, the person with stroke, and their family and caregivers. Refer to Heart & Stroke virtual care decision framework for additional information.
  3. Approaches to delivering virtual stroke rehabilitation, including location, assessment, treatment, and communication technology, should be tailored to the needs and expertise of the local clinician and the person with stroke and their family and caregivers, and meet applicable privacy and security policies and legislation. For example, people with stroke may be able to participate in videoconferencing at a local clinic or hospital if they do not have access to virtual compatible devices, broadband Wi-Fi, high speed Internet, or other technology for virtual rehabilitation encounters at home. 
  4. An evaluation plan for virtual stroke rehabilitation encounters, including mechanisms for data collection, analysis, and reporting, should be developed to monitor key performance indicators to inform ongoing quality improvement and the sustainability of virtual rehabilitation services. 

    Refer to Performance measures: Key quality indicators for additional information. 
Section 3: Training and competency

3.1 Training for healthcare providers  

3.1 Recommendations 

  1. Team members who are providing virtual stroke rehabilitation therapy should have expertise and experience in stroke rehabilitation [Strong recommendation; Low quality of evidence].
  2. Rehabilitation team members should receive training to attain and maintain the necessary competencies to provide safe and appropriate virtual stroke rehabilitation using designated virtual care platforms [Strong recommendation; Low quality of evidence]. 

Section 3.1 Clinical considerations 

  1. Non-clinical team members should receive relevant training (e.g., on use of designated digital platforms or communication with people with aphasia) to effectively arrange and support a virtual stroke rehabilitation encounter. 

3.2 Training for people with stroke, families, and caregivers  

Note, no evidence-based recommendations included for this section. 

3.2 Clinical considerations 

  1. People with stroke and their families and caregivers should be provided with clear and appropriately adapted instructions on how to access, test, and use the designated virtual stroke rehabilitation platform on their own digital devices.
  2. People with stroke and their families and caregivers should be taught how to access and use the virtual rehabilitation platforms that will be used in their outpatient sessions and/or community programs, ideally prior to discharge from hospital or during an in-person session where appropriate.
  3. People with stroke and their families and caregivers should be provided with clear and appropriately adapted instructions on how to prepare for the virtual stroke rehabilitation session, including appropriate clothing, lighting, and equipment that are needed to facilitate the encounter. They should also provide an alternate means of contact should the system be interrupted or a safety issue arise.
Section 4: Assessment and service delivery

4.1 Assessment  

4.1 Recommendations 

  1. Where available, tools selected for assessment of impairments, activity limitations, participation restrictions, and environmental factors relevant to stroke rehabilitation should have evidence of validity for the method of virtual administration and be administered by trained personnel using a structured process. 
    1. Assessment tools selected for use via videoconferencing should have evidence of validity for this administration method [Conditional recommendation; Low quality of evidence] 
    2. Assessment tools selected for use via telephone should have evidence of validity for this administration method [Conditional recommendation; Moderate quality of evidence].
  2. Screening for pre-stroke mental health and cognitive status and for changes in mood or cognition following stroke should be included as a routine component of virtual stroke rehabilitation [Strong recommendation; Moderate quality of evidence].
  3. For people with stroke who have communication differences or limitations, such as aphasia, assessment tools should be adapted for use through virtual modalities, as required [Strong recommendation; Low quality of evidence]. 

Section 4.1 Clinical considerations   

  1. There is limited published evidence on the safety, feasibility, reliability, and validity of approaches to administering standardized assessment tools post-stroke using virtual rehabilitation platforms or technologies. Safety precautions should be taken during virtual performance-based health assessments.
  2. Assessment considerations may include ensuring the person with stroke has sufficient capacity to follow instructions, access to handholds to maintain balance, and a support person present to assist. 
  3. When assessments cannot be fully administered virtually, a hybrid model that combines in-person and virtual assessment should be considered. 
  4. Self-reported measures of rehabilitation outcomes, which are typically evaluated using performance-based assessment, may be feasible and useful to integrate when in-person assessment is not available. 

4.2 Service delivery 

4.2 Recommendations 

  1. Virtual outpatient stroke rehabilitation services, whether delivered using virtual modalities alone or a hybrid model, should offer the same elements as coordinated, in-person rehabilitation services [Strong recommendation; Moderate quality of evidence]. These elements ideally include: 
    1. An interdisciplinary stroke rehabilitation team [Strong recommendation; High quality of evidence]. 
    2. A case coordination approach that includes regular team communication to discuss assessment of new referrals and review management, goals, and plans for discharge or transition [Strong recommendation; Moderate quality of evidence]. 
    3. Outpatient therapy provided for a minimum of 45 minutes per day [Strong recommendation; Moderate quality of evidence] per required discipline, two to five days per week, based on individual needs and goals of the person with stroke [Strong recommendation; High quality of evidence]; ideally for at least eight weeks [Strong recommendation; Low quality of evidence]. 
    4. Ongoing assessment at appropriate intervals, to monitor for changes in function or health status in the person with stroke that may signal an in-person visit, is required [Strong recommendation; Low quality of evidence]. Refer to Heart & Stroke virtual care decision framework for additional information.
Rationale +-

The COVID-19 global pandemic created the necessity for large-scale, rapid conversion to virtual healthcare delivery. Many health providers have quickly acquired new knowledge and skills in order to deliver virtual rehabilitation and they are willing to integrate this new skillset into their future practices.  The challenge now is to maintain this momentum and build sustainable models for virtual healthcare to meet the ongoing healthcare needs of people in Canada. Virtual stroke care supports equitable and timely access to optimal stroke services across the continuum of care and geographic boundaries. It improves communication and networking and enables better access to stroke expertise, regardless of the location of the patient or the treating hospital, facility or healthcare provider. Many communities do not have access to physicians with stroke expertise, neurologists, physiatrists or other experts in stroke rehabilitation and recovery. Virtual stroke care can be a cost-effective tool to help health systems close the urban/rural and tertiary/primary care gap.  

Evidence related to the benefits and effectiveness of virtual stroke rehabilitation in facilitating optimal recovery after the acute phase is emerging. Virtual stroke rehabilitation can facilitate more timely access to rehabilitation specialists and therapeutic programs through remote connections in care facilities and patients’ homes.  

A Heart & Stroke online survey of more than 3,000 people living with stroke, heart conditions, and vascular cognitive impairment, as well as caregivers, found that more than half wanted the option of virtual appointments. Similarly, the Heart & Stroke Virtual Care Community Consultation and Review Panel (CCRP) also supported virtual encounters, citing increased access to care and resources, as well as access to more specialized care and multiple healthcare providers at one virtual encounter for a coordinated visit. They discussed the financial and time savings, and the benefit of avoiding travel which is especially important for those living far from large urban stroke centres or those unable to travel due to other factors.  

The panel emphasized the importance of equitable access to necessary infrastructure, such as Internet connections and technology. They talked about potential challenges for those engaging in virtual stroke rehabilitation, such as discomfort with use of technology and low digital literacy, and being unfamiliar with what virtual care is and how it can be used. They outlined the need for education about virtual care and training on the use of technology. They also discussed the value in having a support person with them when participating in virtual rehabilitation to help with technology, remember information, support and enhance safety, aid movements, and provide encouragement. They acknowledged that having a support person may not be possible for everyone, and they encourage healthcare providers and those receiving care to consider the impact this may have on those participating in a virtual visit. 

During discussions about advancing virtual stroke rehabilitation and expanding information available online, the CCRP stressed the value of being connected to a stroke rehabilitation team to help determine credible information and ensure they are receiving the best care possible. With many resources available online, the CCRP shared that at times it can be difficult to discern what information is appropriate and what is not; access to a stroke rehabilitation team provides a credible source of information to support their recovery journey.  

Finally, the CCRP identified that, for a variety of reasons, virtual care may not be appropriate for some people, and so there is a need for joint decision-making between the person with stroke and the healthcare provider to determine the most appropriate way forward, whether that be virtual, in-person, or a hybrid model. 

System Implications +-

To ensure that as many of these virtual stroke rehabilitation recommendations as possible are implemented across Canada, health system leaders, funders, and administrators at all levels of government and in all regions need to be actively engaged in and committed to building sustainable models for virtual care across the continuum. Many of the enablers listed below are beyond the scope of direct clinical care providers and many health professional groups.  

Health system leaders, funders and administrators should ensure that all healthcare providers have the necessary tools, resources, and processes to provide high-quality, evidence-based stroke care across the full continuum of care.   

For virtual stroke rehabilitation, the following actions, structures, resources, and processes need to be considered: 

  • The need for appropriate technology and access to stable Internet and phone services to support virtual stroke rehabilitation for clinicians and people with stroke. 
  • The need to train and support healthcare providers and people with stroke on how to use virtual stroke rehabilitation technologies.
  • Virtual stroke rehabilitation should be integrated and seen as part of larger regional or provincial stroke delivery plans that decentralize expertise to support clinical care in less well-resourced areas. Inherent in such a system are clear criteria, protocols, algorithms, and service agreements for the transfer and repatriation of people with stroke when clinically indicated. 
  • A governance structure with a clear framework of accountabilities for virtual healthcare services is required. This includes facility, regional and/or provincial levels of governance. 
  • The considerable human resource implications include establishing the appropriate number of healthcare providers to participate in virtual encounters, and right-sizing the work force to take into account the time taken away from the in-person clinical duties of consulting clinicians at their places of work.
  • Clear guidelines and processes for healthcare provider reimbursement need to be established as part of the development of a virtual stroke rehabilitation program. 
  • The need for service agreements that address the availability of maintenance and technical support to ensure the clinical requirements of virtual care are met.
  • The need for all users of a virtual stroke rehabilitation system to be aware of their roles and responsibilities and know how to use the technology. This includes regular updates to maintain competence.  
  • The need for agreements and protocols for interprovincial and territorial consultations where appropriate and time efficient, and where service gaps exist. 
  • Processes need to be established to monitor and evaluate virtual stroke rehabilitation services, including the use of validated data collection mechanisms and the establishment of standardized key quality indicators. 
  • Provincial healthcare administrators need to work together to build sustainable models for cross-border care delivery. Licensing requirements for virtual healthcare vary among provinces and territories. Healthcare professionals may have to be licensed in multiple jurisdictions, possibly both in their location and in the location of the person with stroke receiving care. In addition, special requirements and/or conditions on the provision of services may be required in some jurisdictions. Privacy legislation should also be followed in each applicable jurisdiction. 
  • Virtual stroke rehabilitation may present challenges with consent. In addition to obtaining informed consent for the proposed treatment, healthcare professionals may want to ask people with stroke to read and accept standard terms and conditions for virtual stroke rehabilitation care and services and document the consent and any discussion. 
Performance Measures +-

Virtual stroke rehabilitation is an emerging field. It is critically important that mechanisms be established to collect consistent high-quality data to inform planning and improvement and provide evidence for quality and sustainability. Virtual care should be considered as one modality in the delivery of stroke care. This interim module is specific to virtual stroke rehabilitation and should be considered in addition to the CSBPR Rehabilitation and Recovery following Stroke and CSBPR Transitions and Community Participation Following Stroke modules, including the performance measures in that document. 

Jurisdictions may consider using one or more of the following indicators to monitor virtual care services: 

Health system and clinical indicators

(Please refer to Quality of Stroke Care in Canada Key Quality Indicators and Stroke Case Definitions for more details.) 

  1. Proportion of people with stroke who receive access to stroke rehabilitation through virtual healthcare modalities for assessment and/or management. 
  2. Number of scheduled rehabilitation appointments for people with stroke accessing rehabilitation services through virtual healthcare modalities, with values reported separately for each service accessed (e.g., physiotherapy, speech therapy). 
  3. Median time from stroke onset to rehabilitation referral for:
    1. Inpatient stroke rehabilitation
    2. Ambulatory stroke rehabilitation
    3. Virtual stroke rehabilitation 
  4. Proportion of people with stroke who underwent a virtual care session indicated by the presence of the virtual care consultant’s note in the person’s health record.
  5. Median duration of scheduled virtual stroke rehabilitation encounters, with values reported separately for each service (e.g., physiotherapy, speech therapy).
  6. Cost effectiveness of virtual stroke rehabilitation compared to in-person stroke rehabilitation.
  7. Proportion of virtual stroke rehabilitation encounters requiring urgent transfer of person with stroke to an in-person healthcare visit.
  8. Proportion of virtual stroke rehabilitation encounters disrupted by technical difficulties by the healthcare provider.
  9. Proportion of virtual stroke rehabilitation appointments provided using synchronous two-way video conferencing compared to by telephone only. 

Persons with lived experience–oriented indicators 

  1. Patient-reported experience with virtual stroke rehabilitation related to attributes such as feasibility, satisfaction, quality, sound, visual clarity, reliability of technology, and ease of use. 
  2. Proportion of virtual stroke rehabilitation encounters disrupted by technical difficulties by healthcare provider. 
  3. Median time from referral for virtual stroke rehabilitation to first virtual stroke rehabilitation encounter. 
  4. Patient-reported experience of their safety during virtual stroke rehabilitation encounters, including prevention of risks associated with virtual stroke rehabilitation. 
  5. Proportion of virtual stroke rehabilitation encounters that included family members and/or caregivers who were in a different location from the person with stroke.

Measurement notes  

Refer to the Canadian Stroke Best Practices to Quality of Stroke Care in Canada Key Quality Indicators and Stroke Case Definitions for detailed indicator definitions, numerators and denominators, and additional analysis considerations. 

Documentation for virtual healthcare encounters is often not standardized, making it harder to gather performance measure information. 

Refer to the appropriate sections in the CSBPR Rehabilitation and Recovery following Stroke and CSBPR Transitions and Community Participation Following Stroke modules for information on indicators related to actual therapies. 

The National Rehabilitation Reporting System does not currently collect data on virtual healthcare encounters. 

Summary of the Evidence +-

Virtual stroke rehabilitation, also known as telerehabilitation, refers to the use of information and communication technologies to deliver rehabilitation services from a distance, often using video or telephone conferencing. The most familiar application of stroke telerehabilitation is the provision of therapies that mimic in-person interactions, which are provided synchronously over weeks or months, as required. Remote interventions, monitoring, evaluation and education can also be provided in asynchronous forms, using a variety of technologies. One of the key advantages of telerehabilitation is that it provides the opportunity for people who live in isolated or rural communities access to specialized rehabilitation services, which would otherwise be unavailable to them. Furthermore, telerehabilitation reduces or eliminates transportation problems that are commonly encountered by stroke survivors and their caregivers. 

The results from a rapidly expanding volume of literature suggests that virtual stroke rehabilitation can be both feasible and effective compared with in-persons encounters.  The authors of recently published systematic reviews examining remotely delivered therapy reported that measures of balance, upper and lower extremity motor function, mobility, and performance of activities of daily living, were not significantly different compared to those of persons receiving conventional rehabilitation (Laver et al. 2020, Appleby et al. 2019, Sarfo et al. 2018, Tchero et al. 2018, Chen et al. 2015). In the Cochrane review (Laver et al. 2020), virtual care was also used successfully to treat persons with speech and language impairments and low mood post stroke. Knepley et al. (2021), reported that functional outcomes among those that received virtual stroke rehabilitation were equivalent or better compared with those that received in-person therapy, as was patient satisfaction. Additionally, some virtually provided therapies were less costly than in-person therapy.  The outcomes of patients who received virtual rehabilitation services have been shown to be better than those who received conventional outpatient therapy. The Fugl-Meyer Assessment scores of patients who received a 12-week telerehabilitation program were significantly higher compared to those who received the same duration of outpatient therapy (Chen et al. 2020). In the same study, telerehabilitation was found to be non-inferior for the modified Barthel index. 

Adaptation of existing rehabilitation programs may offer alternative solutions to in-person therapy. Yang et al. (2021) provided a virtual version of the Graded Repetitive Arm Supplementary Program (GRASP) over 10 weeks, to 9 persons with residual difficulty using their affected upper extremity following remote stroke. There were significant improvements over time for all outcome measures, which included the Arm Capacity and Movement test (ArmCAM), a new assessment tool developed for online use. 

Assessment of performance-based measures in a virtual setting has not been well studied and poses challenges. Some previously validated outcome measures may not be appropriate, feasible or valid for virtual use. It remains to be determined whether new assessment tools will need to be developed and validated for virtual use. In some cases, adaptation of an existing measure may be sufficient. For example, Peters et al. (2021) developed a version of the Fugl-Meyer (FM) assessment, suitable for virtual care use (FM-tele) and demonstrated its feasibility. In addition, although the sample size was small (n=5), the proportional agreement between the FM-tele conducted in person and conducted remotely by the same assessor, one week apart, was good. Both patients and assessors reported some issues with technical difficulties, a common complaint when using virtual platforms.  Inter-rater reliability of the Balance Scale, Fugl-Meyer Assessment and the Action Research Arm Test has been shown to be good to excellent when comparing in-person assessments with those conducted virtually through videoconference (Gillespie et al. 2021, Amano et al. 2018). 

Refer to the CSBPR Rehabilitation and Recovery following Stroke and CSBPR Transitions and Community Participation Following Stroke modules for additional evidence for each element of stroke rehabilitation.

Virtual Stroke Rehabilitation Evidence Tables and Reference

Stroke Resources