Canadian Best Practice
Recommendations for Stroke Care
Canadian
Best Practice
(Updated 2008)
Recommendations for
Stroke Care: 2008
Section # 3
Recommendation
5: Management
Hyperacute Stroke
Stroke Rehabilitation and
Community Reintegration
5.0 Stroke Rehabilitation and
Community Reintegration
5.1 Initial stroke rehabilitation assessment
 5.2 Provision of inpatient stroke rehabilitation
 5.3 Components of inpatient stroke rehabilitation
 5.4 Outpatient and community-based
rehabilitation
 5.5 Follow-up and community
reintegration
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5.1 Initial Stroke Rehabilitation
Assessment
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All persons with stroke should be assessed for their
rehabilitation needs.
All people admitted to hospital with acute stroke
should have an initial assessment by rehabilitation
professionals as soon as possible after admission;
preferably within the first 24-48 hours.
All people with acute stroke with any residual strokerelated impairments who are not admitted to hospital
should have a comprehensive outpatient assessment
for functional impairment, preferably within
two weeks.
5.1 Initial Stroke Rehabilitation
Assessment
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Functional assessment should include:
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A cognitive evaluation
Screening for depression
Screening of fitness to drive
Functional assessments for potential rehabilitation treatment
Clinicians should use standardized, valid assessment
tools to evaluate the patient’s stroke-related impairments
and functional status.
Survivors of a severe or moderate stroke should be
reassessed at regular intervals for their rehabilitation
needs.
Outcome Tools for Stroke Rehabilitation
Recommended by SCORE/CSQCS Stroke
Rehabilitation Outcomes Panel
Domain
Selected Measure
Measures of Stroke Severity
Orpington or NIH Stroke Scale
Medical Conditions
Charlson Co-Morbidity
Upper Extremity Structure and
Function
Chedoke-McMaster Assessment
(CMSA)
Lower Extremity
Chedoke-McMaster Stroke
Assessment
Spasticity
Modified Ashworth + Spasticity
Subscale of CMSA
Bayley, Lindsay et al, Canadian Stroke Network, 2006
Outcome Tools for Stroke Rehabilitation
Recommended by SCORE/CSQCS Stroke
Rehabilitation Outcomes Panel
Domain
Selected Measure
Visual Perception
a)
b)
c)
d)
Language
a) Screening in acute and follow-up:
Frenchay Aphasia Screening Test
b) Rehabilitation: Boston Diagnostic
Aphasia Assessment
Cognition
a) MoCA
b) Five Minute protocol from the MoCA
c) Screening MMSE + Line
Bisection+Semantic Fluency
Bayley, Lindsay et al, Canadian Stroke Network, 2006
Comb and Razor
Behavioural Inattention Test
Line Bisection
Alternates: Rivermead, OSOT,MVPT
Outcome Tools for Stroke Rehabilitation
Recommended by SCORE/CSQCS Stroke
Rehabilitation Outcomes Panel
Domain
Selected Measure
Arm Function
a) Chedoke Arm and Hand Activity
Inventory
b) Box and Block
c) Nine Hole Peg Test
Walking/Lower Extremity
a)
b)
c)
d)
Balance
Berg Balance Scale
Functional Communication
Amsterdam (ANELT)
Alternate: ASHA-Functional
Assessment of Communication of
Activities of Daily Living (ASHA-FACS)
Bayley, Lindsay et al, Canadian Stroke Network, 2006
Chedoke Inventory
Timed up and Go
6 Minute walk test
Alternate-Rivermead Mobility Index
Outcome Tools for Stroke Rehabilitation
Recommended by SCORE/CSQCS Stroke
Rehabilitation Outcomes Panel
Domain
Selected Measure
Self-Care Activities of Daily
Living
Functional Independence
Measure (FIM)
Instrumental Activities of Daily a) Reintegration to Normal
Living
Living Index
b) Leisure section of the
LIFE-H
Participation
Stroke Impact Scale
Bayley, Lindsay et al, Canadian Stroke Network, 2006
System Implications
Adequate complement of experienced clinicians
 Clear referral processes
 Screening and assessment tools
 Access to follow-up services
 Strong partnerships
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Performance Measures
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Median time from hospital admission for stroke
to initial rehabilitation assessment for each of
the rehabilitation disciplines.
Proportion of acute stroke patients discharged
from acute care to inpatient rehabilitation.
% of stroke patients discharged to the community
who receive a referral for outpatient rehabilitation
before discharge from hospital.
Median time between referral for outpatient
rehabilitation to admission to a community
rehabilitation program.
5.2 Provision of Inpatient Stroke
Rehabilitation
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All patients with stroke who are admitted to hospital
and who require rehabilitation should be treated in a
comprehensive or rehabilitation stroke unit by an
interdisciplinary team.
Post-acute stroke care should be delivered in a setting
in which rehabilitation is formally coordinated and
organized.
All patients should be referred to a specialist
rehabilitation team on a geographically defined unit as
soon as possible after admission.
 Pediatric acute and rehabilitation stroke care should be
provided on a specialized pediatric unit.
5.2 Provision of Inpatient Stroke
Rehabilitation
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Post-acute stroke care should be delivered by a variety of
treatment disciplines, experienced in providing post-stroke care, to
ensure consistency and reduce the risk of complications.
The interdisciplinary rehabilitation team may consist of:
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Physician
Nurse
Physiotherapist
Occupational therapist
Speech-language pathologist
Pharmacist
Psychologist
Recreation therapist
Patient/family caregivers
For children, also includes educators and
child-life workers.
5.2 Provision of Inpatient Stroke
Rehabilitation
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The interdisciplinary rehabilitation team should assess
patients within 24-48 hours of admission and develop a
comprehensive individualized rehabilitation plan which
reflects severity of the stroke and needs and goals of
the stroke patient.
Patients with moderate or severe stroke who are
rehabilitation ready and have goals should be given an
opportunity to participate in inpatient stroke
rehabilitation.
5.2 Provision of Inpatient Stroke
Rehabilitation
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Stroke unit teams should conduct at least one formal
interdisciplinary meeting a week to discuss progress and
problems, rehabilitation goals and discharge arrangements
for patients on the unit; individualized rehabilitation plans
should be regularly updated based on patient status
reviews.
Clinicians should use standardized, valid assessment tools
to evaluate the patient’s stroke-related impairments and
functional status.
Where admission to a stroke rehabilitation unit is not
possible, a less optimal solution is inpatient rehabilitation
on a mixed rehabilitation unit.
System Implications
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Timely access to specialized inpatient rehabilitation
services.
Adequate number of geographically defined stroke
units with critical mass of trained staff; interdisciplinary
team during the rehabilitation period.
Clinicians with expertise in stroke rehabilitation.
Timely access to appropriate type and intensity of
rehabilitation professionals.
Optimization of strategies to prevent complications and
recurrence of stroke.
Consistent implementation of evidence-based
best practices for stroke rehabilitation across the
continuum of care.
Performance Measures
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Number of stroke patients treated in a
geographically defined stroke rehabilitation unit
at any time during their inpatient rehabilitation
phase following an acute stroke event.
Final discharge disposition for stroke survivors
following inpatient rehabilitation:
 % discharged to original place of residence
 % discharged to long-term care facility or nursing
home
 % requiring readmission to an acute care hospital for
stroke-related causes.
Performance Measures
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Number of stroke patients assessed during inpatient rehabilitation
by:
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Physiotherapist
Occupational therapist
Speech-language pathologist
Social worker
Proportion of total time during inpatient rehabilitation following
acute event spent on stroke rehabilitation unit.
Frequency, duration and intensity of therapies received from
rehabilitation professionals while in an inpatient rehabilitation
setting.
Change in functional status measured with a standardized
measurement tool, from time of admission to an inpatient
rehabilitation unit for stroke patients to the time of discharge.
5.3 Components of Inpatient Stroke
Rehabilitation
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All patients with stroke should begin rehabilitation therapy as
early as possible once medically stable.
Patients should receive intensity and duration of clinically
relevant therapy defined in their individualized rehabilitation
plan and appropriate to their needs and tolerance levels.
Stroke patients should receive, through an individualized
treatment plan, a minimum of one hour of direct therapy by
the interprofessional stroke team for each relevant core
therapy, for a minimum of five days a week based on
individual tolerance, with duration of therapy being
dependant on stroke severity.
5.3 Components of Inpatient Stroke
Rehabilitation
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The team should promote the practice of skills gained
in therapy into patient’s daily routine in a consistent
manner.
Therapy should include repetitive and intense use of
novel tasks that challenge patient to acquire necessary
motor skills to use the involved limb during functional
tasks and activities.
Stroke unit teams should conduct at least one formal
interdisciplinary meeting a week at which patient
problems are identified, rehabilitation goals set,
progress monitored and support after discharge
planned.
5.3 Components of Inpatient Stroke
Rehabilitation
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The care management plan should include a
pre-discharge needs assessment. Elements of
discharge planning should include a home visit
by a health care professional.
 Ideally before discharge, to assess home environment
and suitability for safe discharge.
 Determine equipment needs and home modifications
 Begin caregiver training for how patient will manage
activities of daily living and instrumental activities
of daily living in their environment.
System Implications
Timely access
 Critical mass of trained clinicians
 Protocols and partnerships
 Strategies to prevent recurrence
 Initiatives for caregivers
 Ability to reassess as required
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Selected Performance Measures
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Length of time from stroke admission in an
acute care hospital to assessment of
rehabilitation potential by a rehabilitation
health care professional.
Length of time between stroke onset and
admission to stroke inpatient rehabilitation.
Number or percentage of patients admitted
to a coordinated 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).
Selected Performance Measures
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Change (improvement) in functional status scores
using a standardized assessment tool from
admission to an inpatient rehabilitation program to
discharge
Final discharge disposition for stroke survivors following
inpatient rehabilitation: percentage discharged to their
original place of residence, percentage discharged to a longterm care facility or nursing home, percentage discharged to
supportive housing or assisted living.
Percentage of patients requiring readmission to an acute
care hospital for stroke-related causes.
5.4 Outpatient and Community-Based
Rehabilitation
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After leaving hospital, stroke survivors must have access
to specialized stroke care and rehabilitation services
appropriate to their needs (acute and/or inpatient
rehabilitation).
Early supported discharge services and transition
planning should be provided by a well-resourced,
coordinated specialist interdisciplinary team with ageappropriate expertise.
 These are an acceptable alternative to extended in-hospital
rehabilitation and can reduce length of stay for selected
patients.
 Patients requiring early supported discharge services
should not be referred to generic (non-specific)
community services.
5.4 Outpatient and Community-Based
Rehabilitation
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People who have difficulty in activities of daily living,
including self care, productivity and leisure should receive
occupational therapy or multi-disciplinary interventions
targeting activities of daily living.
Multifactorial interventions provided in the community
including an individually prescribed exercise program, may
be provided for people who are at risk for falling, in order
to prevent or reduce the number and severity of falls.
5.4 Outpatient and Community-Based
Rehabilitation
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People with difficulties in mobility should be
offered an exercise program and monitored
throughout the program.
5.4 Outpatient and Community-Based
Rehabilitation
Patients with aphasia should be taught
supportive conversation techniques.
 Patients with dysphagia should be offered
swallowing therapy and opportunity for
reassessment as required.
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5.4 Outpatient and Community-Based
Rehabilitation
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Children affected by stroke should be offered
advice on and treatment aimed at achieving
play, self-care, leisure and school-related skills
that are developmentally relevant and
appropriate in their home, community and
school environment.
System Implications
Organized and accessible stroke care in
communities
 Increased number of experienced clinicians
 Access to services in the community
 Early supported discharge services
 Support for caregivers
 Long-term rehabilitation services widely
available in nursing and continuing care
facilities, and in outpatient community
programs.
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Selected Performance Measures
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Percentage of stroke patients discharged to the
community who receive a referral for ongoing
rehabilitation before discharge from hospital (acute
and/or inpatient rehabilitation).
Change in functional status scores, using a
standardized measurement tool, for stroke
survivors engaged in community rehabilitation
programs.
Number of stroke patients assessed by
physiotherapy, occupational therapy, speechlanguage pathologists and social workers in the
community
5. 5 Follow-Up and Community
Reintegration
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People with stroke living in the community should
have regular and ongoing follow-up assessment
to assess recovery, prevent deterioration and
maximize functional outcome.
Post acute stroke patients should be followed up by a
primary care provider to address:
 Stroke risk factors
 Ongoing rehabilitation needs
 Continuation of treatment of comorbidities and other
sequelae of stroke
 Stroke survivors and their caregivers should have
psychosocial and support needs reviewed
on a regular basis.
5.5 Follow-Up and Community
Reintegration
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People living in the community who have difficulty with
activities of daily living should have access, as
appropriate, to therapy services to improve or prevent
deterioration in activities of daily living.
Identification and Management of Post-Stroke
Depression (Rec. # 6.2) should also be observed as part
of follow-up and evaluation of stroke survivors in the
community.
Any stroke survivor with declining activity at six
months or later after stroke should be assessed
for appropriate targeted rehabilitation.
5.5 Follow-Up and Community
Reintegration
Infants and children, in whom new motor,
language or cognitive deficits emerge over time,
require ongoing follow-up and assessment
throughout their development.
 Pediatric stroke survivors in the community
should have ongoing assessments of education
and vocational needs throughout their
development.
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5.5 Follow-Up and Community
Reintegration
Stroke survivors and families should be provided
with timely, up-to date information in
conjunction with opportunities to learn from
members of the interdisciplinary team and other
appropriate community service providers. Simple
information provision alone is not sufficient.
 Patients and caregivers should be offered
education programs to assist them in
adapting to their new role.
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System Implications
Assistance for stroke survivors and families
 Stroke care expertise and education in
community and long-term care settings
 Support including community programs, respite
care and education to support caregivers
 Social supports and re-engagement strategies
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Selected Performance Measures
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Proportion of patients who are discharged
from acute care who receive a referral for
home care or community supportive
services.
Median wait time from referral to
admission to nursing home or long-term
care facility.
Number of visits to an emergency
department within specified time frames.
Number of readmissions from stroke
rehabilitation to acute care for strokerelated causes
Implementation Tips
Form a working group, consider both local and
regional stakeholders and include a stroke
survivor and family.
 Complete a gap analysis to compare current
practices using the Canadian Best Practice
Recommendations: 2008 Gap Analysis Tool.
 Identify strengths, challenges, opportunities.
 Identify 2-3 priorities for action.
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Implementation Tips
Identify local and regional champions.
 Identify professional education needs and
develop a professional education learning plan.
 Consider local or regional workshops to focus on
Stroke Rehabilitation and Community
Reintegration.
 Access resources such as CSS experts, Heart
and Stroke Foundation, provincial contacts,
stroke recovery groups.
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www.canadianstrokestrategy.ca
www.cmaj.ca