Canadian Stroke Guidelines for Rehabilitation

1. Canadian Stroke Guidelines for Rehabilitation Robert Teasell MD FRCPC Professor Physical Medicine and Rehabilitation Schulich School of Medicine Western University London, Ontario, Canada “In theory there is no difference between theory and practice. In practice there is.” Yogi Berra

2. Importance of Evidence-Based Practice

3. Implementing Research Into Practice • “All breakthrough, no follow-through” • Simple existence of research evidence does not automatically result in alterations in policy or clinical decisions (Grol 2001) • Clinical care not being delivered in accordance with evidence-based guidelines (Buchan 2004, Grimshaw and Eccles 2004, Grol 2001, McGlynn 2003, Priest 2011) • Evidence-based medicine increasingly seen as a paradigm shift in health care

4. Korner-Bitensky et al. interviewed 1733 stroke clinicians (OT, PT, SLP) in 10 provinces, • 3 typical case-based questionnaires (acute, subacute and commumity) to determine what clinicians do and why they do it • Average therapist had 10 years in practice • Used hundreds of different outcome measures (heterogeneous and regional) Four most common rationales for use of outcome measures in order of importance: • It is available where I work • Its use is required at my place of work • Learned it during my professional training • It has known reliability and validity

5. Clinical Practice Guidelines (CPGs) CPGs or Consensus Recommendations are designed to help practitioners assimilate, evaluate and implement the ever-increasing amount of evidence and opinion on best current practice There has seen a surge of interest in the use of clinical practice guidelines, driven by: • Large unexplained variations in clinician practice • Significant rates of inappropriate care • Increasing emphasis on managing health care costs and improving quality of care

6. Structure, Process and Outcomes in Stroke Rehab • Hoenig et al. (2002) 2 year prospective trial of 288 acute strokes in the VA system • Examined Structure of Care: systemic organization, staffing expertise and technological sophistication • Examined Processes of Care: adherence to AHCPR post-stroke rehabilitation guidelines • Studied FIM motor subscale 6 months post-stroke as Outcome measurement Hoenig et al. Med Care 2002: 40(11):1036-1047

7. Structure, Process and Outcomes in Stroke Rehab • Structure of Care not directly associated with better Outcomes • Processes of Care wereassociated with better Outcomes – better adherence to guidelines meant improved outcomes and improved patient satisfaction (Hoenig et al. 2002; Duncan et al. 2002; Reker et al. 2002) • Indicates importance of Clinical Practice Guidelines or Use of Best Practices Hoenig et al. Med Care 2002: 40(11):1036-1047 Duncan et al. Stroke 2002; 33(1): 167-177 Reker et al. Arch Phys Med Rehabil2002; 83(6):750-756

8. Canadian Best Practice Recommendations for Stroke Care 4th edition Chapter 5: Stroke Rehabilitation(UPDATE July 2013) Dawson D, Knox J, McClure A, Foley N, Teasell R (Leads) on Behalf of the Stroke Rehabilitation Best Practices Writing Group 2013 “If you don’t know where you are going, you will wind up somewhere else” Yogi Berra

9. Best Practice Recommendation 5.1 • Once a stroke patient has undergone assessments, a standardized approach should be used to determine the appropriate setting for rehabilitation (inpatient, outpatient, community, and/or home-based settings) [Evidence Level C] • Criteria for admission to any rehabilitation setting should be standardized and communicated to all referring centres and services [Evidence Level C] One of criticisms of rehabilitation is that admission criteria is often seemingly ad hoc without a standardized approach. Ontario Auditor-General Recommendation 2 “To better ensure that inpatient rehabilitation meets patients’ needs as efficiently and equitable as possible hospitals should … in conjunction with the MOHLTC and LHINs develop standardized practices regarding patient eligibility for similar programs, prioritization of patients based on patient need, and the frequency and duration of therapy.”

10. Best Practice Recommendation 5.1Suggested Performance Measures • Proportion of acute stroke patients discharged from acute care to inpatient rehabilitation (core). In Ontario 23-25% of stroke discharges from acute care hospital are admitted to rehab Ideal number estimated as high as 40% The Impact of Moving to Stroke Best Practices in Ontario, OSN, 2012

11. Best Practice Recommendation 5.25.2.1 Stroke Rehabilitation Care • All patients who require inpatient rehabilitation following stroke should be treated on a specialized stroke rehabilitation unit [Evidence Level A]. • Rehabilitation care is formally coordinated and organized [Evidence Level A] • The rehabilitation unit is geographically defined [Evidence Level A] • The rehabilitation unit is staffed by an interprofessional rehabilitation team consisting of … • The interprofessional rehabilitation team follows evidence-based best practices as defined by the current consensus-based clinical practice guidelines [Evidence Level B] etc.

12. Organized Stroke Care: Stroke Rehabilitation Units Foley et al. Cerebrovascular Disease 2007:23:194-202

13. Stroke Rehab Units in Ontario • All stroke patients admitted to an inpatient rehab unit in Ontario from 2006-2008 identified through the NRS database • 67 institutions and 6,709 patients provided inpatient rehab services to stroke patients from 2006-2008 • All 67 institutions were contacted and asked 2 questions: Do you have geographically centralized stroke specific (80%) beds and dedicated stroke rehab therapist (80%) • Only 8 of the 67 units met these 2 simple criteria (in 4 large Ontario centers); 1,725 (25.7%) patients were admitted to these 8 units. Foley et al. International Journal of Stroke 2013; 8(6):430-435.

14. Best Practice Recommendation 5.25.2.1 Stroke Rehabilitation Care • Where admission to a stroke rehabilitation unit is not possible, inpatient rehabilitation provided on a general rehabilitation unit… is the next best alternative [Evidence Level B]. Specialized vs. Generalized Rehab of Stroke Patients in Ontario Foley et al. International Journal of Stroke 2013; 8(6):430-435.

15. Best Practice Recommendation 5.25.2.1 Stroke Rehabilitation Care • All patients who require inpatient rehabilitation following stroke should be treated on a specialized stroke rehabilitation unit [Evidence Level A]. • Rehabilitation care is formally coordinated and organized [Evidence Level A] • The rehabilitation unit is geographically defined [Evidence Level A] • The rehabilitation unit is staffed by an interprofessional rehabilitation team consisting of … • The interprofessional rehabilitation team follows evidence-based best practices as defined by the current consensus-based clinical practice guidelines [Evidence Level B] etc.

16. Best Practice Recommendation 5.3Delivery of Inpatient Stroke Rehabilitation • All patients with stroke should receive rehabilitation therapy within an active and complex stimulating environment [Evidence Level C] as early as possible once they are determined to be rehabilitation ready and they are medically able to participate in active rehabilitation [Evidence Level A]. • 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]. • Patients should receive a minimum of three hours of direct task-specific therapy, five days a week, delivered by the interprofessional team [Evidence Level C]. etc.

17. Rehabilitation training (enriched environments with animals) increases brain reorganization with subsequent functional recovery In animal studies key factors promoting recovery include increased activity and a complex, stimulating environment Lack of rehab causes decline in cortical representation and delays recovery

18. Best Practice Recommendation 5.3Delivery of Inpatient Stroke Rehabilitation • All patients with stroke should receive rehabilitation therapy within an active and complex stimulating environment [Evidence Level C] as early as possible once they are determined to be rehabilitation ready and they are medically able to participate in active rehabilitation [Evidence Level A].

19. Best Practice Recommendation 5.3Delivery of Inpatient Stroke Rehabilitation • All patients with stroke should receive rehabilitation therapy within an active and complex stimulating environment [Evidence Level C] as early as possible once they are determined to be rehabilitation ready and they are medically able to participate in active rehabilitation [Evidence Level A]. According to the Ontario Stroke Evaluative Report 2013 (OSN, CSN and ICES), in the 2011-2012 fiscal year, province wide, time to rehab from stroke onset was 10 days. 19% of patients remained in an acute-care hospital longer than necessary waiting for rehab bed. January 2013, the Stroke Clinical Advisory Expert Panel at Health Quality Ontario recommended timely transfer of ischemic strokes at a mean of 5 days and hemorrhagic stroke at 7 days.

20. Best Practice Recommendation 5.3Delivery of Inpatient Stroke Rehabilitation • 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]. • Patients should receive a minimum of three hours of direct task-specific therapy, five days a week, delivered by the inter-professional team [Evidence Level C]. Average therapy hours of direct PT, OT and SLP 5 days per week is about 1.5-2 hours per day; most rehabilitation units do not supply 3 hours of therapy per day Foley et al. Disability and Rehabilitation 2012; 34(25):2132-2138.

21. Ontario Auditor-General Report: Intensity of Stroke Rehabilitation Therapy “Although there is expert consensus recommending that stroke inpatients receive three hours of rehabilitation per day, the research currently available on the intensity of rehabilitation is mixed” “… the amount and type of stroke therapy that each patient receives is based on the professional judgement of his or her therapists” and that how much therapy each patient received in therapy was not actively tracked. Ontario Auditor-General Recommendation 2 “To better ensure that inpatient rehabilitation meets patients’ needs as efficiently and equitable as possible hospitals should … track and monitor information on the amount of therapy actually provided to patients, ...”

22. Inactive and Alone In a therapeutic day • >50% time in bed • 28% sitting out of bed • 13% in therapeutic activities • Alone for 60% of the time Contrary to the evidence that increased activity and environmental stimulation is important to neurological recovery Bernhardt et al. Stroke 2004; 35:1005-1009

23. Role of Intensity of Therapy • Rehab increases motor reorganization while lack of rehab reduces it; more intensive motor training further increases brain reorganization • Clinically greater therapy intensity improves outcomes and there seems to be a dose-response relationship • Still do not know threshold or dosage of rehab intensity needed to obtain a benefit (MacLellan et al 2011), although we know animal studies employ thousands of repetitions to show benefit and the average therapy session does not perform a large number of repetitions of a task. MacLellan et al. NeuroRehab and Neural Repair 2011; 25(8):740-748 Dromericket al. Neurology 2009; 73:195-201

24. Recommendations Regarding Inpatient Therapy Intensity Following Acute Stroke Foley et al. Topics Stroke Rehabil 2012; 19(2):96-103

25. Best Practice Recommendation 5.45.4.1. Outpatient and Community-Based Stroke Rehabilitation • Stroke survivors with ongoing rehabilitation goals should continue to have access to specialized stroke servicesafter leaving hospital [Evidence Level A]. This should include a blend of in-home community-based rehabilitation services … and facility-based outpatient services. • Outpatient and/or community-based rehabilitation services should be available and provided by a specialized interprofessional team … within 48 hours of discharge from an acute hospital or within 72 hours of discharge from inpatient rehabilitation[Evidence Level C]. • Outpatient and/or community-based services should be delivered in the most suitable setting based on patient functional rehabilitation needs and participation-related goals, which may include in the home or other community settings [Evidence Level C].

26. Ontario Stroke Rehabilitation Outpatient Clinics • Outpatients are an important part of stroke rehab • Survey of 49 facilities providing outpatient therapy to more than 5 stroke patients in 2009/2010 • 42 facilities answered the survey • No mandatory data reporting for outpatient therapy • Only 6 facilities were able to report the number of stroke patients who received stroke rehab and the total number of rehabilitation sessions • Ontario Auditor General Report (2013) noted, “a general lack of information available about access province-wide to stroke outpatient and/or community-based rehabilitation.” • In Ontario hospitals survey, 15 hospitals reported stroke OP resources declined of which 8 were eliminated; 11 reported expanding of which 2 were new

27. Community-Based Stroke Rehab • 14 LHINs in Ontario – 13 responded to survey (CCACs/Home Care) • 2007-2008 proportion of stroke patients discharged alive from acute care able to access Home Care services ranged from 30-64% • PT visits per discharge ranged 0.4-1.6; OT 0.8-2.8; SLP <1-0.1; average patient received 3.9 therapy visits in total • 4 LHINs reported no wait list • Remaining 9 LHINs: mean wait times was 48-219 days PT, 56-145 days OT and 28-323 days SLP Ontario Stroke Evaluation Report 2013

28. The Importance of Outpatient Rehab • Meyer et al. (2012) studied “avoidable” mild admissions to inpatient rehabilitation (FIM > 100; RPG 1160) - sufficient function to receive rehabilitation in the community • Compared to community-based rehabilitation resources by LHIN throughout Ontario • Correlation between lack of community outpatient rehabilitation therapy resources and likelihood mild stroke patients would be admitted to inpatient rehab • Particularly true for SLPs • Meyer et al Archives of Physical Medicine and Rehabilitation 2012; 93(10):e38.

29. Best Practice Recommendation 5.45.4.1. Outpatient and Community-Based Stroke Rehabilitation • Outpatient and/or community-based rehabilitation services should be available and provided by a specialized interprofessional team … within 48 hours of discharge from an acute hospital or within 72 hours of discharge from inpatient rehabilitation[Evidence Level C]. Time to Outpatient Rehab or Home Care is on average >20 days.

30. Best Practice Recommendation 5.45.4.1. Outpatient and Community-Based Stroke Rehabilitation • Stroke survivors with ongoing rehabilitation goals should continue to have access to specialized stroke services after leaving hospital [Evidence Level A]. This should include a blend of in-home community-based rehabilitation services … and facility-based outpatient services. • Outpatient and/or community-based services should be delivered in the most suitable setting based on patient functional rehabilitation needs and participation-related goals, which may include in the home or other community settings [Evidence Level C]. Outpatient services are in decline and home care is limited Blended services are rare in Ontario Auditor General Report 2013 noted that “Once reaching the top of the wait list, patients can face challenges in attending outpatient services” which “include a lack of transportation to and from the outpatient facility, and few or no evening or weekend services for clients not able to attend programs on weekdays.”

31. Community Stroke RehabTeam • Southwest Local Health Integrated Network (LHIN) (#2) and Ministry of Health supported development of 3 specialized multidisciplinary stroke rehab teams to coordinate personalized support to stroke survivors in their communities in 2009 • Each team consisted of registered nurse, physiotherapist, occupational therapist, speech language pathologist, social worker, therapeutic recreation therapist and rehabilitation therapist

32. Community Stroke Rehab Teams • Designed to offer rehabilitation in the community for stroke survivors with on-going rehabilitation needs Mandate • Provide direct patient care in the most appropriate setting (home and community) • Offer secondary prevention, system navigation and community re-integration • Provide caregiver support

33. Community Stroke RehabTeam • 919 initiated into active treatment • CSRT patients made gains in FIM (p<0.001) and physical (p=0.01) and psychosocial (p<0.001) domains of SIS with gains maintained at 3 months follow-up • CSRT patients showed fewer signs of depression and required less caregiver assistance Allen et al. Stroke 2013; 44:e213

34. Best Practice Recommendation 5.45.4.1. Outpatient and Community-Based Stroke Rehabilitation • Outpatient and/or community-based rehabilitation services should include the same elements as coordinated inpatient rehabilitation services: • An interprofessional stroke rehabilitation team [Evidence Level B] • A case coordination approach including regular team communication to discuss assessment of new clients, review client management, goals, and plans for discharge or transition [Evidence Level B]. • Therapy should be provided for a minimum of 45 minutes per day up to 3 hours per day, 3-5 days per week, based on individual patient needs and goals [Evidence Level B]. • Patients and families should be involved in their management, goal setting, and transition planning [Evidence Level A].

35. Ontario Auditor General Report 2013 “There was no standardized provincial or LHIN-wide eligibility criteria for admission to outpatient programs in Ontario” and “… noted that eligibility criteria varied for similar programs.” “There is no provincial or LHIN-wide policy for prioritizing patients on wait lists: each hospital follows its own procedures.” “Whereas regular rehabilitation inpatients are assessed by FIM scoring at the beginning and end of treatment to determine their functional improvement, outpatients are not similarly assessed using a standardized measure. Therefore there is little information on whether outpatient programs are effective.” “programs … prioritized internal referrals over external referrals, meaning that externally referred patients might wait longer” and recommended to “prioritize based on need …”

36. Best Practice Recommendation 5.45.4.1. Outpatient and Community-Based Stroke Rehabilitation • At any point in their recovery, stroke survivors who have experienced a change in functional status and who would benefit from additional rehabilitation services should be offered a further trial of outpatient rehabilitation [Evidence Level B]. Concerns About Lack of Chronic Stroke Rehab • Stroke survivors and their families are often frustrated by the scant clinical attention paid to chronic stroke rehabilitation management despite stroke resulting in significant long-term disability • Stroke survivors, once discharged to the communityreceive minimal if any rehabilitation support

37. The Long-Term Rehabilitation Management of Stroke • Natural recovery studies show stroke patient plateau in their recovery within 6-8 months of stroke with most recovery in first 3 months • Normal progression of recovery examined in an environment where rehab resources were invariably front-loaded • Given limited community rehab resources available for chronic stroke survivors, this recovery plateau may be a self-fulfilling prophecy Teasell et al. Topics in Stroke Rehabilitation 2012: 19(6): 457-462.

38. RCTs of Rehabilitation Interventions Greater Than 6 Months Post Stroke Teasell et al. Topics in Stroke Rehabilitation2012: 19(6):457-462

39. Best Practice Recommendation 5.5.1Management of the Arm and Hand following Stroke General Principles • Patients should engage in training that is meaningful, engaging, progressively adapted, task-specific and goal oriented in an effort to enhance motor control and restore sensorimotor function [Evidence Level: Early – Level A; Late – Level A]. • Training should encourage the use of patients’ involved affected limb during functional tasks and be designed to simulate partial or whole skills required in activities of daily living (e.g. folding, buttoning, pouring, and lifting) [Evidence Level: Early – Level A; Late – Level A].

40. Motor Rehab Post Stroke; Early, Late and Chronic Stinear et al. Stroke 2013; 44:2039-2045

41. Best Practice Recommendation 5.5.1Management of the Arm and Hand following Stroke Specific Principles • Therapists should provide supplemental training programs aimed at increasing the active movement and functional use of the affectied arm between training sessions, e.g. GRASP [Evidence Level: Early – Level A; Late – Level C]. • GRASP should include … • Mental Imagery [Evidence Level: Early – Level A; Late – Level B]. • FES [Evidence Level: Early – Level A; Late – Level A]. • CIMT [Evidence Level: Early – Level A; Late – Level A]. • Mirror Therapy [Evidence LevelA]. • Sensory Stimulation [Evidence LevelA].

42. Mirror Therapy Post Stroke • Mirror therapy is a form of motor imagery in which a mirror is used to convey visual stimuli to the brain through observation of one's unaffected body part as it carries out a set of movements • Mirror is placed in patient’s midsagittal plane, reflecting movements of the non-paretic side as if it were the affected side • Premotor cortex is important to neuroplasticity and is responsive to visual feedback • Robotics assisted haptic enabled mirror-like therapy provides both visual and proprioceptive inputs and may serve to accelerate neuroplasticity

43. Mirror Therapy Post Stroke • Cochrane Review (2012) included 14 studies (RCTs and randomized cross-over trials) with a total of 567 participants comparing mirror therapy with any control intervention for patients with stroke. • When compared to all other interventions, mirror therapy may have a significant effect on motor function depending on control intervention • Mirror therapy may improve ADLs, reduce pain and improve visual spatial neglect • Effects on motor function were stable at followup • Positive impact of mirror therapy at least as an adjunct to normal rehabilitation post stroke Thieme et al. Cochrane Database Syst Review 2012

44. Mobility and Upper Extremity Therapy: It Doesn’t Seem to Matter What You Do As Long as You Do Something! • Motor studies account for >50% of rehab RCTs (>600 RCTs) • Moving from relatively small RCTs with weak controls (usual care) to larger multi-centered trials with active control groups • Examples are Treadmill Training Partial Body Weight Support (LEAPS), Constraint-Induced Movement Therapy (VECTORS) and Robotics for Upper Extremity Function (Loh et al.) • As move to larger, more sophisticated RCTs with active controls, it appears intensive goal-directed therapy worksbut it does not seem to matter what therapy is done Duncan PW et al. NEJM 2011;364:2026-36. DromerickAW et al. Neurology 2009. 73:195-201 Lo et al. N Engl J 2010

45. Best Practice Recommendation 5.5.1Management of the Arm and Hand following Stroke Specific Principles • For patients with flaccid arm (CMS<3) electrical stimulation should be considered [Evidence Level: Early – Level A; Late – Level B]. • Where available, virtual reality techniques … can be used as an adjunct .. [Evidence Level B]. Adaptive Devices • Functional dynamic orthoses are an emerging therapy tool that may be offered to patients to facilitate repetitive task-specific training [Evidence LevelC].

46. Best Practice Recommendation 5.6.3Lower-Limb Gait Training following Stroke • Task and goal-oriented training that is progressively adapted, meaningful, salient, and involves active participation should be used to improve performance of selected lower-extremity tasks [Evidence Level: Early – Level B; Late – Level B]. • Treadmill-based gait training … [Evidence Level: Early – Level C; Late – Level B]. • Body weight supported treadmill training … can be used for patients with low ambulatory function when other strategies for walking practice are unsuccessful or unsafe [Evidence Level: Early – Level A; Late – Level A]. • Aerobic exercise program [Evidence Level: Early – Level A; Late – Level A].

47. Best Practice Recommendation 5.8Rehabilitation of Visual Perceptual Deficits • All patients with stroke should be screenedfor visual perceptual deficits as a routine part of the broader rehabilitation assessment process [Evidence Level C]. • Patients with suspected perceptual impairments … should be assessed using validated tools [Evidence Level C]. • Treatment of neglect can include visual scanning techniques, phasic alerting, cueing, imagery, visual reality, hemispheric (limbic) activation and trunk rotation [Evidence Level B]. • Remedial based techniques could include prisms, eye patching, transcranial magnetic stimulation, and neck muscle vibration [Evidence Level A].

48. Prisms for Neglect • Prisms affect spatial representation by bending the visual field input and increase visual fields by 5-10 degrees. • Outside of visual field when looking straight ahead but when gaze is shifted to the affected side increases visual field • Strong evidence prism treatment associated with increases in visual perception scores in stroke patients with homonymous hemianopsia and visual neglect; however, it was not associated with improvement in ADL scores

49. Best Practice Recommendations 7.2.1Vascular Cognitive Impairment and Dementia: Screening and Assessment • Patients with significant vascular risk factors for VCI, such as hypertension, diabetes, TIA or clinical stroke … should be considered for VCI screening [Evidence Level A] • Screening for VCI should be conducted using a validated screening tool, such as the MOCA [Evidence Level C]. • Post-stroke patients with suspected cognitive impairment should also be screened for depression … • Patients who demonstrate cognitive impairments in the screening process should be managed by a healthcare professional with experience in the assessment and management of neurocognitive functioning. …

50. Assessment of Cognition Post Stroke • Many existing cognitive screening tools were developed for dementia and are weighted towards memory and orientation (eg, the Mini-Mental State Examination) (Folstein et al. 1975) • The Mini-Mental State Exam (MMSE) and Montreal Cognitive Assessment (MOCA) are two most commonly employed screening instruments for detecting CI post stroke Folstein et al. J Psychiatr Res. 1975; 12:189-198 Nasreddine et al. J Am GeriatrSoc 2005; 53:695–699