Overview, Methods and Knowledge Translation

The Canadian Stroke Best Practice Recommendations (CSBPR) are designed to support implementation of best practices in stroke care across Canada. Healthcare systems, health organizations and professional organizations, as well as legislation and standards, may vary provincially. The CSBPR provide guidance on a national level; they do not, on the whole, account for provincial variations in legislation or standards. The CSBPR are not intended to supersede any provincial or local law or organizational or professional standard. In considering and implementing the CSBPR, users are encouraged to consult and follow all appropriate legislation or standard.

Methodology

The Canadian Stroke Best Practice Recommendations development and update process is guided by a core set of principles which are applied to all activities of the writing groups. These principles state that all recommendations included in the CSBPR must be:

• Supported by high quality evidence and/or strong consensus that they are essential drivers to delivering high-quality stroke care;
• integral to facilitating health system improvement;
• aligned with other stroke-related Canadian best practice recommendations, e.g., the management of hypertension, diabetes, and dyslipidemia to decrease ambiguity and contradictions for front-line clinicians;
• reflective, in their totality, of the full continuum of stroke care.

The methodology for updating the recommendations includes twelve distinct steps to ensure a thorough and rigorous process.  The detailed methodology and steps in the development and dissemination of the Canadian Stroke Best Practice Recommendations is available in the Canadian Stroke Best Practice Recommendations Overview and Methodology manual.

Updates and Revisions:
The Canadian Stroke Best Practice Recommendations undergo a thorough formal review and update of each chapter every two to three years. The CSBPR were first introduced in 2006, and subsequently updated and expanded in 2008, 2010, 2012 and 2015. The 2016 – 2018 update cycle is in the final completion stages, and the 2019 – 21 cycle was launched in January 2019.
 
Since research evidence for stroke care delivery is very dynamic and evolving, a protocol has been established to address late-breaking evidence in a timely way. When new evidence is released that may have an impact on any recommendations contained within these guidelines, the appropriate writing group is contacted and the evidence is reviewed, and decisions made regarding its impact on current recommendations. Any proposed revisions proceed through the same rigorous review process that is followed for the full chapter reviews. The CSBPR team then releases an interim bulletin regarding any off-cycle revisions that have been approved.  These bulletins are incorporated into subsequent updates as applicable.

CSBPR Contributors

The CSBPR are made possible through the leadership of Heart and Stroke in collaboration with the Canadian Stroke Consortium and an extensive list of volunteers on our advisory committee and writing groups.  These volunteers include people who are recognized leaders in the field of stroke care delivery, epidemiology, guideline development, systems change, and people who have experienced a stroke first hand or as a caregiver to someone who has had a stroke.  All members of the CSBPR advisory committee and writing groups are required to complete declarations of conflict of interest prior to participation.

Current members of the Canadian Stroke Best Practices and Quality Advisory Committee are available here.

Current members of the CSBPR writing groups are available here.

The CSBPR are made possible through the leadership of Heart and Stroke in collaboration with the Canadian Stroke Consortium and an extensive list of volunteers on our advisory committee and writing groups.  These volunteers include people who are recognized leaders in the field of stroke care delivery, epidemiology, guideline development, systems change, and people who have experienced a stroke first hand or as a caregiver to someone who has had a stroke.  All members of the CSBPR advisory committee and writing groups are required to complete declarations of conflict of interest prior to participation.

Current members of the Canadian Stroke Best Practices and Quality Advisory Committee are available here.

Current members of the CSBPR writing groups are available here.

• The human cost of stroke is immeasurable.
• Every year, approximately 62,000 people with ischemic stroke, hemorrhagic stroke and transient ischemic attack (TIA) are treated in Canadian hospitals. 
• It is estimated that for each symptomatic stroke, there are nine covert strokes that result in vascular cognitive impairment – that can range from subtle changes in cognitive function and processes to severe vascular dementia. 
• Stroke and other cerebrovascular diseases are the third leading cause of death in Canada.
• Stroke is the leading cause of adult disability, with over 405,000 Canadians living with the effects of stroke.
• About 60% of stroke patients are left with some disability and more than 40% are left with moderate to severe disability that requires more intense rehabilitation and support in the community. In Canada, 19% of people with stroke accessed inpatient rehabilitation services in 2016 and 10% were admitted to long-term care.
• 1.9 million brain cells die every minute during a stroke.
• The annual cost of stroke is approximately $3.6 billion, taking into account both healthcare costs and lost economic output.
• Although there are many proven interventions for stroke prevention, treatment and rehabilitation, they are not widely or consistently applied.
• In Canada there are more than 10,000 children (0 – 18 years) living with stroke.

This theme stresses the importance of integration and coordination across the healthcare system to ensure timely and seamless care of stroke patients to optimize recovery and outcomes.

Involvement of individuals who have had a stroke, their families and caregivers, is paramount to collaborations and partnerships and emphasized a patient and family-centred approach to stroke care delivery.

Working with interprofessional stroke care team members, other vascular care groups, emergency medical services, community care providers, educators, researchers, health system funders, planners and managers, will strengthen our ability to reduce risk factor prevalence, incidence, morbidity, and mortality from stroke.

Individuals who experience a stroke often present with additional health conditions or issues, which increases the challenges and complexity of comprehensive stroke management. Partnerships and collaborations with healthcare providers from a range of specialties is imperative to ensure people with multimorbidities have optimal control of each condition, do not fall through the cracks, do not receive conflicting or contra-indicated treatments, and do receive support to navigate the healthcare system.

Partnerships and collaborations are also necessary to support stroke care in rural and remote settings where some basic stroke services may not be available. People experiencing a stroke in those regions may not have access to optimal treatment strategies, which may result in poorer outcomes.

This theme aligns with and supports the Heart and Stroke Foundation’s Promote Recovery mission priority and is included as part of each module for the 2016-2018 update of the Canadian Stroke Best Practice Recommendations.

Heart & Stroke leads professional education activities that target members of interdisciplinary healthcare teams and system leaders who care for people who experience a stroke. We provide learning opportunities that address stroke care delivery across the full continuum of care. Our core knowledge translation activities  include:

• Stroke Best Practices webinar series: regular webinars that focus on new updates to our recommendations and more deeply explore current evidence and practice on specific topics relevant to stroke. Presentations are delivered by experts to increase knowledge and support the implementation of stroke best practice recommendations. Webinars are recorded and archived. To access the list of upcoming webinars and archived recordings visit the SBP webinars page.
• Implementation resources – a range of quick reference resources,  training programs and links to high quality knowledge translation tools are available within each recommendation section and Heart & Stroke developed resources are available on the professional resources webpage. Resources to support people experiencing stroke and their families are available on the patient resources page.
• Canadian Stroke Congress –The Canadian Stroke Congress (CSC), co-hosted by the Heart and Stroke Foundation and the Canadian Stroke Consortium, is the premier stroke congress in Canada.  The goals of the Canadian Stroke Congress are to provide a high-quality educational event that will increase capacity and capability for stroke care in Canada.  Information regarding the Canadian stroke congress can be found on the events webpage.
• Clinical Update – The Heart & Stroke Clinical Update is a two-day learning event that enables participants to bring the latest clinical developments, guidelines and practical knowledge pertaining to the prevention, diagnosis, assessment and management of cardiovascular and cerebrovascular diseases to patient practice.  Clinical update is designed for healthcare providers across the continuum of care who support and manage people with heart disease and conditions, stroke and vascular cognitive impairment within their practice, especially primary care health team members and community-based providers across all disciplines and specialty areas.

Activities of daily living: The basic elements of personal care such as eating, washing and showering, grooming, walking, standing up from a chair and using the toilet.

Activity: The execution of a task or action by an individual. Activity limitations are difficulties that an individual may have in executing activities

Agnosia: The inability to recognize sounds, smells, objects or body parts (other people’s or one’s own) despite having no primary sensory deficits.

Alternate level of care: A patient receiving an alternate level of care is one who has finished the acute care phase of treatment but remains in an acute care bed, awaiting placement in an alternate care setting (chronic care unit, home for the aged, nursing home, home care program, etc.). This classification occurs when the patient is admitted as a patient’s physician gives an order to change the level of care from acute care and requests a transfer for the patient. Sometimes a patient is admitted as a patient requiring an alternate level of care because alternate care is not available (Canadian Institute for Health Information Discharge Abstract Antiplatelet agents: Agents that inhibit platelet aggregation. These agents are used in the prevention of ischemic stroke in high-risk patients.

Anxiety following stroke is characterized by feelings of tension, extreme apprehension and worry, and physical manifestations, such as increased blood pressure. Anxiety disorders occur when symptoms become excessive or chronic. In the post-stroke literature, anxiety has been defined both by consideration of the presence and severity of symptoms using validated screening and assessment scales (such as the Hospital Anxiety and Depression Scale), or by defining syndromes using diagnostic criteria (e.g., panic disorders, general anxiety disorder, social phobia).

Apathy is most commonly defined as a multidimensional syndrome of diminished goal-directed behavior, emotion, and cognition (Sachdev 2017; Chen 2018). People present with loss of motivation, concern, interest, and emotional response, resulting in a loss of initiative, decreased interaction with their environment, and a reduced interest in social life. It can negatively impact recovery post-stroke. Apathy can occur as an independent syndrome, although it may also occur as a symptom of depression or dementia (Marin,1991; Starkstein 2008). Apathy has been reported to occur in 29 – 40% of people who have experienced a stroke (van Dalen 2013).

Aphasia: Loss of the inability to produce or comprehend language as a result of injury to specialized areas in the brain related to these functions, affecting the ability to speak, understand, or read and write.

Apraxia: Impaired planning and sequencing of movement that is not due to weakness, incoordination or sensory loss.

Assistive technology: Technology designed to help a patient with limitations to perform daily activities and social roles.

Atrial fibrillation: Rapid, irregular beating of the heart.

Balance: Acquisition and maintenance of postural stability at rest or during activities.

Balance training: Sensory motor and cognitive intervention to promote postural stability.

Biofeedback: A technique monitoring physiological functions and providing extrinsic feedback, which may include somatosensory, visual and auditory input.

Canadian Institute for Health Information: An independent, not-for-profit organization that provides essential data and analysis on Canada’s health system and the health of Canadians. This organization tracks data in many areas, using information supplied by hospitals, regional health authorities, medical practitioners, governments and other sources.

Canadian Stroke Strategy: A joint initiative of the Canadian Stroke Network and the Heart and Stroke Foundation of Canada. It brings together a multitude of stakeholders and partners with the common vision that “All Canadians have optimal access to the integrated high quality, and efficient services in stroke prevention, treatment, rehabilitation and community reintegration”.

Cardio Respiratory Fitness: Related to the ability to perform large muscle, dynamic, moderate-to-high intensity exercise for prolonged periods. Improvements in cardiorespiratory fitness result in improvements of the heart to deliver oxygen to the working muscles and in the muscle`s ability to generate energy with oxygen and result in better endurance performance. (America College of Sports Medicine Guidelines, 2000)

Cardiovascular Disease: Disease pertaining to the heart and blood vessels.

Caregiver refers to a family member or friend who is unpaid and involved in the care of a person who has had a stroke across their illness and recovery trajectory. They assist with many aspects of care including activities and instrumental activities of daily living, attending to health care needs, supporting emotional needs, advocacy, rehabilitation, and community re-integration and resuming life roles. As an integral member of the care team, they need to be recognized and supported in their caregiving role and their capacity to provide the many facets of care.

Carotid endarterectomy: Surgical opening in one of the main neck arteries (the carotid arteries) performed when the artery is partially blocked by plaque (the buildup of fatty materials, calcium and scar tissue that narrows the artery). The procedure helps prevent a first stroke or reduces the risk of further strokes. It works best for people whose artery is narrowed but not completely blocked. (Heart and Stroke Foundation)

Case Managers enable people, their families, and caregivers to maintain and achieve their highest level of functioning and independence. Case managers maintain an ongoing assessment process, which involves identifying the changing needs of the person and helps to facilitate optimal outcomes. They oversee, coordinate, and integrate the delivery of care. Case managers possess the knowledge, skill, and judgement to ensure that people receive the highest possible quality of care when they need it.

Cerebrovascular Disease: Disease pertaining to the blood vessel of the brain.

Cognitive: Relating to the ability to think, remember and solve problems.

Cognitive deficits: The pattern of cognitive deficits in vascular cognitive impairment may encompass any cognitive domain (see Sachdev et al., 2014, Table 1). The most common areas are attention, processing speed, and frontal-executive function (which includes functions such as planning, decision making, judgment, error correction, impairments in the ability to maintain task set, inhibit a response, or shift from one task to another) and deficits in the ability to hold and manipulate information (e.g., working memory). Other cognitive domains that could be affected include learning and memory (immediate, recent and recognition memory), language (expressive, receptive, naming, grammar and syntax), visuoconstructional-perceptual ability, praxis-gnosis-body schema, and social cognition.

Community is defined as the physical and social care environment where individuals may live after having a stroke. It includes any non-hospital setting, where one would reside and resume life roles and activities following a stroke such as a family home, assisted living facility, long-term care, or other residential settings.

Community-based care programs are services and programs that are based in the community, in the home of the person receiving services, or in group living situations (Canadian Centre for Accreditation).

Community-based rehabilitation therapy: Rehabilitation provided in the home or community-based organizations.

Community reintegration: A return to participation in desired and meaningful activities of daily living, community interests and life roles following a stroke event. The term encompasses the return to mainstream family and active community living and continuing to contribute to one’s social groups and family life. Community reintegration is a component in the continuum of care after stroke; rehabilitation helps clients identify meaningful goals for community reintegration and, though structured interventions, facilitates resumption of these activities to the best of their abilities. The stroke survivor, family, friends, stroke recovery associations, rehabilitation programs and the community at large are all integral to successful community reintegration.

Comorbid condition: Relates to the effect of all other diseases or conditions a patient may have in addition to the primary disease of interest

Compensatory therapy: Adaptive therapeutic interventions designed to enhance activity and participation (the focus is on function and not impairment).

Comprehensive stroke centres: Centres with specialized resources and personnel available at all times (24 hours a day, 365 days a year) to provide assessment and management of stroke patients. These facilities have established written protocols for emergency services, in-hospital care and rehabilitation; the ability to offer thrombolytic therapy to suitable ischemic stroke patients; timely neurovascular imaging and expert interpretation; and coordinated processes for patient transition to ongoing rehabilitation, secondary prevention and community reintegration services. Comprehensive stroke centres also include neurosurgical facilities and interventional radiology services. Comprehensive stroke centres have a leadership role in establishing partnerships with other local hospitals for supporting stroke care services. Comprehensive stroke centres should also have a performance measurement system in place to monitor the quality of stroke care and patient outcomes.

Computed tomography scan: Radiographic images of the head, appearing as a series of thin slices showing details of the brain`s anatomy. In some cases, a contrast dye may be injected to better define tissues and blood vessels and enhance the images. These images can show whether a stroke was due to a blood clot (an ischemic stroke) or uncontrolled bleeding (a hemorrhagic stroke). This is often one of the first tests scheduled for someone who has had a stroke.

Constraint induced therapy: Intervention designed to enhance recovery of function or a body part by restraining a less affected function or body part.

Continuing Care Reporting System: Contains standardized clinical and administrative information on continuing care in Canada, which includes detailed clinical, functional and service information (e.g., residents` preferences, needs and strengths) and provides a snapshot of the services they use. Two types of facilities are included: hospitals that have beds designated and funded as continuing care beds, commonly known as extended, auxiliary, chronic or complex beds; and residential care facilities, commonly known as nursing homes, personal care homes or long-term care facilities. The data are collected using the Resident Assessment Instrument (RAI) Minimum Data Set (MDS 2.0).

Conventional therapy: The usual care offered in a particular setting and must be defined in terms of their intensity, frequency, and duration.

Cryptogenic Stroke: Cryptogenic stroke is defined as a brain infarction not clearly attributable to a definite cardioembolism, large artery atherosclerosis, small artery disease or other identifiable cause despite extensive investigation (Saver et al 2017). This group accounts for 25 to 40% of all stroke (Saver, 2016; Yaghi et al, 2017).

Day hospital: A defined geographic outpatient unit dedicated to interdisciplinary care and rehabilitation of an individual.

Deep vein thrombosis: Thrombosis (a clot of blood) in the deep veins of the leg, arm or abdomen.

Depression following stroke: Within this module, we consider depression following stroke. The DSM5 category that applies is mood disorders due to another medical condition such as stroke with depressive features, major depressive-like episode, or mixed-mood features. It is often associated with large vessel infarction. (DSM-5 293.83; Robinson and Jorge, AJP, Volume 173, Issue 3, March 01, 2016, PP. 221-231). 

• A patient who is a candidate for this diagnosis would present with depressed mood or loss of interest or pleasure along with four other symptoms of depression (e.g., weight loss, insomnia, psychomotor agitation, fatigue, feelings of worthlessness, diminished concentration, suicidal ideation) lasting two or more weeks. 
• Several mechanisms, including biological, behavioural, and social factors, are involved in its pathogenesis.
• Symptoms usually occur within the first three months after stroke (early onset depression following stroke); however, may occur at any time (late onset depression following stroke). Symptoms resemble those of depression triggered by other causes, although there are some differences - people who have experienced a stroke with depression following stroke experience more sleep disturbances, vegetative symptoms, and social withdrawal.

Disability: A defect in performing a normal activity or action (e.g., inability to dress or walk).

Discharge Abstract Database: Database of information related to acute care hospital discharges across Canada. The database is maintained by the Canadian Institute for Health Information, which receives data directly from all hospitals in every province and territory except Quebec. The database contains demographic, administrative and clinical data for hospital discharges (inpatient acute, chronic, rehabilitation) and day surgeries in Canada.

Discharge disposition: A patient`s destination following a visit to the emergency department or following a stay in hospital. A patient`s discharge disposition may or may not be the same location as before their visit to hospital.

Dysarthria: Impaired ability to produce clear speech due to the impaired function of the speech muscles

Dysphagia: An impairment of swallowing that may occur following a stroke.

Early supported discharge: Early supported discharge services aim to move forward the time of discharge from hospital, as well as to provide a more continuous process of rehabilitation spanning both the period in hospital and the first few weeks at home. In these two ways, early supported discharge alters the conventional pathway of care to ensure more amenable services for patients undertaking rehabilitation.

Emergency department: A hospital or primary care department that provides initial treatment to patients with a broad spectrum of illnesses and injuries, some of which may be life-threatening and require immediate attention.

Emergency medical services: Provide out-of-hospital acute care and transport to definitive care for patients with illnesses and injuries that the patient believes constitute a medical emergency. The most common and recognized type of emergency medical service is an ambulance or paramedic organization.

Enteral tube: Delivery of nutrients directly into the digestive system via a tube.

Executive function: Cognitive functions usually associated with the frontal lobes, including planning, reasoning, time perception, complex goal-directed behaviour, decision-making and working memory.

Exercise therapy: Intervention directed towards optimizing physical capacity.

Functional independence measure: An 18-item, 7-level ordinal scale. It is the product of an effort to resolve the long-standing problem of lack of uniform measurement and data on disability and rehabilitation outcomes.

Gait: The pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.

Hemiparesis: Weakness involving one side of the body (of mild, moderate or severe degree) that may be caused by stroke and can be accompanied by sensory or other neurological deficits.

Hemiplegia: Refers to a complete paralysis. Complete loss of motor function on one side of body that may be caused by stroke localized to the cerebral hemisphere opposite to the side of weakness.

Hemorrhagic stroke: A stroke caused by the rupture of a blood vessel within the brain tissue, subarachnoid space or intraventricular space.

Hemorrhagic infarct: Hemorrhagic infarct is defined as a hemorrhagic transformation into an area of arterial ischemic infarction or venous thrombosis associated tissue congestion.

Home Care is defined as providing medical, nursing, rehabilitation and personal care services to people in a home setting rather than in a medical facility. Home care services enable people to remain safely in their home by continuing their rehabilitation therapy and increasing their independence.

Hyperacute period: The time frame from the initial onset of stroke symptoms and engagement of emergency medical services though interaction with paramedics and within the emergency departments of acute care hospitals.

Hypertension: High blood pressure, defined as a repeatedly elevated blood pressure exceeding 140 ⁄ 90 mm HG. Hypertension is a risk factor for stroke or transient ischemic attack and is managed with regular aerobic exercise, weight reduction (if overweight), salt reduction and medications.

Hypertonia: Abnormal increase in resistance while externally imposing movement about a joint.

Impairment: A problem in the structure of the body (e.g., loss of a limb) or the way the body of a body part functions (e.g., hemiplegia).

Infarction: Death of cells in an organ (e.g., the brain or heart) due to lack of blood.

Integration: An integrated health system would result in coordinated health services that both improve accessibility and allow people to move more easily through the care and treatment continuum of the care health system and would provide appropriate, effective and efficient health services.

Intensity: The level of effort demanded or required of the individual in relation to their current capacity (physical and mental).

Intracranial hemorrhage includes bleeding within the cranial vault and encompasses intraventricular, intraparenchymal, subarachnoid, subdural and epidural hemorrhage.

Interdisciplinary stroke team: A comprehensive team of healthcare professionals who are dedicated to the care of stroke patients within a unit. An interdisciplinary stroke team may include persons who have experienced a stroke, family and caregivers, neurologists and other physicians with expertise in stroke management, physiatrists, nurses, primary care practitioners, physical therapists, occupational therapists, speech language pathologists, social workers, dieticians, pharmacists, psychologists, rehabilitation assistants and pastoral care workers.

International normalized ratio: Used to evaluate the ability of blood to clot properly, this ratio can be used to assess both bleeding and clotting tendencies. One common use is to monitor the effectiveness of anticoagulants such as warfarin.

Ischemia: An inadequate flow of blood to part of the body because of blockage or constriction of the arteries that supply it.

Last seen normal: The date and time a patient was last known to be normal before the onset of symptoms of stroke or transient ischemic attack.

Lack of stay: A measure of the duration of a single hospitalization.

Length of stay: A measure of the duration of a single hospitalization.

Long-term care is the provision of organized institutional care for three or more unrelated people in the same place. Long-term care is provided for people of all ages who need assistance with the activities of daily living (ADL) in order to enjoy a reasonable quality of life. The need for long-term care following a stroke may be due to changes in physical, psychological and/or cognitive abilities. The goal of long-term care is to ensure that an individual who is not fully capable of selfcare can maintain the best possible quality of life, with the greatest possible degree of independence, autonomy, participation, personal fulfilment and human dignity. The need for long-term care following a stroke is influenced by changing physical, psychological and/or cognitive functional capacities, their abilities and level of independence prior to the stroke, and the availability of family and caregivers. Many people may regain lost functional capacities over a shorter or longer period of time following stroke, while others decline. The type of care needed, and the duration of such care are thus often difficult to predict.

Long-term care home: A facility that provides rehabilitative, restorative or ongoing skilled nursing care to residents in need of assistance with activities of daily living.

Low-density lipoprotein: A compound that regulates cholesterol synthesis from the liver to the peripheral tissues. Sometimes referred to as “bad cholesterol,” LDL may put an individual at risk for cerebrovascular disease if it occurs at high levels.

Mean: Simple average, equal to the sum of all values divided by the number of values.

Median: The value that has 50 percent of the data points above it and 50 percent below it.

Medical redirect bypass: Following predefined medical criteria and a written agreement between physicians, hospitals, dispatch and ambulance service, a closer hospital may be bypassed for medical reasons to redirect the person exhibiting signs and symptoms of stroke to a stroke centre that can provide expert timely assessment and treatment

Muscular endurance: Ability of a muscle or muscle group to perform repeated muscle contractions over a period of sufficient to cause muscular fatigue, or to maintain a specific percentage of the maximum voluntary contraction for a prolonged period of time (ACSM, 2001)

Muscle strength: Maximal force that can be generated by a specific muscle or muscle group. (ACSM, 2000)

National Ambulatory Care Reporting System: Includes data for all hospital-based ambulatory care provided departments. Client visit data are collected at the time of service in participating facilities. Currently, data submission to the National Ambulatory Care Reporting System has been mandated in Ontario for emergency departments, day surgery units, dialysis units, cardiac catheterization suites and oncology units (including all regional caner centres). Data elements include demographic data, clinical data, administrative data, financial data and service-specific data elements for day surgery and emergency.

National Rehabilitation Reporting System: Includes client data collected from participating adult inpatient rehabilitation facilities and programs across Canada. Data are collected at time of admission and discharge by service providers in participating facilities. There is also an optional postdischarge follow-up data collection process. The National Rehabilitation Reporting System data elements are organized under the following categories: socio-demographic information, administrative data (e.g., referral, admission and discharge), health characteristics, activities and participation (e.g., activities of daily living, communication, social interaction), interventions. These elements are used to calculate a variety of indicators including wait times and client outcomes.

Neglect: The failure to attend or respond to or make movements toward one side of the environment.

Outpatient rehabilitation: Includes day hospital, outpatient ambulatory care and home-based rehabilitation. Outpatient therapy in the subacute phase of stroke (4 to 8 weeks after stroke) is often prescribed following discharge from inpatient stroke rehabilitation units. (Evidence-Based Review of Stroke Rehabilitation, 10^th edition)

Outpatient Therapy: In the subacute phases of stroke (4-8 weeks after stroke) outpatient rehabilitation therapy in an outpatient clinic affiliated with an acute care or inpatient rehabilitation facility may be prescribed upon discharge from acute inpatient care or inpatient rehabilitation.

Percutaneous endoscopic gastrostomy: A form of enteral feeding in which nutrition is delivered via a tube that has been surgically inserted into the stomach through the skin.

Performance measure: A quantifiable measure of outcomes, outputs, efficiency, access and other dimensions of quality of care.

Peripheral Artery Disease: A circulation disorder that is caused by narrowed or blocked blood vessels in arteries located outside of the heart and brain.

Post-Stroke Fatigue: Fatigue following stroke is a multidimensional motor-perceptive, emotional and cognitive experience characterized by a feeling of early exhaustion with weariness, lack of energy and aversion to effort that develops during physical or mental activity and is usually not ameliorated by rest. Fatigue can be classified as either objective or subjective. Objective fatigue is defined as the observable and measurable decrement in performance occurring with the repetition of a physical or mental task, while subjective fatigue is a feeling of early exhaustion, weariness and aversion to effort (Acciarresi et al, 2014; Staub 2001, Annoni 2008, Lerdal 2009, Eskes 2011).

Characteristics of post-stroke fatigue may include: overwhelming tiredness and lack of energy to perform daily activities; abnormal need for naps, rest, or extended sleep; more easily tired by daily activities than pre-stroke; unpredictable feelings of fatigue without apparent reason.

Primary prevention: Primary prevention can be a population-based approach to prevent disease among communities or an individually based clinical approach to disease prevention, directed toward preventing the initial occurrence of a disorder in otherwise healthy individuals. Primary prevention can be implemented in the primary care setting, and the physician, nurse, physician assistant, pharmacist or patient may initiate a discussion of heart conditions, stroke and vascular cognitive impairment risk reduction. It can also be implemented at a population level using legislative, regulatory and public awareness interventions. Primary prevention and health promotion recommendations related to heart conditions, stroke, TIA, vascular cognitive impairment and peripheral vascular disease emphasize the importance of screening and monitoring and treating those patients at high risk of a first clinical event. Primary prevention areas of focus include lifestyle (healthy diet, physical activity, being smokefree, stress reduction and limiting alcohol, recreational drugs and cannabis use), and screening and management of risk factors such as hypertension screening, dyslipidemia screening, diabetes management, and management of atrial fibrillation. Implementation of primary prevention strategies ideally would involve a Shared DecisionMaking conversation between the patient and the provider to ensure the patient’s goals are incorporated to therapy decisions. Primary prevention also includes the development of strategies to improve population health such as policies that support the population by making healthy choices the easier choices (examples including smoke-free legislation, revised Canada’s Food Guide), and policies that support active and public transportation. These strategies are often led by health-oriented organizations and agencies such as Heart & Stroke, Canadian Cardiovascular Society, Thrombosis Canada, Hypertension Canada, Diabetes Canada, Alzheimer Society of Canada, Health Canada, and national and provincial public health agencies and services.

Pulmonary embolism: Blockage of the pulmonary artery (which carries blood from the heart to the lungs) with a solid material, usually a blood clot or fat, that has travelled there via the circulatory system.

Rankin Scale (modified): An outcomes scale used to measure disability or dependence in activities of daily living in stroke victims.

Recovery: The process whereby the person regains body structure, function, activity and participation. (Not time limited)

Registry of the Canadian Stroke Network: A clinical database that collects data from prehospital stroke onset to discharge from acute care, following a stroke or transient ischemic attack. Information is collected on risk factors, presentation, acute investigations and interventions, inpatient management, complication, discharge disposition, length of stay and mortality. Note: During the data collection period for the 2006 report of the Stroke Evaluation Advisory Committee, only 10 regional stroke centres were participating in the Registry of the Canadian Stroke Network (Central South ⁄ Royal Victoria Hospital was not yet part of the network). Data collection began July 1, 2003, so the fiscal year 2003-04 included only 9 months of data, which means that volumes and counts are underestimated for that year.

Rehabilitation: Restoration of a disabled person t optimal physical and psychological functional independence.

Restorative (remedial) therapy: Therapeutic interventions designed to restore body structure and function by targeting the underlying impairment to enhance recovery.

Risk factor: A characteristic of a person (or group of people) that is positively associated with a particular disease of condition.

Secondary prevention: Secondary prevention is an individually based clinical approach aimed at reducing the risk of a recurrent vascular event in individuals who have already experienced angina, myocardial infarction, heart failure, heart rhythm abnormalities, structural heart disease, stroke, transient ischemic attack, vascular cognitive impairment or peripheral vascular disease. Secondary prevention recommendations are directed to those risk factors shown to reduce recurrent and prolong survival after vascular conditions, including attention to lifestyle (prudent diet, reduced sodium intake, increased level of activity, maintaining ideal body weight, smoking cessation, and controlling alcohol intake), and management of medical conditions such as hypertension, dyslipidemia, and heart rhythm management (e.g. atrial fibrillation). Secondary prevention recommendations can be addressed in a variety of settings— community-based care settings (primary care and subspecialty care), vascular prevention clinics (generalized or specific to conditions such as stroke, heart failure, post myocardial infarction) emergency care, including emergency medical services, acute care, and rehabilitation. They pertain to patients initially seen in primary care, those who are treated in an emergency department and then released and those who are hospitalized and receive treatment in hospital because of angina, myocardial infarction, heart failure, heart rhythm abnormalities, structural heart disease, stroke, transient ischemic attack, vascular cognitive impairment or peripheral vascular disease. Recommendations for secondary prevention of vascular conditions should be implemented throughout the recovery phase, including during inpatient and outpatient rehabilitation, reintegration into the community and ongoing follow-up by primary care practitioners. Secondary prevention should be addressed at all appropriate healthcare encounters on an ongoing basis following angina, myocardial infarction, heart failure, heart rhythm abnormalities, structural heart disease, stroke, transient ischemic attack, vascular cognitive impairment or peripheral vascular disease.

Self-management refers to the ability of individuals to manage their health following a stroke to optimize rehabilitation and prevent recurrent stroke. It includes knowledge, skills, attitudes and behaviours to enhance self-efficacy for managing physical, cognitive and lifestyle changes. It involves active participation of the individual, families and caregivers and may include a plan developed collaboratively with healthcare providers.

Spasticity: Velocity-dependent increase in muscle tone that often occurs in stroke.

Spontaneous, nontraumatic intracerebral hemorrhage is bleeding within the brain parenchyma without obvious systemic, neoplastic, traumatic, or macrovascular etiology. This stroke subtype accounts for about 10-15% of all strokes and a disproportionately higher number of stroke related deaths. ICH are often categorized according to their location within the brain: lobar, deep, cerebellar, and brainstem.

Stroke: Rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin.

Stroke Navigators are individuals who provide holistic case management support and guidance to people with stroke and their families, friends, and caregivers. Navigators provide guidance throughout the stroke recovery experience to help improve the quality of life through education and improved access to, and/or coordination of, healthcare services as well as other needed resources.

Stroke prevention clinic: A clinic providing comprehensive stroke prevention services to patients who are not admitted to the hospital at the time of their emergency department visit. Prevention clinics offer an interdisciplinary team approach and are typically funded for an advanced practice nurse, a medical secretary and a behavioural psychologist or occupational therapist.

Stroke Rehabilitation is a progressive, dynamic, goal orientated process aimed at enabling a person with stroke-related impairment to reach their optimal physical, cognitive, emotional, communicative, and social functional level. Rehabilitation is NOT a setting, rather, it is a process that includes a set of activities that begins soon after the initial event, once the patient is medically stable to participate and can identify goals for rehabilitation, recovery and participation. Rehabilitation occurs across the continuum of stroke care in a variety of settings such as acute care or sub-acute care; rehabilitation units, on general or mixed rehabilitation units; in ambulatory or community settings, such as outpatient or day clinics, home-based services (incudes early supported discharge services), recreation centres, and outreach teams. In the chronic stage of stroke, rehabilitation may also focus on maintaining current functional abilities and preventing or slowing future functional decline and secondary health conditions (such as contractures, and depression).

Stroke unit: A specialized, geographically located hospital unit with a dedicated stroke team and stroke resources (e.g., care pathway, educational material, monitored beds). The unit does not need to have all of these resources, nor does it have to be exclusive for stroke patients, but it must be in one location.

Subarachnoid hemorrhage: Occurs when a blood vessel just outside the bran ruptures and blood fills the subarachnoid space surrounding the brain, Symptoms may include a sudden, intense headache, neck pain, and nausea or vomiting.

Support for individuals, families and caregivers following stroke generally includes assisting with meeting emotional (e.g., providing comfort, listening to problems), instrumental (e.g., providing training, organizing services, helping with household chores), informational (e.g., providing information about illness and services), and appraisal (e.g., providing feedback about their caregiving activities) needs. In addition, support refers to providing direct care, access to required services, and facilitating linkages to resources to ensure that the needs of the individual, family and caregiver are met throughout the continuum of stroke care. Support needs change across the illness and recovery trajectory and are most beneficial if it is closely matched to individuals’ current needs. The goal of individual, family and caregiver support is to enable each person to manage their recovery or the recovery of after the person with stroke and optimize participation and fulfillment of life roles.

Supported Living Environments refers to residential living locations where individuals may transition following stroke, and where they continue to receive healthcare services within a coordinated and organized system. The levels of support and service received are dependent on the individual’s physical and cognitive abilities and ongoing health care needs, as well as available support from family members and caregivers. Supported living environments are settings where individuals can maintain as much control over their lives as possible, while receiving the supports they need to maintain their health and safety. Supportive living environments may include a range of settings and support service levels, such as: a private home or residence where health care services are provided; group settings such as lodges, transitional care or respite centres where the person with stroke resides with others with similar care and support needs; assisted living settings where the individual has a private room(s) within a residential setting and access to personal care support, group meals, organized social activities, and transportation.

Task-specific training: Training that involves repetition of a functional task or part of the task. 

Thrombolytics: An agent (medication) that dissolves or splits up a blood clot.

Tissue plasminogen activator: A clot-busting drug used to treat heart attack and ischemic stroke.

Tone: Resistance to passive stretch while the patient is attempting to maintain a relaxed state of muscle activity.

Training refers to collaborative activities aimed at acquiring knowledge and skills necessary for the person with stroke, families and caregivers.

Transient Ischemic attack (TIA): Transient ischemic attack (often called a ‘mini-stroke’) is a clinical diagnosis that refers to a brief episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, with clinical symptoms, and without imaging evidence of infarction (Easton, 2009; Sacco et al, 2013). Transient ischemic attack and minor acute ischemic stroke fall along a continuum. Transient ischemic attack symptoms fully resolve within 24 hours (usually within one hour). If any symptoms persist beyond 24 hours, then this would be considered a stroke, not a transient ischemic attack. A transient ischemic attack event is significant as it can be a warning of a future stroke event. Patients and healthcare professionals should respond to an acute transient ischemic attack as a potential emergency. Transient ischemic attack and minor acute ischemic stroke follow along a continuum that cannot be differentiated by symptom duration alone.

Transition refers to the movement of people across various healthcare locations, settings, and providers.

Transition management includes working with persons with stroke, their families, and caregivers to establish and implement a transition plan that includes goal setting and has the flexibility to respond to evolving needs. Successful transition management requires transfer of accountability through interdisciplinary collaboration and handover between healthcare providers, persons with stroke, their families, and caregivers. It encompasses the organization, coordination, education, and communication required as people move through the stages and settings for stroke treatment, recovery, reintegration, adaptation, and end-of-life care. Note that a transition plan includes discharge planning.

Vascular cognitive impairment refers to a range of new or worsening cognitive deficits attributed to or accelerated by cerebrovascular injury (Paradise and Sachdev 2019).

1. Cognitive deficits:  The pattern of new or worsening cognitive deficits in VCI may encompass any or all cognitive domains, including executive function, attention, memory, language, or perception, as well as focal stroke syndromes (such as aphasia or spatial neglect). 
2. Cerebrovascular Injury: The predominant etiology is vascular pathology with a range of presentations (symptomatic or covert), including cortical or subcortical infarct(s), strategic infarcts, small-vessel disease with white matter lesions, lacunar infarcts and brain hemorrhage. These cerebrovascular pathologies can be caused by diverse conditions (such as stroke, heart failure, diabetes and high blood pressure). These conditions can occur in isolation or can unmask or accelerate other neurodegenerative processes, such as in Alzheimer’s disease, resulting in mixed pathology (also called mixed dementia).

Vascular depression is a newer concept incorporating a broader range of depressive disorders. Vascular depression is related to small-vessel ischemia and people experiencing vascular depression may have white matter disease seen on brain imaging. Vascular depression also includes post-stroke depression as a sub-category. People who have experienced a stroke with vascular depression have later age of onset, greater cognitive impairment, less family and personal history of depression, and greater physical impairment than geriatric persons with nonvascular depression. They have been found to have different responses to treatment and different prognoses. In addition, persons with vascular depression with executive dysfunction and/or persons who show progression of white matter hyperintensities over time have a poor response to treatment with antidepressants and a more chronic and relapsing clinical course (Taylor WD, Steffens DC, MacFall JR, et al: White matter hyperintensity progression and late-life depression outcomes. Arch Gen Psychiatry 2003; 60:1090–1096).

Vascular Disease: Vascular disease refers to cerebrovascular and peripheral vascular diseases that stiffen, narrow or block the intra- and extracranial arteries or peripheral arteries and veins. Broadly speaking, vascular disease encompasses sclerosis, stenosis and occlusion of arteries or veins. Types of vascular disease include peripheral artery disease, carotid artery disease, venous disease, embolism and thrombosis, and aortic aneurysm and dissection. These abnormal vascular changes may result from endothelial dysfunction, inflammation, atherosclerosis, fibrosis or pathological differentiation including arterial plaque formation and venous thrombosis.

Vascular pathology: Cognitive impairment can result from a range of vascular pathologies (see Sachdev et al., 2014, Table 3), including large or multiple cortical infarcts, multiple subcortical infarcts, covert (“silent”) infarcts, strategic infarcts, small-vessel disease (ischemic white matter changes, multiple lacunar infarcts, dilatation of perivascular spaces, cortical microinfarcts and microhemorrhages), and brain hemorrhage. Risk factors such as hypertension, diabetes and focal or global cerebral hypoperfusion are also associated with cognitive impairment.

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.

Abbreviations

AAC Augmentative and alternative communication

ADL Activities of daily living

AF Atrialfibrillation

ASA AcetylsalicylicAcid (aspirin)

CEA Carotidendarterectomy

CEMRA Contrast enhanced magnetic resonance angiography

CHEP Canadian Hypertension Education Program

CSN Canadian Stroke Network

CSS Canadian Stroke Strategy

CT Computed tomography

DBP Diastolic Blood Pressure

DM Diabetes Mellitus

DVT Deep vein thrombosis

EBRSR Evidence-Based Review of Stroke Rehabilitation

ED Emergency Department

ECG/EKG Electrocardiogram

EMS Emergency Medical Services

ESD Early supported discharge

EWG Expert Working Group

GP General Practitioner

ICH Intracranial hemorrhage

ICU Intensive care unit

INR International normalized ratio

IPC Intermittent pneumatic compression

IV Intravenous

LDL Low-density Lipoprotein

LMWH Low molecular weight heparin

MCA Middle cerebral artery

MI Myocardial Infarction

MR-DWI Magnetic resonance diffusion weighted imaging

MRI Magnetic Resonance Imaging

NINDS National Institute of Neurological Disorders and Stroke

NNT Numbers needed to treat

OBS Observational study

OT Occupational therapist

PE Pulmonary embolism

PEG Percutaneous endoscopic gastrostomy

PT Physical therapist or Physiotherapy

RCT Randomized controlled trial

rFVIIa recombinant activated factor VII

rt-PA Recombinant tissue plasminogen activator

RN Registered nurse

RRR Relative risk reduction

SAH Subarachnoid Hemorrhage

SCORE Stroke Canada Optimization of Rehabilitation through Evidence

SBP Systolic Blood Pressure

SLP Speech Language Pathologist

SR Systematic review

STAIR Stroke transition after inpatient care

STEP Stroke Therapy Evaluation Program

SU Stroke Unit

SW Social work or Social worker

TIA Transient ischemic attack

tPA Tissue plasminogen activator

TTE Transthoracic echocardiography

TEE Transesophageal echocardiography

UK United Kingdom

UFH Unfractionated heparin

VTE Venous Thrombus Embolism