11. Virtual Stroke Rehabilitation

Definitions and descriptions

Virtual care

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

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

Virtual stroke rehabilitation

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

Hybrid model

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

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

Section 1: Access, eligibility, consent and privacy

Based on the literature review and writing group discussion, the following recommendations and clinical considerations have been developed. 

1.1 Access to stroke rehabilitation through virtual care modalities

1.1 Recommendations

1. Virtual stroke rehabilitation should be available as an alternative or adjunct to in-person therapy for people with stroke [Strong recommendation; Moderate quality of evidence].
2. Virtual care modalities should be integrated into stroke care planning and service delivery across the continuum (i.e., from acute stroke care to stroke prevention, stroke rehabilitation, home-based therapy, and ambulatory care) to support optimal recovery of people with stroke, provide support for families, and ensure equitable access to care throughout Canada [Strong recommendation; Moderate quality of evidence].
3. All rehabilitation disciplines should consider the use of virtual care technology for assessment of people with stroke and for delivery of clinical therapies where appropriate (e.g., exercise monitoring and intensity adjustments, speech and language therapies for aphasia) [Strong recommendation; Low quality of evidence].
4. Home-based monitoring for outpatient stroke rehabilitation through web-based applications may be considered as an alternative or adjunct to in-person rehabilitation therapy sessions when frequent monitoring is necessary and access to in-person services is limited [Strong recommendation; Moderate quality of evidence]. Refer to technology and planning for additional information. 

1.2 Eligibility  

1.2 Recommendations 

1. All people with acute stroke admitted to hospital should be assessed to determine the severity of their stroke, their early rehabilitation needs, and the most appropriate mechanism to deliver timely and effective stroke rehabilitation, whether in-person, virtual, or a hybrid (a combination of in-person and virtual modalities) model [Strong recommendation; Moderate quality of evidence]. Refer to CSBPR Rehabilitation and Recovery following Stroke for additional information.
2. All people who present with acute stroke who are not admitted to hospital should be screened in-person or through virtual care modalities for the need to undergo a comprehensive rehabilitation assessment to determine the scope of deficits from the index stroke event and any potential rehabilitation requirements [Strong recommendation; Low quality of evidence].
3. Clearly defined criteria and protocols or algorithms should be available to help referring sites determine when and how people with stroke can access virtual stroke rehabilitation, secondary prevention, and ambulatory services [Strong recommendation; Low quality of evidence]. Refer to Heart & Stroke virtual care decision framework for additional information.
4. Virtual stroke rehabilitation should be offered to eligible people and when an in-person therapy session is not feasible or not available, and the goals of the session can be achieved virtually [Strong recommendation; Moderate quality of evidence]. 

Section 1.2 Clinical considerations 

1. Clinicians should consider the safety and appropriateness of virtual stroke rehabilitation for each person with stroke, taking into consideration the person’s abilities, impairments, and current health status (e.g., cognitive, behavioural, communication, physical, and sensory factors) and available resources. Refer to Heart & Stroke virtual care decision framework for additional information.
2. Individual preferences should be considered when a person with stroke is eligible for both virtual and in-person stroke rehabilitation, and the clinician is able to offer either one or a combination of both options.
3. The clinician should develop a safety or adverse events plan with the person with stroke prior to starting virtual stroke rehabilitation. This includes having the person’s phone number, address, and emergency contact information, and asking them to have a family member or caregiver nearby and/or a phone at hand. Refer to CSBPR virtual stroke care toolkit for additional information.

1.3 Consent and privacy 

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

Section 1.3 Clinical considerations  

1. Protocols to share personal health information should be developed, in accordance with applicable legislation and organizational requirements, to allow clinicians to share personal health information about the person with stroke. These should include electronic health records or other electronic forms of information sharing, if available.
2. Informed consent for virtual care must be obtained from the person with stroke or substitute decision-maker and documented before virtual stroke rehabilitation commences, to ensure an understanding of the nature of virtual rehabilitation, including awareness of the limitations and the risks of virtual care and electronic communication. 
3. Established privacy procedures should be followed when providing virtual stroke rehabilitation, such as confirming the person’s identity at the beginning of the virtual encounter and ensuring that all participants are in an appropriate setting, where privacy can be optimized.
4. When providing virtual stroke rehabilitation, clinicians should follow discipline-specific and organizational virtual care guidelines, policies and other mandates, as well as those established by their professional regulatory organizations. This includes requirements related to consent and privacy when delivering virtual stroke care within clinicians’ jurisdictions and the jurisdiction where the person with stroke is receiving virtual care.

Section 2: Technology and planning

2.1 Technology  

2.1 Recommendations  

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

Section 2.1 Clinical considerations 

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

2.2 Planning delivery of virtual stroke rehabilitation 

2.2 Recommendations 

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

Section 2.2 Clinical considerations 

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

Section 3: Training and competency

3.1 Training for healthcare providers  

3.1 Recommendations 

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

Section 3.1 Clinical considerations 

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

3.2 Training for people with stroke, families, and caregivers  

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

3.2 Clinical considerations 

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

Section 4: Assessment and service delivery

4.1 Assessment  

4.1 Recommendations 

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

Section 4.1 Clinical considerations   

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

4.2 Service delivery 

4.2 Recommendations 

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