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Stroke is the leading cause of death and disability in Canada.(1)  Between 1/3 and 2/3 of stroke survivors will require some form of rehabilitation.(2) After five years, 36% of stroke survivors are left with significant disabilities and more then 40% of these require help with the activities of daily living.(3)  

Physiotherapists play a pivotal role at every stage of the patient pathway, helping individuals reach their full physical potential and functional ability and to reintegrate into society. Physiotherapists are also involved in preventing stroke and stroke recurrence, and improving the nation’s health by promoting healthy active lifestyles. Within a multidisciplinary team, physiotherapists rehabilitate patients from acute care to the home setting, and provide long-term community support. 

Physiotherapy is clinically effective 

Emerging evidence shows that physiotherapy very early after stroke (mobilization within 24 hrs) and at high intensity leads to better outcomes(4)(5) and is cost effective.(6) A minimum of 45 minutes of physiotherapy five days a week is recommended.(6)(7) To meet these requirements some physiotherapy departments are providing weekend services. Seven-day service models offer potential cost savings for the health service.(8)

The Canadian Heart and Stroke Foundation’s Best Practice Recommendations for Stroke Care indicates patients should have an initital assessment within 48 hours of admission and begin early rehabilitation that is appropriate intensity and duration. Therapy should be a minimum of three hours daily five days per week.(9)

Physiotherapy stroke rehabilitation is increasingly based in the community. It is recommended that outpatient or community-based physiotherapy should begin within 48 hours of discharge from acute care or within 72 hours of discharge from inpatient rehabilitation.(9) Early Supported Discharge (ESD) teams fulfill this role and are clinically effective, especially when patients return home with mild or moderate disability.(15)(16) Physiotherapists offer a range of evidence-based interventions depending on the patient’s clinical needs and goals. Treatment may include task oriented training, balance training, gait re-education, task-specific training, constraint-induced movement therapy, and falls management.(6)(17)

Through new technologies such as telemedicine, patient access to rehabilitation will also improve.(18)

Case study

Alberta’s Stroke Action Plan(13)(14) was introduced to ensure patients in small urban and rural centres receive the same level of care as those residing in larger centres. It has three components: stroke equivalent care (stroke units), early supported discharge, and community rehabilitation. Staff in the stroke units receive additional training in stroke care,  follow established protocols and have increased rehabilitation staff. 

Early Supported Discharge (ESD) programs were implemented at five small urban primary stroke centres and stroke unit-equivalent care has been established in 14 sites, reaching nearly 1,000 patients across Alberta. ESD delivers rehabilitation in the homes of stroke survivors. These teams include physical, occupational, and recreational therapists, speech language pathologists, nurses, social workers and therapy assistant.

Community rehabilitation ensures patients are monitored medically and may be followed by a therapist to maintain their status.

Last year, over 200 patients who had mild to moderate strokes were discharged, on average, after two weeks in hospital, compared to a typical stay of four weeks or more. Preliminary results show the Stroke Action Plan could reduce length of stay in both acute care and rehabilitation facilities by 26% as well as reducing the number of admissions to long term care.

Size of the problem

  • Currently an estimated 62,000 Canadians experience a stroke annually - or one stroke every 9 minutes.(10)
  • Over 405,000 Canadians of all ages are estimated to be living with effects of stroke.(3)
  • Over the next two decades, this number is projected to increase to between 654,000 and 726,000.(3)
  • Greatest increase is projected for the prairie provinces - between 116,000 and 132,000 stroke survivors.(3)
  • Although most strokes occur in individuals over 70 years of age, strokes occuring in people in their 50s have increased by 24% and by 13% in people in their 60s.(11)

​Cost of the problem

  • Every year, stroke patients spend over 639,000 days in acute care and 4.5 million days in residential care facilities.(2)
  • Average hospitalization cost over the first year for ischemic stroke is estimated at $74,353, ranging from $107,883 for disabling stroke to $48,339 for non-disabling stroke.(12)
  • Public Health Agency of Canada reports that strokes ‘cost the Canadian economy $3.6 billion in physician costs, hospital wages, lost wages, and decreased productivity.’(11)

​Long-term management

Physiotherapists are ideally placed to provide services that support individuals to re-integrate into their community. Physiotherapists have skills in promoting physical activity, reablement and empowering individuals through self-management techniques.(19)

References

  1. Canada, Ranking and number of deaths for the five leading causes of death, Canada, provinces and territories, 2009,  http://www.statcan.gc.ca/pub/84-215-x/2012001/table-tableau/tbl006-eng.htm
  2. Public Health Agency of Canada, Tracking Heart Disease and Stroke in Canada: Stroke Highlights 2011
  3. Krueger et al, Prevalence of Canadians Experiencing the Effects of Stroke in Canada; Trends and Projections, Stroke. 2015; 46:2226-2231
  4. Cumming TB, Thrift AG, Collier JM, et al. Very early mobilization after stroke fast-tracks return to walking: further results from the phase II AVERT randomized controlled trial. Stroke. 2011 Jan;42(1):153-8. URL: http://tinyurl.com/o3unpsj 
  5. Kwakkel G, van Peppen R, Wagenaar RC, et al. Effects of augmented exercise therapy time after stroke: a meta-analysis. Stroke. 2004 November 1, 2004;35(11):2529-39. URL: http://tinyurl. com/ogqubqj 
  6. National Institute for Health and Care Excellence. Stroke rehabilitation: long term rehabilitation after stroke. CG162. London: National Institute for Health and Care Excellence; 2013. URL: http:// tinyurl.com/qzlp7g7 
  7. Intercollegiate Stroke Working Party. National Clinical Guideline for Stroke. 4th. London: Royal College of Physicians; 2012. URL: http://tinyurl.com/7k3d37y 
  8. Brusco NK, Shields N, Taylor NF, et al. A Saturday physiotherapy service may decrease length of stay in patients undergoing rehabilitation in hospital: a randomised controlled trial. Australian Journal of Physiotherapy. 2007;53(2):75-81. 
  9. Heart and Stroke Foundation Canadian Best Practice Recommendations for Stroke Care, 4th Edition July 2013, http://www.strokebestpractices.ca/index.php/stroke-rehabilitation/
  10. Heart and Stroke Foundation, Access to Care: The Critical First Hours, Heart and Stroke Foundation 2015 Report
  11. Heart and Stroke Foundation, Together Against a Rising Tide: Advancing Stroke Systems of Care, Heart and Stroke Foundation Report 2014.
  12. Mittman et al, Impact of Disability Status on Ischemic Stroke Costs in Canada in the First Year, Can J Neurol Sci 2012; 39: 793-800
  13. Science Daily, October 7, 2014    http://www.sciencedaily.com/releases/2014/10/141007092350.htm
  14. Alberta Health Services, AHS Spez Buzz, Edmonton Zone, Winter 2015, volume 4 Issue 1 www.albertahealthservices.ca/ps-1091612-stroke-edm-spez-newsletter-2.
  15. Saka Ö, Serra V, Samyshkin Y, et al. Cost-effectiveness of stroke unit care followed by early supported discharge. Stroke. 2009;40(1):24-9. URL: http://tinyurl.com/od6dojl 
  16. Fearon P, Langhorne P. Services for reducing duration of hospital care for acute stroke patients. Cochrane Database Syst Rev. 2012;9:CD000443. URL: http://tinyurl.com/opmpnkd 
  17. M.P. Lindsay et al. Canadian Best Practice Recommendations for Stroke Care - Update 2010 (Ottawa: Canadian Stroke Network, 2010)
  18. Schwamm LH, Holloway RG, Amarenco P, et al. A review of the evidence for the use of telemedicine within stroke systems of care: a scientific statement from the American Heart Association/American Stroke Association. Stroke. 2009 July 1, 2009;40(7):2616-34. URL: http://tinyurl.com/nf5qhq8 
  19. Lennon S, McKenna S, Jones F. Self-management programmes for people post stroke: a systematic review. Clinical Rehabilitation. 13;27(10):867-78

Acknowledgement

Adapted and used with permission of the Chartered Society of Physiotherapy.