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The 2022 update of theCanadian Stroke Best Practice Recommendations (CSBPR) for Acute Stroke Management, 7thedition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by an interdisciplinary team of healthcare providers and system planners caring for persons with an acute stroke or transient ischemic attack. These recommendations are a timely opportunity to reassess current processes to ensure efficient access to acute stroke diagnostics, treatments, and management strategies, proven to reduce mortality and morbidity. The topics covered include prehospital care, emergency department care, intravenous thrombolysis and endovascular thrombectomy (EVT), prevention and management of inhospital complications, vascular risk factor reduction, early rehabilitation, and end-of-life care. These recommendations pertain primarily to an acuteischemicvascular event. Notable changes in the 7thedition include recommendations pertaining the use of tenecteplase, thrombolysis as a bridging therapy prior to mechanical thrombectomy, dual antiplatelet therapy for stroke prevention,1the management of symptomatic intracerebral hemorrhage following thrombolysis, acute stroke imaging, care of patients undergoing EVT, medical assistance in dying, and virtual stroke care. An explicit effort was made to address sex and gender differences wherever possible. The theme of the 7thedition of the CSBPR is building connections to optimize individual outcomes, recognizing that many people who present with acute stroke often also have multiple comorbid conditions, are medically more complex, and require a coordinated interdisciplinary approach for optimal recovery. Additional materials to support timely implementation and quality monitoring of these recommendations are available atwww.strokebestpractices.ca.

The 2020 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for the Secondary Prevention of Stroke includes current evidence-based recommendations and expert opinions intended for use by clinicians across a broad range of settings. They provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations address triage, diagnostic testing, lifestyle behaviors, vaping, hypertension, hyperlipidemia, diabetes, atrial fibrillation, other cardiac conditions, antiplatelet and anticoagulant therapies, and carotid and vertebral artery disease. This update of the previous 2017 guideline contains several new or revised recommendations. Recommendations regarding triage and initial assessment of acute transient ischemic attack (TIA) and minor stroke have been simplified, and selected aspects of the etiological stroke workup are revised. Updated treatment recommendations based on new evidence have been made for dual antiplatelet therapy for TIA and minor stroke; anticoagulant therapy for atrial fibrillation; embolic strokes of undetermined source; low-density lipoprotein lowering; hypertriglyceridemia; diabetes treatment; and patent foramen ovale management. A new section has been added to provide practical guidance regarding temporary interruption of antithrombotic therapy for surgical procedures. Cancer-associated ischemic stroke is addressed. A section on virtual care delivery of secondary stroke prevention services in included to highlight a shifting paradigm of care delivery made more urgent by the global pandemic. In addition, where appropriate, sex differences as they pertain to treatments have been addressed. The CSBPR include supporting materials such as implementation resources to facilitate the adoption of evidence into practice and performance measures to enable monitoring of uptake and effectiveness of recommendations.

Spontaneous intracerebral hemorrhage is a particularly devastating type of stroke with greater morbidity and mortality compared with ischemic stroke and can account for half or more of all deaths from stroke. The seventh update of the Canadian Stroke Best Practice Recommendations includes a new stand-alone module on intracerebral hemorrhage, with a focus on elements of care that are unique or affect persons disproportionately relative to ischemic stroke. Prior to this edition, intracerebral hemorrhage was included in the Acute Stroke Management module and was limited to its management during the first 12 h. With the growing evidence on intracerebral hemorrhage, a separate module focused on this topic across the care continuum was added. In addition to topics related to initial clinical management, neuroimaging, blood pressure management, and surgical management, new sections have been introduced addressing topics surrounding inpatient complications such as venous thromboembolism, seizure management, and increased intracranial pressure, rehabilitation as well as issues related to secondary management including lifestyle management, maintaining a normal blood pressure and antithrombotic therapy, are addressed. The Canadian Stroke Best Practice Recommendations ( CSBPR) are intended to provide up-to-date evidence-based guidelines for the prevention and management of stroke and to promote optimal recovery and reintegration for people who have experienced stroke, including patients, families, and informal caregivers.

POINTS CLES En 2016, au Canada (a l’exclusion du Quebec), 270 204 personnes ont ete admises a l’hopital pour un trouble cardiaque, un accident vasculaire cerebral (AVC) ou un deficit cognitif d’origine vasculaire; de ce nombre, 107 391 etaient des femmes, 162 813 etaient des hommes

KEY POINTS In 2016, 270 204 people in Canada (excluding Quebec) were admitted to hospital for heart conditions, stroke and vascular cognitive impairment, including 107 391 women and 162 813 men, of whom 91 524 died.[1][1] This equates to 1 out of every 3 deaths in Canada and outpaces other diseases

The sixth update of the Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery, and Reintegration following Stroke. Part one: Rehabilitation and Recovery Following Stroke is a comprehensive set of evidence-based guidelines addressing issues surrounding impairments, activity limitations, and participation restrictions following stroke. Rehabilitation is a critical component of recovery, essential for helping patients to regain lost skills, relearn tasks, and regain independence. Following a stroke, many people typically require rehabilitation for persisting deficits related to hemiparesis, upper-limb dysfunction, pain, impaired balance, swallowing, and vision, neglect, and limitations with mobility, activities of daily living, and communication. This module addresses interventions related to these issues as well as the structure in which they are provided, since rehabilitation can be provided on an inpatient, outpatient, or community basis. These guidelines also recognize that rehabilitation needs of people with stroke may change over time and therefore intermittent reassessment is important. Recommendations are appropriate for use by all healthcare providers and system planners who organize and provide care to patients following stroke across a broad range of settings. Unlike the previous set of recommendations, in which pediatric stroke was included, this set of recommendations includes primarily adult rehabilitation, recognizing many of these therapies may be applicable in children. Recommendations related to community reintegration, which were previously included within this rehabilitation module, can now be found in the companion module, Rehabilitation, Recovery, and Community Participation following Stroke. Part Two: Transitions and Community Participation Following Stroke.

The 2019 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for Mood, Cognition and Fatigue following Stroke is a comprehensive set of evidence-based guidelines addressing three important issues that can negatively impact the lives of people who have had a stroke. These include post-stroke depression and anxiety, vascular cognitive impairment, and post-stroke fatigue. Following stroke, approximately 20% to 50% of all persons may be affected by at least one of these conditions. There may also be overlap between conditions, particularly fatigue and depression. If not recognized and treated in a timely matter, these conditions can lead to worse long-term outcomes. The theme of this edition of the CSBPR is Partnerships and Collaborations, which stresses the importance of integration and coordination across the healthcare system to ensure timely and seamless care to optimize recovery and outcomes. Accordingly, these recommendations place strong emphasis on the importance of timely screening and assessments, and timely and adequate initiation of treatment across care settings. Ideally, when screening is suggestive of a mood or cognition issue, patients and families should be referred for in-depth assessment by healthcare providers with expertise in these areas. As the complexity of patients treated for stroke increases, continuity of care and strong communication among healthcare professionals, and between members of the healthcare team and the patient and their family is an even bigger imperative, as stressed throughout the recommendations, as they are critical elements to ensure smooth transitions from acute care to active rehabilitation and reintegration into their community.

Purpose. In order to meet a clinical need for better pathways to access genetic testing for ovarian cancer patients, we implemented and reviewed an opt-out referral process for genetic consultation whereby a referral is automatically sent to genetics following a pathological diagnosis of HGSC. Methods. Following implementation of the opt-out referral process, each month a list of new cases of HGSC was generated from the synoptic pathology report and forwarded directly to the Cancer Genetics clinic. Using an advanced directive, patients were automatically referred for genetic counselling two months after surgery. If the patient declined genetic counselling (opted-out) after discussion with their surgeon within the two months after surgery, the Genetic Counsellor was informed and the patient was removed from the referral process. Results. Between January 1, 2015, and December 31, 2017, 168 women were diagnosed with HGSC, of whom 167 received a referral for genetic consultation. In only one case the referral was cancelled by the surgeon, resulting in a referral rate of 99.4%. By the end of the study period, 133 women attended a genetics consultation appointment and 125 (94%) agreed to proceed with genetic testing. Among those who completed genetic testing, 15% tested positive for a BRCA1 or BRCA2 gene mutation. Of the women who tested positive for a BRCA1/2 mutation, 56% had no family history of breast or ovarian cancer. Conclusions. The opt-out referral process described in this study is s a feasible, effective, and patient-centred approach to increase access to BRCA1/2 testing for patients with ovarian cancer.

The sixth update of the Canadian Stroke Best Practice Recommendations for Transitions and Community Participation following Stroke is a comprehensive set of evidence-based guidelines addressing issues faced by people following an acute stroke event. Establishing a coordinated and seamless system of care that supports progress achieved during the initial recovery stages throughout the transition to the community is more essential than ever as the medical complexity of people with stroke is also on the rise. All members of the health-care team engaged with people with stroke, their families, and caregivers are responsible for partnerships and collaborations to ensure successful transitions and return to the community following stroke. These guidelines reinforce the growing and changing body of research evidence available to guide ongoing screening, assessment, and management of individuals following stroke as they move from one phase and stage of care to the next without “falling through the cracks.” It also recognizes the growing role of family and informal caregivers in providing significant hours of support that disrupt their own lives and responsibilities and addresses their support and educational needs. According to Statistics Canada, in 2012, eight million Canadians provided care to family members or friends with a long-term health condition, disability, or problems associated with aging. These recommendations incorporate aspects that were previously in the rehabilitation module for the purposes of streamlining, and both modules should be reviewed in order to provide comprehensive care addressing recovery and community reintegration and participation. These recommendations cover topics related to support and education of people with stroke, families, and caregivers during transitions and community reintegration. They include interprofessional planning and communication, return to driving, vocational roles, leisure activities and relationships and sexuality, and transition to long-term care.

The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider’s recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.

BackgroundStroke risk is increased during pregnancy, but estimates of pregnancy-related stroke incidence vary widely.AimsA systematic review and meta-analysis was conducted to assess the incidence of stroke during pregnancy and the puerperium. Ovid Medline, EMBASE, and ISI Web of Science were searched for studies published between 1990 and January 2017 reporting stroke incidence during pregnancy and postpartum, from defined pregnancy populations. Pooled analyses were conducted using a random effects approach and expressed as an incidence rate per 100,000 pregnancies, with 95% confidence intervals. Subgroup analyses of stroke type and timing were conducted.Summary of reviewEleven studies met inclusion criteria. Variation in estimated rates was noted based on geography and study methodology. The pooled crude rate of pregnancy-related stroke was 30.0 per 100,000 pregnancies (95% confidence interval 18.8–47.9). The pooled crude rates from nonhemorrhagic stroke (arterial and cerebral venous sinus thrombosis) were 19.9 (95% confidence interval 10.7–36.9) and from hemorrhage 12.2 (95% confidence interval 6.4–23.2) per 100,000 pregnancies. For studies separately reporting cerebral venous sinus thrombosis, the rates were roughly equal between ischemic stroke (12.2, 95% confidence interval 6.7–22.2), cerebral venous sinus thrombosis (9.1, 95% confidence interval 4.3–18.9), and hemorrhage (12.2, 95% confidence interval 6.4–23.2). The crude stroke rate for antenatal/perinatal stroke was 18.3 (95% confidence interval 11.9–28.2), and for postpartum stroke was 14.7 (95% confidence interval 8.3–26.1).ConclusionsStroke affects 30.0 per 100,000 pregnancies, with ischemia, cerebral venous sinus thrombosis, and hemorrhage causing roughly equal numbers and with highest risk peripartum and postpartum. Organized approaches to the management of this high-risk population, informed by existing evidence from stroke and obstetrical care are needed.

Every year, approximately 62,000 people with stroke and transient ischemic attack are treated in Canadian hospitals. The 2016 update of the Canadian Stroke Best Practice Recommendations Telestroke guideline is a comprehensive summary of current evidence-based and consensus-based recommendations appropriate for use by all healthcare providers and system planners who organize and provide care to patients following stroke across a broad range of settings. These recommendations focus on the use of telemedicine technologies to rapidly identify and treat appropriate patients with acute thrombolytic therapies in hospitals without stroke specialized expertise; select patients who require to immediate transfer to stroke centers for Endovascular Therapy; and for the patients who remain in community hospitals to facilitate their care on a stroke unit and provide remote access to stroke prevention and rehabilitation services. While these latter areas of Telestroke application are newer, they are rapidly developing, with new opportunities that are yet unrealized. Virtual rehabilitation therapies offer patients the opportunity to participate in rehabilitation therapies, supervised by physical and occupational therapists. While not without its limitations (e.g., access to telecommunications in remote areas, fragmentation of care), the evidence-to-date sets the foundation for improving access to care and management for patients during both the acute phase and now through post stroke recovery.

The Canadian Stroke Best Practice Consensus Statement Acute Stroke Management during Pregnancy is the second of a two-part series devoted to stroke in pregnancy. The first part focused on the unique aspects of secondary stroke prevention in a woman with a prior history of stroke who is, or is planning to become, pregnant. This document focuses on the management of a woman who experiences an acute stroke during pregnancy. This consensus statement was developed in recognition of the need for a specifically tailored approach to the management of this group of patients in the absence of any broad-based, stroke-specific guidelines or consensus statements, which do not exist currently. The foundation for the development of this document was the concept that maternal health is vital for fetal well-being; therefore, management decisions should be based first on the confluence of two clinical considerations: (a) decisions that would be made if the patient wasn't pregnant and (b) decisions that would be made if the patient hadn't had a stroke, then nuanced as needed. While empirical research in this area is limited, this consensus document is based on the best available literature and guided by expert consensus. Issues addressed in this document include initial emergency management, diagnostic imaging, acute stroke treatment, the management of hemorrhagic stroke, anesthetic management, post stroke management for women with a stroke in pregnancy, intrapartum considerations, and postpartum management. These statements are appropriate for healthcare professionals across all disciplines and system planners to ensure pregnant women who experience a stroke have timely access to both expert neurological and obstetric care.

The 2017 update of The Canadian Stroke Best Practice Recommendations for the Secondary Prevention of Stroke is a collection of current evidence-based recommendations intended for use by clinicians across a wide range of settings. The goal is to provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations include those related to diagnostic testing, diet and lifestyle, smoking, hypertension, hyperlipidemia, diabetes, antiplatelet and anticoagulant therapies, carotid artery disease, atrial fibrillation, and other cardiac conditions. Notable changes in this sixth edition include the development of core elements for delivering secondary stroke prevention services, the addition of a section on cervical artery dissection, new recommendations regarding the management of patent foramen ovale, and the removal of the recommendations on management of sleep apnea. The Canadian Stroke Best Practice Recommendations include a range of supporting materials such as implementation resources to facilitate the adoption of evidence to practice, and related performance measures to enable monitoring of uptake and effectiveness of the recommendations. The guidelines further emphasize the need for a systems approach to stroke care, involving an interprofessional team, with access to specialists regardless of patient location, and the need to overcome geographic barriers to ensure equity in access within a universal health care system.

Every year, approximately 62,000 people with stroke and transient ischemic attack are treated in Canadian hospitals. For patients, families and caregivers, this can be a difficult time of adjustment. The 2016 update of the Canadian Managing Transitions of Care following Stroke guideline is a comprehensive summary of current evidence-based and consensus-based recommendations appropriate for use by clinicians who provide care to patients following stroke across a broad range of settings. The focus of these recommendations is on support, education and skills training for patients, families and caregivers; effective discharge planning; interprofessional communication; adaptation in resuming activities of daily living; and transition to long-term care for patients who are unable to return to or remain at home. Unlike other modules contained in the Canadian Stroke Best Practice Recommendations (such as acute inpatient care), many of these recommendations are based on consensus opinion, or evidence level C, highlighting the absence of conventional evidence (i.e. randomized controlled trials) in this area of stroke care. The quality of care transitions between stages and settings may have a direct impact on patient and family outcomes such as coping, readmissions and functional recovery. While many qualitative and non-controlled studies were reviewed, this gap in evidence combined with the fact that mortality from stoke is decreasing and more people are living with the effects of stroke, underscores the need to channel a portion of available research funds to recovery and adaptation following the acute phase of stroke.

Introduction: The hemiplegic shoulder pain is common after a stroke. Its appearance brings pain and limits daily living activities as well as participation in specific Neuro-rehabilitation programs. All this leads to a worse functional outcome. Good management of patients can reduce both the frequency and intensity of shoulder pain, improving functional outcome. Development: We conducted a literature search of various databases between 1980 and 2008. The articles were evaluated using the PEDro scoring system. Five evidence levels were established for the conclusions. Conclusions: Shoulder subluxation occurs at an early stage after stroke and is associated with subluxation of the shoulder joint and spasticity (mainly subscapularis and pectoralis). Slings prevent subluxation of the shoulder. It is preferable to move within a lower range of motion and without aggression to prevent the occurrence of shoulder pain. The injection of corticosteroids does not improve pain and range of motion in hemiplegic patients, while botulinum toxin combined with physical therapy appears to reduce hemiplegic shoulder pain. Resumen: Introducción: El hombro doloroso hemipléjico es frecuente después de un ictus. Su aparición conlleva además del dolor, una limitación para las actividades de la vida diaria, así como para la participación en programas específicos de neurorrehabilitación. Todo este conjunto determina un peor resultado funcional. El buen manejo de los pacientes puede reducir tanto la frecuencia de aparición de hombro doloroso, como la intensidad del mismo, mejorando así el pronóstico funcional. Desarrollo: Entre los años 1980 y 2008 se llevó a cabo una búsqueda de la literatura en diferentes bases de datos. La evaluación de los artículos se realizó con el sistema de puntuación PEDro. Se establecieron 5 niveles de evidencia para obtener las conclusiones. Conclusiones: La subluxación del hombro, ocurre de manera precoz tras el ictus y se asocia con subluxación de la articulación del hombro y con espasticidad (subescapular y pectoral mayor principalmente). Los cabestrillos previenen la subluxación del hombro. Es preferible realizar movimientos con un menor rango de movimiento y sin agresividad, para evitar la aparición del hombro doloroso. La inyección de corticoides no mejora el dolor ni el rango de movimiento de los pacientes hemipléjicos, mientras que la toxina botulínica combinada con fisioterapia parece reducir el dolor del hombro hemipléjico. Keywords: Stroke, Shoulder pain, Neuro-rehabilitation, Hemiplegic, Pain, Mobility, Palabras clave: Ictus, Hombro doloroso, Neurorrehabilitación, Hemiplejía, Dolor, Movilidad

In this article, Ontario's stroke rehabilitation system is used to exemplify the challenges faced by rehabilitation and healthcare systems across Canada who are attempting to provide quality care to patients in the face of increasing demands. Currently, Ontario's rehabilitation system struggles in its efforts to provide accessible and comprehensive care to patients recovering from stroke. We begin our exploration by identifying both the primary stakeholders and the underlying factors that have contributed to the current challenges. The framework put forward in the Canadian Medical Association's recommendations for transformation is then used to suggest a vision for a more patient-focused system incorporating three key principles: a broader perspective, a patient-first approach, and greater unity. The use of health information technology, proper incentives, and greater accountability are discussed as mechanisms to improve the quality and efficiency of care.

Elevations of metabolic rate following traumatic brain injury (TBI) have been reported previously, with estimates ranging from 32% to 200% above normal values. The aim of this systematic review was to describe the pattern of energy expenditure during the first 30 days following TBI. We searched six databases for trials that measured the energy expenditure at least once during the first 30 days post-injury and compared that value to one that would be predicted in the non-injured state. We identified 24 studies, three of which were randomized controlled trials (RCTs). The sample sizes of the included studies ranged from 6 to 80 (mean, 24.7), and the mean Glasgow Coma Scale (GCS) score of subjects was 4.8. Mean energy expenditure, expressed as a percentage of a predicted value, ranged from 75% to 200%. The lowest values were reported in patients admitted in brain death. Several factors were found to have modulating effects on energy expenditure. The administration of paralyzing agents, sedatives, or barbiturates reduced metabolic rate by approximately 12-32%. Propranolol and morphine were associated with smaller decreases in energy expenditure. Factors that do not appear to augment the hypermetabolic response included the administration of steroids and method of feeding (enteral vs. parenteral). Based on our results, it was unclear if elevated temperature, the presence of extracranial injury, or the severity of injury further exacerbate hypermetabolism. We conclude that energy expenditure following TBI is highly variable, and the use of standard factors to estimate the energy needs of individual patients are inappropriate and should be discouraged.

Background: dysphagia is common following stroke and is associated with the development of pneumonia. Many dysphagia treatment options are available, some still experimental and others already rooted in common practice. Previous reviews of these treatments were limited due to a dearth of available studies. Recently, more trials have been published warranting a re-examination of the evidence. Objective: a systematic review of all randomised controlled trials (RCTs), updating previous work and evaluating a broader range of therapeutic interventions intended for use in adults recovering from stroke and dysphagia. Methods: using multiple databases, we identified RCTs published between the years 1966 and August 2007 examining the efficacy of dysphagia therapies following stroke. Across studies, results of similar treatments and outcomes were compared and evaluated. Results: fifteen articles were retrieved assessing a broad range of treatments that included texture-modified diets, general dysphagia therapy programmes, non-oral (enteral) feeding, medications, and physical and olfactory stimulation. Across the studies there was heterogeneity of the treatments evaluated and the outcomes assessed that precluded the use of pooled analyses. Descriptively these findings present emerging evidence that nasogastric tube feeding is not associated with a higher risk of death compared to percutaneous feeding tubes; and general dysphagia therapy programmes are associated with a reduced risk of pneumonia in the acute stage of stroke. Conclusions: dysphagia is known to be a common and potentially serious complication of stroke. Despite the recent newly published RCTs, few utilise the same treatment and outcomes thereby limiting the evidence to support the medical effectiveness of common dysphagia treatments used for patients recovering from stroke.

Objective The effects of stroke on stroke survivors are profound and cannot adequately be understood from a single approach or point of view. Use of qualitative study, in addition to quantitative research, provides a comprehensive picture of the consequences of stroke grounded in the experience of stroke survivors. The purpose of the present study was to examine the contribution of the published qualitative literature to our understanding of the experience of living with stroke. Design Qualitative meta-synthesis. Method A literature search was conducted to identify qualitative studies focused on the experience of living with stroke. Themes and supporting interpretations from each study were compiled and reviewed independently by 2 research assistants in order to identify recurring themes and facilitate interpretation across studies. Results From 9 qualitative studies, 5 inter-related themes were identified as follows: (i) Change, Transition and Transformation, (ii) Loss, (iii) Uncertainty, (iv) Social Isolation, (v) Adaptation and Reconciliation. Conclusion The present synthesis suggests the sudden, overwhelming transformation of stroke forms a background for loss, uncertainty and social isolation. However, stroke survivors may move forward through adaptation towards recovery. Meta-synthesis of qualitative research is needed to promote the inclusion of what we know about patient preferences and values in evidence-based practice.

Background and Purpose. Systematic reviews and meta-analyses often include an evaluation of the methodological quality of the individual studies that have been included, and are usually conducted by at least 2 individuals. The objective of this study was to assess the methodological quality and reliability of a series of randomized controlled trials (RCTs) of both pharmacological and nonpharmacological interventions by use of the 10-item Physiotherapy Evidence-Based Database (PEDro) Scale. Methods. Two abstractors independently reviewed 81 RCTs assessing a variety of interventions. The Cohen kappa statistic and the intraclass correlation coefficient (ICC) were used to assess agreement between abstractors. Results. The average total PEDro scores were 5.94 (SD=1.43) for all studies combined, 6.88 (SD=1.2) for pharmacological studies, and 5.29 (SD=1.26) for nonpharmacological studies. The median score for pharmacological studies was significantly higher than that for nonpharmacological studies (7 versus 5). Pair-wise kappa scores ranged from a low of .452 for concealed allocation among drug trials to perfect agreement (1.00) for randomization and reporting of results from between-group comparisons. The ICCs associated with the cumulative PEDro score were .91 (95% confidence interval [CI]=.83–.94) for all studies, .89 (95% CI=.78–.95) for pharmacological studies, and .91 (95% CI=.84–.952) for nonpharmacological studies. Discussion and Conclusion. The methodological quality for pharmacological interventions was significantly higher than that for nonpharmacological interventions. There was good agreement between raters at an individual item level and in total PEDro scores. A lack of reporting clarity, poor organization of the report, or the failure to include salient details contributed to less-than-perfect agreement between raters. [Foley NC, Bhogal SK, Teasell RW, et al. Estimates of quality and reliability with the Physiotherapy Evidence-Based Database Scale to assess the methodology of randomized controlled trials of pharmacological and nonpharmacological interventions.Phys Ther. 2006;86:817 – 824.]

Objective:The purpose of this study was to describe the outcomes of patients with a severe stroke admitted to a specialized “slow stream” rehabilitation program and to develop a model to predict discharge destination.Methods:Chart review of 196 consecutive non-ambulatory (“lower-band”) stroke patients admitted between 1996-2001, to a specialized in-patient rehabilitation unit designed to accommodate the needs of patients with profound disabilities, and who were considered inappropriate for conventional inpatient rehabilitation programs. Special features of this program included the availability of an independent living unit, therapies tailored to individual tolerance and the opportunity to remain on the unit for an extended period until such time that the patients' rehabilitation potential had been maximized.Results:Patients were admitted to the unit after a median of 49 days following stroke onset. Their median admission and discharge functional independence measure (FIMTM) scores were 46 and 70, respectively. The improvement in ability to perform self-care tasks was statistically significant (Z= -11.18, pConclusions:Patients with severe strokes who received individualized care on a highly specialized stroke rehabilitation unit achieved impressive functional outcomes despite a lag of seven weeks post stroke before rehabilitation was initiated. Many patients were no longer wheelchair dependent and almost half returned home. Active rehabilitation should not be limited to “middle-band” stroke patients.

Background— It has been hypothesized that poststroke depression (PSD) results from left hemisphere lesions. However, attempts to systematically review the data investigating lesion location and PSD have yielded conflicting results. We sought to investigate the methodological differences across the literature studying the relationship between lesion location and PSD. Summary of Review— A MEDLINE literature search to retrieve articles investigating the association between PSD and lesion location was performed. Information sought included source population of samples, definition of depression, standardized measurement of stroke and depression, blinding, time since stroke onset, and study design. Odds ratios (ORs) and 95% CIs were calculated with the use of Review Manager and MetaView statistical software. Twenty-six original articles were reviewed. Much of the heterogeneity across studies reflected differences in methodology. The direction of association between left hemisphere lesion location and PSD varied depending on whether patients were sampled as inpatients (OR, 1.36; 95% CI, 1.05 to 1.76) or from the community (OR, 0.60; 95% CI, 0.39 to 0.92). Change in the direction of association was also observed across assessment interval from the acute stroke (OR, 2.14; 95% CI, 1.50 to 3.04) to the chronic stroke (OR, 0.53; 95% CI, 0.30 to 0.93) phase. Differences in the measurement of depression, study design, and presentations of results also may have contributed to the heterogeneity of the findings. Conclusions— Several key initiatives should be addressed before future research is undertaken, including the development of a comprehensive measure of PSD, optimal poststroke assessment intervals, and determination of a representative population reference.

Background and Purpose— Little is known of the acute, subacute, and longer-term energy demands of stroke, information essential to appropriate clinical and nutritional management. The goals of this study were to (1) determine the resting energy expenditure (REE) of stroke patients from stroke onset to 3 months, (2) examine relations between stroke size, type, location, severity, and REE, and (3) evaluate whether estimation of REE from the Harris-Benedict equation (HB) requires the addition of a “stress factor” to capture the possible additional REE imposed by stroke. Methods— The REE of new stroke patients was measured prospectively at hospital admission and on days 7, 11, 14, 21, and 90 by indirect calorimetry. Stroke patients’ REEs (Kcal/d) over time and REEs as a percentage of HB were compared with control subjects’ single measurements. Results— Mean REE and %HB of stroke patients ranged from 1521±290 to 1663±268 Kcal/d and from 107±14.9 to 114±12.9 %HB, respectively. Mean measurements of control subjects were 1665±265 Kcal/d and 112.9±11.4 %HB (NS). REE was not associated with stroke characteristics (NS). Changes in REE measured longitudinally were not clinically meaningful (4 to 62 Kcal/d) though statistically significant ( P =0.004). Conclusions— The REEs of stroke patients and controls were both ≈10% higher than those predicted by HB. No hypermetabolic response pattern of energy expenditure was evident after stroke. REE did not vary with stroke characteristics, although confirmation with larger subgroups is required.

Every year, approximately 62 000 people with stroke and transient ischemic attack are treated in Canadian hospitals. The 2014 update of the Canadian Secondary Prevention of Stroke guideline is a comprehensive summary of current evidence-based recommendations for clinicians in a range of settings, who provide care to patients following stroke. Notable changes in this 5th edition include an emphasis on treating the highest risk patients who present within 48 h of symptom onset with transient or persistent motor or speech symptoms, who need to be transported to the closest emergency department with capacity for advanced stroke care; a recommendation for brain and vascular imaging (of the intra- and extracranial vessels) to be completed urgently using computed tomography/computed tomography angiography; prolonged cardiac monitoring for patients with suspective cardioembolic stroke but without evidence for atrial fibrillation on electrocardiogram or holter monitoring; and de-emphasizing the need for routine echocardiogram. The Canadian Stroke Best Practice Recommendations include a range of supporting materials such as implementation resources to facilitate the adoption of evidence to practice, and related performance measures to enable monitoring of uptake and effectiveness of the recommendations using a standardized approach. The guidelines further emphasize the need for a systems approach to stroke care, involving an interprofessional team, with access to specialists regardless of patient location, and the need to overcome geographical barriers to ensure equity in access within a universal health-care system.

Background: Although it is generally accepted that deaths associated with pneumonia are more common in patients with dementia, no comprehensive reviews on the subject have previously been published. Summary: Relevant studies were identified through a literature search of the PubMed, EMBASE, Scopus, and ISI Web of Science databases for publications up to August 2013. Studies were included if (1) a group of adult subjects with dementia and a (comparison) group composed of subjects without dementia were included, (2) the cause(s) of death was/were reported, and (3) pneumonia was identified as one of the possible causes of death. The occurrence of death due to pneumonia associated with dementia was expressed as an odds ratio (OR) with 95% confidence interval (CI). Thirteen studies were included. The odds of death resulting from pneumonia were significantly increased for persons with any form of dementia compared with those without dementia (OR = 2.22, 95% CI 1.44-3.42, p < 0.001). In a subgroup analysis, using the results from 8 studies that restricted inclusion to persons with Alzheimer's disease, the odds of death resulting from pneumonia were also significantly higher (OR = 1.70, 95% CI 1.12-2.58, p = 0.013). Key Messages: The odds of pneumonia-associated mortality were increased more than 2-fold for patients with dementia. © 2014 S. Karger AG, Basel

Background and Purpose: Urinary incontinence following stroke is known to have a detrimental effect on rehabilitation progress, resulting in a slower rate of recovery and less functional independence at discharge. Canadian Best Practice Recommendations for Stroke Care (2010) and the American Stroke Association Clinical Practice Guidelines (2005) recommend that a bladder training program, including timed and prompted toileting on a consistent schedule, be implemented in patients who are incontinent of urine following a stroke. Canadian Best Practice Recommendations for Stroke Care (2010) further recommend intermittent catheterization as an intervention to address urinary incontinence. The aim of the present study was to assess the extent to which the Canadian guidelines are being incorporated into clinical practice. Methods: A retrospective chart review was conducted for consecutive stroke admissions to a neuro-rehabilitation unit in Ontario, Canada over a period of six months. Charts were reviewed for the occurrence of urinary incontinence, whether intermittent catheterization was performed, any mention of bladder training and the documentation of a bladder training protocol. Results: One hundred and four charts were reviewed, after excluding four patients that could not be assessed for urinary incontinence due to other medical conditions. Thirty-three patients were reported to be incontinent of urine during their stay in the rehabilitation unit. Intermittent catheterization was performed for 11 patients (33.3%) with urinary incontinence. Bladder training was indicated as a therapy that was used in the rehabilitation of 16 patients (48.5%). However, a formal bladder training protocol followed by the nursing staff was only documented in 5 patients (15.2%). Conclusions: The rehabilitation of urinary incontinence following stroke is an important issue, with a substantial number of patients failing to receive the recommended therapy. There is a need to develop strategies to promote the application of best-practice recommendations to address urinary incontinence.

Given the high prevalence and negative personal and social consequences of post-stroke depression (PSD), identification and application of safe and effective treatments is imperative. While recent publications examining the evidence regarding the impact of physical activity on depression suggest that, in the general population, exercise is associated with significant benefit in terms of reduction of depressive symptomatology, it is not clear that physical activity has the same benefit for individuals who have experienced stroke. Objective: To examine the effectiveness of exercise or physical activity on depressive symptomatology following stroke. Methods: We undertook a literature review to identify stroke-specific clinical trials examining the effectiveness of exercise or exercise programs when compared to a control condition that included longitudinal assessment of depression as a primary or secondary study outcome. Identified studies were evaluated for methodological quality using the PEDro scale and, where possible, results entered into a pooled, random effect analysis based on reported means and standard deviations from repeated assessments. Pre-post test correlations were estimated using published test/re-test reliability coefficients. Results: Eight studies were identified for inclusion; total PEDro scores ranged from 4 to 8. Depression was assessed at baseline and post-intervention using 4 self-report and 1 interview-based assessment tool(s). Participants were community-dwelling individuals; mean age ranged from 56 to 87. Only two trials reported significant between group differences for the outcome of depression, although several noted significant improvement within the intervention group only. Of the 8 identified studies, 6 reported sufficient data for inclusion in pooled analysis. Based on data from 276 participants, there was a moderate reduction in self-reported symptoms of depression associated with post-stroke exercise (ES=0.576; 95% CI 0.22, 0.93). No significant publication bias was identified (Egger’s intercept = 1.21, p=0.64). Conclusions: Although previous trials have reported a positive trend toward improvement of the self-reported symptoms of depression associated with exercise, the impact of exercise on depression has not been clear. On pooled analysis, however, it is apparent that participation in exercise is associated with a moderate and significant reduction in self-reported depressive symptomatology in older, community-dwelling individuals with stroke. Since physical impairments may limit participation in exercise programs for many individuals following stroke, additional research is required to examine exercise frequency and/or intensity required to demonstrate benefit.

Background and Purpose: While it remains unclear how much therapy patients should receive to maximize motor recovery, specifically during inpatient rehabilitation, recommendations regarding the daily minimum dose of therapy are included in many clinical practice guidelines. Since these documents are evidence-based, we examined the related literature to determine if a specific recommendation could be supported. Methods: Six clinical practice guidelines were retrieved and examined to determine what recommendation, if any, had been made regarding the daily provision of therapy during inpatient rehabilitation. We then identified all studies cited by the guideline authors to support their recommendations. Studies in which treatment was focused on motor recovery, were initiated during inpatient rehabilitation and provided within 3 months of stroke onset were reviewed in greater detail. Study design, details of the therapy contrasts, the duration of scheduled daily therapy (min/day), actual therapy received (min/day), the primary outcome and the results, were noted for each trial. Results: Three of the 6 identified guidelines recommended daily minimum amounts of therapy, ranging from 45 to 60 minutes each day of occupational (OT) and physiotherapy (PT), one made no recommendation, and two made general statements indicating that increased intensity of therapy was either recommended or was not recommended. Among the 6 guidelines, a total of 73 studies had been cited to support the recommendations. Sixteen randomized controlled trials and 2 controlled trials were reviewed in detail. The majority of trials not reviewed further examined treatments provided in the chronic stage of stroke and/or were non-hospital based. Treatment contrasts included comparisons of intensive inpatient rehabilitation vs. standard inpatient therapy or standard inpatient therapy plus additional therapy provided by OT and/or PT vs. standard therapy only. Details of daily therapy either prescribed or received was included in 9 studies. Patients in the control condition received an average of 48 minutes of therapy per day while those in the experimental group received an average of 61% more, or 77 minutes per day. In only 6 (33%) studies did patients in the experimental group perform significantly better on the primary outcome compared with those in the control group. Conclusions: Although included in several best practice guidelines, we believe the evidence base cannot support a specific recommendations related to therapy intensity during inpatient rehabilitation following stroke.

Resumen: Introducción: El hombro doloroso hemipléjico es frecuente después de un ictus. Su aparición conlleva además del dolor, una limitación para las actividades de la vida diaria, así como para la participación en programas específicos de neurorrehabilitación. Todo este conjunto determina un peor resultado funcional. El buen manejo de los pacientes puede reducir tanto la frecuencia de aparición de hombro doloroso, como la intensidad del mismo, mejorando así el pronóstico funcional. Desarrollo: Entre los años 1980 y 2008 se llevó a cabo una búsqueda de la literatura en diferentes bases de datos. La evaluación de los artículos se realizó con el sistema de puntuación PEDro. Se establecieron 5 niveles de evidencia para obtener las conclusiones. Conclusiones: La subluxación del hombro, ocurre de manera precoz tras el ictus y se asocia con subluxación de la articulación del hombro y con espasticidad (subescapular y pectoral mayor principalmente). Los cabestrillos previenen la subluxación del hombro. Es preferible realizar movimientos con un menor rango de movimiento y sin agresividad, para evitar la aparición del hombro doloroso. La inyección de corticoides no mejora el dolor ni el rango de movimiento de los pacientes hemipléjicos, mientras que la toxina botulínica combinada con fisioterapia parece reducir el dolor del hombro hemipléjico. Abstract: Introduction: The hemiplegic shoulder pain is common after a stroke. Its appearance brings pain and limits daily living activities as well as participation in specific Neuro-rehabilitation programs. All this leads to a worse functional outcome. Good management of patients can reduce both the frequency and intensity of shoulder pain, improving functional outcome. Development: We conducted a literature search of various databases between 1980 and 2008. The articles were evaluated using the PEDro scoring system. Five evidence levels were established for the conclusions. Conclusions: Shoulder subluxation, occurs at an early stage after stroke and is associated with subluxation of the shoulder joint and spasticity (mainly subscapularis and pectoralis). Slings prevent subluxation of the shoulder. It is preferable to move within a lower range of motion and without aggression to prevent the occurrence of shoulder pain. The injection of corticosteroids does not improve pain and range of motion in hemiplegic patients, while botulinum toxin combined with physical therapy appears to reduce hemiplegic shoulder pain. Palabras clave: Ictus, Hombro doloroso, Neurorrehabilitación, Hemiplejía, Dolor, Movilidad, Keywords: Stroke, Shoulder pain, Neuro-rehabilitation, Hemiplegic, Pain, Mobility

OBJECTIVE To clarify the relationship between malnutrition and dysphagia following stroke. DESIGN Systematic review. METHODS All published trials that had examined both the swallowing ability and nutritional status of subjects following stroke were identified. Pooled analyses were performed to establish whether the odds of being malnourished were increased given the presence of dysphagia. RESULTS Eight studies were identified. The presence of malnutrition and dysphagia ranged from 8.2% to 49.0% and 24.3% to 52.6%, respectively. Five of the included trials were conducted within the first 7 days following stroke, while 3 were conducted during the rehabilitation phase. The overall odds of being malnourished were higher among subjects who were dysphagic compared with subjects with intact swallowing (odds ratio: 2.425; 95% confidence interval: 1.264-4.649, p < 0.008). In subgroup analysis, the odds of malnutrition were significantly increased during the rehabilitation stage (odds ratio: 2.445; 95% confidence interval: 1.009-5.925, p < 0.048), but not during the first 7 days of hospital admission (odds ratio: 2.401; 95% confidence interval: 0.918-6.277, p < 0.074). CONCLUSION In a systematic review including the results from 8 studies, the odds of being malnourished were increased given the presence of dysphagia following stroke.

Background and Purpose—The reported prevalence of malnutrition after stroke varies widely, whereas it remains unclear which of the estimates is most accurate. The aim of this review was to explore possible sources of this heterogeneity among studies and to evaluate whether the nutritional assessment techniques used were valid.Methods—A literature search was conducted to identify all studies in which the nutritional state of patients was assessed after inpatient admission for stroke. The percentages of patients identified as malnourished in each study and method of nutritional assessment are reported. For the purposes of this study, an assessment technique was considered valid if at least one form of validity had been demonstrated previously through psychometric evaluation.Results—Eighteen studies meeting inclusion criteria were identified. The reported frequency of malnutrition ranged from 6.1% to 62%. Seventeen different methods of nutritional assessment were used. Four trials used previously validated assessment methods: Subjective Global Assessment, “an informal assessment,” and Mini Nutritional Assessment. The nutritional assessment methods used in the remaining studies used had not been validated previously.Conclusions—The use of a wide assortment of nutritional assessment tools, many of which have not been validated, may have contributed to the wide range of estimates of malnutrition. If so, this underscores the need for valid and reliable assessment tools to further our understanding of the relationship between stroke and nutritional status.

Response: We thank Dr Marshall for his interest in our article and welcome this opportunity to respond to his 2 concerns. In our 2003 review article,1 we concluded that intensive speech language therapy was more effective than less intense therapy. Dr Marshall states that there were inaccuracies in the reporting of one of his studies included in our review.2 It was brought to our attention that the results from 37 patients had been counted twice in our analyses. Dr Marshall is correct. We had not realized that his article reported on a …

OBJECTIVE Delayed admission to rehabilitation may result in poorer outcomes by reducing exposure to therapeutic interventions at a time when the brain is primed for neurological recovery. The present study examined the effects of early vs delayed admission on functional outcome and length of stay in patients admitted to a rehabilitation unit for first-ever unilateral stroke. DESIGN Retrospective chart review. METHODS Differences in length of rehabilitation stay and functional outcome variables among 435 patients, grouped by interval from stroke event to rehabilitation admission (=30 days vs 31-150 days and 5 additional subgroups) were examined using a multivariate technique. RESULTS Admission and discharge FIM scores, FIM change and FIM efficiency were significantly higher among early admission patients (p

Objective—To determine the incidence of dysphagia and associated pulmonary compromise in stroke patients through a systematic review of the published literature.Methods—Databases were searched (1966 through May 2005) using terms “cerebrovascular disorders,” “deglutition disorders,” and limited to “humans” for original articles addressing the frequency of dysphagia or pneumonia. Data sources included Medline, Embase, Pascal, relevant Internet addresses, and extensive hand searching of bibliographies of identified articles. Selected articles were reviewed for quality, diagnostic methods, and patient characteristics. Comparisons were made of reported dysphagia and pneumonia frequencies. The relative risks (RRs) of developing pneumonia were calculated in patients with dysphagia and confirmed aspiration.Results—Of the 277 sources identified, 104 were original, peer-reviewed articles that focused on adult stroke patients with dysphagia. Of these, 24 articles met inclusion criteria and were evaluated. The reported incidence of dysphagia was lowest using cursory screening techniques (37% to 45%), higher using clinical testing (51% to 55%), and highest using instrumental testing (64% to 78%). Dysphagia tends to be lower after hemispheric stroke and remains prominent in the rehabilitation brain stem stroke. There is increased risk for pneumonia in patients with dysphagia (RR, 3.17; 95% CI, 2.07, 4.87) and an even greater risk in patients with aspiration (RR, 11.56; 95% CI, 3.36, 39.77).Conclusions—The high incidence for dysphagia and pneumonia is a consistent finding with stroke patients. The pneumonia risk is greatest in stroke patients with aspiration. These findings will be valuable in the design of future dysphagia research.

While it has been established that organized in-patient rehabilitation provides the greatest opportunity for recovery following stroke (Stroke Unit Trialists' Collaboration 2007), there is no universally accepted, standardized set of criteria available to healthcare providers to assess in-patient rehabilitation candidacy (Wade 2003). However, because stroke represents a significant societal burden, it is important to choose potential candidates wisely to ensure that limited healthcare resources are allocated appropriately. While many patients may benefit from intensive rehabilitation, it is not cost-effective to offer in-patient rehabilitative care to those least likely to demonstrate substantial improvement with treatment, or those left with little or no residual disability whose needs can be met instead within outpatient or home-based programs. Studies of consecutive, unselected patients admitted to an acute care hospital with a diagnosis of stroke have reported that 9.5% to 44% are discharged to in-patient rehabilitation units/programs (Lai et al. 1998; Mayo et al. 1989; Rundek et al. 2000; Schlegel et al. 2003; Mahler et al. 2008; Treger et al. 2008). This wide range may be due to differences in service availability and delivery, as well as methods of remuneration among different regions or countries, and may, in part, reflect restrictions on services or patients' ability or willingness to pay for services. As a result, discharge to a stroke rehabilitation unit is not an accurate indicator of appropriate candidacy and should not be considered a suitable proxy. Although the need for an estimate of the percentage of patients who require in-patient rehabilitation following stroke should be apparent to those charged with the task of planning and administering these services, to date, one does not exist. As a result, it is unknown whether the current level of rehabilitation service provision is sufficient to meet the need. There is evidence to suggest that it does not and that demand exceeds capacity. Across Canada (2007– 2008), 23% of stroke patients spent at least one day in alternative level of care (ALC) status, indicating that the patient no longer required the intensity of medical care available in an acute care facility (CIHI 2009). Waiting for access to a rehabilitation bed was cited as a reason that 19% of patients remained in acute care for longer than necessary. To the best of our knowledge, there are no published reports in which persons with stroke were assessed for in-patient rehabilitation candidacy during their stay in acute care and followed to determine their eventual discharge destination. The objectives of this study were to identify appropriate candidates for admission to in-patient rehabilitation using a standardized screening method, and to establish what percentage of the identified candidates were discharged to an in-patient rehabilitation unit.