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The seventh edition of the Canadian Stroke Best Practice Recommendations for Rehabilitation and Recovery following Stroke includes a new section devoted to the provision of virtual stroke rehabilitation. This consensus statement uses Grading of Recommendations, Assessment, Development and Evaluations methodology and Appraisal of Guidelines for ResearchEvaluation II principles. A literature search was conducted using PubMed, Embase, and Cochrane databases. An expert writing group reviewed all evidence and developed recommendations, as well as consensus-based clinical considerations where evidence was insufficient for a recommendation. All recommendations underwent internal and external review. These recommendations apply to hospital, ambulatory care, and community-based settings where virtual stroke rehabilitation is provided. This guidance is relevant to health professionals, people living with stroke, healthcare administrators, and funders. Recommendations address issues of access, eligibility, consent and privacy, technology and planning, training and competency (for healthcare providers, patients and their families), assessment, service delivery, and evaluation. Virtual stroke rehabilitation has been shown to safely and effectively increase access to rehabilitation therapies and care providers, and uptake of these recommendations should be a priority in rehabilitation settings. They are key drivers of access to high-quality evidence-based stroke care regardless of geographical location and personal circumstances in Canada.

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.

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

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

The sixth update of the

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.

To determine whether salivary flow decreases as a function of aging.Meta-analysis.Literature review.Individuals aged 18 and older reported to be free of major systemic disease.Relevant studies were identified through a literature search of several databases, from their inception to June 2013. Studies were included if saliva had been collected on at least one occasion in subjects aged 18 and older and if the data were presented in a manner that enabled comparisons of younger and older participants. Differences in salivary flow rates between age groups were calculated for each salivary source and condition and reported as standardized mean differences (SMDs), standard errors (SEs) and 95% confidence intervals (CIs). The results were pooled using a random effects model. A separate analysis examining medication use was also conducted.Forty-seven studies were included. Whole (SMD = 0.551, SE = 0.056, 95% CI = 0.423-0.678, P.001) and submandibular and sublingual (SMSL) (SMD = 0.582, SE = 0.123, 95% CI = 0.341-0.823, P.001) salivary flow rates were reduced significantly in older participants and in unstimulated and stimulated conditions. In contrast, parotid and minor gland salivary flow rates were not significantly reduced with increasing age. Additionally, unstimulated and stimulated SMSL, and unstimulated whole salivary flow rates were significantly lower in older adults, regardless of medication usage.The aging process is associated with reduced salivary flow in a salivary-gland-specific manner; this reduction in salivary flow cannot be explained on the basis of medications. These findings have important clinical implications for maintaining optimal oral health in older adults.

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.

The 2015 update of the Canadian Stroke Best Practice Recommendations Hyperacute Stroke Care guideline highlights key elements involved in the initial assessment, stabilization, and treatment of patients with transient ischemic attack (TIA), ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and acute venous sinus thrombosis. The most notable change in this 5th edition is the addition of new recommendations for the use of endovascular therapy for patients with acute ischemic stroke and proximal intracranial arterial occlusion. This includes an overview of the infrastructure and resources required for stroke centers that will provide endovascular therapy as well as regional structures needed to ensure that all patients with acute ischemic stroke that are eligible for endovascular therapy will be able to access this newly approved therapy; recommendations for hyperacute brain and enhanced vascular imaging using computed tomography angiography and computed tomography perfusion; patient selection criteria based on the five trials of endovascular therapy published in early 2015, and performance metric targets for important time-points involved in endovascular therapy, including computed tomography-to-groin puncture and computed tomography-to-reperfusion times. Other updates in this guideline include recommendations for improved time efficiencies for all aspects of hyperacute stroke care with a movement toward a new median target door-to-needle time of 30 min, with the 90th percentile being 60 min. A stronger emphasis is placed on increasing public awareness of stroke with the recent launch of the Heart and Stroke Foundation of Canada FAST signs of stroke campaign; reinforcing the public need to seek immediate medical attention by calling 911; further engagement of paramedics in the prehospital phase with prehospital notification to the receiving emergency department, as well as the stroke team, including neuroradiology; updates to the triage and same-day assessment of patients with transient ischemic attack; updates to blood pressure recommendations for the hyperacute phase of care for ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. The goal of these recommendations and supporting materials is to improve efficiencies and minimize the absolute time lapse between stroke symptom onset and reperfusion therapy, which in turn leads to better outcomes and potentially shorter recovery times.

Hemorrhoidectomy is associated with significant postoperative pain. Oral metronidazole has been recommended as an adjunct to improve posthemorrhoidectomy analgesia.This study aimed to evaluate the impact of oral metronidazole on patient-reported pain following hemorrhoidectomy.We conducted a systematic search in the MEDLINE, EMBASE, ISI Web of Science, and Cochrane Central Register of Controlled Trials databases.Randomized controlled trials examining adults who underwent surgical hemorrhoidectomy were included. Participants in an active intervention group received oral metronidazole postoperatively, and those in a control group received placebo or usual care. Postoperative pain was assessed for at least 3 days postoperatively.A random-effects model was used.The primary outcome was pain during the first 2 postoperative weeks, measured on a visual analogue scale. The secondary outcome was time to return to normal activities.Patients who received oral metronidazole had significantly lower reported pain scores on postoperative day 1 (standardized mean difference, -0.87 ± 0.44; 95% CI, -1.73 to -0.015; p = 0.046; n = 4) and day 4 (standardized mean difference, -1.43 ± 0.71; 95% CI, -2.83 to -0.037; p = 0.044; n = 3). Metronidazole use was associated with a significantly shorter time to return to normal activities (standardized mean difference, -0.76 ± 0.34; 95% CI, -1.43 to -0.088, p = 0.027). The improvements disappeared in a sensitivity analysis excluding the largest trial with a high risk of bias, and no significance was observed during the remaining postoperative days.The meta-analysis was limited by lack of double blinding, absence of a placebo, and unclear or high risk of bias in a proportion of the included trials.Although a favorable adverse effect profile supports consideration of oral metronidazole to reduce posthemorrhoidectomy pain, pooled analysis reveals inconsistent results with no pain reduction on most postoperative days. The current recommendation for routine prescription of oral metronidazole should be reevaluated in the absence of additional well-designed trials.

To examine the effectiveness of botulinum toxin type A (BTX-A) on neurogenic detrusor overactivity (NDO) in individuals with spinal cord injury (SCI).MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for all relevant articles published from 1980 to June 2012.Trials examining the use of BTX-A injections into the detrusor wall in the treatment of NDO after SCI were included if (1) ≥ 50% of study sample comprised subjects post-SCI; (2) outcomes of interest were assessed before and after treatment with a single injection of BTX-A; and (3) the sample size was ≥ 3.A standardized mean difference ± SE (95% confidence interval) was calculated for at least 1 of the following outcomes in every study: postvoid residual urine volume, reflex detrusor volume, bladder capacity, bladder compliance, catheterization frequency, and maximum flow rate. Results from all studies were then pooled using a random-effects model. Treatment effect sizes were interpreted as small,0.2; moderate,0.5; or large,0.8.Fourteen studies representing data from 734 subjects were included. After BTX-A injection, large treatment effects were observed in postvoid residual urine volume, reflex detrusor volume, bladder capacity, bladder compliance, and catheterization frequency (P.01). Rate of incontinence episodes was reduced from 23% to 1.31% after BTX-A treatment. No significant decrease in max flow rate was observed (P=.403).Results of the meta-analysis indicate BTX-A is effective in treating NDO after SCI. The use of BTX-A was associated with a decrease in incontinence episodes, catheter use, and bladder pressures.

Objective To examine whether treatment with botulinum toxin type A (BTX-A) is associated with improvements in activity capacity or performance associated with poststroke spasticity in the upper extremity. Data Sources MEDLINE, EMBASE, Scopus, and ISI Web of Science databases were searched from 1985 to November 2011. Data Selection Studies were included if (1) the study design was a randomized controlled trial comparing injection of BTX-A with placebo or a nonpharmacologic treatment condition; (2) at least 60% of the sample was composed of adult subjects recovering from either first or subsequent stroke; (3) subjects presented with moderate to severe upper-extremity spasticity of the wrist, finger, or shoulder; and (4) activity was assessed as an outcome. Studies were limited to those published in the English language. Data Extraction Data pertaining to participant characteristics, treatment contrasts, and outcomes assessing activity limitations were extracted from each trial. The World Health Organization's International Classification of Functioning, Disability and Health was used to identify outcomes that captured the domain of activity used within each of the included studies. Where possible, a treatment effect size was calculated for each study using the standardized mean difference ± standard error (95% confidence interval) and the results pooled. Data Synthesis Sixteen randomized controlled trials were identified, 10 of which reported sufficient data for inclusion in the pooled analysis (n=1000). Six different outcomes that assessed activity limitations had been used, including the Disability Assessment Scale, the Action Research Arm Test, and the Barthel Index. Overall, BTX-A was associated with a moderate treatment effect (standardized mean difference=.536±.094, 95% confidence interval=.352–.721, P Conclusions The use of BTX-A was associated with moderate improvement in upper-extremity activity capacity or performance after stroke.

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

Mehta S, Hill D, Foley N, Hsieh J, Ethans K, Potter P, Baverstock R, Teasell RW, Wolfe D, the Spinal Cord Injury Rehabilitation Evidence Research Team. A meta-analysis of botulinum toxin sphincteric injections in the treatment of incomplete voiding after spinal cord injury. Objective To conduct a systematic review and meta-analysis to examine the effect of injecting botulinum toxin A (BTX-A) into the detrusor sphincter on improving bladder emptying in individuals with spinal cord injury (SCI). Data Sources MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for all relevant articles published from 1980 to September 2011. Data Selection All trials examining the use of BTX-A injections into the detrusor sphincter for the treatment for incomplete bladder emptying after SCI were included if at least 50% of the study sample comprised subjects with SCI, and if the SCI sample size was 3 or greater. Data Extraction A standardized mean difference (SMD) ± SE and 95% confidence interval (CI) were calculated for each outcome of interest, and the results were pooled using a fixed or random effects model, as appropriate. Outcomes assessed included postvoid residual urine volume (PRV), detrusor pressure (PDet), and urethral pressure (UP). Effect sizes were interpreted as small, 0.2; moderate, 0.5; and large, 0.8. Data Synthesis A relatively limited number of studies (2 randomized controlled trials, 6 uncontrolled trials) were identified. The 8 studies included results from 129 subjects. There was a statistically significant decrease in PRV at 1 month (SMD=1.119±.140; 95% CI, .844–1.394; P P =.009); pooled PDet decreased from 88.7 to 20.5cmH 2 O. A large statistical effect size on UP (SMD=.896±.291; 95% CI, .327–1.466; P =.002) and an improvement from 119.7 to 102.3cmH 2 O were seen. The systematic review also indicated a 50% reduction in urinary tract infections based on 3 studies. Discontinuation or reduction in catheter usage was reported in 4 studies after BTX-A. Conclusions Results of the meta-analysis indicate that BTX-A is effective in reducing PRV and demonstrating a statistically significant reduction in PDet and UP 1 month postinjection. However, the clinical utility of BTX-A is yet to be determined.

Spasticity is a significant problem following stroke. Although there is extensive research examining the efficacy of botulinum toxin as a treatment, there are challenges in implementing its use.The results from previously published randomized controlled trials and systematic reviews examining the use of botulinum toxin as a treatment for poststroke spasticity of the upper and lower limb and the shoulder are summarized. Several barriers to implementation are discussed.There is strong evidence that denervation of muscles, in the lower extremity and upper extremity post stroke, with botulinum toxin reduces focal spasticity. There is also strong evidence that it is associated with a small but significant improvement in gait velocity based on a recent meta-analysis. However, evidence that botulinum toxin injections are associated with improved function and improved quality of life is not as compelling. There is evidence that botulinum toxin injected into the subscapularis muscle can reduce spastic shoulder pain and improve passive range of motion of the hemiplegic shoulder. There are a number of challenges with botulinum toxin, including uncertainty over its role in improving motor dysfunction following stroke, the determination of which subsets of patients may benefit, the cost of treatment, and the identification of meaningful outcome measures.Botulinum toxin has been shown to be an effective treatment in reducing tone and managing spasticity post stroke. However, its effectiveness in improving function has been more controversial.

The rehabilitation of patients who are recovering from severe stroke is associated with a substantial use of resources but limited potential for functional improvement. As a result, these individuals are not perceived as being ideal candidates for inpatient stroke rehabilitation. The objective of this review was to describe the evidence for and discuss some of the challenges of providing inpatient rehabilitation services for individuals with severe stroke.A literature search was conducted to identify relevant studies. Studies were included if (a) inpatient rehabilitation was compared to other rehabilitation settings and (b) the study population included individuals with severe stroke-related disability. Following data abstraction, the methodological quality of randomized controlled trials (RCTs) that met inclusion criteria was assessed using the PEDro scale.Fourteen studies (including 4 RCTs) met inclusion criteria. Despite making limited functional improvement, persons with severe strokes who received inpatient rehabilitation had reduced mortality, decreased lengths of hospital stay, and increased likelihood of discharge home when compared to those who received rehabilitation in other settings. Rehabilitation on specialized stroke units resulted in better outcomes than other forms of inpatient rehabilitation for this group.Inpatient rehabilitation is beneficial for individuals with severe stroke. However, for this group, it may be necessary to rethink the emphasis on functional improvement and focus more on discharge planning. These individuals may still have restricted access to rehabilitation as a result of limited resources, the perception that they have poor rehabilitation potential, limited understanding of the goals of rehabilitation for this population, and a lack of research.

Although Canadian best practice recommendations regarding assessment and management of poststroke depression (PSD) have been established, the degree to which these evidence-based guidelines have been translated into practice is not known. The objectives of the present study are to compare current and recommended best practice and examine possible reasons for identified care gaps.Practice audit by chart review was performed to identify recorded screening, assessment, and treatment for PSD in patients discharged from a specialized inpatient rehabilitation program over a 6-month period. A questionnaire was administered to all clinical staff addressing current screening practices as well as opinions regarding the importance and feasibility of identification and treatment of PSD.Of 123 patients, 40 (32.5%) had been prescribed antidepressants at discharge. However, evidence of screening was found for 4.9% of patients; another 9.8% were referred for psychological consult. Treatment was associated with previous antidepressant use or history of depression, but not screening or assessment. Of the survey respondents, 56.2% were not aware of best practice recommendations. However, most felt screening and assessment to be important and treatment was regarded as both simple and effective.Despite potential benefit associated with identification and treatment of PSD and the availability of evidence-based best practice recommendations, PSD may remain unrecognized and undertreated. Given the juxtaposition of perceived importance with the lack of documented best practice, education regarding standardized screening and the development of consistent clinical protocols including roles and responsibilities in the identification, diagnosis, and treatment of PSD are underway.

Background Acute administration of tissue plasminogen activator has been shown to improve immediate and long-term patient recovery after ischaemic stroke. Yet, despite widespread clinical application, many patients who receive acute tissue plasminogen activator still require inpatient rehabilitation. Aims and Hypothesis This study aimed to examine the effect of tissue plasminogen activator administration on recovery among patients requiring inpatient rehabilitation after stroke in Ontario, Canada. It was hypothesized that after covariate adjustment, administration of tissue plasminogen activator would be associated with accelerated progress through inpatient rehabilitation. Methods Acute and rehabilitation data were retrieved from the Registry of the Canadian Stroke Network and the National Rehabilitation Reporting System for all ischaemic stroke patients admitted to an acute facility and a rehabilitation unit between July 1, 2003 and March 31,2008. Patients were divided into two groups: those who received tissue plasminogen activator and those who were medically eligible but did not receive tissue plasminogen activator. Three rehabilitation progress indicators were compared between groups: Functional Independence Measure gain, active length of stay, and discharge destination. Indicators were modelled using multivariable generalized linear models or logistic regression as appropriate. Results Patients who received tissue plasminogen activator experienced shorter active lengths of stay (log estimate ± standard error: −0.04 ± 0.01 days), and were slightly more likely to be discharged home compared to controls (adjusted odds ratio 1.35, 95% confidence interval 1.004–1.82). No differences were noted on Functional Independence Measure gain during rehabilitation. Conclusion Results suggest that tissue plasminogen activator may contribute to accelerated progress through inpatient rehabilitation; however, there is no evidence to suggest that it contributes to greater functional improvement as measured by the Functional Independence Measure.

To examine the effectiveness of pharmacotherapy for the treatment of depression following traumatic brain injury (TBI).Systematic review and meta-analysis. Multiple electronic databases were searched to identify relevant studies examining effectiveness of pharmacotherapy for depression post-TBI. Clinical trials evaluating the use of pharmacotherapy in individuals with depression at baseline and using standardized assessments of depression were included. Data abstracted included sample size, antidepressant used, treatment timing/duration, method of assessment, and results pertaining to impact of treatment. Study quality was assessed using a modified Jadad scale.Nine studies met criteria for inclusion. Pooled analyses based on reported means (standard deviations) from repeated assessments of depression showed that, over time, antidepressant treatment was associated with a significant effect in favor of treatment (Hedges g = 1.169; 95% confidence interval, 0.849-1.489; P.001). Similarly, when limited to placebo-controlled trials, treatment was associated with a significant reduction in symptoms (standardized mean difference = 0.84; 95% confidence interval, 0.314-1.366; P = .002).Pharmacotherapy after TBI may be associated with a reduction in depressive symptomatology. Given limitations within the available literature, further well-powered, placebo-controlled trials should be conducted to confirm the effectiveness of antidepressant therapy in this population.

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.

The objectives of the present study are (1) to examine whether the content of existing community integration measures used following traumatic brain injury (TBI) is represented in the International Classification of Functioning, Disability and Health (ICF) and (2) to determine if the ICF provides a reasonable framework within which such measurement tools may be compared.Five commonly-used assessment instruments were selected for inclusion. Independent raters mapped identified measurement concepts to the ICF using established linking rules.One hundred and eighty-five concepts were identified from 85 items in five scales. Of these more than 75% could be linked to the ICF. The majority of linked concepts were assigned to 64 categories within the activities and participation component of the ICF; however, the focus of assessment within each instrument varied considerably.Through a standardized process of item mapping to the ICF, one may examine operationalizations of community integration. This may help inform selection of a method of assessment appropriate to both the subject population and clinical or research purpose. However, this process allows comparison of only the objective content of measurement tools. Subjective evaluations may also be necessary to provide comprehensive assessment of community integration.

To review the research literature on pharmacological interventions used in the acute phase of acquired brain injury (ABI) to manage ICP and improve neural recovery.A literature search of multiple databases (CINAHL, EMBASE, MEDLINE and PSYCHINFO) and hand searched articles covering the years 1980-2008 was performed. Peer reviewed articles were assessed for methodological quality using the PEDro scoring system for randomized controlled trials (RCTs) and the Downs and Black tool for RCTs and non-randomized trials. Levels of evidence were assigned and recommendations were made.In total, 11 pharmacological interventions used in the acute management of ABI were evaluated. These included propofol, barbiturates, opioids, midazolam, mannitol, hypertonic saline, corticosteroids, progesterone, bradykinin antagonists, dimethyl sulphoxide and cannabinoids. Of these interventions, corticosteroids were found to be contraindicated and cannabinoids were reported as ineffective. The other nine interventions demonstrated some benefit for treatment of acute ABI. However, rarely did these benefits result in improved long-term patient outcomes.Substantial research has been devoted to evaluating the use of pharmacological interventions in the acute management of ABI. However, much of this research has focused on the application of individual interventions in small single-site trials. Future research will need to establish larger patient samples to evaluate the benefits of combined interventions within specific patient populations.

To review the literature regarding techniques used to promote arousal from coma following an acquired brain injury.A literature search of multiple databases (CINAHL, EMBASE, MEDLINE and PsycINFO) and hand searched articles covering the years 1980-2008 was performed. Peer reviewed articles were assessed for methodological quality using the PEDro scoring system for randomized controlled trials and the Downs and Black tool for RCTs and non-randomized trials. Levels of evidence were assigned and recommendations were made.Research into coma arousal has generally focused on the stimulation of neural pathways responsible for arousal. These pathways have been targeted using pharmacological and non-pharmacological techniques. This review reports the evidence surrounding agents targeting dopamine pathways (amantadine, bromocriptine and levodopa), sensory stimulation, music therapy and median nerve electrical stimulation. Each of these interventions has shown some degree of benefit in improving consciousness, but further research is necessary.Despite numerous studies, strong evidence was only found for one intervention (Amantadine use in children) and this was based on a single study. However, each of the interventions showed promise in some aspect of arousal and warrant further study. More methodologically rigorous study is needed before any definitive conclusions can be drawn.

Caring for a person who has experienced stroke can be a formidable task placing considerable demands upon the informal caregiver. Although the impact of caring on mental health has been well established, less convincing associations between caregiving and declining physical health have been reported. In order to examine the impact of caregiving over time on the physical health of individuals providing informal care for individuals with stroke, we conducted a review of the published literature.Literature searches of three electronic databases were conducted for the years 1996-2008 to identify studies providing longitudinal data based on repeated quantitative assessment of physical health. Pooled analyses were conducted.Sixteen studies were identified for inclusion. On the basis of pooled analyses, perceived physical health appeared stable over time. When comparisons to normative values were possible, the experience of health did not differ substantially from age- and sex-matched norms. Associations between physical health and psychological distress or well-being were identified.Informal caregiving does not result, necessarily, in reduced physical health. Further study is required to examine the timing and nature of the relationship between psychological distress and physical health to inform provision of services intended to maintain caregiver health and well being.

There is a revolution underway in stroke rehabilitation. International comparative studies coupled with an impressive evidence base have provided a platform from which an ideal system for stroke rehabilitation can be envisioned. Using the concepts of structure and process of care, different systems of stroke rehabilitation can be compared and evaluated against best evidence. Two structures of care are examined: specialized interdisciplinary stroke rehabilitation units and outpatient programs. Although specialized interdisciplinary stroke rehabilitation units remain the "gold standard" of care, access to them is often limited. Outpatient programs are essential to stroke rehabilitation systems of care; however, while some countries are investing in outpatient programs, others are scaling back. Even though structures of care have been shown to affect processes of care, it is the processes of care that have proven to be more influential in altering patient outcomes. Four key processes of care are examined: time to admission, intensity of therapy, task-specific therapy, and discharge planning. Within international stroke rehabilitation systems, differences in these processes have resulted in significant differences in outcomes. This allows for "real-world" comparisons of how differing processes affect patient outcomes. Those systems whose structures and processes of care best reflect current best evidence appear to achieve better outcomes.

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.

Despite the importance of community integration to individuals with traumatic brain injury, it is assessed relatively infrequently. The present paper provides a review of current approaches to the assessment of community integration, including evaluation of psychometric and administrative properties reported in the literature.Based on results from existing systematic reviews, the Community Integration Questionnaire (CIQ), Craig Handicap Assessment and Reporting Technique (CHART), Reintegration to Normal Living Index (RNLI), Sydney Psychosocial Reintegration Scale (SPRS) and Community Integration Measure (CIM) were included in the present study. Descriptive details are provided along with results of psychometric evaluations and discussion of the strengths and limitations associated with each instrument.The instruments reviewed all provide assessment of three core elements of community integration: relationships with others, independence in one's own living situation and meaningful activities. Within the context of available information, the CIQ and RNLI appear the most reliable and valid, objective and subjective assessments of community reintegration, respectively. Caution is recommended in use of these tools by proxy raters. Unfortunately, with the exception of the CIQ and RNLI, evaluation of measurement characteristics and clinical usefulness is lacking. To promote an informed process of selection of tools, further evaluation is recommended.

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.

In recent years, the importance of understanding the impact of interventions on an individual’s ability to participate in social roles after a stroke event has gained much attention. Comprehensive assessment of treatment effectiveness should include a broader range of outcomes, including social participation. This study attempted to determine the degree to which the assessment of social participation has been included in randomized controlled trials of stroke rehabilitation. An extensive literature search was used to identify all randomized controlled trials from 1968 to 2005. Assessment scales used to evaluate study outcomes were recorded and classified based on the International Classification of Functioning Disability and Health (ICF) framework. Studies citing assessment of more than one ICF component were identified. In total, 1447 outcomes were assessed using 489 measurement scales and were cited in 491 identified trials. Both number of studies and assessment of participation outcomes increased over time. Participation assessments accounted for less than 6% of all measurement citations. Around 56.8% of studies reported multicomponent assessment. Of these, 25% included assessment at the level of ICF Participation. In conclusion, the vast body of work within the areas of impairment and function is a cornerstone for rehabilitation. This is certainly reflected in the recorded measurement citations. Despite increasing awareness and a significant increase in participation assessment, relatively few studies include assessment at this level, thereby limiting our understanding with regard to the impact of rehabilitation interventions on more complex areas of social participation. International Journal of Rehabilitation Research 30:339–342 c 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins. International Journal of Rehabilitation Research 2007, 30:339–342

An estimated 15% of all patients admitted to stroke rehabilitation units experience a brainstem stroke. Two case studies are presented to illustrate some of the difficulties encountered in the rehabilitation of these individuals. Unlike hemispheric stroke, the characteristic consequences of brainstem stroke include ataxia, dysarthria, and diplopia. Additionally, individuals with brainstem stroke may suffer from severe dysphagia and may require enteral feedings. Unlike the rehabilitation of patients with hemispheric stroke, where there is an impressive and relatively comprehensive research literature, there has been surprisingly little research published on the rehabilitation of patients with brainstem stroke despite the fact they represent a significant number of patients admitted to stroke rehabilitation units.

Every year, approximately 62 000 people with stroke and transient ischemic attack are treated in Canadian hospitals, and the evidence suggests one-third or more will experience vascular-cognitive impairment, and/or intractable fatigue, either alone or in combination. The 2015 update of the Canadian Stroke Best Practice Recommendations: Mood, Cognition and Fatigue Module guideline is a comprehensive summary of current evidence-based recommendations for clinicians in a range of settings, who provide care to patients following stroke. The three consequences of stroke that are the focus of the this guideline (poststroke depression, vascular cognitive impairment, and fatigue) have high incidence rates and significant impact on the lives of people who have had a stroke, impede recovery, and result in worse long-term outcomes. Significant practice variations and gaps in the research evidence have been reported for initial screening and in-depth assessment of stroke patients for these conditions. Also of concern, an increased number of family members and informal caregivers may also experience depressive symptoms in the poststroke recovery phase which further impact patient recovery. These factors emphasize the need for a system of care that ensures screening occurs as a standard and consistent component of clinical practice across settings as stroke patients transition from acute care to active rehabilitation and reintegration into their community. Additionally, building system capacity to ensure access to appropriate specialists for treatment and ongoing management of stroke survivors with these conditions is another great challenge.

Background: Using previously published data, the purpose of this study was to identify and discriminate between three different forms of inpatient stroke care based on timing and duration of treatment and to compare the results of clinically important outcomes. Methods: Randomized controlled trials, including a recent review of inpatient stroke unit/rehabilitation care, were identified and grouped into three models of care as follows: (a) acute stroke unit care (patients admitted within 36 h of stroke onset and remaining for up to 2 weeks; n = 5), (b) units combining acute and rehabilitative care (combined; n = 4), and (c) rehabilitation units where patients were transferred onto the service approximately 2 weeks following stroke (postacute; n = 5). Pooled analyses for the outcomes of mortality, combined death and dependency and length of hospital stay were calculated for each model of care, compared to conventional care. Results: All three models of care were associated with significant reductions in the odds of combined death and dependency; however, acute stroke units were not associated with significant reductions in mortality when this outcome was analyzed separately (OR 0.80; 95% CI: 0.61–1.03). Postacute stroke units were associated with the greatest reduction in the odds of mortality (OR 0.60; 95% CI: 0.44–0.81). Significant reductions in length of hospital stay were associated with combined stroke units only (weighted mean difference –14 days; 95% CI: –27 to –2). Conclusions: Overall, specialized stroke services were associated with significant reductions in mortality, death and dependency and length of hospital stay although not every model of care was associated with equal benefit.

Aphasia is one of the most common consequences of stroke. Early identification, diagnosis and treatment of language deficits are important steps in maximizing rehabilitation gains. A routine screening test is an invaluable tool in the identification and appropriate referral of patients with potential communication problems. The present study presents an evaluation of the measurement properties of screening tools for aphasia found within the stroke research literature.Screening tools were identified following searches of the published research literature in stroke. Instruments were reviewed on the basis of reliability, validity, classification sensitivity and practical utility.Six aphasia screening tools were identified. For most tools, information pertaining to measurement properties and clinical utility was limited.The Frenchay Aphasia Screening Test (FAST) appears to be the most widely used and thoroughly evaluated tool found within the stroke research literature. Further evaluation of the measurement properties and clinical utility of screening tools is recommended.

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.

Reorganization of the brain, specifically the motor cortex surrounding the stroke, accounts for much of the observed neurological recovery following stroke. Not surprisingly, size of the stroke lesion has the greatest impact on neurological recovery in both animal and clinical research studies. Spontaneous recovery of lost function is possible after a cortical lesion, particularly if the lesion is small. Age correlates negatively with recovery; older individuals generally demonstrate slower and less complete recovery. However, age by itself is a poor predictor of functional recovery.

To systematically compare the PEDro scale and the Jadad scale when applied to the stroke rehabilitation literature.A literature search of multiple databases was used to identify all trials from 1968 through 2002. Each article was reviewed and assigned quality scores according to PEDro and Jadad criteria. Quality scores for both scales were compared using descriptive statistics. The correlation between the scales was estimated using the Pearson product moment correlation coefficient.272 randomized controlled trials were retrieved and subjected to quality scoring to both the PEDro scale and the Jadad scale. Mean scores (with standard deviation) for the PEDro and Jadad scales were 5.78 (1.4) and 2.46 (1.1), respectively. The Pearson coefficient determined the PEDro and Jadad scales to be significantly correlated (r = .59, P.01). Although significant, the correlation was not deemed to be very strong. When applied to physical or rehabilitation therapy studies only, the scales were slightly less correlated (r = .49, P.01) than among drug-based studies (r = .52, P.01).In the stroke rehabilitation literature, where double-blinding studies are often not possible due to the nature of the interventions, breaking down the levels of blinding and accounting for concealed allocation, intention-to-treat, and attrition is important. Accordingly, the PEDro scale provides a more comprehensive measure of methodological quality of the stroke literature.

To evaluate the psychometric and administrative properties of outcome measures in the ICF Participation category, which are used in stroke rehabilitation research and reported in the published literature.Critical review and synthesis of measurement properties for six commonly reported instruments in the stroke rehabilitation literature. Each instrument was rated using the eight evaluation criteria proposed by the UK Health Technology Assessment (HTA) programme. The instruments were also assessed for the rigour with which their reliability, validity and responsiveness were reported in the published literature.Validity has been well reported for at least half of the measures reviewed. However, methods for reporting specific measurement qualities of outcome instruments were inconsistent. Responsiveness of measures has not been well documented. Of the three ICF categories, Participation seems to be most problematic with respect to: (a) lack of consensus on the range of domains required for measurement in stroke; (b) much greater emphasis on health-related quality of life, relative to subjective quality of life in general; (c) the inclusion of a mixture of measurements from all three ICF categories.The reader is encouraged to examine carefully the nature and scope of outcome measurement used in reporting the strength of evidence for improved participation associated with stroke rehabilitation. There is no consensus regarding the most important indicators of successful involvement in a life situation and which ones best represent the societal perspective of functioning. In particular, quality of life outcomes lack adequate conceptual frameworks to guide the process of development and validation of measures.

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.

A systematic review of the randomized controlled trials published from 1970-2002 was conducted to assess the effectiveness of early supported discharge programs in the context of stroke rehabilitation. Ten studies, including 1,286 patients, were selected for detailed review. The methodological quality of the studies was assessed using the PEDro Scale. The outcome assessed included functional outcomes, cost analysis, and length of hospital stay. Although the majority of studies reported no statistically significant differences in functional outcomes between the two groups, there was a reduction in hospital stays for patients receiving home-based therapy. These results suggest that patients with milder strokes who receive home-based therapies have similar functional outcomes to patients who receive traditional inpatient rehabilitation.

The Stroke Rehabilitation Evidence-Based Review revealed a wide range of quality scores across primary studies. The aim of this section is to determine what differences there are across studies and to provide a detailed examination of methodological issues in the stroke rehabilitation literature. Methodology of each article was assessed using the Physiotherapy Evidence Database (PEDro) quality scale. Mean PEDro scores and percentage of studies meeting individual PEDro criteria were determined for all studies, for therapy-based studies only, and for drug-based studies only. It was noted that the stroke rehabilitation literature lacked rigor in the area of concealed allocation, blinding of the assessor, and intention-to-treat analysis. Investigation of the methodological quality of stroke rehabilitation literature emphasizes the need for improved treatment protocols, taking into account previous deficits, during research.

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.