1. Stroke Best Practices for outpatient/community rehab
Date: October 11, 2017
Janine Theben

2. Outpatient & Community Based Rehabilitation
Stroke survivors with ongoing rehabilitation goals should have access to specialized stroke services
Services should be available and provided by a specialized interprofessional team, within 48h of discharge from acuter or within 72 hours from rehab
Services should be delivered in the most suitable setting based on needs, goals and availability of social support, preferences

3. Outpatient & Community Based Rehabilitation
Outpatient and/or community based rehabilitation services should include the same elements and inpatient rehab
Interprofessional team
Case coordination including regular team communication to discuss assessments of new clients, review client management, goals, and plans for discharge or transition
Therapy is provided for a minimum of 45 minutes per day per discipline, 2-5 days per week based on patient goals for at least 8 weeks
Patients and families should be involved in their management, goal setting, an transition planning
Team should promote practice and transfer of skills gained in therapy into the patients daily routine and in the community

4. Special Topics Additional topics that could be covered here:
–Rehabilitation of visual perceptual deficits
UE treatments including: Functional Electrical Stimulation, Constraint Induces Movement Therapy, Mirror Therapy
Aerobic Training

5. Visual Perception Effects 21% of stroke patients Treatment – clear …
Remedial based techniques: prisms, eye patching, repetitive transcranial magnetic stimulation, and neck muscle vibration
Errorless learning and gesture training for limb apraxia
Mirror therapy for unilateral inattention
Errorless learning:
Is the process of learning a procedure without allowing the individual to make any mistakes
 The information to be learned is presented in the same way each time and any opportunity to guess is eliminated
Each task is broken down into specific components
 Repetition/Consistency is the key
 Often very time intensive
 Family/care taker carryover into learning process very important
Research shows that clients with significant deficits in explicit memory respond positively to Errorless techniques and the severer the memory dysfunction the better response as there is no interference by the explicit memories
Consistency and repetition is of great importance
Important to provide ongoing feedback
Specific set of instructions for staff to facilitate consistency
Visual support for clients when required
Withdrawing supports as performance improves

6. UE Treatments
FES targeted at wrist and forearm should be considered to reduce motor impairment and improve function
Traditional or modified constraint induced movement therapy should be considered for patients who demonstrate 20 degrees of active wrist extension and 10 degrees active finger extension and minimal sensory or cognitive deficits
Mirror therapy as an adjunct to motor therapy (improves UE motor function and ADL)
GRASP (suitable for hospital use and home) as a supplementary training program

7. Aerobic Training
Screen/submaximal test like 6 min walk or exercise stress test (?) . What is the target intensity of the planned program?
Tailored aerobic training using large muscle groups (3 times per week for 8 weeks, 20 min per session plus warm up and cool down). Monitor HR and BP
Transition to self directed physical activity in home or community
Address barriers to participation

8. Clinician Resources to Guide Evidence Based Practice
Canadian Stroke Best Practice Recommendations
QBP Handbook
Stroke Engine
Heart and Stroke Foundation Website (specifically TACLS)
Evidence Based Review of Stroke Rehabilitation
West GTA Stroke Network Website
Core Competency
SWO Stroke Unit Orientation
Grasp
Via Therapy App

9. Stroke Best Practise at http://www.strokebestpractices.ca
The Canadian Best Practice Recommendations (CSBPR) as 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 (patients, families and informal caregivers).
They are updated and released every 2 to 3 years with interim updates of specific topics when critical new evidence emerges.

10. Who has heard of the West GTA Stroke Network before?
We are going to quiz you right off the bat!
Has anyone heard of the West GTA Stroke Network? And know what it is?
As a brief overview the West GTA Stroke Network was established in 1999, and is part of the Ontario Stroke Network
Vision of OSN “Fewer Strokes, Better Outcomes”. Each of the networks, along with you, is trying to achieve that goal
Currently 11 regional stroke networks in OSN – West GTA is one of them
Our region includes the central west, and Mississauga/Halton LHIN’s and includes 9 hospitals and 40+ LTC homes. Trillium Health Partners Mississauga Site is the Regional Stroke Centre
The primary aim to educate front line health care professional working in stroke care.

11. Upcoming Opportunities for Professional Development Through the West GTA Stroke Network
Marianne Lawton Workshop “Normal Movement Bobath Course” for PTAs/OTAs-November 18, 2017
Interprofessional Workshop for Acute and Rehab staff-___
Sharing Forum for Rehab and the Community-Spring 2018
Hemispheres
Mirror Therapy Lunch and Learn with Tara Packham

12. What are your education needs moving forward?

13. References
Teasall, R et al (2013) Dysphagia and Aspiration Following Stroke. Evidence-Based Review of Stroke Rehabilitation. Retrieved from
Dalmas Griffin, Maggie. (2014, April 20). If you could see what I see. Retrieved from
University of Miami. (n.d.) brain3.gif retrieved from
International Journal of Stroke, 2016, Vol. 11( ) ! 2016 World Stroke Organization