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.
Background The incidence of stroke in young adults is increasing. While many young survivors are able to achieve a good physical recovery, subtle dysfunction in other domains, such as cognition, often persists, and could affect return to work. However, reported estimates of return to work and factors affecting vocational outcome post-stroke vary greatly. Aims The aims of this systematic review were to determine the frequency of return to work at different time points after stroke and identify predictors of return to work. Summary of review Two electronic databases (Medline and Embase) were systematically searched for articles according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 6473 records were screened, 68 were assessed for eligibility, and 29 met all inclusion criteria (working-age adults with stroke, return to work evaluated as an outcome, follow-up duration reported, and publication within the past 20 years). Return to work increased with time, with median frequency increasing from 41% between 0 and 6 months, 53% at 1 year, 56% at 1.5 years to 66% between 2 and 4 years post-stroke. Greater independence in activities of daily living, fewer neurological deficits, and better cognitive ability were the most common predictors of return to work. Conclusion This review highlights the need to examine return to work in relation to time from stroke and assess cognition in working age and young stroke survivors. The full range of factors affecting return to work has not yet been explored and further evaluations of return to work interventions are warranted.
The aim of this study was to employ knowledge user perspectives to develop recommendations that facilitate implementation of a complex, shared decision‐making (SDM)‐based intervention in an interprofessional setting. This study was part of a larger knowledge translation (KT) study in which interprofessional teams from five freestanding, academically affiliated, rehabilitation hospitals were tasked with implementing a cognitive strategy‐based intervention approach that incorporates SDM known as Cognitive Orientation to daily Occupational Performance (CO‐OP) to treat survivors of stroke. At the end of the 4‐month CO‐OP KT implementation support period, 10 clinicians, two from each site, volunteered as CO‐OP site champions. A semi‐structured focus group was conducted with 10 site champions 3 months following the implementation support period. To meet the study objective, an exploratory qualitative research design was used. The focus group session was audio‐recorded, transcribed verbatim and analyzed through the lens of the integrated promoting action on research implementation in health services (iPARIHS) framework. The focus group participants (n = 8) consisted of occupational therapists, physical therapists, and speech language pathologists. Ten recommendations for CO‐OP implementation were extracted and co‐constructed from the focus group transcript. The recommendations reflected all four iPARHIS constructs: Facilitation, Context, Innovation, and Recipients. Implementation recommendations, from the knowledge user perspective, highlight that context‐specific facilitation is key to integrating a novel, complex intervention into interprofessional practice. Facilitators should lay out a framework for training, communication and implementation that is structured but still provides flexibility for iterative learning and active problem‐solving within the relevant practice context.
BackgroundThe Cognitive Orientation to daily Occupational Performance (CO-OP) approach is a complex rehabilitation intervention in which clients are taught to use problem-solving cognitive strategies to acquire personally-meaningful functional skills, and health care providers are required to shift control regarding treatment goals and intervention strategies to their clients. A multi-faceted, supported, knowledge translation (KT) initiative was targeted at the implementation of CO-OP in inpatient stroke rehabilitation teams at five freestanding rehabilitation hospitals. The study objective was to estimate changes in rehabilitation clinicians’ knowledge, self-efficacy, and practice related to implementing CO-OP.MethodsA single arm pre-post and 6-month follow up study was conducted. CO-OP KT consisted of a 2-day workshop, 4 months of implementation support, a consolidation session, and infrastructure support. In addition, a sustainability plan was implemented. Consistent with CO-OP principles, teams were given control over specific implementation goals and strategies. Multiple choice questions (MCQ) were used to assess knowledge. A self-efficacy questionnaire with 3 subscales (Promoting Cognitive Strategy Use, PCSU; Client-Focused Therapy, CFT; Top-Down Assessment and Treatment, TDAT) was developed for the study. Medical record audits were used to investigate practice change. Data analysis for knowledge and self-efficacy utilized mixed effects models. Medical record audits were analyzed with frequency counts and chi-squares.ResultsSixty-five health care providers consisting mainly of occupational and physical therapists entered the study. Mixed effects models revealed intervention effects for MCQs, CFT, and PCSU at post intervention and follow-up, but no effect on TDAT. No charts showed any evidence of CO-OP use at baseline, compared to 8/40 (20%) post intervention. Post intervention there was a trend towards reduction in impairment goals and significantly more component goals were set (z = 2.7, p = .007).
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 Research & Evaluation 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.
Background and Purpose: Many patients with ischemic stroke present with multiple comorbidities that threaten survival and recovery. This study sought to determine the risks of adverse long-term stroke outcomes associated with multimorbid diabetes mellitus and depression. Methods: Retrospective analysis of prospectively collected data on consecutive patients without premorbid dementia admitted from the community for a first-ever acute ischemic stroke to comprehensive stroke centers across Ontario, Canada (2003–2013). Premorbid histories of diabetes mellitus and depression were ascertained within 5 years before stroke admission. Adjusted hazard ratios (aHR [95% CI]) of admission to long-term care, incident dementia, readmission for stroke or transient ischemic attack and all-cause mortality, over time among those discharged back into the community poststroke. Results: Among 23 579 stroke admissions, n=20 201 were discharged back into the community. Diabetes mellitus and depression were associated with synergistic hazards of admission to long-term care (X 2 =5.4; P =0.02) over a median follow-up of 5.6 years. This interaction was observed among women specifically; depression multimorbidity showed particularly high hazards of admission to long-term care (aHR Depression =1.57 [1.24–1.98]) and incident dementia (aHR Depression =1.85 [1.40–2.44]) among women with diabetes mellitus. In the whole cohort, diabetes mellitus and depression were associated individually with long-term care admission (aHR Diabetes =1.20 [1.12–1.29]; aHR Depression =1.19 [1.04–1.37]), incident dementia (aHR Diabetes =1.14 [1.06–1.23]; aHR Depression =1.27 [1.08–1.49]), stroke/transient ischemic attack readmission (aHR Diabetes =1.18 [1.10–1.26]; aHR Depression =1.24 [1.07–1.42]), and all-cause mortality (aHR Diabetes =1.29 [1.23–1.36]; aHR Depression =1.16 [1.05–1.29]). Conclusions: The risks of dementia and needing long-term care in the years after surviving a stroke were particularly elevated among women when premorbid diabetes mellitus and depression occurred together. Long-term stroke recovery strategies might target high-risk patients with mood and metabolic multimorbidity.
Background The incidence of ischemic stroke has increased among adults aged 18 to 64 years, yet little is known about relationships between specific risk factors and outcomes. This study investigates in‐hospital and long‐term outcomes in patients with stroke aged <65 years with preexisting diabetes mellitus. Methods and Results Consecutive patients aged <65 years admitted to comprehensive stroke centers for acute ischemic stroke between 2003 and 2013 were identified from the Ontario Stroke Registry. Multinomial logistic regression was used to estimate adjusted odds ratio (OR [95% CI]) of in‐hospital mortality or direct discharge to long‐term or continuing care. Cox proportional hazards regression was used to estimate the adjusted hazards ratio (aHR [95% CI]) of long‐term mortality, readmission for stroke/transient ischemic attack, admission to long‐term care, and incident dementia. Predefined sensitivity analyses examined stroke outcomes among young (aged 18–49 years) and midlife (aged 50–65 years) subgroups. Among 8293 stroke survivors (mean age, 53.6±8.9 years), preexisting diabetes mellitus was associated with a higher likelihood of in‐hospital death (adjusted OR, 1.46 [95% CI, 1.14–1.87]) or direct discharge to long‐term care (adjusted OR, 1.65 [95% CI, 1.07–2.54]). Among stroke survivors discharged (N=7847) and followed up over a median of 6.3 years, preexisting diabetes mellitus was associated with increased hazards of death (aHR, 1.68 [95% CI, 1.50–1.88]), admission to long‐term care (aHR, 1.57 [95% CI, 1.35–1.82]), readmission for stroke/transient ischemic attack (aHR, 1.37 [95% CI, 0.21–1.54]), and incident dementia (aHR, 1.44 [95% CI, 1.17–1.77]). Only incident dementia was not increased for young stroke survivors. Conclusions Focused secondary prevention and risk factor management may be needed to address poor long‐term outcomes for patients with stroke aged <65 years with preexisting diabetes mellitus.
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