Canadian Stroke Best Practice Recommendations
Canadian Stroke Best Practices Advisory Committee and Writing Groups. (2022).
Ottawa, ON (Canada): Heart and Stroke Foundation, (7th Edition), Retrieved from http://www.strokebestpractices.ca.
This regularly updated guideline from the Heart and Stroke Foundation of Canada provides recommendations for members of multidisciplinary teams caring for children and adults diagnosed with stroke in a variety of settings. The guideline is divided into several modules, which include separately published recommendations and supporting documents pertaining to rehabilitation of physical, functional, cognitive, and emotional issues post-stroke. Modules and recommendations on topics specifically related to speech-language pathologists, such as communication impairments, cognitive deficits, and dysphagia, are included in the following summary.
Heart and Stroke Foundation of Canada
This guideline summary contains recommendations from the following documents found on the Canadian Stroke Best Practice Recommendations website:<br />
<ul>
<li>Blacquiere, D., Lindsay, M. P., et al. (2017). Canadian Stroke Best Practice Recommendations: Telestroke Best Practice Guidelines Update 2017. <em>International Journal of Stroke, 12</em><(8), 886-895. doi:10.1177/1747493017706239</li>
<li>Gladstone, D. J., Poppe, A. Y., et al. (2020). <em>Secondary Prevention of Stroke, Seventh Edition Practice Guidelines, Update 2020</em>. Retrieved from <a title="https://www.strokebestpractices.ca" href="https://www.strokebestpractices.ca/recommendations/secondary-prevention-of-stroke" target="_blank" rel="noopener">https://www.strokebestpractices.ca</a></li>
<li>Heart and Stroke Foundation of Canada. (2016). <em>Summary of Pediatric Recommendations Across Modules, 5th Edition</em>. Retrieved from <a title="https://www.strokebestpractices.ca" href="https://www.strokebestpractices.ca/recommendations/pediatric-stroke" target="_blank" rel="noopener">https://www.strokebestpractices.ca</a></li>
<li>Heran, M., Lindsay, P., et al. (2022). <em>Acute Stroke Management, 7th Edition Practice Guidelines Update 2022. </em>Retrieved from <a title="https://www.strokebestpractices.ca" href="https://www.strokebestpractices.ca/recommendations/acute-stroke-management" target="_blank" rel="noopener">https://www.strokebestpractices.ca</a></li>
<li>Lanctot, K. L. & Swartz, R. H. (2019). <em>Mood, Cognition and Fatigue following Stroke</em>. Retrieved from <a title="https://www.strokebestpractices.ca" href="https://www.strokebestpractices.ca/recommendations/mood-cognition-and-fatigue-following-stroke" target="_blank" rel="noopener">https://www.strokebestpractices.ca</a></li>
<li>Mountain, A., Cameron, J. I., et al. (2019). <em>Rehabilitation, Recovery and Community Participation following Stroke, Part Two: Transitions and Community Participation Following Stroke, Update 2019</em>. Retrieved from <a title="https://www.strokebestpractices.ca" href="https://www.strokebestpractices.ca/recommendations/managing-stroke-transitions-of-care">https://www.strokebestpractices.ca</a></li>
<li>Salbach, N. M., Mountain, A., et al. (2022). Canadian Stroke Best Practice Recommendations: Virtual Stroke Rehabilitation Interim Consensus Statement 2022. <em>American Journal of Physical Medicine & Rehabilitation, 101</em>(11), 1076-1082. doi:10.1097/PHM.0000000000002062</li>
<li>Shoamanesh, A., Lindsay, M. P., et al. (2020). <em>Management of Spontaneous Intracerebral Hemorrhage, Seventh Edition – New Module 2020</em>. Retrieved from <a title="https://www.strokebestpractices.ca" href="https://www.strokebestpractices.ca/recommendations/management-of-intracerebral-hemorrhage" target="_blank" rel="noopener">https://www.strokebestpractices.ca</a></li>
<li>Smith, E., Mountain, A., et al. (2020) Canadian Stroke Best Practice Guidance During the COVID-19 Pandemic. <em>Canadian Journal of Neurological Sciences, 47</em>(4):474-478. doi:10.1017/cjn.2020.74</li>
<li>Teasell, R., Salbach, N. M., et al. (2019). <em>Rehabilitation, Recovery and Community Participation following Stroke, Part One: Rehabilitation and Recovery following Stroke, Update 2019</em>. Retrieved from <a title="https://www.strokebestpractices.ca" href="https://www.strokebestpractices.ca/recommendations/stroke-rehabilitation" target="_blank" rel="noopener">https://www.strokebestpractices.ca</a></li>
</ul>
<div>During the COVID-19 pandemic, individuals who have experienced a stroke should continue to have access to multidisciplinary rehabilitation services with adaptations that follow public health recommendations. When appropriate, telepractice services should be offered (Smith et al., 2020, Expert Opinion).</div>
<div>For patients who have experienced a catastrophic stroke or a stroke when they have a pre-existing comorbidity, the interdisciplinary stroke team should use a palliative approach to discuss the patient’s care goals with the patient and their care provider(s) considering their prognosis, values, and wishes, and determine if care should focus on comfort or prolonging life (Heran et al., 2022, Evidence Level C). These discussions and assessments should be ongoing and documented regularly (Heran et al., 2022, Evidence Level C).</div>
<div>The following recommendations were made regarding the provision of stroke rehabilitation via telepractice/virtual care modalities:</div>
<ul>
<li>Telepractice should be made available as an alternative care model or adjunct to in-person therapy for people with stroke (Strong Recommendation; Moderate Quality of Evidence).</li>
<li>Telepractice services should be integrated into the plan of care across the care continuum to support optimal recovery, provide support for families and care partners, and ensure equitable access to care (Strong Recommendation; Moderate Quality of Evidence).</li>
<li>All rehabilitation disciplines should consider the use of telepractice for the assessment and treatment of people with stroke as appropriate (Strong Recommendation; Low Quality of Evidence).</li>
<li>Home-based monitoring via web-based applications may be a viable alternative or adjunct to in-person outpatient rehabilitation when frequent monitoring is necessary and access to in-person services is limited (Strong Recommendation; Moderate Quality of Evidence). </li>
</ul>
<div>The following recommendations were made regarding clinical considerations for stroke rehabilitation delivered via telepractice/virtual care modalities:</div>
<ul>
<li>Every patient admitted to the hospital with acute stroke should be assessed to determine their stroke severity, early rehabilitation needs, and the most appropriate modality (e.g., inperson, telepractice, hybrid) for the timely and effective delivery of stroke rehabilitation services (Strong Recommendation; Moderate Quality of Evidence).</li>
<li>Every patient with acute stoke that is not admitted to the hospital should be screened either in-person or through virtual care modalities to determine the potential scope of deficits, the need for comprehensive rehabilitation assessment, and the need for any rehabilitation services (Strong Recommendation; Low Quality of Evidence).</li>
<li>Referring sites should have assess to clearly defined criteria or algorithms to determine how and when peopel with stroke can access virtual stroke rehabilitation, secondary prevention, and ambulatory services (Strong Recommendation; Low Quality of Evidence).</li>
<li>Stroke rehabilitation via telepractice should be offered to eligible people when goals can be achieved virtually, especially when in-person therapy sessions are not feasible or available (Strong Recommendations; Moderate Quality of Evidence).</li>
</ul>
<div>The following recommendations were made regarding technology selections for the provision of telepractice rehabilitation services:</div>
<ul>
<li>Internet, video-conferencing tools, and remote monitoring devices may be used to enable consultations and/or service delivery (Strong Recommendation; Low Quality of Evidence).</li>
<li>Asynchronous modalities (e.g., email, text) may be considered, as appropriate, for communication related to educational resources, scheduling, and plan of care development (Conditional Recommendation; Low Quality of Evidence).</li>
<li>Processes and technologies should be in place to ensure timely documentation and transfer of health record information regarding virtual care encounters to and from rehabilitation providers, referring sources, and other members of the stroke care team (Strong Recommendation; Moderate Quality of Evidence). </li>
<li>Preparations for implementing telepractice should involve a clear identification of program goals, a needs assessment to identify barriers and facilitators, an implementation plan to address these barriers and harness the facilitators, and a process for continued quality improvement (Strong Recommendation; Low Quality of Evidence). </li>
<li>Clinicians who are providing stroke rehabilitation via telepractice should have expertise and experience in stroke rehabilitation (Strong Recommendation; Low Quality of Evidence).</li>
<li>Team members should receive training to achieve and maintain the necessary competencies to provide safe and appropriate telepractice services for stroke rehabiliation (Strong Recommendation; Low Quality of Evidence).</li>
</ul>
<div>The following recommendations were made regarding telepractice assessments for post-stroke rehabilitation:</div>
<ul>
<li>Assessment tools with evidence of validity for virtual administration should be administered, when available, for the assessment of impairments, activity limitations, participation restrictions, and environmental factors. These should be delivered by trained personnel using a structured process. Those used via videoconferencing should have evidence of validity for this format (Conditional Recommendation; Low Quality Evidence), and those delivered via telephone should have evidence for validity for this administration method (Conditional Recommendation; Moderate Quality of Evidence). </li>
<li>Screening for changes in mood and/or cognition following stroke should be a routine component of telepractice stroke rehabilitation services (Strong Recommendation; Moderate Quality of Evidence).</li>
<li>Assessment tools should be adapted for use via telepractice for people with stroke with communication differences or limitations (Strong Recommendation; Low Quality of Evidence). </li>
</ul>
<div>Virtual outpatient stroke rehabilitation (alone or hybrid) should contain the same elements as coordinated, in-person services (Strong Recommendation; Moderate Quality of Evidence). These services should include:</div>
<ul>
<li><span style="color: #333333;">an interdisciplinary stroke rehabilitation team (Strong Recommendation; High Quality of Evidence);</span></li>
<li><span style="color: #333333;"> case coordination involving regular team communication of assessment findings and to review management, goals, and transition/discharge planning (Strone recommendation; Moderate Quality of Evidence);</span></li>
<li><span style="color: #333333;">outpatient therapy provided for a minimum of 45 minutes a day (Strong Recommendation; Moderate Quality of Evidence) delivered 2 to 5 days a week per required discipline, based on individual needs and goals (Strong Recommendation; High Quality of Evidence), ideally for at least 8 weeks (Strong Recommendation; Low Quality of Evidence); and</span></li>
<li><span style="color: #333333;">ongoing assessment to monitor for changes in function and health status at appropriate intervals to determine potential needs for an in-person visit (Strong Recommendation; Low Quality of Evidence). </span></li>
</ul>
<div>For stroke patients and their caregiver(s), dysphagia education should include information on swallowing, prevention of aspiration, and feeding recommendations. Whenever possible, patients should feed themselves (Teasell et al., 2019, Evidence Level C). Stroke patients should be provided mouth and dental care in addition to education on good oral hygiene (Teasell et al., 2019, Evidence Level B).</div>
<div>For children who have experienced a stroke, the multi-disciplinary team should include clinicians with expertise and training in child developmental and pediatric stroke such as physicians, speech-language pathologists, nurses, social workers, psychologists, and dieticians (Heart & Stroke Foundation of Canada, 2016, Evidence Level B). The child’s caregiver(s) and other family members should also be included in the rehabilitation team (Heart & Stroke Foundation of Canada, 2016, Evidence Level C).</div>
<div>Stroke patients should be screened as early as possible for the presence of any swallowing impairments by a trained professional (Heran et al., 2022, Evidence Level A). Screening should occur prior to any oral intake (e.g., medication, food, liquid) using valid screening tools (Teasell et al., 2019, Evidence Level B; Heran et al., 2022, Evidence Level A). In the acute care setting, swallow screening should ideally occur within 24 hours of hospital arrival with additional monitoring of status in the first hours following a stroke or transient ischemic attack (TIA) (Heran et al., 2022, Evidence Level B). Within 48 hours of inpatient rehabilitation admission, patients should undergo a swallowing screen with additional rescreening of swallow and nutrition conducted as needed (Teasell et al., 2019, Evidence Level C).</div>
<div>For patients who experience a stroke, initial assessment by interdisciplinary rehabilitation professionals should occur as soon as possible (Teasell et al., 2019, Evidence Level A), ideally within 48 hours of admission (Teasell et al., 2019, Evidence Level C; Heran et al., 2022, Evidence Level A). Assessment for ongoing post-acute rehabilitation services should occur as soon as the patient has stabilized and within the first 72 hours post-stroke (Heran et al., 2022, Evidence Level B). For patients who do not meet the criteria for services during the initial assessment(s), weekly reassessment of rehabilitation needs during the first month, and on an as-needed basis after a month, should be considered (Teasell et al., 2019, Evidence Level C).</div>
<div>For stroke patients with aphasia, speech-language therapy addressing their communication needs and goals should be provided early and intensively. Group therapy or conversation groups may be included in treatment or used to supplement therapy (Teasell et al., 2019, Evidence Levels A and B).</div>
<div>Stroke rehabilitation services provided via telepractice can include real-time, two-way audiovisual communication videoconferencing tools or asynchronous technology (e.g., store-forward, systems for non-urgent consultation) for clinical assessment, therapy, or home-based patient monitoring as appropriate (Blacquiere et al., 2017, Evidence Level C). Telestroke equipment (e.g., video-conferencing devices, imaging systems) should be routinely checked to ensure proper function. Any technology used should be selected for ease of use to facilitate adoption and decrease the need to learn technological requirements (Blacquiere et al., 2017, Clinical Consideration).</div>
<div>For patients who experience a stroke, assessment should include function (e.g., cognition, swallowing), safety, physical readiness, and ability to participate in rehabilitation using standardized, valid assessment tools with adaptations for communication differences or limitations as needed (Gladstone et al., 2020, Evidence Level B; Teasell et al., 2019, Evidence Level B; Heran et al. 2022, Evidence Level B). Such functional and safety assessment should be considered part of a cognitive assessment and any identified risks should be communicated to the care team (Lanctot et al., 2019, Evidence Level C). Assessments should consider transition planning to develop a rehabilitation plan with the patient and the family that reflects the individual's needs and goals, includes the best available research evidence, and incorporates clinical judgment (Teasell et al., 2019, Evidence Level C).</div>
<div>Medically-stable patients with an acute intracerebral hemorrhage who are admitted to a stroke or neuro-intensive care unit should undergo interprofessional assessments to determine their rehabilitation and care needs (Shoamanesh et al., 2020, Evidence Level B). Assessments should address neurological impairments and functional limitations (e.g., cognitive evaluation, depression screening, need for rehabilitation therapy) (Shoamanesh et al., 2020, Evidence Level C).</div>
<div>For stroke patients, “treatment to improve functional communication should include supported conversation techniques for potential communication partners of the person with aphasia” (Teasell et al., 2019, Evidence Level A; p. 83).</div>
<div>For stroke patients and their caregivers, counseling, education, and information should be provided as a part of all healthcare encounters, either in individual or group settings, and during transitions (Mountain et al., 2019, Evidence Level A). Counseling and educational needs should be individualized to include the patient’s goals, be documented by clinicians, and be adapted to meet the patient’s changing needs over time (Mountain et al., 2019, Evidence Level B). Information should include aspects of stroke care and recovery, teaching of self-management skills, family or caregiver training, and available community resources, benefits, and peer support groups (Mountain et al., 2019, Evidence Levels B and C). Education and provided informational materials should facilitate shared decision-making by being interactive or hands-on, being evidence-based, being available in an appropriate language and format for the patient, and being accessible at the patient’s level of health literacy and comprehension ability (Mountain et al., 2019, Evidence Levels A and B). Education and counseling should be regularly reviewed and reinforced with the patient (Mountain et al., 2019, Evidence Level B).</div>
<div>Stroke patients with nutritional, hydration, or dysphagia concerns who are working with a dietician should receive recommendations on food texture and fluid consistency from a speech-language pathologist (Teasell et al., 2019, Evidence Level B).</div>
<div>Stroke patients who present with abnormal results from initial or ongoing swallowing screens should be referred to a speech-language pathologist or another dysphagia-trained clinician for further swallowing assessment and management of swallowing, feeding, nutrition, and hydration (Teasell et al., 2019, Evidence Level C; Heran et al., 2022, Evidence Levels B).</div>
<div>For stroke patients with dysphagia and/or nutritional needs, an individualized management plan should be developed to address therapy and feeding plans, including oral care management as needed (Heran et al., 2022, Evidence Level B).</div>
<div>For patients who experience a stroke, the multi-disciplinary team should follow the best evidence-based practices and should include clinicians with expertise and training in stroke rehabilitation and comorbid communication limitations (e.g., aphasia). Providers may include physicians, speech-language pathologists, occupational therapists, nurses, pharmacists, social workers, and dieticians. (Teasell et al., 2019, Evidence Levels A, B, and C; Heran et al., 2022, Evidence Level A). Referrals for ongoing management to appropriate rehabilitation specialists should be made to address neurological and functional impairments (Shoamanesh et al., 2020, Evidence Level C). The patient and family should also be active members of the core team involved in management, goal setting, and transition planning (Teasell et al., 2019, Evidence Levels A, B, and C). The individualized care plan developed by the team should be person-centered and culturally appropriate. The plan should be regularly reviewed and updated with the patient and family as needs change, and timely, up-to-date information should be shared between healthcare providers across settings (Mountain et al., 2019, Evidence Levels B and C).</div>
<div>For children who have experienced a stroke, an individualized rehabilitation plan should be developed and regularly updated, ideally, on an annual basis, according to the child’s health status and developmental progress. Recommended treatments should be meaningful, engaging, repetitive, progressively adapted, age-appropriate, task-specific, and goal-oriented for the child and family. Interventions may target educational rehabilitation, classroom function and safety, developmentally relevant play, and leisure skills appropriate for their home, school, and/or community environments. Objective baseline measures and progress outcomes for the child’s goals should be measured (Heart & Stroke Foundation of Canada, 2016, Evidence Level C). Changes in the child’s functional status or rehabilitation needs should result in referrals for additional outpatient support (Heart & Stroke Foundation of Canada, 2016, Evidence Level B).</div>
<div>For stroke patients in the acute care setting, the interdisciplinary team should conduct daily or bi-weekly patient care rounds to review patient management issues, discuss family concerns and needs, provide patient and family education, and plan for discharge (Heran et al., 2022, Ungraded Evidence Level).</div>
<div>All patients with stroke should receive rehabilitation therapy as early as possible once they are medically stable and able to participate in active rehabilitation” (Teasell et al., 2019, Evidence Level A; p. 24). Patients should have access to post-acute rehabilitation services across settings including inpatient, community-based, and outpatient rehabilitation services (Heran et al., 2022, Ungraded Evidence Level). Outpatient and/or in-home rehabilitation services should ideally begin within 48 hours of discharge from an acute hospital or within 72 hours of discharge from inpatient rehabilitation (Teasell et al., 2019, Evidence Level C; p. 31).</div>
<div>For some stroke patients, augmentative and alternative communication (e.g., iPad, tablet, speech-generating device, alphabet board) and other communication support tools should be considered (Teasell et al., 2019, Evidence Level C).</div>
<div>For children who have experienced a stroke, education and counseling should be offered to the child and their caregivers regarding changes in the child’s needs, impact on family roles, and potential resources (Heart & Stroke Foundation of Canada, 2016, Evidence Level B). Additional resources may include support groups, available community activities and programs, and relevant agency supports (Heart & Stroke Foundation of Canada, 2016, Evidence Level C).</div>
<div>For stroke patients with communication deficits, speech-language therapy may target production and/or comprehension of words, sentences, and conversation including reading and writing (Teasell et al., 2019, Evidence Level C). Treatment strategies may include conversational treatment, constraint-induced language therapy, non-verbal strategies, augmentative and alternative communication (e.g., assistive devices, iPads), and computerized language therapy (Teasell et al., 2019, Evidence Levels B and C).</div>
<div>For stroke patients, treatment plans may address self-efficacy and self-management skills, vocational interests and return to work, and participation in social and leisure activities. Referral to additional services (e.g., vocational, counseling, community supports) should be made as needed (Mountain et al., 2019, Evidence Levels A, B, and C).</div>
<div>Individuals who have experienced a stroke should be assessed for cognitive impairments by healthcare professionals with expertise in neurocognitive functioning such as a neuropsychologist, psychologist, psychiatrist, neurologist, or speech-language pathologist. These healthcare providers may require additional qualifications to administer cognitive assessments (Lanctot et al., 2019, Evidence Level C).</div>
<div>For stroke patients, restorative swallowing therapy (e.g., lingual resistance, breath holds, effortful swallow) and/or compensatory techniques (e.g., posture, sensory input, texture modification) should be implemented with monitoring and reassessment as required (Teasell et al., 2019, Evidence Level B).</div>
<div>For patients who present with acute stroke or transient ischemic attack (TIA), additional screening of impairments (e.g., onset of cognitive deficits, functional activity limitations) should be considered within two weeks of stroke onset (Teasell et al., 2019, Evidence Level C). Patients who have experienced a TIA or stroke and demonstrate cognitive concerns should be screened for cognitive impairment while in acute care, during inpatient rehabilitation, and/or in the outpatient or community setting (Lanctot et al., 2019, Evidence Level C).</div>
<div>For stroke patients, telemedicine (e.g., video and web-based technology, telerehabilitation) should be considered to improve access to healthcare and rehabilitation services, especially for individuals and their caregivers who may be unable to travel to care (Mountain et al., 2019, Evidence Level B; Heran et al., 2022, Evidence Level C). Telepractice services can be provided across the continuum of care and should be integrated into care planning (Blacquiere et al., 2017, Evidence Level C). The best service delivery model (i.e., remote or in-person) should be selected after considering the goals and digital literacy of the patient and the purpose and availability of the visit (Heran et al., 2022, Evidence Level C).</div>
<div>Children who have experienced a stroke should be assessed by medical professionals for severity of stroke and rehabilitation needs as soon as possible (Heart & Stroke Foundation of Canada, 2016, Evidence Level B). Clinicians should use standardized, valid assessment tools to evaluate impairments, functional activity limitations, participation and environmental restrictions, and mood and behavioral changes (Heart & Stroke Foundation of Canada, 2016, Evidence Level C). Ongoing assessment of educational and vocational needs should occur throughout the child’s development (Heart & Stroke Foundation of Canada, 2016, Evidence Level C).</div>
<div>For stroke patients with cognitive deficits, treatment plans should include individualized, evidence-based, and person-centered goals and interventions that consider the individual’s cognitive and communication profile and the severity of the individual’s impairment(s). Additional support (e.g., family involvement, focus on education, or support of caregivers) may be required to optimize participation and engagement in rehabilitation services (Lanctot et al., 2019, Evidence Level C). Interventions may include compensatory strategies targeting the management of impairment(s) and increasing independence or direct remediation and cognitive skill training targeting impaired domains (Lanctot et al., 2019, Evidence Level B).</div>
<div>For stroke patients, “the impact of aphasia on functional activities, participation and [quality of life] QoL, including the impact on relationships, vocation and leisure, should be assessed and addressed across the continuum of care” (Teasell et al., 2019, Evidence Level C; p. 84).</div>
<div>For children who have experienced a stroke, “pediatric acute and rehabilitation stroke care should be provided on a specialized pediatric unit so that care is formally coordinated and organized" (Heart & Stroke Foundation of Canada, 2016, Evidence Level B; p. 8). "Once a child who has experienced a stroke has undergone assessments, the appropriate setting for rehabilitation (inpatient, outpatient, community, school, and/or home-based settings) may be determined” (Heart & Stroke Foundation of Canada, 2016, Evidence Level C; p. 8).</div>
<div>For stroke patients with executive functioning deficits, treatment(s) may include metacognitive strategy training, formal problem-solving strategies, and other internal strategy training (e.g., improving goal management, time management, reasoning) (Lanctot et al., 2019, Evidence Level B).</div>
<div>“All stroke patients should be screened for communication disorders, ideally by a speech-language pathologist, and using a valid screening tool” (Teasell et al., 2019, Evidence Level C; p. 83). Screening should be conducted by a clinician with experience in stroke rehabilitation (Teasell et al., 2019, Evidence Level C).</div>
<div>For stroke patients, the intensity and duration of rehabilitation services should be individualized and include repetitive, patient-valued tasks to meet the patient’s optimal recovery needs and tolerance levels (Teasell et al., 2019, Evidence Level A). For those who are medically and neurologically stable, direct, task-specific, in-patient therapy may be delivered by an interdisciplinary team 3 hours per day, 5 days per week. Outpatient and/or in-home services may be provided at least 45 minutes per day, 2 to 5 days per week for 8 weeks, for each required discipline (Teasell et al., 2019, Evidence Level B and C).</div>
<div>For stroke patients considered at high risk for dysphagia or poor airway protection, videofluoroscopic swallow study (VSS, VFSS) or fiberoptic endoscopic examination of swallowing (FEES) should be conducted based on bedside swallowing assessment (Teasell et al., 2019, Evidence Level B).</div>
<div>For stroke patients with memory deficits, treatment(s) may include external compensation strategies (e.g., assistive devices) and internal strategies (e.g., encoding, retrieval, self-efficacy training, errorless learning). Computer-based working memory interventions may also be considered (Lanctot et al., 2019, Evidence Level B).</div>
<div>For stroke patients with ongoing rehabilitation needs, outpatient services and/or in-home services should be provided by interdisciplinary team members as needed. The choice of setting should be based on the patient’s functional needs, goals, availability of support, and personal or family preference (Teasell et al., 2019, Evidence Level C). Patients admitted to a community living setting or long-term care setting who have ongoing rehabilitation goals should have continued access to specialized services (e.g., speech-language therapy) (Mountain et al., 2019, Evidence Level A).</div>
<div>Healthcare professionals providing consultations or services via telepractice to individuals who have experienced a stroke should be trained and efficient in using remote technologies. Clearly defined criteria should be used to determine when and how to provide telestroke services for stroke patients (Blacquiere et al., 2017, Evidence Level B). Remote consulting healthcare providers should collaborate with the referring site regarding the patient's medical record, progress, treatment plans, follow-up needs, and discharge recommendations (Blacquiere et al., 2017, Evidence Level C).</div>
<div>Stroke patients with suspected communication deficits should be assessed by a speech-language pathologist for comprehension, verbal production, reading, writing, speech, voice, and cognitive-communication using valid and reliable methods (Teasell et al., 2019, Evidence Level C).</div>
<div>For patients who have experienced a stroke, particularly individuals with additional health risks, screening for cognitive impairment should be considered. Cognitive screening should include a validated screening tool, such as the Montreal Cognitive Assessment screen (Lanctot et al., 2019, Evidence Level B).</div>
<div>For patients who experience a stroke, cognitive assessment should identify strengths and weaknesses for rehabilitation prior to returning to cognitively demanding activities (e.g., driving, work). Assessment results should guide the selection and implementation of intervention or compensatory strategies according to person-centered needs and goals (Lanctot et al., 2019, Evidence Level C).</div>
