A Novel Strategy for Sustaining StrokEngine and StrokEngine-Assess

Project Leader:

Nicol Korner-Bitensky, McGill University

Project Team:

Robert Teasell, University of Western Ontario
Sharon Wood-Dauphinee, McGill University
Mindy Levin, McGill University
Jeff Jutai, University of Western Ontario
Anita Menon-Nair, University of Toronto
Joyce Fung, McGill University
Mark Bayley, University of Toronto
Aura Kagan, University of Toronto
Franceen Kaizer, Jewish Rehabilitation Hospital
Lesley Fellows, McGill University
Carol Richards, Universite Laval
Johanne Desrosiers, Universite de Sherbrooke
Chantal Dumoulin, Universite de Montreal
Annie Rochette, Universite de Montreal
Lorie Kloda, McGill University
Aliki Thomas, McGill University
Rosemary Martino, University of Toronto
Nancy Mayo, McGill University
Janice Eng, University of British Columbia
Pamela Duncan, Duke University
Stephen Page, University of Cincinnati

Project Summary:

Over the past 4 years, an interdisciplinary team of stroke rehabilitation experts has come together to develop StrokEngine, StrokEngine-Assess and most recently E-learning interactive patient modules: all are viewable on www.strokengine.org. More than 75 researchers, clinicians and decision-makers have invested their expertise in creating, evaluating and disseminating StrokEngine content and are committed to taking this project forward. The project has received international recognition from stakeholders, including students in training, clinicians, researchers, policymakers, those with stroke and their family and friends. The next step is to develop additional intervention modules, assessment modules and interactive learning modules, the latter featuring real patients. This includes:

1. Create and make Web-ready 30 additional StrokEngine topic modules with priority to those in high demand as per the clinician/family requests: e.g. cognitive rehabilitation; sexuality post-stroke, mental imagery, and impact of aerobic exercise in chronic stroke;
2. Create 20 additional StrokEngine-Assess modules specific to a national plan to increase the consistent use of standardized outcome measures in Canadian acute, rehabilitation and community-based stroke practice;
3. Create additional interactive e-learning virtual patient scenarios utilizing video clips and interactive decision-making tools and field-test each of these modules in collaboration with the Ontario Stroke Strategy and the Heart and Stroke Foundation. Create links between the E-learning module, StrokEngine and StrokEngine-Assess;
4. Translate newly created modules into French to allow use across Canada and internationally;
5. Field test StrokEngine with key consumer groups on an ongoing basis for its usability and navigability;
6. Ready StrokEngine for use in the “YOU CALL – WE CALL TRIAL”

Stroke Rehabilitation Evidence-Based Review: Transforming the Stroke Rehabilitation System in Canada

Project Leader:

Robert Teasell, University of Western Ontario

Project Team:

Jeff Jutai, University of Western Ontario
Mark Speechley, University of Western Ontario
Norine Foley, Lawson Health Research Institute
Katherine Salter, Lawson Health Research Institute

Project Summary:

The Stroke Rehabilitation Evidence-Based Review (SREBR) is the most comprehensive and extensive research syntheses of stroke rehabilitation anywhere in the world and provides the impetus for a much needed transformation of the Canadian stroke rehabilitation system.

This research project enhances the value of the SREBR, now in its 10th edition, as a resource to researchers, clinicians, decisionmakers and consumers concerned with stroke care.

SREBR has been used for development of clinical guidelines and research priorities worldwide, and has become the platform upon which a number of nationwide, multi-centered projects focused on translating best evidence into clinical practice have been developed. Collaborations have been forged with researchers throughout Canada and internationally and the SREBR continues to be used in new and unique ways to facilitate research and improve patient care. More than 50 peer-reviewed articles have been published based on its findings.

The SREBR will continue to focus on improving the understanding of what makes rehabilitation effective and where the greatest opportunities for efficiencies exist, while working in synergy with CSN researchers.

Getting on with the Rest of Your Life after Stroke: A Cross-Canada Program Aimed at Enhanced Life Participation, Prevention of Deterioration and Optimization of Health Care Utilization

Project Leader:

Nancy Mayo, McGill University

Project Team:

Mark Bayley, University of Toronto
Johanne Desrosiers, Universite de Sherbrooke
Janice Eng, University of British Columbia
Marilyn Mackay Lyons, Dalhousie University
Robert Teasell, University of Western Ontario
Carol Richards, Universite Laval
Jill Cameron, University of Toronto
Maria Huijbregts, University of Toronto
Aura Kagan, University of Toronto
Nancy Salbach, Univeristy of Toronto
Sharon Wood-Dauphinee, McGill University
Helene Carbonneau, Universite de Quebec a Trois-Rivieres
Ruth Barclay-Goddard, University of Manitoba

Project Summary:

In the fall of 2004, a group of rehabilitation researchers developed a protocol for a cross-Canada randomized trial aimed at enhancing life participation after stroke. In December 2004, the Canadian Stroke Network agreed to fund pilot work for this ambitious project, spread over six sites. The pilot funding permitted key aspects of the protocol to be developed and put in place:

• elements of the intervention have been chosen (physical activity, leisure and social);
• the assessment tools have been chosen and tested;
• community-based partner organizations have been identified; and,
• the intervention prototype has been tested for feasibility.

The primary objective of the main trial is to determine the extent to which participation in life’s roles can be optimized through the provision of a community-based structured program providing the opportunity for physical activity, leisure, and social interaction. A secondary objective is to estimate the extent to which participation is associated with health benefits including health-related quality of life and reduction of unplanned health-care encounters for the person with stroke and reduction of burden and improvement in quality of life for caregivers. In this context, the meaning of “participation” is as defined by the World Health Organization (WHO) and reflects both society’s and the person’s perspective. The target population will be persons living in the community who have completed all formal institution-based, in-patient and ambulatory, rehabilitative interventions. No restriction on “time since stroke” will be imposed. Excluded will be persons who are already enrolled in existing community based projects and persons with cognitive impairment. Six sites participated in the feasibility phase. Information emanating from these sites, as well as dissemination activities of the CSN and the Canadian Stroke Strategy, have led to interest expressed by other sites across Canada prepared to run the trial phase of this project. The study design is a two-period, site-stratified, randomized, crossover design with timing of entry randomized to immediate entry or delayed entry so that there is about a six-month time difference between groups. The intervention period is nine months and the follow-up period is an additional 6 months (total 15 mos.) The main outcome is the amount of time spent in meaningful activity during the day (outcome related to primary objective).

Sample size required to have sufficient power to detect between-group differences is 240 subjects from sites across Canada. As there is considerable interest in community reintegration, “snowball” entry of sites would make it more realistic to accumulate sample size and would also make the results locally responsive. The project will take 4 years to complete.

Download this publication about the project.

The YOU CALL – WE CALL TRIAL: Impact of a multimodal support intervention after a “mild” stroke

Project Leader:

Annie Rochette, Universite de Montreal

Project Team:

Nicol Korner-Bitensky, McGill University
Duane Bishop, St-Lukes Hosp. Rhode Island
Robert Teasell, University of Western Ontario
Carole White, U Texas San Antonio
Gina Bravo, Université de Sherbrooke
Robert Côté, MUHC- McGill
Jean Lachaine, Université de Montréal
Luc Marchand, CHUM – St-Luc -UdeM
Teri Green, University of Calgary
Moira Kapral, University of Toronto
Mark Bayley, University of Toronto
Sharon Wood-Dauphinee, McGill University

Project Summary:

Of the 50,000 new strokes in Canada each year, more than 60% are “mild” -- defined as a score greater than 8.5/11.5 on the Canadian Neurological Scale. In the years to come, the proportion of individuals experiencing a “mild” stroke is expected to rise with demographic changes and increased utilization of t-PA (thrombolytic therapies) and other innovations. Those experiencing a “mild” stroke are at risk of serious health consequences, including a rate of depression equal to those with severe stroke and a disquieting fear of recurrent stroke. The fear of stroke recurrence is well founded given that the risk of a second stroke in the first two years is estimated at 20% and the 10-year cumulative risk goes as high as 43%.

Furthermore, even though these individuals are usually able to accomplish basic daily activities, such as eating, washing, and walking to the bathroom, they often present cognitive and perceptual deficits and experience a decreased ability to manage community reintegration, including work, shopping, banking, driving, and recreation activities which commonly persist long-term. Within our current health care system, those with “mild” stroke are typically discharged home within days, without further referral to health or rehabilitation services other than advice to see their family physician. Thus, they have limited access to support from health professionals with stroke-specific knowledge who would typically provide critical information on topics such as secondary stroke prevention, community reintegration, medication counselling and problem solving in regards to specific concerns that arise. Isolation and lack of knowledge may lead to exacerbation of health problems and unnecessary and costly hospital visits. In addition, these individuals are unlikely to receive guidance on how to compensate and adapt to the new post-stroke reality, including a reduced ability to drive safely, high risk of falls, depression, etc. This is poor and costly management of a highly prevalent health condition. Consequently, a randomized clinical trial will assess the effectiveness of a low cost, multimodal support intervention (comprised of information, education and telephone support) on reducing unplanned use of health services for negative events and on improving quality of life for individuals with a first “mild” stroke. If effective, this multimodal intervention could be delivered across the country to Canadians in both urban and rural environments. The Canadian Stroke Strategy and the existing Secondary Stroke Prevention sites make this intervention deliverable and sustainable.

The Economic Burden of Ischemic Stroke In Canada (BURST)

Project Leader:

Nicole Mittman, HOPE Research Centre, Toronto

Project Team:

Mike Sharma, Ottawa Hospital
David Gladstone, Sunnybrook Health Sciences Centre, Toronto
Michael Hill, Foothills Medical Centre, Calgary
Robert Cote, Montreal General Hospital
Ariane Mackey, Hopital de L’Enfant-Jesus, Quebec
Steve Verreault, Hopital de L’Enfant-Jesus, Quebec
Ashfaq Shuaib, University of Alberta Hospital, Edmonton
Abdul M. Nasser, University of Alberta Hospital, Edmonton
Phil Teal, Vancouver General Hospital
Stephen Phillips, Queen Elizabeth II Health Sciences Centre
Gordon Gubitz, Queen Elizabeth II Health Sciences Centre
Peter Bailey, Saint John Regional Hospital
David Howse, Thunder Bay Hospital

Project Summary:

This study is gathering information on what happens to ischemic stroke patients in the first 12 months once they leave the hospital and shift from inpatient to outpatient care.

The objective is to determine the resources and costs associated with treating patients in outside institutions, such as rehabilitation facilities and home care.

About 200 ischemic stroke patients will be recruited into the study at 10 participating stroke centres in six provinces. The goal is to get good data on the economic burden of stroke. This information will help aid future stroke-care planning.

Stroke Canada Optimization of Rehabilitation by Evidence (SCORE)

M. Bayley, S. Wood-Dauphinee

Does a multifaceted implementation intervention improve the uptake of risk assessment recommendations by interdisciplinary acute care stroke teams? Do persons with stroke who are rehabilitated according to the latest evidence have better outcomes than those who do not?

In 2002, the Canadian Stroke Network (CSN) Stroke Canada Optimization of Rehabilitation by Evidence (SCORE) Project team began developing a national network of stroke rehabilitation research centers. The SCORE team also set out to produce evidence-informed practice recommendations (EIPR) in three identified priority areas of Arm rehabilitation, Leg rehabilitation and Risk assessment for those at risk of problems with swallowing, falls, skin breakdown, depression, and cognition post stroke. The innovative process for developing the recommendations involved forming expert interdisciplinary panels of researchers and clinicians from across the country, extensive review of the literature known as the Stroke Rehabilitation Evidence Based Review (SREBR), and systematic identification and appraisal of the quality and content of existing guidelines. Once the panels drafted the evidence-informed recommendations, they were sent to experts in the field for review and feedback.

The practice recommendations are now in the process of being piloted tested in 6 sites with the purpose of identifying any issues/problems with the recommendations, to test the feasibility of collecting outcome measures from providers and patients that could be used in a large scale implementation project, and to observe the implementation of the recommendations in order to better understand what might be useful Knowledge Translation (KT) interventions to promote the uptake of the recommendations.

The proposed study will use a cluster randomized design to evaluate 1) the effectiveness of a multifaceted KT intervention on increasing the uptake of SCORE's evidence-informed risk assessment and arm and leg recommendations (primary question), and 2) the effectiveness and efficiency of SCORE's evidence informed leg and arm practice recommendations (secondary question).

The results from the first evaluation will increase understanding of how to facilitate the uptake of practice recommendations among nurses and rehabilitation therapists working in rehabilitation centres.

The results from the second evaluation will demonstrate the health and organizational impact of using SCORE's leg and arm and risk screening practice recommendations. When taken together, the two components of this study represent the largest KT study involving rehabilitation professionals ever. It will also provide estimates of the clinical and health system effect of using evidence based stroke rehabilitation practices.