1. Rehabilitation across the continuum and beyond our current vision Nicol Korner-Bitensky, PhD

3. Dumoulin C, Korner-Bitensky N, Tannenbaum C. The Cross Canada Study of Stroke Rehabilitation: Finding on the identification, assessment and management of urinary incontinence after stroke. Stroke 2007 38:2745-2751 Each team member contributes a unique piece

4. 1 st JOB Enlarging our post-stroke focus from ….. illness care to health care

5. 2 nd JOB Strong bones Strong hearts Strong limbs Strong minds Strong hope – when we have told them no further improvement is expected Finding out what health focused care is available post-stroke …

6. 3rd JOB – to get the answer to “does health focused care work specifically in the chronic phase”? Mirror therapy Functional electrical stimulation Task-specific training Constraint-induced therapy Aerobic exercise for cardiac health Virtual reality Visual imagery

7. So, that when this lady has a question for us… I had a stroke last year – my hand and leg are partially paralyzed –are there effective therapies for me?

8. Mirror therapy – what is it? Garry, Loftus & Summers (2004) Unaffected hand

9. Mirror therapy – similarly used for lower limb? Unaffected leg

10. Mirror therapy – does it work for the upper limb in chronic stroke? For grip strength Limited but positive evidence in upper limb…. For wrist function For speed of movement No published studies yet for chronic lower limb - but effective for sub- acute

11. Aerobic therapy– does it work in “chronic” stroke? For peak VO 2 max For BP (sub-maximal systolic) For bone density of the femoral neck of the affected limb For walking endurance, distance and speed need at least 8 weeks, 3 x per week, permission of Dr. P. McKinley

12. Functional electrical stimulation –– what is it? Use of electric current to stimulate muscle contraction in paralyzed muscles

13. Functional electrical stimulation – in chronic stroke – does it work? walking speed knee coordination ankle dorsiflexion walking efficiency

14. Constraint induced therapy – does it work in chronic stroke?? unaffected limb

15. Citation 10. October 6, 2008 Status MEDLINE Authors Lin KC. Wu CY. Liu JS.. Title A randomized controlled trial of constraint-induced movement therapy after stroke. Source Acta Neurochirurgica - Supplement. 101:61-4, 2008. Abstract OBJECTIVES: To evaluate the benefits of constraint-induced movement therapy (CIMT) relative to traditional intervention equal in treatment intensity and use of restraint mitt outside rehabilitation on motor performance and daily functions in “chronic” stroke patients. New evidence just yesterday…….

16. Body weight support and treadmill training post-stroke – what is it? For who? – those with severe? or mild? Or moderate? impairments in gait, strength? Valuable for chronic stroke? On what outcomes? speed? function? endurance? Visit www.strokengine.ca to find outwww.strokengine.ca

17. 4 th JOB Find out whether health focused care is being provided post-stroke …. here in Quebec?

18. The Canadian National Survey on Rehabilitation Practices for Stroke

19. Nicol Korner-Bitensky, Sharon Wood-Dauphinee, Robert Teasell, Francine Malouin, Johanne Desrosiers, Aliki Thomas, Eva Kehayia, Margaret Harrison, James Hanley, Francine Kaizer, Rosemary Martino Project coordinator: Anita Menon Post-doctoral fellows: Annie Rochette, Chantal Dumoulin FUNDED BY: The Canadian Stroke Network, FRSQ/REPAR, CRIR, Heart and Stroke Foundation of Ontario University of Western Ontario University of Ottawa

20. Methods We traced > 5500 randomly sampled clinicians Identified >1600 stroke clinicians (OT, PT, SLP) in 10 provinces, Across: acute in-patient in-patient rehabilitation and, community practice

21. Our findings 1. we rarely use any of the new effective interventions; 2. we often use ineffective treatments or untested treatments; 3. we want to provide the best possible treatments but are not Often we are: not aware of what the best treatments are; nor have the training on how to provide them.

22. So, when this lady asks her question of us… I had a stroke last year – my hand and leg are partially paralyzed –are there effective therapies for me? when we say “no further improvement is expected” – WE ARE WRONG!

23. So in the name of the 300,000 Canadians living with chronic stroke My name is Josh. I had a severe stroke 8 years ago. I am now 94. I am back at work full time and improving all the time!