White Coat, Black Art

Early therapy is best after a stroke, but many rural Canadians miss out

Many stroke survivors, especially those like Albertan Robert Windross who live in rural or remote areas, wait far too long for rehabilitation, say experts.

'It's not equal access': Alberta patient waits 3 weeks for intensive rehab

Robert Windross works with community occupational therapist Josie Neilson in Castor, Alta. A stroke in mid-August impaired functions on his left side. (Submitted by Linda Windross)
Listen to the full episode26:29

It was dinner time when Linda Windross heard a thump.

She ran upstairs to find Robert, her husband of 30 years, slumped on the floor.

"He was talking, but he was really struggling and shaking," Linda said, recalling the scene on Aug. 18 at their home in Castor, Alta., about 230 kilometres south of Edmonton.

Windross does occupational therapy in Castor, Alta., his home town. (Submitted by Linda Windross)

The 63-year-old was airlifted to the University of Alberta Hospital in Edmonton. Doctors confirmed he'd had a right frontotemporal stroke.

It would be three weeks before Robert got the intensive rehabilitation therapy doctors recommended, even though experts say the optimal time to begin stroke rehabilitation is within 48 hours.

Early, intensive treatment is best

"I was desperate enough I was even thinking: 'Is there any way we can get to the States for some rehabilitation?' Because I had no idea how long this was going to go on," Linda told White Coat, Black Art host Dr. Brian Goldman.

Therapy that's delivered early and intensively is what people need to recover best, said Dr. Anita Mountain of Dalhousie University in Halifax. (D.K. Kelly)

That 20-day wait for intensive rehabilitation services is too long, but not uncommon, across rural and remote areas of Canada, according to Dr. Anita Mountain, a physiatrist and stroke rehabilitation specialist at Dalhousie University in Halifax. 

"We know that therapy that's delivered early and intense is the type of therapy that people need to make their best functional recovery," she said.

When rehab is delayed, the effects on the health-care system are also widespread, she said. More people may need long-term care or home care and be unable to return to work, driving and other responsibilities.

The Windrosses'​ case was complicated by the fact that the couple lives in rural Alberta. They were initially led to believe Robert would be treated at the Glenrose Rehabilitation Hospital in Edmonton.

But they were informed they lived too far away, and were referred to Red Deer instead.

From Edmonton to Red Deer to Stettler

After 10 days in Edmonton, there was no bed available in Red Deer. Robert was moved to the smaller hospital in Stettler, Alta., halfway between their home and Red Deer. He would wait 20 more days for a bed.

The stroke impaired functions on Robert's left side, and Linda worried that the wait would impact his recovery, since experts say early treatment takes advantage of the brain's capacity to heal itself.

Robert and Linda Windross were married in 1988. (Submitted by Linda Windross)

"I feel like it's not equal access. These people in Alberta in rural communities have a very difficult time," Linda said.

This year alone, it's estimated 62,000 Canadians will have a stroke. Many of them face gaps in stroke care, researchers have found.

At the 11th World Stroke Congress in Montreal in October, Dr. Mountain and Patrice Lindsay, director of stroke for the Heart and Stroke Foundation of Canada, presented their findings on how the quality and intensity of stroke rehab varies across Canada. 
Death rates from stroke have dropped over the last 10 years but the system isn't built for more survivors, said Patrice Lindsay. (Heart and Stroke Foundation of Canada)

"No one province is better or worse with their rural communities. We just haven't solved that yet," Lindsay said.

About 17 per cent of stroke patients in Canada get admitted to an inpatient rehabilitation unit.

Half of stroke patients wait up to 12 days to get rehab, the researchers found. The other half wait longer than that.

Between 2013 and 2017, access to stroke rehab teams and equipment improved, but — as in the Windrosses' case — bed capacity hampered prompt access.

"In some ways we're a victim of our own success, that the mortality from stroke has really dropped over the last 10, 15 years with new therapies," Lindsay said. "We haven't got a system built for that many more survivors."

3 recommendations to improve care

While long-term survival rates aren't affected by prompt access to rehab, quality of life is.

"The more you can gain earlier, the more fulfilling and involved in your lives you can be," Lindsay said.

Their research recommends three innovations to improve stroke rehab care:

  • Offer early supported discharge, where a rehab team follows a patient home to provide the same intensity of therapy as an inpatient unit.
  • Provide telemedicine or video-based care. Health centres in rural Manitoba give patients iPads at home to connect with speech therapists thousands of kilometres away.
  • Teach Indigenous people how to facilitate exercises in a patient's community.  

Their findings have not yet been peer reviewed. The research was based on data from 188 inpatient stroke rehab facilities.

The more you can gain earlier, the more fulfilling and involved in your lives you can be.— Patrice Lindsay

In an email to White Coat, Black Art, Alberta Health Services said it offers early supported discharge for up to 12 patients at a time for eight weeks at most.

It serves patients within a 50-kilometre radius of Red Deer. The Windrosses live too far away to be considered for that program. Alberta Health is exploring virtual rehabilitation to support patients farther away. 

Despite the challenges, Robert has recovered his balance and some movement in his left hand, so he can squeeze Linda's hand.

Now back in Castor, the couple does logic puzzles and tai chi as part of rehab, and Robert sees Josie Neilson, the town's occupational therapist. As he continues to recover, Linda said, she finds herself in a supportive role as therapist, dietitian and personal trainer. 

"Our relationship is different, but that isn't necessarily a bad thing, it is just evolving and changing," she said. "I know that Rob's abilities will continue to change, and I have to take a step back at times and give him the freedom to step out on his own."

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