Stroke Rehabilitation Assessment Tools Survey Final Report

Stroke Rehabilitation Assessment Tools Survey Final Report October 211

Stroke Rehabilitation Assessment Tools Survey Northeastern and Northwestern Ontario Stroke Networks Final Report October 211 Table of Contents Topic Executive Summary 3 Background 4 Purpose 4 Methods 5 Table 1: Assessment Tools Surveyed 6 Findings 7 Table 2: Respondents 7 Table 3: Use of Selected Stroke Rehabilitation Assessment Tools in NEO & NWO 8 Figures 1-6: Top Tools Reported by Clinician Group 9 Figures 7-8: Electronic Resources - Awareness and Usage 14 Next Steps 16 Appendix 1: Survey Template 18 Appendix 2: Physiotherapy Demographics and Discipline Specific Information 2 Appendix 3: Occupational Therapy Demographics and Discipline Specific Information 23 Appendix 4: Speech Language Pathology Demographics and Discipline Specific Information 26 Appendix 5: Social Work Demographics and Discipline Specific Information 29 Appendix 6: Recreation Demographics and Discipline Specific Information 32 Appendix 7: Psychology Demographics and Discipline Specific Information 35 Page Commonly Used Abbreviations Full Name Abbreviation Full Name Abbreviation Berg Balance Scale BBS Northwestern Ontario NWO Boston Diagnostic Aphasia BDAE Occupational Therapist OT Examination Canadian Best Practice CPBRSC Physiotherapy PT Recommendations for Stroke Care Chedoke McMaster Stroke CMSA Psychologist or Psych Assessment Psychological Associate Montreal Cognitive Assessment MOCA Social Worker SW Northeast(ern) NE Speech Language SLP Pathologist Northwest(ern) NW Therapeutic Recreationist Rec or Recreation Therapist Northeastern Ontario NEO 2

Executive Summary In May/June 211 a survey was developed and distributed to determine to what extent rehabilitation clinicians in northeastern (NE) and northwestern (NW) Ontario use standardized, valid assessment tools to evaluate patient s stroke-related impairments and functional status. Assessment tools that were included were drawn from Canadian Best Practice recommendations and only included those that are currently available to clinicians. Additionally, the survey results were used to determine the extent to which the core set of assessment tools *Berg Balance Scale, Montreal Cognitive Assessment, Chedoke-McMaster Stroke Assessment, Boston Diagnostic Aphasia Examination, AlphaFIM /FIM Instruments (not specifically surveyed as regional use already determined)] as recommended by the Provincial Outcome Measures Working Group (Jan 21) were being utilized. Clinicians were also surveyed regarding their familiarity with electronic resources for assessment tools. The information gathered from the survey and the work of other regional stroke networks is currently being used to identify educational opportunities, barriers and facilitators towards the use of assessment tools and to help facilitate improved communication and information transfer between rehabilitation providers across the care continuum. The survey was sent to a total of 493 (253 NE, 24 NW) clinicians (OT, PT, Psych, Rec, SLP, SW). Overall response rate was 36%. There was strong use reported for the core set of assessment tools: Berg Balance Scale (98% PT, 28% OT), Montreal Cognitive Assessment (89% OT), Chedoke-McMaster Stroke Assessment (66% PT, 21% OT) and Boston Diagnostic Aphasia Examination (74% SLP). In reviewing the data from an urban/rural perspective, there was no apparent difference in the overall use of the core set of assessment tools between clinicians practicing in these environments. In the NE AlphaFIM and FIM are being utilized by 5 hospitals, all 5 hospitals have designated rehabilitation beds and 4 of the hospitals are either a district or the regional stroke centre. In the NW AlphaFIM is being utilized by 4 hospitals, including the regional stroke centre, the FIM is being utilized by the 1 NW hospital with designated rehab beds. Additional commonly used assessment tools reported included: OSOT Perceptual Evaluation, Mini Mental State Examination, 9 Hole Peg Test, Box and Block Test, Motor-Free Visual Perception Test, Line Bisection Test, Visual Analogue Scale and Numeric Rating Scale for pain, Timed Up and Go Test, 6 Minute Walk Test, Western Aphasia Battery, Geriatric Depression Scale and the Beck Depression Inventory. Many tools not included in the Canadian Best Practice Recommendations for Stroke Care were also being utilized. The majority of respondents, both urban and rural, were familiar with electronic resources for assessment tools. However some respondents were unaware that the following websites existed: StrokEngine Assess (45% unaware), Evidence-Based Review of Stroke Rehabilitation (41% unaware) and Canadian Best Practice Recommendations for Stroke Care (2% unaware). Action plans to address identified regional priorities around the use of assessment tools are in development. Stroke Rehabilitation Assessment Tools Survey Final Report October 211 3

Background The Northeastern (NE) and Northwestern (NW) Ontario Stroke Networks support the uptake and dissemination of information regarding best practices in stroke care. Published in 21, the Canadian Best Practice Recommendations for Stroke Care (CBPRSC) state that: Clinicians should use standardized, valid assessment tools to evaluate the patient s stroke-related impairments and functional status (5.1.iv.). Other stroke networks in Ontario have also completed various activities (forums, workshops, educational events, surveys, etc ) to collect and disseminate information on use of stroke rehabilitation assessment tools across the continuum of care in their regions. As such, a need to define the current state regarding use of assessment tools in NE and NW Ontario was identified. Purpose An electronic survey was used to determine to what extent Canadian Best Practice Recommendation 5.1.iv (21) is being implemented throughout NE and NW Ontario. Additionally, the survey results will be used to help determine the extent to which the core set of assessment tools [Berg Balance Scale, AlphaFIM /FIM, Montreal Cognitive Assessment, Chedoke-McMaster Stroke Assessment, Boston Diagnostic Aphasia Examination] as recommended by the Provincial Outcome Measures Working Group (Jan 21) are being utilized. The survey results will also assist in the: identification of educational opportunities with respect to assessment tools identification of barriers towards the use of assessment tools in order to develop strategies to support uptake where feasible facilitation of improved communication and information transfer between rehabilitation providers across the care continuum The survey results from the NE and NW Ontario Stroke Networks will add to provincial body of knowledge regarding the use of assessment tools within the Ontario Stroke System. Stroke Rehabilitation Assessment Tools Survey Final Report October 211 4

Methods Data Collection: An electronic survey was distributed using Survey Monkey TM. Assessment tools that were included were drawn from the 28 and 21 CBPRSC reports and only included those that are currently available (see Table 1). The AlphaFIM /FIM Instruments were not included as the extent of regional usage has been determined. Three pain rating scales were included as the domain of pain was reported by clinicians in other provincial stroke assessment tool forums as being a domain that required consideration. In order to encourage participation, clinicians were offered the opportunity to submit their email address to be entered into a prize draw. Two $25. Gift Cards were randomly awarded after the survey deadline. The information provided in the survey was not linked to the email address provided. Participants Surveyed: Physiotherapists (PT), Psychologists or Psychological Associates (Psych), Occupational Therapists (OT), Speech Language Pathologists (SLP), Social Workers (SW), Therapeutic Recreationists/Recreation Therapists (Rec) who treat adults with stroke in publically funded hospital-based programs (acute care, in-patient/ out-patient rehabilitation or CCC, day programs), home/community settings and urban/rural environments were targeted for the survey. Therapists working in the long term care, paediatric and private sectors were not specifically surveyed. E-Mail Distribution Strategy: The link to the survey was e-mailed to: Clinicians (PT, Psych, OT, SLP, SW, Rec) Managers of hospital rehabilitation programs for distribution Managers of CCAC rehab contract providers for distribution Professional practice leaders of OT, PT, Rec, SLP and SW for distribution Timeframe: The data for the survey was collected between May 15, 211 and June 8, 211. Stroke Rehabilitation Assessment Tools Survey Final Report October 211 5

Table 1: Assessment Tools Surveyed Name of Measure (Abbreviation) American Speech-Language-Hearing Association Functional Assessment of Communication Skills (ASHA-FACS) Assessment of Life Habits Leisure Subscale (LIFE-H) Beck Depression Inventory (BDI) Behavioural Inattention Test (BIT) Berg Balance Scale (BBS) Boston Diagnostic Aphasia Examination (BDAE) Box and Block Test (BBT) Chedoke Arm and Hand Activity Inventory (CAHAI) Chedoke-McMaster Stroke Assessment - Impairment Inventory (CMSA) Chedoke-McMaster Stroke Assessment - Impairment Inventory Shoulder Pain (CMSA-SP) Comb and Razor Test (CRT) Frenchay Aphasia Screening Test (FAST) Geriatric Depression Scale (GDS) Hospital Anxiety and Depression Scale (HADS) Line Bisection Test (LBT) Mini Mental State Examination (MMSE) Modified Ashworth Scale (MAshS) Montreal Cognitive Assessment (MOCA) Motor-free Visual Perception Test (MVPT) Nine Hole Peg Test (NHPT) Numeric Pain Rating Scale (NPRS) OSOT Perceptual Evaluation (OSOT) Reintegration to Normal Living Index (RNLI) Six Minute Walk Test (6MWT) Stroke Impact Scale (SIS) Timed Up and Go Test (TUG) Toronto Beside Swallowing Screening Test (TOR-BSST) Visual Analogue Pain Scale (VAS) Western Aphasia Battery (WAB) Wong-Baker FACES Pain Rating Scale (WBFPRS) Stroke Rehabilitation Assessment Tools Survey Final Report October 211 6

Findings Respondents The survey was sent to a total of 493 clinicians (253 NE, 24 NW). Eighteen clinicians indicated that they did not treat people with stroke and therefore were not eligible to participate in the survey. Overall response rate was 36%, representing clinicians from a variety of disciplines, practice locations and settings (e.g. urban/rural, rehab/acute care/community). See Table 2 below and Appendices 2-7 for more detailed information on respondent demographics. Table 2: Respondents PT OT SLP SW Rec Psych TOTAL NE SENT 95 73 26 45 12 2 253 NE RESPONSES 3 26 13 16 8 1 94 % RESPONSE RATE 32% 36% 5% 36% 67% 5% 37% NW SENT 57 69 24 48 38 4 24 NW RESPONSES 26 15 7 4 8 3 63 % RESPONSE RATE 46% 22% 29% 8% 21% 75% 26% Use of Recommended Stroke Rehabilitation Assessment Tools in NE and NW Ontario The use of selected stroke rehabilitation assessment tools by clinicians in NE and NW Ontario is illustrated in Table 3. There was strong use reported for the core set of assessment tools: Berg Balance Scale (98% PT, 28% OT), Montreal Cognitive Assessment (89% OT), Chedoke-McMaster Stroke Assessment (66% PT, 21% OT) and Boston Diagnostic Aphasia Examination (74% SLP). Please refer to Table 3, core set is highlighted. Although not included in the survey, as regional use has been determined, there is significant regional uptake with respect to the use of the AlphaFIM and FIM Instruments. In the NE, AlphaFIM and FIM are being utilized by 5 hospitals, all 5 hospitals have designated rehabilitation beds and 4 of the hospitals are either a district or the regional stroke centre. In the NW AlphaFIM is being utilized by 4 hospitals, including the regional stroke centre, the FIM is being utilized by the 1 NW hospital with designated rehab beds. Additional commonly used assessment tools reported included the OSOT Perceptual Evaluation, Mini Mental State Examination, 9 Hole Peg Test, Box and Block Test, Motor-Free Visual Perception Test, Line Bisection Test, Visual Analogue Scale and Numeric Rating Scale for pain, Timed Up and Go Test, 6 Minute Walk Test, Western Aphasia Battery, Geriatric Depression Scale and the Beck Depression Inventory. Figures 2-7 display the top tools reported on the survey by each professional discipline. Note that for OT, PT, SLP and Psych the top tools are identified as those having 5% use in at least one region. In SW and Rec, no one tool was identified as being used by 5% of respondents and as such, 2% was used to identify the top tools reported. Stroke Rehabilitation Assessment Tools Survey Final Report October 211 7

Table 3: Use of Selected Stroke Rehabilitation Assessment tools in NEO & NWO OT PT SLP SW TR PSYCH NW NE NW NE NW NE NW NE NW NE NW NE N=15 N=26 N=26 N=3 N=7 N=13 N=4 N=16 N=8 N=8 N=3 N=1 Name of Tool % Using American Speech-Language-Hearing Association Functional Assessment of Communication Skills (ASHA-FACS) n/a n/a n/a n/a 29% 15% n/a n/a n/a n/a n/a n/a Assessment of Life Habits (LIFE-H) Leisure Subscale % % % % n/a n/a % 6% 13% % % % Beck Depression Inventory (BDI) 27% 8% 8% % % % % 24% % % 67% 1% Behavioural Inattention Test (BIT) 7% 23% n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a Berg Balance Scale (BBS) 33% 23% 96% 1% n/a n/a n/a n/a n/a n/a n/a n/a Boston Diagnostic Aphasia Examination (BDAE) n/a n/a n/a n/a 71% 77% n/a n/a n/a n/a n/a n/a Box and Block Test (BBT) 47% 35% 4% % n/a n/a n/a n/a n/a n/a n/a n/a Chedoke Arm and Hand Activity Inventory (CAHAI) 27% 54% 12% 47% n/a n/a n/a n/a n/a n/a n/a n/a Chedoke McMaster Stroke Assessment (CMSA) - Impairment Inventory 7% 35% 54% 77% n/a n/a n/a n/a n/a n/a n/a n/a Chedoke McMaster Stroke Assessment - Impairment Inventory Shoulder Pain (CMSA-SP) 7% 15% 46% 53% n/a n/a n/a n/a n/a n/a n/a n/a Comb and Razor Test (CRT) 7% 31% n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a Frenchay Aphasia Screening Test (FAST) n/a n/a n/a n/a % 8% n/a n/a n/a n/a n/a n/a Geriatric Depression Scale (GDS) 27% 35% 15% 3% % % 25% 44% 13% % 1% % Hospital Anxiety and Depression Scale (HADS) 7% % 8% 7% % % 25% 19% 13% % 33% % Line Bisection Test (LBT) 4% 85% n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a Mini Mental State Examination (MMSE) 73% 69% 23% 23% % % % 13% n/a n/a % % Modified Ashworth Scale (MAshS) % % 15% 27% n/a n/a n/a n/a n/a n/a n/a n/a Montreal Cognitive Assessment (MOCA) 93% 85% 8% 13% 14% 23% % 13% n/a n/a 67% % Motor-free Visual Perception Test (MVPT) 4% 77% n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a Nine Hole Peg Test (NHPT) 53% 39% 4% % n/a n/a n/a n/a n/a n/a n/a n/a Numeric Pain Rating Scale (NPRS) 4% 54% 58% 73% n/a n/a % 19% 13% 25% n/a n/a OSOT Perceptual Evaluation (OSOT) 73% 73% n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a Reintegration to Normal Living Index (RNLI) % % 4% % n/a n/a % % 13% 13% % % Six Minute Walk Test (6MWT) % 4% 54% 53% n/a n/a n/a n/a n/a n/a % % Stroke Impact Scale (SIS) % 4% 4% 1% % 8% % 6% % % n/a n/a Timed Up and Go Test (TUG) 13% 8% 65% 73% n/a n/a n/a n/a n/a n/a n/a n/a Toronto Beside Swallowing Screening Test (TOR-BSST) n/a n/a n/a n/a % 8% n/a n/a n/a n/a n/a n/a Visual Analogue Pain Scale (VAS) 13% 39% 73% 73% n/a n/a % 19% 13% % n/a n/a Western Aphasia Battery (WAB) n/a n/a n/a n/a 1% 69% n/a n/a n/a n/a n/a n/a Wong-Baker FACES Pain Rating Scale (WBFPRS) % % % 1% n/a n/a n/a n/a n/a n/a n/a n/a Recommended for inclusion in 'Core Set' of Outcome Measures Highlighted = Recommended for inclusion in core set of assessment tools n/a = discipline was not asked about this tool in the survey as it would generally not be applicable or commonly used by the specific discipline Stroke Rehabilitation Assessment Tools Survey Final Report October 211 8

TOP TOOLS REPORTED (>5% USE IN AT LEAST ONE REGION) Figure 1: Occupational Therapy Top Tools Figure 2: Physiotherapy Top Tools Name of Measure (Abbreviation): Berg Balance Scale (BBS); Chedoke Arm and Hand Activity Inventory (CAHAI); Chedoke-McMaster Stroke Assessment - Impairment Inventory (CMSA); Chedoke-McMaster Stroke Assessment Shoulder Pain (CMSA- SP); Line Bisection Test (LBT); Mini Mental State Examination (MMSE); Montreal Cognitive Assessment (MOCA); Motor-free Visual Perception Test (MVPT); Nine Hole Peg Test (NHPT); Numeric Pain Rating Scale (NPRS); OSOT Perceptual Evaluation (OSOT); Six Minute Walk Test (6MWT); Timed Up and Go Test (TUG); Visual Analogue Pain Scale (VAS) Stroke Rehabilitation Assessment Tools Survey Final Report October 211 9

TOP TOOLS REPORTED (>5% USE IN AT LEAST ONE REGION) Figure 3: Speech Language Pathology Top Tools Figure 4: Psychology Top Tools Name of Measure (Abbreviation): Beck Depression Inventory (BDI); Boston Diagnostic Aphasia Examination (BDAE); Geriatric Depression Scale (GDS); Montreal Cognitive Assessment (MOCA); Western Aphasia Battery (WAB) Stroke Rehabilitation Assessment Tools Survey Final Report October 211 1

TOP TOOLS REPORTED (>2% USE IN AT LEAST ONE REGION)* *No one tool was identified as being used by > 5% of respondents from Recreation or Social Work Figure 5: Recreation Top Tools Figure 6: Social Work Top Tools Name of Measure (Abbreviation): Beck Depression Inventory (BDI); Geriatric Depression Scale (GDS); Hospital Anxiety and Depression Scale (HADS); Numeric Pain Rating Scale (NPRS) Stroke Rehabilitation Assessment Tools Survey Final Report October 211 11

Overview of Common Themes in Core Assessment Tools When reviewing the data collected from the four core assessment tools captured in the survey, there was nearly complete consensus from those who frequently (>5% of the time) administered the core set that each tool took a reasonable length of time to complete. Respondents who frequently administered the tools were asked to rate the usefulness of the tool on a five point scale across four categories. The categories were: Establishing a baseline measure; measuring progress or change; communicating the patient s status; and assisting with identification of goals (see Appendix 1, question 1.c). The majority of the respondents rated all of the four tools as either extremely or very useful for establishing a baseline measure. The same findings occurred for measuring progress or change and communicating the patient s status with the exception of the BDAE which was rated as either very useful or useful. Reponses for rating the usefulness of assisting with the identification of goals were more widespread for three of the tools with the exception of the BDAE which was rated as very useful or useful again. When reviewing the responses for the usefulness of all the tools, only one individual gave a rating of not useful and that was by an OT with reference to the MOCA's assistance with identification of goals. In reviewing the data from an urban/rural perspective, there was no apparent difference in the overall use of the core set of assessment tools between clinicians practicing in these environments. However, it was observed that in some of the rural communities, there was increased use of tools by clinicians who may not traditionally administer that assessment. For example, urban PT s generally did not administer the MOCA citing that the OT s usually assessed cognition. However some rural PT s did use the MOCA as they may not have had access to OT s as part of their interdisciplinary team. The survey explored some common reasons as to why a tool may be used infrequently or not at all, which are summarized under the subheadings below. However, two of the choices (the cost of the tools and licensing requirements) appeared to be non-issues as they were mentioned only once for one specific tool, the CMSA. Montreal Cognitive Assessment (MOCA) The survey results for both the NE and NW showed that the MOCA was primarily administered by the OTs. Physiotherapy, psychology and social work occasionally or rarely administered it. The primary reason for the other professions not using it was they felt it was not applicable to their profession/area of practice or that the OTs at their site administered it. Furthermore, approximately one third of the PTs were unaware this tool existed and a small percentage (1% - 2%) of the SWs and PTs cited lack of training as the reason why they were not using it. Within the comments on the measure, one OT who used it less frequently stated that he/she was awaiting further study re use of the MOCA with stroke patients. Chedoke-McMaster Stroke Assessment - Impairment Inventory (CMSA) In the NE, approximately three quarters of the PTs administered the CMSA and of those, half of them did so frequently (>5% of the time). In comparison, in the NW approximately half of the PTs administered the tool and of those, one third did so frequently. In the NE, slightly more than one third of the OTs administered the CMSA and similar to the PTs half of them did so frequently. A very small percentage (< 1%) of the NW OTs reported administering it and only did so rarely due to lack of training and time. Stroke Rehabilitation Assessment Tools Survey Final Report October 211 12

For both disciplines in both regions, lack of time to administer or not finding the tool to be clinically useful were common themes for infrequently ( 5% of the time) or not using the tool at all. Therapists in acute care most often commented on time constraints, however it was a consistent theme across the continuum from acute to community care. A small percentage of the NE PTs and OTs cited lack of training/expertise as reasons why they were administering it infrequently or not at all, whereas, in the NW a quarter of the therapists reported that as the reason. For both regions, a small percentage the OT group also indicated that they didn t use the CMSA as it was not applicable for their area of practice, that PTs administered it, and a very small percentage were unaware that this tool existed. Boston Diagnostic Aphasia Examination (BDAE) In both regions approximately three quarters of the SLPs use the BDAE, and of those, a quarter used it frequently. Lack of time to administer, across the continuum from acute to community care was the most common reason for either infrequently or not using the tool. Lack of training was only reported on one occasion. Further comments noted that other tools are more useful in the community setting given the client demographics. One SLP commented more severe stroke patients are better suited to assessment using the Western Aphasia Battery, a tool which was reported to be commonly used by both NE and NW SLP s. Berg Balance Scale (BBS) In both regions all PTs use the BBS with the exception of one individual who reported not using it because it was not applicable to their area of practice as their clients were very low functioning. In the NE eighty percent of the PTs use the BBS frequently versus eighty-eight percent in the NW. For OTs and PTs in both regions the issue of time constraints was raised by those who did not administer the tool as frequently. The OTs who did not administer the BBS primarily cited that the PTs administered it or that it was not applicable for their area of practice. Lack of training/expertise was also indicated in the NW by a small percentage of OT respondents. Other Commonly Used Tools Many tools not included in the Canadian Best Practice Recommendations for Stroke Care were also being utilized by clinicians. Examples of additional tools being utilized in stroke rehabilitation in NE and NW Ontario include the Community Balance and Mobility Scale, Trail Making A and B Tests, Boston Naming Test, Cognitive Assessment Scale for the Elderly, Leisure Motivational Scale and Wisconsin Card Sorting Test. Appendices 2-7 outline for each discipline the variety of other tools reported to be used in stroke rehabilitation. Use of Electronic Resources As illustrated in Figures 7 and 8, the majority of respondents were familiar with electronic resources for assessment tools. However some respondents were unaware that the following websites existed: StrokEngine Assess (45% unaware), Evidence-Based Review of Stroke Rehabilitation (41% unaware) and Canadian Best Practice Recommendations for Stroke Care (2% unaware). Stroke Rehabilitation Assessment Tools Survey Final Report October 211 13

Figure 7: NW Electronic Resources: Awareness and Usage Stroke Assessment Tools Survey - All Clinicians - NW 21 Canadian Best Practice Recommendations for Stroke Care (www.strokebestpractices.ca) Unaware this website existed 9 14% Aware of website however have not looked at it 18 29% Visited the website once 16 25% Visited it times 13 21% Visited it greater than 5 times 7 11% Total 63 1% EBRSR: Evidence-Based Review of Stroke Rehabilitation (www.ebrsr.com) Unaware this website existed 26 41% Aware of website however have not looked at it 12 19% Visited the website once 7 11% Visited it times 9 14% Visited it greater than 5 times 9 14% Total 63 1% StrokEngine Assess (www.medicine.mcgill.ca/strokengine-assess) Unaware this website existed 27 43% Aware of website however have not looked at it 9 14% Visited the website once 12 19% Visited it times 7 11% Visited it greater than 5 times 8 13% Total 63 1% Stroke Rehabilitation Assessment Tools Survey Final Report October 211 14

Figure 8: NE Electronic Resources: Awareness and Usage Stroke Assessment Tools Survey - All Clinicians NE 21 Canadian Best Practice Recommendations for Stroke Care (www.strokebestpractices.ca) Unaware this website existed 24 26% Aware of website however have not looked at it 15 16% Visited the website once 13 14% Visited it times 32 34% Visited it greater than 5 times 1 11% TOTAL 94 1% EBRSR: Evidence-Based Review of Stroke Rehabilitation (www.ebrsr.com) Unaware this website existed 39 41% Aware of website however have not looked at it 22 23% Visited the website once 6 6% Visited it times 12 13% Visited it greater than 5 times 15 16% TOTAL 94 1% StrokEngine Assess (www.medicine.mcgill.ca/strokengine-assess) Unaware this website existed 43 46% Aware of website however have not looked at it 11 12% Visited the website once 9 1% Visited it times 11 12% Visited it greater than 5 times 2 21% TOTAL 94 1% Stroke Rehabilitation Assessment Tools Survey Final Report October 211 15

Next Steps Discuss survey findings with each stroke network s steering committees, advisory and professional practice groups. Develop educational strategies to enhance uptake and awareness of the core set of assessment tools and of the resources available to support clinicians. During this process, take into account and build on previous strategies developed by provincial counterparts such as the regional rehabilitator coordinators and the Ontario Regional Educators Group (OREG). Consider the target audience in developing strategies. Although there may be excellent uptake of the tool such as the BBS by PTs who regularly administer the tool we need to also consider the other team members who do not administer the tool. In order to have a common/shared language they need to have a basic understanding of what the reported scores mean. Consider use of communiqués or the possibility of having Lunch and Learn sessions via videoconference providing an overview of the core tools. Look further into the demographics of the respondents (profession, district, area(s) of practice) who expressed interest in learning more about a specific recommended tool. For example, one SLP commented Would be very interested in training related to the TOR-BSST. For comments such as this, we might consider a communiqué to the appropriate professions that at minimum would provide information on how to access education on the tool. Survey and Final Report prepared by: Jenn Fearn Regional Rehabilitation Coordinator NEO Stroke Network Hôpital régional de Sudbury Regional Hospital 41 Ramsey Lake Road, Sudbury, ON P3E 5J1 Ph. 75.523.71 ext. 1718 Fax. 75.523.717 Email: jfearn@hrsrh.on.ca Web: www.neostrokenetwork.com Esmé French Regional Stroke Rehabilitation Specialist NWO Regional Stroke Network 21-984 Oliver Road Thunder, ON P7B 7C7 Ph. 87.684.6498 Fax. 87. 684.5883 Email: frenche@tbh.net Web: www.nwostroke.ca Stroke Rehabilitation Assessment Tools Survey Final Report October 211 16

Appendices Appendix 1: Survey Template Appendix 2: Physiotherapy Demographics and Discipline Specific Information Appendix 3: Occupational Therapy Demographics and Discipline Specific Information Appendix 4: Speech Language Pathology Demographics and Discipline Specific Information Appendix 5: Social Work Demographics and Discipline Specific Information Appendix 6: Recreation Demographics and Discipline Specific Information Appendix 7: Psychology Demographics and Discipline Specific Information 17

Appendix 1: Survey Template Demographic information collected: Profession Location of practice [region, district, urban/rural (size of community) and setting (rehab, acute care etc.)] Years of clinical experience (general and stroke specific) Average percentage of caseload that patients with stroke represent Outcome Measure Specific Questions: For each outcome measure, the following questions were asked: 1. Do you use this tool? Yes No A response of Yes led to the following questions: a. In what percentage of cases do you use this tool with your patients with stroke? If the clinician responded occasionally or rarely ( 5 %) they were asked the following: i. Could you please elaborate why you only occasionally or rarely use this tool? If more than one reason, select all that apply. o Lack of time to administer o Lack of training/expertise o Not clinically useful (information does not inform my practice) o Not clinically appropriate (another measure is more appropriate) o Cost of the tool o Other, please specify: b. Is the length of time to administer the tool reasonable? c. In the following questions, please rate the usefulness of the tool by selecting the number that best reflects the tool in each circumstance (1=not useful 5=extremely useful, n/a) i. Establishing a baseline measure ii. Measuring progress or change iii. Communicating the patient s status iv. Assisting with identification of goals A response of No led to the following question: a. Could you please elaborate why you do not use this tool? If more than one, select all that apply. o Lack of time to administer o Lack of training/expertise o Not clinically useful (information does not inform my practice) o Not clinically appropriate (another measure is more appropriate) o Not applicable for my profession/area of practice o Cost of the tool o Licensing requirements o Unaware this tool existed o Other, please specify 18

2. Please list any other tools you commonly use with your patients with stroke. If they were developed by your facility please provide a brief description of their purpose i.e. Smith test (Swallowing Screen) 3. If you have any further comments you wish to provide, feel free to provide them here. A general question was asked to determine the participant s familiarity with electronic resources that contain information regarding assessment tools in stroke rehabilitation. 4. Please indicate your familiarity/usage of the following 3 websites? (unaware this website existed visited it greater than 5 times) 1. StrokEngine Assess (www.medicine.mcgill.ca/strokengine-assess) 2. Evidence-Based Review of Stroke Rehabilitation (www.ebrsr.com) 3. Canadian Best Practice Recommendations for Stroke Care (www.strokebestpractices.ca) 19

Appendix 2: Physiotherapy Demographics and Discipline Specific Information Stroke Assessment Tools Survey - Demographics NW Physio Please select the geographical district(s) you practice in: Answer Options & Thunder 69.2% 18 West of Thunder 23.1% 6 East of Thunder 7.7% 2 26 What size of setting(s) do you practice in? Please check all that apply. Please select the geographical district(s) you West of Thunder East of Thunder Thunder Population 4 Population 5-39 999 Population < 5 17 65.4% 17 1 5 23.1% 6 1 2 11.5% 3 26 Please indicate the setting(s) that you work in. If more than one, select all that apply. Acute Care In-patient Rehabilitation Complex Continuing Care Out-patient Rehabilitation Hospital-based Day Program Home Care/CCAC Other (please specify) Community, LTC Please select the geographical district(s) you Thunder West of Thunder East of 2 4 2 3.8% 8 8 2 2 46.2% 12 1 2 2 19.2% 5 4 3 2 34.6% 9 2 7.7% 2 5 1 23.1% 6 1 1 7.7% 2 26 Please indicate your total number of years of clinical experience (not stroke specific): Please select the geographical district(s) you West of Thunder East of Thunder Thunder -1 6-1 2+ 2 1 11.5% 3 6 23.1% 6 3 1 15.4% 4 5 4 1 38.5% 1 2 1 11.5% 3 26 Please indicate your total number of years of clinical experience working with people who have had a stroke: Please select the geographical district(s) you West of Thunder East of Thunder Thunder -1 3 1 15.4% 4 7 1 3.8% 8 6-1 3 3 23.1% 6 4 1 1 23.1% 6 2+ 1 1 7.7% 2 26 Please estimate the average percentage of your caseload that patients with stroke represent: Please select the geographical district(s) you West of Thunder East of Thunder Thunder -1 7 5 1 5.% 13 11-25 6 23.1% 6 26-5 1 1 7.7% 2 51-75 1 1 7.7% 2 76-1 3 11.5% 3 26 2

Stroke Assessment Tools Survey - Demographics NE Physio Ple a se se le ct the g e o g ra p hica l d istrict(s) yo u p ra ctice in: Algoma Timmins Nipissing-Temiskaming Sudbury-Manitoulin 2.% 6 2.% 6 2.% 6 4.% 12 3 W ha t size o f se tting d o yo u p ra ctice in? Urban (population 4 ) Rural (population < 4 ) Both Urban and Rural Alg o ma T immins Nip issing - T e miska ming Sud b ury 5 4 1 6 53.3% 16 1 2 4 4 36.7% 11 1 2 1.% 3 3 Please indicate the setting (s) that you work in. If more than one, select all that apply. Acute Care In-patient Rehabilitation Complex Continuing Care Out-patient Rehabilitation Hospital-based Day Program Home Care/CCAC Other (please specify) Alg o ma T immins LTC and elcap beds in LTC facility, LTC, private practice, retirement homes Nip issing - T e miska ming Sud b ury 6 5 3 6 66.7% 2 4 4 1 8 56.7% 17 5 4 2 2 43.3% 13 5 3 3 3 46.7% 14 2 6.7% 2 2 4 1 23.3% 7 1 1 1 1.% 3 Ple a se ind ica te yo ur to ta l numb e r o f ye a rs o f clinica l e xp e rie nce (no t stro ke sp e cific): -1 Alg o ma T immins Nip issing - T e miska ming Sud b ury 3.% 3 1 1 16.7% 5 6-1 2+ 1 1 6.7% 2 4 2 1 4 36.7% 11 1 1 4 6 4.% 12 3 Ple a se ind ica te yo ur to ta l numb e r o f ye a rs o f clinica l e xp e rie nce wo rking with p e o p le who ha ve ha d a stro ke : -1 6-1 Alg o ma T immins Nip issing - T e miska ming Sud b ury 1 1 6.7% 2 2 1 1 13.3% 4 2 1 1 13.3% 4 2+ 3 3 5 36.7% 11 1 4 4 3.% 9 3 Ple a se e stima te the a ve ra g e p e rce nta g e o f yo ur ca se lo a d tha t p a tie nts with stro ke re p re se nt: -1 11-25 26-5 51-75 Alg o ma T immins Nip issing - T e miska ming Sud b ury 3 3 6 5 56.7% 17 3 3 3 3.% 9 1 3.3% 1 2 6.7% 2 76-1 1 3.3% 1 3 21

PHYSIOTHERAPY REPORTED USE OF OTHER TOOLS REPORTED BY BOTH NE & NW Community Balance and Mobility Scale (CBMS) Functional Independence Measure (FIM) Alpha FIM Tinetti Balance Test 2 minute walk test REPORTED BY NE ONLY Elderly Mobility Scale REPORTED BY NW ONLY Clinical Outcome Variables Scale Gait speed 1 m walk test Activities-specific Balance Confidence Scale (ABC Scale) Action Plans for goal setting Manual muscle testing - Oxford scale Modified sphygmomanometer or myometer for assessing muscle strength Range of motion - goniometer Functional reach test Morse fall risk assessment National Institutes of Health Stroke Scale (NIHSS) Gait assessment PT OTHER COMMENTS NW NE I strictly take outpatient neuro clients so the CMSA scale is much too long to be useful for both client and clinician. I have access to the electronic medical record and see the scores that the inpatient physiotherapist has assessed, but I do not redo this score. For a lot of the self-report measures, it is difficult in clinical practice to complete them due to time restrictions. Also, there is often cognitive difficulties and/or communication issues that makes their administration difficult. It would be good to have them completed as they do have an impact on our therapy. Perhaps not directly but definitely indirectly. Working within in a team and having other team members (ie. Psych or Social work) administer these outcome measures would be helpful. I do not actively treat many post-stroke clients in my current position (less than 2 a year) Due to low number of stroke patients per year, there is not a large focus/amount of time spent on learning or attempting to implement a lot of the aforementioned assessment and outcome tools. Perhaps a seminar introducing the previously mentioned tools would be of benefit for those therapists in the area that treat stroke patients so that an informed decision could be made on an individual basis about which tools would be the most appropriate one(s) to use in each particular setting. Due to caseload demands, standardized tools are not commonly used. Functional assessments are used to determine course of treatment and measure progress. I realize, even prior to this survey that I need to be using more outcome measures. However, as I've mentioned, stroke patients make up such a small percentage of my clientele, it is hard to feel confident in using them. Also, time is definitely an issue with many of these, as I am a sole-charge physiotherapist covering many different areas. Do not use all the outcome measurements on every client, more appropriate with some than others. Am limited in the time it takes to do the assessment (and therefore thoroughness) as our agency feels that 1 1/2 hours for an assessment, including travel time & paper work is sufficient. 22

Appendix 3: Occupational Therapy Demographics and Discipline Specific Information Stroke Assessment Tools Survey - Demongraphics NW OT Please select the geographical district(s) you practice in: Thunder West of Thunder East of Thunder 73.3% 11 2.% 3 13.3% 2 Answered Question 15 What size of setting(s) do you practice in? Please check all that apply. Please select the geographical district(s) you practice Population 4 Population 5-39 999 Population < 5 Thunder West of Thunder East of Thunder 8 1 53.3% 8 2 3 1 33.3% 5 3 2 26.7% 4 15 Please indicate the setting(s) that you work in. If more than one, select all that apply. Please select the geographical district(s) you practice in: Acute Care In-patient Rehabilitation Complex Continuing Care Out-patient Rehabilitation Hospital-based Day Program Home Care/CCAC Other (please specify) Thunder contract work for veteran's affairs community geriatric psychiatry Mental Health Case management in the community West of Thunder East of Thunder 4 1 1 4.% 6 3 1 26.7% 4 1 6.7% 1 2 1 2.% 3.% 2 1 2 26.7% 4 2 1 2.% 3 Please indicate your total number of years of clinical experience (not stroke specific): Please select the geographical district(s) you practice -1 6-1 2+ Thunder West of Thunder East of Thunder 1 6.7% 1 1 2 2.% 3 2 1 2.% 3 3 2.% 3 4 2 33.3% 5 15 15 Please indicate your total number of years of clinical experience working with people who have had a stroke: Please select the geographical district(s) you practice -1 6-1 2+ Thunder West of Thunder East of Thunder 1 6.7% 1 5 2 1 46.7% 7 2 1 2.% 3 1 6.7% 1 3 2.% 3 15 Please estimate the average percentage of your caseload that patients with stroke represent: Please select the geographical district(s) you practice -1 11-25 26-5 51-75 76-1 Thunder West of Thunder East of Thunder 5 1 1 46.7% 7 2 2 1 26.7% 4 1 6.7% 1.% 3 2.% 3 15 23

Stroke Assessment Tools Survey - Demongraphics NE OT Please select the geographical district(s) you practice in: Algoma Timmins Nipissing-Temiskaming Sudbury-Manitoulin 11.5% 3 26.9% 7 3.8% 8 38.5% 1 26 Minor Procedures Clinic LTC Interim Long Term Care 2 4 5 8 65.4% 17 3 3 1 26.9% 7 1 1 7.7% 2 Please indicate the setting(s) that you work in. If more than one, select all that apply. Acute Care In-patient Rehabilitation Complex Continuing Care Out-patient Rehabilitation Hospital-based Day Program Home Care/CCAC Other (please specify) Please select the geographical district(s) you practice in: 3 3 23.1% 6 2 7.7% 2 2 7.7% 2 3 3 5 34.6% 9 3 2 2 26.9% 7 26 26 26 Please indicate your total number of years of clinical experience working with people who have had a stroke: -1 6-1 2+ 26 What size of setting do you practice in? Please select the geographical district(s) you practice in: Algoma Timmins Nipissing- Sudbury- Temiskaming Manitoulin Urban (population 4 ) Rural (population < 4 ) Both Urban and Rural Algoma Timmins Nipissing- Sudbury- Temiskaming Manitoulin 2 4 5 3 53.8% 14 2 4 4 5 57.7% 15 2 3 4 34.6% 9 1 5 4 4 46.2% 12.% 1 2 1 1 19.2% 5 1 1 1 11.5% 3 Please indicate your total number of years of clinical experience (not stroke specific): Please select the geographical district(s) you practice in: Algoma Timmins Nipissing- Sudbury- Temiskaming Manitoulin -1 6-1 2+ Please select the geographical district(s) you practice in: Algoma Timmins Nipissing- Sudbury- Temiskaming Manitoulin 3 3 23.1% 6 1 3 15.4% 4 1 3.8% 1 1 5 3 4 42.3% 11 2 2 15.4% 4 Please estimate the average percentage of your caseload that patients with stroke represent: Please select the geographical district(s) you practice in: Algoma Timmins Nipissing- Sudbury- Temiskaming Manitoulin -1 11-25 26-5 51-75 76-1 2 3 3 3 34.6% 9 1 2 2 2 26.9% 7 2 2 3 26.9% 7 1 2 11.5% 3.% 26 24

OCCUPATIONAL THERAPY REPORTED USE OF OTHER TOOLS REPORTED BY BOTH NE & NW Trail Making A and B Clock Drawing Test Alpha FIM Cognitive Assessment of Minnesota JAMAR hand and pinch strength assessments. Canadian Occupational Performance Measure (COPM) Cognitive Competency Test Functional Independence Measure (FIM) REPORTED BY NE ONLY Independent Living Scales Goal Attainment Scale Test of Everyday Attention Rivermead Behavioural Memory Test Protocole d'examen Cognitif de la Personne Agee (PECPA) Cognitive Assessment Scale for the Elderly (CASE) "perceptual screen" - includes letter cancellation, read & write sentence, draw front view of house, person Brain Injury Visual Assessment Battery for Adults (BIVABA) Sunnybrook Neglect Assessment Protocol (SNAP) Manual Muscle Testing Behavioural Assessment of the Dysexecutive Syndrome (BADS) REPORTED BY NW ONLY National Institutes of Health Stroke Scale Functional assessment: e.g. observe transfers from tub, chair, bed, toilet, focus on practical activities Home safety assessment: e.g. measure doorways, recommend ramps Reviewing goals such as cooking, bathing, mobility Gardner Test of Visual Perceptual Skills (non-motor) OT OTHER COMMENTS NW There are a few standardized assessment tools that are new to me and I do hope that there will be some training provided so all clinicians dealing with stroke clients will have more awareness of the tools that are out there. Active rehabilitation is not taking place in the community specifically the client's home. Implementing standardized tools is simply not effective use of time when the client is discharged from home care after 2-4 visits. Primary focus seems to been ensuring home safety and accessibility versus improving overall function. Clients who have participated in an in-pt rehab program often return as an out-pt which limits the role of active home care therapy. I do feel that a more significant role can be played by home care OT, Pt, etc. Therapy in the client's residence can be very effective for some clients at assisting them in re-engaging in their routine activities. NE Some outcome measures, I feel are inappropriate to use, because you are penalized if you've had your stroke a while back whether it be 3, 6 12 months or more. I feel these outcome are biased and these scores are looked at by other health care professionals and decisions are made based on these scores. Even though a client may have a low score, maybe they just need the right therapy to improve and often these scores mask their potential. When working in augmentative communication, I'm not sure if I would be missing an assessment tool that I could be using. At this time, I don't use any. 25

Appendix 4: Speech Language Pathology Demographics and Discipline Specific Information Stroke Assessment Tools Survey - Demographics NW Speech Language Pathology Please select the geographical district(s) you practice in: Thunder West of Thunder East of Thunder & 57.1% 4 28.6% 2 28.6% 2 Answered Question 7 W ha t size o f se tting (s) d o yo u p ra ctice in? Ple a se che ck a ll tha t a p p ly. Population 4 W e st o f T hund e r Ba y Ea st o f 4 1 57.1% 4 Population 5-39 999 Population < 5 1 2 1 42.9% 3 1 2 28.6% 2 7 Please indicate the setting (s) that you work in. If more than one, select all that apply. Acute Care In-patient Rehabilitation Complex Continuing Care Out-patient Rehabilitation Hospital-based Day Program Home Care/CCAC Other (please specify) private practice W e st o f T hund e r Ba y Ea st o f 1 1 1 42.9% 3 2 1 1 57.1% 4.% 1 14.3% 1.% 1 2 2 57.1% 4 1 1 14.3% 1 7 Ple a se ind ica te yo ur to ta l numb e r o f ye a rs o f clinica l e xp e rie nce (no t stro ke sp e cific): -1 6-1 2+ W e st o f T hund e r Ea st o f Ba y 1 14.3% 1 2 1 28.6% 2.% 2 1 42.9% 3 1 14.3% 1 7 Ple a se ind ica te yo ur to ta l numb e r o f ye a rs o f clinica l e xp e rie nce wo rking with p e o p le who ha ve ha d a stro ke : W e st o f T hund e r Ea st o f Ba y -1 1 14.3% 1 6-1 2+ 2 1 1 42.9% 3.% 2 1 42.9% 3.% 7 Ple a se e stima te the a ve ra g e p e rce nta g e o f yo ur ca se lo a d tha t p a tie nts with stro ke re p re se nt: W e st o f T hund e r Ba y Ea st o f -1 1 14.3% 1 11-25 26-5 51-75 76-1 1 14.3% 1 3 1 42.9% 3 1 1 28.6% 2.% 7 26

Stroke Assessment Tools Survey - Demographics NE Speech Language Pathology Please select the geographical district(s) you practice in: Algoma Timmins Nipissing-Temiskaming Sudbury-Manitoulin 23.1% 3.% 46.2% 6 3.8% 4 13 W ha t size o f se tting d o yo u p ra ctice in? Ple a se se le ct the g e o g ra p hica l d istrict(s) yo u p ra ctice in: Alg o ma T immins Nip issing - T e miska ming Sud b ury- Ma nito ulin Urban (population 4 ) Rural (population < 4 ) Both Urban and Rural 2 3 4 69.2% 9 2 15.4% 2 1 1 15.4% 2 13 Please indicate the setting (s) that you work in. If more than one, select all that apply. Ple a se se le ct the g e o g ra p hica l d istrict(s) yo u p ra ctice in: Acute Care In-patient Rehabilitation Complex Continuing Care Out-patient Rehabilitation Hospital-based Day Program Home Care/CCAC Other (please specify) private practice Alg o ma T immins Nip issing - T e miska ming Sud b ury- Ma nito ulin 2 4 1 53.8% 7 2 4 3 69.2% 9 2 4 46.2% 6 2 4 1 53.8% 7.% 1 3 3.8% 4 1 7.7% 1 13 Ple a se ind ica te yo ur to ta l numb e r o f ye a rs o f clinica l e xp e rie nce (no t stro ke sp e cific): -1 6-1 2+ Ple a se se le ct the g e o g ra p hica l d istrict(s) yo u p ra ctice in: Alg o ma T immins Nip issing - T e miska ming Sud b ury- Ma nito ulin 1 7.7% 1 1 3 1 38.5% 5 2 15.4% 2 2 2 3.8% 4 1 7.7% 1 13 Ple a se ind ica te yo ur to ta l numb e r o f ye a rs o f clinica l e xp e rie nce wo rking with p e o p le who ha ve ha d a stro ke : Ple a se se le ct the g e o g ra p hica l d istrict(s) yo u p ra ctice in: -1 6-1 2+ Alg o ma T immins Nip issing - T e miska ming Sud b ury- Ma nito ulin 1 7.7% 1 1 3 1 38.5% 5 1 2 23.1% 3 1 3 3.8% 4.% 13 Ple a se e stima te the a ve ra g e p e rce nta g e o f yo ur ca se lo a d tha t p a tie nts with stro ke re p re se nt: Ple a se se le ct the g e o g ra p hica l d istrict(s) yo u p ra ctice in: -1 11-25 26-5 51-75 76-1 Alg o ma T immins Nip issing - T e miska ming Sud b ury- Ma nito ulin 1 1 1 23.1% 3 2 15.4% 2 1 1 15.4% 2 1 2 23.1% 3 1 2 23.1% 3 13 27

SPEECH LANGUAGE PATHOLOGY REPORTED USE OF OTHER TOOLS REPORTED BY BOTH NE & NW Reading Comprehension Battery for Aphasia (RCBA) Boston Naming Test Frenchay Dysarthria Assessment Scales of Cognitive Ability for Traumatic Brain Injury (SCATBI) Assessment of Intelligiblity of Dysarthric Speech REPORTED BY NE ONLY Burns Left and Right Hemisphere Inventory Woodcock Johnson - passage comprehension subtest Discourse Comprehension Test Swallowing Screening for TIA/CVA - developed at facility Cognitive-Linguistic Quicktest Western Aphasia Battery Revised (bedside) (WAB-R) Butt Non-Verbal Reasoning Test Test of Adolescent/Adult Word Finding Reading Comprehension Battery for Adults with Aphasia Apraxia Battery for Adults (ABA-2) Communication Activities of Daily Living (CADL-2) Examining for Aphasia - 4 (EFA-4) Test for Adolescent and Adult Word-Finding Cognitive-Linguistic Quick Test Ross Information Processing Assessment (RIPA) REPORTED BY NW ONLY Sentence/Discourse Comprehension Test Adapted version of the Morton Plant Mease Health Care Screening tool for Stroke-Dysphagia Screen SLP OTHER COMMENTS NW It is so great that you are doing this survey! I am very interested in improving my knowledge and skills in this area! NE Would be very interested in training related to the TOR-BSST 28

Appendix 5: Social Work Demographics and Discipline Specific Information Stroke Assessment Tools Survey - Demographics NW Social Work Please select the geographical district(s) you practice in: Thunder West of Thunder East of Thunder & 75.% 3 25.% 1.% Answered Question 4 W ha t size o f se tting (s) d o yo u p ra ctice in? Ple a se che ck a ll tha t a p p ly. Population 4 Population 5-39 999 Population < 5 W e st o f T hund e r Ba y Ea st o f T hund e r Ba y 2 5.% 2.% 1 1 5.% 2 4 Please indicate the setting (s) that you work in. If more than one, select all that apply. Acute Care In-patient Rehabilitation Complex Continuing Care Out-patient Rehabilitation Hospital-based Day Program Home Care/CCAC Other (please specify) W e st o f T hund e r Ba y Ea st o f T hund e r Ba y 1 25.% 1 1 25.% 1 1 25.% 1 1 25.% 1.%.% 1 25.% 1 4 hospital palliative Ple a se ind ica te yo ur to ta l numb e r o f ye a rs o f clinica l e xp e rie nce (no t stro ke sp e cific): -1 6-1 W e st o f T hund e r Ba y Ea st o f T hund e r Ba y.%.% 1 25.% 1 1 1 5.% 2 2+ 1 25.% 1 4 Ple a se ind ica te yo ur to ta l numb e r o f ye a rs o f clinica l e xp e rie nce wo rking with p e o p le who ha ve ha d a stro ke : -1 6-1 W e st o f T hund e r Ba y Ea st o f T hund e r Ba y.% 1 1 5.% 2 1 25.% 1 2+ 1 25.% 1.% 4 Ple a se e stima te the a ve ra g e p e rce nta g e o f yo ur ca se lo a d tha t p a tie nts with stro ke re p re se nt: -1 11-25 26-5 51-75 76-1 W e st o f T hund e r Ba y Ea st o f T hund e r Ba y 2 1 75.% 3.% 1 25.% 1.%.% 4 29