Evolving Roles of Advanced Practice Physiotherapists in Stroke Care in Canada

Dear Editor,

Stroke continues to be the predominant cause of disability in Canada, with an estimated 62,000 new cases annually. The impact extends beyond mortality, encompassing long-term functional disability, caregiver burden, and systemic costs associated with extended hospitalization and pressures from alternate levels of care (ALC) [1–4 ]. ALC is a clinical designation applied to patients who continue to occupy acute care hospital beds despite not requiring acute services. This situation arises due to delays in discharge as patients await transfer to a more suitable care setting, such as home care with support, inpatient rehabilitation, long-term care, or access to essential community services [4].

Although acute reperfusion therapies and hyperacute stroke units have significantly improved survival rates, challenges in post- acute rehabilitation and discharge processes remain [5–7 ]. The Canadian Stroke Best Practice Recommendations (CSBPR) propose a continuum of care model that includes acute, rehabilitation, and community integration phases [5–7 ]. Despite their thoroughness, implementation gaps exist, such as delayed access to inpatient rehabilitation, inconsistencies in discharge planning, and disparities in access to specialized services in rural areas. For senior leaders, this presents a dual challenge of maintaining quality of care while managing costs. Advanced Practice Physiotherapy (APP) roles have gained international recognition as an innovative model that bridges the diagnostic and rehabilitation domains [11–13 ].

In Canada, Health Sciences North (HSN) was the first academic hospital to integrate APP into stroke care within interdisciplinary models. The MOTIVE project further illustrates how system-level redesign can utilize APP roles to enhance patient flow and reduce inefficiencies in the ED. Notably, APP are not replacements for neurologists or physicians but serve as collaborators who extend the application of best practices throughout the stroke care pathway.

Health Education England delineated four foundational pillars that characterize advanced practice: clinical practice, leadership, education, and research [11]. Within the realm of clinical practice, APPs conduct advanced functional assessments utilizing validated instruments, frequently informed by initiatives such as the American Physical Therapy Association’s (APTA) Stroke EDGE recommendations [8–10 ]. These assessments complement diagnostic imaging by translating the lesion location into practical functional outcomes. For instance, while a CT or MRI may identify the infarct territory, the APP’s bedside evaluation elucidates the extent of impairments in mobility, endurance, balance, and participation, which are critical for shaping rehabilitation trajectories. Leadership may be exemplified through APPs’ contributions to the redesign of care models, such as Early Supported Discharge (ESD), which has been shown to reduce hospital stay duration and enhance patient satisfaction [8–10 ]. The educational role encompasses not only the instruction of patients and their families but also the mentorship of interdisciplinary colleagues to enhance the standardization of assessment and discharge practices [6, 7]. Research has established a connection between APP practice and system performance, with studies indicating that APP-led pathways enhance throughput, reduce readmissions, and sustain quality outcomes [12, 13]. Collectively, these pillars highlight that the roles of APPs are rooted not only in clinical expertise but also in the transformation of the healthcare system.

Implementation evidence from Health Sciences North demonstrates how APPs can be embedded in the stroke continuum [14]. Physiotherapists with specialized neurological training can effectively perform a comprehensive neurological assessment to triage patients for an appropriate level of rehabilitation in collaboration with neurologists and facilitate referrals to other interdisciplinary members [6, 7]. Such a com- prehensive assessment complements physician-led diagnostic imaging and accelerates decisions regarding rehabilitation intensity. In practice, APP-led triage may support discharge planning: patients with moderate to severe stroke im- pairments are allocated to inpatient rehabilitation, whereas stable patients with mild deficits transition to Early Supported Discharge with outpatient neurological rehabilitation. This reduces ALC days and aligns with the CSBPR’s call for timely, equitable access to rehabilitation [5–7 ].

Ontario’s Bill 179 reforms, currently under implementation, may expand the scope of APP to include ordering select diagnostics. If enacted, this could expedite care when patients present with new neurological symptoms, fractures, or subluxations, enabling them to collaborate with neurologists or physicians on imaging decisions while ensuring continuity and safety [15]. These roles do not replace physician expertise but allow physiotherapists to act decisively within their scope of practice, thereby reducing unnecessary delays.

From a system leadership perspective, the integration of APP roles may contribute to improved efficiency, equity, and sustainability [4, 12, 15]. For example, efficiency gains can arise from minimizing discharge delays, more timely expediting triage processes, and allowing physicians to focus on complex decision-making. Equity may be enhanced as APPs extend evidence- based practices to rural and underserved areas where neurologists are scarce. Sustainability can be supported through APP-led models that reduce hospital length of stay, decrease readmissions, and lower costs associated with alternate levels of care (ALC) [4].

Global evidence from other specialties supports the potential value of these innovations; systematic reviews in musculoskeletal and orthopedic care have consistently demonstrated that APP-led pathways achieve outcomes comparable to physician-led models [12, 13]. Although stroke rehabilitation presents unique complexities and interdisciplinary demands, cautiously adapting similar advanced practice roles could help alleviate system pressures, enhance patient access, and improve stroke outcomes.

Workforce optimization must also be a central consideration for leadership. Given Canada’s human resource shortages, APPs offer a scalable solution that enhances, rather than competes with, interprofessional collaboration. APPs provide a scalable solution that optimizes the entire team by allowing each profession to practice at the full extent of its expertise. Policy alignment further underscores this opportunity: Ontario’s Bill 179 reflects a willingness to modernize the scope of practice, whereas national strategies to re-engineer stroke systems emphasize interprofessional leadership [15].

The MOTIVE project exemplifies how Canadian innovation can operationalize these principles, demonstrating how APP integration reduces emergency department bottlenecks and improves access to rehabilitation [14]. For leaders, the critical question is not whether APP roles add value; they clearly do, but how to best embed, scale, and sustain them across provinces and health care networks.

The APP transcends mere role expansion and represents systemic innovation that aligns with the objectives of Canadian health policy. By operationalizing the four pillars of clinical practice, leadership, education, and research, APPs enhance functional assessment, expedite timely triage, facilitate early discharge, and mitigate system inefficiencies in the hospital. The APP augments the expertise of neurologists and other healthcare professionals, thereby ensuring that diagnostic and rehabilitation pathways are both integrated and centred on the patient. Institutions such as Health Sciences North and MOTIVE exemplify how Canadian entities spearhead global workforce innovation. For senior leaders, the integration of APPs into stroke pathways is not merely an optional enhancement but a strategic imperative to fulfill the dual objectives of improving patient outcomes and sustaining health system performance in the long term.