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The timeliness and intensity of inpatient rehabilitation interventions as well as the environment in which they are provided have been found to be significant predictors of patient outcomes post stroke. In particular, the establishment of stroke units as the optimal organization of care for patients in the acute and rehabilitation phases post stroke has garnered evidence for the importance of these factors in delivery of inpatient rehabilitation. A Cochrane systematic review and meta-analysis (Stroke Trialists’ Collaboration, 2013) included a total of 28 RCTs and quasi-randomized trials and compared stroke patients who received organized stroke unit care to those who received an alternative, less organized service. Patients receiving organized care benefited from this service in terms of being more likely to be alive, independent and living at home 1 year after stroke compared to patients receiving less organized care. The specifics of a stroke unit vary between sites, but are typified by a multidisciplinary team of stroke specialists that offer comprehensive and intensive services to patients, often with the involvement of the caregiver. Organized and comprehensive inpatient stroke rehabilitation services were also found to be beneficial in an observational study by Woo and colleagues (Woo et al., 2008), who compared the functional outcomes at discharge for patients receiving care from one of three inpatient rehabilitation facilities. The authors found that the patients who received care from the facility that offered multidisciplinary services (including weekly team meetings between care providers) and discharge planning/support had greater functional improvements per day over the course of their care compared to patients receiving care from the other two facilities (P<0.0001)(Woo et al., 2008).
Early mobilization post stroke is thought to improve recovery. Findings from three pilot studies by the AVERT Trial Collaboration Group demonstrated positive outcomes for individuals receiving very early mobilization. However, the much anticipated findings from the final report by the AVERT Trial Collaboration Group (2015) appear to counter this notion. This large parallel-group, single-blind, randomized controlled trial spanning 56 acute stroke units in five countries randomized patients (aged ≥18 years) with ischemic or hemorrhagic stroke to very early mobilization (mean 18.5 hours post stroke) or usual care (mean 22.4 hours post stroke). Treatment with tissue plasminogen activator was allowed. The primary outcome was a favorable outcome 3 months post stroke defined as a Modified Rankin Scale score of 0–2. The authors reported that fewer patients in the very early mobilization group had a favorable outcome compared to those in the usual care group (n=480 [46%] vs n=525 [50%]; adjusted odds ratio [OR] 0.73. p=0.004). Overall, 8% and 7% patients died in the very early mobilization versus usual care group, respectively (OR 1.34, p=0.113). Approximately 19% of patients in the very early mobilization group and 20% of those in the usual care group had a non-fatal serious adverse event, with no reduction in immobility-related complications with very early mobilization. Despite that early mobilization after stroke is recommended in many clinical practice guidelines worldwide, the findings from the AVERT trial demonstrate that it may be associated with a reduction in favourable outcomes and challenge this pre-existing notion.
Adequate intensity is another important element of successful inpatient rehabilitation interventions. An early review of the effects of intensive rehabilitation interventions on patient outcomes was completed by Kwakkel and colleagues in 1997 (Kwakkel et al., 1997). This review found positive effects, albeit small effects, of increased rehabilitation frequency on patient outcomes. Several studies since then have found a similar positive relationship between therapy intensity and patient outcomes (Wang et al., 2013; Horn et al., 2005; Foley et al., 2012); two retrospective cohort studies (Wang et al., 2013; Foley et al., 2012) and one prospective cohort study (Horn et al., 2005). Wang and colleagues assessed a cohort of 360 patients with stroke who were discharged from an inpatient rehabilitation facility and found that more than 3 hours of total combined therapy time from a physiotherapist (PT), occupational therapist (OT) and speech language pathologist (SLP) was associated with improved functional outcomes when compared to patients receiving less than 3 hours of therapy (Wang et al., 2013). When therapy time was assessed separately for each type of specialist, there was variability in the type of FIM® gain (i.e. activities of daily living (ADL), motor, cognitive or total) (Wang et al., 2013). Foley et al (2012) found that total (P<0.0001) and average daily PT (P=0.005) and OT (P<0.0001) therapy time was significantly correlated with total FIM® gain (Foley et al., 2012). However, in the multivariate model, only total OT time and total FIM® at admission were significant predictors of total FIM® gain (Foley et al., 2012). The prospective study, a larger cohort consisting of 830 patients, found that more intensive therapy (based on number of minutes) and more intensive therapy in the early stages (first therapy session) was associated with greater discharge FIM® scores. These findings applied to patients with both moderate and severe strokes (Horn et al., 2005).
A narrative review by Cifu and Stewart (1999) summarizes the importance of timing, organization and intensity of rehabilitation interventions after stroke, as well the importance of type of rehabilitation provided (Cifu & Stewart, 1999). Their review of 8 studies related to type of rehabilitation suggested that there is some evidence, although weak, for task specific therapy compared to general therapy in improving functional outcomes post stroke. A more recent systematic review by Legg and colleagues (2007) compiled literature assessing the effect of personal activities of daily living focused interventions for improvement in patient functioning (Legg et al., 2007). Findings from this study indicated that task focused therapy was effective in increasing patient independence (SMD 0.18; 95% CI 0.04 to 0.32; P=0.01); studies assessing task specific interventions in the inpatient setting (n=4) were excluded from this review (Legg et al., 2007). Evidence for task specific interventions in the inpatient rehabilitation setting are more limited, however, a pre-post study was conducted for a group based dressing retraining program in this setting by Christie and colleagues (Christie et al., 2011). From a sample of 119 patients admitted to an inpatient rehabilitation facility there were significant increases in upper and lower body dressing FIM® scores from admission to discharge (P=0.0001). Task specific and impairment based walking interventions were compared to usual care provided by a physiotherapist. Compared to the usual care group, patients in the two intervention groups experienced gains in walking speed, walking frequency, stroke impact scale (SIS) participation, SIS mobility, SIS ADLs/Instrumental ADLs, Fugl-Meyer score and confidence in balance (Nadeau et al., 2013). A cohort study by Chan et al. (2013) evaluated the effect of type of rehabilitation site used post stroke on functional outcomes. Stroke patients receiving different forms of post-acute care were assessed for function using the Activity Measure for Post Acute Care (AM-PAC), which tests for basic mobility, daily activities and applied cognition. The patients received either no treatment, home health care, inpatient rehabilitation facility (IRF), or skilled nursing facility (SNF). Patients who went to an IRF scored higher on the AM-PAC across all three domains compared to patients who went to a SNF and across one domain (cognition) compared to patients who received home health care, indicating that including an IRF in post acute stroke care may be beneficial in terms of making functional gains. However, it should be noted that patients who participated in an IRF did not differ in AM-PAC scores when compared to patients who were receiving no treatment.
Patients and caregivers often struggle and feel overwhelmed with the transition home after inpatient rehabilitation (Gustafsson & Bootle, 2012). A recent Cochrane review including 24 studies aimed to assess the impact of discharge planning interventions on the use of acute care services, patient and carer outcomes, and health care costs during transition in recovery (Shepperd et al., 2013). Due to the heterogeneity between studies, not all studies were included in individual meta-analyses for each outcome. A reduced length of stay in hospital (MD -0.91; 95% CI -1.55 to -0.27), and a decreased risk of readmission to hospital (RR 0.82; 95% CI 0.73 to 0.92) was found for patients in the discharge planning group compared to control group in a subset of 10 and 12 trials respectively (Shepperd et al., 2013). A detailed review of the challenges that exist at the transition point between hospital and community offers further research on this topic, highlighting the importance of continuity of care, patient self-management, communication between care provider and patient, and ensuring appropriate up to date communication of a patient’s medication regimen (Kripalani, Jackson, Schnipper, & Coleman, 2007). Recommended approaches to addressing these challenges include a pre-discharge planning meeting with the care team, patient and caregiver, the coordination of home visits, and implementing strategies to ensure patient educational resources and support are in place (Kripalani et al., 2007).