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Outpatient therapy is often required following discharge from acute and/or rehabilitation inpatient services to help patients continue to make gains towards their rehabilitation goals. Continuing therapy may take several forms, depending on resource availability and patient considerations and include such models as hospital-based “day” hospital programs, community-based programs, or home-based rehabilitation. There is strong evidence that any form of continuing rehabilitation therapy is superior to no additional therapy. The Outpatient Service Trialists (2003) identified 14 RCTs that included patients who were living at home prior to their stroke and whose stroke had occurred within the previous year. In 12 of these trials, participants were recruited from a hospital setting, while in the remaining two trails, participants were recruited from home. Patients were randomized to receive specialized outpatient therapy-based interventions or usual care (often no additional treatment). Service interventions examined included those that were home-based (n=2), day hospital or outpatient clinics (n=12). In these trials, provision of services included physiotherapy, occupational therapy services or interdisciplinary staff, aimed primarily at improving performance in activities of daily living (ADL). Therapy duration in these trials ranged from 5 weeks to 6 months. At the end of scheduled follow-up (mean of 3-12 months), outpatient therapy was associated with reduced odds of a poor outcome, defined as deterioration in ability to perform ADLs, dependency or institutionalization (OR=0.72 95% CI 0.57–0.92; p=0.009) and with small, but significantly greater improvements in ADL, extended ADL and mood scores compared with usual care (SMD=0.14, 95% CI 0.02–0.025; p=0.02, SMD=0.17, 95% CI 0.04–0.30; p=0.01 and SMD=0.11, 95% CI -0.04–0.26; p=0.02, respectively). The authors estimated that for every 100 persons with stroke in the community receiving therapy-based rehabilitation services, 7 (95% CI 2–11) patients would avoid a poor outcome, assuming 37.5% would have had a poor outcome with no treatment.
In terms of establishing the relative superiority of outpatient-based rehabilitation programs compared with continued inpatient services, the differences between service models appears minimal. In a systematic review (Hillier & Inglis-Jassiem 2010) including the results of 11 RCTs of patients who were discharged from inpatient rehabilitation to home following a stroke and who had been living in the community prior to the event, home-based therapy was associated with a 1-point mean difference in Barthel Index gain at 6–8 weeks following the intervention and a 4-point difference at 3–6 months, compared with hospital-based rehabilitation. By 6 months following treatment, there were no longer significant differences between groups. Overall, there were no significant differences in outcomes reported in 4 of the included trials, with some benefits noted in favour of home-based therapy reported in 7 trials (lower cost, less carer strain, lower readmission). No trials reported any benefits in favour of hospital-based rehabilitation. Lincoln et al. (2004) reported no significant differences between groups randomized to receive hospital-based care (outpatient or day hospital) compared with community stroke teams, staffed with multidisciplinary therapists in measures of ADLs, extended ADLs or Euro-QoL scores with the exception of the emotional support item, favouring the community stroke team group. Carer strain and satisfaction scores were higher in the CST group.
Early Supported Discharge
Early-supported discharge (ESD) is a form of rehabilitation designed to accelerate the transition from hospital to home through the provision of rehabilitation therapies delivered by an interdisciplinary team, in the community, as soon as possible following discharge. It is intended as a lower-cost alternative to a complete course of inpatient rehabilitation and is best suited for patients recovering from mild to moderate stroke. Key components of effective ESD programs include in-hospital and discharge planning, a case manager or ‘key worker’ based in the stroke unit who represents the essential link between the stroke unity and the outpatient care, guaranteeing continuity of care and enabling the smooth transition from the hospital to the home. Patients who participated in ESD programs have been shown to achieve similar outcomes compared with those who received a course of inpatient rehabilitation. The effectiveness of ESD programs following acute stroke has been evaluated most comprehensively by the Early Supported Discharge Trialists. In the most updated version of the review (Langhorne et al. 2017), the results from 17 RCTs were included. The majority of the trials evaluated ESD using a multidisciplinary team which, coordinated discharge from hospital, and provided rehabilitation and patient care at home. ESD services were associated with a reduction in the odds of death or dependency at end of scheduled follow-up after a median duration of follow-up of was 6 months (OR=0.80, 95% CI 0.67 to 0.95). The associated NNT per 100 patients was 5. The benefits were greatest among patients with mild-moderate disability. ESD services were also associated with slightly greater improvement in extended ADL performance (SMD= 0.17, 95% CI 0.04-0.30), greater patient satisfaction and a significantly shorter LOS (MD=-5.5, 95% CI -2.9 to -8.2 days).
Langhorne et al. (2005) reported additional patient level analysis from their original Cochrane review, which examined the effects of patient characteristics and differing levels of service provision (more coordinated v. less organized) on the outcome of death and dependency. The levels of service provision evaluated were: (1) early supported discharge team with coordination and delivery, whereby an interdisciplinary team coordinated discharge from hospital and post discharge care and provided rehabilitation therapies in the home; (2) early supported discharge team coordination, whereby discharge and immediate post-discharge plans were coordinated by an interdisciplinary care team, but rehabilitation therapies were provided by community-based agencies; and (3) no early supported discharge team coordination, whereby therapies were provided by uncoordinated community services or by healthcare volunteers. There was a reduction in the odds of a poor outcome for patients with a moderate initial stroke severity (BI 10-20), (OR= 0.73; 0.57-0.93), but not among patients with severe disability (BI< 9) and also among patients who received care from a coordinated multidisciplinary ESD team (0.70; 0.56- 0.88) compared to those without an ESD team. Based on the results of this study, it would appear that a select group of patients, with mild to moderately disabling stroke, receiving more coordinated ESD could achieve better outcomes compared to organized inpatient care on a stroke unit.
Home Exercise Programs
The effectiveness of home-based exercise programs for mobility improvement was recently the subject of a Cochrane review (Coupar et al. 2012). The results from four RCTs (n=166) examining home-based therapy program targeted at the upper limb were included. The effectiveness of therapy was compared with usual care in three studies (Duncan et al. 1998, 2003; Piron et al. 2009). The primary outcomes were performance on ADL and functional movement of the upper limb. The results were not significant for both outcomes (MD 2.85 95% CI -1.43–7.14 and MD 2.25 95% CI -0.24–4.73, respectively). No significant treatment effect was observed for secondary outcome measures as well (performance on extended ADL and upper limb motor impairment). The authors concluded that there was insufficient evidence to draw conclusions regarding the effectiveness of home-based therapy programs compared to usual care.
A number of individual trials, not included in the aforementioned Cochrane review, compared the effectiveness of home-based therapy with usual care, placebo, or no intervention. Nadeau et al. (2013) randomized 408 patients admitted to inpatient rehabilitation within 45 days of stroke, to receive locomotor training program (LTP), home exercise program (HEP), or standard care, for up to 12 to 16 weeks. Both LTP and HEP groups improved significantly in functional walking level and balance, compared to the usual therapy group, with no significant difference separating the two treatment groups. Harris et al. (2009) compared the effectiveness of home-based self-administered program to that of non-therapeutic education program and found significant treatment-associated effects on paretic upper limb performance, which was maintained for up to 3 months post treatment. In a RCT by Langhammer et al. (2007), the intensive exercise group demonstrated significantly greater improvements in motor assessment scale from admission to discharge from acute care, as well as from 6 months to 1 year post stroke, compared with the regular exercise group.