Outpatient and Community-Based Stroke Rehabilitation

More than 70 percent of patients who have experienced a stroke will require some form of rehabilitation by at least one rehabilitation discipline such as physical or occupational therapy or speech-language pathology. Stroke survivors who receive outpatient stroke rehabilitation have been found to have greater improvement in key outcomes compared with patients in the community who do not participate in outpatient rehabilitation.⁴⁷⁴ Community-based rehabilitation may be defined as care received once the patient has passed the acute stage and has transitioned back to their home and community environment. In smaller communities and rural and remote settings, access to outpatient and/or community rehabilitation presents a significant challenge.

There is a marked lack of outpatient and community-based rehabilitation resources and the health system must provide the following:

• Organized and accessible stroke care in communities.
• Increased number of experienced clinicians experienced practicing in outpatient and community rehabilitation.
• Timely access to stroke rehabilitation services in the community after discharge.
• Optimization of strategies to prevent the recurrence of stroke.
• Stroke rehabilitation support for caregivers.
• Long-term rehabilitation services widely available in nursing and continuing care facilities, and in outpatient and community programs.
• Increased use of telemedicine technologies to broaden access to outpatient rehabilitation services.

1. Percentage of stroke patients discharged to the community who receive a referral for ongoing rehabilitation before discharge from hospital (acute and/or inpatient rehabilitation) (core).
2. Median length of time between referral for outpatient rehabilitation to admission to a community rehabilitation program.
3. Frequency and duration of services provided by rehabilitation professionals in the community.
4. Change in functional status scores, using a standardized measurement tool, for stroke survivors engaged in community rehabilitation programs.
5. Length of time between referral for ongoing rehabilitation to commencement of therapy.
6. Percentage of persons with a diagnosis of stroke who receive outpatient therapy after an admission to hospital for a stroke event.
7. Percentage increase in Telehealth/Telestroke coverage to remote communities to support organized stroke care across the continuum and provide rehabilitation assessments and ongoing rehabilitation monitoring and management for stroke survivors in the community.
8. Number of stroke patients assessed by physiotherapy, occupational therapy, speech–language pathologists and social workers in the community.

Measurement notes

• Many performance measures require targeted data collection through audits of rehabilitation records and community program records. Documentation quality may create concerns about data availability and data quality.
• Information regarding frequency and duration of services by rehabilitation professionals requires a chart review or consistent use of reliable workload measurement tools that are implemented locally or regionally.
• Data availability regarding community programs varies considerably across programs, regions and provinces. Efforts should be made to introduce standard audit tools for collection of these data.

• Evidence-Based Review of Stroke Rehabilitation
• FIM ® Instrument
• Chedoke-McMaster Stroke Assessment
• Reintegration to Normal Living Index
• Assessment if Life Habits (LIFE-H)
• Stroke Impact Scale

Across healthcare domains, there have been progressive shifts in post acute care from hospitals to community settings. Options for specialized stroke care and rehabilitation may include outpatient services, day hospital programs, community-based or home-based rehabilitation services or other alternative services. While there are several options for ongoing rehabilitation environments, the location should be based on clients’ “medical status, function, social support, and access to care.”¹¹

Wade (2003) notes that there is currently no universally accepted definition of community rehabilitation.⁴⁷⁵As a result, the term can be used to describe almost any combination of therapeutic services provided outside of the hospital setting.

In a comparison of inpatient and outpatient stroke rehabilitation, Weiss and colleagues (2004) noted three disadvantages of inpatient rehabilitation that support outpatient and community-based therapy.⁴⁷⁶First, inpatient rehabilitation is very expensive, differing among countries and type of setting, with the cost ranging from US$235 to US$450 per patient per day.⁴⁷⁷ Second, in an inpatient setting patients are separated from their home and social context. Third, hospital staff emphasize the recovery of physical function, focus on discharge as the endpoint in rehabilitation and pay little attention to psychosocial issues that patients may experience after discharge.^478-480 It has been suggested that a more balanced approach between institution and community should be adopted and that home rehabilitation should be emphasized.⁴⁸¹

Outpatient and community-based stroke rehabilitation may be characterized by:²⁸

• a case coordination approach
• an interprofessional team of specialists in stroke care and rehabilitation
• services that are delivered in the most suitable environment based on client issues and strengths
• emphasis on client- and family-centred practice
• focus on clients’ re-engagement in and attainment of their desired life activities and roles
• enhancement of clients’ quality of life after stroke
• provision of intensive rehabilitation services where indicated to promote and assist in the achievement of client goals

Comparison of models of outpatient and community-based rehabilitation:

In a review of rehabilitation intervention factors that affect functional outcomes following stroke, Cifu and Stewart reported the results of three “moderate quality” randomized controlled trials examining the differences in functional outcomes between groups of patients who had received either home-based therapy or day hospital treatment.^345,483-485 These authors concluded that “overall, the available literature demonstrates that participation in outpatient, home health, and day rehabilitation programs is strongly associated with improved functional outcomes after stroke.”

In a systematic review of randomized controlled trials of stroke patients, the effects of therapy-based rehabilitation services targeted toward patients residing in the community were analyzed.⁴⁷⁴ Researchers identified and analyzed 14 randomized controlled trials of stroke patients (n = 1617 patients) residing in the community and receiving a therapy intervention and compared this to conventional or no care. Electronic databases were searched for the years 1967 to 2001 to ensure all potentially relevant trials were included in the review. Therapy services were defined as those provided by physiotherapy, occupational therapy or interprofessional staff working with patients primarily to improve task-oriented behaviour and hence increase activity and participation. The results indicated that therapy-based rehabilitation services reduced the odds of a poor outcome (Peto OR 0.72 95%CI 0.57–0.92; p = 0.009) and increased personal activity of daily living scores (standardized mean difference 0.14, 95% CI 0.02–0.25; p = 0.02). For every 100 stroke patients resident in the community receiving therapy-based rehabilitation services, 7 (95% CI 2–11) patients would be spared a poor outcome, assuming 37.5 percent would have had a poor outcome with no treatment. The authors concluded that therapy-based rehabilitation services targeted toward stroke patients living at home appear to improve independence in personal activities of daily living.

A meta-analysis using individual patient level data to evaluate the effect of outpatient occupational therapy interventions on the enhancement of personal activities of daily living and leisure activities, reported that patients receiving additional therapies had greater independence at the end of the intervention.⁴⁸⁶

For patients with moderate to severe strokes, specialized stroke care and rehabilitation result in improved functional outcomes. Enhanced stroke rehabilitation for these patients reduces length of hospital stay and increases the likelihood of discharge home.⁴⁸⁷ Community-based stroke rehabilitation services can enhance mobility and fitness, reduce or prevent the number and severity of falls, and enable clients to access relevant information about community programs and resources. ³⁵² In addition, occupational therapy can improve function in activities of daily living and extended activities of daily living. Such interventions may reduce the potential for hospital readmission as well as reducing healthcare and caregiver burden.

Benefits of aerobic exercise

A randomized controlled trial assigned older individuals (aged >50 years) with chronic stroke (n = 63) to either a community-based group exercise program or a control group.⁴⁸⁸ The intervention group received a one-hour fitness and mobility exercise session, three times a week for 19 weeks. The control group participated in a seated upper-extremity program. Pang and associates concluded that significant gains were made for the intervention group in cardiorespiratory fitness, mobility and paretic leg muscle strength in comparison to the control group.⁴⁸⁸ Pang and collaborators conducted a systematic review of aerobic exercise following stroke.⁴⁷² Seven randomized controlled trials were included which investigated effect of exercise for patients in the acute, subacute and chronic stages. The findings from this review suggested a significant benefit of exercise therapy regardless of the phase of recovery after stroke.

The Evidence-Based Review of Stroke Rehabilitation (EBRSR) examined the evidence related to cardiovascular and aerobic exercise following stroke and concluded that there was strong evidence to suggest that, “while cardiovascular training post stroke improves level of physical fitness and gait performance, it does not result in additional improvement in activities of daily living performance.”²⁸ A review suggested that, although limited, there is evidence that exercise trainability is feasible and safe in the early phases of stroke recovery when appropriate screenings and monitoring are employed.⁴⁷¹

Benefits of supportive conversation techniques: There is moderate evidence that Supported Conversation for Adults with Aphasia, a technique for training conversation partners, is associated with enhanced conversational skill for both the trained partner and the individual with aphasia. There is limited evidence, based on several small studies, that training conversation partners is associated with increased well-being and social participation in addition to positive communication outcomes.

Benefits of follow-up of dysphagia: There is moderate evidence that rehabilitative strategies for dysphagia are associated with enhanced swallowing function.³⁴⁴ An estimate of incidence of dysphagia after stroke is difficult to determine; however, it is thought that the range is anywhere between 23 percent and 50 percent. While there are few clinical trials investigating effective treatment for post-stroke dysphagia, keeping patients safe during the spontaneous recovery phase is important. Singh and Hamdy suggested that this could be achieved through compensatory strategies such as changing food consistencies, regulating bolus size, head rotation before swallowing and the chin tuck maneuver.³⁴⁴ There is no evidence to support the use of drug therapy for dysphagia treatment after stroke.

Pediatric stroke rehabilitation: Given the plasticity of the young brain, rehabilitation for children following stroke or transient ischemic attack can likely lead to vast improvements in long-term outcomes.^{473, 489} As with adult stroke patients, rehabilitation of children who have experienced a stroke or transient ischemic attack should involve a interprofessional team to ensure enhanced outcome and quality of life for the child and family.⁴¹ Neuropsychologic assessments document cognitive and language deficits and assist in planning educational programs after a child’s stroke. The rehabilitation team must be cognizant that the emotional well-being of the family following a stroke may influence recovery of the child.⁴¹