3. Delivery of Inpatient Stroke Rehabilitation

To obtain maximum benefit from inpatient stroke rehabilitation, several essential elements are required. These elements include adequate intensity of therapy, task-oriented training, excellent team coordination and early discharge planning. Early mobilization and intensive rehabilitation following a stroke are both important elements for promoting optimal recovery and reducing long-term disability. Initiating movement and physical activity as soon as medically safe helps to prevent complications, while intensive rehabilitation improves the likelihood of independence in mobility, and self-care. Other essential elements of rehabilitation include a highly coordinated, interdisciplinary specialized team, which meets regularly to discuss rehabilitation goals and progress, and begins transition planning early in the process. 

Individuals with stroke, their families and caregivers really appreciate being regularly informed about their care, including the assessment tools, timelines and decision-making regarding specialist referrals, and the need for support and guidance as they navigate the healthcare system following release from hospital, including psychosocial support. This includes establishing rapport and developing trust. They highly valued person-centred care and appreciated when communication and discussions on rehabilitation plans and goals including family members and caregivers, when consent is provided. The importance of flexibility and reassessment and updating the rehabilitation plan throughout the rehabilitation journey is a critical element to reflect changes in needs and goals, and this has to be balanced with the burden of repetitive assessments on an individual. Delivery of rehabilitation therapy should take a wholistic approach that also includes “invisible” stroke impairments such as cognitive changes, fatigue, mental health status, pain, visual and perceptual changes, as these will contribute to optimized recovery. The current constraints of the system on frequency and duration of rehabilitation services also impact outcomes and dedicated staff members, such as stroke navigators, was considered valuable by individuals with stroke and family members and perceived to aid the recovery process. They also valued a regular rehabilitation schedule with time for appropriate rest.  Delivery of rehabilitation therapy also includes individuals with stroke being provided exercises they could continue on the weekend should rehabilitation sessions be unavailable, and the benefit of access to specialized rehabilitation equipment to support exercises and recovery. 

System indicators:

1. Median length of time from stroke admission to an acute care hospital to assessment of rehabilitation potential by a rehabilitation healthcare professional.
2. Median length of time from stroke onset to stroke rehabilitation referral.

Process indicators:

3. Proportion of individuals with stroke requiring readmission to an acute care hospital for stroke-related causes during inpatient rehabilitation. 
4. Median length of time spent on a stroke rehabilitation unit during inpatient rehabilitation.
5. Median number of hours of direct therapy for each type of service received while in inpatient rehabilitation.
6. Number of individuals with stroke screened for cognitive impairment using valid screening tool during inpatient rehabilitation.
7. Number of individuals with stroke screened for depression using valid screening tool during inpatient rehabilitation.
8. Median number of days spent in active rehabilitation (i.e., length of stay less days unable to participate due to service interruptions, such as illness or short-term readmission to acute care).
9. Median number of days spent waiting for transfer to an inpatient rehabilitation setting (i.e. from the time a patient is ready for rehabilitation to the time of admission to inpatient rehabilitation).
10. Median number of days spent in alternate level of care or inpatient rehabilitation while waiting for return to home or placement in a residential or long-term care setting.

Patient-oriented indicators:

11. Change (improvement) in functional status scores using a standardized assessment tool from admission to an inpatient rehabilitation program to discharge (e.g., FIM® Instrument, AlphaFIM®, Modified Rankin Scale).
12. Time from stroke onset to mobilization: e.g., sitting, standing upright, and walking with or without assistance.
13. Time from stroke onset to independence in feeding, dressing, grooming, toileting and bathing and other self-care. 
14. Final discharge disposition for individuals with stroke following inpatient rehabilitation: proportion discharged to their original place of residence, proportion discharged to a long-term care facility or nursing home, proportion discharged to supportive housing or assisted living.

Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices or Heart & Stroke. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Healthcare Provider Information

• Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery and Community Participation following Stroke, Part Two: Delivery of Stroke Rehabilitation to Optimize Functional Recovery; and, Part Three: Optimizing Activity and Community Participation following Stroke, Update 2025
• Stroke Engine: FIM® Instrument
• UDS: AlphaFIM® Instrument
• Stroke Engine: Modified Rankin Scale
• Evidence-Based Review of Stroke Rehabilitation: Managing the Stroke Rehabilitation Triage Process
• Stroke Engine
  
   

Resources for Individuals with Stroke, Families and Caregivers

• Heart & Stroke: Signs of Stroke
• Heart & Stroke: FAST Signs of Stroke…what are the other signs?
• Heart & Stroke: Your Stroke Journey
• Heart & Stroke: Post-Stroke Checklist
• Heart & Stroke: Rehabilitation and Recovery Infographic
• Heart & Stroke: Transitions and Community Participation Infographic
• Heart & Stroke: Enabling Self Management Following Stroke Checklist
• Heart & Stroke: Virtual Healthcare Checklist
• Heart & Stroke: Recovery and Support
• Heart & Stroke: Online and Peer Support
• Heart & Stroke: Services and Resources Direct
• Aphasia Institute 
• Stroke Engine

Evidence Table and Reference List

Early mobilization

Early mobilization post stroke is intended to reduce the risk of medical complications including deep vein thrombosis, pressure sores, painful shoulders, and respiratory infections. While the potential benefits of early mobilization were examined in several smaller randomized controlled trials (RCTs),^20-22 the largest and most definitive trial was A Very Early Rehabilitation Trial for Stroke (AVERT) trial. Bernhardt et al. ²³ randomized 2,104 adults (1:1) to receive early mobilization, a task-specific intervention focused on sitting, standing, and walking activity, initiated within 24 hours of stroke onset, or to usual care for 14 days, or until hospital discharge. The median time to first mobilization was significantly earlier in the early mobilization group (18.5 vs. 22.4 hrs, p<0.0001). Patients in the early mobilization group received significantly more out of bed sessions (median of 6.5 vs. 3, p<0.0001) and received more daily therapy (31 vs. 10 min, p<0.0001). However, significantly fewer patients in the early mobilization group had a favourable outcome (modified Rankin score [mRS] 0-2), the primary outcome, at 3 months (46% vs. 50%; adjusted odds ratio [OR]=0.73, 95% CI 0.59-0.90, p=0.004). There were no significant differences between groups for any of the secondary outcomes (shift in distribution of mRS scores, time to achieve assisted-free walking over 50 metres, proportion of patients able to walk unassisted at 3 months, death or serious adverse events), nor were any interactions identified based on pre-specified subgroups for the primary outcome (age, stroke type, stroke severity, administration of tissue plasminogen activator, or geographical region of recruitment). 

Further analysis of AVERT data,²⁴ controlling for age and stroke severity, suggested that shorter, more frequent mobilization early after acute stroke was associated with improved odds of favorable outcome at 3 months, while increased amount (minutes per day) of mobilization reduced the odds of a good outcome. Additional analysis from AVERT indicated that very early mobilization (VEM) was associated with an increased risk of early mortality. ²⁵ After adjustment for age and stroke severity, the odds of 14-day mortality were significantly higher in the early mobilization group (adj OR=1.76, 95% CI 1.06–2.92). In a recent systematic review Rethnam et al.²⁶ included the results from AVERT and 5 other trials. Significantly fewer patients in the VEM group had a favourable outcome (mRS 0-2) at 3 months (48% vs. 52%; adj OR=0.75, 95% CI 0.62–0.92), with no increased risk of death (7% vs. 7%, adj OR=1.46, 95% CI 0.92–2.31). In contrast to these findings, a 2018 Cochrane review, ²⁷ which included the results from 9 RCTs of 2,958 patients who had sustained an acute stroke, reported no significant difference between groups (early mobilization, starting a median of 18.5 hours after admission vs. usual care, with mobilization initiated a median of 33 hours after admission) in the odds of the primary outcome (death, dependency or institutionalization at 3 months), with 51% of patients in the early mobilization group achieving the primary outcome vs. 49% in the usual care group (OR= 1.08, 95% CI 0.92 to 1.26). Li et al. ²⁸ also reported that at 3 months, there was no significant difference between groups in the proportion of patients with an mRS score of 0-2 (relative risk [RR]=0.80; 95% CI 0.58-1.02), in a systematic review that included the results from 6 RCTs. Early mobilization was associated with higher Barthel Index scores at 3 months (standardized mean difference [SMD]=0.66, 95% CI 0.0-1.31) and a significantly reduced length of stay [LOS] (weighted mean difference [WMD]=-1.97, 95% CI -2.63 to -1.32). 

Intensity

Greater amounts of rehabilitation therapies have been associated with significantly greater improvements in activities of daily living (ADL). In early systematic, Kwakkel et al. ²⁹ including the results from 9 RCTs, reported that greater amounts of physical therapy (PT) and/or occupation therapy (OT) were associated with significantly higher ADL scores (Hedges’ g=0.28, 95% CI 0.16-0.41), and better neuromuscular outcomes (Hedges’ g =0.37, 95% CI 0.13-0.62). In one of the trials included in this review rehabilitation therapy was compared with no treatment, likely leading to an overestimation of the benefit. Lohse et al. ³⁰ included 30 RCTs in a systematic review & meta-regression and reported that in studies where participants received more therapy, functional outcome was improved beyond control groups that received less (Hedges’ g=0.35; 95% CI 0.26–0.45). Mean scheduled therapy time was significantly longer in treatment groups compared with control groups (57.4 vs. 24.1 hours, Δ=33.3 hours). Schneider et al.³¹ included the results of 14 studies of 954 participants, most of whom were recovering from stroke. Outcomes of trials comparing additional dose of rehabilitation interventions vs. standard amount of the same rehabilitation interventions, aimed at improving upper or lower activity, or both, were pooled. Additional rehabilitation was associated with significantly greater improvements in standardized measures of upper and lower extremity activity (SMD=0.39, 95% CI 0.07-0.71, p=0.02), with a larger increase in additional therapy (≥100%) having a greater effect (SMD=0.59, 95% CI 0.23-0.94, p=0.001). Results from receiver-operator characteristic curve analysis indicated that an increase of ≥240% of standard dose of therapy would be required to ensure true benefit to result in an improvement in activity. 

In a recent 2021 Cochrane review, Clark et al.³² examined the effect of more time spent in the same type of rehabilitation on activity measures post stroke, including the results of 21 RCTs (n=1,412). Most of the participants had received therapy within 6 months of stroke onset. Different amounts of the same type of OT and/or PT provided daily, were compared. The difference in total time between control and intervention groups ranged widely from 186 to 6,160 minutes with a median difference was 840 minutes, depending on the number of weeks or months therapy was provided. At the end of the active intervention period, more time spent in rehabilitation therapies was not associated with significant improvement in ADL performance compared with less time (SMD=0.13, 95% CI -0.02 to 0.28; 19 trials, GRADE: very low), nor with activity measures of the upper (SMD=0.09, 95% CI -0.11 to 0.29, 18 trials, GRADE: very low) or lower limb (SMD=0.25, 95% CI -0.03 to 0.53; 5 trials, GRADE: low). However, in subgroup analysis of studies with a larger difference in total amount of therapy between treatment arm, there was a significant benefit of more therapy in ADL performance (SMD=0.40, 95% CI 0.14 to 0.66).

Task-Specific Training

Task-specific training involves the repeated practice of functional tasks, which combines the elements of intensity of practice and functional relevance. The tasks should be challenging and progressively adapted and should involve active participation. French et al.³³ included the results from 11 RCTs that included an upper limb rehabilitation component. Repetitive task-specific training was associated with a small treatment effect on arm and hand function, assessed post intervention. (SMD=0.25, 95% CI 0.01 to 0.49, and SMD=0.25, 95% CI 0.00 to 0.51, respectively). The benefits appeared to persist up to 6 months follow-up. Patients treated from 16 days to 6 months post stroke derived the greatest value.

Sex & Gender Considerations

There is no research focused specifically on sex and gender differences on the topic of early mobilization; however, in the patient-level meta-analysis mentioned earlier,²⁶ sex was not found to be an effect size modifier in subgroup analyses of the primary outcome (favourable outcome at 3 months).

With respect to intensity of rehabilitation therapies, a recent publication by MacDonald et al.³⁴ used administrative data sets including 12,770 patients to examine the differences between the sexes with respect to the amount of therapy received during inpatient rehabilitation. The average length of hospital stay (LOS) was approximately 30 days, with no significant differences between the sexes. The mean admission FIM score was significantly higher for men (72.77 vs. 69.91, p<0.0001). The mean daily provision of therapy was significantly higher for men (75.86 min/day vs. 73.33 min/day). In adjusted analysis, the difference remained after age stratification, with men aged <60 years and 60-79 years receiving more therapy per day by 3.34 and 1.37 minutes/day, respectively. The difference between men and women aged ≥80 years was not significant (1.15 min/day). Mean rehabilitation intensity, the primary outcome, defined as minutes/ per day of direct therapy provided to a patient/ rehabilitation LOS, was also significantly higher for men (29.76 vs. 29.69, p<0.0001). While these differences are statistically significant, their impact on rehabilitation outcome is unclear; however, in an earlier, and related publication MacDonald et al.³⁵ reported there were no significant differences between the sexes in the discharge FIM scores. Mean length of hospital stay was 2% shorter for women and women were more likely to be discharged home (adjusted odds ratio [OR]= 1.14, 95% CI 1.05 to 1.24).