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Stroke Rehabilitation

3. Delivery of Inpatient Stroke Rehabilitation

February 2016 - 2016 UPDATE


The Canadian Stroke Best Practice Recommendations for Stroke Rehabilitation, 5th Edition (2015) is published in the International Journal of Stroke (IJS) and available freely online. To access the specific recommendations for Delivery of Inpatient Stroke Rehabilitation, and all other sections of the Stroke Rehabilitation recommendations, please click on this URL which will take you to the recommendations online in the IJS.

For the French version of these recommendations, open the appendix at this link.

All other supporting information, including performance measures, implementation resources, evidence summaries and references, remain available through this website, and not through the IJS.  Please click on the appropriate sections on our website below for this additional content.

Rationale +-

In order to obtain maximum benefit from inpatient stroke rehabilitation, a number of essential elements are required. These elements include adequate intensity of therapy, task-oriented training, excellent team coordination and early discharge planning. Both animal and human research suggests that the earlier rehabilitation starts, the better the outcome. Early, intensive rehabilitation care for patients in both the acute and subacute stage of stroke helps to improve arm and leg motor recovery, language and communication function, which in turn improves mobility, independence in self-care and participation in leisure activities. It is important that the rehabilitation therapies be tailored to the tasks that need to be retrained and developed, as well as to the activities of the patient’s choice and to their social roles. The need for a highly-coordinated, specialized team, who meet regularly to discuss the rehabilitation goals and progress, is also vital. Early discharge planning, including a home assessment and caregiver training, support and education, is required to identify and remove potential barriers to discharge and facilitate efficient transition back to the community.

System Implications +-

Working together to achieve optimal functional outcomes after stroke requires the health system and organizations to ensure:

  1. Timely access to specialized, interprofessional stroke rehabilitation services, regardless of geographic location of the patients’ home community and the patient’s financial means.
  2. A critical mass of trained healthcare providers functioning as a coordinated interprofessional team during the rehabilitation period following stroke.
  3. Adequate clinician resources to provide the recommended intensity of individualized therapies for stroke patients. Current estimates suggest the ratio of patients to therapists should be no more than 6:1 in order to achieve these targets.
  4. Establishment of protocols and partnerships between inpatient rehabilitation and community care providers to ensure safe and efficient transitions between hospital and community. Particular considerations should be made for patients residing in more rural or remote locations.
  5. Communication strategies to facilitate the sharing of all information concerning the patient, including assessments, rehabilitation goals and results between healthcare providers and settings.
  6. Access to all stroke rehabilitation services for patients who have communication limitations such as aphasia.
  7. Optimization of strategies to prevent the recurrence of stroke through health promotion and education.
  8. Stroke rehabilitation support initiatives for caregivers to increase patient/caregiver understanding of rehabilitation plans and improve adherence.
  9. Processes for patients and caregivers to re-access the rehabilitation system as required. Financial barriers should not limit access to rehabilitation services.
  10. All rehabilitation hospital services have mechanisms established to contribute to the CIHI National Rehabilitation Reporting System.
Performance Measures +-
  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.
  3. Median length of time from stroke rehabilitation referral to and admission to stroke inpatient rehabilitation.
  4. Percentage of stroke patients who are discharged from acute care without rehabilitation referrals in place.
  5. Number or percentage of patients admitted to a stroke unit — either a combined acute care and rehabilitation unit or a rehabilitation stroke unit in an inpatient rehabilitation facility — at any time during their hospital stay (acute and/or rehabilitation) (core).
  6. Final discharge disposition for stroke patients following inpatient rehabilitation: percentage discharged to their original place of residence, percentage discharged to a long-term care facility or nursing home, percentage discharged to supportive housing or assisted living (core).
  7. Percentage of patients requiring readmission to an acute care hospital for stroke-related causes (core).
  8. Median length of time spent on a stroke rehabilitation unit during inpatient rehabilitation.
  9. Average 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).
  10. 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).
  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. Median number of hours of direct therapy for each type of service received while in inpatient rehabilitation.
  13. Total number of days spent in inpatient rehabilitation, by stroke type.
  14. Number of patients screened for cognitive impairment using valid screening tool during inpatient rehabilitation.
  15. Number of patients screened for depression using valid screening tool during inpatient rehabilitation.
  16. Time from stroke onset to mobilization: sitting, standing upright, and walking with or without assistance.
  17. Time from stroke onset to independence in feeding, dressing, grooming, toileting and bathing and other self-care.
  18. 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.

Measurement notes

  • Some acute care hospitals provide combined acute and rehabilitation stroke units, where patients progress to being ready to start rehabilitation, and may not actually move beds, or change locations. This information could be found in patient records through primary chart audit.
  • Many performance measures require primary chart audit of inpatient rehabilitation records. Quality of documentation (good or poor) by rehabilitation staff will impact validity of these measures.
  • The Canadian Institute for Health Information has a database known as the National Rehabilitation Reporting System. This database includes data on inpatient rehabilitation encounters to designated rehabilitation beds. It is mandated in some provinces to submit data to the National Rehabilitation Reporting System; in other provinces, it is optional. The National Rehabilitation Reporting System (NRS) has information on an estimated 80% of all inpatient rehabilitation encounters in Canada and can distinguish stroke cases from other rehabilitation patients by diagnosis.
  • Duration or intensity of services by rehabilitation professionals requires a chart review or consistent use of reliable workload measurement tools implemented locally or regionally.
  • For performance measure 2, efforts should be made to collect information on reasons for delay, if any, in admission to inpatient rehabilitation from acute care. These may include such issues as bed availability, patient health status and other aspects of the referral and transfer process. This information may provide direction on areas to target quality improvement initiatives.
  • Workload measurement systems are a key source of data and information on intensity and frequency of services, but these are not consistently or widely implemented in Canada. Use of such systems should be encouraged in addition to the NRS.
  • Performance measures 8 and 9 can be combined to calculate a FIM® efficiency value: Change in FIM® score from admission to discharge/total days in stroke rehabilitation.
Summary of the Evidence +-

Evidence Table 3: Delivery of Inpatient Stroke Rehabilitation

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).

Stroke Resources