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Rehabilitation and Recovery following Stroke

3. Delivery of Inpatient Stroke Rehabilitation

6th Edition - 2019 UPDATED


Recommendations
  1. All patients with stroke should receive rehabilitation therapy as early as possible once they are medically stable and able to participate in active rehabilitation [Evidence Level A]. Refer to Section One, Box One: Eligibility and Criteria for Stroke Rehabilitation for more information.
  2. Early prolonged mobilization of patients within the first fewdaysafter a stroke, especially a severe stroke, is not recommended (Evidence Level A).
  3. Earlier mobilization may be reasonable for select patients with acute stroke (for instance people with more mild strokes or transient ischemic attack) but caution is advised, and clinical judgement should be used (Evidence Level C)
  4. Once deemed to be medically and neurologically stable, patients should receive a recommended three hours per day of direct task-specific therapy, five days a week, delivered by the interdisciplinary stroke team [Evidence Level C]; more therapy results in better outcomes [Evidence Level A].
  5. Individualized rehabilitation plans should include a patient-centered approach, shared decision-making, culturally appropriate and agreed-upon goals and preferences of the patient, family, caregivers and the healthcare team [Evidence Level C].
  6. Patients should receive rehabilitation therapies of appropriate intensity and duration, individually designed to meet their needs for optimal recovery and tolerance levels [Evidence Level A].
  7. Therapy should include repetitive and intense use of patient-valued tasks that challenge the patient to acquire the necessary skills needed to perform functional tasks and activities [Evidence Level A].
  8. The team should promote the practice and transfer of skills gained in therapy into the patient’s daily routine during inpatient stay [Evidence Level A] and continue after discharge to the community [Evidence Level C].
  9. A pre-transition (discharge to another setting) needs assessment should be conducted to ensure a smooth transition from rehabilitation back to the community [Evidence level B].
  10. Elements of transition planning may include:
    1. A home visit by a healthcare professional, ideally conducted before discharge, for patients where the stroke rehabilitation team and/or family have concerns regarding changes in functional, communication and/or cognitive abilities that may affect patient safety [Evidence Level C].
    2. Assessment of the safety of the patient’s home environment and the need for equipment and home modification [Evidence Level C].
    3. Caregiver education, training and access to resources to assist the patient with activities of daily living and increase the patient’s level of independence [Evidence Level B].
  11. Patients in stroke rehabilitation should be considered for referral to transition planners (such as stroke navigators) where these roles are available [Evidence Level B]. Refer to CSBPR Transitions and Community Participation following Stroke module for additional information.

 

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.

People with stroke, their families and caregivers state that they really appreciate being regularly informed about their care, including the assessment tools, timelines and decision-making regarding specialist referrals. 

Feedback received from people with stroke emphasized the need for support and guidance as they navigate the health care system following release from hospital.  Dedicated staff members, such as stroke navigators, was considered valuable by people with stroke and family members and perceived to aid the recovery process.  During the inpatient stay, people with stroke often feel the meetings regarding their care could be intimidating and stated that a dedicated staff member to support them  at this stage would be helpful and improve their experience.  They also note that having a peer mentor who has also experienced a stroke as an asset, specifically one that they are connected to from the beginning of their inpatient admission. 

An individualized approach that focused on self-management was important to people with stroke, including inclusion of family members into therapy sessions.  Teaching the family members and caregivers how to safely support and engage in exercise therapy is an important aspect of self management outside the hospital.  

People with stroke have reported that the return back home after inpatient rehabilitation can be overwhelming. One step in preparing for this transition could include meeting with appropriate therapists to support the physical, emotional and mental transition, anticipating potential challenges and planning ahead for solutions.

 
System Implications +-

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

  • Timely access to specialized, interdisciplinary stroke rehabilitation services, regardless of geographic location of the patients’ home community and the patient’s financial means.
  • A critical mass of trained healthcare providers functioning as a coordinated team during the rehabilitation period following stroke.
  • 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.
  • 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.
  • Communication strategies to facilitate the sharing of all information concerning the patient, including assessments, rehabilitation goals and results between healthcare providers and settings.
  • Access to all stroke rehabilitation services for patients who have communication limitations such as aphasia.
  • Optimization of strategies to prevent the recurrence of stroke through health promotion and education.
  • Stroke rehabilitation support initiatives for caregivers to increase patient/caregiver understanding of rehabilitation plans and improve adherence.
  • Processes for patients and caregivers to re-access the rehabilitation system as required. Financial barriers should not limit access to rehabilitation services.
  • 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 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. The potential benefits of early mobilization have been examined in several RCTs, with ambiguous results. One of the potential sources of variability, which may account for conflicting results, is the difference in the definitions of early mobilization. Early mobilization was defined as early as 12 hours following stroke to as long as 52 hours, while patients in the delayed group were mobilized from time periods ranging from 48 hours to 7 days. Small sample sizes (i.e. under- powered samples sizes) may also have contributed to null findings. In the Akerhus Early Mobilization in Stroke Study (AKEMIS), 65 patients were randomized to a very early mobilization (VEM) group or to a control group following ischemic or hemorrhagic stroke (Sundseth et al. 2012). Patients in both groups received standard stroke unit care. Patients in the VEM group were mobilized as soon as possible (within 24 hours post stroke), while patients in the control group were mobilized between 24 and 48 hours. The median time to first mobilization from stroke onset was significantly shorter for patients in the VEM group (13.1 vs. 33.3 hrs, p<0.001); however, there were no significant differences between groups on any of the outcomes of interest, including poor outcome at 3 months (mRS score of 3-6), death or dependency, dependency, or number of complications at 3 months. Diserens et al. (2011) randomized 50 patients with ischemic stroke to either an “early mobilization” group who were mobilized out of bed after 52 hours or to a “delayed mobilization” group where patients were mobilized after 7 days. While there were significantly fewer severe complications among patients in the early mobilization group (8% vs. 47%, p < 0.006), there were no significant differences between groups in the numbers of minor complications, neurological deficits, or blood flow modifications.

Several publications are associated with the A Very Early Rehabilitation Trial for Stroke (AVERT) trial. The safety and feasibility of an early mobilization intervention was first established by Bernhardt et al. (2008) in Phase I, in which 71 patients were randomized to receive either very early and frequent mobilization (upright, out of bed, activity – 2x/day, for 6 days a week until discharge beginning within 24 hours of stroke), or usual multi-disciplinary stroke team care.  There was a non-significant increase in the number of patient deaths in the early mobilization group at 3 months (21% vs. 9%, absolute risk difference = 12.0%, 95% CI, 4.3% to 28.2%, p=0.20). After adjusting for age, baseline NIHSS score and premorbid mRS score, the odds of experiencing a good outcome were significantly higher at 12 months for the very early mobilization (VEM) group (OR= 8.15, 95% CI 1.61-41.2, p<0.01), although not at 3 or 6 months. In AVERT II, examining medical complications associated with VEM, Sorbello et al. (2009) reported there were no differences in the total number of complications between groups. Severe complications or stroke-related complications occurred in 91 patients in the control group compared with 87 in the VEM group. Cumming et al. (2011) reported that patients in the VEM group returned to walking significantly sooner than patients in the standard care group (median of 3.5 vs. 7.0 days, p=0.032). While there were no differences between groups in proportions of patients who were independent in ADL, or who experienced a good outcome at either 3 or 12 months, VEM group assignment was a significant, independent predictor of independence in ADL at 3 months and of good outcome at both 3 and 12 months. Pooling the results from both the AVERT and VERITAS trials, which used similar protocols for early mobilization, Craig et al. (2010) reported that, compared with patients receiving standard care, patients in the VEM group were more likely to be independent in activities of daily living at 3 months (OR= 4.41, 95% CI 1.36-14.32), and were less likely to experience immobility related complications (OR= 0.20, 95%CI 0.10-0.70). The most recent replication of AVERT examined the effectiveness of a protocol of more intensive, early out-of-bed activity.  Bernhardt et al. (2015) 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, the primary outcome, defined as mRS 0-2, at 3 months (46% vs. 50%; adjusted 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, time to achieve assisted- free walking over 50m, proportion of patients able to walk unassisted at 3 months, death or serious adverse events), nor were any interactions identified based on pre-specified sub groups for the primary outcome (age, stroke type, stroke severity, administration of t-PA, or geographical region of recruitment). Further analysis of AVERT data (Bernhardt et al. 2016), 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.

Finally, in a recent systematic review (Li et al. 2018), the results from 6 RCTs including AVERT and AKEMIS, were pooled. At 3 months, there was no significant difference between groups in the proportion of patients with an mRS score of 0-2, although early mobilization was associated with higher Barthel Index scores at 3 months (SMD=0.66, 95% CI 0.0-1.31) and a significantly reduced LOS (WMD=-1.97, 95% CI -2.63 to -1.32).

Intensity

Adequate intensity of therapy is another important element associated with successful inpatient rehabilitation outcomes. An early systematic review of the effects of intensive rehabilitation interventions (Kwakkel et al. 1997) suggested that greater treatment intensity was associated with significantly higher ADL scores (ES=0.28, 95% CI 0.16-0.41), and better neuromuscular outcomes (ES=0.37, 95% CI 0.13-0.62), but not better functional outcome (ES=0.10, 95% CI -0.10 to 0.30). Several studies since then have found a similar positive relationship between therapy intensity and patient outcomes. Wang et al. (2013) reviewed the charts of 360 patients who were discharged from an inpatient rehabilitation facility following a stroke and found that more than 3 hours of daily 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. Controlling for age, sex, comorbidities, and total baseline motor and cognition scores, patients who received a total therapy time of <3.0 hours per day had significantly lower total FIM gains compared with those treated for ≥3.0 hours per day. In another retrospective study, Foley et al (2012) found that in a multivariate model, including daily time spent in physiotherapy, occupational therapy (OT) and speech-language pathology, only total OT time and total FIM at admission were significant predictors of total FIM gain. The prospective study, Post-Stroke Rehabilitation Outcomes Project (Horn et al. 2005), included a cohort of 830 patients with moderately, or severely-disabling stroke. The authors found that more intensive therapy (based on number of minutes of therapy per day) and more intensive therapy in the early stages (first therapy session) were associated with higher discharge FIM scores. These findings applied to patients with both moderate and severe strokes.

In a more recent systematic review 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, Schneider et al. (2016) reported that the immediate effect of additional rehabilitation was significantly improved measures of activity (SMD=0.39, 95% CI 0.07-0.71, p=0.02). Small increases in additional therapy were not associated with significant improvement in measures of activity, while large increases were.

 

Stroke Resources