THE PROVISION OF REHABILITATION CARE

Organization of Post-Acute Stroke Rehabilitation Care

BACKGROUND

Stroke rehabilitation begins during the acute hospitalization, as soon as the diagnosis of stroke is established and life-threatening problems are under control. The highest priorities during this early phase are to prevent a recurrent stroke and complications, ensure proper management of general health functions, mobilize the patient, encourage resumption of self-care activities, and provide emotional support to the patient and family. Following the "acute" phase of stroke care, the focus of care turns to assessment and recovery of any residual physical and cognitive deficits, as well as compensation for residual impairment.

Over the years, the organization and delivery of stroke care has taken many forms. With the growth of physical medicine, occupational therapy, and physical therapy, varying therapeutics and treatment settings have evolved. Assessment of the effect of stroke care organization and settings is difficult due to the extreme variability of organizational settings. For example, on the one extreme, rehabilitation services can be provided in an outpatient setting-one hour per day, three days per week, by one therapist. At the other end of the structural continuum, rehabilitation services can be provided in a rehabilitation hospital setting-five hours per day, seven days per week, by a team made up of several clinicians.

The Agency for Healthcare Policy and Research Guideline for Post-Stroke Rehabilitation (AHCPR, 1995) has concluded, "A considerable body of evidence, mainly from countries in Western Europe, indicates that better clinical outcomes are achieved when patients with acute stroke are treated in a setting that provides coordinated, multidisciplinary stroke-related evaluation and services. Skilled staff, better organization of services, and earlier implementation of rehabilitation interventions appear to be important components."

The VA/DoD Working Group reviewed several studies and trials addressing the question of organization of care. Although the reviews and trials make it clear that rehabilitation is a dominant component of organized services, it is not possible to specify precise standards and protocols for specific types of specialized units for stroke patients. Their limitations stem from imperfections in the way the reviews and trials controlled for differences in the structure and content of multidisciplinary/standard care programs, the period defined as acute post-stroke care, staff experience and staff mix, and patient needs for rehabilitation therapy (i.e., stroke severity and type).

RECOMMENDATIONS

1. Better clinical outcomes are achieved when post-acute stroke patients, who are candidates for rehabilitation, receive coordinated, multidisciplinary evaluation and intervention.
• Post-acute stroke care should be delivered in a setting where rehabilitation care is formally coordinated and organized.
• Post-acute care should be delivered by a variety of treatment disciplines, experienced in providing post-stroke care, to ensure consistency and reduce the risk of complications.
• The multidisciplinary team may consist of a physician, nurse, physical therapist, occupational therapist, kinesiotherapist, speech and language pathologist, psychologist, recreational therapist, patient, and family/caregivers.
2. If an organized rehabilitation team is not available in the facility, patients with moderate or severe symptoms should be offered a referral to a facility with such a team, or a physician or rehabilitation specialist with some experience in stroke should be involved in the patient's care.
3. An organized team approach should also be continued in coordinating the outpatient or home-based rehabilitation care. Community resources for stroke rehabilitation services that include an organized team should be identified and provided to patients and families/caregivers.

DISCUSSION
The evidence for both acute and post-acute (rehabilitation) stroke care suggests that organized care for post-stroke patients is worthwhile to achieve optimal outcomes, and the outcomes measured are substantial (i.e., mortality and dependency and return to community living). In several randomized controlled trials, stroke unit care or organized inpatient multidisciplinary rehabilitation showed improved outcome compared to "standard" care.

Studies of Care in the Acute and Post-Acute Rehabilitation Settings

The Stroke Unit Trialists' Collaboration review (updated in 2001) concluded, "Patients receiving organized inpatient stroke unit care were more likely to survive, regain independence, and return home than those receiving a less organized service." The Cochrane review further concluded, "Acute stroke patients should be offered organized inpatient stroke unit care, typically provided by a coordinated multidisciplinary team operating within a discrete stroke ward that can offer a substantial period of rehabilitation, if required. There are no firm grounds for restricting access according to a patient's age, sex, or stroke severity." However, the reviewers also cautioned that there could be a wide range of results because of varying outcome rates and confidence intervals. The most recent update of this systematic review involved investigators from nearly all the trials, to try to determine why stroke unit care was superior. They found little evidence of differences in staff numbers or mix, although a tendency was shown for assessment and therapy to begin earlier in organized settings.

Evans and colleagues (1995) compared the effectiveness of multidisciplinary inpatient physical rehabilitation programs with standard medical care. Based on 11 studies, the researchers found that rehabilitation services improved short-term survival, functional ability, and most independent discharge location. However, they did not find long-term benefits. The authors suggested, "The lack of long-term benefits of short-term rehabilitation may suggest that therapy should be extended to home or sub-acute care settings, rather than being discontinued at discharge."

Cifu and Stewart (1999) reviewed studies that investigated the type of inpatient rehabilitation (interdisciplinary versus multidisciplinary) as a predictor of outcome following a stroke. The authors concluded that an interdisciplinary setting (i.e., services "provided by diverse professionals who constitute a team that communicates regularly and uses its varying expertise to work toward common goals") is strongly related to improved outcome. A specialized multidisciplinary team (which usually includes similar professionals as an interdisciplinary team, but with less consistent "regular communication and common goal orientation") appears to be less effective if it lacks the organizational structure provided by regular communication. Other predictors for improved outcome at hospital discharge and follow-up were increased functional skills on admission to rehabilitation and early initiation of rehabilitation services. Specialized therapy and a greater intensity of therapy services had "a weak relationship with improved functional outcome at hospital discharge and follow-up" and the authors observed that the "current literature is too limited to allow an assessment of the relationship of specific types of non-inpatient rehabilitation services after stroke and functional outcome."

Indreavik et al. (1997-1999) examined the long-term benefits for a combined acute and rehabilitation stroke unit in Norway. Starting with 220 patients, the researchers compared outcomes for surviving patients at 5 years (n=77) and 10 years (n=31) after discharge. Differences in treatment were confined to the first six weeks of treatment. Reportedly, there were no differences in the severity of the strokes in the control and experimental groups. Quality of life was measured by the Frenchay Activities Index (FAI), Nottingham Health Profile (NHP) (81 percent of patients), and a visual analog scale (86 percent of patients). Functional status was measured using the Barthel Index (BI). More patients in the stroke unit group had an FAI score >30 than did patients in the general ward. The FAI and visual analog scale scores favored stroke unit patients (34.2 versus 27.2; P=0.01 for FAI and 72.8 versus 50.7 mm; P=0.002 for the visual analog scale). Patients in both groups who had better functional status measured by the BI also had higher quality of life scores. Acute care in a stroke unit improved quality of life for patients at 5 years (Indreavik et al., 1998). The researchers also studied survival, proportion of patients living at home, and functional status measured by the BI. Intention-to-treat analysis was used. At 5 years, the Kaplan-Meier survival curve analysis showed that survival was higher in the stroke unit group than in the ward care group (41 versus 29 percent; P=0.04). More patients who received stroke unit care were living at home (P=0.006), were independent (BI score >95; P=0.004), or were at least partly independent (BI score >60; P=0.006) (Indreavik et al., 1999). The groups did not differ for help or support received at home. Stroke unit care improved long-term survival and functional status and increased the number of patients living at home.

In a randomized control trial (Kalra et al., 2000), 457 acute stroke patients were assigned to three differing levels of treatment (stroke unit, general ward, domiciliary care). Patients who survived without severe disability at 1 year post-stroke in the three groups were: 129 (85 percent), 99 (66 percent), and 102 (71 percent). Stroke unit care was significantly better than the two lower levels of care. The net effect of the stroke unit was profoundly different for approximately 30 patients (20 percent of sample).

Studies of Care in the Post-Acute Rehabilitation Setting

Langhorne and Duncan (2001) conducted a systematic review of a subset of the studies identified by the Stroke Unit Trialists' Collaboration, those that deal with post-acute rehabilitation stroke services. They defined intervention as "organized inpatient multidisciplinary rehabilitation commencing at least one week after stroke" and sought randomized trials that compared this model of care with an alternative. In a heterogeneous group of 9 trials (6 involving stroke rehabilitation units and 3 involving general rehabilitation wards) recruiting 1,437 patients, organized inpatient multidisciplinary rehabilitation was associated with a reduced odds of death (OR = 0.66; 95% CI, 0.49 to 0.88; P<0.01), death or institutionalization (OR = 0.70; 95% CI, 0.56 to 0.88; P<0.001), and death or dependency (OR = 0.65; 95% CI, 0.50 to 0.85; P<0.001), which was consistent across a variety of trial subgroups. For every 100 patients receiving organized inpatient multidisciplinary rehabilitation, an extra 5 returned home in an independent state. This review of post-acute care concluded that there can be substantial benefit from organized inpatient multidisciplinary rehabilitation in the post-acute period, which is both statistically significant and clinically important.

One RCT has been published (Evans et al., 2001) since the most recent update of the collaboration's work. This study, which deals with both acute and rehabilitative care, sought to quantify the differences between staff interventions in a stroke unit versus staff interventions on a general ward supported by a stroke specialist team. Observations were made daily for the first week of acute care, but only weekly during the post-acute phase. During the observation period, the stroke unit patients were monitored more frequently and received better supportive care, including early initiation of feeding.

Due to the heterogeneity of the literature regarding patient samples, structural design, and outcome measures, it is difficult to identify a "best practice" that applies to all patients with stroke. The evidence does not indicate the specific nature of the intervention or provide explanation of the nature of the team approach or which factor has the greatest impact on patient outcome. The very nature of stroke and its multifaceted effects create the need for a flexible and multifaceted treatment approach.

EVIDENCE