Selection for Inpatient Rehabilitation After Acute Stroke: A Systematic Review of the Literature

Guidelines: basic principles of neurorehabilitation for patients with acquired brain injury. Recommendations of the Spanish Society of Neurorehabilitation

INTRODUCTION

We present the Spanish Society of Neurorehabilitation's guidelines for adult acquired brain injury (ABI) rehabilitation. These recommendations are based on a review of international clinical practice guidelines published between 2013 and 2020.

DEVELOPMENT

We establish recommendations based on the levels of evidence of the studies reviewed and expert consensus on population characteristics and the specific aspects of the intervention or procedure under research.

CONCLUSIONS

All patients with ABI should receive neurorehabilitation therapy once they present a minimal level of clinical stability. Neurorehabilitation should offer as much treatment as possible in terms of frequency, duration, and intensity (at least 45-60minutes of each specific form of therapy that is needed). Neurorehabilitation requires a coordinated, multidisciplinary team with the knowledge, experience, and skills needed to work in collaboration both with patients and with their families. Inpatient rehabilitation interventions are recommended for patients with more severe deficits and those in the acute phase, with outpatient treatment to be offered as soon as the patient's clinical situation allows it, as long as intensity criteria can be maintained. The duration of treatment should be based on treatment response and the possibilities for further improvement, according to the best available evidence. At discharge, patients should be offered health promotion, physical activity, support, and follow-up services to ensure that the benefits achieved are maintained, to detect possible complications, and to assess possible changes in functional status that may lead the patient to need other treatment programmes.

Factors Determining the Functional Efficiency of Patients After Ischemic Stroke After Neurological Rehabilitation

Introduction

The factors determining the level of functional efficiency in patients after ischemic stroke are: age, sex, physical condition, mental activity before stroke, previous neurological deficits, comorbidities, nutritional status and the course of the stroke.

Aim

Assessment of the functional efficiency of patients before and after rehabilitation due to ischemic stroke and determination of the influence of selected factors on the effects of rehabilitation measured by functional efficiency.

Material and Methods

The study was conducted in neurological rehabilitation centers among 82 people diagnosed with ischemic stroke. The examination was performed twice: on admission to the ward and after a month of neurological rehabilitation. The diagnostic survey method, the Barthel scale, the NRS 2002 scale were used, and the BMI was calculated.

Results

The functional efficiency level of the patients was varied, higher after one month of rehabilitation (p <0.05). Among the patients who achieved a lower level of functional efficiency, the following factors had a significant influence: underweight and overweight (p = 0.002), risk of malnutrition (p = 0.002), right-sided paresis (p = 0.016), limited physical activity before stroke (p = 0.01) and the later rehabilitation period (p = 0.01). There was no correlation between sociodemographic data and the level of efficiency of patients after a stroke after one month of rehabilitation.

Conclusion

The level of functional efficiency after rehabilitation improved in all patients, however, to a different extent depending on the nutritional status and physical activity. Therefore, it is important to to undertake rehabilitation in the shortest possible time.

Predicting the functional outcome of intensive inpatient rehabilitation after stroke: results from the RIPS Study

BACKGROUND

The complexity of stroke sequelae, the heterogeneity of outcome measures and rehabilitation pathways, and the lack of extensively validated prediction models represent a challenge in predicting stroke rehabilitation outcomes.

AIM

To prospectively investigate a multidimensional set of variables collected at admission to inpatient post-stroke rehabilitation as potential predictors of the functional level at discharge.

DESIGN

Multicentric prospective observational study.

SETTING

Patients were enrolled in four Intensive Rehabilitation Units (IRUs).

POPULATION

Patients were consecutively recruited in the period December 2019-December 2020 with the following inclusion criteria: aged 18+, with ischemic/haemorrhagic stroke, and undergoing inpatient rehabilitation within 30 days from stroke.

METHODS

This is a multicentric prospective observational study. The rehabilitation pathway was reproducible and evidence-based. The functional outcome was disability in activities of daily living, measured by the modified Barthel Index (mBI) at discharge. Potential multidimensional predictors, assessed at admission, included demographics, event description, clinical assessment, functional and cognitive profile, and psycho-social domains. The variables statistically associated with the outcome in the univariate analysis were fed into a multivariable model using multiple linear regression.

RESULTS

A total of 220 patients were included (median [IQR] age: 80 [15], 112 women, 175 ischemic). Median mBI was 26 (43) at admission and 62.5 (52) at discharge. In the multivariable analysis younger age, along with better functioning, fewer comorbidities, higher cognitive abilities, reduced stroke severity, and higher motor functions at admission, remained independently associated with higher discharge mBI. The final model allowed a reliable prediction of discharge functional outcome (adjusted R2=77.2%).

CONCLUSIONS

The model presented in this study, based on easily collectable, reliable admission variables, could help clinicians and researchers to predict the discharge scores of the global functional outcome for persons enrolled in an evidence-based inpatient stroke rehabilitation program.

CLINICAL REHABILITATION IMPACT

A reliable outcome prediction derived from standardized assessment measures and validated treatment protocols could guide clinicians in the management of patients in the subacute phase of stroke and help improve the planning of the rehabilitation individualized project.

Why do some people with stroke not receive the recommended 45 min of occupational therapy and physiotherapy after stroke? A qualitative study using focus groups

OBJECTIVES

To generate qualitative data on the views of Occupational Therapists and Physiotherapists about why people do not receive the Royal College of Physicians' recommended minimum of 45 minutes (min) of daily therapy after stroke, in order to inform a Delphi study.

DESIGN

Focus group study.

SETTING

Stroke services in the South of England.

PARTICIPANTS

A total of nine participants, in two groups, including therapists covering inpatient and Early Supported Discharge (ESD) services with awareness of the 45 min guideline.

RESULTS

Thematic analysis of focus group data identified five factors that influence the amount of therapy a person receives: The Person (with stroke), Individual Therapist, Stroke Multidisciplinary Team, the Organisation and the Guideline. Study findings suggest that the reasons why a person does not receive the therapy recommendation in inpatient and ESD services relate to either the suitability of the guideline for the person with stroke, or the ability of the service to deliver the guideline.

CONCLUSION

This study provides evidence for possible reasons why some people do not receive a minimum of 45 minutes of therapy, 5 days per week, related to (1) the suitability of the guideline for people with stroke and (2) services' ability to deliver this amount of intervention. These two factors are related; therapists decide who should receive therapy and how much in the context of (a) resource availability and (b) people's need and the benefit they will experience. The study findings, combined with the findings from other studies, will be used to initiate a Delphi study, which will establish consensus among therapists regarding the reasons why some people do not receive the guideline amount of therapy.

Why do some people who had a stroke not receive the recommended 45 min of occupational therapy and physiotherapy? A Delphi study

OBJECTIVES

To gain a consensus among therapists for reasons why a person who had a stroke may not receive the Royal College of Physicians' recommended minimum of 45 min of daily therapy.

DESIGN

Three-round remote e-Delphi study.

SETTING

National study, based in the UK.

PARTICIPANTS

Occupational therapists and physiotherapists with experience of delivering therapy after stroke and awareness of the 45 min guideline.

RESULTS

Forty-five therapists consented to participate in the study. Thirty-five (78%) completed round one, 29 of 35 (83%) completed round 2 and 26 of 29 (90%) completed round three. A consensus (75%) was reached for 32 statements. Reasons why a person may not receive 45 min were related to the suitability of the guideline for the individual (based on factors like therapy tolerance or medical status) or the capability of the service to provide the intervention. In addition to the statements for which there was a consensus, 32 concepts did not reach a consensus. Specifically, there was a lack of consensus concerning the suitability of the guideline for people receiving Early Supported Discharge (ESD) services and a lack of agreement about whether people who need more than 45 min of therapy actually receive it.

CONCLUSION

Some people do not receive 45 min of therapy as they are considered unsuitable for it and some do not receive it due to services' inability to provide it. It is unclear which reasons for guideline non-achievement are most common. Future research should focus on why the guideline is not achieved in ESD, and why people who require more than 45 min may not receive it. This could contribute to practical guidance for therapists to optimise therapy delivery for people after stroke.

Association Between Race and Receipt of Home- and Community-Based Rehabilitation After Traumatic Brain Injury Among Older Medicare Beneficiaries

Importance

Non-Hispanic Black (hereafter Black) patients with traumatic brain injury (TBI) experience worse long-term outcomes and residual disability compared with non-Hispanic White (hereafter White) patients. Receipt of appropriate rehabilitation can improve function among older adults after TBI.

Objective

To assess the association between race and receipt of home- and community-based rehabilitation among a nationally representative sample of older Medicare beneficiaries with TBI.

Design, Setting, and Participants

This cohort study analyzed a random sample of Medicare administrative claims data for community-dwelling Medicare beneficiaries aged 65 years or older who were hospitalized with a primary diagnosis of TBI and discharged alive to a nonhospice setting from 2010 through 2018. Claims data for Medicare beneficiaries of other races and ethnicities were excluded due to the small sample sizes within each category. Data were analyzed January 21 to August 30, 2022.

Exposures

Black or White race.

Main Outcomes and Measures

Monthly use rates of home-based or outpatient rehabilitation were calculated over the 6 months after discharge from the hospital. The denominator for rate calculations accounted for variation in length of hospital and rehabilitation facility stays and loss to follow-up due to death. Rates over time were modeled using generalized estimating equations, controlling for TBI acuity, demographic characteristics, comorbidities, and socioeconomic factors.

Results

Among 19 026 Medicare beneficiaries (mean [SD] age, 81.6 [8.1] years; 10 781 women [56.7%]; and 994 Black beneficiaries [5.2%] and 18 032 White beneficiaries [94.8%]), receipt of 1 or more home health rehabilitation visits did not differ by race (Black vs White, 47.4% vs 46.2%; P = .46), but Black beneficiaries were less likely to receive 1 or more outpatient rehabilitation visits compared with White beneficiaries (3.4% vs 7.1%; P < .001). In fully adjusted regression models, Black beneficiaries received less outpatient therapy over the 6 months after TBI (rate ratio, 0.60; 95% CI, 0.38-0.93). However, Black beneficiaries received more home health rehabilitation therapy over the 6 months after TBI than White beneficiaries (rate ratio, 1.15; 95% CI, 1.00-1.32).

Conclusions and Relevance

This cohort study found relative shifts in rehabilitation use, with markedly lower outpatient therapy use and modestly higher home health care use among Black patients compared with White patients with TBI. These disparities may contribute to reduced functional recovery and residual disability among racial and ethnic minority groups. Additional studies are needed to assess the association between the amount of outpatient rehabilitation care and functional recovery after TBI in socioeconomically disadvantaged populations.

Regression-based prognostic models for functional independence after postacute brain injury rehabilitation are not transportable: a systematic review

BACKGROUND AND OBJECTIVES

To identify and summarize validated multivariable prognostic models for the Functional Independence Measure® (FIM®) at discharge from post-acute inpatient rehabilitation in adults with acquired brain injury (ABI).

METHODS

This review was conducted based on the recommendations of the Cochrane Prognosis Methods Group and adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three databases were systematically searched in May 2021 and updated in April 2022. Main inclusion criteria were: a) adult patients with ABI, b) validated multivariable prognostic model, c) time of prognostication within 1-week of admission to post-acute rehabilitation, and d) outcome was the FIM® at discharge from post-acute rehabilitation.

RESULTS

The search yielded 3,169 unique articles. Three articles fulfilled the inclusion criteria, accounting for n = 6 internally and n = 2 externally validated prognostic models. Discrimination was estimated as an area under the curve between 0.76 and 0.89. Calibration was deemed to be assessed insufficiently. The included models were judged to be of high risk of bias.

CONCLUSION

Current prognostic models for the FIM® in post-acute rehabilitation for patients with ABI lack the methodological rigor to support clinical use outside the development setting. Future studies addressing functional independence should ensure appropriate model validation and conform to uniform reporting standards for prognosis research.

Ethical Issues in Medical Rehabilitation: The Dilemma of Who to Admit

ABSTRACT

Ethical allocation of scare medical resources is a ubiquitous challenge in many, if not all, medical specialties. The field of physical medicine and rehabilitation is no exception and presents its own unique dilemmas. We report on a small inpatient rehabilitation unit at a large university medical center with a large catchment area representing a vast range of socioeconomic classes. The decision of whom to admit is a constant challenge. We review the existing literature regarding ethical considerations in rehabilitation department admission criteria and attempt to analyze criteria used to admit patients to a general physical medicine and rehabilitation ward. Finally, we discuss our medical center approach to the ethical dilemma of admission priority. A systemic search was conducted in six sources (PubMed, Google Scholar, ScienceDirect, Cochrane Library, LILACS, Embase). Searches were limited to English language articles with no date restriction, reflecting all available data. A reviewer applied the inclusion criteria to identify relevant articles.This review highlights a number of important ethical issues in evaluation and selection criteria that may assist clinicians in improving selection procedures and standardizing access to inpatient rehabilitation. Further high-quality empirical studies and reviews of ethical admission practice with regard to rehabilitation acceptance are required.

Factors influencing clinicians' referral or admission decisions for post-acute stroke or traumatic brain injury rehabilitation: A scoping review

Demand for post-acute stroke and traumatic brain injury (TBI) rehabilitation outweighs resource availability. Every day, clinicians face the challenging task of deciding which patient will benefit or not from rehabilitation. The objectives of this scoping review were to map and compare factors reported by clinicians as influencing referral or admission decisions to post-acute rehabilitation for stroke and TBI patients, to identify most frequently reported factors and those perceived as most influential. We searched four major databases for articles published between 1946 and January 2021. Articles were included if they reported clinicians' perceptions, investigated referral or admission decisions to post-acute rehabilitation, and focused on patients with stroke or TBI. Twenty articles met inclusion criteria. The International Classification of Functioning, Disability and Health framework was used to guide data extraction and summarizing. Patient-related factors most frequently reported by clinicians were age, mental status prior to stroke or TBI, and family support. The two latter were ranked among the most influential by clinicians working with stroke patients, whereas age was ranked of low importance. Organizational factors were reported to influence decisions (particularly the availability of post-acute care services) as well as clinicians' characteristics (eg, knowledge). Moreover, clinicians' prediction of patient outcome ranked among the most important driver of referral or admission decisions by clinicians working with stroke patients. Findings highlight the complex nature of decision-making regarding patient selection for rehabilitation and provide insight on important factors that frontline clinicians need to consider when having to make rapid decisions in high-pressured acute care environments.

[Racial inequalities in access to rehabilitation after a stroke: study of the Brazilian population]

This article aims to verify the association between race/skin color and access to post-stroke rehabilitation services. It is a cross-sectional population-based study including 966 post-stroke adults (≥18 years) that responded to the National Health Survey (PNS). The outcome, access to rehabilitation, and exposure (race/skin color) were collected in a self-reported manner. Socio-demographic variables, clinical history, healthcare plan and post-stroke limitation were considered for the adjustment. Poisson regression with robust variance estimation was used to estimate the association in the crude and adjusted analyses. Based on the sample, 51.8% are self-declared black and 61.4% require rehabilitation, with only 20% having access to the rehabilitation service. Difficulty in accessing rehabilitation was reported by 57.5% of other self-declared races, 43% blacks, and 35.4% whites. In the adjusted analysis, 4% of self-declared black (PR 1.04, CI95%1.00-1.08) and 17% of self-declared yellow and indigenous (PR 1.17, IC95%1.13-1.20) have less access to rehabilitation than their white peers. In Brazil, self-declared black and yellow and indigenous people have worst access to post-stroke rehabilitation in comparison with self-declared white people, highlighting racial inequities in rehabilitation in stroke survivors.

The Wolfson Assessment Matrix: a potential tool to support clinicians in establishing access to specialized neuro rehabilitation by capturing important prognostic factors. Sharing more equitable and transparent criteria

BACKGROUND

Specialized Rehabilitation Services (SRSs) are designed to offer intensive multidisciplinary rehabilitation to patients with complex needs, who are expected to make significant functional gains in their ADLs over a relatively limited period of time. Although national guidelines offer a guidance on how to band patients by complexity, there is no consensus on how to screen patients with regard to rehabilitation prognosis.

AIM

The aim of this study was to improve the selection of patients admitted to an SRS, defining transparent and equitable prognostic criteria to guide clinicians' decision making.

DESIGN

This is a retrospective observational study SETTING: an SRS in the UK.

POPULATION

We included 121 patients affected by a neurological condition consecutively admitted for multidisciplinary rehabilitation.

METHODS

Rehabilitation Complexity Scale Extended is used to describe rehabilitation complexity. A short list of potential barriers to rehabilitation was analysed to predict the functional outcome measured by the Functional Independent Measure and the Barthel Index.

RESULTS

Older age, a heavier burden of co-morbidities, pre-morbid cognitive difficulties or dementia and a lower function level at admission were the most important variables to predict a lower functional gain.

CONCLUSIONS

We have used this list of barriers to create the Wolfson Assessment Matrix as a potential support tool to guide clinicians navigating through the different rehabilitation service options when assessing complex patients for eligibility to an SRS.

CLINICAL REHABILITATION IMPACT

SRSs are highly expensive services representing a possible step along the rehabilitation pathway for patients with complex needs. A tool such as the Wolfson Assessment Matrix would represent a step forward to help consistency in decision making regarding appropriateness for SRSs. It would also help to set realistic long-term goals with patients and families and support Health Services in the further development of alternative rehabilitation settings.

Comparing two identically protocolized, multicentre, randomized controlled trials on caregiver-mediated exercises poststroke: Any differences across countries?

Background

The evidence for rehabilitation interventions poststroke lack sufficient robustness. However, variation in treatment effects across countries have been given little attention.

Objective

To compare two identically protocolized trials conducted in different western countries in order to identify factors that may have caused variation in secondary trial outcomes.

Methods

Comparative study based on individual patient data (N = 129) from two randomized controlled trials, conducted in hospitals and rehabilitation facilities in the Netherlands (N = 66) and Australia (N = 63). Patients with stroke and their caregivers were randomly allocated to an 8-week caregiver-mediated exercises intervention (N = 63; 31 Australian and 32 Dutch) or to a control group (N = 66; 32 Australian and 34 Dutch). Patient characteristics, compliance, usual care and process measures were compared across countries. We examined if study setting significantly moderated the trial outcomes: Hospital Anxiety and Depression Scale, Fatigue Severity Scale and General Self-Efficacy Scale, measured at 8- and 12 weeks follow-up. In addition, we explored if factors that were significantly different across countries caused variation in these trial outcomes.

Results

Most patients suffered an ischemic stroke, were in the subacute phase and participated with their partner. Dutch patients were younger (P = 0.005) and had a lower functional status (P = 0.001). Australian patients were recruited earlier poststroke (P<0.001), spent less time in exercise therapy (P<0.001) and had a shorter length of stay (P<0.001). The level of contamination was higher (P = 0.040) among Dutch controls. No effect modification was observed and trial outcomes did not change after controlling for cross-country differences.

Conclusions

The present study highlighted important clinical differences across countries whilst using an identical study protocol. The observed differences could result in a different potential for recovery and variation in treatment effects across trials. We argue that we can proceed faster to evaluating interventions within international pragmatic trials.

Which Road to Recovery?: Factors Influencing Postacute Stroke Discharge Destinations: A Delphi Study

BACKGROUND AND PURPOSE

The criteria for determining the level of postacute care for patients with stroke are variable and inconsistent. The purpose of this study was to identify key factors influencing the selection of postacute level of care for these patients.

METHODS

We used a collaborative 4-round Delphi process to achieve a refined list of factors influencing postacute level of care selection. Our Delphi panel of experts consisted of 32 panelists including physicians, physical therapists, occupational therapists, speech-language pathologists, nurses, stroke survivors, administrators, policy experts, and individuals associated with third-party insurance companies.

RESULTS

In round 1, 207 factors were proposed, with subsequent discussion resulting in consolidation into 15 factors for consideration. In round 2, 15 factors were ranked with consensus on 10 factors; in round 3,10 factors were ranked with consensus on 9 factors. In round 4, the final round, 9 factors were rated with Likert scores ranging from 5 (most important) to 1(not important). The percentage of panelists who provided a rating of 4 or above were as follows: likelihood to benefit from an active rehabilitation program (97%), need for clinicians with specialized rehabilitation skills (94%), need for active and ongoing medical management and monitoring (84%), ability to tolerate an active rehabilitation program (74%), need for caregiver training to return to the community (48%), family/caregiver support (39%), likelihood to return to community/home (39%), ability to return to physical home environment (32%), and premorbid dementia (16%).

CONCLUSIONS

This study provides an expert, consensus-based set of key factors to be considered when determining where stroke patients are discharged for postacute care. These factors may be useful in developing a decision support tool for use in clinical settings.

A systematic review of the qualitative literature on older individuals' experiences of care and well-being during physical rehabilitation for acquired brain injury

Aims

To acquire an in‐depth understanding of how older individuals diagnosed with acquired brain injury (ABI) experience their well‐being and care when undergoing physical rehabilitation.

Design

Systematic literature review.

Data sources

The electronic databases of PubMed, CINAHL, APA PsycInfo, ASSIA and SCOPUS were searched from 2005 to 2020. Extensive reference checking was also conducted.

Review methods

A systematic review was conducted following PRISMA guidelines, including predominantly qualitative studies. Studies’ quality was appraised using the critical apraisal skills programme (CASP) tool.

Results

Seventeen studies met the inclusion criteria. Following methods of thematic synthesis, four overarching interpretive themes were identified: (a) Rehabilitation processes and their impact on older individuals’ well‐being; (b) Identity and embodiment concerns of older individuals during rehabilitation; (c) Institutional factors affecting older individuals’ care and well‐being experiences; and (d) Older individuals’ participation in creative activities as part of rehabilitation.

Conclusion

Organizational and structural care deficiencies as well as health disparities can adversely impact older individuals’ autonomous decision‐making and goal‐setting potentials. The discrepancy between older individuals’ expectations and the reality of returning home along with the illusionary wish to return to a perceived normality, can further negatively affect older individuals’ sense of well‐being. Constructive communication, emotional support, family involvement in rehabilitation and creating a stimulating, enriching social environment can humanize and facilitate older individuals’ adjustment to their new reality following ABI.

Impact

There is a lack of qualitative research on older individuals’ ABI rehabilitation experiences, especially traumatic brain injury incidents. Further study should consider patients’ concerns over their involvement in decision‐making and goal setting about their care. Overall, this review reveals the need to examine further the significance of humanizing care and the factors that affect older individuals’ sense of well‐being.

Most Important Factors for Deciding Rehabilitation Provision for Severe Stroke Survivors Post Hospital Discharge: A Study Protocol for a Best-Worst Scaling Experiment

Efficient decision-making is crucial to ensure adequate rehabilitation with optimal use of healthcare resources. Establishing the factors associated with making decisions concerning rehabilitation provision is important to guide clinical staff towards person-centred decisions for rehabilitation after severe stroke. In this study we conduct a best–worst scaling (BWS) experiment to identify the most important factors and their relative weight of importance for deciding the type of ongoing rehabilitation services a person with severe stroke might receive post hospital discharge. Fractional, efficient designs are applied regarding the survey design. Key multidisciplinary staff regularly involved in making decisions for rehabilitation in a stroke unit will be recruited to participate in an online BWS survey. Hierarchical Bayes estimation will be used as the main analysis method, with the best–worst count analysis as a secondary analysis. The survey is currently being piloted prior to commencing the process of data collection. Results are expected by the end of September 2021. The research will add to the current literature on clinical decision-making in stroke rehabilitation. Findings will quantify the preferences of factors among key multi-disciplinary clinicians working in stroke units in the UK, involved in decision-making concerning rehabilitation after stroke.

Frequency of Hypoalbuminemia and In-Hospital Mortality in Acute Ischemic Stroke Patients Presenting at a Tertiary Care Hospital, Hyderabad

Background The aim of this study was to determine the frequency of hypoalbuminemia and in-hospital mortality in acute ischemic stroke patients at a tertiary care hospital in Hyderabad. Methodology This was a prospective observational study conducted at the Department of Medicine, Isra University Hospital, Hyderabad, from February 17, 2017 to August 18, 2017. A total of 196 consecutive cases of acute ischemic stroke were included. Hypoalbuminemia was defined as serum albumin of <3.5 mg/dL. In-hospital outcome in terms of survival or death within seven days of admission was assessed and recorded. Data were analyzed using SPSS, version 20.0. (IBM Corp., Armonk, NY, US). Chi-square test was applied, and p-value of ≤0.05 was considered significant. Results Out of the 196 acute ischemic stroke cases, 146 (74.5%) were males and 50 (25.5%) were females. The mean age was 49.31 ± 10.46 years. A total of 90 (45.9%) cases had hypoalbuminemia. Out of these 196 cases, 22 (11.2%) expired within seven days of presentation of acute ischemic stroke, and out of these 22 expired cases, 18 (81.8%) had hypoalbuminemia. In-hospital mortality was found to be strongly associated with hypoalbuminemia (p < 0.001). Conclusions Frequency of hypoalbuminemia was significantly higher in ischemic stroke patients and was found to be associated with in-hospital mortality, warranting monitoring at regular intervals, as well as recognizing and treating it early for risk stratification.

Early physical rehabilitation therapy between 24 and 48 h following acute ischemic stroke onset: a randomized controlled trial

PURPOSE

Early mobilization is believed to be helpful for patients with acute ischemic stroke. This study aimed to compare the difference between starting rehabilitation between 24 and 48 h and 72 and 96 h following the onset of ischemic stroke.

MATERIALS AND METHODS

This was a single-center, single-blind, randomized controlled trial. The early rehabilitation (ER) group started exercising between 24 and 48 h after stroke onset, which the standard rehabilitation (SR) group started exercising between 72 and 96 h. The two groups received sitting, standing, and repetitive body strength training respectively.

RESULTS

In this study, 110 patients were analyzed. Patients in the early rehabilitation group had more favorable outcomes (The modified Rankin scale score 0-2, ER group = 32 versus SR group = 20, adjusted odds ratio 2.27, 95% CI 1.05-4.87; p = 0.036) at 3-month follow-up. The simplified Fugl-Meyer assessment (FMA) scores for the lower extremity were influenced by the interaction effect (F = 7.24, p = 0.01). The post-hoc analysis revealed a difference in the lower extremity FMA score at one week after stroke (difference 2.30 (95% CI 0.65-3.96); p = 0.007).

CONCLUSIONS

Early physical rehabilitation training between 24 and 48 h may be beneficial and improve patients' lower extremity function within the first week.

CLINICAL TRIAL REGISTRATION UNIQUE IDENTIFIER

NCT02718534Implications for rehabilitationAcute ischemic stroke has a variety of symptoms, and acroparalysis is a major concern.Starting physical rehabilitation early can improve the prognosis of patients with ischemic stroke.Early rehabilitation is more conducive to the recovery of lower extremity motor function, but in the subsequent rehabilitation process, the upper extremity function should be paid more attention.

Using the Technology Acceptance Model to Identify Factors That Predict Likelihood to Adopt Tele-Neurorehabilitation

Tele-neurorehabilitation has the potential to reduce accessibility barriers and enhance patient outcomes through a more seamless continuum of care. A growing number of studies have found that tele-neurorehabilitation produces equivalent results to usual care for a variety of outcomes including activities of daily living and health related quality of life. Despite the potential of tele-neurorehabilitation, this model of care has failed to achieve mainstream adoption. Little is known about feasibility and acceptability of tele-neurorehabilitation and most published studies do not use a validated model to guide and evaluate implementation. The technology acceptance model (TAM) was developed 20 years ago and is one of the most widely used theoretical frameworks for predicting an individual's likelihood to adopt and use new technology. The TAM3 further built on the original model by incorporating additional elements from human decision making such as computer anxiety. In this perspective, we utilize the TAM3 to systematically map the findings from existing published studies, in order to explore the determinants of adoption of tele-neurorehabilitation by both stroke survivors and prescribing clinicians. We present evidence suggesting that computer self-efficacy and computer anxiety are significant predictors of an individual's likelihood to use tele-neurorehabilitation. Understanding what factors support or hinder uptake of tele-neurorehabilitation can assist in translatability and sustainable adoption of this technology. If we are to shift tele-neurorehabilitation from the research domain to become a mainstream health sector activity, key stakeholders must address the barriers that have consistently hindered adoption.

Use of the Activity Measure for Post-Acute Care "6 Clicks" Basic Mobility Inpatient Short Form and National Institutes of Health Stroke Scale to Predict Hospital Discharge Disposition After Stroke

OBJECTIVE

Therapists in the hospital are charged with making timely discharge recommendations to improve access to rehabilitation after stroke. The objective of this study was to identify the predictive ability of the Activity Measure for Post-Acute Care "6 Clicks" Basic Mobility Inpatient Short Form (6 Clicks mobility) score and the National Institutes of Health Stroke Scale (NIHSS) score for actual hospital discharge disposition after stroke.

METHODS

In this retrospective cohort study, data were collected from an academic hospital in the United States for 1543 patients with acute stroke and a 6 Clicks mobility score. Discharge to home, a skilled nursing facility (SNF), or an inpatient rehabilitation facility (IRF) was the primary outcome. Associations among these outcomes and 6 Clicks mobility and NIHSS scores, alone or together, were tested using multinomial logistic regression, and the predictive ability of these scores was calculated using concordance statistics.

RESULTS

A higher 6 Clicks mobility score alone was associated with a decreased odds of actual discharge to an IRF or an SNF. The 6 Clicks mobility score alone was a strong predictor of discharge to home versus an IRF or an SNF. However, predicting discharge to an IRF versus an SNF was stronger when the 6 Clicks mobility score was considered in combination with the NIHSS score, age, sex, and race.

CONCLUSION

The 6 Clicks mobility score alone can guide discharge decision making after stroke, particularly for discharge to home versus an SNF or an IRF. Determining discharge to an SNF versus an IRF could be improved by also considering the NIHSS score, age, sex, and race. Future studies should seek to identify which additional characteristics improve predictability for these separate discharge destinations.

IMPACT

The use of outcome measures can improve therapist confidence in making discharge recommendations for people with stroke, can enhance hospital throughput, and can expedite access to rehabilitation, ultimately affecting functional outcomes.

Inpatient stroke rehabilitation: prediction of clinical outcomes using a machine-learning approach

BACKGROUND

In clinical practice, therapists often rely on clinical outcome measures to quantify a patient's impairment and function. Predicting a patient's discharge outcome using baseline clinical information may help clinicians design more targeted treatment strategies and better anticipate the patient's assistive needs and discharge care plan. The objective of this study was to develop predictive models for four standardized clinical outcome measures (Functional Independence Measure, Ten-Meter Walk Test, Six-Minute Walk Test, Berg Balance Scale) during inpatient rehabilitation.

METHODS

Fifty stroke survivors admitted to a United States inpatient rehabilitation hospital participated in this study. Predictors chosen for the clinical discharge scores included demographics, stroke characteristics, and scores of clinical tests at admission. We used the Pearson product-moment and Spearman's rank correlation coefficients to calculate correlations among clinical outcome measures and predictors, a cross-validated Lasso regression to develop predictive equations for discharge scores of each clinical outcome measure, and a Random Forest based permutation analysis to compare the relative importance of the predictors.

RESULTS

The predictive equations explained 70-77% of the variance in discharge scores and resulted in a normalized error of 13-15% for predicting the outcomes of new patients. The most important predictors were clinical test scores at admission. Additional variables that affected the discharge score of at least one clinical outcome were time from stroke onset to rehabilitation admission, age, sex, body mass index, race, and diagnosis of dysphasia or speech impairment.

CONCLUSIONS

The models presented in this study could help clinicians and researchers to predict the discharge scores of clinical outcomes for individuals enrolled in an inpatient stroke rehabilitation program that adheres to U.S. Medicare standards.

Are Stroke Survivors Discharged to the Recommended Postacute Setting?

OBJECTIVE

To examine the processes and barriers involved in providing postdischarge stroke care.

DESIGN

Prospective study of discharge planners' (DP) and physical therapists' (PT) interpretation of factors contributing to patients' discharge destination.

SETTING

Twenty-three hospitals in the northeastern United States.

PARTICIPANTS

After exclusions, data on patients (N=427) hospitalized with a primary diagnosis of stroke between May 2015 and November 2016 were examined. Of the patients, 45% were women, and the median age was 71 years. DPs and PTs caring for these patients were queried regarding the selection of discharge destination.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Comparison of actual discharge destination for stroke patients with the destinations recommended by their DPs and PTs.

RESULTS

In total, 184 patients (43.1%) were discharged home, 146 (34.2%) to an inpatient rehabilitation facility, 94 (22.0%) to a skilled nursing facility, and 3 (0.7%) to a long-term acute care hospital. DPs and PTs agreed on the recommended discharge destination in 355 (83.1%) cases. The actual discharge destination matched the DP and PT recommended discharge destination in 92.5% of these cases. In 23 cases (6.5%), the patient was discharged to a less intensive setting than recommended by both respondents. In 4 cases (1.1%), the patient was discharged to a more intensive level of care. In 2 cases (0.6%), the patient was discharged to a long-term acute care hospital rather than an inpatient rehabilitation facility as recommended. Patient or family preference was cited by at least 1 respondent for the discrepancy in discharge destination for 13 patients (3.1%); insurance barriers were cited for 9 patients (2.3%).

CONCLUSIONS

Most stroke survivors in the northeast United States are discharged to the recommended postacute care destination based on the consensus of DP and PT opinions. Further research is needed to guide postacute care service selection.

Development of a Point System to Predict Discharge to Home for Acute Stroke Patients

BACKGROUND

While in an acute hospital setting, it is challenging for clinicians to make discharge decisions due to the multifactorial process and individual patient characteristics.

OBJECTIVE

To evaluate and develop a scoring system utilizing the Japan Rehabilitation Database (JRD) to identify acute stroke patients with a high possibility of discharge to home.

DESIGN

Retrospective observational cohort study.

SETTING

Thirty-seven acute hospitals in Japan.

PARTICIPANTS

A total of 10 270 patients admitted to the acute hospitals with stroke were identified. The inclusion criteria were (1) admission within 3 days of onset and (2) admission from home. Exclusion criteria were (1) incomplete data and (2) death in hospital. A total of 4216 patients were included in the study.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASUREMENTS

Discharge destination from acute care hospital, that is, home versus other locations.

RESULTS

In the multivariate logistic regression, age, stroke type, Barthel Index on admission, modified Rankin scale on admission, the National Institutes of Health Stroke Scale on admission, and extent of paralysis were retained. When the cutoff point was 33, the scoring system showed a sensitivity of 80.4% and specificity of 80.3%. The area under curve (AUC) was 0.88. On evaluating the predictive performance, the model showed a sensitivity of 78.2% and a specificity of 78.5% with an AUC = 0.86.

CONCLUSIONS

We developed a point system to identify acute stroke patients with a high possibility of discharge to home using the JRD. This point system may provide useful information for clinicians to plan the discharge of acute stroke patients.

Exploring discharge destination following severe stroke

Background:

Patients with severe stroke frequently present with substantial impairments but are often not prioritised for post-discharge rehabilitation. There is a need to determine where these patients are discharged to in order to facilitate appropriate allocation of post-discharge pathway resources.

Aim:

The present study aimed to describe the discharge pathways of patients with severe stroke and to identify predictors of discharge destination for these patients.

Method:

A descriptive, retrospective design was utilised to determine the discharge destination for 770 patients with severe stroke in Queensland, Australia. Binomial logistic regression was used to determine the variables that predicted discharge destination.

Results:

The results indicated that 58.44% of patients were discharged home (n = 450). Age, length of stay, discharge ward and geographical region emerged as significant predictors of discharge destination. The full model containing all predictors was statistically significant and, as a whole, explained 36.50% of the variance in discharge destination.

Conclusion:

These results highlight the importance of these variables in influencing the outcomes of patients with severe stroke, which may assist post-hospital discharge services in allocating resources for patients with severe stroke.

Occupational engagement following mild stroke in the Australian context using the occupational gaps questionnaire

BACKGROUND

There is a need for research to identify the impact of mild stroke on occupational engagement. The Occupational Gaps Questionnaire (OGQ) measures the difference between a person's actual and preferred occupational engagement.

AIMS/OBJECTIVES

This study aimed to test the feasibility of the English version of the OGQ, and describe occupational gaps of people with mild stroke.

MATERIAL AND METHODS

A mixed methods, cross-sectional study involving 10 people with mild stroke at 1 and/or 9 months after stroke. Quantitative data were summarised descriptively and thematic analysis explored qualitative responses.

RESULTS

Participants reported a mean of 6.7 (SD 5.1) gaps at 1-month and 3.00 (SD 2.1) gaps at 9-months. Outdoor activities, work, sports, and light home and heavy-duty maintenance were identified as gaps at both time-points. Two themes emerged from the qualitative analysis: Drivers of occupation and Occupations can be challenged or enabled. An additional finding in terms of feasibility was drawn from qualitative data: Feasibility of Conducting the OGQ with people with mild stroke.

CONCLUSIONS AND SIGNIFICANCE

The English version of the OGQ was found to be a feasible instrument for identifying occupational gaps following mild stroke and may be suitable to support research and clinical practice with this population.

Patient and service factors associated with referral and admission to inpatient rehabilitation after the acute phase of stroke in Australia and Norway

Background

Unequal access to inpatient rehabilitation after stroke has been reported. We sought to identify and compare patient and service factors associated with referral and admission to an inpatient rehabilitation facility (IRF) after acute hospital care for stroke in two countries with publicly-funded healthcare.

Methods

We compared two cohorts of stroke patients admitted consecutively to eight acute public hospitals in Australia in 2013–2014 (n = 553), and to one large university hospital in Norway in 2012–2013 (n = 723). Outcomes were: referral to an IRF; admission to an IRF if referred. Logistic regression models were used to identify and compare factors associated with each outcome.

Results

Participants were similar in both cohorts: mean age 73 years, 40–44% female, 12–13% intracerebral haemorrhage, ~ 77% mild stroke (National Institutes of Health Stroke Scale < 8). Services received during the acute admission differed (Australia vs. Norway): stroke unit treatment 82% vs. 97%, physiotherapy 93% vs. 79%, occupational therapy 83% vs. 77%, speech therapy 78% vs. 13%. Proportions referred to an IRF were: 48% (Australia) and 37% (Norway); proportions admitted: 35% (Australia) and 28% (Norway). Factors associated with referral in both countries were: moderately severe stroke, receiving stroke unit treatment or allied health assessments during the acute admission, living in the community, and independent pre-stroke mobility. Directions of associations were mostly congruent; however younger patients were more likely to be referred and admitted in Norway only. Models for admission among patients referred identified few associated factors suggesting that additional factors were important for this stage of the process.

Conclusions

Similar factors were associated with referral to inpatient rehabilitation after acute stroke in both countries, despite differing service provision and access rates. Assuming it is not feasible to provide inpatient rehabilitation to all patients following stroke, the criteria for the selection of candidates need to be understood to address unwanted biases.

Predicting functional outcomes after stroke: an observational study of acute single-channel EEG

Background: Early and objective prediction of functional outcome after stroke is an important issue in rehabilitation. Electroencephalography (EEG) has long been utilized to describe and monitor brain function following neuro-trauma, and technological advances have improved usability in the acute setting. However, skepticism persists whether EEG can provide the same prognostic value as neurological examination.Objective: The current cohort study examined the relationship between acute single-channel EEG and functional outcomes after stroke.Methods: Resting-state EEG recorded at a single left pre-frontal EEG channel (FP1) was obtained from 16 adults within 72 h of first stroke. At 30 and 90 days, measures of disability (modified Rankin Scale; mRS) and involvement in daily activities (modified Barthel Index; mBI) were obtained. Acute EEG measures were correlated with functional outcomes and compared to an early neurological examination of stroke severity using the National Institute of Health Stroke Scale (NIHSS). Classification of good outcomes (mRS ≤1 or mBI ≥95) was also examined using Receiver Operator Curve analyses.Results: One-third to one-half of participants experienced incomplete post-stroke recovery, depending on the time point and measure. Functional outcomes correlated with acute theta values (r_s 0.45-0.60), with the strength of associations equivalent to previously reported values obtained from conventional multi-channel systems. Acute theta values ≥0.25 were associated with good outcomes, with positive (67-83%) and negative predictive values (70-90%) comparable to those obtained using the NIHSS.Conclusions: Acute, single-channel EEG can provide unique, non-overlapping clinical information, which may facilitate objective prediction of functional outcome after stroke.

Inpatient Rehabilitation Care in Alberta: How Much Does Stroke Severity and Timing Matter?

BACKGROUND

We examined the impact of stroke severity and timing to inpatient rehabilitation admission on length of stay (LOS), functional gains, and discharge destination.

METHODS

Alberta inpatient stroke rehabilitation data between April 2013 and March 2017 were analyzed. We evaluated the impact of stroke severity, as measured by the Functional Independence Measure (FIM), on timing to inpatient rehabilitation, functional gains, LOS, and discharge destination. Further, we examined whether timing to inpatient rehabilitation impacted the latter three factors.

RESULTS

The 2404 adults were subcategorized as mild (1237), moderate (1031), or severe (136) based on FIM at inpatient rehabilitation admission. Length of time to rehabilitation admission was not significantly (p = 0.232) different between stroke severities. Mean length of time (days) to rehabilitation admission was 19.79 (20.3 SD) for mild, 27.7 (35.7 SD) for moderate, and 37.70 (56.8 SD) for severe stroke. Mean FIM change for mild (M = 16.3, 9.9 SD) differed significantly (p = 5.1 × 10-9) from moderate (M = 30.4, 16.4 SD) and severe (M = 31.0, 25.7 SD) stroke. The mean LOS for mild stroke (M = 41.3, 31.9 SD) was significantly (p = 5.1 × 10-9) different from moderate stroke (M = 86.8, 76.4 SD) and severe stroke (M = 126.1, 104.2 SD). Time to inpatient rehabilitation admission showed a small, significant impact on FIM change (p = 1.4 × 10-9, partial η2 0.022) and LOS (p = 1.1 × 10-19, partial η2 0.042). Shorter times to rehabilitation admission and mild stroke were associated with discharging home without needing homecare.

CONCLUSION

Stroke severity has a significant impact on the conduct of inpatient rehabilitation. Yet, despite suggestions shortening timing to rehabilitation should improve outcomes, the impact on functional gains and rehabilitation LOS was small.

Post-stroke cognition with the Oxford Cognitive Screen vs Montreal Cognitive Assessment: a multi-site randomized controlled study (OCS-CARE)

Background: Cognitive impairment is common following stroke. The Oxford Cognitive Screen (OCS) was designed to assess focal post-stroke cognitive deficits in five domains. Here, we investigated whether results generated by the OCS vs the domain-general Montreal Cognitive Assessment (MoCA) at baseline impacted patient outcomes at 6 months follow-up.   Methods: Patients <2 months post-stroke were randomized to receive either the OCS and corresponding information leaflet or standard care with the MoCA at baseline. After 6 months, patients received both the OCS and MoCA. The primary registered outcome measures were the Stroke Impact Scale (SIS) and change in stroke severity (National Institutes of Health Stroke Scale; NIHSS) at 6 months. The secondary outcome was change in cognitive performance from baseline to 6-month follow-up. The relationship between scores from the two cognitive screens at follow-up was also explored. Results: A total of 821 patients from 37 different hospital or rehabilitation sites (England, UK) were recruited to the OCS-CARE study, with 467 completing 6-month follow-up. Patient outcomes defined by overall SIS scores and changes in NIHSS did not differ between the OCS or MoCA groups. There were high accordance rates between the OCS and MoCA at 6 months, with severity of cognitive impairment reflected in both screening tools. Cognitive performance in both groups over the 6-month follow-up declined in 22% of patients. A larger proportion of OCS group patients demonstrated improvements in cognitive scores (49% vs 40% in MoCA). Conclusions: The type of cognitive screening test did not impact broad stroke outcome measures, and the two screening tools showed a high overall accordance. The results suggest that more of the domain-specific deficits in OCS recover subacutely, providing a more granular picture of cognitive recovery as well as decline.             Registration: ISRCTN50857950; registered on 27/03/2014.

Prognostic Factors of Functional Outcome Assessed by Using the Modified Rankin Scale in Subacute Ischemic Stroke

Background

Most stroke survivors spent their lifetime with disability which not only affects the clients themselves and the family but also brings economic cost to the country. Therefore, this retrospective cohort study aimed to identify independent prognostic determinants associated with functional recovery in ischemic stroke within 6 months after onset.

Methods

Data from all first-onset ischemic stroke patients admitted to the acute stroke unit of the tertiary, university hospital were reviewed for 5 years consecutively. The functional outcome of the patients was recorded during 6-month follow-up by using the modified Rankin Scale (mRS). Baseline characteristics, motor assessment and all stroke-related variables were assessed during first week after stroke and 6-month follow-up. In order to derive clinical predictors, the backward stepwise multivariable risk regression analyses were used with the generalized linear model.

Results

The result revealed that in the 358 patients recruited into this study, 255 (71.2%) were in the functional recovery group (mRS score of 1 - 3) within 6 months after onset. The final model of multivariable risk regression analysis, with generalized linear model, demonstrated that the independent variables of functional recovery were leg score with a risk ratio (RR = 1.92, 95% confidence interval (CI): 1.14 - 3.21, P = 0.013), arm score (RR = 1.75, 95% CI: 1.02 - 3.01, P = 0.042) and age older than 75 years (RR = 1.36, 95% CI: 1.04 - 1.77, P = 0.025).

Conclusions

Achieving functional recovery during 6 months post stroke was related to age and motor improvement. With limited resources, continuity of rehabilitation training in the community system or allocation of caregiver training should be a part of discharge planning to promote recovery.

The Effect of Frailty on Discharge Location for Medicare Beneficiaries After Acute Stroke

OBJECTIVE

To examine the effect of frailty on poststroke discharge location with respect to stroke severity and create a risk-adjusted model for understanding the effects of frailty on discharge to an inpatient rehabilitation facility.

DESIGN

Retrospective cohort.

SETTING

A 2014 5% Medicare sample.

PARTICIPANTS

Patients hospitalized for a first-time acute ischemic stroke (N=7258).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

A prehospitalization 6-month baseline was used to calculate a frailty score. Logistic regression to predict odds of discharge to inpatient rehabilitation was used to calculate for 3 levels of baseline frailty, controlling for patient demographics, stroke severity, and comorbidities.

RESULTS

About 1603 patients were discharged to inpatient rehabilitation. Patients who were nonfrail (odds ratio [OR] 1.716; 95% confidence interval [95% CI], 1.463-2.013) or prefrail (OR 1.519; 95% CI, 1.296-1.779) were more likely to be discharged to inpatient rehabilitation. The final logistic regression model had a C-statistic of 0.63. Most of the patients discharged to inpatient rehabilitation were nonfrail (44.2%) and had moderate strokes (38.9%). Individuals who were frail and suffered a moderate (OR 0.78; 95% CI, 0.558-1.091) or severe stroke (OR 0.509; 95% CI, 0.358-0.721) were less likely to be discharged to an inpatient rehabilitation facility.

CONCLUSIONS

A lack of a claims-based measure for prestroke functional ability makes it difficult to understand discharge decision-making patterns for individuals' poststroke. Prestroke frailty was found to have a significant effect on predicating inpatient rehabilitation discharge after an acute stroke when controlling for stroke severity, comorbidities, and age. Further investigation is warranted to examine differences in rehabilitation utilization based on frailty and to quantify the effect of rehabilitation on frailty status in individuals poststroke.

The new frontiers of rehabilitation medicine in people with chronic disabling illnesses

Because of the demographic shift and the increased proportion of patients surviving acute critical illnesses, the number of people living with severely disabling chronic diseases and, consequently, the demand for rehabilitation are expected to increase sharply over time. As underscored by the World Health Organization, there is substantial evidence that the provision of inpatient rehabilitation in specialized rehabilitation units to people with complex needs is effective in fostering functional recovery, improving health-related quality of life, increasing independence, reducing institutionalization rate, and improving prognosis. Recent studies in the real world setting reinforce the evidence that patients with ischemic heart disease or stroke benefit from rehabilitation in terms of improved prognosis. In addition, there is evidence of the effectiveness of rehabilitation for the prevention of functional deterioration in patients with complex and/or severe chronic diseases. Given this evidence of effectiveness, rehabilitation should be regarded as an essential part of the continuum of care. Nonetheless, rehabilitation still is underdeveloped and underused. Efforts should be devoted to foster healthcare professional awareness of the benefits of rehabilitation and to increase referral and participation.

Discharge Destination from a Rehabilitation Unit After Acute Ischemic Stroke

Background: We reviewed numerous variables for ischemic stroke patients admitted to a rehabilitation unit to determine those that were statistically associated with discharge destination. Methods: A retrospective chart review of patients with ischemic stroke discharged from the rehabilitation unit between January 1, 2005 and December 31, 2015. Variables were examined for their association with discharge destination (home versus long-term care (LTC)). Univariable relationships with discharge destination were assessed, and a multivariable logistic regression model was built. Results: Univariate predictors of discharge to LTC: advanced age, decreasing admission and discharge functional independence measure (FIM) scores, increasing change in FIM score from admission to discharge, dependency, residence outside of home before the stroke, absence of a caregiver, urinary and bowel incontinence, low Berg balance score at admission and discharge, low Montreal Cognitive Assessment scores, smoking, chronic heart failure, and an inability to transfer. Multivariable logistic regression: five factors remained significant predictors with LTC disposition: advanced age, bowel incontinence, residence outside of the home prior to stroke, right hemisphere site of the stroke, and absence of a caregiver. Conclusions: Several easily measured variables were significantly associated with discharge to LTC versus home following stroke rehabilitation.

What factors affect clinical decision-making about access to stroke rehabilitation? A systematic review

Objectives:

To determine the factors affecting clinical decision-making about which patients should receive stroke rehabilitation.

Methods:

Data sources (MEDLINE, CINAHL, AMED and PsycINFO) were searched systematically from database inception to August 2018. Full-text English-language studies of data from stroke clinicians were included. Studies of patients were excluded. The included studies were any design focussed on clinical decision-making for referral or admission into stroke rehabilitation. Summary factors were compiled from each included study. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool.

Results:

After removing duplicates, 1915 papers were identified, of which 13 met the inclusion criteria. Eight included studies were qualitative and one used mixed methods. A total of 292 clinicians were included in the studies. Quality of the included studies was mixed. Patient-level and organizational factors as well as characteristics of individual clinicians contributed to decisions about rehabilitation. The most often described factors were patients’ pre- and poststroke function (n = 6 studies), presence of dementia (n = 6), patients’ social/family support (n = 6), organizational service pressures (n = 7) and the decision-making clinician’s own knowledge (n = 5) and emotions (n = 5).

Conclusion:

The results highlight a lack of clinical guidance to aid decision-making and reveal that a subjective approach to rehabilitation decision-making influenced by patient-level and organizational factors alongside clinicians’ characteristics occurs across services and countries.

Rehabilitation Outcomes of Patients With Severe Disability Poststroke

OBJECTIVE

To characterize rehabilitation outcomes of patients with severe poststroke motor impairment (MI) and develop a predictive model for treatment failure.

DESIGN

Retrospective cohort study. Correlates of treatment failure, defined as the persistence of severe MI after rehabilitation, were identified using logistic regression analysis. Then, an integer-based scoring rule was developed from the logistic model.

SETTING

Three specialized inpatient rehabilitation facilities.

PARTICIPANTS

Patients (N=1265) classified as case-mix groups (CMGs) 0108, 0109, and 0110 of the Medicare classification system.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Change in the severity of MI, as assessed by the FIM, from admission to discharge.

RESULTS

Median FIM-motor (FIM-M) score increased from 17 (interquartile range [IQR] 14-23) to 38 (IQR, 25-55) points. Median proportional recovery, as expressed by FIM-M effectiveness, was 26% (IQR, 12-47). Median FIM-M change was 18 (IQR, 9-34) points. About 38.5% patients achieved the minimal clinically important difference. Eighteen point six percent and 32.0% of the patients recovered to a stage of either mild (FIM-M ≥62) or moderate (FIM-M 38-61) MI, respectively. All between-CMG differences were statistically significant. Outcomes have also been analyzed according to classification systems used in Australia and Canada. The scoring rule had an area under the curve of 0.833 (95% confidence interval, 0.808-0.858). Decision curve analysis displayed large net benefit of using the risk score compared with the treat all strategy.

CONCLUSIONS

This study provides a snapshot of rehabilitation outcomes in a large cohort of patients with severe poststroke MI, thus filling a gap in knowledge. The scoring rule accurately identified the patients at risk for treatment failure.

Association of Urinary Incontinence with Cognition, Transfers and Discharge Destination in Acute Stroke Inpatient Rehabilitation

BACKGROUND

Acute-stroke prognostic indicators remain controversial including relationship of urinary incontinence with outcomes in cognition, transfers, and discharge destination.

OBJECTIVE

To examine if urinary incontinence is associated with inpatient-rehabilitation (IR) outcomes in cognition, transfers, and discharge destinations.

DESIGN

Retrospective observational study of 303 of 579(52%) acute-stroke patients admitted to IR 2012-2015 with complete urinary incontinence (total assistance for bladder management). Discharge Functional Independence Measure (FIM) scores were correlated for continence, cognition, transfers-(bed/chair/wheelchair), and discharge destination.

RESULTS

Patients were admitted to IR on average 7.4 days after acute stroke. Average length-of-stay in IR was 14 days. At discharge 118 of 303(39%) remained urinary incontinent (total assistance). Continence/bladder-management FIM scores at discharge were associated with cognition FIM scores at discharge (chi square =105.8; P < .0001), and associated with transfer FIM scores at discharge (chi square = 153.1; P < .0001). Patients total to moderate assistance for continence at discharge included greater percentage that were dependent to moderate assistance for cognition and transfers than those minimal assistance to independent for continence. Continence/bladder-management FIM scores at discharge were associated with discharge disposition destinations (chi square = 29.98; P < .002). Patients total to moderate assistance for continence at discharge included greater percentage of acute care transfers, and skilled-nursing-facility dispositions, than patients that recovered to minimal assist to independent for continence. Urinary-incontinence recovery to minimal assistance to independent was associated with a home/community disposition rate of 82%.

CONCLUSIONS

52% stroke patients were total assistance with bladder management for urinary incontinence on IR admission. Partial to complete continence recovery occurred in 61%. Continence/bladder-management FIM scores at discharge were associated with cognition and transfer FIM scores, and discharge destinations.

What do randomized controlled trials say about virtual rehabilitation in stroke? A systematic literature review and meta-analysis of upper-limb and cognitive outcomes

BACKGROUND

Virtual-reality based rehabilitation (VR) shows potential as an engaging and effective way to improve upper-limb function and cognitive abilities following a stroke. However, an updated synthesis of the literature is needed to capture growth in recent research and address gaps in our understanding of factors that may optimize training parameters and treatment effects.

METHODS

Published randomized controlled trials comparing VR to conventional therapy were retrieved from seven electronic databases. Treatment effects (Hedge's g) were estimated using a random effects model, with motor and functional outcomes between different protocols compared at the Body Structure/Function, Activity, and Participation levels of the International Classification of Functioning.

RESULTS

Thirty-three studies were identified, including 971 participants (492 VR participants). VR produced small to medium overall effects (g = 0.46; 95% CI: 0.33-0.59, p < 0.01), above and beyond conventional therapies. Small to medium effects were observed on Body Structure/Function (g = 0.41; 95% CI: 0.28-0.55; p < 0.01) and Activity outcomes (g = 0.47; 95% CI: 0.34-0.60, p < 0.01), while Participation outcomes failed to reach significance (g = 0.38; 95% CI: -0.29-1.04, p = 0.27). Superior benefits for Body Structure/Function (g = 0.56) and Activity outcomes (g = 0.62) were observed when examining outcomes only from purpose-designed VR systems. Preliminary results (k = 4) suggested small to medium effects for cognitive outcomes (g = 0.41; 95% CI: 0.28-0.55; p < 0.01). Moderator analysis found no advantage for higher doses of VR, massed practice training schedules, or greater time since injury.

CONCLUSION

VR can effect significant gains on Body Structure/Function and Activity level outcomes, including improvements in cognitive function, for individuals who have sustained a stroke. The evidence supports the use of VR as an adjunct for stroke rehabilitation, with effectiveness evident for a variety of platforms, training parameters, and stages of recovery.

Improved functions and reduced length of stay after inpatient rehabilitation programs in older adults with stroke: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

to examine the effects of inpatient rehabilitation programs on function and length of stay in older adults with strokeMETHODS: A total of five electronic databases were searched for relevant randomized controlled trials that examined the effects of inpatient rehabilitation programs on functional recovery, as measured by the functional independence measure and length of stay, which was measured in days. We included full-text articles written in English, and no time limit. The methodological quality and risk of bias were assessed using the Physiotherapy Evidence Database Scale and the Cochrane collaboration tools respectively. The effect sizes and confidence intervals were estimated using fixed-effect modelsRESULTS: Eight randomized controlled trials involving 1,910 patients with stroke were included in the meta-analysis showed that patients who participated in the inpatient rehabilitation programs had significantly (p less than 0.05) higher functional independence measure scores (effect size = 0.10; 95 percent confidence interval = 0.01, 0.22) and shorter length of stay (effect size = 0.14; 95 percent confidence interval = 0.03, 0.22).

CONCLUSIONS

This systematic review provided evidence that inpatient rehabilitation programs have beneficial effects, improving functionality and reducing length of stay for older adults with stroke.

Immunity and inflammation predictors for short-term outcome of stroke in young adults

BACKGROUND

The current study was conducted to identify independent predictors of severity and short-term outcome of first-ever ischemic stroke in young adults.

METHODS

We retrospectively enrolled 325 consecutive patients aged 18-49 years with first-ever ischemic stroke admitted to our center between April 2013 and June 2015. Variables were systematically registered and compared between patients with different neurological severity (mild stroke: National Institutes of Health Stroke Scale [NIHSS] ≤ 8 and severe stroke: >8) and different stroke outcome (favorable: modified Rankin scale score 0-2 and unfavorable: 3-5 or death) at 14 days after stroke onset.

RESULTS

A total of 325 patients fulfilled the inclusion criteria. There were 242 patients with mild stroke. They exhibited lower white blood cell (WBC), globulin, plasma glucose, fibrinogen (Fib) levels and higher albumin, albumin/globulin (A/G), free triiodothyronine (FT3) levels. Logistic regression analysis showed that FT3 (≧3.18) and WBC (≧7.1) were independent predictors. There were 122 patients demonstrating an unfavorable outcome. Higher WBC, globulin, plasma glucose and Fib levels, lower albumin, FT3, A/G levels, higher NIHSS score and longer hospital stay were significantly associated with unfavorable outcome. In the logistic regression model, we found that A/G (≧1.56), FT3 (≧4.09) and WBC (≧7.1) were independent predictors for short-term outcome.

CONCLUSIONS

Our data suggested that higher A/G, FT3 levels served as independent predictors of favorable outcome, and a higher FT3 value may also predict mild stroke, while higher WBC may predict a poor functional outcome and severe stroke in patients with acute ischemia.

Healthcare resource utilization and clinical outcomes associated with acute care and inpatient rehabilitation of stroke patients in Japan

Objective

To investigate healthcare resource utilization and changes in functional status in stroke patients during hospitalization in an acute hospital and a rehabilitation hospital.

Design

Retrospective cohort study.

Setting

One acute and one rehabilitation hospital in Japan.

Participants

Patients who were admitted to the acute hospital due to stroke onset and then transferred to the rehabilitation hospital (n = 263, 56% male, age 70 ± 12 years).

Main outcome measures

Hospitalization costs and functional independence measure (FIM) were evaluated according to stroke subtype and severity of disability at discharge from the acute hospital.

Results

Median (IQR) costs at the acute hospital were dependent on the length of stay (LOS) and implementation of neurosurgery, which resulted in higher costs in subarachnoid hemorrhage [$52 413 ($49 166-$72 606) vs $14 129 ($11 169-$19 459) in cerebral infarction; and vs $15 035 ($10 920-$21 864) in intracerebral hemorrhage]. The costs at the rehabilitation hospital were dependent on LOS, and higher in patients with moderate disability than in those with mild disability [$30 026 ($18 419-$39 911) vs $18 052 ($10 631-$24 384)], while those with severe disability spent $25 476 ($13 340-$43 032). Patients with moderate disability gained the most benefits during hospitalization in the rehabilitation hospital, with a median (IQR) total FIM gain of 16 (5-24) points, compared with a modest improvement in patients with mild (6, 2-14) or severe disability (0, 0-5).

Conclusions

The costs for in-hospital stroke care were substantial and the improvement in functional status varied by severity of disability. Our findings would be valuable to organize efficient post-acute stroke care.

The organisation of physiotherapy for people with multiple sclerosis across Europe: a multicentre questionnaire survey

BACKGROUND

Understanding the organisational set-up of physiotherapy services across different countries is increasingly important as clinicians around the world use evidence to improve their practice. This also has to be taken into consideration when multi-centre international clinical trials are conducted. This survey aimed to systematically describe organisational aspects of physiotherapy services for people with multiple sclerosis (MS) across Europe.

METHODS

Representatives from 72 rehabilitation facilities within 23 European countries completed an online web-based questionnaire survey between 2013 and 2014. Countries were categorised according to four European regions (defined by United Nations Statistics). Similarities and differences between regions were examined.

RESULTS

Most participating centres specialized in rehabilitation (82 %) and neurology (60 %), with only 38 % specialising in MS. Of these, the Western based Specialist MS centres were predominately based on outpatient services (median MS inpatient ratio 0.14), whilst the Eastern based European services were mostly inpatient in nature (median MS inpatient ratio 0.5). In almost all participating countries, medical doctors - specialists in neurology (60 %) and in rehabilitation (64 %) - were responsible for referral to/prescription of physiotherapy. The most frequent reason for referral to/prescription of physiotherapy was the worsening of symptoms (78 % of centres). Physiotherapists were the most common members of the rehabilitation team; comprising 49 % of the team in Eastern countries compared to approximately 30 % in the rest of Europe. Teamwork was commonly adopted; 86 % of centres based in Western countries utilised the interdisciplinary model, whilst the multidisciplinary model was utilised in Eastern based countries (p = 0.046).

CONCLUSION

This survey is the first to provide data about organisational aspects of physiotherapy for people with MS across Europe. Overall, care in key organisational aspects of service provision is broadly similar across regions, although some variations, for example the models of teamwork utilised, are apparent. Organisational framework specifics should be considered anytime a multi-centre study is conducted and results from such studies are applied.

A retrospective observational study of functional outcomes, length of stay, and discharge disposition after an inpatient stroke rehabilitation program in Saudi Arabia

Functional outcomes, length of stay (LOS), and discharge disposition have become frequent outcome measures among stroke patients after rehabilitation programs. To examine the trends of changes in functional outcomes, LOS, and discharge disposition in stroke patients discharged from an inpatient rehabilitation facility.All patients (n = 432) were admitted to a tertiary inpatient rehabilitation hospital in Riyadh, Saudi Arabia with stroke diagnoses from November 2008 to December 2014. The functional independence measure (FIM) instrument used to assess the patient's functional status. The LOS was measured as the number of days the patients spent in the hospital from the day of admission to the day of discharge. The FIM efficiency was used to measure the patient's rehabilitation progress. All of the variables of the prospectively collected data were retrospectively analyzed.There were significant changes by years in the total FIM ranging from 23 to 29 (P < 0.001) and subscores: FIM motor ranging from 20 to 26 (P < 0.001); FIM cognitive ranging from 1.8 to 3 (P < 0.001). The mean LOS remained constant, from 52 days in 2011 to 40 days in 2013. The FIM efficiency was stable between years and ranged from 0.52 to 0.72. The rates of discharge (to home) were significantly unstable and ranged from 100% in 2010 and 2011 to 92% in 2013.Our results suggest that functional outcomes in patients with stroke have improved after an inpatient stroke rehabilitation program between 2008 and 2014 even with a constant LOS. Discharge disposition has remained unstable over this period. To improve the efficiency of the stroke rehabilitation program in Saudi Arabia, there is a need to decrease the LOS and emphasize a comprehensive interdisciplinary approach.

Physiatrist referral preferences for postacute stroke rehabilitation

This study was intended to determine if there is variation among physiatrists in referral preferences for postacute rehabilitation for stroke patients based on physician demographic characteristics or geography.A cross-sectional survey study was developed with 5 fictional case vignettes that included information about medical, social, and functional domains. Eighty-six physiatrist residents, fellows, and attendings were asked to select the most appropriate postacute rehabilitation setting and also to rank, by importance, 15 factors influencing the referral decision. Chi-square bivariate analysis was used to analyze the data.Eighty-six surveys were collected over a 3-day period. Bivariate analysis (using chi-square) showed no statistically significant relationship between any of the demographic variables and poststroke rehabilitation preference for any of the cases. The prognosis for functional outcome and quality of postacute facility had the highest mean influence ratings (8.63 and 8.31, respectively), whereas location of postacute facility and insurance had the lowest mean influence ratings (5.74 and 5.76, respectively).Physiatrists' referral preferences did not vary with any identified practitioner variables or geographic region; referral preferences only varied significantly by case.

Genetics as a molecular window into recovery, its treatment, and stress responses after stroke

Stroke remains a major source of adult disability in the USA and worldwide. Most patients show some recovery during the weeks to months following a stroke, but this is generally incomplete. An emerging branch of therapeutics targets the processes underlying this behavioral recovery from stroke toward the goal of reducing long-term disability. A key factor hampering these efforts is the very large degree of variability between stroke survivors. Available data suggest that genetic differences could explain an important fraction of the differences between subjects. The current review considers this from several angles, including genetic differences in relation to drugs that promote recovery. Genetic factors related to physiological and psychological stress responses may also be critically important to understanding recovery after stroke and its treatment. The studies reviewed provide insights into recovery and suggest directions for further research to improve clinical decision-making in this setting. Genetic differences between patients might be used to help clinical trials select specific patient subgroups, on a biological basis, in order to sharpen the precision with which new treatments are evaluated. Pharmacogenomic factors might also provide insights into inter-subject differences in treatment side effects for pharmacological prescriptions, and behavioral interventions, and others. These efforts must be conducted with the strictest ethical standards given the highly sensitive nature of genetic data. Understanding the effect of selected genetic measures could improve a clinician's ability to predict the risk and efficacy of a restorative therapy and to make maximally informed decisions, and in so doing, facilitate individual patient care.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).