Reconsidering the value of rehabilitation for patients with cerebrovascular disease in Japanese acute health care hospitals

Effectiveness of early rehabilitation interventions in patients with traumatic brain injury using a large database

BACKGROUND

Rehabilitation is important for patients with moderate-to-severe traumatic brain injury (TBI). However, the timing of early rehabilitation initiation is ambiguous, and its safety and effectiveness are unknown.

OBJECTIVE

To examine the effectiveness and safety of early rehabilitation in patients with moderate-to-severe TBI using propensity score analysis and a large database.

DESIGN

Retrospective cohort study.

SETTING

A large medical database (JMDC database) of tertiary care facilities was used to compare outcomes of early and delayed rehabilitation.

PATIENTS

Patients aged between 20 and 90 years who were diagnosed with TBI were admitted to acute care hospitals. Inclusion criteria were patients undergoing rehabilitation within 7 days of admission with a Glasgow Coma Scale score of 3 to 12 on admission. This study included 3074 patients with moderate-to-severe TBI.

INTERVENTIONS

Patients were classified into an early rehabilitation group (within 2 days of admission) or a delayed rehabilitation group (3 to 7 days postadmission), depending on when rehabilitation started after TBI. Rehabilitation was defined as any type or intensity of intervention provided by a physical, occupational, and/or speech/language therapist. Interventions were not controlled.

MAIN OUTCOME MEASURE(S)

The primary outcome was Barthel Index (BI) efficiency (BI gain/length of stay). Secondary outcomes included BI gain (discharge BI - admission BI), incidence of aspiration pneumonia complications during hospitalization, discharge to home, mortality, and length of stay.

RESULTS

After applying inverse probability weighting with propensity scores, the total was 6152 patients. 3074 (50.0%) patients received early rehabilitation. The early rehabilitation group showed no difference in inpatient mortality (p = .438), improved BI efficiency (β = 0.86, p < .001), and shorter length of stay (β = -5.00, p = .018).

CONCLUSIONS

Early rehabilitation in patients with moderate-to-severe TBI is associated with more efficient functional improvement and reduced hospital stays without an increase in inpatient mortality.

[The early post-stroke mobilization]

Early mobilization is an important prerequisite for the successful recovery after stroke. However, it is unclear at present how early mobilization should be started after stroke. Three randomized controlled trials were devoted to the comparison of the effectiveness and safety of very early (within the first day after stroke) and early (within two days after stroke) mobilization. The meta-analysis of the results of these studies did not reveal any advantages of very early mobilization over early mobilization. One randomized control study was designed to compare the consequences of mobilization within 3 and 7 days after stroke. It has demonstrated that earlier mobilization is associated with fewer complications and does not exert negative effect on cerebral haemodynamics. A number of observational studies confirmed the positive effect of early mobilization on the outcome of stroke. It is concluded that it may be justified to start mobilization on the second day after stroke provided there are no contraindications to such modality. The practicability of very early mobilization remains to be elucidated.

When Should Physical Rehabilitation Commence after Stroke: A Systematic Review

Background

Knowing when to commence physical rehabilitation after stroke is important to ensure optimal benefit for stroke survivors and efficient health care. The aims of this review were to: determine the effects on mortality, function and complications when physical rehabilitation commences ‘early’ (within seven days of stroke); and describe the effects of early transfer to rehabilitation wards/hospitals when sustained rehabilitation is unavailable in acute stroke units.

Review summary

From 3751 potential articles we included 5 randomized controlled trials and 38 cohort studies. Meta-analysis was performed with 3 randomized controlled trials involving 159 people to investigate the effects of commencing physical rehabilitation within 24 h of stroke compared to 48 h. Commencing physical rehabilitation within 24 h trended towards greater mortality (Mantel-Haenszel odds ratio 2·58; 95% confidence interval 0·98 to 6·79, P = 0·06), with no differences in complications or health outcomes. The cohort studies provided evidence of benefits when physical rehabilitation was commenced on the day of admission ( n = 1), within 3 days of stroke ( n = 3), or ‘sooner rather than later’ (3 of 4 studies). The effect of earlier transfer to rehabilitation was reported in 32 cohort studies. In 23/26 (88%) cohort studies that accounted for age and stroke severity, results favored earlier transfer for improving post-stroke function, with no consensus on timeframes.

Conclusion

In summary, the benefits of commencing physical rehabilitation within 24 h of stroke remain unclear from the current literature. Commencing physical rehabilitation or transferring to rehabilitation services ‘early’ may provide better functional outcomes.