What is the association between the different components of stroke rehabilitation and health outcomes?

Optimising Stroke Outcomes through Evidence-Based Nursing Practice: An Australian Perspective

Stroke is the third leading cause of death of people in the world today and the highest cause of disability and handicap, producing a huge burden on individuals and society more broadly. Yet unlike its counterpart acute myocardial infarction (AMI), little has been done to promote early intervention in evolving strokes. Recommendations from the American Heart Association and more recently the European Stroke Initiative are available; however, in Australia (as with many other countries) practice guidelines are scarce and clinicians largely operate in an ad hoc manner with little awareness of ‘best practice’. The controversial role of thrombolysis with limitations in respect to selecting appropriate patients, in addition to a small window of opportunity for therapeutic beneficial effects and a high risk for haemorrhage, has inhibited its widespread application. As such, emergent stroke management clearly lags behind that of AMI–both with respect to the range of treatment options and the application of best practice. This paper reviews the literature regarding best practice management of evolving stroke and the crucial role of nurses in triaging and managing patients to deliver optimal outcomes within the Australian context.

Stroke Rehabilitation 2007: What Should it Be?

Background

There are an estimated 62 million stroke survivors worldwide. The majority will have long-term disability. Despite this reality, there have been few large, high-quality randomized controlled trials of stroke rehabilitation interventions.

Summary of review

There is excellent evidence for the effectiveness of a number of stroke rehabilitation interventions, notably care of stroke patients in inpatient stroke units and stroke rehabilitation units providing organized, goal-focused care via a multidisciplinary team. Stroke units (in comparison with care on general medical wards) effectively reduce death and disability with the number needed to treat to prevent one person from failing to regain independence being 20. Unfortunately, only a minority of stroke patients have access to stroke unit care. The key principles of effective stroke rehabilitation have been identified. These include ( 1 ) a functional approach targeted at specific activities e.g. walking, activities of daily living, ( 2 ) frequent and intense practice, and ( 3 ) commencement in the first days or weeks after stroke.

Conclusion

The most effective approaches to restoration of brain function after stroke remain unknown and there is an urgent need for more high-quality research. In the meantime, simple, broadly applicable stroke rehabilitation interventions with proven efficacy, particularly stroke unit care, must be applied more widely.

Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke

Purpose—

To critically review and evaluate the science behind individual eligibility criteria (indication/inclusion and contraindications/exclusion criteria) for intravenous recombinant tissue-type plasminogen activator (alteplase) treatment in acute ischemic stroke. This will allow us to better inform stroke providers of quantitative and qualitative risks associated with alteplase administration under selected commonly and uncommonly encountered clinical circumstances and to identify future research priorities concerning these eligibility criteria, which could potentially expand the safe and judicious use of alteplase and improve outcomes after 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 Stroke Council’s Scientific Statement Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge and, when appropriate, formulated recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on and approved the final version of this document. The document underwent extensive American Heart Association internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.

Results—

After a review of the current literature, it was clearly evident that the levels of evidence supporting individual exclusion criteria for intravenous alteplase vary widely. Several exclusionary criteria have already undergone extensive scientific study such as the clear benefit of alteplase treatment in elderly stroke patients, those with severe stroke, those with diabetes mellitus and hyperglycemia, and those with minor early ischemic changes evident on computed tomography. Some exclusions such as recent intracranial surgery are likely based on common sense and sound judgment and are unlikely to ever be subjected to a randomized, clinical trial to evaluate safety. Most other contraindications or warnings range somewhere in between. However, the differential impact of each exclusion criterion varies not only with the evidence base behind it but also with the frequency of the exclusion within the stroke population, the probability of coexistence of multiple exclusion factors in a single patient, and the variation in practice among treating clinicians.

Dependence in Prestroke Mobility Predicts Adverse Outcomes Among Patients With Acute Ischemic Stroke

Background and Purpose— Stroke survivors are commonly dependent in activities of daily living; however, the relation between prestroke mobility impairment and poststroke outcomes is poorly understood. The primary objective of this study was to evaluate the association between prestroke mobility impairment and 4 poststroke outcomes. The secondary objective was to evaluate the association between prestroke mobility impairment and a plan for physical therapy.

Methods— This was a secondary analysis of the National Stroke Project data, a retrospective cohort of Medicare beneficiaries who were hospitalized with an acute ischemic stroke (1998 to 2001). Logistic-regression modeling was used to examine the adjusted association between prestroke mobility impairment with patient outcomes and a plan for physical therapy.

Results— Among the 67 445 patients hospitalized with an ischemic stroke, 6% were dependent in prestroke mobility. Prestroke mobility dependence was independently associated with an increased odds of poststroke mobility impairment (odds ratio [OR]=9.9; 95% CI, 9.0 to 10.8); in-hospital mortality (OR=2.4; 95% CI, 2.2 to 2.7); discharge to a skilled nursing facility (OR=3.5; 95% CI, 3.2 to 3.8); and the combination of in-hospital death or discharge to a skilled nursing facility (OR=3.5; 95% CI, 3.3 to 3.8). Prestroke mobility dependence was independently associated with a decreased odds of having a plan for physical therapy (OR=0.79; 95% CI, 0.73 to 0.85).

Conclusions— These data, obtained from a large, geographically diverse cohort from the United States, demonstrate a strong association between dependence in prestroke mobility and adverse outcomes among elderly stroke patients. Clinicians should screen patients for prestroke mobility impairment to identify patients at greatest risk for adverse events.

Validation of an Item Bank in a Sample of Community-Dwelling Survivors of a Stroke

PURPOSE

The purpose of this study was to validate an item bank of questions associated with activities of daily living (ADL), using graded item response theory (G-IRT), in a sample of community-dwelling survivors of a stroke.

METHODS

The study sample consisted of 364 community-dwelling individuals who reported a recent history of stroke. Sixteen line items from the 1999-2000 National Health and Nutrition Examination Surveys (NHANES) survey were analyzed using factor analysis, internal analyses of consistency, and G-IRT.

RESULTS

The 16 line items demonstrated unidimensionality and were internally reliable. Thirteen line items demonstrated good discrimination and suitable thresholds. The majority of items exhibited appropriate sensitivity across the entire spectrum of functional severity indicating that these items closely reflected the relationship of decreased function with increased severity of illness.

CONCLUSION

Each of the 13 items is scale independent, is valid for measurement of functional impairment, and may be applicable for use in a scale for assessment of functional change in community-dwelling stroke survivors.

Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better?

Horn SD, DeJong G, Smout RJ, Gassaway J, James R, Conroy B. Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better?

OBJECTIVE

To examine associations of patient characteristics, rehabilitation therapies, neurotropic medications, nutritional support, and timing of initiation of rehabilitation with functional outcomes and discharge destination for inpatient stroke rehabilitation patients.

DESIGN

Prospective observational cohort study.

SETTING

Five U.S. inpatient rehabilitation facilities.

PARTICIPANTS

Post-stroke rehabilitation patients (N=830; age, >18 y) with moderate or severe strokes, from the Post-Stroke Rehabilitation Outcomes Project database.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Discharge total, motor, and cognitive FIM scores and discharge destination.

RESULTS

Controlling for patient differences, various activities and interventions were associated with better outcomes including earlier initiation of rehabilitation, more time spent per day in higher-level rehabilitation activities such as gait, upper-extremity control, and problem solving, use of newer psychiatric medications, and enteral feeding. Several findings part with conventional practice, such as starting gait training in the first 3 hours of physical therapy, even for low-level patients, was associated with better outcomes.

CONCLUSIONS

Specific therapy activities and interventions are associated with better outcomes. Earlier rehabilitation admission, higher-level activities early in the rehabilitation process, tube feeding, and newer medications are associated with better stroke rehabilitation outcomes.

Applying the clinical practice improvement approach to stroke rehabilitation: methods used and baseline results

Gassaway J, Horn SD, DeJong G, Smout RJ, Clark C, James R. Applying the clinical practice improvement approach to stroke rehabilitation: methods used and baseline results.

OBJECTIVES

To describe the methods used and baseline data for the Post-Stroke Rehabilitation Outcomes Project (PSROP).

DESIGN

Prospective observational cohort study.

SETTING

Seven inpatient rehabilitation facilities (IRFs) in the United States and New Zealand.

PARTICIPANTS

Consecutive convenience sample of 1291 poststroke rehabilitation patients, age older than 18, who were treated between 2001 and 2003 in 7 IRFs (1161 patients in 6 U.S. IRFs).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Change in FIM score, change in severity of illness, and discharge destination.

RESULTS

For the U.S. sample, the average age was 66 years, 52% were men, 60% were white, and 23% were black. Medicare was the most frequent payer. Seventy-seven percent of strokes were ischemic, with 43% in the left brain, 44% in the right brain, and 11% bilateral. Mean admission total FIM score was 61, with a mean motor FIM score of 40 and mean cognitive FIM score of 21. Lower FIM scores are associated with higher severity-of-illness scores. Mean rehabilitation length of stay was 18.6 days; 78% of patients were discharged home. At discharge, the average increase in total FIM score was 26, in motor FIM score was 22, and in cognitive FIM score was 4.

CONCLUSIONS

This article outlines methods used in the PSROP, provides an overview of participating IRFs, describes the database, and summarizes key characteristics to enable readers of subsequent articles to better interpret study findings and determine generalizability.

Physical Therapy During Stroke Rehabilitation for People With Different Walking Abilities

Latham NK, Jette DU, Slavin M, Richards LG, Procino A, Smout RJ, Horn SD. Physical therapy during stroke rehabilitation for people with different walking abilities.

OBJECTIVE

To describe how physical therapy (PT) activities during post-stroke inpatient rehabilitation vary by admission walking ability and over time.

DESIGN

Observational cohort study.

SETTING

Six inpatient rehabilitation hospitals in the United States.

PARTICIPANTS

People receiving post-stroke PT (N=715) who were classified as walking at admission.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Percentage of time spent in 11 activities, percentage of patients who participated in each activity, and the FIM instrument scores.

RESULTS

The majority of PT time was spent in gait activities. Even people with the most limited mobility spent 25% to 38% of PT time in gait activities during the first 6-hour treatment block. Treatment progression was evident, and a shift to more advanced activities occurred over time (eg, less bed mobility and more advanced gait). However, even in the final 6-hour block, a small proportion of time was spent on community mobility activities (1.2%-5.2%), and most people received no community mobility training.

CONCLUSIONS

PT activities focused on specific functional tasks at the ability level of each individual patient and provided higher-level activities as patients improved their function. However, although there is increasing recognition that the environment influences task performance, little time was spent in community mobility activities before discharge.

Characterizing Occupational Therapy Practice in Stroke Rehabilitation

Richards LG, Latham NK, Jette DU, Rosenberg L, Smout RJ, DeJong G. Characterizing occupational therapy practice in stroke rehabilitation.

OBJECTIVES

To describe how occupational therapy (OT) activities during stroke inpatient rehabilitation vary by admission functional status and over time and how time spent in these various activities relates to functional status at discharge.

DESIGN

Observational cohort study.

SETTING

Six inpatient rehabilitation hospitals in the United States.

PARTICIPANTS

People (N=713) receiving 4 to 19 hours of post-stroke OT.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Patients were categorized by number of 4-hour blocks of OT received and by admission upper-extremity (UE) dressing score on the FIM instrument. In each group, the percentage of time spent in 16 activities and the percentage of patients who received each activity were calculated. The amount of time in activities was compared for those patients scoring 1 or 2 at admission who achieved at least a level of supervision for UE dressing (a score of >or=5) using Wilcoxon 2-sample tests.

RESULTS

The majority of OT time was spent in impairment-focused activities (37.5%) or training basic activities of daily living (31.9%). Treatment progressed to more advanced activities over time (eg, less bed mobility, more home management), yet little time was spent on community integration or leisure activities and with very few patients. Successful patients received more higher-level activities, whereas unsuccessful patients received larger amounts of basic-level activities.

CONCLUSIONS

OT activities focused on a combination of remediating impairments and retraining specific functional tasks, at the ability level of each individual patient, and provided higher-level activities as patients improved their function. More time in higher-level activities was related to greater success in rehabilitation. However, higher-level activities remain the least common activities provided during inpatient rehabilitation.

Timing of Initiation of Rehabilitation After Stroke

Maulden SA, Gassaway J, Horn SD, Smout RJ, DeJong G. Timing of initiation of rehabilitation after stroke.

OBJECTIVE

To study associations between days from stroke symptom onset to rehabilitation admission and rehabilitation outcomes, controlling for a variety of confounding variables.

DESIGN

Observational cohort study of 200 consecutive post-stroke rehabilitation patients in each of 6 inpatient rehabilitation facilities.

SETTING

Six U.S. inpatient rehabilitation hospitals.

PARTICIPANTS

Patients (N=969) with moderate or severe strokes who had days from stroke symptom onset to rehabilitation admission recorded in their medical records.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Discharge total FIM, discharge motor FIM, discharge activities of daily living (ADL) FIM, and discharge mobility FIM scores, as well as rehabilitation length of stay (LOS).

RESULTS

Fewer days from stroke symptom onset to rehabilitation admission was associated significantly with better functional outcomes: higher total, motor, mobility, and ADL discharge FIM scores, controlling for confounding variables. For severely impaired patients with stroke in case-mix groups (CMGs) 108-114, the relation was strongest, with F statistics greater than 24.1 for each functional outcome. For patients with moderately severe stroke in CMGs 104-107, fewer days from stroke symptom onset to rehabilitation admission was associated significantly with shorter rehabilitation LOS.

CONCLUSIONS

Fewer days from stroke symptom onset to rehabilitation admission is associated with better functional outcomes at discharge and shorter LOS.

Late multidisciplinary rehabilitation in young people after stroke

PURPOSE

Stroke has a major impact on physical and cognitive ability, and quality of life. This study aims to examine the effect of multidisciplinary rehabilitation on outcome in an Irish young stroke population.

METHODS

Fifty consecutive patients younger than 65 were prospectively recruited to this observational study. Physical and cognitive ability, and quality of life were measured on admission and discharge.

RESULTS

All patients were transferred to the rehabilitation unit from the acute hospital where they had received their initial management. Median length of time from stroke onset to transfer was 112 days. After a median of 70 days, 43 patients were discharged home. Patients made significant gains in physical (Barthel index 12 to 18) and cognitive ability (mini-mental state examination 22 to 25). Quality of life improved in all eight domains of the 36-items Short Form with four domains returning to level seen in the general population.

CONCLUSIONS

This study documents the improvements in physical and cognitive abilities, and quality of life in a sample of patients in rehabilitation. A comprehensive rehabilitation programme that includes acute and late multidisciplinary phases can improve the outcome of patients following stroke.

Rules for rehabilitation: an agenda for research

Rehabilitation services have grown tremendously in the United States over the past 2 decades. Rules originally designed to guide Medicare reimbursement policies have had substantial effects in shaping the design of clinical services. This article traces the development of the most significant federal rules regarding rehabilitation, outlines the existing empirical evidence to support these rules, and discusses an agenda for research to improve the evidence for future policy development.

Measurement properties of the short form (SF)-12 applied to patients with stroke

The purpose of this study was to examine the reliability and validity of the Short Form (SF)-12 and to determine its ability to detect changes in health related quality of life (HRQOL) following stroke. The study involved a cohort of 90 patients admitted with an ischemic stroke to a hospital in the northeastern United States. The items of the SF-12 were found to be reliable (alpha=0.833-0.894) and to load on a physical and mental component. Three months post-stroke the physical component summary (PCS) scores of the SF-12 were significantly less than population norms. The PCS scores were also lower after stroke (3 month=42.5, 12 month=46.3) than before stroke (48.8). Mental component summary (MCS) scores did not differ significantly from population norms or across time (range=53.6 to 54.9). We conclude that the reliability and validity of the SF-12, as well as its brevity and capacity to document changes in the physical component of HRQOL, provide support for its use in patients with stroke.

Psychometric properties of the SF-36 in the early post-stroke phase

BACKGROUND

Patients who have had a stroke are a large group in whom long-term disability is common and therefore impaired general health is likely. The Short Form 36 (SF-36) is a popular measure of general health that has been used with this patient group, but not all aspects of its psychometric properties have been established for use in this context, and its use in the early post-stroke phase has been neglected.

AIMS

To examine the reliability, validity and sensitivity to change of the SF-36 (UK version I) in patients in the early post-stroke period.

DESIGN

A prospective, observational study of stroke outcomes was carried out.

RESEARCH METHODS

From May 1996 to April 1997, patients who had had a stroke were identified by 24 general practices in Scotland and were recruited within 1 month of their stroke, whether in hospital or at home. Outcome measures including the SF-36 were administered at one, 3 and 6 months after onset.

RESULTS

The internal consistency of the eight subscales at all three time-points was good except for 1 month Vitality (alpha = 0.6824) and 3 month General Health (alpha = 0.6650), which were borderline in comparison with the criterion value of 0.7. Construct validity was adequate overall, although correlations between Role Physical and General Health and the Barthel Index and Canadian Neurological Scale were lower than hypothesized. Most SF-36 subscales were sensitive to change between 1 and 3 months post-stroke, but none detected change between 3 and 6 months.

CONCLUSIONS

There were some practical problems in using the SF-36 in an acutely unwell stroke population. However, analysis of psychometric properties suggested that most of the subscales were adequately reliable and valid. Sensitivity to change was poorer in the later stages of the study.

Modern stroke unit

The modern stroke unit is making significant contributions to the care of stroke victims and is proving to be an effective, cost-saving enterprise. The precise factors that contribute to the efficacy of these units have yet to be identified, but a combination of protocolized approaches to patient care, critical paths, a focus of expertise, and heightened index of suspicion for comorbidities all probably play a role. This article outlines the basic features of a modern stroke unit and surveys the literature on stroke unit outcomes.