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Integrating Evidence into Clinical Practice in Stroke Rehabilitation: The Forgotten Revolution Robert Teasell MD FRCPC Professor and Chair-Chief Physical Medicine & Rehabilitation. Objectives. Understand the evidence for why stroke rehabilitation works

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Integrating Evidence into Clinical Practice in Stroke Rehabilitation: The Forgotten RevolutionRobert Teasell MD FRCPC Professor and Chair-ChiefPhysical Medicine & Rehabilitation

  • Understand the evidence for why stroke rehabilitation works
  • Appreciate the gaps between real-life practice and the evidence
  • Build support for evidence-based practice and innovation
the forgotten revolution in stroke rehabilitation
The Forgotten Revolution in Stroke Rehabilitation
  • Stroke rehab works!
  • Once stroke occurs rehab offers best opportunity for improving outcomes
  • Confluence of animal and clinical evidence (almost 500 RCTs) points to efficacy and benefits of investing in stroke rehab
  • Demand for stroke rehab is increasing
  • Good care saves money and improves lives
  • Stroke rehab should be transforming!
the forgotten revolution in stroke rehabilitation5
The Forgotten Revolution in Stroke Rehabilitation
  • Evidence is being ignored
  • We have an antiquated and increasingly inadequate system
  • Stroke rehab not changed in 4 decades
  • Undervalued and organized in an ad hoc fashion
  • Not rehabilitating at the right time, in the right place with the right treatment
  • Need system change and reinvestment!
psrop post stroke rehabilitation outcomes project
PSROP (Post-Stroke Rehabilitation Outcomes Project)
  • Study of 7 stroke rehab centers (6 in United States, n=1161; 1 in New Zealand, n=130)
  • Comprehensive study of stroke rehabilitation examining the “black box”
  • Compare with IBM Data of Canadian Centers (most in Ontario)
what do the psrop u s centers do differently fim efficiency 2 5x
What do the PSROP (U.S.) Centers Do Differently? (FIM efficiency 2.5X)
  • Pts get admitted to specialized inter-disciplinary stroke rehab units
  • Admitted earlier and more disabled
  • More intensive therapy (incl. W/E)
  • Less time in assessments
  • Move to high level tasks early
  • Well developed outpatient services
  • Apply best-evidence to save money!
meta analysis of rcts
Meta analysis of RCTs

29 trials (6536 patients)

  • Mortality at 1 year 0.86 (0.71-0.94)
  • Death or dependence 0.78 (0.68-0.89)
  • Death or institution 0.80 (0.71-0.90)

Independent of age and gender

Trials primarily acute-subacute rehab or subacute rehab

indredavik et al 1990 combined acute subacute stroke unit
Indredavik et al. (1990) (Combined acute-subacute stroke unit)
  • Randomized 220 acute strokes to Stroke Unit or General Medical Unit
  • Maintained treatment for 6 weeks
  • Outcomes: home vs institution, mortality, Barthel index - at 6 and 52 weeks, 5 and 10 years
indredavik et al 1990 at 6 weeks
Indredavik et al. (1990) at 6 weeks

Significant benefit still seen at 10 years

ronning and guldvog 1998 subacute rehab unit
Ronning and Guldvog (1998) (Subacute rehab unit)
  • Randomized Controlled Trial
  • n = 251 stroke patients
  • Inpatient rehab unit (RU) vs. ad-hoc care in community (CR)
ronning and guldvog 1998
Ronning and Guldvog (1998)


  • Acute stay 10 days – randomized to treatment (rehab) or control (community care)
  • Rehab Unit LOS = 27.8 days
  • Community Care - 40% nursing home, 30% outpatient therapy, 30% no formal rehab treatment
ronning and guldvog 199816
Ronning and Guldvog (1998)


  • 7 month follow-up for all stroke patients
  • Dependent (BI < 75) or dead - 23% vs 38% (p=.01)
  • 39% reduction in worse outcomes with stroke rehab
r nning guldvog 1998 moderate to severe strokes
Rønning & Guldvog (1998) Moderate to Severe Strokes
  • Moderate to severe stroke (BI<50) (n=114):
  • 62% CR vs 32% RU dead or dependent (p=.002)
  • 48% reduction in bad outcomes
  • Barthel Index scores - 90 vs. 73 (p=.005)
r nning guldvog 1998 mild strokes do not benefit from rehab
Rønning & Guldvog (1998)Mild Strokes do not benefit from Rehab

BI Score > 50 at time of admission to rehabilitation



% Patients








stroke rehab units
Stroke Rehab Units
  • Specialized interdisciplinary stroke rehabilitation results in improved functional outcomes and less mortality
  • Moderate to severe stroke patients make the greatest improvement
  • Milder strokes can be rehabilitated in community/outpatient setting without negative functional outcomes
conclusions on stroke rehab units
Conclusions on Stroke Rehab Units

Stroke rehab units associated with:

  • mortality
  • combined outcome of death and dependency
  • institutionalization
  • length of hospital stay
conclusions on stroke rehab units21
Conclusions on Stroke Rehab Units

Subacute Stroke Rehab Units result in:

  • 10 day reduction in inpatient stay
  • 1 in 27 patients treated will not need institutionalization
  • Increased functional outcomes with decrease in informal care costs

In SWOntario there are only 2 designated stroke rehab units with PT or OT:patient ratios <10:1

> 50% not admitted to stroke rehab units!

the earlier the better23
The Earlier the Better
  • Brain is “primed” to “recover” early in post-stroke period
  • Animal studies suggest there is a time window when brain is “primed” for maximal response to rehab therapies, such that delays are detrimental to recovery
  • Clinical association between early admission to rehab and better outcomes
benefit of early therapy in animals
Benefit of Early Therapy in Animals


  • Biernaskie et al. (2004) subjected rats to rehab x 5 weeks beginning at 5, 14 and 30 days post small strokes
  • Control animals – social housing
benefit of early therapy in animals25
Benefit of Early Therapy in Animals


  • All received 5 weeks of enriched enviornment
  • Day 5 admission marked improvement
  • Day 14 moderate improvement
  • Day 30 no improvement vs. controls
  • Corresponding cortical reorganization in brain around stroke
stroke rehab should be started asap
Stroke Rehab Should be Started ASAP
  • Animal studies indicate early rehab is associated with improved recovery; late rehab is not
  • In clinical studies earlier rehab is associated with better functional outcomes
  • Time is Recovery!
conclusions on early admission
Conclusions on Early Admission

Early Admission results in:

  • Reduced length of acute care
  • Improved functional outcomes, which reduces informal care needs
  • U.S. admits patients earlier, sicker and more disabled and yet do better

In Canada waiting lists are common!

use it or lose it
Use It or Lose It

Rehab training (enriched environments with animals) increases cortical representation with subsequent functional recovery

In animal studies key factors promoting recovery include increased activity and complex, stimulating environment

Lack of rehab decreases cortical representation and delays recovery

role of intensity of therapy
Role of Intensity of Therapy
  • Post-stroke rehab increases motor brain reorganization, while lack of rehab reduces reorganization
  • More intensive motor training in animals further increases brain reorganization
  • Clinically, greater intensity of stroke rehab therapies is associated with improved outcomes
role of intensity of therapy31
Role of Intensity of Therapy
  • The greater the intensity of therapies - the better the outcomes
  • Seen to be true for physiotherapy, occupational therapy, aphasia therapy, treadmill training and upper extremity function in selected patients (i.e. CIMT)
kalra et al 1994
Kalra et al. (1994)
  • RCT of 146 “middle band” strokes to stroke unit (SU) or gen med (GM) unit
  • Median BI = 4/20 initially in both
  • Stroke Unit - BI = 15 after 6 wks; discharged at 6 wks
  • General Medical Unit - BI = 12 after 12 wks; discharged at 20 wks
kalra et al 199436
Kalra et al. (1994)
  • Both groups received same amount of therapy overall
  • Stroke Unit therapy more intensive and specialized - “front loading”
  • Significant differences in cost and outcomes
sonoda et al 2004
Sonoda et al. 2004


  • Comparative study conventional stroke rehab 5 days/wk vs. full-time integrated treatment (FIT) program 7 days/wk
  • Both groups had similar FIM scores on admission


  • FIT group significantly shorter lengths of stay and discharged with higher avg FIM scores and nearly double the FIM efficiency scores
intensity of therapies
Intensity of Therapies
  • Lenze et al. (2004) poor participation in therapy during inpatient rehab was common
  • Associated with less improvement in FIM scores and longer lengths of stay even when controlling for admission FIM scores
inactive and alone
Inactive and Alone

In a therapeutic day

  • >50% time in bed
  • 28% sitting out of bed
  • 13% in therapeutic activities
  • Alone for 60% of the time

Contrary to the evidence that increased activity and environmental stimulation is important to neurological recovery

(Inactive and alone, Bernhardt et al, Stroke 2004)

conclusions on intensity of therapies
Conclusions on Intensity of Therapies
  • More therapy results in improved outcomes and is cost-effective
  • Careful attention to actual amount of therapist-patient time and time spent in activation activities
  • Minimum of 1 hr/day of each therapy
  • Increasing therapy aids and volunteers
  • Less time charting, assessing and meeting
  • More stimulating environments
conclusions on intensity of care
Conclusions on Intensity of Care
  • Core Therapies of PT, OT and SLP are most sensitive to intensity
  • <20% of total hospital budget spent on core therapies
  • <10% in overall budget = 50% in core therapies
  • Can do weekend therapy and overall therapy intensity
  • Reduce LOS and costs by 30%
stroke rehab must be task specific
Stroke Rehab Must Be Task-Specific
  • Functional reorganization of cortex greater for tasks meaningful to animal; repetitive activity not enough
  • Rehab must be task-specific, focusing on tasks important and meaningful to patient
  • Compensatory Approaches result in faster recoveries than Remedial Approaches
  • Trends moving away from Bobath and other NDT forms of treatment because they increase length of stay
task specific therapy
Task-Specific Therapy
  • In U.S. PSROP centers, patients were given challenging tasks which simulated real-life tasks early on
  • Assessments were kept to bare minimum
  • Task-specific therapy reduce LOS!
outpatient therapy
Outpatient Therapy
  • Outpatient therapy improves short-term functional outcomes
  • Doesn’t seem to matter if it is hospital or home-based
  • Timing (later) and intensity (inevitably less) and insensitive outcome measures make detecting benefit difficult
outpatient therapy47
Outpatient Therapy
  • Outpatient therapy reduces hospital stay and reduces rehospitalization
  • 8 week course of outpatient PT and OT, 1 hr each 3 days/wk x 8 wks or 2 days/wk x 12 wks costs $2,000
  • Estimated savings per patient in reduced inpatient costs is $4,000
conclusions re outpatient therapy
Conclusions re Outpatient Therapy
  • Outpatient therapy reduces costs and is relatively inexpensive
  • First thing cut with budget pressures
  • Reduction in CCAC support
  • U.S. emphasize the importance of outpatient supports
  • Outreach programs also save $
community reintegration
Community Reintegration

“Doctor says you can come home when I am up to it.”

kalra et al 2004
Kalra et al. 2004

RCT of 300 patients and caregivers

Formal training of caregivers during patient’s rehab associated with:

  • Less caregiving burden
  • Better psychological outcomes in patients and caregivers
  • Higher quality of life in patients and caregivers
  • Reduced overall costs of health and social care
conclusions on community supports
Conclusions on Community Supports
  • Higher levels of social support are associated with greater functional gains, less depression, improved mood and social interaction
  • Predictive of discharge destination
  • Interventions to help access community support-services is associated with increased social activity
  • Important to include caregiver as well in social support interventions
conclusions on community supports52
Conclusions on Community Supports
  • Evidence of a positive benefit of education; one-on-one more effective than written information
  • Skills training in basic nursing skills for caregivers results in less depression and anxiety and improved quality of life for both caregiver and patient
structure process and outcomes in stroke rehab
Structure, Process and Outcomes in Stroke Rehab
  • Hoenig et al. (2002) 2 yr prospective trial of 288 acute strokes in the VA system
  • Examined Structure of Care: systemic organization, staffing expertise and technological sophistication
  • Examined Processes of Care: adherence to AHCPR post-stroke rehabilitation guidelines
  • Studied FIM motor subscale 6 mos post-stroke as Outcome
structure process and outcomes in stroke rehab55
Structure, Process and Outcomes in Stroke Rehab
  • Structure of Care helped to predict Processes of Care but was not directly associated with Outcomes
  • Processes of Care were associated with Outcomes – better adherence to guidelines meant improved outcomes
  • Providing Outcomes information does not change provider behavior
  • Better to measure Processes of Care than Outcomes?
dealing with processes of care
Dealing with Processes of Care
  • Staff education is important
  • Over half of the cost of in-patient rehab is nursing care – yet little funding is devoted to Nursing Education
  • Need to specifically teach evidence and guidelines related to stroke rehab care
  • Need to focus on Processes of Care
canadian pm r consensus on standards of care
Canadian PM&R Consensus on Standards of Care
  • Early access to specialized interdisciplinary rehab
  • Early assessment for stroke rehab
  • Appropriate intensities of therapies
  • Available outpatient therapy on d/c
  • Appropriate community supports
  • Secondary prevention of stroke
  • Stroke rehabilitation (interdisciplinary specialized team) works
  • Get them in early
  • Treat intensively incl w/e therapy
  • Create stimulating active rehab environ
  • Focus on high level meaningful tasks and challenge patients
  • Limit the number of assessments
  • Outpatient therapy must be available
  • Processes of care are critical