Why are you focusing on intensity rather than the EXACT PROTOCOLS NEEDED TO RECOVER? Your mentors and senior researchers need re-education in the only goal in stroke: 100% recovery!
The association between inpatient rehabilitation intensity and outcomes after stroke in Ontario, Canada
Abstract
Background:
Several
studies have demonstrated improved outcomes poststroke when higher
intensity rehabilitation is provided. Canadian Stroke Best Practice
Recommendations advise patients receive 180 min of therapy time per day;
however, the exact amount required to reach benefit is unknown.
Aims:
The
primary aim of this study was to determine the association between
rehabilitation intensity (RI) and total Functional Independence Measure
(FIM) Instrument change. Secondary aims included determining the
association between RI and discharge location, 90-day home time,
rehabilitation effectiveness, and motor and cognitive FIM change.
Methods:
A
retrospective cohort study was conducted using available administrative
databases of acute stroke patients discharged to inpatient
rehabilitation facilities in Ontario, Canada, from January 2017 to
December 2021. RI was defined as number of minutes per day of direct
therapy by all providers divided by rehabilitation length of stay. The
association between RI and the outcomes of interest were analyzed using
regression models with restricted cubic splines.
Results:
A total of
12,770 individuals were included. Mean age of the sample was
72.6 years, 46.0% of individuals were female, and 87.6% had an ischemic
stroke. Mean RI was 74.7 min (range: 5–162 min) per day. Increased RI
was associated with an increase in mean FIM change. However, there was
diminishing incremental increase after reaching 95 min/day. Increased RI
was positively associated with motor and cognitive FIM change,
rehabilitation effectiveness, 90-day home time, and discharge to
preadmission setting. Higher RI was associated with a lower likelihood
of discharge to long-term care.
Conclusions:
None
of the patients met the recommended RI of 180 min/day based on the
Canadian Stroke Best Practice Recommendations. Despite this, higher
intensity was associated with better outcomes. Given that most positive
associations were observed with a RI ⩾95 min/day, this may be a more
feasible target.(But you could easily add action observation or mirror therapy to get to 180 minutes. Don't you people ever think?)
Introduction
Advances in acute stroke management have led to improved survival.1,2
Stroke rehabilitation progresses care further by optimizing functional
recovery and quality of life. The Canadian Stroke Best Practice
Recommendations (CSBPR) recommend higher rehabilitation intensity (RI)
to aid recovery.3 Several studies have found an overall functional benefit of higher RI as measured by the Functional Independence Measure (FIM)4,5 while others have shown that higher RI improves specific outcomes, such as aphasia,6,7 dysphagia,8 lower or upper limb ability,9 balance,10 and gait.11,12 These previous studies have focused on specific impairments,6–8,10–12 have been small,4 or have not examined RI on a continuous scale.5,9
Higher
intensity can be defined in a variety of ways including heart rate and
rate of perceived exertion, though it is most commonly defined by more
minutes spent in active therapy.13 The exact duration to achieve maximum benefit is currently unknown.14 The CSBPR suggest at least 3 h per day, 5 days per week;3
however, this recommendation is based on limited data. Furthermore,
local audits have suggested that most patients likely do not receive
this amount due to lack of resources and prioritization of therapy. Our
goal was to determine the association between RI and functional
outcomes.
Aims
The
primary aim was to determine the association between RI and total FIM®
Instrument change. Secondary aims included determining the association
between RI and discharge back to preadmission setting, discharge to
long-term care (LTC), 90-day home time,15 rehabilitation effectiveness,16 as well as motor and cognitive FIM change.
Methods
Design and setting
This
was a retrospective cohort study of individuals with stroke who were
discharged from acute care in Ontario, Canada, between 1 January 2017
and 31 December 2021 and subsequently admitted to an inpatient stroke
rehabilitation bed within 72 h. The observation window extended until
91 days postdischarge from inpatient stroke rehabilitation.
Data source
Administrative
databases, including the Canadian Institute for Health Information’s
acute care Discharge Abstract Database and the National Rehabilitation
Reporting System (NRS), held at ICES were used. In Ontario, it is
mandatory for rehabilitation facilities to report several data elements,
such as admission and discharge FIM, to the NRS. Total therapy time
delivered by each discipline (e.g. physiotherapy) during a
rehabilitation stay was included as a mandatory reporting element in
2015. These data sets were linked using unique encoded identifiers and
analyzed at ICES. ICES is an independent, nonprofit research institute
whose legal status under Ontario’s health information privacy law allows
it to collect and analyze health care and demographic data, without
consent, for health system evaluation and improvement.
Participants
Individuals
who had a subarachnoid hemorrhage (International Classification of
Diseases (ICD) 10th version, code I60), intracerebral hemorrhage (ICD
code I61), or ischemic stroke (ICD codes I63 and I64)17
were included. Individuals were aged 19–100 years, inclusive. Exclusion
criteria included a rehabilitation length of stay (LOS) less than
3 days, admission from LTC, the presence of an acute stroke in the
5 years prior to stroke onset date, final discharge destination of acute
care, RI <1st or >99th percentile, and individuals with missing
RI, sex, or preadmission setting data. Patients with missing outcome
data were also excluded. For individuals with more than one stroke
during the observation period, we only included the first episode of
care (acute care admission followed by inpatient rehabilitation).
Variables
The
primary predictor variable was RI; the number of minutes per day of
direct therapy by speech–language, occupational, and physiotherapy
services for each patient divided by rehabilitation LOS. Other
hypothesized predictors, based on previous research and clinical
experience, included age; sex; Charlson co-morbidity index (CCI:
low = 0–1 and high = ⩾2); rurality (residing in a community with a
population ⩽10,000); whether the individual was admitted to acute care
from home, assisted living, or other; whether they were living alone
prior to acute care admission; and nearest census-based neighborhood
income quintile. Acute care data included LOS and if the individual was
treated on an acute stroke unit. Rehabilitation institution and
admission total FIM were also included as potential predictors.
Outcomes
The
primary outcome was total FIM change (total discharge FIM − total
admission FIM). Additional outcomes included discharge back to
preadmission setting, discharge to LTC, time spent at home in the first
90 days after stroke (90-day home time),15 rehabilitation effectiveness ((discharge FIM − admission FIM) / (126 − admission FIM) × 100%),16
as well as motor and cognitive FIM change (discharge motor—admission
motor FIM and discharge cognitive—admission cognitive FIM,
respectively).
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