Rehabilitation Therapy Doses Are Low After Stroke and Predicted by Clinical Factors

Abstract

BACKGROUND: Stroke is a leading cause of long-term disability. Greater rehabilitation therapy after stroke is known to improve functional outcomes. This study examined therapy doses during the first year of stroke recovery and identified factors that predict rehabilitation therapy dose. METHODS: Adults with new radiologically confirmed stroke were enrolled 2 to 10 days after stroke onset at 28 acute care hospitals across the United States. Following an initial assessment during acute hospitalization, the number of physical therapy, occupational therapy, and speech therapy sessions were determined at visits occurring 3, 6, and 12 months following stroke. Negative binomial regression examined whether clinical and demographic factors were associated with therapy counts. False discovery rate was used to correct for multiple comparisons. RESULTS: Of 763 patients enrolled during acute stroke admission, 510 were available for follow-up. Therapy counts were low overall, with most therapy delivered within the first 3 months; 35.0% of patients received no physical therapy; 48.8%, no occupational therapy, and 61.7%, no speech therapy. Discharge destination was significantly related to cumulative therapy; the percentage of patients discharged to an inpatient rehabilitation facility varied across sites, from 0% to 71%. Most demographic factors did not predict therapy dose, although Hispanic patients received a lower cumulative amount of physical therapy and occupational therapy. Acutely, the severity of clinical factors (grip strength and National Institutes of Health Stroke Scale score, as well as National Institutes of Health Stroke Scale subscores for aphasia and neglect) predicted higher subsequent therapy doses. Measures of impairment and function (Fugl-Meyer, modified Rankin Scale, and Stroke Impact Scale Activities of Daily Living) assessed 3 months after stroke also predicted subsequent cumulative therapy doses. CONCLUSIONS: Rehabilitative therapy doses during the first year poststroke are low in the United States. This is the first US-wide study to demonstrate that behavioral deficits predict therapy dose, with patients having more severe deficits receiving higher doses. Findings suggest directions for identifying groups at risk of receiving disproportionately low rehabilitation doses.

Transforming modeling in neurorehabilitation: clinical insights for personalized rehabilitation

“…Superimposed on different biologic phases of recovery is a complex post-acute care continuum [ 3 ] with changing clinical care teams and widely varying amounts and types of rehabilitation therapy administered [ 4 ]. Moreover, access to clinical rehabilitation is variable and influenced by a number of factors including geographic location, socioeconomic circumstances, insurance, personal factors, and support [ 5 ]. DS and ER both transitioned through different care settings (acute stroke hospitalization, inpatient rehabilitation, skilled nursing facility) in the acute and subacute phases of recovery and had different access to outpatient rehabilitation in the chronic phase.…”

Combining high dose therapy, bilateral motor priming, and vagus nerve stimulation to treat the hemiparetic upper limb in chronic stroke survivors: a perspective on enhancing recovery

“…In the context of the findings of Ward and McCabe, the amount of scheduled therapy in the United States (US) is far below what is needed to optimize recovery. A recent multi-site study (28 acute care hospitals) in the US tracked amount of therapy that patients received over 1 year post-stroke ( 22 ). The mean combined number of occupational (OT) and physical therapy (PT) sessions attended within a 12 month period post-stroke was just 31.7 ( 22 ).…”

“…A recent multi-site study (28 acute care hospitals) in the US tracked amount of therapy that patients received over 1 year post-stroke ( 22 ). The mean combined number of occupational (OT) and physical therapy (PT) sessions attended within a 12 month period post-stroke was just 31.7 ( 22 ). “Session” was defined as any active participation with a therapist lasting at least 1 min, and average duration was not reported.…”

The effect of post-acute rehabilitation setting on 90-day mobility after stroke: A difference-in-difference analysis

“…Nearly 90% of individuals receive rehabilitation during their initial hospitalization for stroke; 8,9 however, after discharge from the hospital, participation in post-acute rehabilitation is highly variable [10][11][12][13] despite its positive impact on functional outcomes. [1][2][3][4] This variability starts with the initial post-acute setting in which an individual receives rehabilitation (i.e., discharge location from the hospital), with 20-30% of individuals being discharged to an inpatient rehabilitation facility (IRF), [14][15][16][17] 15-25% to a skilled nursing facility (SNF), 14,16,17 approximately 10% home with community services (i.e., home health-HH-or outpatient clinics-OP), 10,16,17 and 30-40% home without follow up rehabilitation.…”