Timing of Initiation of Acute Stroke Rehabilitation and Management Corresponding to Complications at Primary Stroke Centers in Japan: A Nationwide Cross-Sectional Web-Based Questionnaire Survey

Abstract

<b><i>Introduction:</i></b> Many guidelines now recommend early rehabilitation for acute stroke patients. However, evidence remains lacking regarding the specific timings for initiation of various rehabilitation steps and management when complications are encountered in acute stroke rehabilitation. This survey aimed to investigate actual clinical situations in acute stroke rehabilitation in Japan and to improve the medical systems for rehabilitation and plan further studies. <b><i>Methods:</i></b> This nationwide, cross-sectional, web-based questionnaire survey was administered between February 7, 2022, and April 21, 2022, targeting all primary stroke centers (PSCs) in Japan. Among several components of the survey, this paper focused on the timing of the initiation of three rehabilitation steps (passive bed exercise; head elevation; and out-of-bed mobilization), along with the management of rehabilitation (continued or suspended) in the event of complications during acute stroke rehabilitation. We also investigated the influence of facility features on these contents. <b><i>Results:</i></b> Responses were obtained from 639 of the 959 PSCs surveyed (response rate: 66.6%). In cases of ischemic stroke and intracerebral hemorrhage, most PSCs initiated passive bed exercise on day 1, head elevation on day 1, and out-of-bed mobilization on day 2 (with day of admission defined as day 1). In cases with subarachnoid hemorrhage, rehabilitation steps were delayed compared to other stroke subtypes or showed wide variation depending on the facility. Passive bed exercise was accelerated by the presence of protocols for rehabilitation and weekend rehabilitation. Out-of-bed mobilization was accelerated by the presence of a stroke care unit. Facilities with board-certified rehabilitation doctors were cautious regarding the initiation of head elevation. Most PSCs suspended rehabilitation training in the event of symptomatic systemic/neurological complications. <b><i>Conclusion:</i></b> Our survey revealed the actual situation of acute stroke rehabilitation in Japan and indicated that some facility features appear to influence early increases in physical activity levels and early mobilization. Our survey provides fundamental data to improve the medical systems for acute stroke rehabilitation in the future.

Evidence and Recommendations for Acute Stroke Rehabilitation from the Japan Stroke Society: Abridged Secondary Publication of the Japanese-language Version

“…In patients with subarachnoid hemorrhage (after ruptured aneurysm treatment), the training tended to start later. 12) These findings indicate that starting in-bed ROM training early after onset does not result in an increase in adverse events and may improve functional outcome, although further evidence is required.…”

“…29) A questionnaire survey on acute stroke rehabilitation conducted in Japan in 2022 showed that the greatest number of facilities started mobility training (sitting, transferring, standing, and walking) in branch atheromatous disease, atherothrombotic brain infarction, and cardioembolic stroke on hospitalization day 2, followed in descending order of frequency by hospitalization day 3 and the day of admission. 12) In patients with lacunar infarctions, the timing of starting mobilization was earlier than in other types, with approximately the same proportion of facilities (slightly more than 40%) starting mobilization on the day of admission and on hospitalization day 2. 12) As indicated above, if one were to suggest the appropriate timing for mobilization, at present it would likely be considered between 24 and 48 h. Very early mobilization within 24 h of onset may be considered for patients with mild symptoms or those with non-elderly ischemic stroke provided that mobilization time is shortened and its frequency is increased.…”

“…12) In patients with lacunar infarctions, the timing of starting mobilization was earlier than in other types, with approximately the same proportion of facilities (slightly more than 40%) starting mobilization on the day of admission and on hospitalization day 2. 12) As indicated above, if one were to suggest the appropriate timing for mobilization, at present it would likely be considered between 24 and 48 h. Very early mobilization within 24 h of onset may be considered for patients with mild symptoms or those with non-elderly ischemic stroke provided that mobilization time is shortened and its frequency is increased.…”

“…A questionnaire survey of 959 primary stroke centers in Japan in 2022 showed that in ischemic stroke and intracerebral hemorrhage (nonoperative patients), more than half of the facilities started head elevation of at least 30 degrees on the day of admission and that nearly all started elevation by the second day of hospitalization. 12) Moreover, there was a tendency for such elevation to start earlier in lacunar infarction, branch atheromatous disease, atherothrombotic brain infarction, cardiogenic cerebral embolism, and intracerebral hemorrhage, in that order. Elevation tended to start later in subarachnoid hemorrhage after surgical clipping or endovascular coiling for ruptured aneurysm.…”

“…14) A questionnaire survey on acute stroke rehabilitation conducted in Japan in 2022 found that in patients with any type of ischemic stroke, in-bed training (maintaining functional position, positioning, and ROM training during bed rest) was started on the day of admission at approximately 60% of the facilities. 12) By the second day of hospitalization, in-bed training had been started at nearly all facilities. In patients with intracerebral hemorrhage (nonoperative patients), inbed training was started on the day of admission at slightly less than 50% of the facilities and, by the second day of hospitalization, had been implemented at more than 90% of facilities.…”