Outcome
Result from pooled analyses: OR (95 % CI) or weighted mean difference (95 % CI)
Death
0.79 (0.65, 0.98)
Death and dependency
0.59 (0.49, 0.71)
Need for institutionalization
0.69 (0.54, 0.87)
Length of stay
−16.4 (−31.2,−1.6)
Outpatient/Community-Based Rehabilitation
As Health Care Systems attempt to improve efficiencies and reduce costs, there has been increasing emphasis on outpatient rehabilitation care. Outpatient care is much less expensive because it avoids the high nursing and hoteling costs associated with inpatient rehabilitation. Post-acute care has been evaluated by the Outpatient Rehabilitation Trialists [55], the Early Supported Discharge Trialists [56], and others assessing home-based rehabilitation [57]. Outpatient Service Trialists data demonstrated the positive impacts of post-hospital care. Patients who received rehabilitation after being discharged to their home experienced a reduction in poor outcomes or death (OR 0.72, 95 % CI 0.57–0.92, p = 0.009) and an improvement in Activities of Daily Living (ADL) (OR 0.67, 95 % CI 0.46–0.97, p = 0.03) compared to those receiving no intervention or routine care. Moreover, in comparison to inpatient rehabilitation, outpatient rehabilitation is relatively inexpensive.
Building on the evidence for outpatient care, Early Supported Discharge (ESD) was introduced to expedite a patient’s discharge back into the community through the provision of timely home-based support. Three forms of ESD were identified in the literature: a hospital-based team managing the entire continuum of care for a patient, a team involved in predischarge planning followed by referral to an existing community-based team, and finally, no ESD team, but the availability of multidisciplinary care once a patient was discharged to the community. The comparison groups were patients recruited from an organized stroke unit, neurological unit, or general ward. Findings indicated that ESD services reduced patient duration in hospital (P < 0.0001), improved patient outcomes with a decreased odds of death or dependency (OR 0.80, 95 % CI 0.67–0.97), and increased patient satisfaction with care (OR 1.60, 95 % CI 1.08–2.38) compared to no ESD team. When analyses were performed separately for each ESD model of care, only the model involving the hospital-based team managing the entire continuum of care (discharge planning and delivery of community-based care) demonstrated significant improvements in patient outcomes. Compared to conventional care, the ESD model of care decreased odds of death or institutional care (OR 0.65, 95 % CI 0.45–0.93), decreased odds of death or dependency (OR 0.71, 95 % CI 0.55–0.91), and increased odds of satisfaction with care (OR 1.74, 95 % CI 1.13–2.67).
While the ESD concept remains theoretically popular, uncertainties regarding the appropriate length of ESD care [58] and the relevance of ESD for patients with severe stroke [58] still exist. The success of ESD is dependent on the immediate availability of community resources for patients upon discharge. ESD is an attempt to “pull” patients out of expensive inpatient beds and therefore one of the biggest challenges is in ensuring that no waiting lists for these services exist.
ESD is but one form of outpatient therapy. Once discharged to the community to an outpatient program, the question becomes where to provide care. Location of care is dependent on level of functioning, availability of services, and presence of a caregiver. Hiller and Inglis-Jassiem [57] completed a systematic review of the literature comparing home-based care to center-based care for stroke rehabilitation. Eleven RCTs were reviewed, most based on studies from the UK. Interventions were home-based therapy (multidisciplinary team or a select discipline such as PT or OT) and, except for Anderson et al. [59] who made comparisons between disciplines, the comparison groups were individuals receiving center-based or usual care. Patients receiving home-based care experienced significant improvements compared to controls in the Barthel Index at 3–6 months post-intervention (P = 0.03). However, at 6 months, patients in the intervention group did not show significant differences in the Barthel Index compared to controls (P = 0.27). There was insufficient evidence to draw conclusions about caregiver outcomes and the differences in outcomes according to type of intervention. Further evidence is needed to assess the efficacy of home-based rehabilitation services.
The Future of Stroke Rehabilitation
Challenges in Knowledge Translation, Reducing the Gap between Research and Practice
In medicine, outcomes are optimized when clinical practice reflects the latest research findings. However, studies of health care delivery have found that only 55–67 % of patients actually receive care that is based on best evidence [60, 61] and 20–30 % of patients receive care that is contradicted [62]. Translating research evidence into clinical practice is challenging and stroke rehabilitation is no exception.
Insufficient time has been cited as the most significant barrier to knowledge translation by occupational therapists [63]. Lack of evidence in the field and lack of skills and knowledge in evidence-based medicine are other notable barriers [63]. However the large majority of those who noted barriers also agreed on the value of current research for informing patient care. Stroke rehabilitation is interdisciplinary in nature and nurses, physiotherapists, occupational therapists, and managerial staff vary with respect to perceived barriers of Evidence-Based Medicine (EBM) [64]. Barriers may include lack of time and insufficient knowledge, training, and skills in EBM [64, 65] although all disciplines cite time as the most widely cited barrier for bringing best available evidence into practice [64].
The development and maintenance of a sustained research synthesis, the Stroke Rehabilitation Evidence-Based Review (www.ebrsr.com) has had a substantial impact on knowledge translation within the area of stroke rehabilitation, both nationally and internationally. It offers a multidisciplinary, methodologically sound, timely and regularly updated review of evidence in stroke rehabilitation. In the context of the knowledge to action process proposed by Graham et al [66], it is an effective mode of knowledge synthesis and is invaluable in informing the surrounding phases of the model.
The Role of Technology
Functional Electrical Stimulation (FES) in Hemiparetic Upper and Lower Extremities
FES of the common peroneal nerve has been used to enhance ankle dorsiflexion during the swing phase of gait. Although weak ankle dorsiflexion with plantar flexion hypertonicity is typically corrected by an ankle foot orthosis, FES may be a suitable alternative for highly motivated patients who are able to walk independently or with minimal assistance. FES combined with gait training improves hemiplegic gait [67]. Systematic reviews [68, 69] have both shown a benefit for walking speed. There is strong evidence FES and gait retraining results in improvements in hemiplegic gait. FES has also been studied in a number of RCTs examining the hemiparetic upper extremity [70, 71]. There is strong evidence that FES treatment improves upper extremity function in acute stroke (<6 months post onset) and chronic stroke (>6 months post onset).
Robotics in Rehabilitation of Upper Extremity Post-stroke
Electromechanical and robotic-assisted therapy are being increasingly utilized in stroke motor rehabilitation, although they account for a very small amount of therapy provided. Theoretically, robot-assisted therapies are able to provide an alternative to labor-intensive therapist-assisted interventions, thus fulfilling the stroke rehabilitation principles of high intensity and task specificity. However, the potential benefits have not yet been fully apparent in research and clinical practice, with studies showing mixed outcome results. There is strong evidence that sensorimotor training with robotic devices improves upper extremity functional outcomes, and motor outcomes of the shoulder and elbow [72, 73] as well as ambulation [74–77]. There is strong evidence that robotic devices do not improve motor outcomes of the wrist and hand [72, 73]. As the technology improves, robotics are going to gain an increasing role.
Virtual Reality in Stroke Rehabilitation
The Long-Term Management of Stroke
Changing views and emerging scientific evidence over the past decades have questioned the presumed 6-month recovery plateau [80, 81]. A growing body of literature, including over 350 randomized controlled trials, have focused on rehabilitation during the chronic (6 months or more post) stroke period [82]. While this work was primarily conducted due to the stable deficits exhibited during this stage, this body of research provides particularly strong evidence for effective functional motor gains from a variety of interventions such as exercises, functional electrical stimulation, and constraint-induced movement therapy [80]. The impact of these interventions on patients who are at least 6 months post-stroke demonstrates the efficiency and potential for true gains with rehabilitation during the chronic stroke stage. These gains are largely due to the fact that, while spontaneous recovery does occur, neuroplasticity is about learning or relearning abilities and can, thus, occur at virtually any time [83].
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