Benefit of inpatient multidisciplinary rehabilitation up to 1 year after stroke1

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Benefit of Inpatient Multidisciplinary Rehabilitation Up to 1 Year After Stroke Hajime Yagura, MD, Ichiro Miyai, MD, PhD, Yujiro Seike, MD, PhD, Tsunehiko Suzuki, MD, PhD, Takehiko Yanagihara, MD ABSTRACT. Yagura H, Miyai I, Seike Y, Suzuki T, Yanagihara T. Benefit of inpatient multidisciplinary rehabilitation up to 1 year after stroke. Arch Phys Med Rehabil 2003;84:1687-91. Objective: To analyze the benefit of inpatient multidisciplinary rehabilitation up to 1 year after stroke. Design: Retrospective cohort study. Setting: Inpatient rehabilitation hospital in Japan. Participants: A total of 1056 patients with stroke were divided into 3 groups based on the interval between stroke onset and admission to the rehabilitation hospital: group I, within 90 days (n⫽507, 48%); group II, 91 to 180 days (n⫽377, 36%); and group III, more than 180 days (n⫽172, 16%). Interventions: Not applicable. Main Outcome Measures: Functional outcome (A to D; independent to totally dependent) in walking, affected upper extremity, and activities of daily living (ADLs) and discharge disposition. Results: Walking status improved in 70.9% of nonambulatory patients in group I, in 54.8% in group II, and in 43.9% in group III. Similarly, ADLs improved in 66.7% of the totally dependent patients in group I and in approximately 50% in groups II and III. Functional gain in those with a totally nonfunctional upper extremity at admission was poor (29.7%). Initial functional categories affected each outcome (P⬍.0001). On discharge, 73.8% in group I and approximately 60% in groups II and III went home. Conclusion: Approximately half of all patients regained their abilities in walking and ADLs after inpatient multidisciplinary rehabilitation up to 1 year after stroke. However, there was considerable limitation in functional recovery of the affected upper extremity. Key Words: Rehabilitation; Stroke; Treatment outcome. © 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation HERE IS AMPLE EVIDENCE that multidisciplinary rehabilitation is effective in improving functional outcome T and in increasing the rate of discharge to home for patients with stroke.1-8 However, more than half of patients who survive

From the Neurorehabilitation Research Institute, Bobath Memorial Hospital, Osaka (Yagura, Miyai, Seike, Suzuki); and Osaka Neurological Research Institute, Osaka (Yanagihara), Japan. Supported by Comprehensive Research on Aging and Health, Japanese Ministry of Health, Labor and Welfare. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. Reprint requests to Hajime Yagura, MD, Neurorehabilitation Institute, Bobath Memorial Hospital, 1-6-5, Higashinakahama, Joto-ku, Osaka 536-0023, Japan, e-mail: [email protected]. 0003-9993/03/8411-7926$30.00/0 doi:10.1053/S0003-9993(03)00286-7

after stroke remain moderately to severely disabled 3 months after the acute stroke.9 Patients with severe stroke reach a plateau in the functional state more slowly than those with mild to moderate disabilities after stroke.10 Few studies address the efficacy of inpatient rehabilitation for patients who have moderate to severe residual disabilities several months after stroke, probably because of the limitation in medical insurance coverage in many countries. The Japanese medical insurance system covers inpatient multidisciplinary rehabilitation for patients with chronic disabilities after stroke, as well as those with acute stroke. As the result, patients with stroke can undergo long-term inpatient multidisciplinary rehabilitation until they reach a plateau in both impairment and disability levels. Because of the residence structure and habit unique to Japan, including narrow spaces, different levels between rooms, oldfashioned toilet requiring squatting, high bathtub level, preference of taking a bath to shower, and taking off shoes indoors, it may take more time for patients to reach a plateau in improving disabilities and for their caregivers to acquire sufficient skill to manage them at home. Nevertheless, such a long-term rehabilitation effort might be cost-effective if patients achieve significant reduction in disabilities, thus saving costs for home and nursing home care. Although measurements of disabilities with validated methods such as Barthel Index11 and the FIM™ instrument12 are useful and have been used widely, it is also important to directly show how many nonambulatory patients regain independent gait and how many patients achieve functional use of the paretic arm. For instance, the Barthel Index and FIM assess how patients perform activities of daily living (ADLs) without regard to motor recovery of the paretic arm. In the present study, therefore, we investigated such real-world outcomes of multidisciplinary inpatient rehabilitation for patients up to 1 year after stroke. METHODS We analyzed functional outcome of inpatient multidisciplinary rehabilitation in 1056 patients with stroke who had been admitted to Bobath Memorial Hospital, in Osaka, Japan, from 1996 to 1999 (table 1). They were transferred to our hospital primarily because they needed assistance in ambulation or ADLs after staying in acute care hospitals for a period ranging from 1 to 12 months, where they usually received physical therapy sessions 3 to 5 days a week. Some patients came even later, because of their needs for medical control of complications or comorbidities, or because they remained dependent even after inpatient multidisciplinary rehabilitation at other rehabilitation facilities. To compare the functional outcome of patients who were transferred to our hospital at different intervals from stroke onset, we divided patients into 3 groups (group I, ⬍90d, n⫽507; group II, 91–180d, n⫽377; group III, ⬎180d, n⫽172). Compared with the insurance systems in many Western countries, the Japanese insurance system has allowed much longer stay in acute care and rehabilitation hospitals. Consequently, almost all patients belonging to groups I and II came from general wards of acute care hospitals. Of patients in group III, approximately 70% were transArch Phys Med Rehabil Vol 84, November 2003

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BENEFIT OF REHABILITATION AFTER STROKE, Yagura Table 1: Demographic Features of Patients With Stroke

No. of patients Age (y) Gender (M/F) Type of stroke (I/H) Side of stroke (R/L/Other) Time poststroke (d) LOS (d) MMSE score

Total

Group I

Group II

Group III

1056 60.7⫾10.1 672/384 537/519 520/459/77 112.0⫾72.5 101.8⫾27.3 22.6⫾8.7

507 60.5⫾10.2 343/164 254/253 265/207/35 58.0⫾21.0 101.9⫾27.5 21.3⫾8.7

377 60.4⫾10.4 224/153 190/187 179/176/22 122.9⫾25.8 101.8⫾25.7 22.8⫾9.2

172 61.6⫾9.4 105/67 93/79 76/76/20 246.5⫾50.0 101.0⫾30.2 22.1⫾8.8

NOTE. Values are mean ⫾ standard deviation or n. Abbreviations: M, male; F, female; I, infarction; H, hemorrhage; R, right; L, left; LOS, length of stay; Other, patients with ataxia, tetraparesis, and double hemiparesis; MMSE, Mini-Mental State Examination.

ferred from general wards, whereas the remainder came from their homes or nursing facilities. Our multidisciplinary rehabilitation program consisted of a 40-minute one-to-one session of physical therapy, occupational therapy, and/or speech-language therapy, as needed, 5 days a week by using a neurodevelopmental technique.13 In addition, a group session of physical exercise to improve their mobilization was provided once a day. Their ADLs, such as eating, transfer, toileting, and taking a bath, were supervised or assisted in the wards by multidisciplinary rehabilitation staff, if patients were not able to execute independently. If they reached the level of standing or walking with assistance, they were also trained to stand and/or walk in the wards by multidisciplinary rehabilitation staff. Family members were also trained to assist patients safely and efficiently. All received our standard rehabilitation nursing care. Discharge planning was provided by social workers according to the opinions presented at the weekly rehabilitation team conference. Outcome measures (table 2) included walking, upper-extremity functioning, an ADL categorization, and discharge site. Because Japanese elderly people prefer taking a bath to shower, we did not evaluate the ability to take a shower in this study. For statistical analyses, we used the chi-square test to compare the probability of reaching independence in each functional category of walking, affected upper extremity, ADLs on discharge, and discharge disposition among the 3 groups. Statistical significance was set at P less than .05. We did an overall chi-square test first to compare functional outcome on discharge among patients with different functional categories (B, C, D) on admission, and if we found it significant, we did pairwise evaluation comparing functional outcome between patients with 2 different functional categories on admission. Similarly, we also did a chi-square test comparing functional outcome among patients with different intervals after the onset of stroke (groups I, II, III) within the same functional category group. RESULTS Overall Functionality Demographic features and the hospital length of stay of patients in each group are in table 1. No significant differences existed in cognitive status among the 3 groups as measured by their Mini-Mental State Examination14,15 scores (group I, 22.6⫾8.7; group II, 21.3⫾8.7; group III, 22.8⫾9.2). A score of 24 or higher is considered normal.15 Table 3 shows the distribution of functional categories of the 3 outcome measures on admission. After inpatient multidisciplinary rehabilitation, the probability of reaching independence Arch Phys Med Rehabil Vol 84, November 2003

(functional category A) in each outcome measure was higher in patients who had less disability on admission (category B⬎C⬎D, P⬍.0001) as commonly expected (fig 1). Improvement was obvious in all 3 functional categories, but particularly for patients with milder disabilities. Functional use of the affected upper extremity and full independence on ADLs were difficult to achieve. Patients in group I (⬍90d) improved more than those in group II (91–180d) or group III (⬎180d) regardless of the degree of disability on admission. Considerable improvement was also observed for nonamubulatory patients in groups II and III. Ambulation. Of all the measures, walking status was expected most likely to improve, and 60.3% of patients who were Table 2: Definitions of Functional Category (A to D) for Ambulation, Use of Upper Extremities, and ADLs Ambulation

Category

Category

Description

A B C D In each

Can walk outdoors without physical assistance more than 200m Can walk indoors without physical assistance more than 50m Can walk indoors with physical assistance Is totally dependent in walking group, patient may use any type of cane or orthosis

UpperExtremity Function Category

Description

A

Dominant side affected, can use chopsticks, fork, spoon, and write with a pen Nondominant side affected, can hold a cup and can eat using both upper extremities Can grasp, hold, and release objects Can hold objects on a table with the affected upper extremity only with assistance of the unaffected upper extremity No functional use of the affected upper extremity

B C

D

ADL Function Category

Eating

Toileting

Bathing

A B C D

Independent Independent Independent Dependent

Independent Independent Dependent Dependent

Independent Dependent Dependent Dependent

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Table 3: Distribution of Functional Categories T Admission, by Group Functional Category on Admission

Walking Group I Group II Group III Upper extremity Group I Group II Group III ADLs Group I Group II Group III

B (%)

C (%)

D (%)

Total n

162(16.3) 93(19.7) 48(13.4) 21(12.9)

112(11.3) 54(11.4) 39(10.9) 19(11.7)

720(72.4) 326(68.9) 270(75.6) 123(75.5)

994 473 357 163

176(18.6) 105(23.6) 48(14.0) 23(14.5) 408(41.8) 213(46.7) 141(39.4) 54(33.1)

195(20.6) 98(22.1) 68(19.8) 28(17.6) 467(47.8) 204(44.7) 182(50.8) 81(49.7)

576(60.8) 241(54.3) 228(66.3) 107(67.3) 102(10.4) 39(8.6) 35(9.8) 28(17.2)

947 444 344 159 978 456 358 163

nonambulatory on admission (category D) showed significant gain in walking status, with 32.6% reaching the independent level (categories A, B; fig 1). For patients who required assistance with walking on admission (category C), 80.4% gained independence (categories A, B; fig 1). When the ambulatory status of all 3 groups was assessed according to the interval between acute onset and admission to our hospital, 70.8% of nonambulatory patients (category D on admission) in group I, 54.8% in group II, and 43.8% in group III gained some type of ambulation (categories A, B, C; fig 2), whereas 90.8% of patients in group I, 84.6% of patients in group II, and 42.1% of patients in group III gained independent walking (categories A, B; fig 2), if they could walk with assistance (category C) on admission. The probability of reaching independent walking was significantly greater in patients with a shorter interval between acute onset and admission to our hospital, although groups I and II had comparable gain (group I, II⬎III; P⬍.0001). Upper-extremity function. Patients in group I improved more (⬍90d) than those in group II (91–180d) or group III (⬎180d) regardless of their degree of disability on admission.

Fig 1. Percentage of patients who improved in walking, functional use of upper extremity, and ADLs after inpatient multidisciplinary rehabilitation. Abbreviation: UE, upper extremity. Each category was compared by pairwise evaluation. *P<.0001.

Fig 2. Percentage of patients who improved in functional ability between acute stroke onset and admission to our hospital. Each category and each group was compared by pairwise evaluation. *P<.0001; †P<.0005.

Outcome of the upper-extremity function was disappointing if the affected limb was nonfunctional (category D) on admission (see fig 1). Although 29.7% of these patients improved (categories A, B, C), only 0.2% of them gained full functional use (category A) of the affected upper extremity (see fig 1). On the other hand, 37.5% of patients gained full functional use of the affected upper extremity (category A), if they could grasp, hold, and release objects in the affected hand (category B) on admission (see fig 1). When we evaluated the status of the affected upper extremity according to the interval between acute onset and admission to our hospital, we found that 43.8% of patients in group I, 31.3% of patients in group II, and 21.7% of patients in group III who retained reasonable function in the affected hand (category B) on admission gained full functional use of the affected upper extremity (category A; fig 3). The probability of restoring

Fig 3. Percentage of patients who improved in use of the affected upper extremity between acute stroke onset and admission to our hospital. Each category and each group was compared by pairwise evaluation. *P<.0001.

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BENEFIT OF REHABILITATION AFTER STROKE, Yagura

DISCUSSION

Fig 4. Percentage of patients who improved in ADLs between acute stroke onset and admission to our hospital. Each category and each group was compared by pairwise evaluation. *P<.0001; †P<.0005.

functional use of the paretic arm was significantly greater in patients whose interval between onset and admission was shorter, although groups I and II had comparable gain (group I⬎II, III; P⬍.0001). ADL function. Improvement in ADLs was seen in 56.8% of patients who were totally dependent (category D) on admission. Of the patients who on admission were independent except for bathing (category B), 36.2% became totally independent (category A; fig 1). Among the patients who were totally dependent at admission (category D), few (1.0%) achieved independence in ADLs. Likewise, few (5.8%) of the patients who were dependent except for eating (category C) achieved independence. This finding may be related to the Japanese bathtub structure, which is as deep as the waist level. Next, we examined changes in ADLs according to the interval between acute onset and admission to our hospital (fig 4). Functional improvement for patients in categories B and C was significantly better in group I than in group II or group III, but considerable improvement was also observed for patients in groups II and III. For those who on admission were independent except for bathing (category B), 40.6% in group I, 28.4% in group II, and 18.5% in group III achieved total independence (category A). There were significant differences for the probability of improvement among the 3 groups (P⬍.05): patients with a shorter interval between onset and admission (group I⬎II⬎III) were more likely to improve. For those who at admission were independent except for bathing and toileting (category C), 69.1% in group I, 44.0% in group II, and 51.9% in group III improved. Significant differences also existed for the probability of improvement among the 3 groups (P⬍.05). However, only 12.3% in group I achieved total independence and only 1 patient in groups II and III achieved total independence (category A; fig 4). For those who were totally dependent at admission (category D), 66.7% in group I, 48.6% in group II, and 53.5% in group III gained some degree of independence (categories A, B, C) at the time of discharge, and there was no significant difference between the groups. On discharge from our hospital, 66.8% of patients went home. The rate of discharge to home was 73.8% in group I, 59.9% in group II, and 61.0% in group III (group I⬎II, III; P⬍.05). Arch Phys Med Rehabil Vol 84, November 2003

The present study showed the benefit of inpatient multidisciplinary rehabilitation even for patients several months after acute onset of stroke. First, we compared functional outcome among patients admitted to our hospital with different intervals after the ictus. Second, we compared the course of recovery of our patients with those available in the literature concerning the functional outcome after stroke.5,9,10 As reported in previous research,5 functional recovery after stroke is believed to reach 80% of the maximum by 3 months, 95% of the maximum by 6 months, and 100% by 12 months. Recovery of neurologic function appears to plateau earlier than that of self-care or mobility function. After stroke, recovery in the upper and lower extremities may continue for up to 3 months among patients with moderate impairment, and up to 6 months among patients with severe stroke.9 On the other hand, approximately 70% of patients, who had been nonambulatory 90 days poststroke but received rehabilitation afterward, were able to walk more than 150ft (45m) with assistance within 180 days poststroke.10 These data are comparable to our results in the present study in which we found that 71% of patients who were nonambulatory 90 days poststroke were able to walk with assistance after inpatient rehabilitation. According to the literature, approximately 30% of these patients become able to walk independently,10 whereas 47.2% of our patients reached that level in the present study. Even for patients who were admitted to our hospital more than 180 days after acute events (group III), our results were encouraging. Of note, the probability of reaching independence on walking was comparable between group I (the interval between stroke onset and admission to our hospital within 90d: 90.7%) and group II (91–180d; 84.6%) for patients requiring assistance in walking at the time of admission. This finding suggests that inpatient rehabilitation more than 3 months after stroke may still be beneficial for those nonambulatory patients. On the other hand, improvement of the paretic upper extremity was very limited even after inpatient multidisciplinary rehabilitation. Nakayama et al16 also found the possibility of reaching the level of functional use of the severely paretic upper extremity to be only 5% and stated that functional recovery of the upper extremity should not be expected for these patients beyond 11 weeks after stroke. Thus, our results confirm that it is unrealistic to expect full recovery of upperextremity function even with extended therapy unless functional improvement occurs quite early. We found that 27% of patients who were partially dependent in ADLs at admission (category B⫹C⫹D) but only 1.0% of patients who were totally dependent 90 days poststroke achieved independent ADL status (category A) on discharge. Reding and Potes10 observed that 37% of patients dependent in ADLs 90 days poststroke reached the independent level (Barthel Index score ⱖ95) within 180 days. This discrepancy is likely to be related to the Japanese bathtub structure, because the probability of reaching ADLs requiring only mild assistance by 180 days was slightly higher (60%) in our patients than that (52%) in the literature.10 Tangeman et al17 reported that improvement of ADLs after intensive rehabilitation for 5 weeks appeared to be possible even for patients who were at least 1 year poststroke. However, their patients were mildly disabled, resided in the community, and were ambulatory without assistance.17 Our data indicated that more than half of moderately to severely disabled patients 180 days poststroke were likely to improve by inpatient multidisciplinary rehabilitation.

BENEFIT OF REHABILITATION AFTER STROKE, Yagura

The rate of discharge to home in group I (73.8%) was even higher than that in the literature reporting on the efficacy of the stroke unit (60%– 65%). Jørgensen et al6 reported that 65% of patients admitted to the stroke unit and 56% of persons admitted to general wards were discharged to home. Indredavik et al1 showed that 56.4% of patients in the stroke unit and 32.7% of persons in general wards were discharged to home after 6 weeks: the rates were 62.7% and 44.6%, respectively, after 52 weeks. In the present study, approximately 60% of patients who were not able to go home more than 90 days after acute stroke could go home after further inpatient multidisciplinary rehabilitation. In Japan, Kubo et al18 evaluated 933 patients with stroke (489 men, 444 women; avg age, 71.3y) who had been admitted to the rehabilitation unit between 1985 and 1995, and found that the percentage of patients discharged to home was approximately 60%. Our data support previous works showing that earlier rehabilitative intervention by the multidisciplinary team resulted in better functional outcome in patients with stroke. Paolucci et al19 showed that inpatient rehabilitation within the first 20 days after stroke was associated with a significantly higher probability of excellent therapeutic responses than rehabilitation starting later. This response might be partly because the natural recovery mainly occurs in the first few weeks.9 Among patients in a study by Duncan et al,9 a considerable number were still nonambulatory or dependent in ADLs 3 months after acute stroke. However, our present data suggested that inpatient multidisciplinary rehabilitation was nevertheless effective even for such patients with significant disabilities. There is a precedent regarding the efficacy of late intervention. Miyai et al20 showed that multidisciplinary rehabilitation resulted in comparable functional gains in patients with stroke, no matter whether it was started within 3 months (avg, 2mo) or after 3 months (avg, 9mo). It may be reasonable for nonambulatory or moderately to severely disabled patients to expect measurable improvement after inpatient multidisciplinary rehabilitation several months after stroke. Further study is needed to confirm these possibilities and to determine whether improvement is associated with a reduced burden for those patients’ caregivers. There is a clear limitation in our study in that we could not have a control group who received no rehabilitative intervention. This type of control group is not ethically permissible. A second limitation is that we did not control for initial stroke severity, because those data were not available to us. CONCLUSION Inpatient multidisciplinary rehabilitation is effective for functional improvement in walking and ADLs even several months after stroke. Gains are better when provided earlier, but late rehabilitation still confers significant benefits. Acknowledgment: We thank Kojiro Kasai, PT, and Tomoyuki Ohashi, PT, for collection and evaluation of data.

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References 1. Indredavik B, Bakke F, Solberg R, Rokseth R, Haaheim LL, Holme I. Benefit of stroke unit: a randomized controlled trial. Stroke 1991;22:1026-31. 2. Feigenson JS, Gitlow HS, Greenberg SD. The disability oriented rehabilitation unit—a major factor influencing stroke outcome. Stroke 1979;10:5-8. 3. Indredavik B, Bakke F, Slordahl SA, Rokseth R, Håheim LL. Treatment in a combined acute and rehabilitation stroke unit. Which aspects are most important? Stroke 1999;30:917-23. 4. Kaste M, Paloma¨ ki H, Sarna S. Where and how should elderly stroke patients be treated? Stroke 1995;26:249-53. 5. Miyai I, Reding MJ. Stroke recovery and rehabilitation. In: Ginzberg MD, Bogousslavsky J, editors. Cerebrovascular disease: pathology, diagnosis, and management. Malden: Blackwell Scientific; 1998. p 2043-56. 6. Jørgensen HS, Nakayama H, Raaschou HO, Larsen K, Hu¨ bbe P, Olsen TS. The effect of a stroke unit: reduction in mortality, discharge ratio to nursing home, length of hospital stay, and cost. A community-based study. Stroke 1995;26:1178-82. 7. Kelly-Hayes M, Wolf PA, Kannel WB, Sytkowski P, D’Agostino RB, Gresham GE. Factors influencing survival and need for institutionalization following stroke: the Framingham study. Arch Phys Med Rehabil 1998;69:415-8. 8. Jørgensen HS, Nakayama H, Raaschou HO, Vive-Larsen J. Outcome and time course of recovery in stroke. Part II: Time course of recovery. The Copenhagen Stroke Study. Arch Phys Med Rehabil 1995;76:406-12. 9. Duncan PW, Lai SM, Keighley J. Defining post-stroke recovery: implications for design and interpretation of drug trials. Neuropharmacology 2000;39:835-41. 10. Reding MJ, Potes E. Rehabilitation outcome following initial unilateral hemispheric stroke. Life table analysis approach. Stroke 1988;19:1354-58. 11. Guidance for the Uniform Data System for Medical Rehabilitation (adult FIM), version 4.0. Buffalo: State Univ New York; 1993. 12. Mahoney FI, Barthel BW. Functional evaluation: the Barthel index. Md St Med J 1965;14:61-5. 13. Bobath B. Adult hemiplegia: evaluation and treatment. 2nd ed. London: Heinemann Medical Books; 1978. 14. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98. 15. Mori E, Mitani Y, Yamadori A. [Usefulness of a Japanese version of the Mini-Mental State test in neurological patients] [Japanese]. Jpn J Neuropsychol 1985;1:82-90. 16. Nakayama H, Jørgensen HS, Raaschou HO, Olsen TS. Recovery of upper extremity function in stroke patients: the Copenhagen Stroke Study. Arch Phys Med Rehabil 1994;75:394-8. 17. Tangeman PT, Banaitis DA, Williams AK. Rehabilitation of chronic stroke patients: changes in functional performance. Arch Phys Med Rehabil 1990;71:876-80. 18. Kubo A, Arahata K, Onuma M, Takahashi R. [Changes in patterns of morbidity over 10 years among elderly patients with stroke who were treated in a rehabilitation unit] [Japanese]. Nippon Ronen Igakkai Zasshi 1997;34:583-8. 19. Paolucci S, Antonucci G, Grasso MG, Morelli D, Troisi E, Coipo P, Bragoni M. Early versus delayed inpatient stroke rehabilitation: a matched comparison conducted in Italy. Arch Phys Med Rehabil 2000;81:695-700. 20. Miyai I, Suzuki T, Kii K, Kang J, Kajiura I. Functional outcome of multidisciplinary rehabilitation in chronic stroke. J Neurol Rehabil 1998;12(3):95-9.

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