Stroke Rehabilitation at a Crossroads: Will We Be Just Good or Will - - PowerPoint PPT Presentation

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Stroke Rehabilitation at a Crossroads: Will We Be Just Good

• r Will We Be Great?

Robert Teasell MD FRCPC Professor, Physical Medicine and Rehabilitation Western University Parkwood Institute Research, Lawson Research Institute

Faculty/Presenter Disclosure

Faculty: Robert Teasell Relationships with commercial interests:

• Grants/Research Support: Allergan
• Speakers Bureau/Honoraria: Allergan (2015)
• Consulting Fees: None
• Other: None

Conflicts of Interest

Allergan – research grant

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Objectives

• 1. Appreciate key principles in stroke rehabilitation needed to

maximize stroke rehabilitation outcomes

• 2. Understand the challenges in how those principles are
• perationalized in the real world.

Stroke Impact

• Stroke is a common life-altering event
• In Canada 62,000 people per year suffer a stroke and >405,000 are living

with stroke complications of stroke; will increase over next 2 decades.

• 36-42% stroke survivors with discernable disability or still dependent

for ADLs 5 years post stroke (Hankey et al 2002; Hackett et al 2000).

• Caregivers experience increase in physical demands (Sit et al 2004)

along with decrease in health-related quality of life (Godwin et al 2013); 2.5X greater risk of psychological distress (Simon et al 2009).

• Up to 50% of chronic stroke patients report depression (Visser-Meily et

al 2008).

Godwin et al. J Neurosci Nurs 2013; 45(3):147-54 Simon et al. Soc Sci Med 2009; 69(3):404-10 Visser-Meily et al. Patient Educ Couns 2008; 73(1):153-8 Hankey et al. Stroke 2002; 33(4):1034-40 Hackett et al. Stroke 2000; 31(2):440-7 Sit et al. J Clin Nurs 2004; 13(7):816-24

21st Century Stroke Rehab in Canada

• Exponential increase research evidence-base ( >300 RCTs/yr) (www.ebrsr.com )
• Initiated Ontario Stroke Strategy in 1999, followed by Canadian Stroke Network

and Strategy, followed by Ontario QBP; Canadian Stroke Guidelines (6th edition) (Hebert and Teasell et al. 2016)

• Over past decade dramatic changes in stroke rehab; in Ontario, FIM efficiency has

almost doubled; 1.0 is new normal; proportion of severe strokes admitted up to 41%; Ontario leads the country

• Early, intensive, task-specific, organized care (EITSOC) is becoming recognized

standard across Canada; in Ontario wait times are down

• Innovative new approaches to achieve EITSOC commonplace across Canada
• Stroke rehab is integrating into stroke continuum and last 5 years a big push to

better organize and improve rehab services across Canada

Hebert D, Lindsay P, … Teasell R. International J Stroke July 2016

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Stroke Rehabilitation at a Crossroads

As we are achieving many of our provincial goals, the question is how do we get better? Directions for Stroke Rehabilitation 1. Better Understanding Stroke Rehab and Recovery 2. Standardizing Care: Guidelines, Benchmarking and Increased Accountability 3. Role of Technology/Medications 4. Shifting Rehabilitation to the Community

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Stroke Rehab and Recovery

• The brain has significant capacity to reorganize itself to recover from loss of

function following a stroke; depends on training or rehab Rehabilitation training (enriched environments with animals) increases brain reorganization with subsequent functional recovery In animal studies key factors promoting recovery include increased activity and a complex, stimulating environment Lack of rehab causes decline in cortical representation and delays recovery

Brain Reorganization

• Key elements of stroke rehab should be increased activity

and a complex and stimulating environment

Brain Reorganization

Recovery Post-Stroke

Recovery after a stroke is associated with cortical reorganization Motor recovery is a complex process combining: 1. Neurological or Spontaneous Recovery. Recovery of impairment or normal way of moving as measured by Fugl- Meyer score or 3D Kinematics (restoration of normal motor patterns) 2. Functional Recovery. Recovery of tasks or activities often through learned compensatory movements (new motor patterns) as measured by ARAT, Barthel Index or arguably the FIM Both involve changes to the remaining motor cortex and relationship is not fully understood

Motor Learning Theory

Rehab has been transformed over the last two decades by the concept that:

• 1. repetitive practice,
• 2. of increasingly challenging task-related

activities,

• 3. assisted by a therapist in an adequate dose,
• 4. will lead to gains in motor skills,
• 5. through brain reorganization.

(Dobkin 2016)

Dobkin et al. Neurorehabilitation and Repair 2016

Recovery by Fixed Proportion (Spontaneous Recovery)

• Within 6 mos upper limb impairment resolves by fixed

proportion

• For those with weakness secondary to cortical damage but

relatively intact corticospinal (motor) tract function, 70% of maximum possible improvement occurs regardless of initial impairment (i.e. Fugl-Meyer score) (Prabhakaran et al 2008)

• Holds true for patients across all ages and countries with

different rehab services (Byblow et al. 2015)

• Exception is irreversible structural damage to the

corticospinal tract severely limits recovery of the upper limb movement (Stinear et al 2007; 2012)

Prabhakaran et al. Neurorehabil Neural Repair 2008; 22:64-71 Byblow et al. Ann Neurol 2015; 78:848-859 Stinear et al. Brain 2007; 130:170-80. Stinear et al. Brain 2012; 135:2427-35

Proportional Resolution of Upper Limb Impairment

• Proportional resolution of U/E impairment is minimally affected by rehab therapy
• 3D kinematics in subacute and chronic stroke victims have shown motor recovery

associated with rehabilitation is driven more by adaptive (or compensatory) learning strategies (Jolkkonen and Kwakkel 2016)

• Most clinical tests (i.e. Action Reaction Arm Test (ARAT) or walking speed 6MWT)
• nly assess a patient’s ability to accomplish a certain task or function; do not

measure impairment (Jolkkonen and Kwakkel 2016)

• Rehab promotes largely, likely entirely, adaptive or compensatory motor recovery

and brain reorganization reflects that relearning by remaining functioning brain.

Jolkkonen and Kwakkel. Translational Stroke Research 2016

Predict Recovery Potential (PREP) Algorithm

• Combines clinical measures and biomarkers to predict upper

extremity recovery.

• Step 1 (<72 hrs post stroke). Assessment paretic shoulder

abduction and finger extension (SAFE score) (sum of Medical Research Council scores max =10); SAFE > 8 Excellent potential; <8 move to Step 2.

• Step 2 (10 days post stroke): Transcranial Magnetic

Stimulation: MEP present = Good potential; MEP absent = Limited or No Potential; then move to Step 3 which involves diffuse-weighted MRI to determine assymetry of mean fractional anisotropy of posterior limbs of internal capsule.

• In New Zealand in a comparative study of 192 stroke patients,

pts with PREP algorithm result revealed had reduced length of hospital stay of 1 week; algorithm successfully predicted patient outcome 80% of time.

Stinear et al. Stroke 2017; 48:1011-1019.

Early Rehab

• Animal studies suggest there is a time window when

brain is “primed” for maximal response to rehab therapies, such that delays are detrimental to recovery (Bernaskie et al. 2004)

• Brain is “primed” to “recover” early in post-stroke

period

• Clinical association between early admission to rehab

and better functional outcomes (Paolucci et al. 2000, Salter et al. 2006 and Bai et al. 2012)

• The effects of training after stroke are generally

greater when started early after stroke, perhaps because of a “sensitive period” of enhanced neuroplasticity.

Bernaskie et al. J Neurosci 2004; 24(5):1245-54 Paolucci et al. Arch Phys Med Rehab 2000; 81(6):695-700 Bai et al. J Clin Neurosci 2012; 19(10):1376-9 Salter et al. J Rehabil Med 2006; 38(2):113-7

AVERT Trial: Can Rehab Be Too Early?

• Patients < 24 hrs post stroke randomly assigned to standard care (SC) (N=1050) or

SC + Very Early Mobilization (VEM) (N=1054) until discharge or 14 days

• 56 site international RCT over 8 years
• VEM group started earlier (18.5 vs. 22.4 hrs post stroke), got more out of bed

sessions (6.5 vs. 3.0) and received more therapy (31 min/day: total 201 min vs. 10 min/day: total 70 min)

• More pts in Usual Care (n=525) than VEM (n=480) (p=.001) had favourable
• utcome (modified Rankin Scale [0-2] at 3 mos post stroke)
• Later analysis (Bernhardt et al. 2016) found improved odds of favourable outcome

with increased daily frequency of out-of-bed sessions

• Overall, shorter more frequent early mobilization improves chance of regaining

independence; higher doses of long-term mobilization worsens outcomes.

The AVERT Trial Collaboration Group. Lancet 2015; 386:46-55 Bernhardt et al. Neurology 2016; 86:2138-2145

Role of Intensity of Therapy

• Greater intensity of practice results in better outcomes most of the time
• However, research with animals involves thousands of repetitions
• Pollock et al. (2014) in a review of upper extremity stroke rehab found that

“adequately powered high-quality RCTs confirmed the benefit of … a high dose of repetitive task practice”.

• Van Peppen et al. (2004) noted additional therapy time of 17 hours over 10 weeks is

necessary to see significant positive effects; affirmed by Verbeek et al. (2014)

• Canadian Stroke Guidelines note stroke rehab patients should receive a minimum of

three hours of direct task-specific therapy, five days a week, delivered by the inter- professional team.

Van Peppen et al. Clinical Rehab 2004; 18:833-862. Verbeek et al. PLOS ONE 2014; 9(2):e87987

Role of Intensity of Therapy

• Rehab increases motor reorganization while lack of rehab reduces it; more

intensive motor training further increases brain reorganization

• Clinically greater therapy intensity improves outcomes and there seems to be a

dose-response relationship

• Still do not know threshold or dosage of rehab intensity needed to obtain a

benefit (MacLellan et al 2011), although we know animal studies employ thousands of repetitions to show benefit and the average therapy session does not perform a large number of repetitions of a task.

MacLellan et al. NeuroRehab and Neural Repair 2011; 25(8):740-748 Dromerick et al. Neurology 2009; 73:195-201

Recommendations Regarding Inpatient Therapy Intensity Following Acute Stroke

Guideline Recommendation AHA/ASA 2005 “…as much therapy as needed to adapt, recover and/or establish …

• ptimal level of functional independence.”

European Stroke Organization “Increase the duration and intensity of rehabilitation” Intercollegiate Stroke Working Party 2008 A minimum of 45 minutes daily of each therapy required in the early stages of stroke SIGN 118 Increased intensity of therapy to improve gait should be pursued Increased intensity of therapy for improving upper limb function is not recommended National Stroke Foundation, Australia 2010 Minimum of 1 hour of occupational and physiotherapy 5 days per week Canadian Best Practice Recommendations 2010 Minimum of 1 hour per day, 5 days a week of each of the relevant core therapies (PT, OT, SLP)

Foley et al. Topics Stroke Rehabil 2012; 19(2):96-103

Increasing Intensity in a Time of Restraint

• Few patients receive the recommended intensity of therapy
• In Ontario/Canada the estimate is the average rehabilitation patient was

getting 1-2 hours of direct patient-therapist time (Foley et al. 2012) 5 days per week.

• In SIRRACT trial, ankle sensors collecting daily data revealed the average

amount of daily walking practice during inpatient rehab for stroke across 16 facilities was only 17 minutes and decreased as patients achieved walking speeds of only 0.8 m/s (Dorsch et al. 2015)

• Lang et al. (2007) found practice of task-specific, functional U/E movements
• ccurred in half of U/E rehab sessions: Average number of reps = 32

Foley et al. Disability and Rehabilitation 2012; 34(25):2132-2138. Dorsch et al. Neurorehabil Neural Repair 2015; 29:4007-415. Lang et al. Arch Phys Med Rehabil 2009: 90:1692-1698

Increasing Intensity in a Time of Restraint

Innovative approaches from group therapy to videogames to altering therapist mix:

• Group therapy. 73 inpatient stroke patients referred to group therapy gait task

training or individual gait task training did equally well (Renner et al. 2016).

• Videogames (non-immersive virtual reality) improves outcomes but are equal to

spending a comparable amount of time playing board games (Saposnik et al. 2016)

• Activity monitoring using wearable sensors are being developed – currently irregular

accelerations and decelerations of hemiparetic leg confuse most commercial sensory algorithms.

• Weekend therapy is present in almost all rehab units now.
• General rehab assistants are a less expensive alternative to increase intensity and

have become very popular across Canada; can cross disciplines.

Renner et al. Clinical Rehabilitation 2016; 30(7):637-648. Saposnik et al. Lancet Neurology 2016; 15(10):1019-27.

• Interdisciplinary stroke rehab team

concept developed in 1950-60’s

• Very discipline-specific
• No longer as relevant – rigid,

expensive, paperwork heavy, inefficient

Interdisciplinary The Change in the Rehab Team

Physio- therapy Nursing Speech Therapy Occup. Therapy

Transdisciplinary

Physio- therapy Speech Therapy Occup. Therapy Nursing Rehab Therapists Recreational Therapy RPNs/Nurse Assistants

• Large influx of rehab therapists (cross between therapy and

nursing aids)

• Lines between therapies becoming blurred and how

rehabilitation redefined

• Rehab becoming less discipline specific
• Opportunity to better engage nursing (represent the

majority of team members)

Applying the Evidence

Stroke Rehab Units

• Stroke Units are often regarded as “gold standard” of stroke care (Foley et al

2007)

• According to Canadian Stroke CPGs this means: 1) Care is formally coordinated

and organized; 2) Managed by an interprofessional team; 3) Specialized team on a geographically defined unit.

• Stroke Unit Trialists’ Collaboration notes patients managed on a stroke unit were

more likely to be alive, independent and living at home after a stroke (SUTC 2013)

• Population-based study in Australia noted organized stroke unit (acute/rehab)

care provided greatest potential absolute benefit to the community (Gilligan et al 2005)

Foley et al. Cerebrovascular Disease 2007; 23:194-202 SUTC Cochrane Database Syst 2013 Gilligan et al. Cerebrovascular Dis 2005; 20(4):239-244

Stroke Rehabilitation Units

Foley et al. Cerebrovascular Disease 2007:23:194-202

Quality of Research: Stroke Rehab Motor RCTs

• 1376 RCTs involving interventions for the upper extremity alone up to 2016
• The 2 most important elements in PEDro score reducing bias, concealed allocation
• f randomization and blinded assessment of outcomes were done in only 34% and

38% of RCTs respectively, raising concerns about bias

• Vast majority RCTS are single site usual care or conventional controls; more Proof-
• f Principle or Phase II studies (mean N start/finish 46.5/42.7; 67% < 40 subjects)
• RCTs often underpowered because of resource limitations and may be unreliable,
• verestimating effect sizes (Roberts and Kerr).

Stroke Rehab Motor Interven. RCTs 2016 N (start/ finish) PEDro Conceal Allocat Blind Assess Intent to Treat RCTs < 6mos RCTS > 6mos RCTs N/A

• r Both

Total

1376 46.5/42.7 6.1 34% 38% 55% 561 699 116

Quality of Motor Therapy RCTs Post Stroke

• Need for larger multi-centered trials with active or dose matched control groups
• Example is the LEAPS Trial (Locomotor Experience Applied Post Stroke) (Duncan

et al. 2011) for BWSTT which had a dose matched control; intervention not better than the active control; however both groups improved.

• With larger, more sophisticated motor RCTs with active controls, both groups
• ften improve similarly with dose matched therapy (LEAPS, ICARE, CIRCIT,

EVREST, SIRRACT).

It appears intensive goal-directed therapy works but it does not seem to matter what actual therapy is done.

Duncan PW et al. NEJM 2011;364:2026-36

Constraint Induced Movement Therapy

• Key features CIMT were restraint of unaffected hand/arm and increased practice/use of

the affected hand/arm

• Overcome learned non-use (Taub et al. 1999)

Motor Intervention RCTs 2015 N (start/ finish) PEDro Conceal Allocat Blind Assess Intent toTreat <6mos >6mos CIMT 72 45.1/40.0 5.9 35% 24% 57% 25 41

• There is level 1a evidence CIMT in the acute and chronic phase of

stroke improves upper extremity function.

• Verbeek et al. (2014) reported high intensity mCIMT (mitt worn 90% of

day and 3-6 hrs of therapy/day) and lower intensity mCIMT (mitt <90%

• f day and 0-3 hrs of therapy/day) demonstrated significant SESs for

paretic arm (synergies) and arm-hand activities.

Constraint Induced Movement Therapy

• Therapy with substantial evidence (>72 RCTs

for upper extremity alone)

• Unique therapy that adheres to our

understanding of neurological recovery

• Easy to do – offers the opportunity to

increase intensity of therapy at minimal cost.

• Not commonly implemented because

patients/clinicians do not necessarily see it as feasible or superior and it is outside of the typical norm of rehab therapy.

Guidelines/Accountability

• CPGs or Consensus Recommendations are designed to help practitioners assimilate,

evaluate and implement the ever-increasing amount of evidence and opinion on best current practice

• Hoenig et al. (2002) examined Structure of Care: systemic organization, staffing

expertise and technological sophistication vs. Processes of Care: adherence to AHCPR post-stroke rehabilitation guidelines

• Structure of Care not directly associated with better Outcomes
• Processes of Care were associated with better Outcomes – better adherence to

guidelines meant improved outcomes and improved patient satisfaction (Hoenig et

• al. 2002; Duncan et al. 2002; Reker et al. 2002)

Grimshaw et al. 2012 Hoenig et al. Med Care 2002: 40(11):1036-1047 Duncan et al. Stroke 2002; 33(1): 167-177 Reker et al. Arch Phys Med Rehabil 2002; 83(6):750-756

Impact of Depression Post Stroke

• Estimated impact of depression on

physical and functional outcomes is up to 50% of variance

• Also more likely to suffer deterioration in

physical and cognitive functioning and on discharge from rehab

• Depression has been linked to higher

mortality among elderly patients with physical illness

• Depression can be diagnosed and

treated

Depression Post Stroke Canadian Stroke Guidelines 2013

1. SCREEN: All patients with stroke should be screened for depressive symptoms using a validated tool [Evidence Level A] 2. ASSESS: At risk patients should be referred to a healthcare professional with expertise in diagnosis and management of depression in stroke patients. 3. TREAT: Patients diagnosed with a depressive disorder should be given a trial of an antidepressant medication.

Salter K, McClure JA, Foley N, Teasell R. Adherence to Canadian Best Practice Recommendations for Post-Stroke Depression: Who are we treating, anyway? Stroke 2012; 43(11):e140.

Depression Post Stroke: Evaluation of Current Practices in Light of Best Practices to Identify Gaps

Cross-Ontario Audit of Post-Stroke Depression in Stroke Rehab Units

In a practice audit of 11 facilities (n=605): – 23.9% of patients were screened for depression – 17.5% were referred for assessment – 3.6% diagnosed with depression properly – Yet 34.7% were treated – Recall 25-33% of stroke patients suffer from depression

Salter et al. Topics in Stroke Rehabilitation 2012; 19(2):132-140

• Were the right people treated? We don’t know!
• Accuracy of informal identification and diagnosis is reported to be approximately

33 – 48% (doctors) and 43% (nurses in an inpatient setting) (Mitchell et al. 2010; Mitchell & Kakkadasam, 2010)

• Lowe et al. (2004) – 40% (physician), 88% (HADS), 98% (PHQ-9) sensitivity; in a

primary care setting

Quality Based Procedures/Funding Results

• MOHLTC established Health System Funding Reform in Ontario in 2012
• Quality-Based Procedure (QBP) funding is premised on no longer global funding

budget but rather payment for patient outcomes

• “Money follows the patient” and not the bed
• Performance mandate based on service demand and system efficiency
• Developed standards for stroke care, involving expectations for timing, intensity and

rehab locale

• Just the prospect of QBP in Ontario has transformed stroke rehab by engaging

administrators; Ontario now leads all provinces in FIM efficiency.

• Sped up the implementation of EITSOC – improved integration of care, weekend

therapy, outpatient programs – spurred innovation and restructuring

Flow Chart for the Stroke Patient Cohort Across Care Settings

Benchmarking: Accountability for Resources

• For inpatient rehab we have Rehab Patient Groups

based on stroke severity with target discharge dates

• Our center voluntarily adopted Benchmarking and

were able to reduce LOS by 12 days with no

• utcome changes (Meyer et al. 2012)
• Team responsible for team outcome and it has

become the focus of team rounds; increasingly judged by ability to meet benchmarks, FIM efficiency at the level of the hospital, LHIN and province.

Meyer et al. Length of stay benchmarks for inpatient rehabilitation after

• stroke. Disability and Rehabilitation 2012: 34 (13): 1077-81.

Team Conference

Program and Interdisciplinary Team with Benchmarking

Physio- therapy Nursing Speech Therapy Occup. Therapy MD Admin Discharge Planning Benchmarking

Shifting Care to the Community

Shift to Outpatient and Long-Term Rehabilitation

• Rehabilitation is not a place; it is a process
• There is a move to moving rehab care where possible to community
• Cochrane review of 14 RCTs of 1,617 patients (Outpatient Trialists 2003) involved

in home based, day hospital and outpatient clinic

• Therapy reduced the odds of a poor outcome (death, deterioration or

dependency) (OR 0.72; 95% CI 0.57-0.92; p=0.009)

• NNT in order to spare one person from experiencing a poor outcome was 14
• Reduces rehospitalization and allows earlier discharge home
• Estimated savings is $2 for every $1 spent on outpatient therapies
• Greater intensity may not be as critical (ICARE; Winstein et al. 2016

Outpatients Services Trialists. Cochrane Database Syst Rev 2003

The Importance of Outpatient Rehab

• Meyer et al. (2012) studied “avoidable” mild admissions to

inpatient rehabilitation (FIM > 100; RPG 1160) - sufficient function to receive rehabilitation in the community

• Compared to community-based rehabilitation resources by

LHIN throughout Ontario

• Correlation between lack of community outpatient

rehabilitation therapy resources and likelihood mild stroke patients were admitted to more expensive inpatient rehab

• Particularly true for Speech Therapy
• Too often inpatient stroke rehab has been the “costlier”

default option because of a lack of alternatives

• Illustrates continuing concerns about stroke rehab system’s

“inability to adapt to the changing needs of patients along the care continuum” (Lewis et al. 2006)

Meyer M, Thind A, Speechley M, Koval J, Teasell R. Mild stroke: Do community-based resources impact rates of admission to inpatient rehabilitation? Archives of Physical Medicine and Rehabilitation 2012; 93(10):e38.

Canadian Best Practice Guideline Update 2015

Recommendations 4.1 Outpatient & Community-Based Rehabilitation i. Stroke survivors with ongoing rehabilitation goals should continue to have access to specialized stroke services after leaving hospital [Evidence Level A]. This should include in-home community-based rehabilitation services … or facility-based outpatient services [Evidence Level A]. ii. Outpatient and/or community-based services should be delivered in the most suitable setting based on patient functional rehabilitation needs, participation-related goals, availability of family/social support, patient and family preferences which may include in the home or other community settings [Evidence Level C].

Hebert D … Teasell R. Canadian Stroke Best Practice Recommendations: … Update 2015. International Journal of Stroke July 2016.

Community Stroke Rehab Teams

• Southwest Ontario Local Health Integrated Network

supported development of 3 specialized multidisciplinary stroke rehab teams to coordinate personalized support to stroke survivors in their homes in 2009

• >4000 patients assessed; half only need 1-3 visits
• >2000 patients have > 4 visits; these Patients get on

average 30 rehab visits in their home, 14 are core therapies of PT, OT and SLP while remainder are therapeutic recreation, RN, SW with the majority rehabilitation therapy assistants

• Length of treatment averages about 50-55 days

CSRT: Referral Sources

Acute Care Inpatient Rehab Community

Referral Sources Referral Source n=1499 Acute Care Inpt Rehab Community Percentage n=471 31.4% n=742 49.35% N=286 19.3% Time Post Stroke (median weeks) 3.85 9.21 10.14 Admission FIM 110.8 101.3 104.0 Therapy Visits as OP 22.4 33.4 28.4

• Data obtained CSRT central data base on all clients admitted

between January 2009 and September 2015 (N=3030)

• For those with > 4 visits; mean 30 visits

Patients with > 4 Treatments Referred from Acute Care to Community Stroke Teams

20 40 60 80 100 120 140 160 180

2009 2010 2011 2012 2013 2014

Acute

Early Supported Discharge

Death or dependency Significant results Odds Ratio (OR) and 95% CI Overall result Yes 0.80 (0.64 to 0.97) ESD team with coordination and delivery Yes 0.71 (0.55 to 0.91) ESD team coordination No 0.77 (0.54 to1.11) No ESD team coordination No 1.23 (0.79 to 1.91)

• ESD is a popular concept for rehabilitating milder stroke patients outside of

hospital using an interdisciplinary approach Outcome on Death or Dependency for ESD vs Conventional Care Stratified by Level

• f Service Provision (Fearon and Langhorne 2012)

Fearon P, Langhorne P. Cochrane Database of Systematic Reviews 2012 Issue 9

• It is just not enough to provide the resources; continuity of care matters

In-Patient and ESD Same Team

ESD Team In Patient Team In Patient Team ESD Team

Early Supported Discharge

Significant Benefit Trend to Less Benefit Trend to Benefit

Fearon P, Langhorne P. Cochrane Database of Systematic Reviews 2012 Issue 9

• It is just not enough to provide the resources; continuity of care matters

Stroke Rehab at a Crossroads

• Growing evidence base (research) and clinical practice guidelines
• Stroke rehab is evolving towards more evidence-based care with tangible results as

clinicians, administrators and researchers have risen to the challenge

• Environment is changing; demographics, funding limitations, technology
• Research needs to be more sophisticated (multi-center RCTs with dose matched

controls)

• Need to better refine early and intensive therapy and better understand stroke

rehab and recovery

• Must standardize care, get the right patient in right place at right time, and better

use available resources

• Can begin to incorporate technology into rehab, including better data tools
• Recognize there is a shift of care into the community with greater potential for long-

term rehab management

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The End