Therapy-Based Rehabilitation for Stroke Patients Living at Home
Stroke unit care is now accepted as an effective service model for hospital care, but the effectiveness of outpatient services are less certain. This review focuses on therapy-based rehabilitation services (defined as input from occupational therapy, physiotherapy, or a multidisciplinary team) targeted at stroke patients living at home.
To assess the effects of therapy-based rehabilitation services targeted toward stroke patient resident in the community within 1 year of stroke onset or discharge from hospital following stroke.
We searched the Cochrane Stroke Group Specialised Trials Register (last searched by the Review Group Coordinator in November 2001), the Cochrane Controlled Trials Register (Cochrane Library, Issue 4, 2001), MEDLINE (1966–November 2001), EMBASE (1980–November 2001), CINAHL (1983–November 2001), PsycINFO (1967–November 2001), AMED (1985–November 2001), Wilson Social Sciences Abstracts (1984–November 2001), and Science Citation Index and Social Sciences Citation Index (1981-Nov 2001). Other strategies to ensure identification of all potentially relevant trials included scanning reference lists of relevant articles and original papers, hand-searching relevant journals, and personal communication.
We considered all unconfounded, truly randomized controlled trials of stroke patients resident in the community receiving a therapy service intervention, which was compared with conventional care (ie, normal practice or no routine intervention). Two reviewers independently selected trials, extracted data, and assessed trial quality.
A total of 27 trials were identified by November 2001 of which 10 did not meet the inclusion criteria. Three trials are not yet completed, and the remaining 14 contained outcome information on a total of 1617 patients. Losses to follow-up were small (138 patients; 8.5%).
Patients allocated therapy-based rehabilitation services were less likely to deteriorate in ability to perform activities of daily living (odds ratio 0.72; 95% CI 0.57 to 0.92; P=0.009) and increased their ability to perform personal activities of daily living (standardized mean difference 0.14; 95% CI 0.02 to 0.25; P= 0.02). These findings were not substantially altered if analyses were restricted to trials that described a clearly concealed randomization process and unequivocally blinded final outcome assessment.
Stroke patients living at home who received input from a therapy-based rehabilitation service were less likely to experience deterioration in their ability to perform activities of daily living. The absolute risk of deteriorating in ability to perform activities of daily living was 7 per 100 patients allocated therapy-based rehabilitation. However, interpreting and implementing these results raise a number of challenges. Further research is needed to define the most effective interventions, their economic benefit, and the most appropriate level of service delivery.
Section Editor: Graeme J. Hankey, MD, FRACP
- Received November 11, 2003.
- Accepted November 26, 2003.