The association between inpatient rehabilitation intensity and outcomes after stroke in Ontario, Canada

Shannon L MacDonald; Elizabeth Linkewich; Mark Bayley; Irene Jh Jeong; Jiming Fang; Jamie L Fleet

doi:10.1177/17474930231215005

The association between inpatient rehabilitation intensity and outcomes after stroke in Ontario, Canada

Int J Stroke. 2024 Apr;19(4):431-441. doi: 10.1177/17474930231215005. Epub 2023 Dec 11.

Authors

Shannon L MacDonald¹, Elizabeth Linkewich², Mark Bayley^{1

3}, Irene Jh Jeong⁴, Jiming Fang⁴, Jamie L Fleet^{5

6}

Affiliations

¹ ICES, Department of Medicine, University of Toronto and Hennick Bridgepoint Hospital, Sinai Health, Toronto, ON, Canada.
² Department of Occupational Science and Occupational Therapy, University of Toronto and Practice Based Research, Sunnybrook Research Institute, North & East GTA Stroke Network, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
³ KITE Research Institute, UHN-Toronto Rehabilitation Institute and Division of Physical Medicine and Rehabilitation, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
⁴ ICES Central, Toronto, ON, Canada.
⁵ Department of Physical Medicine and Rehabilitation, Western University, London, Canada.
⁶ Parkwood Institute, St. Joseph's Health Care London, London, ON, Canada.

PMID: 38078378
DOI: 10.1177/17474930231215005

Abstract

Background: Several studies have demonstrated improved outcomes poststroke when higher intensity rehabilitation is provided. Canadian Stroke Best Practice Recommendations advise patients receive 180 min of therapy time per day; however, the exact amount required to reach benefit is unknown.

Aims: The primary aim of this study was to determine the association between rehabilitation intensity (RI) and total Functional Independence Measure (FIM) Instrument change. Secondary aims included determining the association between RI and discharge location, 90-day home time, rehabilitation effectiveness, and motor and cognitive FIM change.

Methods: A retrospective cohort study was conducted using available administrative databases of acute stroke patients discharged to inpatient rehabilitation facilities in Ontario, Canada, from January 2017 to December 2021. RI was defined as number of minutes per day of direct therapy by all providers divided by rehabilitation length of stay. The association between RI and the outcomes of interest were analyzed using regression models with restricted cubic splines.

Results: A total of 12,770 individuals were included. Mean age of the sample was 72.6 years, 46.0% of individuals were female, and 87.6% had an ischemic stroke. Mean RI was 74.7 min (range: 5-162 min) per day. Increased RI was associated with an increase in mean FIM change. However, there was diminishing incremental increase after reaching 95 min/day. Increased RI was positively associated with motor and cognitive FIM change, rehabilitation effectiveness, 90-day home time, and discharge to preadmission setting. Higher RI was associated with a lower likelihood of discharge to long-term care.

Conclusions: None of the patients met the recommended RI of 180 min/day based on the Canadian Stroke Best Practice Recommendations. Despite this, higher intensity was associated with better outcomes. Given that most positive associations were observed with a RI ⩾95 min/day, this may be a more feasible target.

Keywords: Stroke; functional status; stroke rehabilitation; treatment outcome.

MeSH terms

Aged
Female
Humans
Inpatients
Length of Stay
Male
Ontario / epidemiology
Recovery of Function
Rehabilitation Centers
Retrospective Studies
Stroke Rehabilitation*
Stroke* / epidemiology
Stroke* / therapy
Treatment Outcome