Stroke Patient Rehabilitation

Stroke is the second leading cause of death after ischemic heart disease; there were 6.5 million stroke-related deaths worldwide in 2013.¹ Approximately 795,000 strokes occur in the United States each year, with an average incidence of new stroke every 40 seconds and death from stroke every 4 minutes.¹ Those who survive stroke are often left with a wide range of neurologic deficits that directly affect their all-cause mortality outcome. It is therefore essential to maximize stroke survivors’ structure and function in order to improve their quality of life and reduce their all-cause mortality. Aggressive rehabilitation is recommended after a stroke in order to enhance recovery and improve patient outcomes. In a retrospective cohort study of 1,716 stroke patients, better long-term outcomes were achieved in patients who underwent rehabilitation within 7 days after a stroke, compared to those who received therapy 1 month or more after a stroke.² Even stronger evidence was provided that proved patients who continued to receive therapy had better outcomes than those who did not, between 15 and 30 days after an acute stroke.² All stroke patients need a rehabilitation assessment, and the majority have deficits requiring therapy services. Of those patients who are medically appropriate for rehabilitation, it is necessary to determine the optimal location for short- and long-term rehabilitation in the post–acute care setting.

Common Rehabilitation Disposition Options

On an acute neurology service, disposition is one of the primary challenges managed from the moment a patient is admitted to the inpatient ward. Although there are multiple factors involved in the disposition decision-making process, it is important that acute stroke providers are aware of the benefits and drawbacks of each post-acute care option. One way to think of post-acute options is to rank them from most medically complex/highest acuity to most medically stable/lowest acuity (Figure 1).

The Inpatient Rehabilitation Facility

Inpatient rehabilitation facilities (IRFs) have the benefit of close physician supervision, multidisciplinary care, and favorable patient outcomes proven through retrospective and prospective research. One of the most important facts to consider when discharging a patient to an IRF is their need to provide the availability of physicians and nurses with specialized training or experience in medical rehabilitation for 24 hours a day 7 days per week.³ The specialized medical professionals in this setting include a physiatrist (physical medicine and rehabilitation physician) and certified rehabilitation nurses (Figures 2 and 3). In addition to these medical professionals, licensed practitioners in occupational therapy (Figure 4), physical therapy (Figure 5), speech–language pathology (Figure 6), recreational therapy, and respiratory therapy are available. Other members of the multidisciplinary staff include a psychologist, social worker, vocational counselor, a prosthetics and orthotics department, and dietitians or nutritional counselors. The IRF must employ enough staff members such that they are able to provide each patient with at least 3 hours of therapy daily and meet the rehabilitation medicine and rehabilitation nursing needs of the patients.³ In order to achieve a goal-oriented and well-rounded multidisciplinary effort, it is a requirement that all of the professionals involved in the patient’s care communicate as a group at least once per week to discuss the patient’s progress, reestablish goals, and conduct discharge planning.³

The Inpatient Rehabilitation Stroke Patient

In order for a patient to meet criteria for an IRF, their characteristics must relate to their needs for both medical management and rehabilitation programs. The patient must have substantial functional deficits as well as medical and nursing needs. The patient must need close medical supervision by a physiatrist and a 24-hour need for nurses skilled in rehabilitation. Physical therapists, occupational therapists, speech–language pathologists, and psychologists provide a medically coordinated program. The patient must have clear functional goals identified that are realistic in order to warrant admission.³ Achievement of practical rehabilitation improvements are expected within a reasonable time period.³

The medical and surgical comorbidities of a patient must be considered to be manageable in the rehabilitation hospital and sufficiently under control in order to permit simultaneous participation in the rehabilitation program.³

In most circumstances, the patient has a home and available family or care provider to ensure the likelihood of the patient to return home or to a community-based environment after completion of the rehabilitation course.

The Skilled Nursing Facility

Most skilled nursing facilities (SNFs) provide fewer than 3 hours per day of therapy due to lack of a time requirement. In an SNF, the physician must provide general medical supervision of the patient. However, these visits are only required on admission, then once every 30 days, and only once every 60 days after the first 3 months.³ Midlevel practitioners are allowed to substitute for physicians on an intermittent basis, and patient assessments are only required quarterly or within 14 days of a significant change.³

In regards to the rehabilitation program at the SNF, physicians do not necessarily manage therapy services, whereas this is routinely performed on a daily basis at an inpatient rehabilitation hospital. SNFs provide similar therapy services to the stroke patient if required by the patient’s plan of care. However, there is no minimum therapy time requirement compared to an IRF. At an SNF, there is no requirement for interdisciplinary team conferences. Therapy providers may also determine independently of one another when therapy will end.³ There is no requirement that the SNF provides prosthetic or orthotic services. Social services must be available by a social worker. In regards to the nursing program at the SNF, 24-hour nursing staffing is not required, nor is certified rehabilitation nursing.

The Long-Term Acute Care Hospital

Long-term acute care hospitals (LTACHs) provide care to patients with complex needs who require longer hospital stays and highly specialized medical and therapy services. LTACHs are designed for patients who need intense, extended care for more than 25 days.⁴ This patient population includes those who require long-term mechanical ventilation requiring slow weaning off their ventilator dependence, complex cardiac recovery, wound care, or cancer care. Therefore, the majority of patients admitted to LTACHs arrive directly from the intensive care unit of traditional acute hospitals.⁴ Similar to the inpatient rehabilitation hospital, LTACHs require around-the-clock onsite physician and nursing coverage. LTACHs use a multidisciplinary team approach to meet the individual needs of patients.

Home Health and Outpatient Therapy

Home health and outpatient therapy are two options for patients who are medically and functionally appropriate to be discharged directly home from the acute care hospital with or without caregiver support. The acute care physician and acute care therapy team must both come to the decision that discharge to home is a safe and appropriate disposition for the stroke patient.

Home health therapy is chosen when the patient is medically or functionally unable to leave the home. There has been a significant positive growth trend in the last 8 years for patients with minor strokes to be discharged home with home health therapies.⁵ In this care, home health is chosen in order to provide in-home therapy services to the stroke patient. These services can range from physical therapy to occupational therapy to speech–language pathology. An important point to understand when considering this option for a patient is that this type of care is limited to a short amount of time in home, ranging on average 30 to 45 minutes per professional, two to three times weekly. The other limitation is the minimal amount of equipment available for each professional to work with in the home.

Outpatient therapy is chosen when the patient is able to leave the home and can transport to an outpatient therapy site. Services are provided to the stroke patient in an outpatient facility. These services include physical therapy, occupational therapy, speech–language pathology, or vocational rehabilitation. The benefit of this option over home health therapy is the larger availability of equipment to work with that may be present in the outpatient facility. Also, the amount of service time provided is slightly more than that of home health, 45 to 60 minutes, two to three times weekly.

Which Disposition Is Associated With the Most Favorable Outcome?

Table 1 provides a succinct guide to the different post–acute care options described above. In addition to discussing options with an acute therapist or case manager, it is essential to know the studied outcomes for the common rehabilitation options. Two functional scales are primarily used in stroke research to stratify a patient’s medical and functional level. The modified Rankin Scale (mRS) is a clinician-reported measure of global disability that has been widely applied for evaluating recovery from stroke and as a primary endpoint in randomized clinical trials of emerging acute stroke treatments.⁶ In addition, the well-known National Institutes of Health Stroke Scale (NIHSS) is a scale used initially and repeatedly to objectively analyze the neurologic function of the stroke patient.

A prospective randomized controlled trial analyzed both the 24-hour NIHSS and the 90-day mRS.⁷ The severity of stroke was initially classified into three groups based on the 24-hour NIHSS: less than 6 for mild, 6 to 13 for moderate, and greater than 13 for severe. The disposition of the stroke patient following the acute hospital stay was classified as home, IRF, or SNF, and a favorable outcome was defined as a 90-day mRS ≤2.7. Out of a total of 429 subjects, 6% of subjects discharged to an SNF achieved a 90-day mRS ≤2, whereas in the IRF group, 32% achieved a 90-day mRS ≤2.7. Interestingly, when stratified by stroke severity, no subjects in the NIHSS <6 group who went to an SNF had a favorable outcome.⁷ For NIHSS 6 to 13, 47% of subjects discharged to an IRF had a favorable outcome, and 61.9% who went home had an unfavorable outcome.⁷

It was determined that patients with stroke treated at an IRF were more than three times as likely as those at an SNF to return to the community.⁸ Researchers attributed this to the comprehensive array of services available at the IRF. In addition, patients who were treated at an SNF were seven times more likely to return to the community compared to those who were discharged to traditional nursing homes without skilled therapy.⁸ Overall, subjects who were discharged to an IRF were strongly associated with having a favorable outcome compared to those who were discharged to an SNF.

Physician and Nursing Treatment in the IRF

As discussed, stroke patients who obtain medical and rehabilitation services at an IRF have a more favorable outcome compared to disposition to other facilities. This is likely due to the daily care of an in-house physician along with 24-hour in-house certified rehabilitation nursing. The daily care of a physician allows for continued medical care as the patient transitions from the acute to subacute setting. This decreases delayed medical care that often occurs weeks after acute care discharge at the outpatient follow-up visit. This also directly mitigates the lack of medical care that is not provided to a stroke patient who becomes lost to follow-up.

There are a number of poststroke complications that may occur during the rehabilitation phase of stroke care (Table 2).

Disability and Ability Outcomes

Disability is defined by a medical condition causing functional impairments, which lead to activity limitations and therefore create participation restriction. When choosing the next step for a stroke patient, it is important to analyze the impairment level in order to project a rehabilitation goal. The goal for a patient is to progress from disability to ability in regards to an activity limitation. The severity of a neurologic impairment and level of disability after a stroke are strong predictors for disposition after stroke.⁹ The NIHSS was determined to be a good predictor of hospital disposition.⁹ A prospective research study was performed that correlated stroke patient disposition with a respective NIHSS. Of those patients with mild neurologic impairment, defined as NIHSS score <5, 81% were discharged home, 18% to an IRF, and only 0.4% to an SNF.⁹ Of patients with NIHSS scores between 6 and 10, 45% were sent home, 50% to an IRF, and 5% to an SNF.⁹ Of patients with NIHSS scores 11 to 15, 30% were discharged to home, 48% to an IRF, and only 22% to an SNF.⁹ Finally, of patients with NIHSS scores >16, 50% were discharged to an IRF, 37% to an SNF, and 13% to home.⁹ Therefore, most stroke patients with NIHSS 6 or greater were discharged to an IRF.

The patient’s functional status at the time of acute care discharge may be objectively analyzed with the mRS. It was determined that up to 57% of severely disabled patients, indicated by an mRS of 4 to 5, were discharged to an IRF, 23% to home, and 19% to an SNF.⁹ Only one-third of patients with moderate disability defined by mRS of 2 to 3 were discharged to an IRF, whereas 65% went home and 1% went to an SNF.⁹ Of those patients with good functional condition indicated by mRS of 0 to 1, only 6% were discharged to an IRF.⁹

Another variable that may be used to determine stroke patient disposition is the acute hospitalization length of stay. Patients with longer hospitalization periods were more likely to be discharged to an SNF than to any other location.⁹ The median length of stay was found to be 4 days for stroke patients who were discharged home, 8 days for those discharged to an IRF, and 13 days for those discharged to an SNF.

In the above study population, mortality rates at 1-year follow-up were substantially higher in patients discharged to SNFs than those discharged to home or IRFs: 60% death rate among those discharged to SNFs, 15% of those discharged to IRFs, and 10% of those discharged to home.⁹

Although functional scales are useful, medically complex patients are not always straightforward in regard to decisions for stroke patient disposition. In a retrospective analysis of a population-based stroke registry in France, it was found that patients with advanced age, anticoagulants at time of stroke, and dementia were less likely to return home or to an IRF and more likely to be discharged to an SNF.¹⁰

Overall, determining the optimal location for short and long-term rehabilitation in the post–acute care setting poses a challenge to acute care stroke providers. During this process, it is important to take into account all aspects of the patient’s life when making this decision. The medical, functional, social, and economic status of the patient must all be analyzed in order to determine optimal stroke patient disposition.¹¹ We have provided a comprehensive knowledge base for the different post–acute care settings as a guide to ease stroke patient disposition decisionmaking.

1. American Heart Association. Statistical Update: Heart Disease and Stroke: American Heart Association Stroke Update. Dallas: American Heart Association; 2017.

2. Sowerbutt C. Multidisciplinary rehab in acute stroke: Canadian model sign of things to come? Appl Neurol. 2007;3:24.

3. Melvin JL. American Academy of Physical Medicine and Rehabilitation Task Force on medical inpatient rehabilitation criteria: standards for assessing medical appropriateness criteria for admitting patients to rehabilitation hospitals or units. 2006. http://www.aha.org/content/00-10/2006mirc.pdf. Accessed September 2, 2017.

4. RML Specialty Hospital. What is an LTACH? http://www.rmlspecialtyhospital.org/why-rml/ltach/. Accessed September 2, 2017.

5. Bettger J, McCoy L, Smith EE, et al. Contemporary trends and predictors of postacute service use and routine discharge home after stroke. J Am Heart Assoc. 2015;4:e001038.

6. Banks JL, Marotta CA. Outcomes validity and reliability of the modified Rankin Scale: implications for stroke clinical trials: a literature review and synthesis. Stroke. 2007;38:1091-1096.

7. Belagaje S, Gupta R, Foster L, et al. The role of discharge disposition in the Interventional Management of Stroke (IMSIII) Trial (P1.062). Neurology 2015;84(suppl P1.062). http://www.neurology.org/content/84/14_Supplement/P1.062. Accessed September 2, 2017.

8. Mor V. Better stroke outcomes in rehab hospitals. Brown University Long-Term Care Quality Advisor 1997;9:4.

9. Treger I, Ring H, Schwartz R, et al. Hospital disposition after stroke in a national survey of acute cerebrovascular diseases in Israel. http://dx.doi.org/10.1016/j.apmr.2007.11.001. Accessed September 2, 2017.

10. Béjot Y, Troisgros O, Gremeaux V, et al. Poststroke disposition and associated factors in a population-based study: The Dijon Stroke Registry. Stroke. 2012;43:2071-2077.

11. Brosseau L, Potvin L, Philippe P, Boulanger YL. Post-stroke inpatient rehabilitation: II: predicting discharge disposition. Am J Phys Med Rehabil. 1996;75:431-436.

Vivek Sindhi, MD, MBA
Resident Physician, Department of Physical Medicine and Rehabilitation
East Carolina University
Greenville, North Carolina

John Norbury, MD
Assistant Professor, Department of Physical Medicine and Rehabilitation
East Carolina University
Greenville, North Carolina

Clinton Faulk, MD
Associate Professor, Vice Chairman, Residency Program Director, Department of Physical Medicine and Rehabilitation
East Carolina University
Greenville, North Carolina

Dimitri Avgeropoulos, MS
Medical Student
Saba University School of Medicine
Saba, Dutch Caribbean

Ian Lee, MD
Assistant Professor, Deptartment of Neurology
East Carolina University
Greenville, North Carolina

Steven Mandel, MD
Clinical Professor, Dept. of Neurology
Hofstra Northwell School of Medicine
New York, New York