Do rehabilitation at a proper facility with a rehabilitation medicine department; intensity follows the therapist — more is not always better (evidence from stroke)

After a stroke, people admitted to an organized stroke unit are more often still alive and still living at home one year later. But do not add intensity on your own: starting earlier, more often, and with more volume within 24 hours after stroke led to worse three-month outcomes. How much and when to practice — follow rehab medicine and the therapists.

Cost

Inpatient rehab several hundred yuan a day; the out-of-pocket part varies by place. Time is counted in months. Practice every day; it is dull.

Benefit

A Cochrane systematic review included 29 trials and 5902 participants, comparing organized inpatient stroke-unit care with other care. The review describes a stroke unit as a team using standard approaches to common post-stroke problems and providing coordinated multidisciplinary care. At final follow-up (median 1 year), the odds ratio for a poor outcome (death, disability, or need for institutional care) was 0.77 (95% CI 0.69–0.87, credible range), for death 0.76 (95% CI 0.66–0.88), and for death or dependence 0.75 (95% CI 0.66–0.85); evidence quality moderate. In absolute terms, per 100 people in stroke-unit care, 2 more survive, 6 more live at home, and 6 more live independently. Separately, the AVERT trial randomized 2104 patients across 56 acute stroke units in 5 countries to “usual care” or “usual care plus very early high-intensity activity.” At three months, a good outcome (modified Rankin Scale 0–2) was 480 people (46%) in the very-early group versus 525 (50%) in usual care; adjusted odds ratio 0.73 (95% CI 0.59–0.90, P=0.004). Deaths were 88 versus 72, with no difference shown (odds ratio 1.34, 95% CI 0.93–1.93, P=0.113)

Notes

Contested: both bodies of evidence are from stroke; applying them to spinal cord injury, amputation, burns, and other causes of disability is an extrapolation. AVERT shows that “earlier and harder” does not hold; it does not mean early activity is useless. In the trial almost everyone in both arms was out of bed within 24 hours; the difference was frequency and total volume. When choosing a facility, check for a rehabilitation medicine department and dedicated rehab and occupational therapists — do not go by the word “rehab” on a sign alone. That follows from stroke-unit care resting on a multidisciplinary team. How to transfer between primary and tertiary hospitals and how deductibles stack is in Section 24, item 1 (step-by-step referral). Community rehab and assistive-device configuration are in item 7 of this section (ask the county Disabled Persons’ Federation (残联) for the full list).

Sources · 2

1. Langhorne P, Ramachandra S; Stroke Unit Trialists' Collaboration (2020). Organised inpatient (stroke unit) care for stroke: network meta-analysis. Cochrane Database of Systematic Reviews, 4:CD000197. doi.org/10.1002/14651858.CD000197.pub4
2. AVERT Trial Collaboration group (2015). Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. Lancet, 386(9988):46-55. doi.org/10.1016/S0140-6736(15)60690-0