Outpatient Stroke Rehabilitation

EBRSR
[Evidence-Based Review of Stroke Rehabilitation]
7
Outpatient Stroke Rehabilitation
Robert Teasell MD, Norine Foley MSc, Marina Richardson MSc, Laura Allen MSc, Andreea Cotoi MSc
Last Updated: March 2018
Abstract
With the aging of the general population and an increasing number of stroke survivors, there is growing
interest in outpatient stroke rehabilitation as a both an extension of and less expensive alternative to in-
patient hospital-based programs. In this chapter, we evaluate the effectiveness of three forms of
outpatient rehabilitation, which we have defined as: hospital-based, community-based and early
supported discharge. Each will be evaluated again standard or traditional care for an outpatient stroke
patient.
7. Outpatient Stroke Rehabilitation pg. 1 of 28
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Key Points
Early Supported Discharge
• Early supported discharge provides similar outcomes for patients with milder strokes, compared
to inpatient rehabilitation.
• Current evidence suggests that the cost associated with early supported discharge is lower than
that of usual care; however, more research is needed in this area of rehabilitation.
Outpatient Therapy
• It is unclear if outpatient therapy results in improved functional outcomes.
• Home-based and hospital-based outpatient therapy do not show any difference in effectiveness.
Dr. Robert Teasell

Parkwood Institute, 550 Wellington Road, London, Ontario, Canada, N6C 0A7
Phone: 519.685.4000 ● Web: www.ebrsr.com ● Email: Robert.Teasell@sjhc.london.on.ca

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Table of Contents
Abstract .............................................................................................................................................1
Key Points..........................................................................................................................................2
Table of Contents ...............................................................................................................................3
7.1 Early Supported Discharge .........................................................................................................4
7.1.1 Potential for Cost Savings of ESD ................................................................................................ 10
7.1.2 Effective Elements of an ESD Program ........................................................................................ 12
7.2 Outpatient Therapy ................................................................................................................. 13
7.2.1 Outpatient Stroke Rehabilitation Provided Within 6 Months of Stroke Onset ........................... 14
7.2.2 Outpatient Stroke Rehabilitation Provided Beyond 6 Months of Stroke Onset ......................... 16
7.2.3 Home-Based Therapy vs. Hospital-Based Outpatient Therapy ................................................... 17
7.3 Cochrane Reviews for Outpatient Rehabilitation Therapies following Stroke ............................ 20
Summary ......................................................................................................................................... 23
References....................................................................................................................................... 24

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7.1 Early Supported Discharge
With the aging of the general population and an increasing number of stroke survivors, there is growing
interest in outpatient stroke rehabilitation as both an extension to and a less expensive alternative to in-
patient hospital-based programs. Debate continues as to which setting provides the best opportunity for
continued improvement following discharge from inpatient rehabilitation. Arguments in favour of
hospital, community, and home-based outpatient programs have all been made. There is also debate as
to whether early-supported discharge programs may, in fact, be superior to inpatient rehabilitation for a
select group of patients which is later addressed in this chapter.
Early supported discharge (ESD) programs arose from a recognition that many patients preferred being
home following a stroke and that inpatient interdisciplinary stroke rehabilitation may not be necessary
for some stroke patients in need of rehabilitation or even be associated with the best outcomes. Since
the goal of therapy is to establish skills that are applicable to the home environment, where better to
learn but in one’s home? Critics of ESD argue that most patients are already discharged as soon as it is
feasible and with increasing pressures on rehabilitation length of stay that is becoming increasingly the
case; however, not all have immediate access to outpatient stroke rehabilitation.
A Cochrane Review assessing the efficacy of ESD for acute stroke patients, conducted by the Early
Supported Discharge Trialists, was first published in 2001 and updated in 2012 (Fearon & Langhorne,
2012). The purpose of this review was to determine whether ESD, with appropriate community support,
could be as effective as conventional inpatient rehabilitation and reduce the length of hospital stay. ESD
interventions in these studies were designed to accelerate the transition from hospital to home. The
review included the results from 14 trials (1,957 patients).
A variety of outcomes were assessed comparing early supported discharge with conventional care at the
end of scheduled follow up, which ranged from 3 to 5 years. The results are presented in Table 7.1.1 and
in Section 7.3 (Summary of Cochrane Reviews). ESD programs were associated with shorter periods of
initial hospitalization, and a reduction in the number of patients requiring institutional care following
discharge as well as reduced levels of dependency at 6 months. The programs did not appear to
adversely affect the health status, mood or satisfaction of caregivers. Costing data were available for
seven trials. The estimated costs of the programs ranged from 23% less to 15% more compared with the
control condition, with the majority of the trials reporting cost savings.
Table 7.1.1 Services for Reducing Hospital Care For Acute Stroke Patients (Fearon & Langhorne, 2012).
Outcome Significant Result OR and 95% CI or * Weighted Mean
(Y/N) Difference and 95% CI
Death No 0.91 (0.67 to 1.25)
Death or need for institutionalization Yes 0.78 (0.61 to 1.00)
Death or dependency Yes 0.80 (0.67 to 0.97)
ADL Barthel Index scores No 0.03 (-0.08 to 0.15) *
Length of initial hospital stay (days) Yes -7.0 (-10.0 to –4.2)*
Length of total hospital stay Yes -9.7 (-13.6 to -5.8)*
Subjective Health status No 0.0 (-0.10 to 0.11) *
Satisfaction with services Yes 1.6 (1.08 to 2.38) *
Number of readmissions to hospital No 1.26 (0.94 to 1.67)

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In a further breakdown of the meta-analysis, there were three types of ESD service organization
identified in the review:
1. ESD team with coordination and delivery: a multidisciplinary team, which coordinated discharge
from hospital and post discharge care, and provided rehabilitation therapies in the home.
2. ESD team coordination: discharge and immediate post discharge plans were coordinated by a
multidisciplinary care team, but rehabilitation therapies were provided by community-based
agencies.
3. No ESD team coordination: therapies were provided by uncoordinated community services or by

health-care volunteers.
As hypothesized by the authors, the increasing coordination of services was associated with an
improved outcome (see Table 7.1.2).
Table 7.1.2 Outcome At End Of Scheduled Follow-Up (ESD Vs. Conventional Care) Stratified By Level
Of Service Provision (More Coordinated To Less Coordinated) (Fearon & Langhorne, 2012)
Death or dependency Significant Result Odds Ratio (OR) and 95% CI
(Y/N)
Overall result Yes 0.79 (0.64 – 0.97)
ESD team with coordination and delivery Yes 0.71 (0.53 – 0.94)
ESD team coordination No 0.68 (0.46 – 1.01)
no ESD team coordination No 1.23 (0.79 – 1.91)
In this comparison of different delivery models for ESD, there was no difference in the proportion of
patients who were dead or dependent at the end of scheduled follow up when stratified for age (≤ 75
yrs or > 75 yrs), sex, presence of a caregiver, ESD team base (hospital outreach or community in-reach)
or control service (stroke unit or other ward). There was a reduction in the odds of a poor outcome for
patients with a moderate initial stroke severity (BI 10-20), (OR= 0.73; 0.57-0.93), but not among patients
with severe disability (BI<9) and also among patients who received care from a coordinated
multidisciplinary ESD team (0.70; 0.56-0.88) compared to those without an ESD team. Based on the
results of this study, it would appear that a select group of patients, with mild to moderately disabling
stroke, receiving more coordinated ESD could achieve better outcomes compared to usual care, which
was generally organised inpatient care on a stroke unit. Langhorne (2003) suggested that the reason
that studies have reported superior outcomes among ESD patients is likely due to the effect of the home
environment, which is probably the best place to relearn ADL skills.
Early supported discharge, providing interdisciplinary rehabilitation in the home instead of in a hospital,
appears to offer the same benefits as an in-hospital stroke rehabilitation unit in less severely disabled
stroke patients, where the concept has been largely tested and which intuitively makes sense.
Two other reviews have investigated this topic (Anderson et al., 2002; Noorani et al., 2003). Anderson et
al. (2002), reported the benefits of ESD programs in reducing hospital length of stays by an average of 13
days and offering an average of 15% cost savings compared to inpatient rehabilitation. The Canadian
Coordinating Office of Health Technology Assessment (CCOHTA) conducted a review of ESD compared to
usual care (Noorani et al., 2003). The review included RCTs published from 1995 to July 2002, with nine
articles representing five RCTs met their inclusion criteria.

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The five RCTs included a total of 940 patients. Stroke severity was noted to be mild. At six months
follow-up the odds of death or institutionalized care were similar between the groups. There were no
significant differences observed between the two groups in the mean Barthel Index (BI) score, although
in the two trials where it was measured, a higher number of the ESD patients were considered
independent (BI≥19) compared to controls (OR 1.82, 95% CI 1.16, 2.86). The ESD patients showed a
significant decrease in length of hospital stay (approximately 10 days) when compared to controls
(Noorani et al., 2003).
Individual Studies
Twenty-five studies have evaluated the efficacy of early supported discharge post stroke. The results
are presented in Table 7.1.3. When examining the results of studies reporting the outcomes of patients
who received early supported discharge, it is important to consider the process by which patients were
selected for inclusion. If the eligibility criteria are very restrictive and many potential patients excluded,
this results in a selection bias that in turn influences the generalizability of the results.
Table 7.1.3 Summary of Studies Evaluating Early Supported Discharge

Author/Year/
PEDro score Methods Results
Sample Size
Anderson et al. (2000) E: Early supported discharge with home • LOS (+)
RCT (8) rehabilitation • SF-36 (-)
N=86 C: Conventional rehabilitation • Modified Barthel Index (-)
• Adelaide Activities Profile (-)
• Nottingham Health Profile (-)
• Care satisfaction (-)
• McMaster Family Assessment Device (-)
• Mortality (-)
• Falls (-)
Bautz-Holter et al. (2002) E: Early supported discharge with home • LOS (+)
RCT (8) rehabilitation • Nottingham EADL (-)
N=82 C: Conventional rehabilitation
Kalra et al. (2000) E1: Receive care on a stroke unit • Barthel Index: 3 mo E1 vs E2 (+), E1 vs C (-), E2 vs C (-);
RCT (8) E2: Receive care by a stroke team 12 mo E1 vs E2 (+), E1 vs C (+), E2 vs C (-)
N=457 C: Receive care at home • Modified Rankin Scale: : 3 mo E1 vs E2 (+), E1 vs C (-),
E2 vs C (-);12 mo E1 vs E2 (+), E1 vs C (+), E2 vs C (-)
• Mortality: 3 mo E1 vs E2 (+), E1 vs C (-), E2 vs C (-); 6
mo E1 vs E2 (+), E1 vs C (-), E2 vs C (-); 12 mo E1 vs E2
(+), E1 vs C (-), E2 vs C (-)
• Institutionalization: 3 mo E1 vs E2 (-), E1 vs C (-), E2 vs
C (-); 6 mo E1 vs E2 (-), E1 vs C (-), E2 vs C (-); 12 mo E1
vs E2 (-), E1 vs C (-), E2 vs C (-)
• LOS (-)
Askim et al. (2004) E: Extended stroke unit with early • LOS (-)
Askim et al. (2006) supported discharge • Barthel Index (-)
RCT (7) C: Ordinary stroke unit service • Modified Rankin (-)
N=62 • Berg Balance Scale (-)
• Walking Speed (-)
• Nottingham Health Profile: social subscore at 26wk (+)
Donnelly et al (2004) E: Community-based rehabilitation • LOS (-)
RCT (7) C: Inpatient rehabilitation • Barthel Index (-)
N=113 • Nottingham ADL (-)

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• EuroQoL (-)
• SF-36 (-)
• Patient satisfaction (-)
Indredavik et al. (2000) E: Receive care on an enhanced stroke • LOS (+)
Fjaertoft et al (2003) unit with early supported discharge • Barthel Index: 6/26/52 wk (-)
Fjaertoft et al. (2004) C: Receive care on an ordinary stroke • Modified Rankin: 6wk (-), 26/52wk (+), 5yr (+)
Fjaertoft et al. (2005) unit • % of patients at home: 6wk (+), 26wk (-), 5yr (+)
Fjaertoft et al. (2011) • % of institutionalization: 6wk (+), 26wk (-), 5yrs (-)
RCT (7) • Nottingham Health Profile: 52wk (+)
N=30 • Modified Rankin Scale: 5yr (-)
• Proportion of patients living at home (+)
Mayo et al. (2000) E: Receive home intervention • LOS (+)
RCT (7) C: Receive usual post stroke care • Barthel Index (-)
N=114 • Timed Up &Go (-)
• Reintegration to Normal Living (+)
• ADL scale for Older Americans (+)
• Physical Health at 3 mo (+)
• Patient’s Mental Health at 3 mo (-)
Rudd et al. (1997) E: Receive specialist community • LOS (+)
RCT (7) rehabilitation for up to 3 months after • Barthel Index (-)
N=331 discharge • Rivermead ADL (-)
C: Receive conventional hospital and • Total Nottingham Health Profile (-)
community care • Caregiver strain (-)
Widen Holmqvist et al (1998) E: Receive early supported discharge • LOS (+)
von Koch et al. (2000) with continuity of rehabilitation at • Barthel Index (-)
von Koch et al (2001) home • Katz ADL (-)
Thorsen et al. (2005) C: Receive routine rehabilitation service • Frenchay Activities Index (-)
Ytterberg et al. (2010) in a hospital, day care and/or • Motor Capacity (-)
RCT (7) outpatient care • Katz Extended ADL (+)
N=81 • 10 metre timed walk (-)
Gjelsvik et al. (2014) E1: Early supported discharge with • LOS (-)
RCT (6) treatment in a community day unit • Postural Assessment Scale for Stroke (-)
NStart=167 E2: ESD with treatment at home (via • Trunk control (+)
NEnd=105 home visits from the community health • Self-report on walking (+)
team), • ADL (+)
C: Received treatment as usual care • Timed up and go (-)
without any intervention • 5m timed walk (-)
Torp et al. (2006) E: Received care from an • LOS (-)
RCT (6) interdisciplinary team, which also • Barthel Index (-)
N=198 coordinated discharge planning and
provided a maximum of 10 home visits
to provide care/therapy
C: Received standard care, which
included discharge planning, home care
services, day care services and
physiotherapy
Rodgers et al. (1997) E: Early support discharge • LOS (+)
RCT (6) C: Conventional care • Nottingham Extended ADL (-)
N=92 • Global health status of patients (-)
• Carer stress (-)
Hofstad et al. (2014) E1: Early supported discharge (ESD) • LOS (-)
RCT (6) with treatment in a community day unit • Modified Rankin Scale: at 3/6mo (-)
NStart=306 E2: ESD with treatment at home (via • Barthel Index (-)

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NEnd=229 home visits from the community health • NIHSS (-)
team) • Discharge destination (-)
C: Received treatment as usual care • Days spent in stroke unit (-)
without any intervention
Suwanwela et al. (2002) E1: Receive hospitalization for 3 days • NIHSS (-)
RCT (5) followed by home rehabilitation • Barthel Index (-)
N=102 provided by family members and Red • Modified Rankin Scale (-)
Cross volunteers • Mortality (-)
E2: Receive conventional 10 day • Dependency (-)
hospitalization
Duncan et al. (1998) E: Receive home based exercise • Upper extremity dexterity (-)
RCT (5) program • Functional healthy status (-)
N=20 C: Receive usual post-stroke care.
Ricauda et al. (1998) E: Rehabilitation at home • Functional status (+)
RCT (3) C: Rehabilitation at general medical • Short Portable Mental Status Questionnaire (+)
N=40 ward
+ Indicates a significant beneficial effect of home-based rehabilitation compared to conventional rehabilitation.
- Indicates no differences between home-based rehabilitation compared to conventional rehabilitation.
Discussion
The percentages of patients who were screened and randomized to receive treatment or the percentage
of patients randomized from the pool of total acute stroke admissions are presented in Table 7.1.4. The
wide range of percentages reported (7% -70%) likely speaks to the differences in the timing and the
types of interventions offered under the broad category of what is considered to be ESD. In addition to
an ESD services, Askim et al. (2004) also provided an enhanced component of care in the acute stages of
hospital care. Although distinguishing between the effects on the outcome from two separate sources is
difficult, the results of the study are consistent with those described by others and the study is included
for completeness.
Table 7.1.4 Percentages of Stroke Patients Randomized to RCTs Evaluating ESD

Study Proportion of Randomized Patients Either Admitted to Acute Care or Screened
Rodgers et al. (1997) 92/402 total admissions (22.9%)
Rudd et al. (1997) 300/660 total admissions (45.5%)
Duncan et al. (1998) Not reported
Holmqvist et al. (1998) 81/220 screened (37%)
Ricauda et al. (1998) Not reported
Ronning & Guldvog (1998) 251/849 total admissions (30%)
Anderson et al. (2000) 86/398 stroke admissions (21.7%)
Indredavik et al.(2000) 320/468 of patients screened (68%)
Kalra et al. (2000) 457/979 total admissions (47%)
Mayo et al. (2000) 114/1542 total admissions (7%)
Bautz-Holter et al. (2002) 82/439 total admissions (19%)
Suwanwela et al. (2002) Not reported
Askim et al. (2004) 62/89 of patients screened (70%)
Donnelly et al. (2004) 113/896 total admissions (13%)
Torp et al. (2006) 198/410 (48%)
Taule et al. (2015) 154/251 (61%)
Gjelsvik et al. (2014) 167/306 (55%)

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The results of RCTs from the United Kingdom, Sweden, Norway, Canada and Australia, have shown that
highly-selected, mildly impaired stroke patients can be managed successfully at home by an
interdisciplinary team, with similar outcomes compared to in-patient care. Unfortunately, the essential
elements or characteristics of an effective ESD program remain uncertain. Moreover, it is important to
emphasize that the stroke patients included in these studies had achieved relatively high levels of
independence at the time of admission into the various studies. Nevertheless, patients were more
satisfied with this type of care when compared to hospitalization and may have been more motivated.
Von Koch et al. (1998) found that patients receiving rehabilitation in their homes took greater initiative
and assumed more responsibility for their own care, compared to those receiving treatment in the
hospital. Therapies also emphasized both a task-specific and contextual approach. However, even
though patients were functioning at a high level, Anderson et al. (2000) found the mental stress of
caregivers was significantly greater in the early supported hospital discharge group.
For patients with moderate and severe strokes, Anderson et al. (2000) suggested that early supported
discharge was no longer cost-effective or advantageous, since the benefits were inversely proportional
to the severity of the stroke. Bautz-Holter et al. (2002) reported non-significant differences in
Nottingham Extended ADL scores at both three and six months in mildly impaired stroke patients
receiving either conventional in-patient rehabilitation or early-supported discharge. Kalra et al. (2000)
examined the efficacy of stroke unit care compared to a stroke team or to domiciliary (at home) care for
early stroke rehabilitation and reported that for patients with moderate to severe stroke, stroke unit
care was “more effective in reducing mortality, the need for institutional care and dependence.
Moreover, rehabilitation of patients randomized to domiciliary care proved difficult as one third of the
153 patients so randomized were admitted to the stroke unit within two weeks for a variety of care
reasons.”
Two trials assessing ESD programs included a follow-up period of 5 years (Fjaertoft et al., 2011; Thorsen
et al., 2005). In both of these studies, there were beneficial effects associated with ESD in at least one of
the outcomes assessed (Katz extended ADL and mRS scores). Of course, it was not possible to know
what additional services patients in both groups may have received in the intervening years.
ESD was not associated with an improvement in health-related quality of life, a measure that was
assessed in two of the studies (Donnelly et al., 2004; Ytterberg et al., 2010). At the end of 1 and 5 years
there were no significant differences in study groups on HRQoL including the SF-36, EuroQoL or the
Sickness Impact Profile.
Taule et al. (2015) sought to compare several models of rehabilitation including, ESD in a day unit, ESD
at home, and traditional therapy or usual care in the community. The primary measure was the
Assessment of Motor and Process Skills (AMPS), an ADL measurement. The AMPS was followed by the
modified Rankin Scale (mRS), which has been extensively used in previous literature to roughly measure
disability status after stroke. A total of 251 were recruited; however, only 103 were re-tested at the 3
month follow-up. The study found no significant difference between the ESD groups and the control
group receiving traditional therapy for the AMPS, although there was a significant difference on the
mRS. Findings suggest that the ESD groups had significantly greater odds of being considered
independent compared to the control group. The authors acknowledge the high loss to follow-up as a
significant limitation to the study which limited the power of the study and may have introduced type II
errors in the results.
Hofstad et al. (2014) allocated participants to receive rehabilitation after ESD in a community day unit,
at home, or to receive rehabilitation as part of usual care, similar to above. The mRS was the primary

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outcome measured at baseline, 3 and 6 months. The NIHSS, Barthel Index, and a patient satisfaction
questionnaire were assessed as secondary measures at the same time as the mRS. A total of 306
participants were recruited in the study, with a 20.9% decline by 3 months (N=242), and a 25.2% drop-
out by 6 months (N=229). The results of the trial revealed no significant differences between mean
values of the mRS at any time point between the groups. Within-group analyses however, demonstrated
that both ESD groups improved significantly from baseline to 3 months but the effect was not found to
be significant by 6 months. Furthermore, the control group receiving traditional rehabilitation showed
no significant change over time on the mRS or any of the secondary outcomes. Subgroup analyses
revealed that men demonstrated greater improvements on the mRS at 3 and at 6 months compared to
women. Discharge destination and length of stay were not different between groups. Lastly, the
compliance to the 4hr/d, 5d/wk for 5 weeks rehabilitation intensity was poor due to participants feeling
tired, lack of motivation and present neurological impairments that made the program schedule difficult
to follow.
As part of the same large trial conducted by Hofstad et al. (2014), participants were assessed using the
Postural Assessment Scale for Stroke (PASS), Trunk Impairment Scale, Timed Up and Go Test, and self-
reports for balance and walking ability after ESD either in a day unit, at home, or as part of traditional
uncoordinated treatment (Gjelsvik et al., 2014). At 3 months, no significant between-group difference
was found on the PASS. The only between-group improvements observed pertained to trunk control and
self-reports on walking and ADL. Participants in the day unit demonstrated greater self-reported walking
ability and participants rehabilitated at home reported better ADLs compared to the control group
respectively. These positive findings were limited to participants having mild-to-moderate disability as
patients with more severe strokes were excluded from the analyses.
There is limited knowledge regarding the effects of ESD on other aspects of well-being including
caregiver burden. Tistad and von Koch (2015) conducted a follow-up observational study to better
understand the potential beneficial effects of ESD on frequency of social activities, life satisfaction,
independence in activities of daily living, use and cost of healthcare in the first year after stroke. After
discharge from inpatient care, patients took part in ESD with continued rehabilitation at home, or
continued with usual care (No ESD). At 3 and 12 months, no difference was found between groups
regarding independence in ADLs, life satisfaction, and the frequency of participation in social activities.
Although the length of stay in acute care was lower in the ESD group (8 days) relative to the No ESD
group (15 days), no difference was found when all inpatient care during the first year was totalled.
Caregiver burden was significantly greater in the No ESD group at 12 months compared to participants
receiving rehabilitation at home. Cost analyses revealed that total healthcare cost for those in the ESD
group was 260,425 SEK/person (i.e. $30,426 USD) and 287,964 SEK/per person (i.e. $33,643 USD) for
those in the No ESD group (no significant difference). The authors did use a broad definition of ESD
which included any home services provided within 7 days of discharge with a LOS less than 90 days.
Additionally, the ESD group had poorer speaking ability of at baseline, which may have increased
rehabilitation costs and complexity.
7.1.1 Potential for Cost Savings of ESD

Several of the RCTs included in the above review included an economic component in their study in an
attempt to establish if ESD was associated with cost savings. Although Beech et al. (1999) found that the
cost of ESD was 8% less compared with conventional inpatient rehabilitation; the authors concluded
that early community discharge was “unlikely to lead to financial savings” and its primary benefit was
increasing the capacity of limited hospital beds. The relatively small cost savings from early discharge
would be offset by increased financial costs of community-based rehabilitation services. The

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community-based rehabilitation costs, “would depend on (1) whether the community rehabilitation was
introduced by reorganizing existing staffing establishments and (2) whether the increased demands on
community health and social services could be absorbed within existing staffing structures.” Teng et al.
(2003) in a follow-up study of Mayo et al. (2000), found that the total costs associated with the home
care group after three months was significantly less compared to the usual care group ($7,784 vs.
$11,065 Canadian, p<0.0001)(Figure 7.2). Fjaertoft et al. (2005) reported that although there was a
significant reduction in inpatients days after 52 weeks (66 days for ESUS vs. 85 days for OSUS, p=0.012),
this was not associated with a corresponding statistically significant reduction in mean total cost (18,937
EUR for ESUS vs. 21,824 EUR for OSUS).
Several systematic reviews have also been conducted on this topic. Brady et al. (2005) published an
economic evaluation of ESD services including the results from 8 RCTs that included costing data. Using
the data from the 6 studies with higher methodological quality, ESD was associated with cost-savings of
4 to 30 percent; however, the savings reached statistical significance in only a single study (Teng et al.,
2003). The authors noted that it was difficult to generalize these findings since there were large
variations in service delivery. For example, the duration of home rehabilitation varied from 4 weeks to 4
months. However, they did conclude that ESD could be provided at a modestly lower cost compared
with inpatient rehabilitation for patients suffering from mild or moderate disability.
Larsen et al. (2006) conducted a systematic review of ESD including an examination of the costs
compared with the alternative intervention, usually inpatient stroke rehabilitation. Using the results
from 5 previously published RCTs, the average cost of home rehabilitation, which included an average of
11 home therapy sessions, was $1,340 USD per person. Although the authors do not provide the cost
associated with inpatient rehabilitation they did report the cost average cost savings in bed days and
nursing home stays, amounting to $140 USD per person. These authors concluded that ESD was the
dominant intervention, since it was associated with both a cost savings and improved outcome, in the
form of a reduction in the odds of death or institutionalization (OR: 0.75, 95% CI 0.46 to 0.95).
Saka et al. (2009) also examined the cost-effectiveness of stroke unit care combined with ESD using data
on outcome from a previous trial (Rudd et al., 1997). The authors reported that at the end of 10 years,
the combination of ESD and SU care was more cost-effective than a SU without ESD. The incremental
cost-effectiveness ratio was £17,721 (increased incremental cost of £1,400/ increase of 2.23 quality
adjusted life year gained per patient), which was below the willingness to pay threshold of £30,000 in
the UK. The authors of this study converted Barthel Index scores to a measure of health-related quality
of life using an unconventional method. For this reason the results should be interpreted cautiously.
Included as part of systematic review assessing the economic evidence for all integrated care provided
to patients recovering from stroke across the spectrum of inpatient programs to the community,
Tummers et al. (2012) reported on six ESD studies that met inclusion criteria. The studies included were
all RCTs reporting no evidence for adverse effects on patient outcomes with ESD programs relative to
the comparator group. Cost savings with ESD services were reported for all studies (4%-30% cost
reduction); however only one study by Teng et al. (2003) was statistically significant; these results were
similar to those found in Brady et al. (2005).
Potential cost savings associated with the implementation of ESD programs, when part of larger package
of interventions including increased use of thrombolytic agents and stroke units was recently examined
in a model including stroke admissions over a 3-year period in Canada. Cost avoidance associated
specifically with increased use of ESD programs was estimated to be $133 million and $25.1 million, in
direct and indirect costs, respectively (Krueger et al., 2012).

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Conclusions Regarding Early Supported Discharge
There is level 1a evidence that stroke patients with mild to moderate disability, discharged early
from an acute hospital unit, can be rehabilitated in the community by an interdisciplinary stroke
rehabilitation team and attain similar or superior functional outcomes when compared to patients
receiving in-patient rehabilitation.
There is level 1a evidence that the cost associated with early-supported discharge is lower when
compared to usual care; however, savings are generally not dramatic or consistent across the
studies.
Early supported discharge provides similar outcomes for patients with milder strokes, compared to
inpatient rehabilitation.
Current evidence suggests that the cost associated with early supported discharge is lower than
that of usual care however, more research is needed in this area of rehabilitation.
7.1.2 Effective Elements of an ESD Program

The results from a consensus panel including 10 of the authors whose RCTs had been included in a
Cochrane ESD review, using a modified Delphi process to determine who should be included in an ESD
team and what features it should include (Fisher et al., 2011). There was strong agreement (i.e. 100%)
that the members of the team should have specialized stroke care knowledge and that the team should
be multidisciplinary, including: a physiotherapist, occupational therapist and a nurse. There was also
strong agreement that an ESD team should be hospital-based, organised by a team coordinator and
each patient be assigned a key person to coordinate their care. There was also strong agreement that
ESD teams should meet on a weekly basis.
An additional consensus process was undertaken including 26 participants from the U.K., to build on the
ESD work, for community based rehabilitation services in general (Fisher et al., 2013). Participants
agreed (73%) that community stroke rehabilitation teams are distinct from ESD programs, but offer
complimentary services. If patients are eligible for ESD and have ongoing rehabilitation needs, 96% of
participants agreed that they should also have access to community rehabilitation services. Participants
strongly agreed (92%) that ESD services could be provided by a community rehabilitation team given
they are sufficiently and appropriately resourced, somewhat contradicting the authors consensus
panel’s recommendation of a hospital-based approach. Additionally, 92% of participants strongly agreed
that those patients who are not eligible for ESD should have access to community rehabilitation if
necessary when discharged, and if a stroke survivor has complex needs related to the stroke, they
should only be transferred to the community when the appropriate supports are in place (Fisher et al.,
2013).
A review of evidence for ESD implementation highlighted that ESD services should be composed of a
multidisciplinary team with stroke specialists, the team should work cohesively, and specific patient
eligibility criteria should be in place (Mas & Inzitari, 2012).
Two qualitative studies of ESD services from the patients’ and carers’ (Cobley et al., 2013), as well as
healthcare professionals and commissioners (Chouliara et al., 2013), perspectives have also provided

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stakeholder comment on the components of an effective ESD program. The majority of patients from
two ESD stroke centres in the UK were satisfied with the speed of transition home, home as the care
location, the intensity and type of therapy, and the equipment used. Likewise, the majority of carers
expressed their appreciation for the respite time. However, there was dissatisfaction with the
abruptness of discharge from ESD services and the limited care, support, and education for caregivers.
Receipt of relevant information was also cited as inadequate (Cobley et al., 2013). Another study from
the UK interviewed 25 people involved with the provision of care for the two ESD teams (Chouliara et
al., 2013). These informants noted that the ESD program allowed for an intensive, patient-centred
intervention, reduced hospital stay and facilitated a smoother transition home for the patients.
However, they noted some challenges with the referral decision making, transitions along the pathway
of care, and redundancy of assessments across care locations (Chouliara et al., 2013).
7.2 Outpatient Therapy

Outpatient therapy in the sub-acute phase of stroke (4-8 weeks post stroke) is often prescribed
following discharge from in-patient stroke rehabilitation units. Continuing therapy may include hospital-
based “day” hospital programs or home-based rehabilitation.
The Outpatient Service Trialists (2003) identified 14 studies that had randomized stroke patients to
receive specialized outpatient therapy-based interventions (usually physiotherapy/occupational therapy
or occupational therapy alone which largely focused on modifying task-oriented behaviour such as
walking or dressing) or no routine treatment, including the results from 1,617 patients. The majority of
therapies were provided in the patients’ homes (see Table 7.2.1).
Table 7.2.1 RCTs Included in the Outpatient Service Trialists (2002) Evaluating the Effect of Therapy-
Based Rehabilitation vs. No Therapy
Study Focus of Therapy Home or Hospital Based
Corr et al. (1995) Occupational therapy Home
Andersen et al. (2000) Physiotherapy Home
Gilbertson et al. (2000) Occupational therapy Home
Hui et al. (1995) Multidisciplinary team Hospital
Duncan et al. (1998) Physiotherapy Home
Smith et al. (1981) Multidisciplinary team Hospital
Drummond & Walker (1998) Leisure and ADL performance Home
Walker & Drummond (1996) Dressing Home
Logan et al. (1997) Occupational therapy Home
Walker et al. (1999) Occupational therapy Home
Goldberg et al. (1997) Multidisciplinary team Home
Wolfe et al. (2000) Multidisciplinary team Home
Parker et al. (2001) Leisure and ADL performance Home
Jongbloed & Morgan (1991) Leisure Home
Outpatient therapy was associated with an improvement in ADL and EADL function at the end of
scheduled follow-up but was not associated with reductions of death or dependency, nor did it affect
the outcomes assessed for carers. (Table 7.2.2)
Table 7.2.2 Results of Comparisons Evaluated at the End of Scheduled Follow-up

Statistically Significant Differences Between Non-Statistically Significant Differences Between Groups
Groups

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ADL score (Barthel Index) Death
EADL score (Nottingham Extended Activities of Death or Institutional care
Daily Living) Death or Dependency
Death or Poor Outcome (deterioration/dependency)
Quality of Life QoL (Nottingham Health Profile)
Mood (General Health Questionnaire)
Carers’ QoL (Pearlman’s 6-point QoL scale and Social Functioning Examination)
Carers’ mood (General Health Questionnaire)
A Cochrane review (Aziz et al. 2008) evaluated the benefit of therapy-based rehabilitation programs
initiated more than one-year following stroke. Five trials were identified involving 487 subjects (Green et
al., 2002; Mulder et al., 1986; Sackley et al., 2006; Wade et al., 1992; Werner & Kessler, 1996). The
summary results from pooled analyses are presented in Table 7.2.3. The authors concluded that there
was insufficient evidence to demonstrate that therapy was superior to usual care, which usually
amounted to no additional care.
Table 7.2.3 Results of Cochrane Review of Therapy-Based Rehabilitation Services for Patients at Home
More than One-year after Stroke (Aziz et al., 2008)
Statistically Significant Differences Between Non-Statistically Significant Differences Between Groups
Groups
None Death or Poor Outcome (deterioration/dependency)
Activities of Daily Living
Case fatality at the end of follow-up
Extended ADL
Sickness Index Profile
Patient’s mood
Carer’s mood
A recent meta-analysis (Ferrarello et al., 2011) including the results from 15 RCTs that examined the
benefit of additional therapy late (>6 months) following stroke. The majority of the studies provided
physiotherapy in an outpatient setting. The length of treatment ranged from 6 to 52 hours. The
combined treatment effect for all outcomes assessed was 0.29, 95% CI of 0.14 to 0.45, indicating a small
effect. The treatment effect associated with ADL was small and not significant (0.08, p=0.58).
In the following section, we examined the benefit of additional therapy provided either as home or
hospital based rehabilitation, following discharge. Interventions provided within 6 months and beyond 6
months of stroke onset are presented separately.
7.2.1 Outpatient Stroke Rehabilitation Provided Within 6 Months of Stroke Onset

Fourteen studies evaluated the efficacy of additional outpatient rehabilitation following stroke that had
occurred within the previous 6 months. (Table 7.2.1.1)
Table 7.2.1.1 Summary of RCTs Evaluating Hospital or Home-Based Stroke Rehabilitation within 6
Months of Stroke
Author/Year/ Intervention Results
PEDro score
Logan et al. (1997) E: Enhanced home occupational therapy • Barthel Index: 6mo (-)
RCT (8) C: Standard occupational therapy • Nottingham Extended ADL: 3mo (+), 6mo (-)
N=101

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Andersen et al. (2000) E1: Physician home based rehabilitation • Readmission rates (+)
Andersen et al. (2002) E2: Physiotherapy home based
RCT (8) rehabilitation
N=155 C: Standard aftercare
Gilbertson et al (2000) E: Occupational therapy at home • Nottingham Extended ADL: 8wk (+), 6mo(-)
RCT (8) C: Standard rehabilitation • Barthel Index: 8wk (+), 6mo (+)
N=138
McClellan & Ada (2004) E: 6 week home based rehabilitation • Functional reach (+)
RCT (8) C: Upper limb home based care • Quality of Life (-)
N=26 • Walking (-)
Walker et al. (1999) E: Home based occupational therapy • EADL (+)
Walker et al. (2001) C: No treatment at all • Barthel Index (+)
RCT (7) • London Handicap Scale (+)
N=185
Wolfe et al. (2000) E: Home based rehabilitation team • Barthel Index (-)
RCT (7) C: Standard community care • Nottingham Health Profile (-)
N=43 • Rivermead Activities of Daily Living (-)
• 5m timed walk (-)
Ricauda et al. (2004) E: Home based multidisciplinary • 6 point ADL score (-)
RCT (7) rehabilitation immediately post-stroke • FIM (-)
N=120 C: Standard inpatient care
Chaiyawat & Kulkantrakorn E: Home based physiotherapy • Barthel Index (+)
(2012) C: Standard care • Modified Rankin Scale (+)
RCT (7) • Hospital Anxiety & Depression Scale (+)
N=60
Corr et al (1995) E: Home based occupational therapy • Barthel Index (-)
RCT (6) C: Standard care • Nottingham Extended ADL (-)
N=110
Forster & Young (1996) E: Home visits by outreach nurse • Barthel Index (-)
RCT (6) C: Standard care
N=240
Sackley et al. (2006) E: Client-centered occupational therapy • Barthel Index (+)
RCT (7) in nursing home
N=118 C: Standard care in nursing home
Welin et al. (2010) E: Stroke outpatient clinic • Barthel Index at 1 year (-)
RCT (6) C: Routine care by general practitioner • Modified Rankin Scale (-)
N=163 • Montgomery-Asberg Scale (-)
+ Indicates a significant beneficial effect of community-based stroke rehabilitation versus routine care
- Indicates no difference between treatment groups
Discussion
There were 17 RCTs of good quality that evaluated the functional outcomes of patients who received
additional outpatient therapy following a course of standard inpatient rehabilitation (see Table 7.2.1.1).
In one case, additional therapy was provided within a nursing home (Sackley et al., 2006). In most cases,
the control condition was no additional therapy following inpatient discharge. The results demonstrated
some short-term improvements in functional outcomes, although these differences disappeared over
the long-term in studies where assessments were repeated beyond the treatment period. It is not clear
whether the positive effects were lost over time due to a loss of gained function or due to delayed
improvement in the control group.

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Conclusions Regarding Outpatient Stroke Rehabilitation Provided within the First 6 Months of Stroke
Onset
There is conflicting level 1a evidence that additional outpatient therapy improves performance of
ADLs.
It is unclear if outpatient therapy results in improved functional outcomes.
7.2.2 Outpatient Stroke Rehabilitation Provided Beyond 6 Months of Stroke Onset

Eight RCTs evaluated the outcomes of patients who received either home, community or hospital-based
therapy or services compared to patients who received standard or routine care, after 6 months of the
stroke (see Table 7.2.2.1). The control condition was usually no additional therapy following inpatient
rehabilitation.
Table 7.2.2.1 Summary of RCTs with PEDro > 6 Evaluating Outpatient Therapy Provided Greater than
6 Months Post Stroke
Author/Year/ Intervention Results
PEDro score
Sample Size
Green et al. (2002) E: Community physiotherapy • Rivermead Mobility Index: 3 mos (+); 6 mos (-);
RCT (8) C: No treatment 9 mos (-)
N=170
Logan et al. (2004) E: Occupational therapy with • Getting out of the house (+)
RCT (8) sessions designed to increase • Nottingham EADL : 4mo (+), 10mo (-)
N=168 outdoor mobility • Nottingham Leisure Questionnaire (-)
C: Standard treatment
Lin et al. (2004) E: Home-based physiotherapy • Barthel Index (-)
RCT (7) C: No treatment • STREAM (-)
N=19
Wade et al. (1992) E: Home based physiotherapy • Gait Speed (+)
RCT (6) C: No treatment
N=94
Werner and Kessler (1996) E: Additional physical and • FIM: 3 mos (+), 9 mos (-)
RCT (6) occupational therapy in clinic
N=49 C: No treatment
Walker et al. (1996) E: Home based occupational therapy • Nottingham Dressing assessment (+)
RCT (6) for dressing • EADL (+)
N=30 C: No treatment • Barthel Index (+)
• London Handicap Scale (+)
Parker et al. (2001) E: ADL focused occupational therapy • Barthel Index (-)
RCT (6) at home • Nottingham Extended ADL (-)
N=466 E2: Leisure focused occupational • Oxford Handicap Scale (-)
therapy at home
C: No treatment
Egan et al. (2007) E: Home visits by an OT • Canadian Occupational Performance Measure:
RCT (6) C: No treatment performance (-), satisfaction (+)
N=16 • SF-36 (-)
• Re-integration to Normal Living (-)

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Discussion
A summary of 8 RCTs of good quality is presented in table 7.2.3.2. There was great variation in both the
interventions provided and the outcomes assessed. Three good quality studies assessed the
effectiveness of home therapy among chronic stroke patients. Green et al. (2004) pooled the data from
Wade et al. (1992) and Green et al. (2002), which included the results from a total of 264 patients. There
was a small, but statistically significant difference in the Rivermead Mobility Index scores between the
treatment and control groups at 3 months. There were no other differences in the change scores from
baseline to 3 months between the groups for Barthel Index, Frenchay Activities Index, or Hospital
Anxiety & Depression Scale. The authors speculated that the reasons for their negative results may have
be due to the low intensity of the interventions provided or to the heterogeneity of patients included in
the two studies.
Conclusions Regarding Outpatient Therapy Provided at Least One-Year Following Stroke
There is conflicting level 1a evidence regarding the association between home based therapy for
chronic stroke survivors and improvements in performance on ADLs and mobility.
7.2.3 Home-Based Therapy vs. Hospital-Based Outpatient Therapy

The increased focus on patient-driven care versus provider-driven care has sparked a debate as to
whether stroke patients should be rehabilitated in hospital-based (inpatient and outpatient) programs
or by community rehabilitation programs, which are usually home-based.
Young and Lincoln (1994) first debated this issue in the United Kingdom. Young (1994) argued that
community care allowed stroke patients to reach their full potential, stating, “I do not believe that
hospital care should be replaced by community services but that a more appropriate balance needs to
be achieved; one which recognizes the limitations of hospitals and the pressing community (home)
needs of stroke patients and their families.” Anderson et al. (1992) suggested that stroke rehabilitation
required a longer-term commitment, probably at least 3-5 years after the initial stroke. This group
argued that community-based rehabilitation offered a greater opportunity to deal with handicaps and
address psychosocial issues more effectively following a stroke. A community-based approach was also
argued to be more effective and efficient, addressing problems “in a way that is more relevant to the
patient”.
In contrast, Lincoln (1994) argued that hospitals were the best venue to provide the required therapies,
since co-ordinated care, so critical to interdisciplinary rehabilitation, was “difficult in practice” to put in
place in a community setting, since often the services provided were not stroke focused. The benefits of
specialized stroke rehabilitation units have already been discussed in chapter 5. Specialized stroke
rehabilitation centres also make it much easier to educate and train new stroke clinicians as well as
conduct research.
A number of authors have noted the advantages of rehabilitation at home (Gilbertson & Langhorne,
2000; Gladman et al., 1993; Rudd et al., 1997). From the results of animal studies, it is well known that
enriched environments, characterised by increased activities and greater social interactions, contribute
to better outcomes (Johansson & Ohlsson, 1996). However, there is evidence that much of a stroke
patients’ time spent on a rehabilitation unit is both inactive and alone. Surprisingly little time is spent in
therapy (Lincoln et al., 1996). Therefore, while theoretically stroke rehabilitation units should provide a
more enriched environment compared with other forms of inpatient rehabilitation, the home
environment may actually be more stimulating. Skills learned on the stroke rehabilitation unit may not

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transfer well to the home (Corr, 1995; Forster & Young, 1996; Indredavik et al., 2000). Adding to the
complexity of the debate is the notion of supervised vs. unsupervised therapy time. Koh et al. (2012)
assessed the relationship between the percentage of prescribed therapy time a patient performed at
home (unsupervised) and at the hospital outpatient clinic (supervised) and a patient’s score on the
Barthel Index (BI) at 1, 6 and 12 months after discharge. Performing more than 25% of the prescribed
supervised therapy resulted in a statistically significant greater mean BI score at 1 and 6 months post
stroke compared to those who performed less than 25% of the prescribed supervised therapy (β-
estimate 8.8, 95% CI 0.5 to 17.0, P=0.39; β-estimate 20.1, 95% CI 11.0 to 29.2, P<0.001). These effects
were not evident for patients who were more compliant (>75%) with unsupervised therapy time
compared to those who were less compliant (<75%) (Koh et al., 2012). This study used a proxy measure
for adherence and therapy time; results should be interpreted with caution.
Hillier and Inglis-Jassiem (2010) conducted a systematic review to compare the effectiveness of home vs.
hospital-based outpatient rehabilitation services. Eleven trials were included. The authors reported that
when the results from Barthel Index scores were pooled there was a significant effect in favour of home-
based rehabilitation at 6 weeks and 3–6 months, although the effects were less clear at 6 months.
There is currently no standard for the services that are provided and their intensity or duration for
community based rehabilitation following stroke. The superiority of home vs. hospital outpatient
rehabilitation remains unresolved.
There were twelve RCTs evaluating the functional outcomes of patients who received home-based
therapy compared to hospital-based outpatient therapy. The results are presented in Table 7.2.3.1.
Table 7.2.3.1 Summary of RCTs Evaluating Home-Based Rehabilitation vs. in Clinic

Author, Year Methods Results
Country
PEDro Score
Bjorkdahl et al. (2006) E: Home-based rehabilitation • Assessment of Motor & Process Skills (-)*
RCT (8) C: Day hospital rehabilitation • Functional Independence Measure (-)*
N=59 • Instrumental Activity Measure (-)*
• National Institutes of Health Stroke Scale (-)*
• Barrow Neurological Institutes Screening (-)*
• *assessed at discharge form hospital, 3 weeks, 3
months and 1 year
Baskett et al. (1999) E: Home visits by trained specialists • Barthel Index (+)
RCT (7) C: Outpatient/day hospital services • 10 Meter Walk Test (-)
N=100
Roderick et al. (2001) E: Rehabilitation at home • Barthel Index (-)
RCT (7) C: Rehabilitation in clinic • Rivermead Mobility Index (-)
N=140 • Frenchay Activities Index (-)
Lord et al. (2008) E: Rehabilitation in the community • 10 Meter Walk Test (-)
RCT (7) C: Hospital-based physiotherapy
N=32
Lincoln et al. (2004) E: Rehabilitation from a community stroke • Activities of daily living (mood, quality of life or
RCT (7) team knowledge of stroke) (-)
N=428 C: Rehabilitation to routine care (day
hospitals or outpatient departments)
Balci et al. (2013) E: Rehabilitation at home • Centre of gravity (-)
RCT(7) C: Rehabilitation in hospital • Length of stay (-)

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NStart=25 • Berg Balance Scale (-)
NEnd=25 • Dizziness Handicap Inventory (-)
• Dynamic gait index (-)
Malagoni et al. (2016) E: Hospital-based training and home-based • 6-minute Walk Test (-)
RCT (7) exercise • Timed Up and Go Test (-)
N=12 C: Hospital-based group rehabilitation and • Stair Climb Test (-)
exercise
Gladman et al. (1993) E: Domiciliary rehabilitation service • Extended ADL household and leisure sub-scores at
RCT (6) C: Hospital-based rehabilitation service 6 months (-)
N=327
Rasmussen et al. (2016) E: Home-based therapy (transported home) • Rankin Scale (+)
RCT (6) C: Hospital-based standard inpatient • Body Mass Index (+)
NStart=71 rehabilitation • Motor Assessment Scale (+)
NEnd=61 • Barthel Index (-)
• CT-50 (-)
• EQ-5D (-)
Olaleye et al. (2014) E: Rehabilitation at home • Modified Motor Assessment Scale (-)
RCT (6) C: Rehabilitation in primary health care centre • Short Form Postural Assessment Scale for Stroke (-)
NStart=56 • Reintegration to Normal living index (-)
NEnd=52
Young and Forster E: Rehabilitation at home • Barthel Index (+)
(1992) C: Rehabilitation in hospital • Motor Club Assessment (+)
RCT (6) • Functional Ambulatory Category (+)
N=124 • Frenchay Activities Index (-)
• Nottingham Health Profile (-)
Gersten et al. (1968) E: Rehabilitation at home • Functional, social, psychological status (-)
RCT (5) C: Rehabilitation in a clinic
N=238
Wall and Turnball E1: Therapy in clinic • Single support on affected side (-)
(1987) E2: Therapy at home • Gait symmetry (-)
RCT (3) E3: Therapy in clinic and at home • Walking speed (-)
N=20 C: No treatment
Redzuan et al. (2012) E: Outpatient therapy + Home DVDs • Modified Barthel Index (-)
RCT (3) C: Outpatient therapy • Occurrence of stroke or related complications (-)
N=106
+ Indicates a statistically significant difference between treatment groups
- Indicates a statistically non-significant difference between treatment groups
Discussion
Gladman et al. (1993), studied 327 stroke patients who were randomized to receive home outpatient
therapy or hospital-based outpatient rehabilitation after stratification by hospital ward at discharge
(Health Care of the Elderly (HCE), general medicine and stroke unit). Patients with significant disability
were eligible to participate in the study if they had been admitted to hospital with an acute stroke and
were being discharged to their own homes, unless they required respite care, or refused to give consent.
Overall, the study reported no difference at 3 and 6 months in functional outcomes, perceived health of
the patients, social engagement or life satisfaction of their carers between the home or community-
based and the hospital-based outpatient services. However, overall the hospital-based outpatient
rehabilitation services were less costly. Similar findings were found in the Roderick et al. (2001) study,
which recruited 140 patients to determine the efficiency of home-based rehabilitation compared to
hospital-based rehabilitation. Findings reflect no significant difference between the intervention

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modalities regarding mobility, mood, quality of life, functional independence, and knowledge of stroke
suggesting that both methods are equally efficient at improving various impairments. Similar results
were found in other smaller studies (Balci et al., 2013; Bjorkdahl et al., 2006; Gersten et al., 1968; Lord
et al., 2008; Malagoni et al., 2016; Olaleye et al., 2014; Wall & Turnball, 1987). However, a few trials
suggest that rehabilitation at home may improve activities of daily living compared to hospital
outpatient rehabilitation (Baskett et al., 1999; Rasmussen et al., 2016; Young & Forster, 1992).
Performing exercises using home DVD in addition to outpatient therapy was not found to differ with
respect to function of activities of daily living when compared to outpatient therapy alone (Redzuan et
al., 2012). Lincoln et al. (2004) demonstrated that receiving rehabilitation services from the community
was no different than receiving services from the hospital as part of routine care. Despite the lack of
difference between the two groups, Lincoln et al. (2004) revealed that carers of patients in the
community stroke team experienced less strain and greater overall satisfaction compared to those in
the routine rehabilitation group.
These patients were also tracked between six months and one-year in a follow-up study (Gladman &
Lincoln, 1994). The largest group of patients was transferred from the HCE ward. These were elderly
and frail patients and the rate of death and institutionalization at one year was higher (38% for home-
based rehabilitation and 24% for hospital-based rehabilitation) than in the other two strata. However,
the day hospital service costs were estimated to be 26% higher. A second group of patients were
discharged from the stroke unit and had better household and leisure activity scores at 6 months when
treated with home-based outpatient therapy. These patients were usually younger with extensive
neurological involvement. Here the home-based outpatient costs were 2.6 times greater. The third
group of patients, discharged from general medical wards was of intermediate age and received routine
hospital-based care. There were no differences in outcomes although the cost of hospital-based
outpatient care was only 56% that of the home-based rehabilitation care. This study suggested that
different sub-groups of stroke patients might have different rehabilitation requirements.
Conclusions Regarding Home-Based vs. Hospital-Based Stroke Rehabilitation
There is level 1a evidence that home-based and hospital-based outpatient stroke rehabilitation
programs are equally effective in achieving modest gains in ADL following inpatient rehabilitation.
Home-based and hospital-based outpatient therapy do not show any difference in effectiveness.
7.3 Cochrane Reviews for Outpatient Rehabilitation Therapies following Stroke

There are currently five Cochrane reviews examining the effectiveness of Outpatient Therapies for the
rehabilitation of stroke. These reviews examine slightly different populations and therapy approaches,
however, primary outcomes all focus on the improvement or deterioration in Activities of Daily Living
(ADLs) and risk of death. A summary of these reviews is presented in table 7.3.1.
Table 7.3.1 Summary of Cochrane Reviews for Outpatient Rehabilitation Therapies following stroke
Author, Year
Country Methods Results
Title
Outpatient Service 14 RCTs examining therapy No statistically significant difference was found in the
Trialists interventions to increase task oriented combined odds of death or being less dependent at the end

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(2003) behaviour (physiotherapy, occupational of follow up between patients receiving therapy based
UK therapy, multi-disciplinary care) services vs. controls (OR 0.93, 95%CI: 0.7-1.22, p=0.6).
Therapy based compared with conventional or no care The odds of deterioration in ADLs or dependency were
rehabilitation for were included in the review. Therapies significantly less in the group receiving therapy based
stroke patients at could take place in a hospital, home, or services (OR 0.72, 95%CI: 0.58-0.97, p=0.009)
home centre based location. There was an overall increase in ADL scores in the therapy
group compared with controls (SMD 0.14, 95%CI: 0.02-
Primary Outcome: proportion of 0.25, p=0.02)
patients who were dependent (or had
deteriorated) in personal ADLs at the
end of follow up
Secondary Outcomes: death at follow
up, proportion requiring
institutionalization at follow up,
extended ADL performance, subjective
quality of life or mood at follow up,
caregiver mood at follow up
Legg et al. (2007) 64 studies were identified, and 9 were Individuals receiving OT interventions were significantly
UK included in the review. All studies were more independent in ADLs than controls (SMD 0.18,
RCTs of occupational therapy (OT) 95%CI:0.04-0.32, p=0.01)
Occupational therapy interventions with a focus on ADL The odds of death and deterioration (poor outcome) were
for patients with performance compared to usual or no significantly less in groups receiving OT therapy when
problems in ADL care. compared with controls (0.60, 95%CI: 0.39-0.91, p=0.02)
following stroke There were no significant differences in the risk of death or
Primary Outcome: proportion of institutionalization between the groups.
patients who were dependent (or had Reviewers were unable to assess between group
deteriorated) in personal ADLs at the differences in mood and quality of life
end of follow up, death, or poor
outcome (dependency in ADLs)
up, proportion requiring
institutionalization at follow up,
extended ADL performance, subjective
quality of life or mood at follow up,
caregiver mood at follow up
Aziz et al. (2008) 5 RCTS were included in the review. Only one trial reported poor outcome at the end of study
Malaysia Trials that examined community based follow up. This study reported a significant difference
stroke patients receiving therapy between groups in favour of the treatment group (26%
Therapy-based services compared with conventional difference in outcome, p-=0.03).
rehabilitation care were reviewed. At least 75% of Pooled analysis was not able to detect a difference
services for patients participants in the included studies were between groups in ADL performance (SMD -0.06, 95%CI: -
at home more than ≥12 months post stroke. 0.32-0.20, p=0.65)
one year following No significant differences in death, performance in
stroke Primary Outcome: death or poor extended ADLs, subjective health, or mood were noted
outcome, including the proportion of between groups
patients who were dependent (or had
deteriorated) in personal ADLs at the
end of follow up
up, extended ADL performance,
subjective quality of life or mood at
follow up, caregiver mood at follow up,
hospital re-admission

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Fearon and 14 RCTs comparing conventional The intervention group showed a significantly shortened
Langhorne (2012) inpatient hospital stroke care with length of stay in hospital (p<0.0001)
UK service intervention aimed at providing The odds of death at end of study was non-significant
rehabilitation support in a community between groups (OR 0.91, 95%CI: 0.67-1.25, p=0.58).
Services for reducing setting and, thereby, reducing the The odds of death or institutionalization and death or
the duration of length of hospital care, were included in dependency was reduced in the intervention group (OR
hospital care for this review 0.78, 95%CI: 0.61-1.0, p=0.05) and (OR 0.80, 95%CI: 0.67-
stroke patients 0.97, p=0.02) respectively.
Primary outcome: death or long term An increase in extended ADL scores were noted in
dependency at end of follow up, length intervention participants (SMD 0.14, 95%CI: 0.02-0.26,
of index hospital stay p=0.02)
Secondary outcomes: ADL and extended No significant differences were noted between groups in
ADL scores, subjective health status, ADLs, health status, or mood.
mood, carer outcomes
Fletcher-Smith et al. Included studies examined the impact of Only one trial was included in this review.
(2013) occupational therapy for care home The trial was insufficient for conclusions to be drawn
UK residents (i.e. long term or nursing care regarding all primary and secondary outcomes.
facility) with stroke as compared to
Occupational therapy standard care.
for care home
residents with stroke Primary outcome: performance in ADLs
at end of study follow up
Secondary outcomes: ADL performance
at end of intervention, death, global
quality of life, mobility, mood, cognition,
hospital admission or admission to a
higher dependency facility, adverse
events
The results of these five reviews are generally quite positive in favour of therapy treatment groups when
compared with no therapy or usual care controls. Three of the five reviews observed either less
deterioration or greater improvement in intervention subjects when examining measures of ADL and
extended ADL. This was even observed in a population of participants that were >12 months post stroke.
A reduction in the risk of death, dependency, and poor outcome was also noted in the majority of
studies. However, studies looking at improvements in mood, health status, and quality of life were not
able to detect any differences in outcomes between groups. Overall, the provision of outpatient
therapies to patients following stroke is effective in improving patient outcomes, particularly pertaining
to an improvement (or reduced decline) in ADL performance and the risk of death. Furthermore, in
addition to an improvement in ADLs, one study was able to show that therapy services post discharge
has the potential to significantly reduce hospital length of stay. There is no current evidence to support
the impact of occupational therapy for home care residents, and this may be a potential area of interest
for future research.

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Summary
1. There is level 1a evidence that stroke patients with mild to moderate disability, discharged early
from an acute hospital unit, can be rehabilitated in the community by an interdisciplinary stroke
rehabilitation team and attain similar or superior functional outcomes when compared to
patients receiving in-patient rehabilitation.
2. There is level 1a evidence that the cost associated with early-supported discharge is lower when
compared to usual care; however, savings are generally not dramatic or consistent across the
studies.
3. There is conflicting level 1a evidence that additional outpatient therapy improves performance of
ADLs.
4. There is conflicting level 1a evidence regarding the association between home based therapy for
chronic stroke survivors and improvements in performance on ADLs and mobility.
5. There is level 1a and level 2 evidence that home-based and hospital-based outpatient stroke
rehabilitation programs are equally effective in achieving modest gains in ADL following
inpatient rehabilitation.

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Outpatient Stroke Rehabilitation

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EBRSR

[Evidence-Based Review of Stroke Rehabilitation]

Last Updated: March 2018

Dr. Robert Teasell

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3. No ESD team coordination: therapies were provided by uncoordinated community services or by

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Table 7.1.3 Summary of Studies Evaluating Early Supported Discharge

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Table 7.1.4 Percentages of Stroke Patients Randomized to RCTs Evaluating ESD

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7.1.1 Potential for Cost Savings of ESD

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7.1.2 Effective Elements of an ESD Program

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7.2 Outpatient Therapy

Table 7.2.2 Results of Comparisons Evaluated at the End of Scheduled Follow-up

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7.2.1 Outpatient Stroke Rehabilitation Provided Within 6 Months of Stroke Onset

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It is unclear if outpatient therapy results in improved functional outcomes.

7.2.2 Outpatient Stroke Rehabilitation Provided Beyond 6 Months of Stroke Onset

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Conclusions Regarding Outpatient Therapy Provided at Least One-Year Following Stroke

7.2.3 Home-Based Therapy vs. Hospital-Based Outpatient Therapy

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Table 7.2.3.1 Summary of RCTs Evaluating Home-Based Rehabilitation vs. in Clinic

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Conclusions Regarding Home-Based vs. Hospital-Based Stroke Rehabilitation

7.3 Cochrane Reviews for Outpatient Rehabilitation Therapies following Stroke

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