Effectiveness of an intensive outpatient rehabilitation program for postacute stroke patients. Rehabilitation of limb apraxia improves daily life activities in patients with stroke. Effect of a therapeutic intervention for the hemiplegic upper limb in the acute phase after stroke: a single-blind, randomized, controlled multicenter trial. Remedial therapy after stroke: a randomised controlled trial. A randomized controlled trial of a stroke rehabilitation ward. The significance of intensity of rehabilitation of stroke--a controlled trial. Constraint-induced movement therapy during early stroke rehabilitation. A randomized controlled trial of rehabilitation at home after stroke in southwest Stockholm. The effectiveness of community-based rehabilitation for stroke patients who remain at home: a pilot randomized trial.
The effectiveness of ongoing rehabilitation services for postacute stroke survivors is poorly documented. We designed a randomized control, single-blinded study to demonstrate the effectiveness of intensive outpatient therapy. The treatment intervention consisted of 1 hr each of physical and occupational therapy, four times per week, for 12 wk; therapy focused on neuromuscular facilitation and functional tasks. All subjects were screened before the therapies and after 3 mo and 9 mo. Forty-nine stroke survivors, who were at least l yr (mean, 2.9 yr) poststroke, were randomized with two treated patients to each control (no treatment supplied). All patients had received inpatient rehabilitation at the time of their acute stroke, but no patient had any ongoing therapy within the last 6 mo. The outcome measures included the Functional Independence Measure (FIM), Brunnstrom stages of motor recovery, timed mobility tasks, and the Jebson hand evaluation. We also evaluated the level of depression, self-esteem, and socialization. The treated patients demonstrated an improvement of 6.6 points over the 3 mo of therapy compared with only 1.5 points in the control group in the FIM motor score transformed using Rasch analysis. The change from time 0 to 3 mo was significant in the treated group but not in the controls. Treated patients maintained their gains at the 9-mo follow-up, and controls lost ground. The treated group improved in terms of socialization and self-esteem as evidenced by a lower Sickness Impact Profile, whereas the controls tended to get worse. There was a trend toward less depression, but this did not reach a P = 0.05 level of significance. This study demonstrates that significant functional gains can still be attained in the postacute stroke survivor, despite prior inpatient rehabilitation services. We randomly assigned 33 patients with left hemisphere stroke, limb apraxia, and aphasia to an apraxia or a control (aphasia) treatment group. Before and after each treatment, patients underwent a comprehensive neuropsychological testing battery and a caregiver evaluation of patient's activities of daily life (ADL) independence. Apraxia severity was related with ADL independence. Control (aphasia) treatment improved patients' language and intelligence performance. Apraxia treatment specifically improved praxic function and ADL. Arm function recovery is notoriously poor in stroke patients. The effect of treatment modalities, particularly those directed at improving upper limb function, has been studied primarily in chronic stroke patients. The purpose of this study was to investigate the effect of a specific therapeutic intervention on arm function in the acute phase after stroke.
                In a single-blind, randomized, controlled multicenter trial, 100 consecutive patients were allocated to either an experimental group that received an additional treatment of sensorimotor stimulation or to a control group. The intervention was applied for 6 weeks. Patients were evaluated for level of impairment (Brunnström-Fugl-Meyer test) and disability (Action Research Arm test, Barthel Index) before, midway, and after the intervention period and at follow-up 6 and 12 months after stroke.
                Patients in the experimental group performed better on the Brunnström-Fugl-Meyer test than those in the control group throughout the study period, but differences were significant only at follow-up. Results on the Action Research Arm test and Barthel Index revealed no effect at the level of disability. The effect of the therapy was attributed to the repetitive stimulation of muscle activity. The treatment was most effective in patients with a severe motor deficit and hemianopia or hemi-inattention. No adverse effects due to the intervention were found.
                Adding a specific intervention during the acute phase after stroke improved motor recovery, which was apparent 1 year later. These results emphasize the potential beneficial effect of therapeutic interventions for the arm. Of 1094 patients with a confirmed stroke admitted to Northwick Park, a district general hospital, 364 (33%) died while in hospital, 215 (20%) were fully recovered when discharged, and 329 (30%) were too frail or too ill from diseases other than stroke to be considered for active rehabilitation. Only 121 (11%) were suitable for intensive treatment. They and 12 patients referred direct to outpatients were allocated at random to one of three different courses of rehabilitation. Intensive was compared with conventional rehabilitation and with a third regimen which included no routine rehabilitation, but under which patients were encouraged to continue with exercises taught while in hospital and were regularly seen at home by a health visitor. Progress at three months and 12 months was measured by an index of activities of daily living. Improvement was greatest in those receiving intensive treatment, intermediate in those receiving conventional treatment, and least in those receiving no routine treatment. Decreasing intensity of treatment was associated with a significant increase in the proportions of patients who deteriorated and in the extent to which they deteriorated. Probably only a few stroke patients, mostly men, are suitable for intensive outpatient rehabilitation, but for those patients the treatment is effective and realistic. In S.E. Kent, during 1978 and 1979, 225 patients, representing 228 occurrences of hemiplegia, were referred to a new 20-bed stroke rehabilitation ward. These patients were randomly allocated to treatment in the special ward (group A 112 strokes) or to remain in conventional treatment locations (group C 116 strokes); the two groups were closely similar, except for the initial level of consciousness. Survivors were observed at four-month intervals to one year. There are indications of benefit for patients in group A by comparison with Group C in terms of treatment received (number treated by remedial therapists, the extent of treatment, and the arrangements for after-care), and in outcome (survival and the proportion returned to the community). The direction of the trend of advantage is consistent with another recent controlled trial, although not all modes of improvement are identical in the two trials. It is suggested that every health district should develop a comprehensive policy of stroke management. Of the 373 stroke patients 95 were admitted to the feasibility study of stroke rehabilitation. The patients were divided into two groups, an intensive and a normal treatment group. In this study, the functional recovery of stroke, measured by ADL and motor function was significantly better in the intensive treatment group. There was no difference in institutionalization or incidence of death between the groups. The gain of ADL and motor function was greatest during the first three months after stroke in the intensive treatment group. The conclusion is that intensified physiotherapy seems to improve the functional recovery of stroke patients. Limited data are available about the effectiveness of early rehabilitation after stroke.
                This is the 1st randomized controlled trial of constraint-induced movement therapy (CIMT) in subacute stroke to investigate neurophysiologic mechanisms and long-term outcome.
                Within 2 weeks after stroke, 23 patients with upper extremity (UE) weakness were randomized to 2 weeks of CIMT or traditional therapy at an equal frequency of up to 3 h/day. Motor function of the affected UE was blindly assessed before treatment, after treatment, and 3 months after stroke. Transcranial magnetic stimulation (TMS) measured the cortical area evoking movement of the affected hand.
                Long-term improvement in motor function of the affected UE did not differ significantly between patients who received CIMT versus intensive traditional therapy. All outcome comparisons showed trends favoring CIMT over intensive traditional therapy, but none was statistically significant except for improvements in the Fugl-Meyer (FM) UE motor scale immediately following treatment and in reported quality of hand function at 3 months. Improvement in UE motor function on the FM was associated with a greater number of sites on the affected cerebral hemisphere where responses of the affected hand were evoked by TMS.
                Future trials of CIMT during early stroke rehabilitation need greater statistical power, more inclusive eligibility criteria, and improved experimental control over treatment intensity. The relationship between changes in motor function and in evoked motor responses suggests that motor recovery during the 1st 3 months after stroke is associated with increased motor excitability of the affected cerebral hemisphere. This study describes the methodology, patient outcome, and use of hospital and rehabilitation services at 3 months of a population-based randomized controlled trial. The purpose was to evaluate rehabilitation at home after early supported discharge from the Department of Neurology, Huddinge Hospital, for moderately disabled stroke patients in southwest Stockholm.
                The patients were eligible if they were continent, independent in feeding, had mental function within normal limits, and had impaired motor function and/or aphasia 1 week after stroke. Patients were randomized either to early supported discharge with continuity of rehabilitation at home for 3 to 4 months or to routine rehabilitation service in a hospital, day care, and/or outpatient care. The home rehabilitation team consisted of two physical therapists, two occupational therapists, and one speech therapist; one of the therapists was assigned as case manager for the patient. The rehabilitation program at home emphasized a task- and context-oriented approach. The activities were chosen on the basis of the patient's personal interests. Spouses were offered education and individual counseling. A total of 81 patients were followed up for a minimum of 3 months. Patient outcome was assessed by the Frenchay Social Activity Index, Extended Katz Index, Barthel Index, Lindmark Motor Capacity Assessment, Nine-Hole Peg Test, walking speed over 10 m, reported falls, and subjective dysfunction according to the Sickness Impact Profile. Patient use of hospital and home rehabilitation service and patient satisfaction with care were studied.
                Overall there were no statistical significant differences in outcome. Multivariate logistic regression analysis suggested a systematic positive effect for the home rehabilitation group in social activity, activities of daily living, motor capacity, manual dexterity, and walking. A considerable difference in resource use during such a 3-month period was seen. A 52% reduction in hospitalization was observed: from 29 days in the routine rehabilitation group to 14 days in the home rehabilitation group. Patient satisfaction was in favor of the latter group.
                Early supported discharge with continuity of home rehabilitation services for the majority of moderately disabled stroke patients during the first 3-month period after acute stroke is not less beneficial than routine rehabilitation and can be a rehabilitation service of choice if follow-up at 6 and 12 months confirms the suggested effectiveness and considerable reduction in use of health care. To assess the effectiveness of community-based rehabilitation for stroke patients who were not admitted to hospital in South London.
                Randomized controlled trial.
                Patients' homes in South London.
                Stroke patients not admitted to hospital after a stroke.
                Rehabilitation at home by rehabilitation team for up to three months or usual care.
                The primary outcome measure was the Barthel score. Secondary measures included the Motricity Index, Rivermead ADL, Hospital Anxiety and Depression score and Nottingham Health Profile.
                Forty-three patients who remained at home were randomized to rehabilitation team (23) or 'usual' care (20). The mean number of physiotherapy sessions was three (range 1-14) for the rehabilitation team group and two for the usual care group. Patients (with a deficit) in the rehabilitation arm of the trial were more likely to receive occupational, physical and speech therapy than those in the control arm (p = 0.03, 0.01 and 0.008, respectively). For those patients actually receiving therapy, there was no evidence that the amount received differed between the groups. However, the number of patients in each of these comparisons was very small. The outcome for patients in the rehabilitation team arm of the trial was nonsignificantly higher (0.05 < p < 0.2) than for those in the control arm for the areas of Nottingham Health Profile, anxiety, depression, caregiver strain and the proportion of patients living at home. Based on the data observed here, a trial with approximately 150 patients in each arm would be needed to have adequate power to detect a 33% difference between intervention and control groups in these outcomes.
                Community therapy support for patients not admitted to hospital is feasible but to determine whether it is cost- or clinically effective would require trials of adequate size.
There is insufficient evidence to support or refute the effectiveness of specific therapeutic interventions for motor apraxia after stroke. Further research of higher quality is required. As we did not review whether patients with apraxia benefit from rehabilitation input in general, they should continue to receive general stroke rehabilitation services.