Impact of Rehabilitation on Outcomes in Patients With Ischemic Stroke

Abstract

Early rehabilitation for stroke patients can potentially prevent negative effects on the musculoskeletal, car-diovascular, respiratory, and immune systems 1 and reduce immobility-related complications. 2 Although many guidelines have recommended early rehabilitation after stroke to improve activities of daily living (ADL), such recommendations are only supported by limited evidence. 3 The timing of starting rehabilitation and intensity of training remain controversial. About the timing of starting rehabilitation, several studies suggested that post-stroke rehabilitation should be initiated immediately after onset to achieve optimal results. A previous meta-analysis demonstrated a positive correlation between early rehabilitation and improved outcomes. 4 However, a literature review showed inconsistent results for the effects of early rehabilitation versus delayed rehabilitation. 5 Recent ran-domized controlled studies showed that very early rehabilitation within 24 hours of onset was feasible and likely to be safe 6 and showed promising improvement in walking recovery. 7 With respect to rehabilitation intensity, several meta-analyses reported weak-to-moderate relationships between rehabilitation intensity and functional improvement of ADL. 8-10 However, these studies did not take into account the timing of starting rehabilitation. Thus, the concurrent effects of timing and intensity of rehabilitation on ADL remain unclear in patients with ischemic stroke. The purpose of the present retrospective observational study was to examine the effect of rehabilitation, taking into consideration both the timing of starting rehabilitation and training Background and Purpose-We aimed to examine the concurrent effects of timing and intensity of rehabilitation on improving activities of daily living (ADL) among patients with ischemic stroke. Methods-Using the Japanese Diagnosis Procedure Combination inpatient database, we retrospectively analyzed consecutive patients with ischemic stroke at admission who received rehabilitation (n=100 719) from April 2012 to March 2014. Early rehabilitation was defined as that starting within 3 days after admission. The average rehabilitation intensity per day was calculated as the total units of rehabilitation during hospitalization divided by the length of hospital stay. A multivariable logistic regression analysis with multiple imputation and an instrumental variable analysis were performed to examine the association of early and intensive rehabilitation with the proportion of improved ADL score. Results-The proportion of improved ADL score was higher in the early and intensive rehabilitation group. The multivariable logistic regression analysis showed that significant improvements in ADL were observed for early rehabilitation (odds ratio: 1.08; 95% confidence interval: 1.04-1.13; P<0.01) and intensive rehabilitation of >5.0 U/d (odds ratio: 1.87; 95% confidence interval: 1.69-2.07; P<0.01). The instrumental variable analysis showed that an increased proportion of improved ADL was associated with early rehabilitation (risk difference: 2.8%; 95% confidence interval: 2.0-3.4%; P<0.001) and intensive rehabilitation (risk difference: 5.6%; 95% confidence interval: 4.6-6.6%; P<0.001). Conclusions-The present results suggested that early and intensive rehabilitation improved ADL during hospitalization in patients with ischemic stroke. (Stroke. 2017;48:740-746.