Randomized controlled trial of an early discharge rehabilitation service: the Belfast Community Stroke Trial. Randomised controlled trial to evaluate early discharge scheme for patients with stroke. A six-week, resource-efficient mobility program after discharge from rehabilitation improves standing in people affected by stroke: placebo-controlled, randomised trial. A randomized controlled trial of rehabilitation at home after stroke in southwest Stockholm. Randomized controlled trial of integrated (managed) care pathway for stroke rehabilitation. Expanding the role of the stroke nurse: a pragmatic clinical trial.
To compare a community-based multidisciplinary stroke team (CST) approach with hospital-based rehabilitation in terms of hospital stay, functioning, quality of life, and service use and costs.
                Stroke patients who met pre-agreed criteria were allocated randomly to the CST service (n=59) or to usual inpatient rehabilitation and follow-up care (n=54). Assessments were completed at randomization and 12 months later. Caregiver strain and satisfaction (n=55) were also assessed. Cost data were collected for a subsample of 38 patients.
                Almost 80% of surviving patients (n=691) were discharged home and a small number (n=55) were readmitted. Approximately 17% (113/649) were randomized. There were no statistically significant differences in hospital duration, costs, or outcome measures at baseline and 12 months except for higher satisfaction reported by CST patients. Overall, both groups recorded improvement in most domains over time. Carers reported a high level of satisfaction although the level of strain among carers is cause for concern. The community group (n=18) cost less than the hospital group (n=20).
                A mixed model of hospital-based and community-based rehabilitation services is likely to lead to increased patient choice and satisfaction and a potential reduction in bed pressures for less severe stroke patients. To assess the clinical effectiveness of an early discharge policy for patients with stroke by using a community based rehabilitation team.
                Randomised controlled trial to compare conventional care with an early discharge policy.
                Two teaching hospitals in inner London.
                331 medically stable patients with stroke (mean age 71) who lived alone and were able to transfer independently or who lived with a resident carer and were able to transfer with help.
                167 patients received specialist community rehabilitation for up to 3 months after randomisation. 164 patients continued with conventional hospital and community care.
                Barthel score at 12 months. Secondary outcomes measured impairment with motoricity index, minimental state examination, and Frenchay aphasia screening test; disability with the Rivermead activity of daily living scales, hospital anxiety and depression scale, and 5 m walk; handicap with the Nottingham health profile; carer stress with caregiver strain index and patient and carer satisfaction. The main process measure was length of stay after randomisation.
                One year after randomisation no significant differences in clinical outcomes were found apart from increased satisfaction with hospital care in the community therapy group. Length of stay after randomisation in the community therapy group was significantly reduced (12 v 18 days; P < 0.0001). Patients with impairments were more likely to receive treatment in the community therapy group.
                Early discharge with specialist community rehabilitation after stroke is feasible, as clinically effective as conventional care, and acceptable to patients. Considerable reductions in use of hospital beds are achievable. Although intervention is effective in reducing the disability associated with stroke, limited resources mean that physiotherapy services often cease by six months after stroke. The purpose of this clinical trial was to investigate the efficacy of resource-efficient physiotherapy services in improving mobility and quality of life after stroke. Twenty-six people with residual walking difficulties after stroke were randomised into an experimental or control group after discharge from physiotherapy services. The experimental group participated in a six-week, home-based mobility program. The control group participated in a six-week, home-based program of upper-limb exercises (i.e. 'sham' mobility exercises). Subjects met with the therapist for prescription of exercises only three times during the six weeks. Strategies used to offset potential problems associated with minimal subject-therapist interaction included videotaped instructions to encourage correct performance of exercises, modification of the environment and involvement of carers to enhance safety, and telephone contact and self-monitoring to promote compliance. Standing (Functional Reach), walking (MAS Item 5) and quality of life (SA-SIP30) were measured prior to, immediately after, and two months after intervention ceased by an assessor who was blinded to group allocation. Subjects in the experimental group demonstrated significant improvement in standing compared to the control group (p = 0.01) which was maintained two months after the cessation of intervention (p = 0.04). There was no difference between the groups in walking (p = 0.50) or quality of life (p = 0.70). The six-week, resource-efficient mobility program was effective in improving some of the mobility in people after discharge from stroke rehabilitation. The provision of resource-efficient programs is recommended wherever possible so that people affected by stroke may continue rehabilitation for longer. 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. Integrated Care Pathway (ICP) is an organized, goal-defined, and time-managed plan that has the potential of facilitating timely interdisciplinary coordination, improving discharge planning, and reducing length of hospital stay.
                An ICP for stroke rehabilitation based on evidence of best practice, professional standards, and existing infrastructure was developed. Its effectiveness was tested in 152 stroke patients undergoing rehabilitation who were randomized to receive ICP care coordinated by an experienced nurse (n=76) or conventional multidisciplinary care (n=76).
                The age, sex, premorbid functional ability, and stroke characteristics of the 2 groups were comparable. There were no differences in mortality rates (10 [13%] versus 6 [8%]), institutionalization (10 [13%] versus 16 [21%]), or length of hospital stay (50+/-19 versus 45+/-23 days) between patients receiving ICP or multidisciplinary care. Patients receiving conventional multidisciplinary care improved significantly faster between 4 and 12 weeks (median change in Barthel Activities of Daily Living Index 6 versus 2; P<0.01) and had higher Quality of Life scores at 12 weeks (65 versus 59; P=0.07) and 6 months (72 versus 63; P<0.005). There were no significant differences in the mean duration of physiotherapy (42.8+/-41.2 versus 39.4+/-36.4 hours) or occupational therapy (8.5+/-7.5 versus 8.0+/-7.5 hours) received between the 2 groups.
                ICP management offered no benefit over conventional multidisciplinary care on a stroke rehabilitation unit. Functional recovery was faster and Quality of Life outcomes better in patients receiving conventional multidisciplinary care. This paper reports a study evaluating whether expanding a specialist nursing role to provide outreach education and support to stroke patients and carers after discharge from hospital is effective in promoting recovery.
                Building therapeutic relationships with patients and carers is a key component of the nursing role in stroke rehabilitation, although this is limited by the constraints of service organization.
                A pragmatic randomized controlled trial was undertaken. Patients with a diagnosis of stroke were randomized to receive continued support from a stroke nurse (n = 87) or usual care and follow-up (n = 89) after discharge from hospital. Patients were recruited from two hospitals in the north-west of England from November 1999 to April 2001. Patient dependence (Barthel Index), general health (Nottingham Health Profile), activities of living (Frenchay Activity of Living Index), depression (Beck Depression Inventory) and carer strain (Carer Strain Index) were assessed at 3 and 12 months after stroke.
                The continued intervention of a stroke nurse after discharge was associated with improved patient perceptions of general health at 12 months (median difference 42.6, P = 0.012), and in particular reduced negative emotional reaction (P = 0.037) and perceived social isolation (P = 0.002). In addition, the intervention reduced carer strain at 3 months (P = 0.045), and reduced deterioration in physical dependence from 3 to 12 months (P = 0.049).
                The provision of continued intervention from a stroke nurse after discharge from hospital, focusing on education and support, has tangible benefits for patients and carers.
CCT is safe and effective in improving mobility for people after moderate stroke and may reduce inpatient length of stay. Further research is required, investigating quality of life, participation and cost-benefits, that compares CCT to standard care and that also investigates the differential effects of stroke severity, latency and age.