Elsevier

The Lancet

Volume 363, Issue 9406, 31 January 2004, Pages 352-356
The Lancet

Articles
Rehabilitation therapy services for stroke patients living at home: systematic review of randomised trials

https://doi.org/10.1016/S0140-6736(04)15434-2Get rights and content

Summary

Background

Stroke-unit care can be valuable for stroke patients in hospital, but effectiveness of outpatient care is less certain. We aimed to assess the effects of therapy-based rehabilitation services targeted at stroke patients resident in the community within 1 year of stroke onset or discharge from hospital.

Methods

We did a systematic review of randomised trials of outpatient services, including physiotherapy, occupational therapy, and multidisciplinary teams. We used Cochrane collaboration methodology.

Findings

We identified a heterogeneous group of 14 trials (1617 patients). Therapy-based rehabilitation services for stroke patients living at home reduced the odds of deteriorating in personal activities of daily living (odds ratio 0·72 [95% CI 0·57–0·92], p=0·009) and increased ability of patients to do personal activities of daily living (standardised mean difference 0·14 [95% CI 0·02–0·25], p=0·02). For every 100 stroke patients resident in the community receiving therapy-based rehabilitation services, seven (95% CI 2–11) would not deteriorate.

Interpretation

Therapy-based rehabilitation services targeted at selected patients resident in the community after stroke improve ability to undertake personal activities of daily living and reduce risk of deterioration in ability. These findings should be considered in future service planning.

Introduction

Stroke is a major health-care challenge, especially in the developed world, where it is one of the most frequent causes of disability and accounts for considerable costs for health and social services.1 Organised inpatient care in multidisciplinary stroke units can reduce these adverse outcomes compared with less organised inpatient care.2 However, there is not much consensus about the effects of rehabilitation services for stroke patients once they have left hospital. This omission is important, because patients returning home after a stroke sometimes lose some of their independence.3 Furthermore, such services are recommended in UK Government documents and are valued by patients and carers, but provision is inconsistent.4, 5, 6

We aimed to review evidence that rehabilitation services for stroke patients who had returned home could affect their recovery. We restricted definition of services to those provided by physiotherapists, occupational therapists, or multidisciplinary teams. We then aimed to do a systematic review to test the null hypothesis that such services do not affect recovery of patients living at home after a stroke.

Section snippets

Procedures

We included any randomised controlled trial that compared an outpatient therapy-based rehabilitation service with no routine input. We classified these services as interventions provided by qualified physiotherapists, occupational therapists, or multidisciplinary staff, or under the supervision of qualified therapy staff. This definition was developed from a previous descriptive analysis of rehabilitation services, which indicated that these services had a consistent approach to reduction of

Results

4946 references were screened, of which most could be excluded from the title alone. Of 27 trials selected for assessment, ten were excluded. Reasons for exclusion included trials of early discharge services (comparison of inpatient and outpatient services; n=2), inappropriate intervention (4), late intervention (3), and insufficient numbers of stroke patients (1); further details are presented in the Cochrane Library version of this review.10 Three trials were not yet completed. The remaining

Discussion

We have shown that therapy-based rehabilitation services for individuals living at home after stroke can reduce risk of deterioration in ability to undertake activities of daily living. In general, this conclusion is secure: our search strategy was comprehensive, quality of trials was good, and we obtained additional detailed unpublished information from trialists. From a funnel plot and sensitivity analyses, we recorded no evidence of significant publication bias (data available from authors);

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