Article: Sharon - How Much Therapy Time Do Stroke Patients Actually Receive in Rehabilitation?

Sharon - SSTattler

It is well established that intensive and early rehabilitation is very effective at reducing impairment after stroke.  This is so important that for patients admitted for inpatient rehabilitation, Canada’s Best Practice Recommendations for Stroke Care recommend a minimum of one hour per day of each of the relevant core therapies—physical therapy, occupational therapy, and speech therapy.

Dr. Robert Teasell’s  group (Foley et al., 2012)  recently had a paper published that  examined whether this standard was met on a single, specialized stroke rehabilitation unit and if amount of therapy was an independent contributor to functional improvement.

Over a 6 month period there were 123 patients admitted to the stroke rehabilitation unit. Workload data was used to estimate amount of therapy patients received during their inpatient stay.  Active rehabilitation days were the 5 days a week patients receive care and excluded weekend days, holidays, days during which patients were no longer receiving active rehabilitation but remained on the unit awaiting transfer to another unit or facility, service interruptions (whereby patients were transferred to an acute medical facility to receive medical care) and patient leaves of absence.


All time licensed therapists and therapy assistants spent engaged in therapeutic intervention with patients are reported as mean minutes/day and standard deviation (SD). The total amount of time, in hours, therapists spent with patients over their entire hospitalization period was also recorded.

Gains were measured on the Functional Independence Measure [FIM]. The FIM instrument provides an assessment of physical and cognitive impairments in terms of how much care will be needed. It assesses six areas of function (self-care, sphincter control, mobility, locomotion, communication and social cognition).

Therapists score each item on a Likert type scale that ranges  from 1 (total assistance required) to 7 (total independence). Total scores range from 18 to 126, with higher scores indicating greater independence.

The FIM gain was calculated by the subtraction of admission from discharge scores.

What Were These 123 Patients Like? Were They Like You?

Four patients came from a residential or assisted-living institution and 119 lived at home before their stroke  The mean age of patients was 67.  It was an average of 33 days (median 16 days) before they were admitted to the stroke rehabilitation unit. About 76% arrived within 30 days of their stroke.  The mean length of stay on the unit was 37. 4 days, but the mean active length of stay was 25.3 days.  In other words, for the last 12 days of their stay, patients had been discharged from the rehabilitation unit and were waiting to go someplace else.

Table I. Mean (SD) admission and discharge FIM scores of patients (n = 123).

                                                 Admission         Discharge
Mean Total FIM score 77 (25) 103 (22)
Mean Motor FIM Score 52 (22)             74  (19)
Mean Cognitive FIM Score 25 (6) 29  (5)
Mean Motor FIM Gain 21  (15)
Mean Cognitive FIM Gain 3.9 (3.7)
Mean Total FIM Gain 25  (17)

How many patients went home?

Ninety-one (74%) patients returned home.

So on average how much therapy did stroke survivors receive per day?  

Patients  spent, on average, approximately 75 minutes per day engaged in hands on therapy with occupational and physical therapists, and their associated therapy aides each working day. Speech therapist, who may not have provided therapy on a daily basis, recorded substantially less therapy time spent with patients requiring their services. If the services of an SLP were required a total of three hours per day should have been provided; if not, the minimum daily amount of therapy would have been reduced to two hours.

• 37 minutes  of active therapy from physiotherapists (PT) and 
• 37 minutes of active therapy from  occupational therapists (OT) and 
• 13 minutes of active therapy from speech-language pathologists per day. 

The amount of therapy time provided by occupational, speech and physical therapists, and their associated therapy aides did not meet the Canadian Best Practice Recommendations.

Did time in therapy make a difference? 

Admission FIM scores, LOS, daily average and total amount of therapy time provided by OTs and PTs were significantly correlated with gains in function.   Since correlations with total therapy times were stronger, they were selected preferentially.  There were very strong correlations between daily therapy and total therapy for physiotherapy (0.812) , occupational therapy (0.812)  and SLP (0.788). When entered into a regression model, these four variables explained 35% of the variability in FIM gain (F 4,114 = 15.567, p < 0.0001); however, only OT and admission FIM scores were significant predictors of the gains. Roughly for each three-quarter hour (0.72) increase in occupational therapy time was associated with a gain of one additional FIM point. (Foley et al., 2012)


If you would like more information about this paper, please email the administrator:

• How long did you have to wait until you were admitted rehabilitation? 
• How much therapy did you receive per day? 
• Do you think it was enough? 

References:

• Foley, N., Mcclure, J. A., Meyer, M., Salter, K., Bureau, Y., & Teasell, R. (2012). Inpatient rehabilitation following stroke: Amount of therapy received and associations with functional recovery. Disability and Rehabilitation, 34(25), 2132-2138.