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Do rehabilitation at a proper facility with a rehabilitation medicine department, and let the therapist set the intensity: harder is not better

  • Moderate value
  • Evidence A
  • Buys life
  • Disputed
  • Costs a lot
  • Takes time daily
  • Long-term effort

In plain words

Taking the person home to lie down and wait for natural recovery is the most common mistake. After a stroke, organized care by a multidisciplinary team means more people are still alive a year later and still able to live at home. But don't add extra on your own either: practicing earlier, more often and more within 24 hours after a stroke led to worse outcomes at three months. How much to practice, and when, is for the rehabilitation department and the therapist to say.

Cost

Inpatient rehabilitation costs a few hundred yuan a day, and the self-paid part varies by place. It is counted in months. You have to practice every day, and it is tedious.

What you get

A Cochrane systematic review included 29 trials with 5902 participants, comparing organized inpatient stroke unit care with other forms of care. At the last follow-up (median 1 year), the odds ratio for a poor outcome (death, disability or needing institutional care) was 0.77 (95% CI 0.69–0.87, a range of plausible values), for death 0.76 (95% CI 0.66–0.88), and for death or dependence 0.75 (95% CI 0.66–0.85), with moderate-quality evidence. In absolute numbers, for every 100 people given stroke unit care, 2 more survive, 6 more live at home, and 6 more are independent in daily life. On the other hand, the AVERT trial randomly assigned 2104 patients in 56 acute stroke units in 5 countries to “usual care” or “usual care plus very early, high-intensity activity.” At three months, a good outcome (modified Rankin Scale 0—2) was seen in 480 people (46%) in the very early group and 525 (50%) in the usual care group, adjusted odds ratio 0.73 (95% CI 0.59–0.90, P=0.004). Deaths were 88 versus 72, which did not show a difference (odds ratio 1.34, 95% CI 0.93–1.93, P=0.113).

Notes

Disputed: both pieces of evidence come from stroke, so applying them to other causes of disability such as spinal cord injury, amputation or burns is extending them beyond what they cover. The AVERT result shows that “earlier and harder” does not hold; it does not say that early activity is useless. In the trial the great majority of people in both groups were out of bed within 24 hours, and what differed was how often and how much. When choosing a facility, look at whether it has a rehabilitation medicine department and full-time rehabilitation therapists and occupational therapists, and don't go by the word “rehabilitation” on the sign. For how to transfer between primary-level and tertiary hospitals and how the deductible is figured, see §24.1 (step-by-step referral). For community rehabilitation and assistive devices, see §33.7 (go to the county Disabled Persons' Federation and ask about everything).

Evidence grade
A : Specific numbers from meta-analyses, large cohorts or randomized trials; for law and policy, the statute or official text.
Sources
  1. Langhorne P, Ramachandra S; Stroke Unit Trialists' Collaboration (2020). Organised inpatient (stroke unit) care for stroke: network meta-analysis. Cochrane Database of Systematic Reviews, 4:CD000197. https://doi.org/10.1002/14651858.CD000197.pub4
  2. AVERT Trial Collaboration group (2015). Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. Lancet, 386(9988):46-55. https://doi.org/10.1016/S0140-6736(15)60690-0

Translated from the Chinese original. Original book, section 33, tip 16. Content may be out of date and rules differ by place. When you actually deal with an agency, a doctor or a court, follow what local officials, doctors and lawyers tell you. Disclaimer