Authors (including presenting author) :
Wong HY (1), Ng HP (1), Chan YL (1), To TS (1), Chung SF (1), Chan CH (1), Law LY (1), Yu KK (2), Yeung MP (2), Lau PK (2), Mo MM (2)
Affiliation :
(1) Occupational Therapy Department, Kowloon Hospital (2) Rehabilitation Department, Kowloon Hospital
Introduction :
Stroke is defined as an acute cerebrovascular event where the blood supply to brain is being interrupted by an infarct or a hemorrhage. Although a declining trend has been reported in the stroke incidence rate of Hong Kong, the actual population of stroke survivors remains large due to decreased case fatality and aging population (Woo, Ho, Goggins, Chau, & Lo, 2014). Despites the advancement of medical treatment and setup of acute stroke unit, a local study found that more than 50% of stroke survivors still suffer from functional impairment and require assistance in activity of daily living (ADL) after one year (Lo et al., 2008). Stroke rehabilitation focuses on restoring functional independence and minimizing secondary complications, which is proven to be beneficial to stroke survivors.
Recently, 365 days Stroke Rehabilitation Service (STROKE-365) has been launched in Kowloon Hospital. STROKE-365 refers to seven days per week rehabilitation, in which rehabilitation during the weekends and on Public Holidays is provided in addition to conventional weekdays rehabilitation. Current evidence suggested that extending five days per week rehabilitation to six / seven days per week rehabilitation is associated with better outcomes in patients with stroke and other physical conditions (Peiris, Shields, Brusco, Watts, & Taylor, 2013; Scrivener, Jones, Schurr, Graham, & Dean, 2015). However, these current studies recruited patients with mixed medical conditions and were conducted in foreign context, which lowered the specificity and generalizability in applying to local clinical setting. Therefore, a local study on examining the effect of seven days per week rehabilitation specifically on stroke patients may provide a more comprehensive clinical picture. Moreover, among studies examining the effect of weekend stroke rehabilitation on stroke patients, most of the studies focused on the outcome of lower limb recovery (e.g. walking speed, walking distance, Modified Rankin Scale, Functional Ambulation Classification etc.); some examined the recovery in ADL performance; and nearly none explored the recovery of hemiplegic upper extremity function and cognitive function (English et al., 2015; Kinoshita, Momosaki, Kakuda, Okamoto, & Abo, 2017; Nakazora et al., 2018). This is the first local study to examine the outcome of seven days per week rehabilitation on stroke patients in terms of ADL functions, hemiplegic upper extremity function and cognitive function.
Objectives :
The aims of this study are: (1) to examine the rehabilitation outcomes of STROKE-365; (2) to compare the rehabilitation outcomes between conventional weekdays rehabilitation and STROKE-365; (3) to identify which group of stroke patients may benefit from STROKE-365.
Methodology :
This study was conducted in Kowloon Hospital Ward 3B. This was a retrospective study with a historical control group and a retrospective exposure group. Subjects were identified retrospectively in the Clinical Data Analysis & Reporting System (CDARS). The inclusion criteria of control group were: (i) diagnosed with acute cerebral infarction/ cerebral hemorrhage (ICD-9; 430-436.99); (ii) received conventional stroke rehabilitation during weekdays from 1st October, 2018 to 30th September, 2019. The inclusion criteria of exposure group were: (i) diagnosed with acute cerebral infarction/ cerebral hemorrhage (ICD-9; 430-436.99); (ii) received conventional stroke rehabilitation during weekdays and STROKE-365 during the weekends and on Public Holidays from 1st October, 2019 to 30th September, 2020. Subjects with the following conditions were excluded: (i) premorbid old aged home (OAH) residents; (ii) insufficient rehabilitation period (length of stay < 14days); (iii) prolonged hospitalization (length of stay > 60 days); (iv) death during hospital stay; (v) incomplete rehabilitation course in Kowloon Hospital Ward 3B (transferred to acute unit and not returning to Kowloon Hospital Ward 3B) and (vi) missing data in major parameters.
Subjects in control group received conventional stroke rehabilitation from Monday to Friday. Conventional stroke rehabilitation includes 1-hour physiotherapy (PT) gymnasium training and 1-hour occupational therapy (OT) gymnasium training on every weekday. Subjects in exposure group received conventional stroke rehabilitation from Monday to Friday and additional weekend rehabilitation on Saturdays, Sundays and Public Holidays. Ward-based PT and OT training, around 15 minutes each, were provided on Saturdays, Sundays and Public Holidays. Ward-based OT training includes grooming training; upper and lower garment dressing training; toileting and toilet transfer training; reality orientation and bedside cognitive training; and upper extremity and hand function training.
The outcome measures were: length of stay; discharge destination; Modified Barthel Index (MBI); Functional Independence Measure (FIM); Hong Kong version of The Functional Test for Hemiplegic Upper Extremity (FTHUE-HK), Hong Kong version of Montreal Cognitive Assessment (MoCA-HK) and Abbreviated Mental Test (AMT). All outcome measures were measured at baseline and upon discharge.
Statistical Package for the Social Sciences (SPSS) version 23 was used for data analysis. Statistical significance was set at p< 0.05. Normality of variables was assessed by Kolmogorov-Smirnov test before data analysis. Independent t-test for continuous data and Chi-square test for categorical data were used to compare the rehabilitation outcomes for between-group comparison.
Result & Outcome :
A total of 614 subjects were identified retrospectively from CDARS. 93 subjects were excluded after application of exclusion criteria. A total of 394 subjects were eligible to be included in this study, in which 239 subjects were in historical control group and 155 subjects were in STROKE-365 group. Most of the baseline characteristics among subjects in control group and STROKE-365 group were homogeneous with no statistically significant difference (p>0.05).
The mean length of stay of STROKE-365 group (30.6 ± 10.3 days) and control group (29.5 ± 10.0 days) were comparable (p= 0.291). Larger proportion of subjects in the STROKE-365 group (84.5%) was able to discharge home when compared to the control group (81.5%) (p=0.496). Statistical significant improvements were observed in MBI gain (p=0.020), FIM gain (p=0.040), FTHUE-HK gain (p=0.014) of STROKE-365 group in between-group comparison.
A sub-group analysis was done to further explore which group of subjects would benefit from STROKE-365. Stroke patients could be divided into three groups according to their admission FIM-Motor subscale (FIM-M) score: stroke patients with severe impairment (admission FIM-M score =< 26), stroke patients with moderate impairment (admission FIM-M score = 27-52) and stroke patients with mild impairment (admission FIM-M score >=53). Among stroke patients with moderate impairment, more proportion of stroke patients in STROKE-365 group attained FTHUE-HK gain with statistical significance (p=0.021). Among stroke patients with mild impairment, statistical significance improvement was observed in MBI gain (p=0.017); FIM gain (p=0.007); FTHUE gain (p=0.020) of STROKE-365 group in between-group comparison. The rehabilitation outcomes of the control group and the STROKE-365 group with stratification of admission FIM-M score were summarized in Table 3.
In addition, STROKE-365 service satisfaction survey was collected from patients, care givers and colleagues. Overall, patients (average of total satisfaction score: 8.68), care givers (average of total satisfaction score: 9.04) and colleagues (average of total satisfaction score: 7.46) were very satisfied and expressed positive feedback towards STROKE-365 program.
In conclusion, this study provides convincing evidence that STROKE-365 program improves rehabilitation outcome of stroke patients in terms of ADL functional performance and upper limb recovery. It was observed that stroke patients with mild to moderate impairment (admission FIM-M score >= 27) would benefit more from STROKE-365 program.
