Multidisciplinary Rehab in Acute Stroke: Canadian Model Sign of Things to Come?

Organized and early acute stroke treatment has been shown to improve functional deficits, reduce the need for institutionalization after stroke, and reduce patient mortality. Today, stroke research has evolved to incorporate an integrated, multidisciplinary treatment approach. Data from a study done in 2005 in Ontario, Canada, demonstrate the utility of providing rapid and integrated acute stroke treatment in a real-world setting. The study evaluated functional outcomes associated with rehabilitation services that are part of a flagship stroke treatment program initiated by the Ontario government. The hope for the future is that this approach to patient management will reduce associated health care costs, which are anticipated to increase dramatically in the coming decades.

Evidence for multidisciplinary acute stroke treatment comes from several sources, including a study by Musicco and colleagues¹ that reported data from a cohort of 1716 stroke patients. Musicco and team saw better long-term outcomes in patients who received rehabilitation within 7 days after stroke, compared with those who received therapy at 1 month or more after stroke (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.35 to 3.34). Similarly, patients also did better if they received therapy between 15 and 30 days after acute cerebrovascular event (OR, 2.11; 95% CI, 1.37 to 3.26).

Ronning and Guldvog² demonstrated that patients who had suffered acute stroke and were "initially treated in a stroke unit or general medical ward for a relatively short length of time benefited from treatment in a hospital-based specialist rehabilitation facility compared with treatment through a package of municipality-based services." Specifically, with respect to the combined number of deaths and persons who remained dependent (Barthel Index [BI] score less than 75) there was a significant difference between those who had been treated in a stroke unit and those treated within the municipality: 23% versus 38%, respectively (P = .01). Furthermore, the authors reported that the greatest benefits were seen in patients with moderate or severe stroke.

In 2005, Elizabeth A. Linkewich, an occupational therapist at the Northwestern Ontario Regional Health Sciences Center in Thunder Bay, Ontario, and colleagues³ completed a clinical evaluation of the functional recovery of patients treated in the stroke program at their center. The study is among the first of its kind within the Ontario Stroke Strategy and confirmed the findings reported by Musicco and Ronning that early multidisciplinary interventions-specifically occupational therapy and physiotherapy-significantly benefited patients' functional recovery.

THE ONTARIO DATA
Linkewich and colleagues approached inpatients who were referred to their multidisciplinary service or stroke team for both occupational therapy and physiotherapy. Patients with severe dementia or those with another disability or debilitating disease that could affect their recovery were excluded.

Data on patients' smoking history and other risk factors, such as age and sex and their living or home support, were collected. "We also looked at whether or not they had received tissue plasminogen activator (tPA) or had any complications while in the hospital," Linkewich said. Patients' destinations after discharge from the hospital also were assessed to see whether there were any correlations with functional recovery.

The rehabilitation program in the study included 30 minutes to an hour of occupational therapy and physiotherapy, depending on patient tolerance, 4 days per week. The treatment plans were individualized and based on patient needs.

Participants were evaluated at admission and discharge for functional recovery over a 2-week period. Functional recovery was defined as improvements in scores for balance (Berg Balance Scale [BBS]), cognition (Mini-Mental State Examination [MMSE]), functional independence (BI), and stroke severity (NIH Stroke Scale [NIHSS]).

Results showed the average age of patients was 72 years. The length of stay in the hospital during the study ranged from 2 days to 2 weeks, with an average length of stay of 13 days. Data from the one sample of t tests on the different scores for each outcome variable (to test for significant change from 0) showed significant improvements in scores on the NIHSS (t [24] = 6.063 [P < .001]), BBS (t [24] = 3.626 [P = .001]) and BI (t [24] = 4.543 [P < .001]).

"Overall, we found that people had improved significantly in terms of their functional recovery during the course of their stay," Linkewich said. Interestingly, women demonstrated significantly greater improvements on tests of stroke severity, compared with their male counterparts (t [23] = 22.502 [P = .02]).

Risk factors-specifically smoking history, length of hospital stay, and age-were not found to be predictive of outcome. "We need to do further research to clarify this," Linkewich said.

Linkewich and her team also evaluated the relationship between different assessment tools used with a view to streamlining their use. They found strong correlations among the BBS, NIHSS, BI, and MMSE. "As a result, we have changed our program accordingly," Linkewich said. "We have decided to continue to use the NIHSS as a communication tool and neurologic screen, as well as the BBS because they offer 2 separate components. However, we've chosen not to continue using the BI because it correlated so highly with the other instruments. With respect to individual patients, more observational information, as opposed to the numbered score data, wasn't as meaningful in our populations," she explained.

The MMSE also has been dropped as an outcome measure. "Cognition generally doesn't tend to change over that period [2 weeks], unless there's some area of elemental delirium," she said. The team uses cognitive assessments; however, they are more in-depth than the MMSE and are not applied as outcome measures.

THE ONTARIO STROKE STRATEGY:
A LEADING-EDGE TREATMENT APPROACH
The Ontario Stroke Strategy⁴ is unique in Canada, and resulted, in part, from a growing government awareness of the costs associated with treating stroke. In 1994, direct and indirect costs associated with stroke care in Ontario were estimated to be between Can$718 million and Can$964 million. In 1997, the Institute for Clinical Evaluative Sciences estimated that 14,937 Ontario hospital discharges were patients who had ischemic and hemorrhagic strokes. The goal of the program was to decrease the incidence of stroke and improve patient care and outcomes. This was to be achieved by reorganizing stroke care delivery so that treatment was accessible in a timely manner to all persons living within the province.

As a result, the Coordinated Stroke Strategy was initiated in 1998 by the Heart and Stroke Foundation of Ontario.⁴ It was intended as a demonstration project that would test a model of region-wide coordinated stroke care "across a continuum." The project ran for 3 years, and subsequently formed the foundation of the Ontario Stroke Strategy.

The scope of the program includes not only health promotion and primary prevention but also recognition of symptoms, acute care, secondary prevention, rehabilitation, and long-term and community care. Furthermore, best practices for rehabilitation services are developed through rehabilitation initiatives that are extended throughout a stroke rehabilitation network. Pilot projects are developed and tested with a view to being adopted province-wide as best practices.

"Ontario has perhaps the most solid set of collaborations in stroke treatment of anywhere in the world. It really is an outstanding model," said Steven L. Wolf, PhD, professor of rehabilitation medicine at Emory University School of Medicine in Atlanta. Wolf sits on the Canadian Stroke Network Advisory Board. Linkewich concurs: "Ontario is quite far along in terms of their strategy. The stroke units themselves have already become part of the global budget and have been going on for 2 years now."

The stroke rehabilitation center at Thunder Bay, however, is only a 9-bed unit, which, according to Linkewich, usually has more than 9 patients in it. "It is a designated stroke unit with a neurologist and 3 physicians who also are on call. We have a designated stroke nurse, a dietitian, and a speech-language pathologist-these are all designated enhanced services-and we have a secondary prevention nurse and a case manager," she said.

FOLLOWING ONTARIO'S MODEL
According to data reported by Brown and colleagues,⁵ costs associated with stroke treatment in the United States are expected to exceed $2 trillion (2005 dollar valuation) between 2005 and 2050. Brown and colleagues at the University of Michigan in Ann Arbor evaluated data from the 2000 US Census and 2 stroke surveillance studies-namely, the stroke epidemiology and service utilization data from the Northern Manhattan Stroke Study and the Brain Attack Surveillance in Corpus Christi Project. Costs associated with inpatient hospitalization and rehabilitation, drugs, nursing home and outpatient services, ambulance services, potential lost earnings, and informal caregiving also were taken into consideration. Lost earnings and informal caregiving were found to account for nearly half the total costs across ethnic groups (non-Hispanic white persons, Hispanic persons, and African Americans). Notably, overall costs were highest among non-Hispanic white persons at $1.52 trillion, followed by $379 billion for African Americans and $313 billion among Hispanic persons.

Demographically, approximately half the total costs were accounted for by persons between the ages of 45 and 64 years, compared with just 10% of total costs associated with those aged 85 years or older, dispelling the belief that stroke is largely a disease of the elderly. The authors state that interventions to reduce the cost of stroke should not be targeted strictly at the elderly. Rehabilitation of stroke patients in the 45- to 64-year-old group would seem critical for a number of reasons, not the least of which is that many would not be ready for retirement.

Taking the components of the Thunder Bay stroke center program into consideration, Linkewich believes that the key to its success is, not surprisingly, early intervention with a multidisciplinary team. "We had pushed really hard, based on previous research, to get patient referrals right away, so that we were seeing people on day 1 poststroke. We were there right away to get these patients up and going, even with post-tPA," she said. "We really noticed that this plays a huge part in the improvements we saw."

"We also found that when working with a multidisciplinary team, using tools that function across disciplines and are understood by all team members is very helpful for communications. For example, by using the NIHSS, we were talking the same language as the neurologist and other physicians. Such communication and understanding is very important between team members," she said.

In terms of further research, Linkewich and colleagues are in the process of evaluating outcome measures with a view to longer-term outcomes. "We want to see if the outcomes we found in our study are sustainable 6 months down the road," she said.

REFERENCES1. Musicco M, Emberti L, Nappi G, Caltagirone C. Early and long-term outcome of rehabilitation in stroke patients: the role of patient characteristics, time of initiation, and duration of interventions. Arch Phys Med Rehabil. 2003; 84:551-558.
2. Ronning OM, Guldvog B. Outcome of subacute stroke rehabilitation: a randomized controlled trial. Stroke. 1998;29:779-784.
3. Linkewich EA, MacLean FA, Chevarie N. Functional recovery in acute stroke rehabilitation. Presented at: American Academy of Neurology Annual Scientific Meeting; April 1-8, 2006; San Diego.
4. Solomon R. Ontario Stroke Strategy. Available at: www.hhrc.net/pubs/workshops/pds_stroke.pdf. Accessed December 6, 2006.
5. Brown DL, Boden-Albala B, Langa KM, et al. Projected costs of ischemic stroke in the United States. Neurology. 2006;67:1390-1395.