Duy Le, MD
It is often stated that lack of proof is not proof itself. Such is the case of rehabilitation after stroke. While there is no clear prospective randomized trial showing that rehabilitation is beneficial, by and large, consensus is that it is beneficial for patients. We spend tremendous resources screening and triaging patients to see who would be good acute rehabilitation candidates. But the large looming question still remains: Who actually gets better, and what are predictors of good outcomes at rehab?
While there is much research left to do regarding rehabilitation post stroke, it’s also quite an exciting venture because there is so much left to learn. Previous work done on rehab post stroke have identified comorbid conditions, demographic information, social status, vocational status, functional limitations and stroke subtype as being predictive factors in outcome after inpatient rehab. However these reports are limited by small sample size and single center reviews.
Brown et al. attempt to up the ante by evaluating the Uniform Data System for Medical Rehabilitation (UDSMR) which contains data collected from the Inpatient Rehabilitation Patient Assessment Instrument (IRF-PAI). They evaluate patients with a diagnosis of stroke from 2005 to 2007. Patients were included if they were older than 18 years of age and were admitted for rehabilitation from an acute care facility. Patients were excluded if they were not living at home prior to acute hospitalization, or had interruption of their rehab stay.
This study finds that the admission Functional Independence Measurement (FIM) score is the best predictor of patients doing well post rehabilitation (i.e., being discharged home and having a higher change in FIM score from admission to discharge). The FIM score is broken into components; a motor and cognitive portion. It was found that the motor component has a high predictive value of good outcome.
Weaknesses of this study stem from the inherent nature of a retrospective review. The bias of patient selection for acute rehab itself likely contributes to the outcome of this study. Take for example that the FIM motor component is more predictive of outcomes and that the cognitive portion is not as predictive. Most patients who are selected to attend acute rehab usually have good cognition with ability to participate. Thus, the patient spectrum of poor cognition was not truly evaluated for predictive outcome. Of note, prior reported predictors such as pre-existing medical condition and stroke related comorbid conditions did not substantially contribute poor outcome in this study. Nonetheless, this study still makes strides in the rehabilitation research due to the large sample size on which to draw conclusions. This is a good launching point and a strong data base to continue extrapolating more answers. Again, much work still needs to be done in the realm of research to see what factors influence good outcomes; as this will be crucial to optimize rehabilitation care.
When are we going to get away from subjective evaluations and use objective data like CT and PET scans for predicting outcomes from stroke?
Such is the case of rehabilitation after stroke. While there is no clear prospective randomized trial showing that rehabilitation is beneficial, by and large, consensus is that it is beneficial for patients. stroke rehabilitation program