Factors enhancing activities of daily living after stroke in specialized rehabilitation: an observational multicenter study within the Sunnaas International Network

BACKGROUND: Stroke may lead to serious, long-term disability. Consequently, many individuals with stroke will be in need of rehabilitation, and some of specialized rehabilitation. The content and organization of rehabilitation vary within and between countries, reflecting the preferences, customs, traditions, and values of a society or community, that may have an impact on outcomes. The main aim of the present study was to evaluate the influence of team models in specialized rehabilitation on outcomes as measured by stroke patients' performance in activities of daily living (ADL), at a standardized time and at discharge in the various specialized rehabilitation clinics. Secondary aims were to identify explanatory factors for possible differences in ADL changes at standardized time points. DESIGN: A prospective descriptive cross-sectional explorative, multicenter study. SETTING: Specialized rehabilitation clinics in Norway, China, the USA, Russia, Israel, Palestine, and Sweden, for a total of nine clinics. POPULATION: Persons with stroke. METHODS: Outcomes measures were the modified Rankin Scale (mRS) and the National Institute of Health Stroke Scale (NIHSS), both on admission and at discharge from the inpatient rehabilitation unit, and Barthel Index (BI) or alternatively Functional Independence Measure (FIM), on admittance, 18-22 days into rehabilitation, at discharge, and at 6 and 12 months after discharge. RESULTS: In total 230 stroke patients from nine clinics were recruited. There were significant differences in change scores of ADL from admittance to standardized time point 18-22 days into rehabilitation, (P<0.001, R2=0.19) and when controlled for baseline NIHS and mRS (P<0.001, R2=0.18; P=0.01, R2=0.9 respectively). Analysis divided into intra-, multi- and interdisciplinary models showed significant differences at 18-22 days (P=0.02) and at discharge (P<0.001), indicating a more favorable outcome in ADL with the multi-disciplinary model. The linear regression analysis explained 55% of the changes in ADL (R2=0.55) at the standardized time point and 48% (R2=0.48) at discharge. Main explanatory factors were disability (mRS) and severity (NIHS), team models, hours in therapy, and location at discharge. ADL was maintained for the majority of participants at 6 and 12 months post discharge. The correlations mRS/ADL (r=-0.68, P<0.0001), NIHS/ADL (r=-0.55, P<0.0001) and NIHS/mRS (r=0.46, P<0.0001) disclosed medium to large associations at 18-22 days into rehabilitation. CONCLUSIONS: The study indicates that the organization of services in specialized rehabilitation after stroke has a major impact on improvement of ADL outcomes. Main positive predictive factors were models of teamwork, with the multidisciplinary model as most beneficial, and concentrated hours of therapy. Negative predictors were the level of baseline severity and disability post stroke.