The association between inpatient rehabilitation intensity and outcomes after stroke in Ontario, Canada

Background — Several studies have demonstrated improved outcomes post-stroke when higher intensity rehabilitation is provided. Canadian Stroke Best Practice Recommendations advise patients receive 180 minutes of therapy time per day, however, the exact amount required to reach benefit is unknown.

Aims — The primary aim of this study was to determine the association between rehabilitation intensity and total Functional Independence Measure® Instrument change. Secondary aims included determining the association between rehabilitation intensity and discharge location, 90-day home time, rehabilitation effectiveness, and motor and cognitive FIM change.

Methods — A retrospective cohort study was conducted using available administrative databases of acute stroke patients discharged to inpatient rehabilitation facilities in Ontario, Canada from January 2017 to December 2021. Rehabilitation intensity was defined as number of minutes per day of direct therapy by all providers divided by rehabilitation length of stay. The association between rehabilitation intensity and the outcomes of interest were analyzed using regression models with restricted cubic splines.

Results — 12,770 individuals were included. Mean age of the sample was 72.6 years, 46.0% of individuals were female, and 87.6% had an ischemic stroke. Mean rehabilitation intensity was 74.7 minutes (range 5 to 162 minutes) per day. Increased rehabilitation intensity was associated with an increase in mean FIM change. However, there was diminishing incremental increase after reaching 95 mins/day. Increased rehabilitation intensity was positively associated with motor and cognitive FIM change, rehabilitation effectiveness, 90-day home time, and discharge to pre-admission setting. Higher rehabilitation intensity was associated with a lower likelihood of discharge to long-term care.

Conclusions — None of the patients met the recommended rehabilitation intensity of 180 mins/day based on the Canadian Stroke Best Practice Recommendations. Despite this, higher intensity was associated with better outcomes. Given that most positive associations were observed with a RI ≥95 mins/day, this may be a more feasible target.