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Objective: To prospectively monitor occupational therapy activities and intervention techniques used during inpatient stroke rehabilitation in order to provide a description of current clinical practice., Methods: Data were collected prospectively from 954 clients with stroke receiving occupational therapy from six U.S. rehabilitation hospitals. Descriptive statistics summarized frequency, intensity, and duration of occupational therapy sessions; proportion of time spent in 16 therapeutic activities; and proportion of those activities that included any of 31 interventions., Results: Clients received on average 11.8 days (SD = 7.2) of occupational therapy, with each session lasting on average 39.4 min (SD = 16.9). Upper-extremity control (22.9% of treatment time) and dressing (14.2% of treatment time) were the most frequently provided activities. Interventions provided most frequently during upper-extremity control activities were strengthening, motor learning, and postural awareness., Conclusion: Occupational therapy provided reflected an integration of treatment approaches. Upper-extremity control and basic activities of daily living were the most frequent activities. A small proportion of sessions addressed community integration.

Unlabelled: Gassaway J, Horn SD, DeJong G, Smout RJ, Clark C, James R. Applying the clinical practice improvement approach to stroke rehabilitation: methods used and baseline results., Objectives: To describe the methods used and baseline data for the Post-Stroke Rehabilitation Outcomes Project (PSROP)., Design: Prospective observational cohort study., Setting: Seven inpatient rehabilitation facilities (IRFs) in the United States and New Zealand., Participants: Consecutive convenience sample of 1291 poststroke rehabilitation patients, age older than 18, who were treated between 2001 and 2003 in 7 IRFs (1161 patients in 6 U.S. IRFs)., Interventions: Not applicable., Main Outcome Measures: Change in FIM score, change in severity of illness, and discharge destination., Results: For the U.S. sample, the average age was 66 years, 52% were men, 60% were white, and 23% were black. Medicare was the most frequent payer. Seventy-seven percent of strokes were ischemic, with 43% in the left brain, 44% in the right brain, and 11% bilateral. Mean admission total FIM score was 61, with a mean motor FIM score of 40 and mean cognitive FIM score of 21. Lower FIM scores are associated with higher severity-of-illness scores. Mean rehabilitation length of stay was 18.6 days; 78% of patients were discharged home. At discharge, the average increase in total FIM score was 26, in motor FIM score was 22, and in cognitive FIM score was 4., Conclusions: This article outlines methods used in the PSROP, provides an overview of participating IRFs, describes the database, and summarizes key characteristics to enable readers of subsequent articles to better interpret study findings and determine generalizability.

Unlabelled: Horn SD, DeJong G, Smout RJ, Gassaway J, James R, Conroy B. Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better?, Objective: To examine associations of patient characteristics, rehabilitation therapies, neurotropic medications, nutritional support, and timing of initiation of rehabilitation with functional outcomes and discharge destination for inpatient stroke rehabilitation patients., Design: Prospective observational cohort study., Setting: Five U.S. inpatient rehabilitation facilities., Participants: Post-stroke rehabilitation patients (N=830; age, >18 y) with moderate or severe strokes, from the Post-Stroke Rehabilitation Outcomes Project database., Interventions: Not applicable., Main Outcome Measures: Discharge total, motor, and cognitive FIM scores and discharge destination., Results: Controlling for patient differences, various activities and interventions were associated with better outcomes including earlier initiation of rehabilitation, more time spent per day in higher-level rehabilitation activities such as gait, upper-extremity control, and problem solving, use of newer psychiatric medications, and enteral feeding. Several findings part with conventional practice, such as starting gait training in the first 3 hours of physical therapy, even for low-level patients, was associated with better outcomes., Conclusions: Specific therapy activities and interventions are associated with better outcomes. Earlier rehabilitation admission, higher-level activities early in the rehabilitation process, tube feeding, and newer medications are associated with better stroke rehabilitation outcomes.

Unlabelled: Hatfield B, Millet D, Coles J, Gassaway J, Conroy B, Smout RJ. Characterizing speech and language pathology outcomes in stroke rehabilitation., Objectives: To describe a subset of speech-language pathology (SLP) patients in the Post-Stroke Rehabilitation Outcomes Project and to examine outcomes for patients with low admission FIM levels of auditory comprehension and verbal expression., Design: Observational cohort study., Setting: Five inpatient rehabilitation hospitals., Participants: Patients (N=397) receiving post-stroke SLP with admission FIM cognitive components at levels 1 through 5., Interventions: Not applicable., Main Outcome Measure: Increase in comprehension and expression FIM scores from admission to discharge., Results: Cognitively and linguistically complex SLP activities (problem-solving and executive functioning skills) were associated with greater likelihood of success in low- to mid-level functioning communicators in the acute post-stroke rehabilitation period., Conclusions: The results challenge common clinical practice by suggesting that use of high-level cognitively and linguistically complex SLP activities early in a patient's stay may result in more efficient practice and better outcomes regardless of the patient's functional communication severity level on admission.

Unlabelled: James R, Gines D, Menlove A, Horn SD, Gassaway J, Smout RJ. Nutrition support (tube feeding) as a rehabilitation intervention., Objective: To describe site variation in use of enteral feeding and its association with stroke rehabilitation outcomes, controlling for a variety of confounding variables., Design: Prospective observational cohort study., Setting: Six inpatient rehabilitation facilities in the United States., Participants: Patients (N=919) from the Post-Stroke Rehabilitation Outcomes Project database with moderate or severe stroke who were discharged to home, community, or skilled nursing facility., Interventions: Not applicable., Main Outcome Measures: Change in total, motor, and cognitive FIM instrument scores and change in severity of illness., Results: Monitoring of nutritional status and the frequency of tube-feeding interventions for patients with moderate and severe stroke varied significantly among sites. Patients with tube feeding had higher severity of illness and lower functioning on admission compared with patients who did not receive tube feeding. However, when we controlled for severity of illness, admission FIM score, and other important covariates, we found that patients with severe strokes who were tube fed for more than 25% of their stay had greater increases in total, motor, and cognitive FIM scores and greater improvement in severity of illness by discharge., Conclusions: Nutrition support (tube feeding) is an effective therapy in rehabilitation service for patients with severe strokes and is associated with greater motor and cognitive improvements, even in patients with the most severe strokes.

Unlabelled: Maulden SA, Gassaway J, Horn SD, Smout RJ, DeJong G. Timing of initiation of rehabilitation after stroke., Objective: To study associations between days from stroke symptom onset to rehabilitation admission and rehabilitation outcomes, controlling for a variety of confounding variables., Design: Observational cohort study of 200 consecutive post-stroke rehabilitation patients in each of 6 inpatient rehabilitation facilities., Setting: Six U.S. inpatient rehabilitation hospitals., Participants: Patients (N=969) with moderate or severe strokes who had days from stroke symptom onset to rehabilitation admission recorded in their medical records., Interventions: Not applicable., Main Outcome Measures: Discharge total FIM, discharge motor FIM, discharge activities of daily living (ADL) FIM, and discharge mobility FIM scores, as well as rehabilitation length of stay (LOS)., Results: Fewer days from stroke symptom onset to rehabilitation admission was associated significantly with better functional outcomes: higher total, motor, mobility, and ADL discharge FIM scores, controlling for confounding variables. For severely impaired patients with stroke in case-mix groups (CMGs) 108-114, the relation was strongest, with F statistics greater than 24.1 for each functional outcome. For patients with moderately severe stroke in CMGs 104-107, fewer days from stroke symptom onset to rehabilitation admission was associated significantly with shorter rehabilitation LOS., Conclusions: Fewer days from stroke symptom onset to rehabilitation admission is associated with better functional outcomes at discharge and shorter LOS.

Deep venous thrombosis (DVT) is a common and preventable complication after a stroke. Although the treatment of DVT is simple and straightforward, its prevention remains controversial. The Post-Stroke Rehabilitation Outcomes Project (PSROP) database was used to describe the incidence and temporal sequence of DVT and trends in the prevention and treatment of DVT. Of the 1,161 patients in the PSROP database, 383 (32.99%) patients without DVT and 8 (0.69%) with DVT had no documented orders for anticoagulant medications. Sixty-five (5.60%) patients had DVTs during the inpatient rehabilitation facility stay. Of 10 (0.86%) patients with DVTs in the common femoral vein, 4 (40%) were diagnosed within 24 hours of admission. Nine (90%) of these 10 patients were classified as moderate or severe strokes. All patients with common femoral DVT received appropriate therapy. Although much is known about the prevention, diagnosis, and treatment of poststroke DVT, clinicians need to learn and apply treatment protocols to prevent DVTs and allow more quality time for rehabilitation.

Pain remains one of the most common, yet most challenging, medical problems in health care today, and it is one of the most common complications that occurs after a stroke. Pain can affect the course of stroke rehabilitation adversely, and it occasionally may be a cause for transfer back to an acute care hospital. The Post-Stroke Rehabilitation Outcomes Project (PSROP) database was used to describe the incidence of pain by body location and trends in the use of different classifications of medications to treat pain. Of the 1,122 participants in the PSROP database, the most common locations of pain in stroke survivors were the head, leg, back, and shoulder. The most frequently prescribed classifications of pain medications were other analgesics (acetaminophen and tramadol), followed by narcotic analgesics, non-steroidal antiinflammatory drugs (NSAIDs), anticonvulsants, and tricyclic antidepressants. After acetaminophen, the most frequently prescribed medications in each classification, respectively, include hydrocodone APAP, cox-2 inhibitors, gabapentin, and amitriptyline. Other frequently prescribed pain medications included sumatriptan (migraine analgesic), cyclobenzaprine (muscle relaxant), and baclofen (antispasticity muscle relaxant). Medications should be chosen based upon the medical condition causing pain, the ability of the stroke survivor to comply with administration of the medication, and the cost of the medication. Appropriate and timely treatments of painful conditions result in maximum function and the ability to lead active lives and maintain an adequate quality of life.

Secondary prevention of strokes is an important issue during the admission to the inpatient rehabilitation facility (IRF). There are many clinical practice guidelines with strong levels of evidence that address the secondary prophylaxis of strokes. The Post-Stroke Rehabilitation Outcomes Project (PSROP) database was used to describe the frequency that antiplatelet and/or anticoagulant medications are prescribed for the secondary prophylaxis of a stroke. Of the 1,161 participants in the PSROP, 890 (76.66%) had nonhemorrhagic strokes. Of the participants with nonhemorrhagic strokes, 169 (18.99%) did not receive any antiplatelet or anticoagulant medication. Of 717 participants who did not have an embolic event, 140 (19.5%) did not receive a salicylate, antiplatelet agent, or warfarin. Of 173 participants who had an embolic event, 29 (16.8%) did not receive a salicylate, antiplatelet agent, or warfarin. Unless patients have any medical contraindications to these medications, they should receive these evidence-based treatments for secondary stroke prophylaxis. As more stroke survivors receive antiplatelet and/or anticoagulant medications, it is more likely that the incidence of recurrent strokes will decrease.

Blood pressure management is an important issue for the primary prevention, acute management, and secondary prevention of a stroke. Rehabilitation professionals need to consider the timing in lowering blood pressures in stroke survivors, the types of medications that should be used in managing hypertension, and the target pressures to achieve. The Post-Stroke Rehabilitation Outcomes Project (PSROP) database was used to describe the types of antihypertensive medications prescribed to stroke survivors, compare prescription patterns with current practice guidelines of the management of hypertension after a stroke, and determine whether systolic and diastolic blood pressures decrease during admissions to inpatient rehabilitation facilities (IRFs). Of the 1,161 patients in the PSROP database, the most commonly prescribed antihypertensive medications were the angiotensin-converting enzyme antagonists and angiotensin II antagonists, followed by beta-blockers, calcium-channel blockers and diuretics, adrenergics (alpha-blockers), and other (minoxidil, hydralazine) medications. Systolic, diastolic, and mean arterial pressures declined in participants during admissions to IRFs. However, blood pressures were significantly higher throughout IRF stays in participants receiving antihypertensive medications when compared to those not receiving antihypertensive medications. Rehabilitation professionals need to be cognizant of the relationship between stroke and hypertension, clinical practice guidelines that provide evidence-based management tools for hypertension, and patient issues that may hinder the effective treatment of hypertension.

Motor recovery after a stroke depends upon many upon different modalities. Intensive therapy using compensatory and facilitatory techniques is the primary method to improve movement and function in affected extremities. However, medications used to modulate neurotransmitters may be useful in augmenting therapy approaches. The Post-Stroke Rehabilitation Outcomes Project (PSROP) database was used to describe the frequency of prescribing neurostimulant medications; the types of neurostimulant medications used; and how the use of neurostimulant medications affected rehabilitation length of stay, motor recovery, cognitive recovery, and discharge destination. Of the 1,161 patients in the PSROP database, 929 (80.0%) patients did not receive any treatment with methylphenidate, modafinil, levodopa, amantadine, or bromocriptine. Patients who received neurostimulant medications did not have any more significant changes in length of stay, motor recovery, cognitive recovery, or discharge destination than patients who did not receive neurostimulant medications. Much research needs to be completed before clinicians know precisely whether and how rehabilitation therapies and medications interact to assist in functional recovery.

Background and Purpose: The purpose of this study was to describe physical therapy provided to patients with stroke in inpatient rehabilitation facilities., Subjects and Methods: Data were collected from 972 patients with stroke receiving physical therapy services at 6 rehabilitation facilities in the United States. Descriptive statistics were derived to describe physical therapy sessions, including proportion of therapy time spent in specific functional activities and proportion of those activities that included any of 59 interventions., Results: Mean length of stay was 18.7 days (SD=10.3), and patients received physical therapy, on average, 13.6 days (SD=7.8). Patients attended, on average, 1.5 (SD=0.3) physical therapy sessions per day, with each session lasting 38.1 minutes (SD=17.1). Gait and prefunctional activities were performed most frequently (31.3% and 19.7% of total treatment time, respectively). For gait activity, physical therapists used balance and postural awareness training in more than 50% of sessions and used strength training for more than 50% of sessions of prefunctional activities. Eighty-six percent of the patients received evaluation, and 84% of the patients and families received education., Discussion and Conclusion: Therapists selected an eclectic approach to intervention rather than specific intervention techniques. The approach to patients' care included interventions to remediate impairments and to compensate for functional limitations. Therapists also reported frequently using motor control and motor learning approaches to facilitate all activities. This approach to care is largely consistent with existing stroke care guidelines and advances in the scientific theories of motor control and motor learning.