Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Home physiotherapy was better than day hospital attendance for improving functional ability after stroke

ACP J Club. 1992 Sept-Oct;117:34. doi:10.7326/ACPJC-1992-117-2-034


Source Citation

Young JB, Forster A. The Bradford community stroke trial: results at six months. BMJ. 1992 Apr 25; 304:1085-9.


Abstract

Objective

To compare the effectiveness of day-hospital attendance and home physiotherapy for stroke patients with residual disability after hospital discharge.

Design

Randomized, single-blind, controlled trial.

Setting

4 day hospitals in 2 health districts in the United Kingdom.

Patients

124 patients aged > 60 years (median age, 71 y; 69 men) were randomized after hospital discharge following a new stroke that resulted in persistent disability. 87% of patients were followed for 6 months.

Intervention

Patients attended 1 of 4 geriatric day hospitals twice a week (n = 61) or were treated at home by 1 of 5 experienced community physiotherapists (n = 63).

Main outcome measures

Performance of activities of daily living was assessed by the Barthel index; functional movement, by the Motor Club assessment; social activities, by the Frenchay activities index; and perceived health status, by the Nottingham health profile. The amount of assistance required for walking was recorded by placing the patients in 1 of 6 functional ambulation categories. Emotional stress of the main caregiver was assessed by the General Health Questionnaire. The extent of rehabilitation treatment and community support service utilization was also recorded.

Main results

Patients in both groups showed an improvement in Barthel index and Motor Club assessment scores at 6 months (P ≤ 0.003 for the difference between baseline and follow-up scores). The improvement in functional ability was greater, however, for patients treated with home physiotherapy (Barthel index, median difference 2, 95% CI 0 to 3, P = 0.01; and Motor Club assessment, median difference 2, CI 1 to 5, P = 0.01). At 6 months, 45% of the patients treated with home physiotherapy were able to walk outside on uneven ground and slopes compared with 23% of the patients attending day hospitals (P = 0.03). 21% of patients treated with home physiotherapy were receiving treatment at 6 months compared with 52% of day-hospital patients (P = 0.002). {The absolute risk reduction of 31% means that 4 patients would need to be treated with home physiotherapy (rather than attend day hospitals) to prevent 1 additional patient from the need for treatment at 6 months, CI 2 to 8; the relative risk reduction was 59%, CI 29% to 77%.}* The home physiotherapy group received fewer hours of therapy time overall (P < 0.001). No other comparisons were statistically significant.

Conclusion

Home physiotherapy used fewer resources and was more effective than day-hospital attendance in producing functional improvements in stroke patients with persistent disability after hospital discharge.

Source of funding: Chest, Heart and Stroke Association.

Address for article reprint: Dr. J.B. Young, Department of Health Care for the Elderly, St. Luke's Hospital, Bradford BD5 0NA, United Kingdom.

*Numbers calculated from data in article.


Commentary

Stroke, the third leading cause of death in this country, affects 500 000 Americans each year. Many physicians are unaware of the long-term potential for improvement in function in patients with disability after a stroke. The progress is often slow, but, over a period of months to years, many stroke patients are able to show marked improvement in their ability to carry out activities of daily living and may resume a productive life. To reach these goals, professional rehabilitative services (physical, occupational, and speech therapy) are usually required. Provision of these services at an acceptable cost becomes, therefore, a significant medical and social issue.

The study by Young and colleagues is important because, in a methodologically rigorous fashion, it compares the effectiveness of different settings for the provision of such care. After 6 months, the patients receiving physiotherapy in their homes showed greater improvement in functional ability than those treated in a day-hospital setting. The improvement was accomplished with significantly fewer treatment sessions. In addition, almost 80% of the home-treated group were able to stop therapy after 6 months, whereas more than 50% of the day-hospital group were still receiving treatment. One reason why the patients in the home program did so well may be that they received a flexible program of care that was better individualized to their needs.

A theoretical advantage of an organized outpatient program is that patients in this setting may socialize more with others and be less subject to depression. This difference was not found; both groups had low levels of social activity, and more than one third of all patients were depressed.

Although this study was done in the United Kingdom, the findings should be generalizable to North America. If confirmed in further studies, expanded home care rehabilitation programs would seem to offer major medical, social, and fiscal benefits in the treatment of stroke patients with residual deficits.

Arthur W. Feinberg, MD
Cornell University Medical CollegeManhasset, New York, USA