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Am Fam Physician. 2004;70(6):1157

Although specialized units and inpatient therapy have been shown to improve outcomes in stroke patients, less is known about the effectiveness of community-based rehabilitation services for these patients after hospital discharge. The British Outpatient Service Trialists group studied outcomes of rehabilitation services provided to stroke patients who had returned home.

They searched electronic databases, professional journals, and reference lists, and also contacted experts to identify relevant studies. The identified studies were rated independently for quality by two reviewers. From more than 4,900 references, 27 trials were identified for potential inclusion in the analysis, but only 14 were eligible for the study. Data were extracted from the eligible studies using a standard data recording form.

The average age of the more than 1,600 patients studied was 70 years, and they generally had mild to moderate disability (Barthel index, 14 to 18 out of 20). In all but two studies, patients were recruited after hospital discharge. The 14 studies had different purposes and designs. Some aimed to compare different forms of therapy, whereas others sought to evaluate therapy against usual care. In the six trials that reported changes in activities of daily living (ADL) scores, the chances of deterioration were significantly lower in patients who received therapy (odds ratio, 0.67). The authors calculate that the absolute reduction in risk of deterioration in the ability to perform ADL was seven per 100 patients receiving therapy. In the 12 studies that addressed dependency in ADL, scores also were improved by an average of about one point on the Barthel index in the therapy group. Significant improvements also were recorded in extended ADL in the nine trials that examined this outcome. Data were insufficient to draw conclusions about the impact of therapy on quality of life, mood, hospital readmission, and admission to long-term care facilities.

The authors conclude that home-based rehabilitation services for stroke survivors are associated with reduced risk of deterioration in ability to perform ADL. Although the gains appear to be modest, further study could indicate specific types of therapy that would be more helpful or subgroups of patients who could benefit the most from such services.

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