1462

Improving Stroke Rehabilitation

A Controlled Study
Lalit Kalra, PhD, MRCP(UK); Penny Dale, MCSP, SRP; Peter Crome, MD, FRCP
Background and Purpose: Assessment of stroke rehabilitation is complicated by the heterogeneity of
patients and settings and by difficulties in disentangling effects of organization from effects of types and
amounts of treatment input.
Methods: A prospective controlled study was undertaken in 245 stroke patients stratified into three
groups according to prognosis and managed on a stroke rehabilitation unit (n = 124) or general medical
wards (n=121). Patients were randomly allocated to either setting 2 weeks after stroke and were
comparable for baseline characteristics.
Results: Patients on general medical wards received more physiotherapy on average (16.27.2 versus
14.33.2 hours; P<.05) but similar amounts of occupational therapy (9.32.8 versus 9.53.2 hours)
compared with stroke unit patients. More time was spent on individual rehabilitation on the stroke unit
compared with general wards (P<.001). Functional abilities at discharge, destination of discharge, and
length of hospital stay in patients with good prognosis were comparable in both settings. Patients with
poor prognosis managed on general wards showed higher mortality (P<.05) and longer hospital stay
(123.248.2 versus 52.319.8 days; P<.OO1), but functional abilities at discharge in survivors were
comparable with those of stroke unit patients. Patients with intermediate prognosis had significantly
better outcome on the stroke unit, with more patients being discharged home (75% versus 52%; P<.OO1),
shorter average length of hospital stay (48.7 17.2 versus 104.628.6 days; P<.001), and better functional
abilities at discharge (P<.05).
Conclusions: Stroke units improve outcome and reduce hospital stay without increasing therapy time.
Their effectiveness may be enhanced by patient selection. (Stroke. 1993;24:1462-1467.)
KEY WoRDs * hospitalization * prognosis * rehabilitation

rganization of rehabilitation is a key consideration in stroke management. Treatment of

stroke on general wards has been criticized
because of poor coordination between disciplines, lack
of planning consistent with patient needs or abilities,
and breakdown of communication between professionals, patients, and carers.' Dissatisfaction with standards
of provision on general medical wards has resulted in
the development of more specific strategies in stroke
management during the last decade.2 Although intensive treatment of stroke patients may be beneficial, the
benefits of stroke intensive care units3 -6 in reducing
mortality and morbidity remain unproven.7.8 There is
some evidence that stroke rehabilitation units may
reduce disability and long-term institutionalization, but
despite several studies to evaluate the benefits of such
units, their effectiveness remains controversial.79 ~14
Several factors contribute to the difficulties in assessing effectiveness of stroke rehabilitation units. Measurement of differences in stroke rehabilitation is complicated because of (1) the heterogeneity of patient
characteristics, (2) failure to stratify for severity of
O

Received February 4, 1993; final revision received April 21,

1993; accepted April 23, 1993.
From the Orpington Stroke Unit, Bromley Hospitals, Bromley
(L.K., P.D.), and the Department of Health Care for the Elderly,
King's College School of Medicine, London (L.K., P.C.), UK.
Correspondence to Dr L. Kalra, Orpington Hospital, Sevenoaks
Rd, Orpington BR6 9JU, UK.

stroke15 (which determines both prognosis as well as the

level of resources needed), (3) the variety of settings in
which stroke is treated, (4) differences in quantity and
quality of treatment received by patients, (5) variation
in resources allocated to stroke management and the
organization of services, (6) difficulties in disentangling
the effects of differing service organizations from the
effects of different types and duration of treatment
received by patients, and (7) difficulties in assessing
objectively the impact of available services or new
developments because of the lack of baseline information and poor quality of data collected in this field.8
The present study is a controlled prospective study
comparing therapy input and outcome in stroke patients, stratified according to expected prognosis, who
were managed either on general wards or a stroke
rehabilitation unit.

Subjects and Methods

Subjects for the study were recruited from 377 stroke
patients admitted to a general hospital during a period
of 18 months. Stroke was defined as acute onset of
neurological deficit lasting more than 24 hours or leading to death, with no apparent cause other than cerebrovascular disease. Patients with first (83%) as well as
recurrent (17%) strokes were included in the study. The
diagnosis of stroke was based on history and clinical
examination. Computed tomographic (CT) scanning
was not routinely undertaken except when indicated by

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Kalra

TABLE 1. Indications for Computed

Tomographic Scan
(1) Doubt about the clinical diagnosis
(a) Unclear history of focal neurological symptoms
(b) Atypical clinical features
(c) Atypical progression of stroke after onset
(2) Patient is <60 years of age with no vascular risk factors
(3) Cerebellar stroke suspected
(4) Subarachnoid hemorrhage suspected
(5) Anticoagulation indicated or already being given
(6) Carotid endarterectomy being considered

defined criteria (Table 1). Eighty-two (22%) of the 377

stroke patients had CT scans.
Because the incidence of stroke increases with age,14
42 (11%) patients with dementia were included in the
study since this frequently complicates stroke rehabilitation in the older age group.16 No attempts were made to
classify dementia patients into multi-infarct or the Alzheimer type because of difficulties in accurately differentiating between the two conditions clinically and their
frequent association. It was presumed that both groups
would be equally disadvantaged in rehabilitation because
of diminished learning abilities. Patients with spaceoccupying lesions, cerebral metastatic disease, low-pressure hydrocephalus, congenital malformations, head injury, or central nervous system (CNS) infections on
clinical or CT evidence were excluded. Although CT
scanning was undertaken in all patients in whom the
clinical diagnosis of stroke was equivocal, the possible
limitation of not having 100% CT scanning is
acknowledged.
Stroke patients were admitted to general medical
wards during the acute phase of their illness for initial
management and stabilization. Of the 377 patients
diagnosed as having stroke, CT scans demonstrated
subdural hematomas in 2 and brain tumors in 7 patients.
Seventy-nine (21%) patients died, and 37 (10%) patients with mild deficits secondary to reversible ischemic
neurological disease were discharged within 2 weeks of
admission.

The remaining 252 survivors at 2 weeks were entered

into the study. Details of age, sex, side of stroke, power
in the arm and leg on the affected side (Medical
Research Council grading),17 hemianopia, dysphasia,
dysphagia, sensory deficits, inattention (visual/sensory),
continence, mobility,18 and Barthel activities of daily
living (ADL) scores'9 were recorded. Cognitive state
was assessed using Hodkinson's abbreviated mental test
score, which is a well-validated 10-item test for memory
and orientation.20,21 The test was conducted on the ward
with the patient responding verbally to questions asked
by the observer. In the presence of dysphasias, patients
were expected to respond appropriately by speech or
signs to spoken or written answers suggested by the
observer.
The 252 patients were standardized for severity of
stroke and expected outcome by stratification into
groups according to prognostic criteria based on clinical
measures of impairment.22 Possible scores ranged from

et

al Patient Selection in Stroke Unit Rehabilitation

1463

TABLE 2. The Orpington Prognostic Scale

Used to Categorize Patients in the Three
Groups Included in the Study
Clinical Features
Motor deficit in arm
MRC grade
5
4

3
1-2
0

Proprioception (eyes closed)

Locates affected thumb
Accurately
Slight difficulty
Finds thumb via arm
Unable to find thumb
Balance
Walks 10 feet without help
Maintains standing position
Maintains sitting position
No sitting balance
Cognition
Mental test score
10
8-9
5-7
0-4

Score

0.4
0.8
1.2
1.6

0.4
0.8
1.2
0

0.4
0.8
1.2

0.4
0.8
1.2

Total score = 1.6+ motor+ proprioception + balance+cognition

MRC indicates Medical Research Council.

1.6 (best prognosis) to 6.8 (worst prognosis) (Table 2).

Three groups were identified: patients with mild to
moderate deficits showing the best prognosis (prognostic score less than 3), patients with moderate to severe
deficits in whom prognosis was intermediate (prognostic
score 3 through 5), and patients with severe or very
severe deficits who had poor prognosis (prognostic score
greater than 5). After stratification, patients were randomly allocated to a 13-bed stroke rehabilitation unit or
continued to be managed on general medical wards
according to existing practices.
Despite different settings, all stroke patients received
nursing care, physiotherapy, and occupational therapy
appropriate to their disability. Input was also provided
by the speech therapists, social workers, and nursing
home placement officer for patients unable to return
home. Progress, therapy, rehabilitation goals, and discharge plans of patients were monitored in multidisciplinary meetings in both settings.
Subjects were followed up from entry to the study
until discharge from the hospital. Objective assessments
for neurological deficit, cognitive function, continence,
mobility, and ADL were undertaken at weekly intervals

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1464

Stroke Vol 24, No 10 October 1993

in both groups. The duration and type of therapy given

to individual stroke patients in both groups was recorded by the physiotherapists and occupational therapists working with the patients. The duration of therapy
was measured in 30-minute time units of face-to-face
contact with the patient. The amount of time devoted to
different types of therapy work within each discipline
was also recorded. Professionals involved in the assessment and day-to-day management of these patients
were unaware of their prognostic scores or expected
outcome.
Primary outcome measures included mortality during
hospital stay, the percentage of patients discharged
home, the percentage of patients discharged to longterm institutional care, and the length of hospital stay.
Because stroke is predominantly a disease of the elderly
in whom destination on discharge may depend on
factors other than stroke,'1123 the Barthel ADL score at
discharge, the change in Barthel ADL score from
inclusion in the study to discharge, and the proportion
of patients with a Barthel ADL score of greater than 11
in each group were also recorded.
The sample size was calculated using a comparison
nomogram24 to include the minimum number of patients in each prognostic group to give the study a 90%
power at 5% significance level for primary outcome
measures (destination of discharge, median discharge
Barthel ADL scores, length of hospital stay) based on
observations in previous studies.22,25 Group homogeneity was analyzed with a x2 test for sex, neurological
deficits, dementia, recurrent strokes, and prognostic
classification in each group. Age on admission, motor
power on affected side, and Barthel ADL scores on
initial assessment were analyzed by the Mann-Whitney
test. Mortality, destination of discharge, differences in
the type of therapy received, and the proportion of
patients with a Barthel ADL score greater than 11 at
discharge in each group were analyzed using the X2 test.
Statistical analysis was not undertaken if any cell had 0
value or if a value of less than 5 was present in more
than 20% of cells. The length of hospital stay, amount of
therapy received, discharge Barthel scores, and change
in Barthel score during rehabilitation were analyzed by
the Mann-Whitney test. The study was approved by the
Bromley Ethics Committee.

Results
Of the 252 patients in the study, 126 were treated on
the stroke rehabilitation unit and 126 on general medical wards. Seven patients (2 from the stroke rehabilitation unit and 5 from general medical wards) were
transferred to other hospitals (residing out of district or
to be closer to relatives) and hence did not complete the
study.
The baseline characteristics of the 124 patients managed on the stroke unit were comparable to the 121
patients treated on general medical wards (Table 3).
Patients with an intermediate prognosis formed the
largest group, accounting for nearly 60% of patients in
both settings. The extent of neurological deficit, mobility, and functional abilities at the initial assessment in
patients treated on the stroke rehabilitation unit were
comparable to those treated on general wards.
Patients treated on general medical wards received
significantly more physiotherapy on average than patients

the stroke rehabilitation unit during their hospital stay

(Table 4). A greater proportion of physiotherapy input on

on

stroke rehabilitation wards was directed toward individual

needs of patients compared with general medical wards
(P<.001). There were no differences in the average
amount of occupational therapy received by patients in
either setting. However, a significantly greater proportion
(P<.001) of time on the stroke rehabilitation unit was
spent on specific needs of individual patients compared
with general medical wards (Table 4).
There were no significant differences in functional
abilities at discharge, destination of discharge, or length of
hospital stay in stroke patients with a good prognosis
(prognostic score less than 3) managed in either setting
(Table 5). One patient managed on general medical wards
required long-term care because of social circumstances
rather than disability (Barthel ADL score of 16).
Although a high mortality was seen in severely disabled patients with poor prognosis (prognostic score
greater than 5) in both settings, a significantly greater
number of patients died on the general medical ward
compared with the stroke rehabilitation unit (Table 5).
Clinical causes of deaths were aspiration pneumonia,
pulmonary embolism, recurrent stroke, and unrelated
myocardial infarction. The functional abilities and the
discharge destination of survivors were, however, comparable between the two groups (Table 5).
The greatest differences between the stroke rehabilitation unit and general medical wards were seen in
stroke patients with intermediate prognosis (prognostic
score 3 through 5). A significantly greater proportion of
patients managed on the stroke rehabilitation unit were
discharged home compared with those on general medical wards. In addition, patients managed on the stroke
unit had significantly better functional abilities at discharge and a shorter length of hospital stay (Table 5).

Discussion
This study, undertaken in stroke patients stratified for
neurological deficit and prognosis, demonstrates that
organized and directed stroke management does lead to
a more rapid recovery of function and more rapid
discharge from the hospital without any major increase
in time allocated by the therapist. Patients with moderately severe deficit and intermediate prognosis appear
to benefit most by stroke unit rehabilitation compared
with those with mild or very severe deficits.
Patients with dementia and recurrent strokes were
not excluded from the study to make the sample more
representative of the stroke population. Mortality
within the first 2 weeks was high in these groups, with
less than 40% of patients in these groups completing the
study and being included in the analysis (Table 3). The
distribution of these patients between the stroke unit
and general medical wards was comparable (Table 3).
The prognostic disadvantage due to dementia or recurrent strokes is reflected by higher Orpington Prognostic
Scale scores,22 and inclusion of such patients in the
study does not compromise its value.
Computed tomography was not undertaken routinely
in this study. The value of CT scanning has been
investigated previously, with the conclusion that it did
not predict or influence functional outcome in stroke
patients.26 28 It may not be possible for every stroke
patient to undergo CT scanning, even in health care

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Kalra et al Patient Selection in Stroke Unit Rehabilitation

1465

TABLE 3. Baseline Characteristics of Stroke Patients on Stroke

Rehabilitation Unit and General Medical Wards at Time of Inclusion
Into Study
SU
P
Clinical Features
GMW
No. of patients
124
121
NS
Age, y (meanSD)
77.811.4
78.612.2
NS
Sex, % female
56
59
NS
Recurrent strokes
14
11
NS
7
Dementia
8
NS
Recurrent stroke and dementia
3
4
NS
Left hemiplegia
59
58
NS
Right hemiplegia
55
51
NS
Brain stem/cerebellar
10
12
NS
Prognostic groups
OPS score <3
31
32
NS
OPS score 3-5
75
71
NS
OPS score >5
18
18
NS
Mean power in affected arm (triceps)*
2.31.7
2.61.2
NS
Mean power in affected leg (quadriceps)*
3.11.4
3.01.6
NS
14
16
NS
Sensory loss
42
Hemianopia
39
NS
54
57
Sensory/visual inattention
NS
26
Dysphasia
23
NS
11
Dysphagia
9
NS
1 (0-3)
Median FAC score (range)
1 (0-3)
5 (0-12)
Median Barthel ADL score (range)
5 (0-14)
NS
32
CT scans
29
NS
SU indicates stroke unit; GMW, general medical wards; OPS, Orpington Prognostic Scale (see
Table 2); FAC, Functional Ambulation Categories; ADL, activities of daily living; CT, computed
tomography; and NS, not significant.
*Medical Research Council grading for power.

systems such as the British National Health Service. It

has been suggested that rapid access to expert clinical
evaluation of neurological deficit with urgent access to
CT scanning and neurosurgical facilities if required may
be a more appropriate strategy in stroke management.8

This approach has been followed in this study with

well-defined criteria for CT scanning after comprehensive clinical appraisal of patients.
A double-blind study was not possible because of the
logistics of separate wards and the nature of intervention. The possibility of bias introduced by observer
preference and staff as well as patient motivation by the
observed positive, or even negative, discrimination by
allocation to the stroke unit must be recognized. These
pitfalls were reduced by "blinding" the nursing and the
therapy staffs to prognostic scores and outcome measures. The broad categories of therapy input were
decided among professionals in advance. Therapists or
clinicians involved in management on the stroke unit did
not provide input to general medical wards and hence
were unable to influence therapy input or outcome in
these settings. Finally, ensuring an even mix of patients
with good as well as poor prognostic expectations in
both settings prevented nihilistic or negative attitudes

among staff or patients in either setting, reinforcing the

validity of the findings of this study.
The conflicting results of previous studies on the
benefits of stroke units using similar outcome measures
may have been due to the type of patients recruited into
these studies. Results of the present study show that
patients with mild deficits achieve independence in
personal ADL regardless of their setting, whereas those
with very severe deficits and poor prognosis do not
regain significant basic functional abilities irrespective
of management on a stroke unit. Although most studies
are controlled for the severity of deficit, there is little
information about the actual proportion of patients with
different levels of disability.7'9-12 Inclusion of a large
proportion of patients at either end of the spectrum
would minimize differences between stroke units and
general wards and may have been responsible for the
negative results in some controlled studies.9"10"12
The difference in mortality among patients with a
poor prognosis between the stroke rehabilitation unit
and general medical wards was an unexpected finding in
this study (Table 5). The possibility of type I error due
to small numbers cannot be excluded because mortality
was not taken into consideration in determination of

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1466

Stroke Vol 24, No 10 October 1993

TABLE 4. Comparison of Therapy Input in Stroke Patients Managed on

Stroke Rehabilitation Unit With Those Managed on General Medical Wards
(n=124)

GMW
(n=121)

14.3+3.2

16.2-+7.2

SU

Therapy Input and Type

Physiotherapy
Mean duration per patient, h*
No. of half-hour sessions spent on
Sitting balance (%)
Standing balance (%)
Transfers (%)
Ambulation (%)
Individual rehabilitationt (%)
Occupational therapy
Mean duration per patient, h*
No. of half-hour sessions spent on
Personal ADL (%)
Kitchen activities (%)
Home visits (%)
Postdischarge follow-up (%)
Individual rehabilitationt (%)

486 (13.7)
720 (20.3)
571 (16.1)

<.05

580 (14.8)
855 (21.8)
596 (15.2)
858 (21.9)

734 (20.7)
1036 (29.2)

1031 (26.3)

<.02t

9.53.2

9.32.8

NS

1430
245
304
106
271

(60.7)
(10.4)
(12.9)
(4.5)
(11.5)

1476
216
333
58
166

(65.6)
(9.6)
(14.8)
(2.6)
(7.4)

<.001t

SU indicates stroke unit; GMW, general medical wards; ADL, activities of daily living; and NS, not
significant.
*Time spent in face-to-face activities with patients, excluding administrative time.
tindividual rehabilitation: time spent on activities aimed at addressing specific needs of individual
patients (eg, specific transfer/washing/dressing techniques, use of aids) identified by therapist or
patient as contributing significantly to discharge to chosen environment.
fLargest determinant of a significant two-sided x 2 test for independent proportions.
to isolate specific components important to overall results.
Despite the general belief that patients on stroke units do
better because of increased therapy input, this was not the
case in the study. In keeping with another study," results
showed that the average duration of therapy input on the
stroke unit was less than that on general medical wards.
The type of treatment, however, differed in that it was
specifically matched to individual patient needs. This may
have contributed significantly to the observed differences

sample size. However, reduction in medium-term mortality on stroke units has been observed elsewhere,7'1
achieving statistical significance in only one other
study.7 This may possibly be due to better management
of swallowing problems and awareness of deep vein
thrombi on stroke units, although no definite conclusions can be drawn from this study.
Several factors may have contributed to the improved
outcome on the stroke rehabilitation unit, and it is difficult

TABLE 5. Outcome According to Prognostic Groups in Patients Treated on Stroke Unit and General
Medical Wards
Prognostic Score <3
SU

GMW

(n=31)

(n=32)

Measure
Mortality
Discharge home
Long-term care
Discharge BADL >11

No.
0
31
0
31

Median discharge BADL*

Median change in BADL*
Length of stay, d (mean+SD)

18
12
13.2+6.7

%
...
100
...
100

No.
0
31
1
32

Prognostic Score 3-5

GMW
SU

...

...

97

NS

3
100

...

NS

14.64.2

NS
NS
NS

18
12

Prognostic Score >5

(n=75)
%
3
75
22
81

No.
2
56
17
61

15
12

48.7+17.2

GMW

(n=71)
No.
3
37
31
42

%
4
52
44

60

13
8
104.6+28.6

SU

P
NS
<.001
<.001
<.05
<.05
<.05
<.001

(n=18)

No.
7
3
8
1

%
39
16
45
6

6
4

(n=18)
No.
12
1
5
0

%
67
6
23
0

6
4

52.3+19.8 123.248.2

SU indicates stroke unit; GMW, general medical wards; BADL, Barthel activities of daily living score; and NS, not significant.
*Barthel score measured in survivors.

tFisher's exact test.

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P
<.05
NSt
NS
...

NS
NS
<.001

Kalra et al Patient Selection in Stroke Unit Rehabilitation

in outcome. Better multidisciplinary coordination with

patients and carers, a positive attitude among nurses,29
and their involvement as informal therapists may be
additionally responsible for improved outcome. The psychological impact of being on the stroke unit may have
also contributed by boosting patients' morale and motivation to achieve greater functional independence. These
interactive effects are highly complex and have not been
assessed in this study.
Because stroke is predominantly a disease of advancing years, assessing outcome of rehabilitation, even in
the short term, presents problems. The number of
patients discharged home is a simplistic measure and
does not take into account other factors that may
influence discharge. To enable a more accurate evaluation of rehabilitation outcome, measures of functional
ability have also been included in this study (Table 5).
Previous experience has shown that patients with Barthel ADL scores greater than 11 require supervision or
intermittent help for walking and self-care and can be
maintained at home.30 The percentage of patients
achieving this functional level was greater than those
discharged home in both settings and appears to be a
better measure of stroke rehabilitation. However, the
effectiveness of stroke rehabilitation cannot be assessed
by one measure in isolation, and it would be more
appropriate to use a combination of measures when
evaluating the effectiveness of strategies in stroke
management.
This study has demonstrated that patient selection can
significantly influence the effectiveness of stroke units.
While it is inconceivable to deny any stroke patient
adequate treatment solely on the basis of severity of
disability, there may be advantages both for the patient
and the hospital service in directing stroke unit resources
toward patients most likely to benefit from such input.31
With the exception of a small group of patients with poor
prognosis in whom mortality may be reduced, rehabilitation on stroke units would be of little benefit to stroke
survivors who would do well or those who would do badly
whatever their setting or therapy input. It appears that the
most appropriate patients for stroke unit rehabilitation
are those with moderately severe deficits and an intermediate prognosis. Identification of this subgroup of patients
can be facilitated by incorporating major determinants of
outcome into a well-defined set of simple but objective
clinical criteria that can be applied in day-to-day hospital
work and by professionals who may not be medically
trained. Several sets of criteria have been suggested.22'32-35
The criteria used in this study incorporate measures of
power, balance, proprioception, and cognitive function
and are recommended for wider use.22230
Well-defined criteria of patient selection can improve
the effectiveness of stroke rehabilitation units, but it will
never be possible to design a single simple mathematical
model that can predict outcome in every single stroke
patient. Hence, selection of patients for stroke unit
rehabilitation needs to remain flexible, depending on
multidisciplinary assessment of patients' needs.
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Improving stroke rehabilitation. A controlled study.

L Kalra, P Dale and P Crome
Stroke. 1993;24:1462-1467
doi: 10.1161/01.STR.24.10.1462
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 1993 American Heart Association, Inc. All rights reserved.
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