Therapy-based rehabilitation services for stroke patients at home.

BACKGROUND Stroke Unit care is now accepted as an effective service model for hospital care, but the effectiveness of outpatient care is less certain. This review focuses on therapy-based rehabilitation services targeted at stroke patients living at home. OBJECTIVES To assess the effects of therapy-based rehabilitation services targeted towards stroke patient resident in the community within one year of stroke onset/ discharge from hospital following stroke. SEARCH STRATEGY We searched the Cochrane Stroke Group Trials Register (last searched November 2001). In addition we searched the following electronic databases: the Cochrane Controlled Trials Register (Cochrane Library Issue 4, 2001), MEDLINE (1996 - Nov 2001), EMBASE (1980 - Nov 2001), CINAHL (1983 - Nov 2001), PsycINFO (1967 - Nov 2001), AMED (1985 - Nov 2001), Wilson Social Sciences Abstracts (1984-Nov 2001), Science Citation Index and Social Sciences Citation Index (1981-Nov 2001). Other strategies to ensure identification of all potentially relevant trials included scanning reference lists of relevant articles and original papers, personal communication and hand searching journals. SELECTION CRITERIA All unconfounded, truly randomised controlled trials of stroke patients resident in the community receiving a therapy service intervention, which was compared to conventional or no care. Therapy services were those provided by physiotherapy, occupational therapy, or multidisciplinary staff working with patients primarily to improve task-orientated behaviour (e.g. walking, dressing) and hence increase activity and participation. DATA COLLECTION AND ANALYSIS Two reviewers independently selected trials and extracted data on a number of prespecified outcomes. The primary outcomes were the proportion of patients who had deteriorated or were dependent in personal activities of daily living and performance in personal activities of daily living at the end of follow-up. MAIN RESULTS We identified a heterogeneous group of 14 trials including 1617 patients. Therapy-based rehabilitation services reduced the odds of a poor outcome (Peto odds ratio 0.72 (95% CI 0.57 to 0.92; P = 0.009) and increased personal activity of daily living scores (standardised mean difference 0.14 (95% CI 0.02 to 0.25; P = 0.02). For every 100 stroke patients resident in the community receiving therapy-based rehabilitation services, 7 (95% CI 2 to 11) patients would be spared a poor outcome, assuming 37.5% would have had a poor outcome with no treatment. REVIEWER'S CONCLUSIONS Therapy-based rehabilitation services targeted towards stroke patients living at home appear to improve independence in personal activities of daily living. However, the evidence is derived from a review of heterogeneous interventions and therefore further exploration of the interventions is justifiable.