early physical activity in comprehensive stroke unit...

EARLY PHYSICAL ACTIVITY

IN COMPREHENSIVE STROKE UNIT CARE

Tanya Narelle West

Graduate Diploma (Neurological Rehabilitation) Bachelor of Science (Physiotherapy)

Bachelor of Science (Human Movement)

A thesis submitted in total fulfilment of the requirements for the degree of

Master of Applied Science

Department of Physiotherapy

School of Allied Health

Faculty of Health Sciences

La Trobe University Bundoora, Victoria 3086

Australia

December, 2012

TABLE OF CONTENTS

LIST OF TABLES ...........................................................................................................vii

LIST OF FIGURES ....................................................................................................... viii

SUMMARY OF THESIS ..................................................................................................x

STATEMENT OF AUTHORSHIP .................................................................................xi

ACKNOWLEDGEMENTS ............................................................................................xii

CHAPTER 1

Introduction .....................................................................................................................1

1.1 Stroke unit care........................................................................................................2

1.2 Early physical activity after stroke..........................................................................3

1.3 Aims of thesis..........................................................................................................4

1.4 Hypotheses ..............................................................................................................5

1.5 References ...............................................................................................................5

CHAPTER 2

How do comprehensive and acute stroke units differ? ................................................10

2.1 Abstract .................................................................................................................11

2.2 Introduction ...........................................................................................................12

2.3 Methods.................................................................................................................12

2.3.1 Literature search and selection ......................................................................12

2.3.2 Data extraction and analysis ..........................................................................13

2.4 Findings.................................................................................................................14

2.4.1 Admission and discharge policies...................................................................17

2.4.2 Personnel, multidisciplinary policies and training.........................................17

2.4.3 Assessment, investigations and monitoring ....................................................18

2.4.4 Stroke management, secondary prevention and treatment of complications..21

2.4.5 Rehabilitation and mobilisation policies ........................................................23

2.4.6 Patient and carer involvement ........................................................................23

2.5 Discussion .............................................................................................................23

2.6 Conclusion.............................................................................................................26

2.7 References .............................................................................................................27

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CHAPTER 3

Physical activity in hospitalised stroke patients............................................................31

1. Introduction .............................................................................................................32

2. Methods...................................................................................................................32

2.1 Literature search................................................................................................32

2.2 Selection of literature.........................................................................................33

2.3 Data extraction and analysis .............................................................................33

3. Results .....................................................................................................................33

3.1 General patient activity......................................................................................34

3.1.1 Activity monitoring method .........................................................................34

3.1.2 Participants monitored ................................................................................35

3.1.3 Care settings ................................................................................................35

3.1.4 Physical activity...........................................................................................35

3.1.5 People present .............................................................................................36

3.1.6 Patient location............................................................................................37

3.1.7 Organisation of care and time after stroke .................................................37

3.2 Therapy specific activity ....................................................................................37

3.2.1 Activity monitoring methods ........................................................................37

3.2.2 Participants monitored ................................................................................38

3.2.3 Therapy settings...........................................................................................38

3.2.4 Therapy intensity .........................................................................................38

3.2.5 Therapy activity ...........................................................................................39

3.2.6 Upper limb therapy......................................................................................39

4. Discussion ...............................................................................................................39

5. Conclusions .............................................................................................................42

References ...................................................................................................................43

CHAPTER 4

What, where, who and when: activity patterns of acute stroke patients managed in a

rehabilitation focused stroke unit .................................................................................45

4.1 Abstract .................................................................................................................46

4.2 Introduction ...........................................................................................................47

4.3 Method ..................................................................................................................48

4.3.1 Study design and participants .........................................................................48

4.3.2 Behavioural mapping ......................................................................................48

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4.3.3 Therapist report ..............................................................................................49

4.3.4 Commencement of physical activity................................................................49

4.3.5 Patient characteristics ....................................................................................49

4.3.6 Data analysis...................................................................................................50

4.4 Results ...................................................................................................................50


4.4.2 Physical activity ..............................................................................................52

4.4.3 People present and location of activity...........................................................52

4.4.4. Therapy activity .............................................................................................54

4.4.5 First mobilisation out of bed...........................................................................55

4.5 Discussion .............................................................................................................56

4.6 Clinical messages ..................................................................................................59

4.7 References .............................................................................................................60

CHAPTER 5

Early physical activity after stroke: a comparative study of acute and comprehensive

stroke unit care ..............................................................................................................63

5.1 Introduction ...........................................................................................................64

5.2 Methods.................................................................................................................64

5.2.1 Study design, setting and participants ............................................................64

5.2.2 Behavioural mapping ......................................................................................65

5.2.3 Therapist report ..............................................................................................66

5.2.4 First mobilisation............................................................................................66


5.2.6 Patient discharge ............................................................................................66

5.2.7 Ethics...............................................................................................................67

5.2.8 Data analysis ..................................................................................................67

5.3 Results ...................................................................................................................68


5.3.2 Behavioural mapping data..............................................................................70

5.3.2.1 Physical activity........................................................................................70

5.3.2.2 Location ....................................................................................................70

5.3.2.3 People Present ..........................................................................................70

5.3.3 Therapist report data ......................................................................................72

5.3.4 First mobilisation data....................................................................................72

iv

5.3.5 Discharge data................................................................................................73

5.4 Discussion .............................................................................................................74

5.5 Conclusion.............................................................................................................77

5.6 References .............................................................................................................78

CHAPTER 6

Discussion and Conclusions..........................................................................................80

6.1 Main findings ........................................................................................................80

6.2 Clinical implications .............................................................................................81

6.2.1 Stroke unit model of care ................................................................................81

6.2.2 Increasing early physical activity after stroke ................................................81

6.3 Strengths and limitations .......................................................................................85

6.4 Suggestions for future research .............................................................................87

6.4.1 Stroke unit care ...............................................................................................87

6.4.2 Early physical activity after stroke .................................................................88

6.5 Conclusions ...........................................................................................................88

6.6 References .............................................................................................................89

APPENDICES

APPENDIX A: Ethics approval - Royal Perth Hospital................................................94

APPENDIX B: Ethics approval - Austin Hospital ........................................................95

APPENDIX C: Ethics approval - La Trobe University, Faculty of Health Sciences....96

APPENDIX D: Participant information and consent form, Royal Perth Hospital ........97

APPENDIX E: Person responsible information and consent form, Royal Perth Hospital

............................................................................................................100

APPENDIX F: Participant information and consent form, Austin Hospital ..............103

APPENDIX G: Person responsible information and consent form, Austin Hospital..108

APPENDIX H: Observed motor activity case report form..........................................113

APPENDIX I: Patient demographics case report form..............................................114

APPENDIX J: Mobility scale for acute stroke...........................................................118

APPENDIX K: Therapy form .....................................................................................119

APPENDIX L: Statement from co-authors confirming the authorship contribution of

the masters candidate (review paper – chapter 2) ..............................120

APPENDIX M: Statement from co-authors confirming the authorship contribution of

the masters candidate (systematic review paper – chapter 3) ............121

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APPENDIX N: Statement from co-authors confirming the authorship contribution of

the masters candidate (observational study – chapter 4)....................122

APPENDIX O: Stroke unit location for included studies in literature review of stroke

unit models of care (chapter 2) ..........................................................123

APPENDIX P: Additional data for amount of therapy in observational study of

comprehensive stroke unit care (chapter 4) .......................................124

vi

LIST OF TABLES

Chapter 2

Table 1: Included publications, study design and patient groups ......................15

Table 2: Data extraction .....................................................................................16

Table 3: Frequency of documentation of complication management in acute

(ASU) vs comprehensive (CSU) stroke unit care ................................22

Chapter 3

Table 1: General patient activity studies ............................................................34

Table 2: Included studies showing number of included patients and reason for

grouping ...............................................................................................35

Table 3: Therapy-specific activity studies .........................................................40

Table 4: Therapy activity patient groups and therapy intensity .........................41

Chapter 4

Table 1: Patient characteristics...........................................................................51

Table 2: Amount of therapy provided................................................................54

Table 3: Time to first mobilisation.....................................................................55

Chapter 5

Table 1: Patient characteristics...........................................................................69

Table 2: Amount of therapy provided in acute (ASU) vs comprehensive (CSU)

stroke unit care .....................................................................................72

Table 3: Time to first mobilisation in acute (ASU) vs comprehensive (CSU)

stroke unit care .....................................................................................73

vii

LIST OF FIGURES

Chapter 2

Figure 1: Results of literature search and reasons for exclusion .........................14

Figure 2: Frequency of documentation of investigations and assessments in acute


Figure 3: Frequency of documentation of investigations, monitoring and

treatment for all papers and for papers published from 2003 to 2011, in

acute (ASU) vs comprehensive (CSU) stroke unit care.......................20

Figure 4: Frequency of documentation of physiological monitoring in acute


Figure 5: Frequency of documentation of stroke management and secondary

prevention in acute (ASU) vs comprehensive (CSU) stroke unit care

..............................................................................................................22

Chapter 3

Figure 1: Physical activity across the day ...........................................................36

Figure 2: Proportion of time spent alone.............................................................37

Figure 3: Patient location.....................................................................................38

Figure 4: Patient activity, people present, and location according to organisation

of care and time after stroke.................................................................39

Figure 5: Therapy activity ...................................................................................42

Figure 6: Upper limb therapy ..............................................................................42

Chapter 4:

Figure 1: Mean (SD) proportion of the day (A) in each physical activity

category, (B) in each location and (C) with different people present ..53

Figure 2: Mean proportion of formal therapy time in each physical activity

category for physiotherapy (PT) and occupational therapy (OT) ........54

Figure 3: Proportion of patients first mobilised by different staff.......................55

viii

Chapter 5:

Figure 1: Patient activity in acute (ASU) vs comprehensive (CSU) stroke unit

care........................................................................................................71

Figure 2: Comparison of discharge destination from acute (ASU) vs

comprehensive (CSU) stroke unit care ................................................74

ix

SUMMARY OF THESIS

Treatment in organised stroke units is advocated for all people affected by stroke and

increased early physical activity is considered a key feature of stroke unit care. However,

it is unclear whether the degree to which early physical activity is promoted is consistent

in different models of stroke unit care. This thesis aims to examine early physical activity

in the comprehensive stroke unit (CSU) and to compare activity in this stroke unit model

to that in an acute stroke unit (ASU).

A review of the stroke unit literature was conducted to identify and differentiate the

components of care in the ASU and CSU models. The findings suggest that there may be

an increased acute medical focus in the ASU model, but a greater focus on early

multidisciplinary rehabilitation in the CSU model.

A second literature review of observational studies was undertaken to examine physical

activity in hospitalised stroke patients. The review indicated that approximately half of

the patient day is spent inactive. Low levels of physical activity appear more common

within 14 days post-stroke and in patients admitted to conventional care, including

general medical wards, elderly care units and general neurology wards.

An observational study was conducted to examine physical activity in patients within 14

days post-stroke admitted to a CSU. Physical activity levels compared favourably to

previous studies investigating early physical activity in conventional care wards and

ASUs.

A comparative study was undertaken to examine differences in early physical activity

after stroke in an ASU and a CSU. Patients in the CSU were more active and more likely

to be discharged directly to home than those in the ASU.

The findings of this thesis demonstrate that early physical activity levels tend to be low in

hospitalised stroke patients. The CSU model of care appears to have a strong emphasis on

multidisciplinary rehabilitation and this emphasis may in part explain the higher levels of

early physical activity in this model.

x

STATEMENT OF AUTHORSHIP

Except where reference is made in the text of the thesis, this thesis contains no material

published elsewhere or extracted in whole or in part from a thesis submitted for the award

of any other degree or diploma. No other person's work has been used without due

acknowledgment in the main text of the thesis. This thesis has not been submitted for the

award of any degree or diploma in any other tertiary institution.

The data collected for this project was collected as part of a larger project titled

Contamination of Standard Care: A Sub-study of AVERT (A Very Early Rehabilitation

Trial) which is being conducted by the AVERT Early Intervention Research Program at

the Florey Neuroscience Institutes. Data was collated in the AVERT Phase III CRF

Database. The study design, data collection methods and the database were developed by

the staff in this program.

Staff and students from the Royal Perth Hospital Physiotherapy Department assisted with

data collection at the Royal Perth Hospital. Staff and students from the AVERT Early

Intervention Research Program assisted with recruitment and data collection at the Austin

Hospital and also provided assistance with database management, including entry and

cleaning of data.

Dr Julie Bernhardt and Professor Peter Langhorne assisted with the revision of Chapter 2

for the purpose of publication. Dr Julie Bernhardt also assisted with the revision of

Chapters 3 and 4 for the purpose of publication. Dr Julie Bernhardt and Associate

Professor Leonid Churilov advised on data analysis for Chapter 5.

The research procedures reported in this thesis were approved by the La Trobe University

Health Sciences Faculty Human Ethics Committee, the Austin Health Human Research

Ethics Committee and the Royal Perth Hospital Ethics Committee.

Signed: Date: 29th November 2012

xi

SJYoung

Text Box

xii

ACKNOWLEDGEMENTS

First and foremost, I would like to thank my supervisor Dr Julie Bernhardt for constantly

sharing her knowledge, wisdom and time throughout my project. Her endless enthusiasm,

support, guidance and encouragement have been invaluable.

Thankyou to all the staff from the AVERT Early Intervention Research Program at the

Florey Neurosciences Institutes who provided me with assistance with the collection,

management and analysis of data for my project. In particular I would like to thank Jan

Chamberlain for her meticulous assistance with data cleaning, Li Chun Quang for

assistance with data extraction, and Associate Professor Leonid Churilov for helping me

to make sense of my data.

Thankyou to the staff and students from the Royal Perth Hospital Physiotherapy

Department who provided me with support and assistance in conducting my research

project. I would also like to thank the many amazing staff from the Royal Perth Hospital

Stroke Unit who have supported, educated and guided me while I have worked in the unit.

Most importantly thankyou to Jacqui Ancliffe, who has been a mentor and an inspiration

since I first entered the world of neurological physiotherapy ten years ago.

I would like to thank all the participants for their involvement in this project.

Finally, a huge thankyou to my family and friends for their endless support and

encouragement. In particular I would like to thank my mum and dad, who have never

quite understood exactly why I wanted to do so much study, but have always been proud

of me anyway. Thankyou to my amazing friends Julie, Melissa, Georga and Di who have

kept me sane and have made me smile when I needed it most. Thankyou to my

wonderful, patient and understanding husband Alex for putting up with me and providing

my own personal IT service every time I ran into computer problems. I cannot put into

words how much I appreciate his love and support. Last of all, thankyou to my gorgeous

children Abby and Zac, who were both born into this project and made life busier, more

challenging and more wonderful all at the same time.

CHAPTER 1

Introduction

Stroke is defined as an acute neurologic dysfunction, with rapid onset, involving focal

areas of the brain [1]. Stroke occurs as a consequence of an interruption of blood supply

to areas of the brain resulting from either the occlusion (ischaemic stroke) or rupture

(haemorrhagic stroke) of a blood vessel. Approximately 85% of strokes are ischaemic

strokes and 15% of strokes are haemorrhagic [2]. Signs and symptoms of stroke include

impairments in strength, coordination, balance, speech and language, swallowing

sensation, perception, cognition, and vision.

In Australia, an estimated 60 000 strokes occur each year [3]. Approximately three

quarters of these are first-ever strokes and one quarter recurrent strokes [4]. The total cost

of stroke is estimated to be more than $2 billion each year [5].

Stroke is the second leading cause of death in Australia behind ischaemic heart disease

[6]. Approximately one in five persons who have a stroke will die within the first month

[4]. Approximately one third of first-ever stroke sufferers will die within the first year [4,

7] and the risk of death remains elevated over the long-term, with more than half dying

within five years and 80% within 10 years [7].

While two-thirds of stroke sufferers are still alive 12 months after a first-ever stroke,

approximately half of these survivors are dependent in basic activities of daily living [8].

Even beyond the first 12 months, a substantial proportion of stroke survivors continue to

experience long-term dependency [9, 10] handicap [11, 12], and poor quality of life [13,

14]. In 2003 an estimated 346 700 people living in Australia had experienced a stroke at

some time in their lives, 12% of which required institutional care [2]. A further 69% of

these stroke survivors were living at home with some form of disability, approximately

half of which needed assistance with health care, household chores, home maintenance,

mobility and transport, and about one-quarter of which needed help with self care,

cognitive or emotional tasks, meal preparation and paperwork [2].

1

1.1 Stroke unit care

The treatment of stroke patients in organised stroke units has been shown to reduce death,

dependency and institutionalisation in an updated meta-analysis of randomised controlled

trials [15]. Furthermore these outcomes have been reproduced in a meta-analysis of

observational studies of stroke unit care [16]. Stroke unit care is defined as an organised

inpatient service, comprised of a multidisciplinary team providing a complex package of

stroke care, which is best delivered within a discrete geographical ward with specialised

nursing staff [15]. The benefits of stroke unit care have been demonstrated for people of

all ages, stroke severities and both genders [15]. These benefits are obtained without an

increase in length of stay [15] and are sustained for as long as ten years post-stroke [17].

Stroke unit care is associated with improved stroke management processes [18, 19] and a

reduction in the frequency of post-stroke complications, in particular immobility related

complications [20]. The reduced mortality produced by stroke unit care is attributable to

fewer deaths caused by these immobility related complications [20, 21]. It has also been

proposed that the reduced institutionalisation and dependency seen with stroke unit care is

a result of more intensive therapy input, increased purposeful activity time,

encouragement of greater involvement of patients and carers, and improvement in patient

motivation and morale [21].

Previous studies suggest that the key features of effective stroke unit care include

coordinated multidisciplinary team care, staff specialisation and education in stroke

management, regular formal and informal team communication, early comprehensive

assessment, active management of physiological abnormalities, early mobilisation and

avoidance of bed rest, early planning of rehabilitation and discharge needs, and

encouragement of patient and carer involvement in the recovery process [22, 23].

However these studies are based on trials published more than 10 years ago and which

mostly investigated stroke units which included a period of rehabilitation. Therefore these

characteristics may not accurately reflect the current stroke unit practices. As the concept

of stroke unit care has evolved different models have emerged, incorporating new

treatments and technologies. Two common models of stroke unit care for acute stroke are

the acute stroke unit (ASU) and the comprehensive stroke unit (CSU). The Stroke Unit

Trialists Collaboration defines the ASU as a unit to which patients are admitted acutely

and discharged early (usually within seven days), and which may include intensive

monitoring, high nurse to patient ratios and the potential for life support [15]. Conversely

2

the CSU is defined as a unit that combines acute care and rehabilitation, admitting

patients acutely but also providing a period of rehabilitation if required [15]. Further

research is required to examine the underlying components of stroke care and to directly

compare different stroke unit models [15].

1.2 Early physical activity after stroke

The inclusion of early mobilisation as a key feature of effective stroke unit care, and the

success of stroke unit care in reducing immobility related complications, provides indirect

evidence to support early physical activity after stroke [24]. The early commencement of

physical activity is recommended in stroke guidelines [3, 25, 26]. However the concept of

early mobilisation after stroke is often poorly defined in the current literature and there is

a lack of consensus concerning the timing, frequency, duration, intensity and nature of

activities involved in this intervention [27].

While specific parameters have not yet been clearly established for early physical activity

after stroke, research conducted in the post-acute phase suggests that improved outcomes

are achieved with an increased amount of activity [28], which is commenced earlier [29],

and involves the practice of higher level, functional tasks such as standing and walking

[29, 30]. In accordance with this research, favourable outcomes have been reported for

stroke unit care in which early mobilisation is defined as getting the patient out of bed

within 24 hours of stroke, regardless of stroke type, and thereafter continuing the frequent

practice of functional, out-of-bed activities until discharge [31]. However, few high-

quality clinical trials have been conducted for this intervention [32] and in a survey of

health professionals working with stroke patients, 60% were found to have concerns

regarding this approach to early mobilisation, including nearly one quarter who believed

it may be harmful, particularly in the case of haemorrhagic stroke [33].

A more conservative approach to early activity after stroke has been advocated by some

clinicians, involving bed rest, gradual elevation of the head and bed exercises for up to

three days post-stroke, before activity out of bed is commenced [34, 35]. This approach

has been based on concerns that the upright position will reduce blood pressure and

cerebral blood flow, resulting in greater damage to the ischaemic penumbra early after

stroke [34, 35]. However, previous studies have shown that moving to an upright position

within the first three days after stroke is more likely to increase, rather than decrease

blood pressure [36, 37] and that this increase in blood pressure may be associated with an

3

improved outcome [36]. Furthermore, there is currently no evidence that early

mobilisation out of bed has any negative effect on cerebral perfusion or on clinical

outcome [38].

The safety and feasibility of commencing increased activity out of bed within 24 hours of

stroke has been established in one small randomised controlled trial [39]. Further analyses

from this trial have demonstrated that this intervention accelerates the return to unassisted

walking [40], reduces the incidence of depression early after stroke [41] and improves

long-term quality of life in relation to independent living [42]. In addition, the findings of

an economic evaluation conducted alongside this trial indicate that early mobilisation may

reduce the cost of stroke [43]. In another small randomised controlled trial involving a

similar early mobilisation procedure a reduction in complications was found in the first

five days post-stroke [44]. A large multi-centre randomised controlled trial investigating

early mobilisation is currently underway and will allow a more comprehensive analysis of

this intervention [45].

Given the emerging literature to support increased early physical activity, there is a need

to identify current practice with regard to the timing, amount and nature of physical

activity undertaken by acute stroke patients, and to identify mechanisms that may

promote increased physical activity early after stroke.

1.3 Aims of thesis

The purpose of this thesis was to examine early physical activity in the CSU model of

care and to determine whether early physical activity differs between the CSU and

ASU. The specific aims of this research project were to:

1. identify and differentiate the key components of care in the CSU and ASU

models of care

2. identify the amount and type of physical activity undertaken by hospitalised

stroke patients

3. describe the physical activity undertaken by patients within 14 days post-stroke in

a CSU

4. compare early physical activity in a CSU and an ASU

4

To achieve these aims a review of descriptive literature was conducted to identify the key

features of care in the ASU and CSU models. The details of this review are described in

Chapter 2. A second literature review of observational studies was conducted to

determine what is currently known about physical activity in hospitalised stroke patients.

This is reported in Chapter 3. Chapter 4 describes an observational study of physical

activity in patients within 14 days post-stroke in a CSU and Chapter 5 reports the results

of a comparative study of these patients with a similar cohort of patients in an ASU.

1.4 Hypotheses

The following hypotheses were tested in this thesis:

1. that components of care likely to promote increased physical activity after stroke

are more commonly incorporated in the CSU model of care than the ASU model

of care

2. that physical activity levels are low in hospitalised stroke patients, particularly

early after stroke

3. that patients admitted to CSU care engage in more early physical activity than

patients admitted to other acute stroke services, including ASU care

1.5 References

1. World Health Organization. Recommendations on stroke prevention, diagnosis,

and therapy. Report of the World Health Organisation on stroke and other

cerebrovascular disorders. Stroke. 1989; 20(10): 1407-1431.

2. Australian Institute of Health and Welfare, Senes S. How we manage stroke in

Australia. AIWH cat. no. CVD 31. Canberra: 2006.

3. National Stroke Foundation. Clinical Guidelines for Stroke Management 2010.

Melbourne: 2010.

4. Thrift AG, Dewey HM, Macdonell RA, McNeil JJ, Donnan GA. Stroke incidence

on the east coast of Australia: the North East Melbourne Stroke Incidence Study

(NEMESIS). Stroke. 2000; 31(9): 2087-2092.

5. Cadilhac DA, Carter R, Thrift AG, Dewey HM. Estimating the long-term costs of

ischemic and hemorrhagic stroke for Australia: new evidence derived from the

North East Melbourne Stroke Incidence Study (NEMESIS). Stroke. 2009; 40(3):

915-921.

6. Australian Bureau of Statistics. 3303.0 Causes of death Australia. Canberra: 2010.

5

7. Hardie K, Hankey GJ, Jamrozik K, Broadhurst RJ, Anderson C. Ten-year survival

after first-ever stroke in the Perth Community Stroke Study. Stroke. 2003; 34(8):

1842-1846.

8. Sturm JW, Dewey HM, Donnan GA, Macdonell RAL, McNeil JJ, Thrift AG.

Handicap after stroke: how does it relate to disability, perception of recovery, and

stroke subtype? Stroke. 2002; 33(3): 762-768.

9. Hankey GJ, Jamrozik K, Broadhurst RJ, Forbes S, Anderson CS. Long-term

disability after first-ever stroke and related prognostic factors in the Perth

Community Stroke Study, 1989-1990. Stroke. 2002; 33(4): 1034-1040.

10. Hardie K, Hankey GJ, Jamrozik K, Broadhurst RJ, Anderson C. Ten-year risk of

first recurrent stroke and disability after first-ever stroke in the Perth Community

Stroke Study. Stroke. 2004; 35(3): 731-735.

11. Gall SL, Dewey HM, Sturm JW, Macdonell RA, Thrift AG. Handicap 5 years

after stroke in the North East Melbourne Stroke Incidence Study. Cerebrovascular

Diseases. 2009; 27(2): 123-130.

12. Sturm JW, Donnan GA, Dewey HM, Macdonell RAL, Gilligan AK, Thrift AG.

Determinants of handicap after stroke. Stroke. 2004; 35(3): 715-720.

13. Paul SL, Sturm JW, Dewey HM, Donnan GA, Macdonell RA, Thrift AG. Long-

term outcome in the North East Melbourne Stroke Incidence Study: predictors of

quality of life at 5 years after stroke. Stroke. 2005; 36(10): 2082-2086.

14. Sturm JW, Donnan GA, Dewey HM, Macdonell RA, Gilligan AK, Srikanth V, et

al. Quality of life after stroke: the North East Melbourne Stroke Incidence Study

(NEMESIS). Stroke. 2004; 35(10): 2340-2345.

15. Stroke Unit Trialists Collaboration. Organised inpatient (stroke unit) care for

stroke. Cochrane Database of Systematic Reviews. 2007; (4): CD000197.

16. Seenan P, Long M, Langhorne P. Stroke units in their natural habitat: systematic

review of observational studies. Stroke. 2007; 38(6): 1886-1892.

17. Indredavik B, Bakke F, Slordahl SA, Rokseth R, Haheim LL. Stroke unit

treatment. 10-year follow-up. Stroke. 1999; 30(8): 1524-1527.

18. Cadilhac DA, Ibrahim J, Pearce DC, Ogden KJ, McNeill J, Davis SM, et al.

Multicenter comparison of processes of care between stroke units and

conventional care wards in Australia. Stroke. 2004; 35(5): 1035-1040.

19. Evans A, Perez I, Harraf F, Melbourn A, Steadman J, Donaldson N, et al. Can

differences in management processes explain different outcomes between stroke

unit and stroke-team care? Lancet. 2001; 358(9293): 1586-1592.

6

20. Govan L, Langhorne P, Weir CJ, Stroke Unit Trialists Collaboration. Does the

prevention of complications explain the survival benefit of organized inpatient

(stroke unit) care?: further analysis of a systematic review. Stroke. 2007; 38(9):

2536-2540.

21. Stroke Unit Trialists Collaboration. How do stroke units improve patient

outcomes? A collaborative systematic review of the randomized trials. Stroke.

1997; 28(11): 2139-2144.

22. Langhorne P, Pollock A, Stroke Unit Trialists Collaboration. What are the

components of effective stroke unit care? Age and Ageing. 2002; 31(5): 365-371.

23. Stroke Unit Trialists Collaboration. Collaborative systematic review of the

randomised trials of organised inpatient (stroke unit) care after stroke. British

Medical Journal. 1997; 314(7088): 1151-1159.

24. Bernhardt J, Dewey H, Thrift A, Donnan G. Inactive and alone: physical activity

within the first 14 days of acute stroke unit care. Stroke. 2004; 35(4): 1005-1009.

25. Intercollegiate Stroke Working Party. National Clinical Guidelines for Stroke. 3rd

ed. London: Royal College of Physicians: 2008.

26. Scottish Intercollegiate Guidelines Network. Management of Patients with Stroke:

Rehabilitation, Prevention and Management of Complications and Discharge

Planning. A National Clinical Guideline. Edinburgh: 2010.

27. Arias M, Smith L. Early mobilization of acute stroke patients. Journal of Clinical

Nursing. 2007; 16(2): 282-288.

28. Kwakkel G, van Peppen R, Wagenaar R, Dauphinee S, Richards C, Ashburn A, et

al. Effects of augmented exercise therapy time after stroke: a meta-analysis.

Stroke. 2004; 35(11): 2529-2539.

29. 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? Archives of Physical Medicine and Rehabilitation. 2005; 86(12

Suppl 2): S101-S114.

30. Van Peppen RPS, Kwakkel G, Wood-Dauphinee S, Hendriks HJM, Van der Wees

PJ, Dekker J. The impact of physical therapy on functional outcomes after stroke:

what's the evidence? Clinical Rehabilitation. 2004; 18(8): 833-862.

31. Indredavik B, Bakke F, Slordahl SA, Rokseth R, Haheim LL. Treatment in a

combined acute and rehabilitation stroke unit: which aspects are most important?

Stroke 1999; 30(5): 917-923.

7

32. Bernhardt J, Thuy MN, Collier JM, Legg LA. Very early versus delayed

mobilisation after stroke. Cochrane Database of Systematic Reviews. 2009; (1):

CD006187.

33. Skarin M, Bernhardt J, Sjöholm A, Nilsson M, Linden T. ‘Better wear out sheets

than shoes’: a survey of 202 stroke professionals' early mobilisation practices and

concerns. International Journal of Stroke. 2011; 6(1): 10-15.

34. Diserens K, Michel P, Bogousslavsky J. Early mobilisation after stroke: review of

the literature. Cerebrovascular Diseases. 2006; 22(2-3): 183-190.

35. Diserens K, Moreira T, Hirt L, Faouzi M, Grujic J, Bieler G, et al. Early

mobilization out of bed after ischaemic stroke reduces severe complications but

not cerebral blood flow: a randomized controlled pilot trial. Clinical

Rehabilitation. 2012; 26(5): 451-459.

36. Aries MJH, Bakker DC, Stewart RE, De Keyser J, Elting JWJ, Thien T, et al.

Exaggerated postural blood pressure rise is related to a favorable outcome in

patients with acute ischemic stroke. Stroke. 2012; 43(1): 92-96.

37. Panayiotou B, Reid J, Fotherby M, Crome P. Orthostatic haemodynamic

responses in acute stroke. Postgraduate Medical Journal. 1999; 75(882): 213-218.

38. Bernhardt J. Very early mobilization following acute stroke: controversies, the

unknowns, and a way forward. Annals of Indian Academy of Neurology. 2008;

11(Suppl): S88-S98.

39. Bernhardt J, Dewey H, Thrift A, Collier J, Donnan G. A very early rehabilitation

trial for stroke (AVERT): phase II safety and feasibility. Stroke. 2008; 39(2): 390-

396.

40. Cumming TB, Thrift AG, Collier JM, Churilov L, Dewey HM, Donnan GA, et al.

Very early mobilization after stroke fast-tracks return to walking: further results

from the phase II AVERT randomized controlled trial. Stroke. 2011; 42(1): 153-

158.

41. Cumming TB, Collier J, Thrift AG, Bernhardt J. The effect of very early

mobilisation after stroke on psychological well-being. Journal of Rehabilitation

Medicine. 2008; 40(8): 609-614.

42. Tyedin K, Cumming TB, Bernhardt J. Quality of life: an important outcome

measure in a trial of very early mobilisation after stroke. Disability and

Rehabilitation. 2010; 32(11): 875-884.

43. Tay-Teo K, Moodie M, Bernhardt J, Thrift A, Collier J, Donnan G, et al.

Economic evaluation alongside a phase II, multi-centre, randomised controlled

8

trial of very early rehabilitation after stroke (AVERT). Cerebrovascular Diseases.

2008; 26(5): 475-481.

44. Langhorne P, Stott D, Knight A, Bernhardt J, Barer D, Watkins C. Very early

rehabilitation or intensive telemetry after stroke: a pilot randomised trial.

Cerebrovascular Diseases. 2010; 29(4): 352-360.

45. Bernhardt J, Dewey H, Collier J, Thrift A, Lindley R, Moodie M, et al. A very

early rehabilitation trial (AVERT). International Journal of Stroke. 2006; 1(3):

169-171.

9

CHAPTER 2

How do comprehensive and acute stroke units differ?

Despite the emergence of a number of different models of stroke unit care, the concept of

stroke unit care is often described only in a very general sense in the literature and

information is lacking regarding the specific characteristics of each of the different stroke

unit models. In this chapter the stroke unit literature is reviewed with the aim of

describing two common models of stroke unit care for acute stroke; the comprehensive

stroke unit (CSU) and the acute stroke unit (ASU). The key features of care specific to the

CSU and the ASU are identified and compared. Of particular importance for this thesis

was the identification of components of care that may promote increased early physical

activity after stroke.

The review reported in this chapter is presented here in its orginal unpublished form. A

modified version of this review has since been published:

West T, Langhorne P, Bernhardt J. How do comprehensive and acute stroke units

differ? A critical review. International Journal of Therapy and Rehabilitation,

2013; 20(1): 41-53.

See Appendix L for the co-authorship contribution statement.

Information regarding the location of the stroke units studied in each of the papers

included in this review is provided in Appendix O.

10

2.1 Abstract

Background: Stroke unit care is advocated for all acute stroke patients. Varying models of

stroke unit care exist and there is a need to identify how these models differ and how

these differences may affect patient outcomes. This review explores the difference

between the comprehensive stroke unit model, which includes rehabilitation, and the

acute stroke unit model, which does not. Content: A review of descriptive information

regarding comprehensive and acute stroke units was performed to determine the

differences in the underlying components of care. Conclusion: While descriptive

information about models of care within the literature is limited, the existing information

suggests that there is a greater acute medical focus in the acute stroke unit model and a

greater multidisciplinary rehabilitation focus, even in the very early stage of care, in the

comprehensive stroke unit model. Further studies that directly compare the outcomes of

patients managed in comprehensive and acute stroke unit models of care, in which the

processes of care are clearly defined, are required.

Key words

stroke, stroke unit, acute care, early rehabilitation, multidisciplinary

11

2.2 Introduction

The treatment of acute stroke patients in organised stroke units is supported by

compelling evidence from an updated meta-analysis of stroke unit clinical trials [1].

Stroke unit care has been defined as an organised inpatient service, comprised of a

multidisciplinary team, providing a complex package of stroke care [1]. Early

rehabilitation, involvement of the patient and family in the rehabilitation process, and

multidisciplinary teamwork have been identified as important components of stroke unit

care, in addition to the medical management of stroke [2, 3]. However there is

considerable variation in the way in which services are delivered across different stroke

units and a number of different models of stroke unit care exist [4, 5].

In Australia, according to a recent audit [6], the most common models of stroke unit care

for acute stroke are the acute stroke unit (ASU) and the comprehensive stroke unit (CSU)

according to the Stroke Unit Trialists Collaboration criteria [1]. The ASU has been

defined as a unit to which patients are admitted acutely and discharged early, and which

may include intensive monitoring, high nurse to patient ratios and the potential for life

support [1]. The CSU is defined as a unit that combines acute care and rehabilitation.

Patients are admitted acutely but also receive rehabilitation that may last for several

weeks if required [1]. However the classification of models of stroke unit care in the

Stroke Unit Trialists Collaboration [1] review heavily relied on clinicians’ descriptions of

their units.

Few trials directly compare the effectiveness of one model of stroke unit care over

another [1, 7, 8], yet this would be valuable. The aim of this study was to review

published literature about stroke units and identify the components of care that may

differentiate ASU and CSU care models.

2.3 Methods

2.3.1 Literature search and selection

Literature was sourced from a search of the Medline, CINAHL, EMBASE, PubMed and

Cochrane Library databases to the end of May 2011. Combinations of the following

search terms were used to locate potentially relevant publications: comprehensive stroke

unit, acute stroke unit, combined acute and rehabilitation, acute stroke, stroke unit, model

of care, process of care, early rehabilitation, early mobilisation. Further literature was

identified from scans of the reference lists of relevant articles and liaison with colleagues.

12

A wide range of English-language publications were searched including review articles,

clinical trials, observational studies and clinical guidelines and date of publication was not

restricted.

Articles were included if they provided descriptive information specifically regarding an

inpatient stroke unit service which could be classified as either an ASU or a CSU.

Classification of services was based on the broad definitions used by the Stroke Unit

Trialists Collaboration [1]. As such, we categorised units that admitted and managed

patients within seven days of stroke and aimed to discharge within seven days of

admission as ASUs and units that admitted and managed patients within seven days of

stroke, but also provided a period of rehabilitation if required as CSUs.

2.3.2 Data extraction and analysis:

We were interested in the following information about care:

Admission and discharge policies

Personnel, multidisciplinary policies and training

Investigations, assessment and monitoring

Stroke management, secondary prevention and treatment of complications

Rehabilitation and mobilisation policies

Patient and carer involvement

Descriptive information about these six components was extracted by one reviewer. This

information was derived from both service descriptions and measures of care processes in

these services. Where publications provided descriptions for more than one type of

service, only the information for the relevant stroke unit services (ASU and/or CSU) was

extracted for the purpose of the current review.

The proportion of publications reporting specific components of care for the CSU and

ASU models was determined. These proportions provide an indication of the prevalence

of the specific components of care in each of the stroke unit models. Where possible,

admission and discharge timeframes are also reported.

In order to account for changes in the medical management of stroke which have occurred

over more recent years, particularly following the approval of thrombolysis for ischaemic

stroke which in many cases was in 2002, we report the proportion of papers describing

13

particular investigations, monitoring and medical management procedures for all included

papers in total and for papers published after 2002 only.

2.4 Findings

The initial search generated 69 potentially relevant journal articles following a review of

the title and abstract. Forty-six publications were excluded leaving 23 publications that

met the criteria for review and included descriptions of 18 CSUs and nine ASUs (Figure

1). The included publications, study designs and patient groups are reported in Table 1.

Twelve of the included papers were published after 2002 and these papers included

descriptions of eight CSUs and eight ASUs (Table 1).

69 Publications Retrieved

46 Publications Excluded

23 Publications Included

General stroke care described: n=7

CSU Publications: n=14

Group of stroke units described: n=4

ASU Publications: n=5

Model of care not ASU or CSU: n=9

ASU and CSU Publications: n=4

Did not differentiate between stroke unit models: n=7

Unable to determine stroke unit model: n=4

Did not describe components of service: n=4

Unit described in more detail in another publication: n=11 Figure 1. Results of literature search and reasons for exclusion ASU – acute stroke unit; CSU comprehensive stroke unit

14

Table 1. Included publications, study design and patient groups Study Design Patient Groups (n)

CSU

Ang, et al. [9] Retrospective Audit CSU (242)

Bisaillon, et al. [10] Descriptive Review & Audit CSU (411)

Blower & Ali [11] Descriptive Review CSU (not applicable)

Cabral, et al. [12] Randomised Controlled Trial CSU (35) vs GMW (39)

Evans, et al. [13] Randomised Controlled Trial CSU (152) vs MST (153) vs DSC (153)

Fagerberg, et al. [14] Randomised Controlled Trial CSU (166) vs GMW (83)

Garraway, et al. [15] Randomised Controlled Trial CSU (155) vs GMW (156)

Hankey, et al. [16] Randomised Controlled Trial CSU (29) vs GMW (30)

Indredavik, et al. [2] Randomised Controlled Trial CSU (110) vs GMW (110)

Jorgensen, et al. [17] Prospective, Consecutive Cases Study CSU (936) vs GMW (305)

Ma, et al. [18] Randomised Controlled Trial CSU (195) vs GMW (197)

Phillips, et al. [19] Descriptive Review & Audit CSU (1284) vs GMW (1324)

Ronning & Guldvog [20] Controlled Clinical Trial CSU (271) vs GMW (279)

Strand, et al. [21] Controlled Clinical Trial CSU (110) vs GMW (183)

ASU

Berry, et al. [22] Retrospective Audit ASU (116) vs GMW (128)

Chen, et al. [5] Retrospective Audit ASU (533) vs GMW (764)

Di Matteo, et al. [23] Retrospective Audit ASU (51) vs GMW (149)

Hanger, et al. [24] Retrospective Audit ASU (72) vs GMW / Neuro (119)

McCann, et al. [25] Retrospective Audit ASU (40) vs GMW (40)

ASU and CSU

Cavallini, et al. [7] Controlled Clinical Trial ASU (134) vs CSU (134)

Roquer, et al. [26] Prospective, Consecutive Cases Study ASU (215) vs CSU (433)

Silva, et al. [27] Controlled Clinical Trial ASU (321) vs CSU (209)

Sulter, et al. [8] Randomised Controlled Trial ASU (27) vs CSU (27)

ASU – Acute Stroke Unit; CSU – Comprehensive Stroke Unit; GMW - General Medical Ward; MST – Mobile Stroke Team; DSC – Domiciliary Stroke Care; Neuro – Neurology Ward

Table 2 summarises the information that was extracted from each included publication.

Supplementary information for two CSU services [2, 16] was obtained from an additional

literature source [28, 29].

15

Table 2. Data extraction

Ad

mis

sio

n &

Dis

char

ge

Po

licie

s

Per

son

nel

, M

ult

idis

cip

linar

y

Po

lici

es a

nd

Tra

inin

g

Ass

ess

men

t, In

vest

igat

ion

s

& M

on

ito

rin

g

Str

oke

Man

agem

ent,

Sec

on

dar

y P

reve

nti

on

&

Tre

atm

ent

of

Co

mp

lica

tio

ns

Reh

abili

tati

on

& M

ob

ilisa

tio

n

Po

licie

s

Pat

ien

t &

Car

er In

volv

emen

t

CSU

Ang, et al. [9]

Bisaillon, et al. [10]

Blower & Ali [11]

Cabral, et al. [12]

Evans, et al. [13]

Fagerberg, et al. [14]

Garraway, et al. [15]

Hankey, et al. [16]

Indredavik, et al. [2]

Jorgensen, et al. [17]

Ma, et al. [18]

Phillips, et al. [19]

Ronning & Guldvog [20]

Strand, et al. [21]

ASU

Berry, et al. [22]

Chen, et al. [5]

Di Matteo, et al. [23]

Hanger, et al. [24]

McCann, et al. [25]

ASU & CSU

Cavallini, et al. [7]

Roquer, et al. [26]

Silva, et al. [27]

Sulter, et al. [8]

16

2.4.1 Admission and discharge policies

Five (28%) CSU models and four (44%) ASU models included an admission policy that

limited patient admission based on the time from stroke onset. In the CSU models patients

were required to be admitted within an average of 6.0 (range 3-7) days of symptom onset.

In the ASU models admission was required within an average of 3.1 (range 1-7) days of

stroke onset.

Four (22%) CSU and three (33%) ASU models specified a maximum length of stay as

part of their discharge policy. Where specified, this ranged from 14 days to an unlimited

timeframe in the CSUs, and from three to seven days in the ASUs.

Average length of stroke unit stay was reported for 12 (67%) CSU models and ranged

from 9.5 to 55.0 days. Average length of stay was reported for five (55%) ASU models

and ranged from 5.9 to 9.2 days.

In five (28%) CSUs patients were reported to receive all of their inpatient rehabilitation in

the unit. In another seven (39%) CSUs patients could be discharged to another ward or

facility for longer-term inpatient rehabilitation. In six (66%) ASU papers patients were

discharged to another ward or facility if inpatient rehabilitation was required. Discharge

destination was not reported for patients requiring inpatient rehabilitation in the remaining

CSU and ASU articles.

2.4.2 Personnel, multidisciplinary policies and training

Medical staff noted in CSU and ASU models included specialists in general medicine,

stroke and neurology. Rehabilitation physicians and gerontologists were also included in

CSU papers, but not in the ASU papers.

Nursing staff were specifically documented in all but one paper. Nurse to patient ratios of

1:4 and 1:10 were reported for two CSUs, and ratios of 1:3 and 1:6 were reported for two

ASUs. In 22% of both models (CSU n=4, ASU n=2) a specific stroke nurse whose

functions included coordination of the stroke team, facilitation of discharge and liaison

with patients and carers was described.

Allied health professionals were noted in most of the included studies but were more

frequently documented in the CSU papers. The most commonly documented allied health

17

professionals were physiotherapy (CSU n=14 (78%); ASU n=6 (67%)), occupational

therapy (CSU n=12 (67%); ASU n=5 (56%)), speech pathology (CSU n=11 (61%); ASU

n=4 (44%)) and social work (CSU n=5 (27%); ASU n=4 (44%)). Other less frequently

reported professions included dietetics, pharmacy, psychology and neuro-psychology.

A multidisciplinary team approach was emphasised in approximately half of all papers

(CSU n=10 (56%); ASU n=4 (44%)). This included reports of joint assessments, team

goal setting, joint discharge planning, and the integration of all team members in

facilitating patient rehabilitation. Regular formal team meetings were reported in

approximately half of the publications (CSU n=9 (50%); ASU n=5 (56%)), and these

meetings were generally carried out on at least a weekly basis. The provision of staff

education in stroke care or the presence of staff with specialist stroke training or

experience was reported more frequently in the CSU papers (CSU n=12 (67%); ASU n=3

(33%)).

2.4.3 Assessment, investigations and monitoring

Figure 2 shows documented diagnostic investigations and clinical assessments. Computed

tomography (CT) scanning and neurological assessment were reported frequently for both

models. CT scanning was cited more often and was more frequently completed within 48

hours in the ASU papers and this finding was unchanged when only papers published

after 2002 were considered (Figure 3). Neurological assessment was cited more

frequently in the CSU papers. Further investigations and assessments including magnetic

resonance imaging, vascular imaging and chest x-ray were documented in less than half

of the papers for both models of care with the exception of haematology and biochemistry

investigations in the CSU publications and swallow assessment in the ASU papers.

18

12 (67%)

8 (44%)

4 (22%)

8 (44%)

8 (44%)

6 (33%)

11 (61%)

12 (67%)

7 (39%)

7 (39%)

1 (6%)

1 (6%)

1 (6%)

1 (6%)

8 (89%)

7 (78%)

2 (22%)

4 (44%)

2 (22%)

1 (11%)

2 (22%)

5 (56%)

4 (45%)

6 (67%)

1 (11%)

1 (11%)

1 (11%)

1 (11%)

0 10 20 30 40 50 60 70 80 90 100

CT

CT within 48h

MRI

Vascular Imaging

Cardiac Investigations

CXR

Haematology &Biochemistry

Neurological Assessment

Functional Assessment

Swallow Assessment

Skin Integrity

Emotional State

Urine Cultures

Bladder Scans

Frequency reported (%)

ASU

CSU

Figure 2. Frequency of documentation of investigations and assessments in acute (ASU) vs comprehensive (CSU) stroke unit care n (%) shown. CT - computed tomography; 48h - 48 hours; MRI - magnetic resonance imaging; CXR - chest x-ray

19

12 (

67%

)

8 (4

4%) 10

(56

%)

0 (0

%)

2 (1

1%)

11 (

61%

)

5 (6

2%)

4 (5

0%) 5

(62%

)

0 (0

%)

2 (2

5%) 3

(37%

)

8 (8

9%)

7 (

78%

)

4 (4

4%)

4 (4

4%) 5

(56%

)

3 (3

3%)

7 (8

7%

)

6 (7

5%)

4 (5

0%)

4 (5

0%) 5

(62%

)

3 (

37%

)

0

10

20

30

40

50

60

70

80

90

100

CT

CT

with

in 4

8h

EC

G w

ithin

24h

Con

tinuo

us M

onito

ring

Intr

aven

ous

Thr

ombo

lysi

s

Ant

icoa

gula

tion

Fre

qu

en

cy

re

po

rte

d (

%)

CSU - all papers

CSU - 2003-2011

ASU - all papers

ASU - 2003-2011

Figure 3. Frequency of documentation of investigations, monitoring and treatment for all papers and for papers published from 2003 to 2011, in acute (ASU) vs comprehensive (CSU) stroke unit care n (%) shown. CT - computed tomography; 48h - 48 hours; 24h - 24 hours; ECG – echocardiogram

Figure 4 shows the frequency of documentation of physiological monitoring. While

physiological monitoring was reported more frequently in the CSU articles, only the ASU

studies incorporated a period of continuous monitoring of various parameters such as

blood pressure, respiration, oxygenation, temperature and ECG. In contrast, the reported

frequency of routine manual observations of vital signs ranged from four to eight-hourly

in four (22%) CSU studies. These findings were not substantially altered when only

studies published after 2002 were included (Figure 3).

20

3 (1

7%)

4 (2

2%)

5 (2

8%)

1 (6

%)

0 (0

%)

8 (4

4%)10

(56

%)

12 (

67%

)

0 (0

%)

0 (0

%)

2 (2

2%)

2 (2

2%)

4 (4

4%)

4 (4

4%)

4 (4

4%)

4 (4

4%)

0

10

20

30

40

50

60

70

80

90

100

Phy

siol

ogic

alM

onito

ring

EC

G w

ithin

24h

Vita

ls

Con

tinuo

usM

onito

ring

Neu

rolo

gica

lS

tatu

s

Blo

od G

luco

se

Flu

id &

Ele

ctol

ytes

Nut

ritio

nal S

tatu

s

Fre

qu

en

cy

re

po

rte

d (

%)

CSU

ASU

Figure 4. Frequency of documentation of physiological monitoring in acute (ASU) vs comprehensive (CSU) stroke unit care n (%) shown. ECG - echocardiogram; 24h - 24 hours

2.4.4 Stroke management, secondary prevention and treatment of complications

Detailed descriptions of interventions for the management and secondary prevention of

stroke were limited (Figure 5). Selective thrombolysis and antiplatelet therapy for

ischaemic strokes was reported more frequently in the ASU papers than the CSU papers.

Reporting of thrombolysis was only slightly higher in both ASU and CSU papers when

only those published after 2002 were considered (Figure 3). Anticoagulation was reported

more frequently in the CSU papers, but when only post-2002 papers were examined there

was no difference between the two models (Figure 3). Antihypertensive therapy, but with

an avoidance of blood pressure reduction in the very acute stages, was reported in

approximately one third of all papers.

21

11 (

61%

)

6 (3

3%)

7 (3

9%)

6 (3

3%)

2 (1

1%)

3 (3

3%)

2 (2

2%)3

(33%

)

5 (5

6%)

5 (5

6%)

0

10

20

30

40

50

60

70

80

90

100

Intr

aven

ous

Thr

ombo

lysi

s

Ant

ipla

tele

t The

rapy

Ant

ihyp

erte

nsiv

eT

hera

py

Avo

idan

ce o

f BP

redu

ctio

n

Ant

icoa

gula

tion

Fre

qu

en

cy

re

po

rte

d (

%)

CSU

ASU

Figure 5. Frequency of documentation of stroke management & secondary prevention in acute (ASU) vs comprehensive (CSU) stroke unit care n (%) shown. BP - blood pressure

Thromboprophylaxis interventions including low-dose anticoagulants and anti-

thromboembolic stockings were cited in nearly half of the papers for both models of care

(Table 3). Other interventions that addressed the management of complications were cited

in less than a third of all papers (Table 3).

Table 3. Frequency of documentation of complication management in acute (ASU) vs comprehensive (CSU) stroke unit care

CSU ASU

Antipyretics 5 (28%) 2 (22%)

Intravenous Hydration 4 (22%) 2 (22%)

Oxygen Therapy 5 (28%) 2 (22%)

Insulin 4 (22%) 2 (22%)

Antibiotics 3 (17%) 1 (11%)

Thromboprophylaxis 8 (44%) 4 (44%)

Bowel and Bladder Management 3 (17%) 1 (11%)

Positioning, Handling, Pressure Care 3 (17%) 1 (11%)

Management of Low Mood 2 (11%) 1 (11%)

Modified Feeding Strategies 5 (28%) 0 (0%)

22

2.4.5 Rehabilitation and mobilisation policies

Early rehabilitation policies were reported in most publications for both models of care

(CSU n=14 (78%); ASU n=7 (78%)). Few defined what was meant by “early

rehabilitation” however the commencement of some form of rehabilitation within 48

hours was documented in approximately one third of both CSU and ASU studies (CSU

n=7 (39%); ASU n=3 (33%)). In one article a policy of 48 hours bed rest was reported for

patients with carotid occlusion for both a CSU and an ASU [27]. In another article a 48

hour bed rest policy was reported for all patients in both a CSU and an ASU [8].

Overall there appears to be little difference in rehabilitation practices between the CSU

and ASU models. However, two (11%) CSU papers reported that early rehabilitation

should include mobilisation out of bed within 48 hours [2, 20] and two (11%) CSU papers

described an “enriched environment” which promoted early rehabilitation and

mobilisation [2, 13]. These practices of early mobilisation out of bed and provision of an

“enriched environment” were not described in any of the ASU models.

2.4.6 Patient and carer involvement

Strategies to promote patient and carer involvement in the recovery process were reported

in approximately half of all papers (CSU n=10 (56%); ASU n=4 (44%)). Such strategies

included patient and carer education and training, family meetings, encouragement of

active participation in rehabilitation, involvement in goal setting and participation in

discharge planning.

2.5 Discussion

In this review we aimed to describe key features of the ASU and CSU models of care and

to identify differences between these models. It needs to be noted however that while

these two models of care are the most prevalent stroke unit models for acute stroke in

Australia, alternative organised services for acute stroke have emerged internationally as

the concept of stroke unit care has evolved. In the United States organised acute stroke

care has been established in the form of primary stroke centres (PSC) [30] and

comprehensive stroke centres (CSC) [31]. A similar system of “regional stroke units” and

“uberregionale stroke units” has emerged in Germany [32]. Under these systems stroke

services are classified based on the complexity of the interventions and investigations

provided. More recently the concept of a “hub and spoke” model of care has been

23

developed with the establishment of hyper acute stroke units (HASU) in London [33] and

stroke neurology receiving centres (SNRC) in California [34]. In these models, services

are classified on the basis of acuity level, with the aim to expedite investigations and

interventions in the high acuity phase. As a consequence of the variability in the

classification and terminology applied to stroke services it can be difficult to define

exactly what constitutes stroke unit care.

This study was limited by the reliance on the descriptions provided by the authors for

each study. In most papers there tended to be a lack of detail regarding processes of care

and therefore it is possible that the differences between models may have merely reflected

differences in the authors’ descriptions rather than a true difference in clinical practice. A

further limitation is the timeliness of the literature studied, meaning that some of the

papers described care processes which no longer reflect contemporary practice or the

emerging evidence base. Long delays to admission were reported compared to current

clinical practice. A number of papers reported the use of thromboembolic stockings, a

practice no longer supported by the current evidence base [35]. Relatively few papers

reported the use of thrombolysis. To address this issue we repeated a number of our

calculations using only papers published from 2003 onwards, particularly to capture

changes in practice which have occurred following the approval of thrombolysis for

ischaemic stroke, however our findings did not change substantially. A survey or an audit

may be useful future research to provide a more accurate and timely description of the

ASU and CSU models of care.

Despite the limitations of the current study, this review provides a starting point in

identifying the components of care in the ASU and CSU models, and some interesting

trends have been found. The results of our review suggest that ASU care is distinguished

by a greater emphasis on acute medical care with higher levels of nurse staffing, earlier

assessment and investigation, more intensive physiological monitoring and an increased

use of thrombolysis and anti-platelet therapy compared to the CSU. In contrast, the

availability of a period of rehabilitation in the CSU appears to create a greater emphasis

on rehabilitation, even in the acute phase, with greater involvement of gerontologists,

rehabilitation physicians and allied health professionals, increased multidisciplinary staff

education and training, and greater patient and carer participation in rehabilitation.

Reports in a small number of CSU papers of an “enriched environment” to promote early

24

rehabilitation and protocols to mobilise patients out of bed within 48 hours of stroke also

provide evidence of a greater rehabilitation focus in the CSU.

Outside of the current review limited information is available which specifically describes

the essential characteristics of the ASU or CSU models of care. A detailed description of

the components of care in the CSU model was presented in the study by Langhorne, et al.

[3]. This study surveyed 11 stroke units, nine of which were classified as CSUs, to

identify common components of stroke unit care. However the results of this survey were

published in 2002 and therefore may not reflect the prevailing CSU model.

Langhorne, et al. [3] found the common characteristics of CSU care include detailed

investigation and assessment, physiological monitoring and management, early

mobilisation and rehabilitation, multidisciplinary organisation, patient and carer

involvement, and early discharge planning. These characteristics were similar in the

studies in this review.

Detailed information regarding the typical components of the ASU model is available in

two descriptive reports of the acute stroke units in Germany and Austria [36, 37]. The age

of these reports may limit their relevance to the modern day ASU, however both reports

support the focus on rapid diagnostic investigation, multidisciplinary personnel, increased

nurse staffing, intensive monitoring, and short length of stay found in the current review

for the ASU model. While an emphasis on early rehabilitation in the ASU model is

suggested by our review, this does not appear to be associated with the early mobilisation

as suggested by Busse [37], nor is it well defined.

Currently there is insufficient evidence to determine whether the ASU or CSU model is

more effective in the acute management of stroke. Meta-analyses by the Stroke Unit

Trialists Collaboration [1] and Foley, et al. [4] provide stronger evidence for the CSU

model of care. Significant favourable outcomes were found for the CSU model when

compared to care on general medical wards or care by a mobile stroke team. In contrast

the benefits of ASU care when compared to an alternative service were smaller and often

not significant.

There are few well designed studies that directly compare outcomes in the ASU and CSU

models of care. The current review included four studies with a direct comparison of

25

patient outcome [7, 8, 26, 27]. Favourable outcomes for the ASU models with regard to

mortality, disability and length of stay were reported in three studies [7, 8, 26] with no

significant differences found in the remaining study [27]. In three of these studies more

than 100 patients were recruited from each stroke unit model, however none of these

studies were randomised controlled trials [7, 26, 27]. The remaining study was a

randomised controlled trial, however patient numbers were small, with only 27 patients

recruited for each stroke unit model [8]. In all four studies the major component of care

which differentiated the ASU and CSU models was the semi-intensive design including

continuous physiological monitoring in the ASU services. It is interesting to note that

intensive instrumented monitoring is controversial and that the potential for monitoring to

impede early rehabilitation and to deskill clinical staff has been noted [38, 39]. At present

there is little evidence that continuous physiological monitoring in its own right will

improve patient outcomes [40]. Early mobilisation and rehabilitation in a CSU in

Trondheim, Norway has been directly compared with five stroke units in Melbourne,

Australia, four of which were ASU’s [41]. The authors found that early mobilisation was

greater in the Trondheim CSU. It may be possible that, because of increased monitoring

and a reduced focus on rehabilitation, the ASU fails to create the “enriched environment”

which helps to promote early mobilisation and rehabilitation.

2.6 Conclusion

Stroke care models will inevitably vary between countries or between regions within the

same country influenced by a myriad of factors including local resources. As we move

towards national or regional accreditation of stroke units, understanding the key

components of care will be critical. While some aspects of evidence based stroke unit care

are well established (e.g. multidisciplinary teams), other components are less certain.

Further research to help unpack these critical care components would be helpful and

studies that directly compare the relative efficacy of one model of care over another could

serve to guide standards for stroke unit care.

26

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19. Phillips S, Eskes G, Gubitz G. Description and evaluation of an acute stroke unit.

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20. Ronning OM, Guldvog B. Stroke unit versus general medical wards, II:

neurological deficits and activities of daily living: a quasi-randomized controlled

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21. Strand T, Asplund K, Eriksson S, Hagg E, Lithner F, Wester PO. A non-intensive

stroke unit reduces functional disability and the need for long-term hospitalization.

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acute stroke. Nursing Times. 1996; 92(7): 29-32.

23. Di Matteo M, Anderson C, Ratnasabapathy Y, Green G, Tryon K. The acute

stroke unit at Middlemore Hospital: an evaluation in its first year of operation.

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25. McCann L, Groot P, Charnley C, Gardner A. Excellence in regional stroke care:

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26. Roquer J, Rodrguez-Campello A, Gomis M, Jimnez-Conde J, Cuadrado-Godia E,

Vivanco R, et al. Acute stroke unit care and early neurological deterioration in

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27. Silva Y, Puigdemont M, Castellanos M, Serena J, Suer R, Garca M, et al. Semi-

intensive monitoring in acute stroke and long-term outcome. Cerebrovascular

Diseases. 2005; 19(1): 23-30.

28. Hankey GJ, Chan, Deleo D, Ancliffe J, Grille, Stewart-Wynne EG. Descriptions

of stroke unit care - Perth. In: Langhorne P, Dennis M, editors. Stroke Units: An

Evidence Based Approach. London: BMJ Books; 1998. p. 84-92.

29. Indredavik B, Bakke F, Solberg R, Rokseth R, Haaheim LL, Holme I, et al.

Descriptions of stroke unit care - Trondheim. In: Langhorne P, Dennis M, editors.

Stroke Units: An Evidence Based Approach. London: BMJ Books; 1998. p. 84-92.

30. Alberts MJ, Hademenos G, Latchaw RE, Jagoda A, Marler JR, Mayberg MR, et

al. Recommendations for the establishment of primary stroke centers. Journal of

the American Medical Association. 2000; 283(23): 3102-3109.

31. Alberts MJ, Latchaw RE, Selman WR, Shephard T, Hadley MN, Brass LM, et al.

Recommendations for comprehensive stroke centers: a consensus statement from

the Brain Attack Coalition. Stroke. 2005; 36(7): 1597-1616.

32. Ringelstein EB, Busse O, Ritter EA. Current concepts of stroke units in Germany

and Europe. Schweizer Archiv Fuer Neurologie Und Psychiatrie. 2011; 162(4):

155-160.

33. Liu S, Rudd A, Davie C. Hyper acute stroke unit services. Clinical Medicine.

2011; 11(3): 213-214.

34. Cramer SC, Stradling D, Brown DM, Carrillo-Nunez IM, Ciabarra A, Cummings

M, et al. Organization of a United States county system for comprehensive acute

stroke care. Stroke. 2012; 43(4): 1089-1093.

35. Clots Trials Collaboration, Dennis M, Sandercock PA, Reid J, Graham C, Murray

G, et al. Effectiveness of thigh-length graduated compression stockings to reduce

the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre,

randomised controlled trial. Lancet. 2009; 373(9679): 1958-1965.

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36. Brainin M, Steiner M. Acute stroke units in Austria are being set up on a national

level following evidence-based recommendations and structural quality criteria.

Cerebrovascular Diseases. 2003; 15(Suppl 1): 29-32.

37. Busse O. Stroke units and stroke services in Germany. Cerebrovascular Diseases.

2003; 15(Suppl 1): 8-10.

38. Indredavik B. Intensive monitoring should not be the routine. Stroke. 2004; 35(4):

1019-1020.

39. Steiner T. Stroke unit design: intensive monitoring should be a routine procedure.

Stroke. 2004; 35(4): 1018-1019.

40. Langhorne P, on behalf of the Stroke Monitoring Trialists. Continuous automated

physiological monitoring in acute stroke: a meta-analysis of randomised

controlled trials. Proceedings of the 19th European Stroke Conference; 2010 May

25-28; Barcelona, Spain. Cerebrovascular Diseases. 2010; 29(Suppl 2): 75.

41. Bernhardt J, Chitravas N, Meslo I, Thrift A, Indredavik B. Not all stroke units are

the same: a comparison of physical activity patterns in Melbourne, Australia, and

Trondheim, Norway. Stroke. 2008; 39(7): 2059-2065.

30

31

CHAPTER 3

Physical activity in hospitalised stroke patients

This chapter describes a systematic review exploring the physical activity undertaken by

hospitalised stroke patients for comparison with the planned observational study in

chapter 4. Included in this review is an examination of the amount and type of physical

activity carried out across the day, the location and people involved in patient activity, the

amount of therapy received and the nature of activity undertaken during therapy sessions.

The activity undertaken by patients within 14 days post-stroke was of particular interest

for the purpose of this thesis.

The review reported in this chapter has been published and is presented here in its

published form:

West T, Bernhardt J. Physical activity in hospitalised stroke patients. Stroke

Research and Treatment. 2012; 2012 http://dx.doi.org/10.1155/2012/813765.

See Appendix M for the co-authorship contribution statement.

Hindawi Publishing CorporationStroke Research and TreatmentVolume 2012, Article ID 813765, 13 pagesdoi:10.1155/2012/813765

Review Article

Physical Activity in Hospitalised Stroke Patients

Tanya West1, 2 and Julie Bernhardt1, 3

1 School of Health Sciences, La Trobe University, Melbourne, VIC 3086, Australia2 Physiotherapy Department, Royal Perth Hospital, Perth, WA 6000, Australia3 Stroke Division, Florey Neuroscience Institutes (formerly National Stroke Research Institute), Heidelberg Heights, VIC 3084, Australia

Correspondence should be addressed to Tanya West, [email protected]

Received 14 May 2011; Revised 6 July 2011; Accepted 10 July 2011

Academic Editor: Gert Kwakkel

Copyright © 2012 T. West and J. Bernhardt. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

The aim of this paper was to examine the amount and type of physical activity engaged in by people hospitalised after stroke.Method. We systematically reviewed the literature for observational studies describing the physical activity of stroke patients.Results. Behavioural mapping, video recording and therapist report are used to monitor activity levels in hospitalised strokepatients in the 24 included studies. Most of the patient day is spent inactive (median 48.1%, IQR 39.6%–69.3%), alone (median53.7%, IQR 44.2%–60.6%) and in their bedroom (median 56.5%, IQR 45.2%–72.5%). Approximately one hour per day is spentin physiotherapy (median 63.2 minutes, IQR 36.0–79.5) and occupational therapy (median 57.0 minutes, IQR 25.1–58.5). Even informal therapy sessions limited time is spent in moderate to high level physical activity. Low levels of physical activity appear morecommon in patients within 14 days post-stroke and those admitted to conventional care. Conclusions. Physical activity levels arelow in hospitalised stroke patients. Improving the description and classification of post stroke physical activity would enhance ourability to pool data across observational studies. The importance of increasing activity levels and the effectiveness of interventionsto increase physical activity after stroke need to be tested further.

1. Introduction

The most beneficial time to commence rehabilitation andphysical activity after stroke has not yet been established;however improved outcome is associated with earlier initi-ation of rehabilitation [1]. Favourable outcomes have beenreported in stroke units where patients are helped to getout of bed within the first 48 hours of admission andcontinue this frequently until discharge [2, 3], and earlystart to activity is recommended in many guidelines [4–6].However, the practice remains controversial [7, 8] and earlycommencement of physical activity is the subject of clinicaltrials [9–11]. Increased activity in the first six months afterstroke has been found to improve functional outcome [12],but once again the optimal dose of physical activity necessaryto aid recovery after stroke is unclear.

Physical activity is defined here as any bodily actionproduced by the skeletal muscles requiring more energyexpenditure than at rest and therefore can include low leveltasks such as actively maintaining sitting posture in a chair.However the effect of increasing therapy is enhanced if it

involves the practice of higher level, functional activities suchas standing and walking [1, 13].

Given the growing interest in promoting physical activityafter stroke apparent within the literature and in clinicalguidelines [4–6], it is important to understand what activitypatients already undertake following their stroke, boththroughout the day and during therapy time. The purpose ofthis paper was to examine common methods of monitoringactivity in hospitalised stroke patients and summarise theamount and type of physical activity undertaken by strokepatients managed in a range of hospital settings. We werealso interested in where patients were most active and whowas with them during activity.

2. Methods2.1. Literature Search. A search of the EMBASE, Medline,PubMed, AMED, and CINAHL databases was carried outup until the end of October 2010 to ascertain observationalstudies investigating the amount and type of physical activityin hospitalised stroke patients. The search was restricted

32

2 Stroke Research and Treatment

to observational studies as this is a common method ofactivity monitoring used in clinical practice. Although wewere interested in publications investigating physical activityearly after stroke (within 14 days), any study conductedin a hospital-based setting, at any time point in the carecontinuum, could be included. Combinations of the fol-lowing search terms were used to locate potentially relevantstudies: stroke, physical activity, mobilisation, rehabilitation,inpatient, hospital, early, acute, observation, observationalstudy. Further literature was sourced from scans of thereference lists of selected publications. Potential studies weredetermined from review of the title and abstract.

2.2. Selection of Literature. Studies selected for inclusionin the review were prospective observational studies whichemployed methods such as behavioural mapping, therapistreport, or video recording to determine the amount andtype of physical activity undertaken by the stroke patients.Patients could be admitted to any inpatient service thatmanaged stroke patients, including general medical wards,aged care units, neurology wards, mixed rehabilitation wards,and stroke units (acute, comprehensive, or rehabilitation).

Publications were included in the review if they describedthe physical activity undertaken either throughout the entireday or, alternatively, during formal therapy time alone.Publications in which only the amount of total therapy timeand not the type of activity undertaken was reported wereexcluded.

2.3. Data Extraction and Analysis. The type of activityreported from each study was categorised as either generalpatient activity or therapy-specific activity. For studies thatreported general patient activity we extracted data regardingpatient activity undertaken throughout the day. For studiesthat investigated therapy-specific activity only we extracteddata on the patient’s activity during formal therapy sessionsonly. As the focus of this paper was on physical activity,only records from physiotherapy and occupational therapysessions were obtained for the therapy-specific data, sincethese disciplines are known to concentrate more on physicalfunction.

Data extracted from the included publications regard-ing the type of activity undertaken by stroke patientswas grouped under four categories reflecting the physicaldemands of the activity.

(i) Nil physical activity: sleeping and other nontherapeu-tic activities while resting in bed including passiverecreation such as reading, watching TV, talking, andeating.

(ii) Low physical activity: including sitting supported outof bed and self-care.

(iii) Moderate physical activity: including sitting unsup-ported and transferring without hoist equipment.

(iv) High physical activity: including activities involvingstanding and walking.

The amount of time spent in different types of activitieswas extracted and calculated as a proportion of total obser-vation time for each individual study. For the general patientactivity studies the locations in which these activities tookplace and the people present when they occurred was alsoextracted and expressed as a proportion of observation time.In the therapy-specific activity studies we determined theminutes of therapy per session and minutes of therapy perday. Wherever possible we extracted information about thestudy settings, patient characteristics, and study methods andprocedures. To summarise data across studies we calculatedmedians and 25th and 75th percentiles (IQR).

We further categorised studies into hospital setting (gen-eral rehabilitation, stroke units, or conventional care) andtime of observation (<14 days). General rehabilitation unitswere defined as units which provided only rehabilitation(not acute care) for both stroke and nonstroke diagnoses.This included mixed rehabilitation wards that accepted bothneurological and nonneurological conditions.

Stroke unit care was defined as a geographically discreteunit which only admitted stroke patients. This includedstroke rehabilitation wards for patients transferred fromacute care usually at least one to two weeks poststroke,acute stroke wards which provided only acute care forpatients usually within one to two weeks poststroke, andcomprehensive stroke wards which combined both acute careand rehabilitation.

Conventional care units included any acute service whichadmitted both stroke and nonstroke diagnoses. This includedgeneral medical wards which could admit a range of medicalconditions, elderly care units which specifically admittedelderly patients with various medical conditions, or generalneurology wards which admitted patients with a range ofneurological diagnoses.

Again, data were summarised across studies and mediansand 25th and 75th percentiles (IQR) are reported. Statisticalcomparison between settings was not suitable as insufficientdata were available to adequately adjust for important factorsthat may influence activity such as stroke severity.

3. Results

Forty-one potentially relevant studies were identified froma review of the title and abstract. Seventeen of these studieswere excluded, eight of which did not provide sufficientinformation about the type of activity [14–21], five reporteddata already reported in another included publication[1, 22–25], two reported the frequency of different types ofactivities but not the total amount of time [26, 27], one studywas a retrospective study [28], and one study included bothstroke and other neurological diagnoses in the same data set[29].

Of the 24 included publications patient activity wasobserved throughout the day in 15 studies [30–44], andpatient activity was observed in therapy sessions only in 10studies [32, 45–53], with one publication examining patientactivity during both the whole day and in therapy timealone [32]. All included studies reported the proportionof time spent in activities of interest across the whole

33

Stroke Research and Treatment 3

Table 1: General patient activity studies.

Study PatientsOrganisation of care

categoriesBehavioural mapping procedure forindividual patients

Bear-Lehman et al. [30]a Rehabilitation inpatients SU8 am–4 pm, every 30 mins, for 1 weekdayand 1 weekend day

Bernhardt et al. [31] Acute (<14 d) inpatients SU (<14 d)8 am–5 pm, every 10 mins, for 2 consecutiveweekdays

Bernhardt et al. [32]b Acute (<14 d) inpatients SU (<14 d) 8 am–5 pm, every 10 mins, for 1 weekday

De Weerdt et al. [33]c Rehabilitation inpatients SU8.30 am–5.10 pm, every 10 mins, for 1weekday

De Weerdt et al. [34] Rehabilitation inpatients SU

8.30 am–5.10 pm, every 10 mins, for 2weekdays in 1st observation period, 1weekday in 2nd period

De Wit et al. [35]d Rehabilitation inpatients SU7 am–12 pm or 12 pm–5 pm or 5 pm–10 pm,every 10 mins, for 1 weekday

Esmonde et al. [36] Rehabilitation inpatients SU9 am–5 pm, average every 10.8 mins, for 4–9weekdays

Keith [37] Rehabilitation inpatients SU8.15 am–16.15 am every 30 mins, for 5consecutive weekdays

Keith and Cowell [38] Rehabilitation inpatients SU, GRU8.30 am–4.30 pm, every 8 mins, for 2weekdays

Lincoln et al. [39] Rehabilitation inpatients SU8.30 am–4.30 pm, average every 30 mins, for3 consecutive days

Lincoln et al. [40] Rehabilitation Inpatients SU, CCU6 am–2 pm or 8.30 am–4.30pm or2 pm–10 pm, ∼ every 10 mins, for 3 days

Mackey et al. [41]e Rehabilitation inpatients GRU7 am–7 pm, every 10 mins, for 3-4 weekdaysand both weekend days

Pound et al. [42] Inpatients SU, CCU

7.30 am–3.30 pm or 9.30 am–5.30 pm or2.30 pm–10.30 pm, ∼ every 20 mins, for 1weekday

Tinson [43]e Inpatients CCU

9 am–1 pm or 1 pm–5 pm, every 30 mins, for4 weekdays, plus 9 am–5 pm, every 30 mins,for 1 weekend day

Wellwood et al. [44] Acute (<14 d) inpatients SU, CCU (<14 d) 8 am–5 pm, every 10 mins, for 1 weekdayaData for stroke patients only, excludes weekend data; bdata for Trondheim patients only; cdata for Switzerland patients only; dexcludes 5 pm–10 pm data;

eexcludes weekend data; GRU: general rehabilitation unit (includes mixed rehabilitation units); SU: stroke unit (includes acute stroke units, comprehensivestroke units and stroke rehabilitation units); CCU: conventional care unit (includes general medical wards, elderly care units and general neurology wards);<14 d—all patients observed within 14 days of stroke.

study population. Few studies reported standard error ordeviations preventing meta-analysis of these studies.

3.1. General Patient Activity3.1.1. Activity Monitoring Method. All 15 of the includedstudies which examined patient activity throughout the dayused a behavioural mapping method (structured observa-tion) to determine patient activity (Table 1). Ten of the stud-ies reported good interrater reliability with the behaviouralmapping method [30, 31, 33–36, 38, 42, 44]. The remainingstudies did not report reliability, and no studies tested thevalidity of behavioural mapping.

The behavioural mapping procedures varied across stud-ies (Table 1). Days of observation ranged from 1 to 9 days(median 2 days). The time across which mapping was carriedout on observation days ranged from 4 to 12 hours each day(median 8 hours) and the frequency of observations rangedfrom every 8 to 60 mins (median 10 minutes). Most studiesfocused on a normal working day, with observations takingplace on weekdays, commencing between 8 am and 9 am andfinishing between 4 pm and 5.30 pm. However four studiesincluded weekday mapping outside the normal working dayhours [35, 40–42]. Three studies also included mapping onweekends [30, 41, 43] but for the purpose of the current

34


paper weekend data were excluded where possible in orderto allow a more accurate comparison of data across studies.

3.1.2. Participants Monitored. All study participants werehospitalised and in most studies only stroke patients wereexamined. One study compared hospitalised stroke patientswith other neurological and nonneurological diagnoses [30];however only the data for the stroke patients were includedin the current paper.

The reported average or median age of the patientsvaried significantly across the studies, ranging from 52 to80 years. Most of the studies had broad inclusion criteria,suggesting representative patient samples. Comparison ofpatient severity across the studies was difficult as a largerange of measures were used to describe the impairmentor disability of the monitored group. These included theNational Institute of Health Stroke Scale (NIHSS), theBarthel Index, and the Functional Independence Measure(FIM). Most studies appeared to include patients from acrossthe spectrum of stroke severity. In two studies patientsneeded to have a specified minimum impairment levelto be included, thereby excluding very mild patients [35,43]. In two studies very severe patients with low function,decreased consciousness, or ongoing acute medical issueswere excluded [40, 43].

The majority of studies investigated patients who werein the “rehabilitation phase” of their admission. The conceptof a “rehabilitation phase” was not well defined acrossstudies; therefore for the purpose of the current paper it waspresupposed to imply that the patients were considered to bemedically stable, not requiring acute medical intervention,and the primary purpose of ongoing hospitalisation wasrehabilitation. The exact days after stroke at the time ofobservation were only reported in five studies [31, 32, 34,36, 39]. The remainder investigated activity in patientswho were assumed to be between several weeks to severalmonths following stroke. Three studies specifically focusedon acute patients within 14 days of their stroke [31, 32, 44].Two included studies may have investigated both acute andrehabilitation patients; however insufficient information wasprovided to confirm patient acuity [42, 43].

3.1.3. Care Settings. In 85% of the studies physical activitymonitoring was conducted in a stroke unit setting. Thiswas usually a stroke rehabilitation unit, but acute andcomprehensive stroke unit settings were described in asmall number of publications [31, 32, 44]. Some studiesalso investigated physical activity in mixed rehabilitationunits, general medical wards, elderly care units, and generalneurology wards.

In 12 of the included publications activity monitoringwas conducted on several groups of patients who weregrouped based on diagnosis, the period of observation, thesite where the unit was based, the organisation of care, orthe structure of the unit. The data for each separate groupare presented in Table 2. Where the same patient group wasanalysed in another included study these data are reportedonly once. Where the group did not include stroke patientsthese data were excluded leaving a total of 35 patient groups(n = 639) across the 15 included publications.

Table 2: Included studies showing number of included patients andreason for grouping.

Study Patient group n

Bear-Lehman et al. [30] Stroke patients 7

Bernhardt et al. [31] Full sample 58

Bernhardt et al. [32] Trondheim unit 37

De Weerdt et al. [33] Swiss unit 8

De Weerdt et al. [34]1 1st observation period 22

De Weerdt et al. [34]2 2nd observation period 16

De Wit et al. [35]A Belgium unit 40

De Wit et al. [35]B United Kingdom unit 40

De Wit et al. [35]C Switzerland unit 40

De Wit et al. [35]D German unit 40

Esmonde et al. [36] Full Sample 17

Keith [37]1 1st observation period 24

Keith [37]2 2nd observation period 23

Keith & Cowell [38]A Unit A 22

Keith & Cowell [38]B Unit B 21

Keith & Cowell [38]C Unit C 20

Lincoln et al. [39]1 1st observation period 15

Lincoln et al. [39]2 2nd observation period 15

Lincoln et al. [40]A Stroke unit 39

Lincoln et al. [40]B Conventional Care Unit 37

Mackey et al. [41]A Unit A 8

Mackey et al. [41]B Unit B 8

Pound et al. [42]A Stroke Unit 12

Pound et al. [42]B Elderly Care Unit 12

Pound et al. [42]C General Medical Ward 12

Tinson [43] Full sample 15

Wellwood et al. [44]A United Kingdom unit 8

Wellwood et al. [44]B France unit 8

Wellwood et al. [44]C Lithuania unit 8

Wellwood et al. [44]D Russia unit 71,2

denote different time periods of observation; A,B,C,Ddenote differentlocations.

3.1.4. Physical Activity. The activity of interest varied acrossstudies; for example, some authors were interested only inthe time patients spent inactive [30], while others wereinterested in the time patients spent engaged in moderateto high activity only [37]. Classification of the type ofactivity also varied across the included studies. In cases whereactivity over the entire observation period was not reported,or where observation points were missing due to patientsmoving away from the ward, we have grouped these togetherunder the category “unobserved or unreported”. In manystudies it was not possible to distinguish between moderateand high level activities according to our predeterminedcategories. However, in all cases it was clear that the activitiesat least met the moderate category; therefore we elected tocombine moderate and high level activities into the onecategory (moderate-high activity) for reporting purposes.We included participation in formal therapy and self-practice

35


0 10 20 30 40 50 60 70 80 90 100

Proportion of time (%)

Bear-Lehman et al. [30]Bernhardt et al. [31]Bernhardt et al. [32]De Weerdt et al. [33]

De Weerdt et al. [34]1


De Wit et al. [35]A

De Wit et al. [35]B

De Wit et al. [35]C

De Wit et al. [35]D

Esmonde et al. [36]Keith [37]1

Keith [37]2

Keith and Cowell [38]A

Keith and Cowell [38]B

Keith and Cowell [38]C

Lincoln et al. [39]1


Lincoln et al. [40]A

Lincoln et al. [40]B

Mackey et al. [41]A

Mackey et al. [41]B

Pound et al. [42]A

Pound et al. [42]B

Pound et al. [42]C

Tinson [43]Wellwood et al. [44]A

Wellwood et al. [44]B

Wellwood et al. [44]C

Wellwood et al. [44]D

NilLow

Moderate to highUnobserved or unreported

Figure 1: Physical activity across the day. 1 and 2 denote different time periods of observation; A, B, C, and D denote different hospitallocations.

of therapy exercises in this moderate to high level activitycategory.

The proportion of time patients spent in the specifiedactivity categories (nil, low, moderate-high) from each studyis summarised in Figure 1. Patients were inactive or involvedin nontherapeutic activity (nil activity) for between 24.2%and 98.0% of the day, with a median of 48.1% of the dayspent inactive (IQR 39.6% to 69.3%). In comparison muchless time tended to be spent in low physical activity (median27.5%, IQR 13.0% to 32.2%) and even less still in moderateto high physical activity (median 21.0%, IQR 12.8% to27.7%).

3.1.5. People Present. The proportion of time patients spentalone was reported for 14 of the 15 behavioural map-ping studies. On average, patients were alone for approx-imately 50% of each observed day (median 53.7%, IQR44.2%–60.6%) (Figure 2). However time spent alone waslower for two patient groups that took part in group therapyas part of their rehabilitation (17.0% [33] and 24.2% [34]).

Reporting of people present throughout the patient dayvaried across studies. For example, in some cases eachprofession was reported separately, such as nursing orphysiotherapy; in other cases all therapists were grouped

under the classification of “therapists”. At times all staffwere grouped together. We elected to group time with anystaff member together under the heading “all treating staff”.Using this classification, treating staff may include nurses,therapists, doctors, psychologists, social workers, and anyother health professionals. As not every health professionalwas represented in the data reports (e.g., four studiesreported only time spent with therapists and nursing staff[32–34, 42]) the time spent with “all treating staff” in thesestudies is likely to be an underestimate. While time spentwith treating staff ranged from 9.2% to 45.0% across studies,patients spent a median of 24.0% of the day (IQR 17.3%–31.1%) with a member of the clinical team.

Little time was spent with visitors (median 11.0%, IQR9.7%–13.1%), apart from three patient groups which spentapproximately one quarter of the day with visitors. Thisincluded two patient groups admitted to stroke units (23%[42] and 27% [44]) and one patient group admitted toa conventional care unit (25% [44]). Little time was alsospent with other patients across studies (median 5.3%, IQR3.6%–8.9%). However time spent with other patients wasmuch greater for two patient groups which both took part ingroup therapy as part of their rehabilitation (24.0% [33] and32.2% [34]).

36


53.660.4

53.917

51.424.2

62.865.3

52.355.8

42.340.5

54.749.5

53.144.8

64.866.4

6940

3849

6059

4261

5582

0 10 20 30 40 50 60 70 80 90 100


Bear-Lehman et al. [30]Bernhardt et al. [31]Bernhardt et al. [32]De Weerdt et al. [33]



De Wit et al. [35]A

De Wit et al. [35]B

De Wit et al. [35]C

De Wit et al. [35]D

Keith [37]1

Keith [37]2

Keith and Cowell [38]A

Keith and Cowell [38]B

Keith and Cowell [38]C





Mackey et al. [41]A

Mackey et al. [41]B

Pound et al. [42]A

Pound et al. [42]B

Pound et al. [42]CAWellwood et al. [44]

Wellwood et al. [44]B

Wellwood et al. [44]C

Wellwood et al. [44]D

Figure 2: Proportion of time spent alone. 1 and 2 denote different time periods of observation; A, B, C, and D denote different hospitallocations.

3.1.6. Patient Location. Discrepancies in the classificationof patient location again made summarising data difficult.One study included time spent in lounge and dining areaswith time spent in the bedroom [41], and a number ofstudies reported different groupings of locations such asbathrooms, corridors, lounge areas, and dining rooms. Asillustrated in Figure 3 most studies reported that patientsspent a substantial proportion of the day in their bedroom(median 56.5%, IQR 45.2%–72.5%). Very little time wasspent in therapy areas (median 6.4%, IQR 3.4%–14.7%).However in a number of studies it was reported that therapyoften took place in other areas such as the bedroom, hallway,lounge, or off the ward [32, 37, 39].

3.1.7. Organisation of Care and Time after Stroke. Variationin activity, time alone and with others, and location whendata were grouped across the different patient settings andfrom an early time post stroke are presented in Figure 4.Patients within 14 days of their stroke and those managedin conventional care wards appear to spend a greaterproportion of the day inactive (median 65.5%, IQR 46.3%to 87.8% and median 71.0%, IQR 69.3% to 86.3%, resp.).They also appear to spend a greater proportion of timealone (median 57.7%, IQR 54.2% to 60.9% and median60.0%, IQR 59.0% to 69.0%, resp.). Patients admitted toconventional care appeared to spend less time with treatingstaff (median 15.0%, IQR 15.0% to 22.0%) than thoseadmitted to stroke units or general rehabilitation (Figure 2).There did not appear to be any differences in time spent withstaff based on the acuity of stroke. Patients observed within14 days after stroke appeared to spend the most time by their

bedside (median 82.1%, IQR 78.8% to 85.3%). They werealso less frequently observed in therapy areas (Figure 4). Thetwo studies that included details of the time patients within14 days after stroke spent in therapy areas reported figures ofonly 0.2% [31] and 3.9% [32] of the day. Patients admittedunder stroke unit care appeared to spend the least amount oftime bedside (median 49.1%, IQR 35.2% to 62.9%). Patientsadmitted to general rehabilitation units appeared to spendthe most time in the therapy area (median 12.5%, IQR11.8%–13.3%).

3.2. Therapy Specific Activity

3.2.1. Activity Monitoring Methods. Ten studies were iden-tified which examined the physical activity undertaken bypatients specifically during therapy time (Table 3). Variousmethods of observation were used to determine patient activ-ity including behavioural mapping, therapist report, andvideo recording. The number of therapy sessions observedalso varied across studies, ranging from single sessions toall sessions across the length of admission. High interraterreliability was reported for the behavioural mapping methodin two publications [32, 46]. Reliability was not reported inthe remaining behavioural mapping studies, and there wereno reports of the validation of mapping procedures. Videorecording was also reported to have good interrater reliabilityin two studies [48, 51] and good intrarater reliability inanother study [49], but again validity was not tested. Thereliability of the therapist report method was not reported inany publication; however two studies reported that validityhad been previously established for this method [32, 46].

37


Bear-Lehman et al. [30]

Bernhardt et al. [31]


De Weerdt et al. [33]



De Wit et al. [35]A

De Wit et al. [35]B

De Wit et al. [35]C

De Wit et al. [35]D

Esmonde et al. [36]

Keith [37]1

Keith [37]2





Mackey et al. [41]A

Mackey et al. [41]B

Pound et al. [42]A

Pound et al. [42]B

Pound et al. [42]C

BedroomTherapy areaOther or unreported

0 10 20 30 40 50 60 70 80 90 100


∗∗

Figure 3: Patient location. 1 and 2 denote different time periods of observation; A, B, C, and D denote different hospital locations; ∗bedsidetime includes time in lounge and dining areas.

3.2.2. Participants Monitored. Patients were in the “reha-bilitation phase” of their stroke recovery in the majorityof studies; however once again this concept was not welldefined across publications, and the exact time followingstroke at the commencement of observation could only bedetermined from five studies [32, 46, 47, 51, 53]. All studiesexamining rehabilitation patients were carried out in eithermixed rehabilitation units or stroke rehabilitation units. Twostudies examined acute stroke patients (within 14 days afterstroke) in either acute or comprehensive stroke unit settings[32, 46].

The average ages of patients across the therapy-specificstudies ranged from 62.7 to 76.5 years. Stroke severity wasagain difficult to compare across studies due to the varietyof impairment measures used. One study only reported datafor less severe strokes during the second week of admissionto rehabilitation [47] and in another study patients wereexcluded if they were unable to walk at least 14 meters withminimal assistance [49], thereby limiting the data to milderstrokes for these two studies. In contrast De Wit et al. [48]excluded patients with a low level of motor impairment,thereby excluding the less severe strokes.

3.2.3. Therapy Settings. Five studies examined activity dur-ing both occupational therapy and physiotherapy sessions,four studies examined physiotherapy sessions alone, and

one study investigated only occupational therapy sessions(Table 3). For the purpose of the current paper, occupationaltherapy and physiotherapy data are presented separately foreach study, with the exception of one study [45] whereonly pooled therapy data was available (Table 4). Data fromindividual therapy sessions and from group therapy sessionsare also presented separately for one study [49]. Four studiescompared different patient groups based on the site wherethe unit was based or the total length of rehabilitationadmission. Where available, the data for each group ispresented separately in the current paper however patientgroups were excluded where the same group was analysedin a previous study. Sample sizes for each data subset variedfrom 11 to 972 across the included studies.

3.2.4. Therapy Intensity. From the data available in eachpublication therapy intensity was determined in terms ofminutes of therapy per session or minutes of therapy per day(Table 4). In all but one study this was determined separatelyfor occupational therapy or physiotherapy. Median sessiontime was 40.6 (IQR 31.4–45.7) minutes for physiotherapyand 35.8 (IQR 29.8–38.7) minutes for occupational therapy.Patients in the acute phase of stroke tended to have shortertherapy sessions [32, 46] (Table 4). Daily therapy timeshowed considerable variation for physiotherapy (median63.2 minutes, IQR 36.0–79.5) and occupational therapy

38


0

10

20

30

40

50

60

70

80

90

100

No therapeuticactivity

Moderate to high Alone With treating staff Bedroom Therapy area

Pro

port

ion

ofti

me

(%)

Total

General rehabilitation unit

Stroke unit

Conventional care unit

<14 d post-stroke

therapeutic activity

Figure 4: Patient activity, people present, and location according to organisation of care and time after stroke. median and IQR.

(median 57.0 minutes, IQR 25.1–58.5). This variation existedeven across the acute stroke patients alone, with one studyof acute strokes reporting a daily therapy time of only 18.1minutes of physiotherapy and 10.7 minutes of occupationaltherapy [46] compared to another study reporting 57.4minutes per day of physiotherapy [32].

3.2.5. Therapy Activity. The type of physical activity under-taken by stroke patients during therapy time was grouped inthe same activity categories as for general patient activity.Although data were incomplete in some publications andthere were differences in the classification of the type ofactivity across the included studies, in general it was possibleto extract and classify activity into nil, low and moderate-high categories.

Figure 5 illustrates the proportion of time spent inthe different activity levels from each study. Although themajority of reported activity in therapy time was in the lowand moderate to high categories, in four studies patientswere still inactive for more than 20% of therapy time [45,46, 49, 51]. This included one study where patients wererecorded as having nil physical activity for 58% of the therapysession [45]. A greater proportion of time appears to be spentin moderate to high physical activity during physiotherapysessions compared to occupational therapy sessions.

Only one study focused on patients within 14 days oftheir stroke, and the proportion of moderate to high physicalactivity undertaken during therapy time from this study didnot appear to be very different from the other studies [46].

3.2.6. Upper Limb Therapy. In six of the included publi-cations the proportion of therapy time specifically spenttreating the upper limb (Figure 6) was reported. Upper limbtreatment time accounted for a median of 16.0% of therapytime (IQR 6.9%–22.9%).

4. Discussion

This paper has identified a range of methods applied across anumber of hospital settings to monitor physical activity afterstroke. Behavioural mapping, using structured observationat regular intervals throughout the day, was commonlyemployed in these studies and is reported to be reliable.In order to capture “typical” patient activity, all studiescarried out mapping during the “usual working day” whenpatients are most active. In some studies patients were alsomapped on weekends and after hours. Observations weremost frequently carried out every 10 minutes, suggesting thatthis time frame was considered frequent enough to minimisemissed activity, but not so frequent that observations wereno longer feasible. Behavioural mapping was also used tomonitor therapy specific activities; however as observationsonly occur on an intermittent basis, video recording andtherapist report were also used and may provide a moreaccurate means of evaluating physical activity during formaltherapy time.

Despite the similarity in activity monitoring procedures,there was large variation across publications in the way inwhich activity was categorised. Classification of the locations

39


Table 3: Therapy-specific activity studies.

Study Method Procedure Therapy Patient typeOrganisation of

caren

Ada et al. [45]Behaviouralmapping

Every 10 mins for allsessions across 3-4weekdays

PT and OTRehabilitationinpatients

GRU 16

Bernhardt et al.[46]

Behaviouralmapping andtherapist report

Mapping every 10 minsplus therapist report, for allsessions across 2 weekdays

PT and OT Acute inpatients SU 58

Bernhardt et al.[32]a

Behaviouralmapping andtherapist report

Mapping every 10 minsplus therapist report, for allsessions over 1 weekday

PT Acute inpatients SU 37

Bode et al. [47]b Therapist report

All therapy sessions acrossadmission recorded, butdata only reported for 2ndweek


GRU 101

De Wit et al.[48]

Video recordingSingle OT and single PTsession


SU 60

Elson et al. [49] Video recordingSingle individual sessionand single group session

PTRehabilitationinpatients

GRU 15

Jette et al. [50] Therapist reportAll therapy sessions acrossadmission

PTRehabilitationinpatients

GRU 972

Kuys et al. [51]Video recordingand heart ratemonitoring

Single session PTRehabilitationinpatients andoutpatients

GRU 30

Latham et al.[52]

Therapist reportAll therapy sessions acrossadmission

OTRehabilitationinpatient

GRU 954

McNaughtonet al. [53]c Therapist report

All therapy sessions acrossadmission

PT and OTRehabilitationinpatient

GRU 130

aData for Trondheim patients only; bdata for less impaired patients only, during second week of inpatient rehabilitation admission; cdata for New Zealand

patients only; GRU: general rehabilitation unit (includes mixed rehabilitation units); SU: stroke unit (includes acute stroke units, comprehensive stroke unitsand stroke rehabilitation units); OT: occupational therapy; PT: physiotherapy.

in which activity took place, as well as the people withwhom it took place also varied across studies. This variationmade comparison of patient activity across studies difficultand required us to make a number of assumptions whenextracting data. Recreation, relaxation, and leisure activitieswere classified as nontherapeutic in terms of physical activitysince recreation was commonly described as includingactivities such as reading, watching TV, watching others,and social interaction [42, 43]. Furthermore, patients wereassumed to be in sitting when being transported or involvedin self-care, which is commonly the case, and were thereforeclassified in the low activity category. Formal therapy andself-exercise described in five of the general activity studies[33–38] was classified in the moderate to high level activitycategory, since the majority of therapy time was spentwith physiotherapists and occupational therapists who focuslargely on physical function. However, data from the therapy-specific studies suggests that a considerable amount oftherapy may have taken place with the patient involved inlow or even no physical activity. It is not surprising that aproportion of therapy time is spent with patients inactive(during rest) or engaged in low levels of physical activity.The assumption that all ‘formal therapy and self-exercise’was at a moderate to high level is likely to have resulted in asmall overestimate of overall activity across the day. Within

the therapy-specific studies in which therapy content wasoften reported, we classified impairment-focused therapysuch as stretching, passive movements, selective movementfacilitation, strengthening, and balance work as low physicalactivity and therapy described only as functional activityas moderate to high physical activity. This seems a veryreasonable approach to classification of activity withintherapy in the face of poor definition; nevertheless, it is alsopossible that the classification assumptions led to over-orunderestimation of patient activity.

The use of assumptions to help summarise available datais not ideal. It became apparent early in the conduct ofthis paper that there is an urgent need for researchers toprovide clear description of the activities observed, or betterstill, for the development and use of a standard classificationsystem for physical activity categories for people after stroke.Such a system should probably be based to a larger extenton how hard the patients must work to engage in differentlevels of activity and include energy expenditure expressedas METS. However, while such a classification system existsin healthy subjects [54], further research on the energyexpenditure of people with stroke during activity at differentstages in recovery is needed. Until then, activity classification,particularly of observed activity, will continue to rely onclinical judgment.

40


Table 4: Therapy activity patient groups and therapy intensity.

Study Therapy Patient group Setting n Minutes per session Minutes per day

Ada et al. [45] PT and OT Full sample Rehabilitation 16 64.0

Bernhardt et al. [46]—PT PT Full sample Acute 58 24.5 18.1

Bernhardt et al. [46]—OT OT Full sample Acute 58 22.8 10.7

Bernhardt et al. [32] PT Trondheim Rehabilitation 37 27.6 57.4

Bode et al. [47]—2 wks PT PT 2 week admission Rehabilitation 34 69.0

Bode et al. [47]—3 wks PT 3 week admission Rehabilitation 27 93.0



Bode et al. [47]—2 wks OT OT 2 week admission Rehabilitation 34 57.0

Bode et al. [47]—3 wks OT 3 week admission Rehabilitation 27 57.0



De Wit et al. [48]—B, PT PT Belgium Rehabilitation 15 46.0

De Wit et al. [48]—UK, PT United Kingdom Rehabilitation 15 43.0

De Wit et al. [48]—S, PT Switzerland Rehabilitation 15 44.8

De Wit et al. [48]—G, PT Germany Rehabilitation 15 33.0

De Wit et al. [48]—B, OT OT Belgium Rehabilitation 15 36.4

De Wit et al. [48]—UK, OT United Kingdom Rehabilitation 15 35.2

De Wit et al. [48]—S, OT Switzerland Rehabilitation 15 40.4

De Wit et al. [48]—G, OT Germany Rehabilitation 15 28.0

Elson et al. [49]—indiv PT PT Individual therapy Rehabilitation 15 30.9

Elson et al. [49]—group PT Group therapy Rehabilitation 15 52.7

Jette et al. [50] PT Full sample Rehabilitation 972 51.6

Kuys et al. [51] PT Full sample Rehabilitation 30 39.4 39.4

Latham et al. [52] OT Full sample Rehabilitation 954 38.1 41.9

McNaughton et al. [53]—PT PT New Zealand Rehabilitation 130 15.3

McNaughton et al. [53]—OT OT New Zealand Rehabilitation 130 6.9

OT: occupational therapy, PT: physiotherapy.

Regardless of these limitations some consistent trends inpatient activity were revealed across the studies reviewed. Alarge proportion of stroke inpatient time is spent inactiveor involved in nontherapeutic activity. Comparatively littletime appears spent involved in moderate to high levelphysical activities such as standing and walking. Additionallyhospitalised stroke patients tend to spend most of theirtime alone and in their bedroom area. Although few studiesinvestigated patients in the acute phase of their stroke, itappears that this lack of activity and isolation are especiallyprevalent for patients within 14 days of stroke compared tothose at later stages of recovery. The current paper suggeststhat hospitalised stroke patients are involved in an averageof approximately one hour per day of formal physiotherapyand one hour per day of formal occupational therapy. Evenduring this time it was reported in a number of studies thatpatients were involved in little or no physical activity for partof the session. Patients frequently spent less than half theirtherapy time involved in moderate to high physical activitiessuch as standing and walking, and even less time was spenton therapy for the upper limb.

It appears that patient activity may be influenced by theorganisation of care. Patients admitted to conventional careunits such as general medical wards, elderly care units, or

general neurology wards appeared to be inactive, alone, andin their bedroom area for longer than patients admitted tostroke units or general rehabilitation units. Patients admittedto stroke units appeared to spend the most time involved inmoderate to high physical activity and the least time locatedin bedside areas when compared with patients admitted toconventional care or general rehabilitation. These apparentdifferences however may be simply due to case-mix variationacross the different samples studied. Further comparisonacross settings could provide insights into the barriers orfacilitators to activity in different organisational settings.However this would require standard data to be availablefrom each study to allow for adjustment for importantpatient and setting factors that may influence activity. Theabsence of even a common measure of stroke severity acrossstudies hampered further exploration of these data.

Patients did appear to be more active during formaltherapy time, and it is tempting to suggest that increasing thetime spent in formal therapy may help to increase physicalactivity in hospitalised stroke patients. Group therapy maybe one approach to increasing formal therapy time. Patientsparticipating in group therapy were found to be involvedin more formal therapy and more physical activity [33, 34,37, 49] and to spend less time alone [33, 34]; however

41



Nil

Low

Moderate to high

Unobserved or unreported

∗∗

0 10 20 30 40 50 60 70 80 90 100

Ada et al. [45]

Jette et al. [50]

Kuys et al. [51]

Latham et al. [52]

Bernhardt et al. [46]—PT

Bernhardt et al. [46]—OT

Bode et al. [47]—2 wks PT




Bode et al. [47]—2 wks OT




De Wit et al. [48]—PT

De Wit et al. [48]—OT

Elson, et al. [49]—indiv PT

Elson et al. [49]—group PT

McNaughton et al. [53]—PT

McNaughton et al. [53]—OT

Figure 5: Therapy activity. ∗Data pooled across sites by authors of original study.

10.9

21∗

38.4

5.6

22.9

0.9

Ada et al. [45]



Kuys et al. [51]

Latham et al. [52]

0 10 20 30 40 50 60 70 80 90 100Proportion of therapy time (%)

McNaughton et al. [53]—OT

Figure 6: Upper limb therapy. ∗Affected upper limb use acrossphysiotherapy, occupational therapy, and speech therapy time.

the proportion of time spent in high level activities such aswalking was reported to be lower during group therapy thanin individual sessions [49]. More structured therapy sessionswith a formal schedule were also suggested as a means ofincreasing therapy time [35, 37]; however Mackey et al. [41]found that this made no difference to overall patient activity.In reality, we do not know the optimal dose or intensityof activity that stroke patients should engage in duringthe hospitalised phase of their care to help their recovery.Nevertheless, the low levels of physical activity commonlyfound in these studies suggest that more could be done.

Increasing formal therapy time is only one way in whichphysical activity could be improved. Greater involvementof nontherapy staff, particularly nursing staff, in facilitatingpatient activity may help to increase physical activity inhospitalised stroke patients [32, 43]. This may be promotedthrough the education and training of nontherapy staff infacilitating patient activity [32, 40] and through therapistsworking together with other staff [32].

The current paper found that a median of less than onequarter of patient time was spent with treating staff. A num-ber of authors suggest that increasing self-directed patientactivity could be another means of increasing physicalactivity [29, 30, 33, 39, 40, 43]. Greater self-directed activitymay be encouraged with patient education and instructionin self-directed exercises [30, 35] and activity diaries [29,43]. Environmental modifications to promote self-directedactivity are recommended [32, 35–38]. In addition greaterfamily involvement [29, 33, 36, 40, 43] and the introductionof an activities coordinator [29, 39] are also suggested toassist with self-directed activity.

5. Conclusions

Physical activity is commonly monitored in hospitalisedstroke patients using behavioural mapping which is easy to

42


conduct and which provides a rich source of data acrossa day. The use of accelerometers, step counters, and otherdevices is becoming more frequent and may provide moreaccurate monitoring of activity after stroke, although theirreliability, accuracy in very low functioning patients, ease ofuse, and the comfort of patients when wearing the deviceneed to be considered. Unlike accelerometers, observationalso provides the researcher with information about thelocation of patients when they are active and who was withthem during the activity. This paper has shown howeverthat considerable improvements to how activity is describedand classified would greatly improve our ability to compareactivity across populations, settings, or time points in therecovery pathway. This paper has highlighted that manypatients are inactive and alone while in hospital, and while wehave summarised suggestions as to how patient activity canbe increased, the importance of improving activity levels andthe effectiveness of interventions to increase physical activityafter stroke need to be tested further.

Acknowledgment

The Florey Neuroscience Institutes received operation infras-tructure support from the Victorian State Government.

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44

CHAPTER 4

What, where, who and when: activity patterns of acute stroke patients

managed in a rehabilitation focused stroke unit

The findings of the previous chapter indicate that hospitalised stroke patients spend

considerable amounts of time physically inactive, particularly during the acute phase after

stroke. However, the findings of chapter 2 suggest that the comprehensive stroke unit

(CSU) model incorporates components of care which may promote increased physical

activity early after stroke in comparison to other acute care services, such as the acute

stroke unit (ASU). This chapter reports an observational study investigating physical

activity in patients within 14 days post-stroke admitted to a CSU. This chapter describes

the amount and type of physical activity undertaken across the day, the location and

people involved in patient activity, the amount and type of therapy activity and the timing

of commencement of physical activity.

The study reported in this chapter has been submitted for publication to Clinical

Rehabilitation:

West T, Bernhardt J. What, where, who and when: activity patterns of acute

stroke patients managed in a rehabilitation focused stroke unit.

See Appendix K for the co-authorship contribution statement.

The format of this paper has been changed to be consistent with this thesis but the content

remains unaltered.

Data summarising the amount of therapy received is presented in Table 2 of this paper. In

addition to Table 2, the medians and interquartile ranges for this data are presented in

Appendix P.

45

4.1 Abstract

Objective: To describe the physical activity undertaken by patients within 14 days post-

stroke admitted to a comprehensive stroke unit, which incorporates acute care and

rehabilitation. Design: Prospective observational study. Setting: Comprehensive stroke

unit in a metropolitan teaching hospital. Subjects: 130 stroke patients, within 14-days

post-stroke. Main measures: The proportion of the day spent in different activities, with

different people present and in different locations was determined using behavioural

mapping. The amount of formal physiotherapy and occupational therapy received on the

day of observation was determined from therapist reports. Time to first mobilisation out

of bed and who first mobilised the patient was obtained from the medical records.

Results: On average patients spent 45% (SD 25) of the day in some form of physical

activity. Patients spent more than half their day alone and more than three quarters of the

day in the bedroom. On average patients received 58 (SD 34) minutes per day of

physiotherapy and occupational therapy combined. Mean time to first mobilisation out of

bed was 46 (SD 32) hours post-stroke and physiotherapists were most frequently involved

in the first mobilisation. Conclusions: Patients within 14 days post-stroke admitted to a

comprehensive stroke unit spend nearly half the day in some form of physical activity.

While this compares favourably to studies of other acute stroke models, the challenge is

to determine what level of activity best promotes recovery after stroke.

Key words

stroke, early mobilisation, physical activity, observation

46

4.2 Introduction

Current stroke guidelines recommend increased physical activity early after stroke [1-3].

Furthermore, favourable outcomes have been reported for stroke unit care in which

patients commence frequent out of bed activity within 24 hours of stroke [4] and

preliminary evidence to support this intervention has emerged from two small randomised

controlled trials [5-10]. Nevertheless in a previous systematic review we found that

hospitalised stroke patients consistently spend large proportions of the day inactive and

this lack of physical activity appears pronounced within the first 14 days post-stroke [11].

Three of the studies included in this review specifically investigated patients within 14

days post-stroke [12-14] and a median of 65% of the day was spent physically inactive

across the patient groups in these three studies [11]. However, in studies of patients

within 14 days post-stroke managed in a stroke unit that incorporates rehabilitation (a so

called ‘comprehensive stroke unit’ (CSU)) in Trondheim, Norway, patients were found to

spend an average of only 30-40% of the day physically inactive [12, 15].

Unlike acute stroke units (ASUs) which focus primarily on acute care, the CSU combines

acute care with a rehabilitation focus. Patients are admitted acutely but also receive

rehabilitation that may last for several weeks if required [16]. Early physical activity has

been described as a key component of the CSU model of care [4, 17]. In a review of the

literature describing the ASU and CSU models of care we found an emphasis on acute

medical management, increased nurse staffing, early assessment and investigation, and

intensive physiological monitoring in ASU care models. In contrast, CSU care tended to

have a greater emphasis on multidisciplinary teamwork and involvement in rehabilitation,

active participation of the patient and family, and early mobilisation policies [18]. These

underlying features of the CSU may facilitate increased physical activity early after stroke

compared to alternative models of acute stroke care. However, with the exception of the

Trondheim CSU, little information exists regarding early physical activity in CSU care.

There is a need to determine if the level of early physical activity reported in the

Trondheim CSU is replicated in other CSUs.

The purpose of this study was to describe the physical activity undertaken by patients

within 14 days post-stroke admitted to a CSU. The primary aim of the study was to

determine how much physical activity is undertaken by patients within 14 days post-

stroke admitted to a CSU. Secondary aims were to determine where and with whom this

activity took place; the amount of formal therapy received and the level of patient activity

47

during formal therapy; when patients first commenced physical activity out of bed and

who initiated this.

4.3 Method

4.3.1 Study design and participants

This study was a prospective observational study conducted in the 14-bed CSU of the

Royal Perth Hospital, a large metropolitan tertiary hospital in Perth, Western Australia.

Eligible patients were aged 18 years or over, with a diagnosis of stroke, who were

admitted to the stroke unit and were within 14 days of stroke onset. Patients were

excluded from the study if they were receiving palliative care or if discharge was planned

prior to completion of the day of behavioural observation. Ethical approval for this study

was obtained from the Faculty of Health Sciences Human Ethics Committee at La Trobe

University and the Royal Perth Hospital Ethics Committee. Informed consent was

obtained from all participants or a responsible third party where the patient was unable to

provide consent themselves.

4.3.2 Behavioural mapping

Physical activity, location and people present was recorded across the day for each patient

using established standardised behavioural mapping procedures, which have been

previously demonstrated to have high inter-rater reliability [13]. High consistency of

patient behaviour across days has been reported in a previous study [12] therefore patients

were observed for a single working day. Behavioural mapping was carried out over a

nine-hour period between 8am and 5pm when the patients were considered to be most

active. Observations took place at 10-minute intervals with the exception of up to five

randomly scheduled 10-minute rest periods for the observer. To accommodate the desire

to obtain a large sample of patients with a wide range of stroke related disability it was

planned that observation would be undertaken approximately every six to eight weeks. Up

to 10 patients could be mapped on each day of observation. Patients and staff were

informed that patient activity was being monitored, however they were instructed that

they should not alter their usual behaviour. Wherever possible the observer attempted to

remain inconspicuous to avoid influencing behaviour.

48

Physical activity was grouped into the following five categories based on previous

activity definitions [13]:

Nil physical activity: lying in bed inactive

Non-physical activity: passive activities while resting in bed including reading,

watching TV, talking and eating

Low physical activity: sitting supported out of bed, hoist transfers

Moderate physical activity: sitting unsupported, transfers with feet on floor

High physical activity: standing, walking, stair climbing

4.3.3 Therapist report

The amount and type of patient activity undertaken during formal physiotherapy and

occupational therapy sessions on the day of observation was recorded in minutes by the

treating therapists on a recording form. This provided more detailed information about

patient activity during formal therapy sessions. The validity of this method of therapist

report has been established previously [19].

4.3.4 Commencement of physical activity

The time to the patients’ first mobilisation out of bed from both the time of stroke onset

and from the time of hospital admission was derived from the patients’ medical records.

The people involved in this first mobilisation were also identified from the medical

records.

4.3.5 Patient characteristics

Demographic data and information regarding the patient’s stroke was obtained from the

patient’s medical notes. Pre-morbid function was measured using the modified Rankin

Scale (mRS) [20]. Type of stroke was classified according to the Oxfordshire Community

Stroke Program (OCSP) classification [21]. Stroke severity was determined using the

National Institutes of Health Stroke Scale (NIHSS) [22] from a retrospective review of

the medical records [23]. The patient’s motor function on the day of observation was

assessed by the treating physiotherapist using the Mobility Scale for Acute Stroke

(MSAS) [24]. The gait score from this scale was used to group patients into independent

(MSAS gait = 6) or dependent (MSAS gait < 6) ambulation categories.

49

4.3.6 Data analysis

The average proportion of the day which patients spent in each activity category, each

location and with different people present was calculated. In order to determine where

and with whom patients were most active, the proportion of observations recorded in each

activity category was calculated for different locations and for different people. To

examine multidisciplinary and family involvement in therapy the proportion of

observations recorded with both therapy staff and other people present was calculated. To

determine where therapy took place the proportion of observations recorded with therapy

staff in different locations was calculated.

The therapist report data was used to determine the proportion of patients treated by

physiotherapists and occupational therapists. Means were calculated for the number of

therapy sessions per day, minutes of therapy per day, minutes per therapy session, and the

proportion of therapy time spent in each activity category.

The mean time to first mobilisation out of bed and the proportion of patients mobilised

within 12, 24 and 48 hours was calculated, as well as the proportion of patients first

mobilised by different health professionals.

4.4 Results


A total of 139 patients were recruited to the study. Nine of these patients were part of a

randomised controlled trial examining very early mobilisation [25] and were excluded

from the data analysis. The characteristics of the remaining 130 patients are presented in

Table 1.

50

Table 1. Patient characteristics

N 130

Age

Mean (SD) 68.3 (13.8)

Gender - n (%)

Male 91 (70.0)

Female 39 (30.0)

First stroke - n (%)

Yes 98 (75.4)

No 32 (24.6)

Days post-stroke at observation

Mean (SD) 6.9 (3.4)

Stroke type - n (%)

Infarct 112 (86.2)

Haemorrhage 18 (13.8)

NIHSS - n (%)

Mean (SD) 10.3 (7.6)

OCSP infarct classification - n (%)

TACI 39 (30.0)

PACI 29 (22.3)

POCI 11 (8.5)

LACI 33 (25.4)

Side of lesion - n (%)

Left 57 (43.8)

Right 65 (50.0)

Brainstem 5 (3.8)

None evident / unknown 3 (2.3)

Pre-morbid MRS - n (%)

Independent (0-2) 114 (87.7)

Dependent (>2) 16 (12.3)

Pre-stroke accommodation - n (%)

Home alone 42 (32.3)

Home with someone 83 (63.8)

Residential care 3 (2.3)

Other 2 (1.5)

Pre-stroke mobility - n (%)

Independent no aids 120 (92.3)

Independent with aid 10 (7.7)

MSAS gait score at observation - n (%)

Independent (= 6) 44 (33.8)

Not independent (< 6) 86 (66.2)

NIHSS – National Institutes of Health Stroke Scale; OCSP - Oxfordshire Community Stroke Project; TACI – total anterior circulation infarct; PACI – partial anterior circulation infarct; POCI – posterior circulation infarct; LACI – lacunar infarct; MRS – modified Rankin score; MSAS – mobility scale for acute stroke patients

51

52

4.4.2 Physical activity

The mean proportion of time spent in each physical activity level, each location and with

different people present is illustrated in Figure 1. On average patients spent 45% (SD 25)

of the day involved in some form of physical activity out of bed, including 22% (SD 21)

of the day in moderate or high physical activity. Patients spent an average of 46% (SD 24)

of the day in the nil or non-physical activity category.

4.4.3 People present and location of activity

Most of the day was spent in the bedroom area (Figure 1B) and for 60% of the

observations recorded in the bedroom patients were inactive or involved in passive

activities, such as talking, reading or watching TV in bed. In contrast, when patients were

in therapy areas, bathrooms, hallways, and off-ward for purposes other than investigations

they were inactive or involved in non-physical activity for less than 10% of these

observations.

On average, patients were alone for more than 50% of the day, and when not alone,

nursing staff and family were the people most often present (Figure 1C). However,

patients were least active when observed alone, with nursing staff or with family,

spending more than half of these observations inactive or not involved in physical

activity.

In less than 1% of observations patients were observed with both a therapist and someone

else present (physiotherapist/nurse 0.3%; physiotherapist/family 0.5%; occupational

therapist/nurse 0.1%; occupational therapist/family 0.7%). Physiotherapy and

occupational therapy staff were both present at the same time for only 0.1% of

observations. Patients also spent very little time with therapists in ward areas including

the bedroom, bathroom and hallway. Only 2.8% of observations were recorded with a

physiotherapist while in a ward area, and 2.6% with an occupational therapist while in a

ward area.

Figure 1. Mean (SD) proportion of the day (A) in each physical activity category, (B) in each location and (C) with different people present. Therapy includes physiotherapy, occupational therapy and speech therapy. People present categories are not mutually exclusive.

53

4.4.4. Therapy activity

Most patients received at least one session of physiotherapy and one session of

occupational therapy per day, averaging approximately one hour per day of therapy from

these two disciplines combined (Table 2).

Table 2. Amount of therapy provided

PT OT PT and/or OT

Patients treated – n (%) 107 (82.3) 85 (65.4) 119 (91.5)

Total number of reported therapy sessions 118 94 212

Number of therapy sessions per day – mean (SD) 0.9 (0.5) 0.7 (0.6) 1.6 (0.8)

Therapy time (mins) per day – mean (SD) 34.8 (24.0) 23.1 (25.6) 57.8 (33.7)

Therapy time (mins) per session – mean (SD) 38.3 (18.1) 31.9 (19.3) 35.5 (18.9)

Frequency of therapy sessions per day – n (%)

None 23 (17.7) 45 (34.6) 11 (8.5)

One 96 (73.8) 76 (58.5) 38 (29.2)

Two 11 (8.5) 9 (6.9) 70 (53.8)

Three 0 (0.0) 0 (0.0) 10 (7.7)

Four 0 (0.0) 0 (0.0) 1 (0.8)

PT – physiotherapy; OT – occupational therapy

Figure 2 illustrates the level of physical activity undertaken during physiotherapy and

occupational therapy sessions. Patients were engaged in moderate to high level activities

for an average of 61% (SD 31) of physiotherapy time and in low level physical activity

for an average of 65% (SD 42) of occupational therapy time.

Figure 2. Mean proportion of formal therapy time in each physical activity category for physiotherapy (PT) and occupational therapy (OT).

54

4.4.5 First mobilisation out of bed

The time to first mobilisation is presented in Table 3, while Figure 3 depicts which people

assisted with the first mobilisation out of bed. The average time to first mobilisation out

of bed was 31 hours from admission and 46 hours post-stroke. In total, physiotherapy

staff were involved in 63% of first mobilisations and nursing staff assisted in 28%.

Table 3. Time to first mobilisation

Stroke to admission - (hrs)

Mean (SD) 15.0 (20.5)

Stroke to mobilisation - (hrs)

Mean (SD) 46.3 (32.4)

Admission to mobilisation (hrs)

Mean (SD) 31.3 (27.7)

Stroke to mobilisation - n (%) *

< 12 hrs – n (%) 8 (6.2)

< 24 hrs – n (%) 28 (21.5)

< 48 hrs – n (%) 80 (61.5)

> 48 hrs – n (%) 50 (38.5)

Admission to mobilisation – n (%) *

< 12 hrs – n (%) 25 (19.2)

< 24 hrs – n (%) 67 (51.5)

< 48 hrs – n (%) 104 (80.0)

> 48 hrs – n (%) 26 (20.0)

* Cumulative totals

Figure 3. Proportion of patients first mobilised by different staff

55

4.5 Discussion

This study examines patient activity after stroke, including physical activity across the

day, the location of activity and the people involved, therapy specific activity, and the

timing of commencement of physical activity. The findings of this study indicate that

patients in the Royal Perth Hospital CSU are involved in some form of physical activity

out of bed for almost half the day, including nearly a quarter of the day in moderate or

high level activity. Furthermore patients usually commence activity out of bed within 48

hours post-stroke and participate in an average of approximately one hour per day of

occupational therapy and physiotherapy combined. Nonetheless, patients still spend a

considerable amount of the day physically inactive, alone, and in bedroom areas.

Few other previous studies have examined physical activity specifically in the first 14

days after stroke [12-15, 26] and in all but one of these studies [15] sample size was small

and the timing of commencement of physical activity was not reported. Given the

emerging literature in support of early physical activity after stroke, including the time to

commencement of physical activity is an important contribution of the current study. In

comparison to previous studies of early activity in acute stroke units (ASUs) in Australia

[13], and general medical wards and an ASU in Europe [14], the patient activity levels in

this Perth CSU are higher. However, despite the fact that the stroke unit examined in this

study employed a CSU model of care, patients were less active in comparison to those in

the Trondheim CSU, where patients spent almost 70% of the day engaged in physical

activity out of bed [15].

In the stroke unit which we studied patients spent approximately three quarters of the day

in their bedroom, where they were less likely to be physically active. Limited time was

spent in locations where increased physical activity might be encouraged, such as the

hallway, bathroom and therapy areas. Providing patients with easier access and more

opportunities to spend time in areas other than the bedroom may help to increase physical

activity. In the Trondheim unit this has been accomplished by providing a communal

dining area and passive recreation areas on the ward [15]. In addition to these

environmental features, however, the Trondheim unit has previously been described as

having a strong emphasis on a team approach to rehabilitation, patient and family

participation, and early mobilisation [4], and it is believed that this ‘culture’ is likely to be

important in promoting physical activity [15].

56

In comparison to the Trondheim unit, there appears to be less involvement of nursing staff

and family in rehabilitation in the stroke unit in this study, as well as a lack of patient-

initiated activity, which may restrict physical activity levels. Patients were alone for a

large proportion of the day and when the patients were not alone they were most often

with nursing staff or family. However for more than half the time where patients were

alone, with nursing staff or with family they were inactive or involved in non-physical

activity such as talking, reading or watching TV in bed.

Patients in the current study were with nursing staff for 15% of the day. In comparison,

patients in the Trondheim unit spent 22% of the day with nursing staff [15]. The reduced

time with nursing staff could be at least partially explained by lower staffing levels in the

Perth stroke unit, with a nurse to patient ratio of 1:4 compared to 1:3 in the Trondheim

unit [12]. Less time with nursing staff could contribute to reduced nursing staff

involvement in rehabilitation.

On average, patients in the Perth unit received 35 minutes per day of physiotherapy and

23 minutes per day of occupational therapy. Patients were involved in some form of

physical activity for most of this time. Patients in the Trondheim unit received more daily

physiotherapy time [15], however occupational therapy is not routinely provided [12],

therefore differences in the amount of time in therapy cannot explain the differences in

the amount of physical activity between the two sites. However, when patients were

observed with therapists there was further evidence of a lack of multidisciplinary input

and family involvement in rehabilitation, which may have contributed to lower activity

levels in the Perth unit. The therapy areas are located separately from the ward and

patients were rarely observed with therapists in ward areas such as the bedroom,

bathroom or hallway. Other staff or family were rarely present when physiotherapy or

occupational therapy staff were with patients. More time with therapists on the ward and

working in conjunction with other staff or family, may promote greater teamwork

between therapy staff and nursing staff and encourage family involvement in

rehabilitation. By practicing therapy activities in ward areas patients may also be better

able to put into practice these activities outside of therapy time.

Time to first mobilisation in the Perth unit compares favourably to that reported for stroke

patients in other hospitals in Australia [27-31] and overseas [32]. However, more patients

were mobilised within 48 hours in one Australian ASU [33] and within 24 hours in the

57

Trondheim CSU [15]. This delay may be at least partially explained by the limited

multidisciplinary cooperation in rehabilitation including a reliance on physiotherapy to

initiate activity out of bed. Physiotherapists assisted in the first mobilisation out of bed in

almost two-thirds of patients in the current study. In comparison, nursing staff were

involved in approximately one third of first mobilisations. Furthermore, physiotherapy

and nursing staff worked together to assist in the first mobilisation for only 2% of

patients. The reliance on physiotherapy could contribute to a greater time to first

mobilisation if physiotherapy staff are not readily available, particularly on weekends and

evenings.

A number of limitations need to be acknowledged. Although the observation technique

used in this study was standardised and the observers trained prior to commencement,

observation has the potential to influence the activity of the staff or patients observed. If

this were true, the activity levels in this study are likely to be higher than those seen under

usual circumstances. Furthermore, intermittent observation provides only a ‘snapshot’ of

patient activity, not continuous measurement of activity. It remains however the only

method currently available to capture not just activity, but people assisting and the

location of the activity which is very valuable in examining how care is organised. For the

purposes of this study, we believe the advantages afforded by observation outweigh the

disadvantages.

A further limitation was the use of the medical record to determine time to first

mobilisation. It is possible that staff may have incorrectly documented the time of first

mobilisation or may have even failed to document the first mobilisation altogether,

therefore the precision of this data may be questionable. As many of the patients were

recruited to the study some days after they were first mobilised out of bed, this was the

most accurate means we had of acquiring this information.

Finally, the comparison of the results of our study to previous studies of early physical

activity after stroke may be limited by inconsistencies in the classification of physical

activity and the possible heterogeneity of patient populations across studies. The same

model of behavioural mapping has been employed in a number of studies, however to

more accurately compare physical activity levels in a CSU with other acute stroke

services further research is required which provides a direct comparison between services.

58

4.6 Clinical messages

In a stroke unit which combines acute care with a rehabilitation focus

(comprehensive stroke unit) patients within 14 days post-stroke spend 45% of the

day engaged in some form of physical activity, this is higher than other reports

from units which focus on acute care alone.

Although many patients are seen by a therapist, in this study few episodes of

cooperation between therapist, nurses or family were observed. Improvement in

cooperation may see even higher levels of patient activity in the future

Whether these levels of physical activity make important contributions to

recovery is currently unknown.

Acknowledgements

The authors would like to thank the participants for their involvement, the therapists,

assistants and students at Royal Perth Hospital for their assistance with data collection,

and the AVERT Central staff for their assistance with data management.

Competing interests

Nil

Funding

Julie Bernhardt is funded by an Australian Research Council Future Fellowship. The

Florey Institute of Neuroscience and Mental Health acknowledges the strong support

from the Victorian Government and in particular the funding from the Operational

Infrastructure Support Grant.

Author contributions

TW was the primary researcher responsible for patient recruitment, data collection, the

quality assurance of the data, analysis and interpretation of the data and writing of the

paper. JB was responsible for the development of the study design and data collection

methods, and for the provision of senior research guidance in the analysis and

interpretation of the data, and the writing and revision of the paper. TW is the guarantor

of this study.

59

4.7 References

1. Intercollegiate Stroke Working Party. National Clinical Guidelines for Stroke. 3rd

ed. London: Royal College of Physicians: 2008.


Melbourne: 2010.

3. Scottish Intercollegiate Guidelines Network. Management of Patients with Stroke:

Rehabilitation, Prevention and Management of Complications and Discharge

Planning. A National Clinical Guideline. Edinburgh: 2010.



Stroke 1999; 30(5): 917-923.



396.




158.



Medicine. 2008; 40(8): 609-614.







2008; 26(5): 475-481.



Rehabilitation. 2010; 32(11): 875-884.

11. West T, Bernhardt J. Physical activity in hospitalised stroke patients. Stroke

Research and Treatment. 2012; 2012 http://dx.doi.org/10.1155/2012/813765.

60






14. Wellwood I, Langhorne P, McKevitt C, Bernhardt J, Rudd AG, Wolfe CDA. An

observational study of acute stroke care in four countries: the European Registers

of Stroke Study. Cerebrovascular Diseases. 2009; 28(2): 171-176.

15. Askim T, Bernhardt J, Løge AD, Indredavik B. Stroke patients do not need to be

inactive in the first two-weeks after stroke: results from a stroke unit focused on

early rehabilitation. International Journal of Stroke. 2012; 7(1): 25-31.





18. West T, Langhorne P, Bernhardt J. How do comprehensive and acute stroke units

differ? International Journal of Therapy and Rehabilitation. In Press, 2012.

19. Wittwer JE, Goldie PA, Matyas TA, Galea MP. Quantification of physiotherapy

treatment time in stroke rehabilitation - criterion-related validity. Australian

Journal of Physiotherapy. 2000; 46(4): 291.

20. van Swieten J, Koudstaal P, Visser M, Schouten H, van Gijn J. Interobserver

agreement for the assessment of handicap in stroke patients. Stroke. 1988; 19(5):

604-607.

21. Bamford J, Sandercock P, Dennis M, Warlow C, Burn J. Classification and natural

history of clinically identifiable subtypes of cerebral infarction. The Lancet. 1991;

337(8756): 1521-1526.

22. Brott T, Adams H, Jr, Olinger C, Marler J, Barsan W, Biller J, et al.

Measurements of acute cerebral infarction: a clinical examination scale. Stroke.

1989; 20(7): 864-870.

23. Kasner SE, Chalela JA, Luciano JM, Cucchiara BL, Raps EC, McGarvey ML, et

al. Reliability and validity of estimating the NIH stroke scale score from medical

records. Stroke. 1999; 30(8): 1534-1537.

24. Simondson J, Goldie P, Brock K, Nosworthy J. The mobility scale for acute stroke

patients: intra-rater and inter-rater reliability. Clinical Rehabilitation. 1996; 10(4):

295-300.

61



169-171.

26. Bernhardt J, Chan J, Nicola I, Collier J. Little therapy, little physical activity:

rehabilitation within the first 14 days of organized stroke unit care. Journal of

Rehabilitation Medicine. 2007; 39(1): 43-48.

27. Luker J, Bernhardt J, Grimmer-Somers K. Demographic and stroke- related

factors as predictors of quality of acute stroke care provided by allied health

professionals. Journal of Multidisciplinary Healthcare. 2011; 4(1): 247-259.

28. Luker J, Bernhardt J, Grimmer-Somers K. Quality in acute stroke care, patients'

age and age-proxy variables. What factors influence the provision of early

mobilisation following acute stroke? Proceedings of the 22nd Stroke Society of

Australasia Annual Scientific Meeting; 2011 Sept 14-16; Adelaide, Australia.

International Journal of Stroke. 2011; 6(Suppl 1): 49.

29. Luker JA, Bernhardt J, Grimmer-Somers KA. Age and gender as predictors of

allied health quality stroke care. Journal of Multidisciplinary Healthcare. 2011;

4(1): 239-245.

30. Purvis T, Cadilhac D, Bernhardt J. Not all Stroke units are the same: early

rehabilitation practices in Melbourne, Australia and Trondheim, Norway.

Proceedings of the 18th European Stroke Conference; 2009 May 26-29;

Stockholm, Sweden. Cerebrovascular Diseases. 2009; 27(Suppl 6): 175.

31. Sheedy R, Shields N, Bernhardt J. Acute stroke care: a hospital audit of

mobilisation practices. Proceedings of the 21st Annual Scientific Meeting of the

Stroke Society of Australasia; 2010 Sept 01-03; Melbourne, Australia.

International Journal of Stroke. 2010; 5(Suppl 1): 22.

32. Abilleira S, Gallofre M, Ribera A, Sanchez E, Tresserras R. Quality of in-hospital

stroke care according to evidence-based performance measures. Stroke. 2009;

40(4): 1433-1438.

33. Luker J, Grimmer-Somers K. Factors influencing acute stroke guideline

compliance: a peek inside the 'black box' for allied health staff. Journal of

Evaluation in Clinical Practice. 2009; 15(2): 383-389.

62

CHAPTER 5

Early physical activity after stroke: a comparative study of acute and

comprehensive stroke unit care

In the previous chapter the practice of early physical activity in a comprehensive stroke

unit (CSU) was described and the patients in this unit were generally found to engage in

more physical activity in comparison to previous studies of other models of acute stroke

care. However, this comparison may be confounded by differences between studies in

observation methods, activity classifications, data analysis, patient characteristics and the

age of the studies. Therefore this chapter describes an observational study of early

physical activity in two matched patient groups, from a CSU and an acute stroke unit

(ASU), which allows for direct statistical comparisons with adjustment for confounding

factors. In addition, this chapter provides a direct comparison of patient outcome in terms

of discharge destination.

63

5.1 Introduction

Evidence of the benefits of organised stroke unit care for the treatment of acute stroke is

now well established [1] and early physical activity has been identified as a key

component of this care [2, 3]. With the emergence of different models of stroke unit care,

stroke unit trialists have identified a need for further research which directly compares

these different models and examines the underlying components of care [1].

The acute stroke unit (ASU) and the comprehensive stroke unit (CSU) have been

identified as common models of acute care for stroke [1]. There are few trials which

directly compare these two stroke unit models [4-7] and there is currently insufficient

evidence to confirm a greater benefit from either model [1]. The findings of a review of

the literature describing these two models of care indicate that ASU care tends to have a

greater emphasis on acute medical management, increased nurse staffing, early

assessment and investigation, and intensive physiological monitoring, while CSU care

tends to have a greater emphasis on early rehabilitation, multidisciplinary teamwork and

the involvement of patients and carers [8]. These features of CSU care may promote an

increased level of early physical activity in comparison to the ASU model of care.

The purpose of this study is to directly compare early physical activity in a CSU and an

ASU. The primary aim is to compare the amount and type of physical activity undertaken

throughout the day by patients in the first 14-days post stroke. Secondary aims are to

compare where and with whom this activity takes place; the amount of formal therapy

received; when patients first commence physical activity out of bed; and the length of

stay and discharge destination. In this study it was hypothesised that patients admitted to

CSU care will be more active, commence activity sooner, receive more therapy and will

be more likely to be discharged directly home when compared to a similar cohort of

patients admitted to ASU care.

5.2 Methods

5.2.1 Study design, setting and participants

This study was a prospective observational study which took place in the stroke units of

two large metropolitan teaching hospitals in Australia. The Austin Hospital is located in

Melbourne, Victoria, and its stroke unit is a 13-bed ASU within a neurology ward. The

Royal Perth Hospital is located in Perth, Western Australia, and its stroke unit is a 14-bed

CSU, also within a neurology ward.

64

In accordance with the Stroke Unit Trialists Collaboration definitions of the ASU and

CSU models of care [1] both stroke units admitted patients acutely and provided acute

care. Patients in the ASU who required inpatient rehabilitation were transferred to a

rehabilitation facility at another site. In the CSU rehabilitation was provided

simultaneously as part of the acute management and ongoing rehabilitation could be

provided for as long as necessary on the stroke unit, however most patients requiring

inpatient rehabilitation beyond a few weeks were usually transferred to a rehabilitation

facility at another site.

Eligible patients were aged 18 years or over, with a diagnosis of first or recurrent stroke

(infarct or haemorrhage), who were admitted to the stroke unit and were within 14 days of

stroke onset. Patients were recruited over a three-year period from January 2008 to

December 2010. Patients were excluded from the study if they were receiving palliative

care or if discharge was planned prior to completion of the day of behavioural

observation.

5.2.2 Behavioural mapping

Physical activity, location and people present was recorded across the day for each patient

using established standardised behavioural mapping procedures, which have been

previously demonstrated to have high inter-rater reliability [9]. High consistency of

patient behaviour across days has been reported in a previous study [10] therefore patients

were observed for a single working day. Observation days were undertaken

approximately every six to eight weeks and up to 10 patients could be mapped on each

day of observation. Behavioural mapping was carried out over a nine-hour period

between 8am and 5pm when the patients were considered to be most active. Observations

took place at 10-minute intervals with the exception of up to five randomly scheduled 10-

minute rest periods for the observer. Patients and staff were informed that patient activity

was being monitored, however they were instructed that they should not alter their usual

behaviour. Wherever possible the observer attempted to remain inconspicuous to avoid

influencing behaviour.

65

Physical activity was grouped into the following five categories based on previous

activity definitions [9]:

Nil physical activity: lying in bed inactive

Non-physical activity: passive activities while resting in bed including reading,

watching TV, talking and eating

Low physical activity: sitting supported out of bed, hoist transfers

Moderate physical activity: sitting unsupported, transfers with feet on floor

High physical activity: standing, walking, stair climbing

5.2.3 Therapist report

Treating occupational therapists and physiotherapists provided a self-report of the amount

and type of physical activity undertaken by recruited patients during therapy sessions on

the day of observation. The validity of this method of therapist report has been previously

established [11] and may provide more accurate and comprehensive information

regarding patient activity during formal therapy sessions than the intermittent behavioural

mapping observations.

5.2.4 First mobilisation

The time to the patients’ first mobilisation out of bed from both the time of stroke onset

and from the time of hospital admission was derived from the patients’ medical records.


Demographic data and information regarding the patient’s stroke was acquired from the

medical record. Pre-morbid function was determined using the modified Rankin Scale

(mRS) [12]. Type of stroke was classified according to the Oxfordshire Community

Stroke Program (OCSP) classification [13]. Stroke severity was determined using the

National Institutes of Health Stroke Scale (NIHSS) [14] from a retrospective review of

the medical records [15]. The patient’s motor function on the day of observation was

assessed by the treating physiotherapist using the Mobility Scale for Acute Stroke

(MSAS) [16]. The gait score from this scale was used to group patients into independent

(MSAS gait = 6) or dependent (MSAS < 6) ambulation categories.

5.2.6 Patient discharge

Length of stay in the stroke unit and discharge destination from the stroke unit was

determined from a retrospective review of the medical record.

66

5.2.7 Ethics

Approval for this study was obtained from the Human Ethics Committees at the Austin

Hospital, the Royal Perth Hospital and the Faculty of Health Sciences at La Trobe

University. Informed consent was obtained from all participants or a responsible third

party where the patient was unable to provide consent themselves.

5.2.8 Data analysis

Unless stated otherwise all statistical analyses were performed using SPSS version 19. To

assess differences in patient characteristics between stroke units, numerical data were

analysed using the Mann Whitney U test and categorical data were analysed using

Fisher’s exact test. Initial analyses revealed significant differences between stroke units in

multiple patient characteristics, therefore patients were matched across sites using Stata

IC version 12, on the basis of age, stroke severity (NIHSS), pre-morbid function (pre-

morbid mRS >2) and ambulation status on the day of observation (MSAS Gait <6).

For the behavioural mapping data Microsoft Access 2003 was used to automatically

determine the highest category of physical activity recorded for each 10-minute

observation period. Medians and interquartile ranges (IQR) are reported for the

percentage of time which patients spent in each activity category, in each location and

with different people present. Linear regression analyses were initially attempted to

examine differences between stroke units in the proportion of the day spent inactive or

involved in non-physical activity, and in moderate or high level physical activity.

However, the data for moderate or high level activity were highly skewed and the

assumption of constant variance of the residuals was not met for a linear regression

model, therefore Stata IC version 12 was used to conduct univariate median regression

analyses. Multivariate median regression analyses were then performed to adjust for the

effect of age, stroke severity, gender, days post-stroke and pre-morbid function.

The median minutes per day, median minutes per session and the proportion of patients

receiving zero, one or two sessions per day are reported for physiotherapy and

occupational therapy from the therapist report data. The minutes per day of physiotherapy

and occupational therapy were compared using the Mann Whitney U test.

67

The median time to first mobilisation was calculated from the first mobilisation data.

Differences between stroke units in the time to first mobilisation were examined using the

Mann Whitney U test.

Median length of stay and the proportion of patients discharged to different destinations

were determined from the discharge data. Univariate logistic regression analysis was used

to examine the difference between units in the proportion of patients discharged directly

home. Multivariate logistic regression analysis was undertaken to adjust for the effect of

age, stroke severity, gender and pre-morbid function.

5.3 Results


Across both units 232 patients were recruited (ASU 93, CSU 139). We excluded 19

patients who were part of a randomised controlled trial investigating very early

mobilisation [17], three patients who did not complete the day of observation due to

unexpected discharge, four who were more than 14 days post-stroke and two who had

already been observed on a previous day. From the remaining 204 patients (ASU 74, CSU

130) we identified 73 matched patients from each site for analysis in the current study.

All but one of the unmatched patients were from the CSU and the patient characteristics

for the full CSU cohort were previously described in Chapter 4 of this thesis. Patient

characteristics for the patients analysed in the current study are summarised in Table 1.

Despite the matching process, some statistically significant differences still existed

between the participants from each site. In the CSU patient group there were more males,

fewer patients with partial anterior circulation infarcts (PACI’s) and more with lacunar

infarcts (LACI’s), and more patients who were able to ambulate independently without

aids prior to their stroke.

68

Table 1. Patient characteristics

ASU CSU

N 73 73

Age

Median (IQR) 78.8 (66.1-83.7) 75.5 (65.9-81.5)

Gender - n (%)

Male 35 (47.9) 51 (69.9)

Female 38 (52.1) 22 (30.1)

First stroke - n (%)

Yes 54 (74.0) 58 (79.5)

No 18 (24.7) 15 (20.5)

Missing 1 (1.4) 0 (0.0)

Days post-stroke

Median (IQR) 6.0 (4.0-8.5) 7.0 (4.5-9.0)

Stroke type - n (%)

Infarct 61 (83.6) 59 (80.8)

Haemorrhage 11 (15.1) 14 (19.2)

Missing 1 (1.4) 0 (0.0)

NIHSS

Median (IQR) 6.0 (4.0-12.0) 6.0 (4.0-10.0)

OCSP infarct classification - n (%)

TACI 13 (17.8) 11 (15.1)

PACI 29 (39.7) 19 (26.0)

POCI 9 (12.3) 6 (8.2)

LACI 6 (8.2) 23 (31.5)

Missing 5 (6.8) 0 (0.0)

Side of lesion - n (%)

Left 30 (41.1) 31 (42.5)

Right 41 (56.2) 39 (53.4)

Brainstem 1 (1.4) 3 (4.1)

None evident / unknown 1 (1.4) 0 (0.0)

Pre-morbid MRS - n (%)

Independent (0-2) 56 (76.7) 58 (79.5)

Dependent (>2) 17 (23.3) 15 (20.5)

Pre-stroke accommodation - n (%)

Home alone 21 (28.8) 26 (35.6)

Home with someone 48 (65.8) 43 (58.9)

Residential care 3 (4.1) 3 (4.1)

Other 1 (1.4) 1 (1.4)

Pre-stroke mobility - n (%)

Independent no aids 51 (69.9) 64 (87.7)

Independent with aid 19 (26.0) 9 (12.3)

Walking with supervision 3 (4.1) 0 (0.0)

MSAS Gait - n (%)

Independent 16 (21.9) 18 (24.7)

Not independent 57 (78.1) 55 (75.3)

NIHSS – National Institutes of Health Stroke Scale; OCSP - Oxfordshire Community Stroke Project; TACI – total anterior circulation infarct; PACI – partial anterior circulation infarct; POCI – posterior circulation infarct; LACI – lacunar infarct; MRS – modified Rankin score; MSAS – mobility scale for acute stroke patients

69

5.3.2 Behavioural mapping data

5.3.2.1 Physical activity

Patients in the CSU appeared to be more active than patients in the ASU (Figure 1A).

The median proportion of the day spent in moderate or high level physical activities was

18.0% (IQR 8.0-35.0) for the CSU patients compared to only 3.8% (IQR 0.0-9.5) for the

ASU patients. Conversely, ASU patients spent more time inactive or involved in non-

physical activities (ASU: median 58.8%, IQR 35.6-83.0; CSU: median 42.0%, IQR 20.0-

63.0).

Using univariate median regression analyses, patients in the CSU spent an additional

14.1% of the day (95% CI: 9.3%-19.0%; p<0.001) in moderate or high level activity,

when compared with the ASU. Conversely, patients in the ASU spent an additional

16.8% of the day (95% CI: 4.7%-29.0%; p=0.007) inactive or involved in non-physical

activity when compared with the CSU. After adjusting for differences in age, stroke

severity, gender, days post-stroke and pre-morbid function, using multivariate median

regression analyses, these findings remained significant. Furthermore patients in the CSU

spent 14.4% (95% CI: 8.9%-19.8%; p<0.001) (adjusted) more of the day in moderate to

high level activity and those in the ASU spent 18.5% (95% CI: 5.0%-32.0%; p=0.008)

(adjusted) more of the day inactive or involved in non-physical activity.

5.3.2.2 Location

Patients in the ASU appeared to spend more time in bedroom areas than patients in the

CSU, however in both units the majority of the day was spent in the bedroom (ASU:

median 94.1%, IQR 88.6-98.1; CSU: median 78.0%, IQR 70.0-86.0) (Figure 1B). The

median combined time spent in areas likely to promote activity, including the bathroom,

hallway, therapy area, and off ward for purposes other than investigations, was only 3.8%

(IQR 0.0-6.0) of the day for the ASU patients compared to 16.0% (IQR 10.0-24.0) of the

day for CSU patients.

5.3.2.3 People present

In both units, patients spent more than half the day alone (ASU: median 58.8%, IQR 44.7-

68.6; CSU: median 54.0%, IQR 41.0-64.0) (Figure 1C). The time spent with different

people present was generally similar across sites, however the CSU patients appeared to

spend more time with a therapist present (physiotherapist, occupational therapist or

speech therapist) (ASU: median 3.8%, IQR 0.0-7.8; CSU: 12.0%, 6.0-16.2).

70

Figure 1. Patient activity in acute (ASU) and comprehensive (CSU) stroke unit care Proportion of the day (A) in each physical activity category, (B) in each location and (C) with different people present. Box: median and interquartile range (IQR); Whiskers: data within 1.5 x IQR of lower and upper quartiles; Dots: data 1.5-3.0 x IQR from lower and upper quartiles. Stars: data >3.0 x IQR from lower and upper quartiles. Therapy includes physiotherapy, occupational therapy and speech therapy. People present categories are not mutually exclusive.

71

5.3.3 Therapist report data

The amount of physiotherapy and occupational therapy provided to patients in each unit is

reported in Table 2. Consistent with the behavioural mapping data, patients in the CSU

received significantly more physiotherapy time (p<0.001) and more occupational therapy

time per day (p<0.001). The median total therapy time per day, combining both

physiotherapy and occupational therapy, was 60.0 minutes (IQR 38.5-80.0) in the CSU

compared to only 5.0 minutes (IQR 0.0-30.5) in the ASU. Thirty-six (49.3%) of the ASU

patients did not receive any therapy from either physiotherapy or occupational therapy on

the day of observation, compared to only 5 (6.8%) patients in the CSU.

Table 2. Amount of therapy provided in acute (ASU) vs comprehensive (CSU) stroke unit care ASU CSU

N=73 N=73

Physiotherapy

Patients treated – n (%) 32 (43.8) 62 (84.9)

Therapy minutes per day

Median (IQR) 0.0 (0.0-19.5) 36.0 (22.0-50.0)

Range 0-116 0-105

Therapy minutes per session

Median (IQR) 20.0 (11.5-33.7) 40.0 (26.0-50.0)

Range 5-65 5-90


None 41 (56.2) 11 (15.1)

One 30 (41.1) 55 (75.3)

Two 2 (2.7) 7 (9.6)

Occupational therapy

Patients treated – n (%) 16 (21.9) 48 (65.8)

Therapy minutes per day

Median (IQR) 0.0 (0.0-0.0) 20.0 (0.0-40.0)

Range 0-60 0-100

Therapy minutes per session

Median (IQR) 29.5 (20.0-35.0) 30.0 (20.0-40.0)

Range 10-60 5-80


None 57 (78.1) 25 (34.2)

One 16 (21.9) 44 (60.3)

Two 0 (0.0) 4 (5.5)

5.3.4 First mobilisation data

Data for the time to admission and time to first mobilisation are summarised in Table 3.

Complete data was not available for 21 (28.8%) of the ASU patients. Two of these

72

patients had not yet been mobilised out of bed by the end of the day of observation, one of

whom was four days post-stroke and the other six days post-stroke. No reason was given

for why these patients had not been out of bed. The time of stroke was not documented

for three patients, the time of first mobilisation was not documented for 14 patients, and

neither the time of stroke or time of first mobilisation were documented for two patients.

Patients in the ASU had a significantly shorter time from stroke to admission. Despite the

longer time to admission, patients in the CSU commenced mobilisation out of bed

significantly earlier, from both time of stroke and time of admission, compared to patients

in the ASU.

Table 3. Time to first mobilisation in acute (ASU) vs comprehensive (CSU) stroke unit care ASU CSU p-value*

Stroke to admission (hours)

N 68 73

Median (IQR) 3.6 (1.5-7.6) 6.4 (2.1-18.1) 0.004

Range 0.0-83.7 0.8-106.0

Stroke to mobilisation (hours)

N 52 73

Median (IQR) 51.0 (27.0-76.7) 32.0 (24.2-52.8) 0.015

Range 2.2-249.5 5.2-209.0

Admission to mobilisation (hours)

N 55 73

Median (IQR) 28.4 (21.3-67.6) 20.6 (12.6-38.3) 0.000

Range 0.3-248.2 1.9-206.6

* Mann Whitney U test

5.3.5 Discharge data

The median length of stay was 13.0 days (IQR 8.0-19.5) for the ASU patients and 14.0

days (IQR 9.5-19.5) for the CSU patients. The discharge destinations for each hospital are

illustrated in Figure 2. More patients were transferred to another ward or hospital in the

ASU compared to the CSU. At both sites patients were usually transferred to another

ward or hospital for the purpose of ongoing inpatient rehabilitation. More patients were

discharged directly home from the CSU. Using univariate logistic regression analysis, the

odds of discharge directly home was significantly higher from the CSU than the ASU

(OR 3.1; 95% CI 1.5-6.5; p=0.003). This result remained significant after adjusting for

the effects of age, gender, stroke severity and pre-morbid function (OR 3.7; 95% CI 1.4-

9.5; p=0.007).

73

Figure 2. Discharge destination from acute (ASU) vs comprehensive (CSU) stroke unit care Proportion of patients discharged to each destination

5.4 Discussion

The results of this study suggest that patients admitted to CSU care are more active within

14 days post-stroke compared to patients admitted to ASU care. Patients in the CSU

commenced activity out of bed sooner, received more therapy time, and spent more time

away from bedroom areas, contributing to a greater level of physical activity. These

results support previous findings from a review of ASU and CSU care [8]. The findings

of this review indicated that the ASU model tends to focus primarily on acute medical

care, while a stronger emphasis on multidisciplinary rehabilitation appears to exist in the

CSU model even in the acute stage of stroke [8]. The greater emphasis on

multidisciplinary rehabilitation in the CSU may promote the increased early physical

activity found in the current study.

The results of the current study are also consistent with a previous study, in which

patients admitted to a CSU in Trondheim, Norway, were found to be more active within

14 days post-stroke than patients in five Melbourne stroke units, four of which were

ASUs [10]. The authors attribute the increased early activity in the Trondheim CSU to an

increased focus on early intensive rehabilitation, policies and procedures which promote

early mobilisation and avoidance of bed rest, training and extensive involvement of

nursing staff in early mobilisation, increased staffing, and a physical environment which

encourages activity [10].

74

The Perth CSU shares similar characteristics with the Trondheim CSU. Staff in the Perth

CSU aimed to commence rehabilitation, including mobilisation out of bed, within 24 to

48 hours of admission, and to continue ongoing intensive rehabilitation thereafter.

Procedures to manage blood pressure and fluid balance supported the practice of early

mobilisation. Staff received education and training in early mobilisation. Bathroom areas

were located separately from the bedroom areas, providing opportunities for mobilisation

when patients need to be transported to the bathroom. Patients who were unable to

ambulate with or without assistance were each provided with their own wheelchair,

allowing them to sit out of bed as much as tolerated each day and to be easily transported

outside of bedroom areas by family and staff. Physiotherapy and occupational therapy

areas were located nearby to the ward, and patients generally attended therapy in these

areas every weekday. In addition, many patients also participated in therapy sessions

away from the ward, including outdoors for the practice of outdoor mobility and in

separate kitchen areas for the practice of higher level activities of daily living. Perhaps the

most noticeable difference between the Perth CSU and the Trondheim CSU are the

staffing levels. A physiotherapist-patient ratio of 1:8 was reported for the Trondheim unit,

however occupational therapy was not routinely provided [10]. In comparison the Perth

unit had a physiotherapist-patient ratio of approximately 1:11 and an occupational

therapist-patient ratio of 1:13. A nurse-patient ratio of 1:3 was reported for the Trondheim

unit [10], compared to 1:4 in the Perth unit. The reduced level of nursing staff in the Perth

unit may have limited the involvement of nursing staff in early mobilisation and

rehabilitation.

In a previous study of physical activity in five Melbourne stroke units, the authors

reported that in the ASUs which they observed, the staff considered that their main role

was to assess new patients and that patients suitable for discharge directly home should be

the main priority for rehabilitation interventions [18]. This previous study included the

Melbourne ASU observed in the current study, and the approach of the staff described by

the authors suggests a limited focus on rehabilitation, in contrast to the Trondheim and

Perth CSUs, which likely contributed to the reduced activity levels found in the

Melbourne ASU in the current study. In addition, the Melbourne ASU observed in the

current study had en-suite bathrooms in most bedroom areas, limiting opportunities for

mobilisation. Access to wheelchairs for patients unable to ambulate was limited, reducing

the amount of time these patients were able to sit out of bed and making transport outside

75

of bedroom areas more difficult. Physiotherapy and occupational therapy areas were

located nearby to the ward, as well as a large lounge area, however these areas were not

frequently used by patients. The Melbourne ASU was staffed with a nurse-patient ratio of

1:4, and an occupational therapist-patient ratio of approximately 1:13, as per the Perth

CSU. Physiotherapy staffing levels were lower than the Perth CSU, with a

physiotherapist-patient ratio of approximately 1:16 in the Melbourne ASU compared to

1:11 in the Perth CSU, however this alone would not account for the fact that the median

combined therapy time in the CSU was 12 times that of the ASU.

The observational design of this study gives rise to a number of limitations, including the

potential for observer bias and the possibility that staff and patient behaviour were

influenced by the presence of the observer. However, a standardised observation

technique was used to reduce observer bias and observers attempted to remain

inconspicuous at all times so as to minimise any influence on staff and patient behaviour.

The intermittent nature of the behavioural mapping method may have overestimated or

underestimated patient activity, however continuous observation would not have been

feasible with the behavioural mapping and this method has the advantage of allowing

patient location and the people present to be observed, in addition to patient activity. The

accuracy of the first mobilisation data may also be limited given that this data was

determined from the medical record. For a number of patients the exact time of stroke or

first mobilisation out of bed was not documented in the medical record and it is possible

that this information may have been incorrectly documented for other patients. However,

this was the most accurate means available for acquiring this information given that

patients could be recruited to the study some days after they were first mobilised.

In addition to the increased early physical activity levels, the results of this study suggest

that patients are also more likely to be discharged directly home from the CSU compared

to the ASU. Although the median length of stay was one day shorter in the ASU than in

the CSU, any economic benefit from this shorter length of stay is likely to have been lost

due to the costs of the increased need for inpatient rehabilitation beyond the acute period.

While the results of this study do not establish a causal relationship between early

physical activity and discharge destination, it does raise the question as to whether a

greater focus on early intensive rehabilitation, an earlier commencement of activity out of

bed, and an increased level of physical activity early after stroke, may improve the

likelihood of discharge home. In a previous randomised controlled trial comparing CSU

76

care to stroke care on a general medical ward, the results of a multivariate analysis

revealed that an earlier start to mobilisation out of bed was the most important factor

associated with an increased likelihood of discharge home within six weeks [2].

Furthermore, in a randomised controlled trial comparing early mobilisation to standard

care after stroke, the utilisation of rehabilitative services including inpatient rehabilitation

was considerably less in the sub-acute stage for the early mobilisation group, contributing

to significant cost savings [19]. However, the findings of a recent study investigating

clinical prioritisation by acute stroke clinicians indicate that planned discharge destination

may actually be a driver of quality of care [20]. This suggests that discharge destination

may have an impact on early physical activity levels, rather than the other way around. In

comparison to patients who are expected to be transferred elsewhere, patients who are

expected to be discharged directly home may be considered a higher priority for

rehabilitation interventions including the promotion of early physical activity. Therefore

the greater proportion of patients discharged directly home may have contributed to the

increased amount of physical activity in the CSU in comparison to the ASU. It is also

possible that the difference in discharge destinations between the two units in the current

study may have been the result of differences in processes of care other than early

mobilisation. In addition, factors such as differences in the availability of ongoing

inpatient and outpatient rehabilitation, early supported discharge programs, and

community-based formal care services, may have also influenced discharge destination,

particularly given that the two units observed were in different states of Australia and

therefore under different systems of healthcare.

5.5 Conclusion

Evidence to support the implementation of any one model of stroke unit care over another

is lacking. The current study indicates that a stroke unit model which incorporates both

acute care and rehabilitation promotes early physical activity and improves the likelihood

of discharge directly home, in comparison to a model which provides acute care alone.

Early physical activity however is just one component of stroke unit care and further

research is required which compares other key features of different stroke unit models and

which provides a more extensive comparison of short-term and long-term outcomes.

77

5.6 References





Stroke 1999; 30(5): 917-923.

3. Stroke Unit Trialists Collaboration. How do stroke units improve patient

outcomes? A collaborative systematic review of the randomized trials. Stroke.

1997; 28(11): 2139-2144.








Diseases. 2005; 19(1): 23-30.




8. West T, Langhorne P, Bernhardt J. How do comprehensive and acute stroke units

differ? International Journal of Therapy and Rehabilitation. In Press, 2012.






11. Wittwer JE, Goldie PA, Matyas TA, Galea MP. Quantification of physiotherapy

treatment time in stroke rehabilitation - criterion-related validity. Australian

Journal of Physiotherapy. 2000; 46(4): 291.

12. van Swieten J, Koudstaal P, Visser M, Schouten H, van Gijn J. Interobserver

agreement for the assessment of handicap in stroke patients. Stroke. 1988; 19(5):

604-607.

78

13. Bamford J, Sandercock P, Dennis M, Warlow C, Burn J. Classification and natural

history of clinically identifiable subtypes of cerebral infarction. The Lancet. 1991;

337(8756): 1521-1526.

14. Brott T, Adams H, Jr, Olinger C, Marler J, Barsan W, Biller J, et al.

Measurements of acute cerebral infarction: a clinical examination scale. Stroke.

1989; 20(7): 864-870.

15. Kasner SE, Chalela JA, Luciano JM, Cucchiara BL, Raps EC, McGarvey ML, et

al. Reliability and validity of estimating the NIH stroke scale score from medical

records. Stroke. 1999; 30(8): 1534-1537.

16. Simondson J, Goldie P, Brock K, Nosworthy J. The mobility scale for acute stroke

patients: intra-rater and inter-rater reliability. Clinical Rehabilitation. 1996; 10(4):

295-300.



169-171.







2008; 26(5): 475-481.

20. Luker J, Edwards I, Bernhardt J. Discharge destination as a driver of care rather

than an outcome: a qualitative study. Proceedings of the Stroke 2012 Conference;

2012 Jul 29-31; Sydney, Australia. International Journal of Stroke. 2012; 7(Suppl

1): 40.

79

CHAPTER 6

Discussion and conclusions

6.1 Main findings

This thesis examines components of care in the comprehensive stroke unit (CSU), in

particular those related to early physical activity. Furthermore, this thesis provides a

comparison of the care provided in the CSU and acute stroke unit (ASU) models of care.

A review of the literature describing these two stroke unit models (Chapter 2) identified a

lack of consistency, clarity and detail in the current literature regarding the key features of

care specific to each model. In general however, the findings of this review suggest that

CSU care is characterised by a greater emphasis on early rehabilitation, multidisciplinary

teamwork and the involvement of patients and carers. Conversely, ASU care tends to be

characterised by a greater emphasis on acute medical management, increased nurse

staffing, early assessment and investigation, and intensive physiological monitoring.

A systematic review of physical activity in hospitalised stroke patients (Chapter 3)

demonstrated that these patients tend to be physically inactive for a substantial proportion

of the day and that this inactivity appears to be more prevalent in patients within 14 days

post-stroke. Additionally, it appears that patient activity may be influenced by the

organisation of care.

An observational study of early physical activity in a Perth CSU (Chapter 4) revealed that

patients within 14 days post-stroke tended to be more active, commence activity sooner

and participate in more therapy, when compared to previous studies involving other

models of acute stroke care. The results of a comparative study of the Perth CSU and a

Melbourne ASU (Chapter 5) substantiate these findings. In comparison to patients

managed in an ASU, patients in the CSU commenced activity sooner, participated in

more therapy, spent more time away from bedroom areas, and overall had a greater level

of physical activity. In addition, patients in the CSU were also more likely to be

discharged directly home compared to those in the ASU.

80

6.2 Clinical implications

6.2.1 Stroke unit model of care

The findings of this thesis provide support for the CSU model of care. These findings

supplement previous studies which provide indirect evidence of greater benefits from

CSU care compared to other stroke unit models. Meta-analyses comparing stroke unit

care to alternative stroke services have demonstrated that the benefits of stroke unit care

are greatest for the CSU model [1, 2]. Additionally, in a recent review of the literature

comparing CSU care to other stroke services, the authors conclude that there is

preliminary evidence to suggest that CSU care is associated with better outcomes

compared to other stroke unit models [3]. The authors suggest that the CSU model offers

a good balance of multidisciplinary input, early management policies including early

mobilisation, and ongoing rehabilitation policies including goal setting and early

discharge planning [3]. In addition, the authors propose that the CSU model may provide

better continuity of care and avoid the delays in early mobilisation and rehabilitation

which may occur in stroke units which only offer acute care [3]. However, the studies

included in this review did not provide any direct comparisons of CSU and ASU

outcomes.

The review of CSU and ASU care in this thesis (Chapter 2) included four studies which

did directly compare outcomes between the two stroke unit models [4-7]. However,

limitations in study design and sample sizes, as well as differing findings across the

studies, prevent the identification of a superior model of care.

In Australia, the current national stroke guidelines suggest that the CSU is the best model

of care for acute stroke patients [8]. Despite these guidelines, in a recent audit of

Australian stroke services only 20% of stroke units were classified as CSUs, while 78%

were classified as ASUs [9]. Nevertheless, given the current lack of conclusive evidence

in favour of either model of care, recommendations for new or existing stroke units to

adopt a CSU model may be premature.

6.2.2 Increasing early physical activity after stroke

Strong evidence to support increased physical activity in the first six months after stroke

is provided by a meta-analysis of randomised controlled trials investigating increased

exercise therapy time [10]. More recently evidence has emerged from two small

randomised controlled trials indicating possible benefits for increased activity within the

81

first 14 days after stroke [11-15]. However, there are currently no clear parameters

regarding exactly how much physical activity should be undertaken after stroke to

maximise recovery. Given the low levels of physical activity in hospitalised stroke

patients found in this thesis, particularly early after stroke (Chapter 3, 4 and 5), there is

clearly a need to implement strategies to increase physical activity levels in the hospital

setting.

In Chapter 4 and 5 the characteristics of CSU care which may promote increased early

physical activity after stroke were identified. These included an emphasis on early

intensive rehabilitation, policies and procedures which support early mobilisation,

multidisciplinary teamwork, involvement of nursing staff in early mobilisation,

encouragement of patient and carer involvement in the recovery process, and a physical

environment which encourages activity. However, even in the CSU setting there may still

be room for improvement. While patients in a Trondheim CSU in Norway spent less than

a third of the day physically inactive [16], the Perth CSU patients observed in this thesis

still spent almost half the day inactive or involved in non-physical activity, despite

favourable comparisons to other stroke services (Chapter 4 and 5). Furthermore, in a

recent observational study of physical activity in another Australian CSU, which included

both acute and sub-acute patients, even lower levels of activity were found with 62% of

the day spent inactive, despite the reported implementation of early mobilisation practices

[17].

The importance of nursing staff involvement in increasing patient activity during non-

therapy time has previously been highlighted by multiple authors [16, 18-20]. Suggested

mechanisms for improving the involvement of nursing staff in facilitating patient activity

include increased levels of nurse staffing [18], education and training for nurses in

facilitating patient activity [18, 21], and therapy staff working in conjunction with nursing

staff to assist patient activity [16, 18]. In the Perth CSU, although education and training

in patient mobilisation was provided for nursing staff, the findings from Chapter 4 of this

thesis suggest nursing involvement in patient activity was still limited. The findings of

Chapter 4 also indicate that in the Perth CSU therapy staff rarely worked in conjunction

with nursing staff. The provision of more therapy sessions in ward-based areas, rather

than in isolated therapy areas, and the inclusion of nursing staff in these sessions were

suggested strategies to increase nursing staff involvement in facilitating patient activity.

With regards to nurse staffing levels, both the Perth CSU and the Melbourne ASU studied

82

in this thesis had a nurse-patient ratio of 1:4. Given that a nurse-patient ratio of 1:3 was

reported, alongside increased patient activity levels, in the Trondheim CSU [18], there

may also be a need to increase levels of nurse staffing in the Perth CSU and the

Melbourne ASU in order to increase nursing staff involvement in facilitating patient

activity. However, increases in nurse staffing levels may be limited by economic

constraints.

The need for greater self-directed patient activity [17, 20-25] and greater family

involvement in assisting patient activity [16, 20, 21, 23, 25, 26] have also been identified,

in order to increase physical activity outside of formal therapy time. Proposed strategies

to increase self-directed patient activity include patient education and instruction in self-

directed exercises [22, 23], activity diaries [17, 20, 25], video self-modelling [27],

equipment provision and environmental modifications [16, 18, 26, 28-30], and the use of

volunteers or activity coordinators to assist patient activity [20, 24, 25]. In the Perth CSU

bathrooms were located away from bedroom areas providing opportunities for more able

patients to mobilise to the bathroom, while less able patients were each provided with

their own wheelchair allowing patients to sit out of bed regularly and family and staff to

more easily transport patients out of bedroom areas. However, the results of Chapter 4

indicate that for more than half the time the Perth CSU patients were alone or with family,

they were not engaged in physical activity. A need to provide recreation areas on the

ward, outside of bedroom areas, for patients and families was identified. Additionally,

family were rarely present when patients were being treated by therapists. Therefore,

greater involvement of family in formal therapy sessions and more therapy sessions in

ward areas were suggested as strategies to increase patient activity. Family involvement

in formal therapy sessions could encourage and train family members to assist in patient

activity outside of therapy, while therapy sessions in ward areas could improve patient

carryover of skills to non-therapy time.

An increase in formal therapy activity is also required to increase physical activity after

stroke. Patients tend to be most active when with a therapist [17, 31, 32] therefore

increasing formal therapy time may increase patient activity. Current clinical guidelines

recommend that stroke patients should be provided with a minimum of one hour of

physical therapy (physiotherapy and occupational therapy) per day, at least five days per

week [8]. The results of the observational studies in this thesis indicate that patients in the

CSU were provided with approximately an hour of physical therapy per weekday

83

(Chapter 4 and 5), thereby meeting the minimum therapy time recommended in the

clinical guidelines. Far less physical therapy was provided in the ASU, with fewer

treatment sessions, shorter treatment time and almost half the patients not receiving any

physical therapy on the day of observation (Chapter 5). Staffing levels for physiotherapy

and occupational therapy in both the Perth CSU and the Melbourne ASU were lower than

minimum recommended staffing levels previously proposed by the National Stroke

Foundation [33]. The argument could therefore be made for increasing therapy staffing

levels in order to increase therapy time. However economic constraints may again prevent

increases in staffing levels and previous studies have found that higher levels of therapy

staffing do not necessarily result in increased therapy time for patients [20, 28], therefore

additional strategies to increase therapy time are required. Previous recommendations for

increasing patient time with therapists have included reducing the time therapists spend

on administrative tasks [28] and assessments [17] as well as the implementation of a more

formalised and structured therapy schedule [28, 29, 32]. Group therapy sessions have

frequently been recommended to increase the time patients spend in therapy [17, 23, 27,

29, 34-36] and the involvement of therapy assistants, volunteers and family members in

formal therapy sessions has also been proposed [27]. Previous studies have reported

increased therapy time and increased physical activity in patients participating in group

therapy [23, 29, 34, 35] however in one study the authors found that the proportion of

time spent in high level activities such as walking was lower during group therapy than in

individual sessions [35].

Despite previous findings of higher activity levels during formal therapy sessions

compared to non-therapy time, four of the studies reviewed in Chapter 3 reported that

patients were inactive for more that 20% of therapy time [31, 35, 37, 38], including one

study in which patients were found to be inactive for 58% of the therapy session [37]. In

another recent review of physical activity after stroke during physiotherapy sessions, the

authors found that patients were physically active for an average of only 60% of therapy

time [36]. These findings indicate a need to not just increase the time patients spend in

formal therapy, but to also increase the level of activity during this time. The use of

intervention protocols specifying the number of required repetitions, treadmill training

and changes in the physical organisation of the therapy environment have previously been

suggested to increase activity levels during therapy sessions [27].

84

6.3 Strengths and limitations

Much has been written about the general concept of stroke unit care but without

differentiating between the different models of stroke units. The main strength of this

thesis is the provision of a detailed investigation specific to the ASU and CSU models of

care.

Chapter 2 updates previous literature regarding the components of stroke unit care.

However, this review was limited by its reliance on author descriptions of stroke unit care

and the timeliness of the literature reviewed. As such the review may still not accurately

reflect current clinical practice. Nevertheless, few studies directly compare care models

and this was a recommendation that flowed from this review.

Chapter 3 provides the first synthesis of previous observational studies of physical

activity in hospitalised stroke patients, examining patient activity both during the entire

working day and specifically during formal therapy sessions. However, this review was

limited by a lack of consensus and clear definitions regarding the classification of

physical activity. This inconsistency of definitions led to a recommendation that

researchers reach consensus about definitions for physical activity into the future.

A strength of the observational studies in Chapter 4 and 5 is the investigation of all

aspects of patient activity, including physical activity across the day, the location of

activity and people involved, therapy specific activity and the commencement of physical

activity. Few previous studies have examined physical activity specifically in the first 14

days after stroke [16, 18, 31, 39, 40] and only one other study has reported the timing of

commencement of physical activity [16]. Given the early timeframe post-stroke in this

thesis, another important feature was the categorisation of supported sitting out of bed as

a low-level physical activity, as opposed to some sub-acute studies in which supported

sitting on its own has been considered inactive [26, 32, 37]. In this thesis physical activity

was considered to be any bodily action produced by the skeletal muscles requiring more

energy expenditure than at rest, including low-level tasks such as actively maintaining

sitting posture with support in a chair. In the early stages of recovery, particularly in low

functioning patients, sitting supported out of bed may have important therapeutic effects

[17], which could potentially include improved respiratory function, head and trunk

control, and tolerance of the upright position. As such, sitting supported out of bed needs

to be distinguished from non-therapeutic activities in bed.

85

A further strength of the observational study in Chapter 5 is the provision of a direct

comparison between the ASU and CSU models. Only two previous studies have directly

compared physical activity in the first 14 days after stroke between different stroke

services [18, 40]. As found in Chapter 3, there is a lack of consistency in the classification

and reporting of activity levels across different observational studies of physical activity

in hospitalised stroke patients, therefore comparison between different stroke services

across different studies is difficult. This issue is eliminated by the direct comparison

provided in Chapter 5. The inclusion of the examination of discharge destination is an

additional strength of this study. No other previous studies of physical activity in

hospitalised stoke patients have included this or any other measure of patient outcome.

The behavioural mapping technique used in the studies in Chapter 4 and 5 gives rise to a

number of limitations. These include the potential for observer bias, the possible

influence of the presence of the observer on staff and patient behaviour, and the potential

for activity (or inactivity) to be missed due to the intermittent nature of the observations.

The impact of these limitations was minimised by the standardisation of the observation

technique, the observer efforts to remain unobtrusive during observation and the spacing

of observation periods only 10 minutes apart. Another limitation of these studies was the

reliance on the medical record to retrospectively determine time to first mobilisation.

The comparison of physical activity and discharge destination between the ASU and CSU

in Chapter 5 is further limited by the potential influence of multiple confounding factors

due to the absence of randomisation to stroke unit allocation and recruitment from two

different patient populations at two different sites. To minimise the effects of potential

confounders, information was collected regarding multiple patient characteristics, patients

were matched between sites on the basis of age, stroke severity, pre-morbid function and

ambulation status, and multivariate analyses were conducted to adjust for age, stroke

severity, gender, days post-stroke and pre-morbid function. However, given that the two

different patient populations were recruited from opposite sides of the country, it is

possible that important differences remained between the patient populations that were

not identified, matched or adjusted for in the statistical analyses. For example, one patient

group could have had more co-morbidities than the other, potentially limiting early

physical activity levels and the likelihood of discharge directly home. Additionally, as the

two stroke units observed in this study were located at hospital sites in different states of

86

Australia, where healthcare is delivered at the state rather than national level, variations in

healthcare services may have contributed to the differences found in this study. For

example, different arrangements for admission and transfer into the stroke units may have

impacted on admission times, thereby contributing to differences in the time to first

mobilisation. Furthermore, variations in the availability of ongoing inpatient and

community based rehabilitation services may have contributed to differences in discharge

destination. However, the potential for differences between patient populations and

healthcare services would still exist even if the stroke units were located in closer vicinity

of one another. Only the random allocation of patients from the same population to stroke

unit models located at the same site could truly eliminate the impact of potential

confounding factors, and the operation of two stroke units at one site is unlikely to be a

feasible option.

6.4 Suggestions for future research

6.4.1 Stroke unit care

Further research is required which directly compares processes of care and patient

outcomes in different stroke unit models. However, given that such research would most

likely require a comparison of stroke unit models located at different sites, a large

randomised controlled trial is unlikely to be feasible. Therefore alternative research

methods, such as qualitative or mixed method approaches may be required for future

comparisons of stroke unit models to help unpack the key components of care in these

different stroke services. Previous stroke unit studies using surveys [41] and audits [42,

43] have focused on the evaluation of care processes without also investigating patient

outcomes, they have only provided a description of stroke unit care as a whole and the

findings may now be somewhat outdated. Large-scale multicenter surveys and audits,

such as the National Stroke Audit Program [9, 44] in Australia, provide information

regarding care processes and patient outcomes which in the future could potentially be

used to compare models of stroke unit care. Large multicenter observational studies

which provide comprehensive comparisons of both care processes and patient outcomes

in different stroke rehabilitation services have previously been undertaken as an

alternative to randomised controlled trials [45, 46]. The comparative observational study

conducted in this thesis demonstrates that acute care services for stroke can also be

compared using a similar study design. However future observational studies need to be

conducted on a larger scale, investigate a more expansive list of care processes, provide a

more complete evaluation of short and long-term patient outcomes and include an

87

evaluation of cost effectiveness, in order to provide more robust evidence for the benefits

of one model of stroke unit care over another.

6.4.2 Early physical activity after stroke

Although the findings of two small randomised controlled trials of early mobilisation

after stroke indicate possible beneficial effects for this practice [11, 14], stronger evidence

in support of early mobilisation is required. Further research into the possible negative

effects of early mobilisation is also required, particularly given the ongoing concerns

regarding the effect of early mobilisation on blood pressure, cerebral perfusion and the

ischaemic penumbra [47, 48], as well as emerging evidence of an increase in falls

incidence in stroke patients with slower walking speeds following exercise programs to

enhance mobility [49, 50]. A large, international, multicenter randomised controlled trial

investigating the effects of early mobilisation after stroke is currently underway [51]. This

trial may also help to address the need for future research to establish physiological

parameters and procedures for safe patient mobilisation, as well as parameters regarding

the optimal dosage of physical activity after stroke.

Strategies to promote increased physical activity in hospitalised stroke patients need

further investigation. In most instances the effectiveness of such strategies has only been

tested in observational studies and in sub-acute and chronic stroke populations. These

strategies need to be subjected to more rigorous evaluation using randomised controlled

trials and their applicability to the acute phase of stroke should also be examined.

Future observational studies of early physical activity after stroke should attempt to

standardise the classification of physical activity to allow better comparison across

studies. In addition, a prospective method of collecting first mobilisation data needs to be

developed to improve the reliability of this measure.

6.5 Conclusions

The key features of the CSU model of care include an emphasis on early intensive

rehabilitation, policies and procedures which support early mobilisation, multidisciplinary

teamwork and nursing staff involvement in early mobilisation, encouragement of patient

and carer involvement in the recovery process, and a physical environment which

encourages activity. These characteristics of CSU care may contribute to the increased

early physical activity found in this thesis in comparison to other acute stroke services

88

such as ASU care. With the emergence of new and more sophisticated methods of

diagnosis, monitoring and medical intervention for stroke it is tempting to focus on these

new technologies in the development and evaluation of models of acute stroke care.

However, this should not be at the expense of more simple processes of care, such as the

promotion of early physical activity, which have the potential to improve patient

outcome.

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observational study of acute stroke care in four countries: the European Registers

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42. Cadilhac DA, Ibrahim J, Pearce DC, Ogden KJ, McNeill J, Davis SM, et al.

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169-171.

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APPENDIX A: Ethics approval - Royal Perth Hospital

94

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APPENDIX B: Ethics approval - Austin Hospital

95

APPENDIX C: Ethics approval - La Trobe University, Faculty of Health Sciences

96

APPENDIX D: Participant information and consent form, Royal Perth Hospital

97

APPENDIX E: Person responsible information and consent form,

Royal Perth Hospital

100

APPENDIX F: Participant information and consent form, Austin Hospital

103

APPENDIX G: Person responsible information and consent form, Austin Hospital

108

APPENDIX H: Observed motor activity case report form

113

APPENDIX I: Patient demographics case report form

114

APPENDIX J: Mobility scale for acute stroke

118

APPENDIX K: Therapy form

119

APPENDIX L: Statement from co-authors confirming the authorship contribution

of the masters candidate (review paper – chapter 2)

As a co-author of the paper:

West T, Langhorne P, Bernhardt J. How do comprehensive and acute stroke units

differ? A critical review. International Journal of Therapy and Rehabilitation,

2013; 20(1): 41-53.

I confirm that Tanya West has made the following contributions:

Development of the review protocol, including the review questions, search

strategy and the inclusion and exclusion criteria

Conducting the literature search and the selection of literature

Data extraction and analysis

Interpretation of the main findings

Leading the writing and revision of the paper

Dr Julie Bernhardt Date:

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APPENDIX M: Statement from co-authors confirming the authorship contribution

of the masters candidate (systematic review paper – chapter 3)

As co-author of the paper:

West T, Bernhardt J. Physical activity in hospitalised stroke patients. Stroke

Research and Treatment. 2012; 2012 http://dx.doi.org/10.1155/2012/813765

I confirm that Tanya West has made the following contributions:

Development of the review protocol, including the review questions, search

strategy and the inclusion and exclusion criteria

Conducting the literature search and the selection of literature

Data extraction and analysis




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APPENDIX N: Statement from co-authors confirming the authorship contribution

of the masters candidate (observational study – chapter 4)

As co-author of the paper:

West T and Bernhardt J. What, where, who and when: activity patterns of acute

stroke patients managed in a rehabilitation focused stroke unit

submitted for publication to Clinical Rehabilitation, I confirm that Tanya West has made

the following contributions:

Ethics applications

Patient recruitment

Data collection and quality assurance of the data

Data analysis




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APPENDIX O: Stroke unit location for included studies in literature review of

stroke unit models of care (chapter 2)

Location of stroke unit

CSU

Ang, et al. [9] Sydney, Australia

Bisaillon, et al. [10] Mississauga, Canada

Blower & Ali [11] London, United Kingdom

Cabral, et al. [12] Joinville, Brazil

Evans, et al. [13] London, United Kingdom

Fagerberg, et al. [14] Goteborg, Sweden

Garraway, et al. [15] Edinburgh, United Kingdom

Hankey, et al. [16] Perth, Australia

Indredavik, et al. [2] Trondheim, Norway

Jorgensen, et al. [17] Copenhagen, Denmark

Ma, et al. [18] Beijing, China

Phillips, et al. [19] Halifax, Canada

Ronning & Guldvog [20] Oslo, Norway

Strand, et al. [21] Umea, Sweden

ASU

Berry, et al. [22] London, United Kingdom

Chen, et al. [5] Oxford, United Kingdom

Di Matteo, et al. [23] Auckland, New Zealand

Hanger, et al. [24] Christchurch, New Zealand

McCann, et al. [25] Warrnambool, Australia

ASU and CSU

Cavallini, et al. [7] Pavia, Italy

Roquer, et al. [26] Barcelona, Spain

Silva, et al. [27] Girona, Spain

Sulter, et al. [8] Groningen, Netherlands

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APPENDIX P: Additional data for amount of therapy in observational study of

comprehensive stroke unit care (chapter 4)

PT OT PT and/or OT

Patients treated – n (%) 107 (82.3) 85 (65.4) 119 (91.5)

Total number of reported therapy sessions 118 94 212

Number of therapy sessions per day

mean (SD) 0.9 (0.5) 0.7 (0.6) 1.6 (0.8)

median (IQR) 1.0 (1.0-1.0) 1.0 (0.0-1.0) 2.0 (1.0-2.0)

range 0-2 0-2 0-4

Therapy time (mins) per day

mean (SD) 34.8 (24.0) 23.1 (25.6) 57.8 (33.7)

median (IQR) 35.0 (20.0-50.0) 20.0 (0.0-35.0) 55.0 (36.75-80.0)

range 0-110 0-150 0-170

Therapy time (mins) per session

mean (SD) 38.3 (18.1) 31.9 (19.3) 35.5 (18.9)

median (IQR) 40.0 (25.0-50.0) 30.0 (20.0-40.0) 34.0 (20.0-45.0)

range 5-90 5-150 5-150


None 23 (17.7) 45 (34.6) 11 (8.5)

One 96 (73.8) 76 (58.5) 38 (29.2)

Two 11 (8.5) 9 (6.9) 70 (53.8)

Three 0 (0.0) 0 (0.0) 10 (7.7)

Four 0 (0.0) 0 (0.0) 1 (0.8)

PT – physiotherapy; OT – occupational therapy

early physical activity in comprehensive stroke unit...

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