EARLY PHYSICAL ACTIVITY IN COMPREHENSIVE STROKE UNIT CARE

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1 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

2 TABLE OF CONTENTS LIST OF TABLES...vii LIST OF FIGURES... viii SUMMARY OF THESIS...x STATEMENT OF AUTHORSHIP...xi ACKNOWLEDGEMENTS...xii CHAPTER 1 Introduction Stroke unit care Early physical activity after stroke Aims of thesis Hypotheses References...5 CHAPTER 2 How do comprehensive and acute stroke units differ? Abstract Introduction Methods Literature search and selection Data extraction and analysis Findings Admission and discharge policies Personnel, multidisciplinary policies and training Assessment, investigations and monitoring Stroke management, secondary prevention and treatment of complications Rehabilitation and mobilisation policies Patient and carer involvement Discussion Conclusion References...27 ii

3 CHAPTER 3 Physical activity in hospitalised stroke patients Introduction Methods Literature search Selection of literature Data extraction and analysis Results General patient activity Activity monitoring method Participants monitored Care settings Physical activity People present Patient location Organisation of care and time after stroke Therapy specific activity Activity monitoring methods Participants monitored Therapy settings Therapy intensity Therapy activity Upper limb therapy Discussion Conclusions...42 References...43 CHAPTER 4 What, where, who and when: activity patterns of acute stroke patients managed in a rehabilitation focused stroke unit Abstract Introduction Method Study design and participants Behavioural mapping...48 iii

4 4.3.3 Therapist report Commencement of physical activity Patient characteristics Data analysis Results Patient characteristics Physical activity People present and location of activity Therapy activity First mobilisation out of bed Discussion Clinical messages References...60 CHAPTER 5 Early physical activity after stroke: a comparative study of acute and comprehensive stroke unit care Introduction Methods Study design, setting and participants Behavioural mapping Therapist report First mobilisation Patient characteristics Patient discharge Ethics Data analysis Results Patient characteristics Behavioural mapping data Physical activity Location People Present Therapist report data First mobilisation data...72 iv

5 5.3.5 Discharge data Discussion Conclusion References...78 CHAPTER 6 Discussion and Conclusions Main findings Clinical implications Stroke unit model of care Increasing early physical activity after stroke Strengths and limitations Suggestions for future research Stroke unit care Early physical activity after stroke Conclusions 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 APPENDIX F: Participant information and consent form, Austin Hospital APPENDIX G: Person responsible information and consent form, Austin Hospital..108 APPENDIX H: Observed motor activity case report form APPENDIX I: Patient demographics case report form APPENDIX J: Mobility scale for acute stroke APPENDIX K: Therapy form APPENDIX L: Statement from co-authors confirming the authorship contribution of the masters candidate (review paper chapter 2) APPENDIX M: Statement from co-authors confirming the authorship contribution of the masters candidate (systematic review paper chapter 3) v

6 APPENDIX N: APPENDIX O: APPENDIX P: Statement from co-authors confirming the authorship contribution of the masters candidate (observational study chapter 4) Stroke unit location for included studies in literature review of stroke unit models of care (chapter 2) Additional data for amount of therapy in observational study of comprehensive stroke unit care (chapter 4) vi

7 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: Table 2: Table 3: Patient characteristics...51 Amount of therapy provided...54 Time to first mobilisation...55 Chapter 5 Table 1: Table 2: Table 3: Patient characteristics...69 Amount of therapy provided in acute (ASU) vs comprehensive (CSU) stroke unit care...72 Time to first mobilisation in acute (ASU) vs comprehensive (CSU) stroke unit care...73 vii

8 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 (ASU) vs comprehensive (CSU) stroke unit care...19 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 (ASU) vs comprehensive (CSU) stroke unit care...21 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: Figure 2: Figure 3: Mean (SD) proportion of the day (A) in each physical activity category, (B) in each location and (C) with different people present..53 Mean proportion of formal therapy time in each physical activity category for physiotherapy (PT) and occupational therapy (OT)...54 Proportion of patients first mobilised by different staff...55 viii

9 Chapter 5: Figure 1: Figure 2: Patient activity in acute (ASU) vs comprehensive (CSU) stroke unit care...71 Comparison of discharge destination from acute (ASU) vs comprehensive (CSU) stroke unit care...74 ix

10 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

11 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: 29 th November 2012 xi

12 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. xii

13 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 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 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

14 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

15 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 highquality 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

16 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

17 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): Australian Institute of Health and Welfare, Senes S. How we manage stroke in Australia. AIWH cat. no. CVD 31. Canberra: National Stroke Foundation. Clinical Guidelines for Stroke Management Melbourne: 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): 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): Australian Bureau of Statistics Causes of death Australia. Canberra:

18 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): 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): 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, Stroke. 2002; 33(4): 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): 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): Sturm JW, Donnan GA, Dewey HM, Macdonell RAL, Gilligan AK, Thrift AG. Determinants of handicap after stroke. Stroke. 2004; 35(3): Paul SL, Sturm JW, Dewey HM, Donnan GA, Macdonell RA, Thrift AG. Longterm outcome in the North East Melbourne Stroke Incidence Study: predictors of quality of life at 5 years after stroke. Stroke. 2005; 36(10): 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): Stroke Unit Trialists Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews. 2007; (4): CD Seenan P, Long M, Langhorne P. Stroke units in their natural habitat: systematic review of observational studies. Stroke. 2007; 38(6): Indredavik B, Bakke F, Slordahl SA, Rokseth R, Haheim LL. Stroke unit treatment. 10-year follow-up. Stroke. 1999; 30(8): 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): 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):

19 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): Stroke Unit Trialists Collaboration. How do stroke units improve patient outcomes? A collaborative systematic review of the randomized trials. Stroke. 1997; 28(11): Langhorne P, Pollock A, Stroke Unit Trialists Collaboration. What are the components of effective stroke unit care? Age and Ageing. 2002; 31(5): 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): 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): Intercollegiate Stroke Working Party. National Clinical Guidelines for Stroke. 3rd ed. London: Royal College of Physicians: Scottish Intercollegiate Guidelines Network. Management of Patients with Stroke: Rehabilitation, Prevention and Management of Complications and Discharge Planning. A National Clinical Guideline. Edinburgh: Arias M, Smith L. Early mobilization of acute stroke patients. Journal of Clinical Nursing. 2007; 16(2): 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): 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-S 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): 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):

20 32. Bernhardt J, Thuy MN, Collier JM, Legg LA. Very early versus delayed mobilisation after stroke. Cochrane Database of Systematic Reviews. 2009; (1): CD 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): Diserens K, Michel P, Bogousslavsky J. Early mobilisation after stroke: review of the literature. Cerebrovascular Diseases. 2006; 22(2-3): 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): 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): Panayiotou B, Reid J, Fotherby M, Crome P. Orthostatic haemodynamic responses in acute stroke. Postgraduate Medical Journal. 1999; 75(882): 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-S 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): 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): 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): 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): 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

21 trial of very early rehabilitation after stroke (AVERT). Cerebrovascular Diseases. 2008; 26(5): 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): 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):

22 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): 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

23 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

24 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 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 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

25 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 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

26 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

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

28 Table 2. Data extraction Admission & Discharge Policies Personnel, Multidisciplinary Policies and Training Assessment, Investigations & Monitoring Stroke Management, Secondary Prevention & Treatment of Complications Rehabilitation & Mobilisation Policies Patient & Carer Involvement 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

29 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 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

30 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%)) 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

31 Bladder Scans Urine Cultures Emotional State Skin Integrity 1 (11%) 1 (6%) 1 (11%) 1 (6%) 1 (11%) 1 (6%) 1 (11%) 1 (6%) ASU CSU Swallow Assessment Functional Assessment 7 (39%) 4 (45%) 7 (39%) 6 (67%) Neurological Assessment 5 (56%) 12 (67%) Haematology & Biochemistry 2 (22%) 11 (61%) CXR 1 (11%) 6 (33%) Cardiac Investigations Vascular Imaging MRI 2 (22%) 2 (22%) 4 (22%) 8 (44%) 4 (44%) 8 (44%) CT within 48h 8 (44%) 7 (78%) CT 12 (67%) 8 (89%) Frequency reported (%) 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

32 Frequency reported (%) (67%) 5 (62%) 8 (89%) 7 (87%) 8 (44%) 4 (50%) 7 (78%) 6 (75%) 10 (56%) 5 (62%) 4 (44%) 4 (50%) 4 (44%) 4 (50%) 2 (25%) 5 (56%) 5 (62%) 11 (61%) 3 (37%) 3 (33%) 3 (37%) CT 0 (0%) 0 (0%) 2 (11%) CT within 48h ECG within 24h Continuous Monitoring Intravenous Thrombolysis Anticoagulation CSU - all papers CSU ASU - all papers ASU 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

33 100 Frequency reported (%) (67%) 4 (44%) 10 (56%) 4 (44%) 8 (44%) 4 (44%) 0 (0%) 4 (44%) Physiological Monitoring 1 (6%) 2 (22%) 5 (28%) 2 (22%) 4 (22%) 0 (0%) 3 (17%) 0 (0%) ECG within 24h Vitals Continuous Monitoring Neurological Status Blood Glucose Fluid & Electolytes Nutritional Status 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 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

34 CSU ASU 80 Frequency reported (%) (11%) 5 (56%) 6 (33%) 5 (56%) 7 (39%) 3 (33%) 6 (33%) 2 (22%) 11 (61%) 3 (33%) 0 Intravenous Thrombolysis Antiplatelet Therapy Antihypertensive Therapy Avoidance of BP reduction Anticoagulation 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 antithromboembolic 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

35 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 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

36 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

37 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

38 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

39 2.7 References 1. Stroke Unit Trialists Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews. 2007; (4): CD 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): Langhorne P, Pollock A, Stroke Unit Trialists Collaboration. What are the components of effective stroke unit care? Age and Ageing. 2002; 31(5): Foley N, Salter K, Teasell R. Specialized stroke services: a meta-analysis comparing three models of care. Cerebrovascular Diseases. 2007; 23(2-3): Chen L-K, McClaran J, Buchan A. Impact of acute stroke unit on hospital length of stay. Archives of Gerontology and Geriatrics. 2009; 49(1): e12-e National Stroke Foundation. National Stroke Audit - Acute Services Organisational Survery Report Melbourne: Cavallini A, Micieli G, Marcheselli S, Quaglini S. Role of monitoring in management of acute ischemic stroke patients. Stroke. 2003; 34(11): Sulter G, Elting JW, Langedijk M, Maurits NM, De Keyser J. Admitting acute ischemic stroke patients to a stroke care monitoring unit versus a conventional stroke unit: a randomized pilot study. Stroke. 2003; 34(1): Ang YH, Chan DK, Heng DM, Shen Q. Patient outcomes and length of stay in a stroke unit offering both acute and rehabilitation services. Medical Journal of Australia. 2003; 178(7): Bisaillon S, Douloff C, LeBlanc K, Pageau N, Selchen D, Woloshyn N. Bringing innovation to stroke care: development of a comprehensive stroke unit. Axone. 2004; 25(4): Blower P, Ali S. A stroke unit in a district general hospital: the Greenwich experience. British Medical Journal. 1979; 2(6191): Cabral NL, Moro C, Silva GR, Scola RH, Werneck LC. Study comparing the stroke unit outcome and conventional ward treatment: a randomized study in Joinville, Brazil. Arquivos de Neuro-Psiquiatria. 2003; 61(2A): 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):

40 14. Fagerberg B, Claesson L, Gosman-Hedstrm G, Blomstrand C. Effect of acute stroke unit care integrated with care continuum versus conventional treatment: a randomized 1-year study of elderly patients: the Göteborg 70+ Stroke Study. Stroke. 2000; 31(11): Garraway WM, Akhtar AJ, Prescott RJ, Hockey L. Management of acute stroke in the elderly: preliminary results of a controlled trial. British Medical Journal. 1980; 280(6220): Hankey GJ, Deleo D, Stewart-Wynne EG. Stroke units: an Australian perspective. Australian and New Zealand Journal of Medicine. 1997; 27(4): Jorgensen HS, Nakayama H, Raaschou HO, Larsen K, Hbbe P, Olsen TS. The effect of a stroke unit: reductions in mortality, discharge rate to nursing home, length of hospital stay, and cost. A community-based study. Stroke. 1995; 26(7): Ma RH, Wang YJ, Qu H, Yang ZH. Assessment of the early effectiveness of a stroke unit in comparison to the general ward. Chinese Medical Journal. 2004; 117(6): Phillips S, Eskes G, Gubitz G. Description and evaluation of an acute stroke unit. Canadian Medical Association Journal. 2002; 167(6): Ronning OM, Guldvog B. Stroke unit versus general medical wards, II: neurological deficits and activities of daily living: a quasi-randomized controlled trial. Stroke. 1998; 29(3): 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. Stroke. 1985; 16(1): Berry D, Spillane N, Zunz A, Thomson H. Specialist unit improves outcome after acute stroke. Nursing Times. 1996; 92(7): 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. New Zealand Medical Journal. 2004; 117(1190): Hanger C, Fletcher V, Fink J, Sidwell A, Roche A. Improving care to stroke patients: adding an acute stroke unit helps. New Zealand Medical Journal. 2007; 120(1250): 28

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42 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): Busse O. Stroke units and stroke services in Germany. Cerebrovascular Diseases. 2003; 15(Suppl 1): Indredavik B. Intensive monitoring should not be the routine. Stroke. 2004; 35(4): Steiner T. Stroke unit design: intensive monitoring should be a routine procedure. Stroke. 2004; 35(4): 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): 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):

43 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; See Appendix M for the co-authorship contribution statement. 31

44 Hindawi Publishing Corporation Stroke Research and Treatment Volume 2012, Article ID , 13 pages doi: /2012/ Review Article Physical Activity in Hospitalised Stroke Patients Tanya West 1, 2 and Julie Bernhardt 1, 3 1 School of Health Sciences, La Trobe University, Melbourne, VIC 3086, Australia 2 Physiotherapy Department, Royal Perth Hospital, Perth, WA 6000, Australia 3 Stroke Division, Florey Neuroscience Institutes (formerly National Stroke Research Institute), Heidelberg Heights, VIC 3084, Australia Correspondence should be addressed to Tanya West, tanya.west@health.wa.gov.au 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 Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 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 stroke patients in the 24 included studies. Most of the patient day is spent inactive (median 48.1%, IQR 39.6% 69.3%), alone (median 53.7%, IQR 44.2% 60.6%) and in their bedroom (median 56.5%, IQR 45.2% 72.5%). Approximately one hour per day is spent in physiotherapy (median 63.2 minutes, IQR ) and occupational therapy (median 57.0 minutes, IQR ). Even in formal therapy sessions limited time is spent in moderate to high level physical activity. Low levels of physical activity appear more common in patients within 14 days post-stroke and those admitted to conventional care. Conclusions. Physical activity levels are low in hospitalised stroke patients. Improving the description and classification of post stroke physical activity would enhance our ability to pool data across observational studies. The importance of increasing activity levels and the effectiveness of interventions to increase physical activity after stroke need to be tested further. 1. Introduction The most beneficial time to commence rehabilitation and physical activity after stroke has not yet been established; however improved outcome is associated with earlier initiation of rehabilitation [1]. Favourable outcomes have been reported in stroke units where patients are helped to get out of bed within the first 48 hours of admission and continue this frequently until discharge [2, 3], and early start to activity is recommended in many guidelines [4 6]. However, the practice remains controversial [7, 8] and early commencement of physical activity is the subject of clinical trials [9 11]. Increased activity in the first six months after stroke has been found to improve functional outcome [12], but once again the optimal dose of physical activity necessary to aid recovery after stroke is unclear. Physical activity is defined here as any bodily action produced by the skeletal muscles requiring more energy expenditure than at rest and therefore can include low level tasks 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 such as standing and walking [1, 13]. Given the growing interest in promoting physical activity after stroke apparent within the literature and in clinical guidelines [4 6], it is important to understand what activity patients already undertake following their stroke, both throughout the day and during therapy time. The purpose of this paper was to examine common methods of monitoring activity in hospitalised stroke patients and summarise the amount and type of physical activity undertaken by stroke patients managed in a range of hospital settings. We were also interested in where patients were most active and who was with them during activity. 2. Methods 2.1. Literature Search. A search of the EMBASE, Medline, PubMed, AMED, and CINAHL databases was carried out up until the end of October 2010 to ascertain observational studies investigating the amount and type of physical activity in hospitalised stroke patients. The search was restricted 32

45 2 Stroke Research and Treatment to observational studies as this is a common method of activity monitoring used in clinical practice. Although we were interested in publications investigating physical activity early after stroke (within 14 days), any study conducted in a hospital-based setting, at any time point in the care continuum, could be included. Combinations of the following search terms were used to locate potentially relevant studies: stroke, physical activity, mobilisation, rehabilitation, inpatient, hospital, early, acute, observation, observational study. Further literature was sourced from scans of the reference lists of selected publications. Potential studies were determined from review of the title and abstract Selection of Literature. Studies selected for inclusion in the review were prospective observational studies which employed methods such as behavioural mapping, therapist report, or video recording to determine the amount and type of physical activity undertaken by the stroke patients. Patients could be admitted to any inpatient service that managed 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 described the physical activity undertaken either throughout the entire day or, alternatively, during formal therapy time alone. Publications in which only the amount of total therapy time and not the type of activity undertaken was reported were excluded Data Extraction and Analysis. The type of activity reported from each study was categorised as either general patient activity or therapy-specific activity. For studies that reported general patient activity we extracted data regarding patient activity undertaken throughout the day. For studies that investigated therapy-specific activity only we extracted data on the patient s activity during formal therapy sessions only. As the focus of this paper was on physical activity, only records from physiotherapy and occupational therapy sessions were obtained for the therapy-specific data, since these disciplines are known to concentrate more on physical function. Data extracted from the included publications regarding the type of activity undertaken by stroke patients was grouped under four categories reflecting the physical demands of the activity. (i) Nil physical activity: sleeping and other nontherapeutic activities while resting in bed including passive recreation such as reading, watching TV, talking, and eating. (ii) Low physical activity: including sitting supported out of bed and self-care. (iii) Moderate physical activity: including sitting unsupported and transferring without hoist equipment. (iv) High physical activity: including activities involving standing and walking. The amount of time spent in different types of activities was extracted and calculated as a proportion of total observation time for each individual study. For the general patient activity studies the locations in which these activities took place and the people present when they occurred was also extracted and expressed as a proportion of observation time. In the therapy-specific activity studies we determined the minutes of therapy per session and minutes of therapy per day. Wherever possible we extracted information about the study settings, patient characteristics, and study methods and procedures. To summarise data across studies we calculated medians and 25th and 75th percentiles (IQR). We further categorised studies into hospital setting (general rehabilitation, stroke units, or conventional care) and time of observation (<14 days). General rehabilitation units were defined as units which provided only rehabilitation (not acute care) for both stroke and nonstroke diagnoses. This included mixed rehabilitation wards that accepted both neurological and nonneurological conditions. Stroke unit care was defined as a geographically discrete unit which only admitted stroke patients. This included stroke rehabilitation wards for patients transferred from acute care usually at least one to two weeks poststroke, acute stroke wards which provided only acute care for patients usually within one to two weeks poststroke, and comprehensive stroke wards which combined both acute care and rehabilitation. Conventional care units included any acute service which admitted both stroke and nonstroke diagnoses. This included general medical wards which could admit a range of medical conditions, elderly care units which specifically admitted elderly patients with various medical conditions, or general neurology wards which admitted patients with a range of neurological diagnoses. Again, data were summarised across studies and medians and 25th and 75th percentiles (IQR) are reported. Statistical comparison between settings was not suitable as insufficient data were available to adequately adjust for important factors that may influence activity such as stroke severity. 3. Results Forty-one potentially relevant studies were identified from a review of the title and abstract. Seventeen of these studies were excluded, eight of which did not provide sufficient information about the type of activity [14 21], five reported data already reported in another included publication [1, 22 25], two reported the frequency of different types of activities but not the total amount of time [26, 27], one study was a retrospective study [28], and one study included both stroke and other neurological diagnoses in the same data set [29]. Of the 24 included publications patient activity was observed throughout the day in 15 studies [30 44], and patient activity was observed in therapy sessions only in 10 studies [32, 45 53], with one publication examining patient activity during both the whole day and in therapy time alone [32]. All included studies reported the proportion of time spent in activities of interest across the whole 33

46 Stroke Research and Treatment 3 Table 1: General patient activity studies. Study Patients Organisation of care categories Bear-Lehman et al. [30] a Rehabilitation inpatients SU Bernhardt et al.[31] Acute(<14 d) inpatients SU (<14 d) Behavioural mapping procedure for individual patients 8 am 4 pm, every 30 mins, for 1 weekday and 1 weekend day 8 am 5 pm, every 10 mins, for 2 consecutive weekdays Bernhardtetal.[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 SU De Weerdt et al. [34] Rehabilitation inpatients SU De Wit et al. [35] d Rehabilitation inpatients SU Esmonde et al. [36] Rehabilitation inpatients SU Keith [37] Rehabilitation inpatients SU Keith and Cowell [38] Rehabilitation inpatients SU, GRU Lincoln et al. [39] Rehabilitation inpatients SU Lincoln etal. [40] Rehabilitation Inpatients SU, CCU Mackey et al. [41] e Rehabilitation inpatients GRU Pound et al. [42] Inpatients SU, CCU Tinson [43] e Inpatients CCU 8.30 am 5.10 pm, every 10 mins, for 1 weekday 8.30 am 5.10 pm, every 10 mins, for 2 weekdays in 1st observation period, 1 weekday in 2nd period 7 am 12 pm or 12 pm 5 pm or 5 pm 10 pm, every 10 mins, for 1 weekday 9 am 5 pm, average every 10.8 mins, for 4 9 weekdays 8.15 am am every 30 mins, for 5 consecutive weekdays 8.30 am 4.30 pm, every 8 mins, for 2 weekdays 8.30 am 4.30 pm, average every 30 mins, for 3consecutivedays 6 am 2 pm or 8.30 am 4.30pm or 2pm 10pm, every 10 mins, for 3 days 7 am 7 pm, every 10 mins, for 3-4 weekdays and both weekend days 7.30 am 3.30 pm or 9.30 am 5.30 pm or 2.30 pm pm, every 20 mins, for 1 weekday 9 am 1 pm or 1 pm 5 pm, every 30 mins, for 4 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 weekday a Data for stroke patients only, excludes weekend data; b data for Trondheim patients only; c data for Switzerland patients only; d excludes 5 pm 10 pm data; e excludes weekend data; GRU: general rehabilitation unit (includes mixed rehabilitation units); SU: stroke unit (includes acute stroke units, comprehensive stroke 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 or deviations preventing meta-analysis of these studies General Patient Activity Activity Monitoring Method. All 15 of the included studies which examined patient activity throughout the day used a behavioural mapping method (structured observation) to determine patient activity (Table 1). Ten of the studies reported good interrater reliability with the behavioural mapping method [30, 31, 33 36, 38, 42, 44]. The remaining studies did not report reliability, and no studies tested the validity of behavioural mapping. The behavioural mapping procedures varied across studies (Table 1). Days of observation ranged from 1 to 9 days (median 2 days). The time across which mapping was carried outonobservationdaysrangedfrom4to12hourseachday (median 8 hours) and the frequency of observations ranged from every 8 to 60 mins (median 10 minutes). Most studies focused on a normal working day, with observations taking place on weekdays, commencing between 8 am and 9 am and finishing between 4 pm and 5.30 pm. However four studies included weekday mapping outside the normal working day hours [35, 40 42]. Three studies also included mapping on weekends [30, 41, 43] but for the purpose of the current 34

47 4 Stroke Research and Treatment paper weekend data were excluded where possible in order to allow a more accurate comparison of data across studies Participants Monitored. All study participants were hospitalised and in most studies only stroke patients were examined. One study compared hospitalised stroke patients with other neurological and nonneurological diagnoses [30]; however only the data for the stroke patients were included in the current paper. The reported average or median age of the patients varied significantly across the studies, ranging from 52 to 80 years. Most of the studies had broad inclusion criteria, suggesting representative patient samples. Comparison of patient severity across the studies was difficult as a large range of measures were used to describe the impairment or disability of the monitored group. These included the National Institute of Health Stroke Scale (NIHSS), the Barthel Index, and the Functional Independence Measure (FIM). Most studies appeared to include patients from across the spectrum of stroke severity. In two studies patients needed to have a specified minimum impairment level to be included, thereby excluding very mild patients [35, 43]. In two studies very severe patients with low function, decreased consciousness, or ongoing acute medical issues were excluded [40, 43]. The majority of studies investigated patients who were in the rehabilitation phase of their admission. The concept of a rehabilitation phase was not well defined across studies; therefore for the purpose of the current paper it was presupposed to imply that the patients were considered to be medically stable, not requiring acute medical intervention, and the primary purpose of ongoing hospitalisation was rehabilitation. The exact days after stroke at the time of observation were only reported in five studies [31, 32, 34, 36, 39]. The remainder investigated activity in patients who were assumed to be between several weeks to several months following stroke. Three studies specifically focused on acute patients within 14 days of their stroke [31, 32, 44]. Two included studies may have investigated both acute and rehabilitation patients; however insufficient information was provided to confirm patient acuity [42, 43] Care Settings. In 85% of the studies physical activity monitoring was conducted in a stroke unit setting. This was usually a stroke rehabilitation unit, but acute and comprehensive stroke unit settings were described in a small number of publications [31, 32, 44]. Some studies also investigated physical activity in mixed rehabilitation units, general medical wards, elderly care units, and general neurology wards. In 12 of the included publications activity monitoring was conducted on several groups of patients who were grouped based on diagnosis, the period of observation, the site where the unit was based, the organisation of care, or the structure of the unit. The data for each separate group are presented in Table 2. Where the same patient group was analysed in another included study these data are reported only once. Where the group did not include stroke patients these 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 and reason for grouping. Study Patient group n Bear-Lehman et al. [30] Stroke patients 7 Bernhardtetal.[31] Full sample 58 Bernhardtetal.[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] Fullsample 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 7 1,2 denote different time periods of observation; A,B,C,D denote different locations Physical Activity. The activity of interest varied across studies; for example, some authors were interested only in the time patients spent inactive [30], while others were interested in the time patients spent engaged in moderate to high activity only [37]. Classification of the type of activity also varied across the included studies. In cases where activity over the entire observation period was not reported, or where observation points were missing due to patients moving away from the ward, we have grouped these together under the category unobserved or unreported. In many studies it was not possible to distinguish between moderate and high level activities according to our predetermined categories. However, in all cases it was clear that the activities at least met the moderate category; therefore we elected to combine moderate and high level activities into the one category (moderate-high activity) for reporting purposes. We included participation in formal therapy and self-practice 35

48 Stroke Research and Treatment 5 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 Weerdt et al. [34] 2 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. [39] 2 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 Nil Low Proportion of time (%) Moderate to high Unobserved 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 hospital locations. of therapy exercises in this moderate to high level activity category. The proportion of time patients spent in the specified activitycategories(nil,low,moderate-high)fromeachstudy is summarised in Figure 1. Patients were inactive or involved in nontherapeutic activity (nil activity) for between 24.2% and 98.0% of the day, with a median of 48.1% of the day spent inactive (IQR 39.6% to 69.3%). In comparison much less time tended to be spent in low physical activity (median 27.5%, IQR 13.0% to 32.2%) and even less still in moderate to high physical activity (median 21.0%, IQR 12.8% to 27.7%) People Present. The proportion of time patients spent alone was reported for 14 of the 15 behavioural mapping studies. On average, patients were alone for approximately 50% of each observed day (median 53.7%, IQR 44.2% 60.6%) (Figure 2). However time spent alone was lower for two patient groups that took part in group therapy as part of their rehabilitation (17.0% [33] and 24.2% [34]). Reporting of people present throughout the patient day varied across studies. For example, in some cases each profession was reported separately, such as nursing or physiotherapy; in other cases all therapists were grouped under the classification of therapists. At times all staff were grouped together. We elected to group time with any staff member together under the heading all treating staff. Using this classification, treating staff may include nurses, therapists, doctors, psychologists, social workers, and any other health professionals. As not every health professional was represented in the data reports (e.g., four studies reported only time spent with therapists and nursing staff [32 34, 42]) the time spent with all treating staff in these studies is likely to be an underestimate. While time spent with 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%, IQR 9.7% 13.1%), apart from three patient groups which spent approximately one quarter of the day with visitors. This included two patient groups admitted to stroke units (23% [42] and 27% [44]) and one patient group admitted to a conventional care unit (25% [44]). Little time was also spent with other patients across studies (median 5.3%, IQR 3.6% 8.9%). However time spent with other patients was much greater for two patient groups which both took part in group therapy as part of their rehabilitation (24.0% [33]and 32.2% [34]). 36

49 6 Stroke Research and Treatment 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 Weerdt et al. [34] 2 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 Lincoln et al. [39] 1 Lincoln et al. [39] 2 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 A Wellwood et al. [44] Wellwood et al. [44] B Wellwood et al. [44] C Wellwood et al. [44] D Proportion of time (%) Figure 2: Proportion of time spent alone. 1 and 2 denote different time periods of observation; A, B, C, and D denote different hospital locations Patient Location. Discrepancies in the classification of patient location again made summarising data difficult. One study included time spent in lounge and dining areas with time spent in the bedroom [41], and a number of studies reported different groupings of locations such as bathrooms, corridors, lounge areas, and dining rooms. As illustrated in Figure 3 most studies reported that patients spent a substantial proportion of the day in their bedroom (median 56.5%, IQR 45.2% 72.5%). Very little time was spent in therapy areas (median 6.4%, IQR 3.4% 14.7%). However in a number of studies it was reported that therapy often took place in other areas such as the bedroom, hallway, lounge, or off the ward [32, 37, 39] Organisation of Care and Time after Stroke. Variation in activity, time alone and with others, and location when data were grouped across the different patient settings and from an early time post stroke are presented in Figure 4. Patients within 14 days of their stroke and those managed in conventional care wards appear to spend a greater proportion 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 time alone (median 57.7%, IQR 54.2% to 60.9% and median 60.0%, IQR 59.0% to 69.0%, resp.). Patients admitted to conventional care appeared to spend less time with treating staff (median 15.0%, IQR 15.0% to 22.0%) than those admitted to stroke units or general rehabilitation (Figure 2). There did not appear to be any differences in time spent with staff based on the acuity of stroke. Patients observed within 14 days after stroke appeared to spend the most time by their bedside (median 82.1%, IQR 78.8% to 85.3%). They were also less frequently observed in therapy areas (Figure 4). The two studies that included details of the time patients within 14 days after stroke spent in therapy areas reported figures of only 0.2% [31] and 3.9% [32] of the day. Patients admitted under stroke unit care appeared to spend the least amount of time bedside (median 49.1%, IQR 35.2% to 62.9%). Patients admitted to general rehabilitation units appeared to spend the most time in the therapy area (median 12.5%, IQR 11.8% 13.3%) Therapy Specific Activity Activity Monitoring Methods. Ten studies were identified which examined the physical activity undertaken by patients specifically during therapy time (Table 3). Various methods of observation were used to determine patient activity including behavioural mapping, therapist report, and video recording. The number of therapy sessions observed also varied across studies, ranging from single sessions to all sessions across the length of admission. High interrater reliability was reported for the behavioural mapping method in two publications [32, 46]. Reliability was not reported in the remaining behavioural mapping studies, and there were no reports of the validation of mapping procedures. Video recording was also reported to have good interrater reliability in two studies [48, 51] and good intrarater reliability in another study [49], but again validity was not tested. The reliability of the therapist report method was not reported in any publication; however two studies reported that validity had been previously established for this method [32, 46]. 37

50 Stroke Research and Treatment 7 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 Weerdt et al. [34] 2 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 Lincoln et al. [39] 1 Lincoln et al. [39] 2 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 Proportion of time (%) Bedroom Therapy area Other or unreported Figure 3: Patient location. 1 and 2 denote different time periods of observation; A, B, C, and D denote different hospital locations; bedside time includes time in lounge and dining areas Participants Monitored. Patients were in the rehabilitation phase of their stroke recovery in the majority of studies; however once again this concept was not well defined across publications, and the exact time following stroke at the commencement of observation could only be determined from five studies [32, 46, 47, 51, 53]. All studies examining rehabilitation patients were carried out in either mixed rehabilitation units or stroke rehabilitation units. Two studies examined acute stroke patients (within 14 days after stroke) in either acute or comprehensive stroke unit settings [32, 46]. The average ages of patients across the therapy-specific studies ranged from 62.7 to 76.5 years. Stroke severity was again difficult to compare across studies due to the variety of impairment measures used. One study only reported data for less severe strokes during the second week of admission to rehabilitation [47] and in another study patients were excluded if they were unable to walk at least 14 meters with minimal assistance [49], thereby limiting the data to milder strokes 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 Therapy Settings. Five studies examined activity during 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, occupational therapy and physiotherapy data are presented separately for each study, with the exception of one study [45] where only pooled therapy data was available (Table 4). Data from individual therapy sessions and from group therapy sessions are also presented separately for one study [49]. Four studies compared different patient groups based on the site where the unit was based or the total length of rehabilitation admission. Where available, the data for each group is presented separately in the current paper however patient groups were excluded where the same group was analysed in a previous study. Sample sizes for each data subset varied from 11 to 972 across the included studies Therapy Intensity. From the data available in each publication therapy intensity was determined in terms of minutes of therapy per session or minutes of therapy per day (Table 4). In all but one study this was determined separately for occupational therapy or physiotherapy. Median session time was 40.6 (IQR ) minutes for physiotherapy and 35.8 (IQR ) minutes for occupational therapy. Patients in the acute phase of stroke tended to have shorter therapy sessions [32, 46] (Table 4). Daily therapy time showed considerable variation for physiotherapy (median 63.2 minutes, IQR ) and occupational therapy 38

51 8 Stroke Research and Treatment Proportion of time (%) No therapeutic activity Moderate to high Alone With treating staff Bedroom Therapy area therapeutic activity Total Conventional care unit General rehabilitation unit <14 d post-stroke Stroke unit 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 ). This variation existed even across the acute stroke patients alone, with one study of acute strokes reporting a daily therapy time of only 18.1 minutes of physiotherapy and 10.7 minutes of occupational therapy [46] compared to another study reporting 57.4 minutes per day of physiotherapy [32] Therapy Activity. The type of physical activity undertaken by stroke patients during therapy time was grouped in the same activity categories as for general patient activity. Although data were incomplete in some publications and there were differences in the classification of the type of activity across the included studies, in general it was possible to extract and classify activity into nil, low and moderatehigh categories. Figure 5 illustrates the proportion of time spent in the different activity levels from each study. Although the majority of reported activity in therapy time was in the low and moderate to high categories, in four studies patients were still inactive for more than 20% of therapy time [45, 46, 49, 51]. This included one study where patients were recorded as having nil physical activity for 58% of the therapy session [45]. A greater proportion of time appears to be spent in moderate to high physical activity during physiotherapy sessions compared to occupational therapy sessions. Only one study focused on patients within 14 days of their stroke, and the proportion of moderate to high physical activity undertaken during therapy time from this study did not appear to be very different from the other studies [46] Upper Limb Therapy. In six of the included publications the proportion of therapy time specifically spent treating the upper limb (Figure 6)wasreported.Upperlimb treatment time accounted for a median of 16.0% of therapy time (IQR 6.9% 22.9%). 4. Discussion This paper has identified a range of methods applied across a number of hospital settings to monitor physical activity after stroke. Behavioural mapping, using structured observation at regular intervals throughout the day, was commonly employed in these studies and is reported to be reliable. In order to capture typical patient activity, all studies carried out mapping during the usual working day when patients are most active. In some studies patients were also mapped on weekends and after hours. Observations were most frequently carried out every 10 minutes, suggesting that this time frame was considered frequent enough to minimise missed activity, but not so frequent that observations were no longer feasible. Behavioural mapping was also used to monitor therapy specific activities; however as observations only occur on an intermittent basis, video recording and therapist report were also used and may provide a more accurate means of evaluating physical activity during formal therapy time. Despite the similarity in activity monitoring procedures, there was large variation across publications in the way in which activity was categorised. Classification of the locations 39

52 Stroke Research and Treatment 9 Table 3: Therapy-specific activity studies. Study Method Procedure Therapy Patient type Ada et al. [45] Bernhardtetal. [46] Behavioural mapping Behavioural mapping and therapist report Behavioural Bernhardtetal. [32] a mapping and therapist report Bode et al. [47] b Therapist report De Wit et al. [48] Video recording Elson et al. [49] Video recording Jette et al. [50] Kuys et al. [51] Latham et al. [52] McNaughton et al. [53] c Therapist report Video recording and heart rate monitoring Therapist report Therapist report Every 10 mins for all sessions across 3-4 weekdays Mapping every 10 mins plus therapist report, for all sessions across 2 weekdays Mapping every 10 mins plus therapist report, for all sessions over 1 weekday All therapy sessions across admission recorded, but data only reported for 2nd week Single OT and single PT session Single individual session and single group session All therapy sessions across admission Single session All therapy sessions across admission All therapy sessions across admission PT and OT Rehabilitation inpatients Organisation of care n GRU 16 PT and OT Acute inpatients SU 58 PT Acute inpatients SU 37 PT and OT PT and OT PT PT PT OT PT and OT Rehabilitation inpatients Rehabilitation inpatients Rehabilitation inpatients Rehabilitation inpatients Rehabilitation inpatients and outpatients Rehabilitation inpatient Rehabilitation inpatient GRU 101 SU 60 GRU 15 GRU 972 GRU 30 GRU 954 GRU 130 a Data for Trondheim patients only; b data for less impaired patients only, during second week of inpatient rehabilitation admission; c data for New Zealand patients only; GRU: general rehabilitation unit (includes mixed rehabilitation units); SU: stroke unit (includes acute stroke units, comprehensive stroke units and stroke rehabilitation units); OT: occupational therapy; PT: physiotherapy. in which activity took place, as well as the people with whom it took place also varied across studies. This variation made comparison of patient activity across studies difficult and required us to make a number of assumptions when extracting data. Recreation, relaxation, and leisure activities were classified as nontherapeutic in terms of physical activity since recreation was commonly described as including activities such as reading, watching TV, watching others, and social interaction [42, 43]. Furthermore, patients were assumed to be in sitting when being transported or involved in self-care, which is commonly the case, and were therefore classified in the low activity category. Formal therapy and self-exercise described in five of the general activity studies [33 38] was classified in the moderate to high level activity category, since the majority of therapy time was spent with physiotherapists and occupational therapists who focus largely on physical function. However, data from the therapyspecific studies suggests that a considerable amount of therapy may have taken place with the patient involved in low or even no physical activity. It is not surprising that a proportion 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 a small overestimate of overall activity across the day. Within the therapy-specific studies in which therapy content was often reported, we classified impairment-focused therapy such as stretching, passive movements, selective movement facilitation, strengthening, and balance work as low physical activity and therapy described only as functional activity as moderate to high physical activity. This seems a very reasonable approach to classification of activity within therapy in the face of poor definition; nevertheless, it is also possible that the classification assumptions led to over-or underestimation of patient activity. The use of assumptions to help summarise available data is not ideal. It became apparent early in the conduct of this paper that there is an urgent need for researchers to provide clear description of the activities observed, or better still, for the development and use of a standard classification system for physical activity categories for people after stroke. Suchasystemshouldprobablybebasedtoalargerextent on how hard the patients must work to engage in different levels of activity and include energy expenditure expressed as METS. However, while such a classification system exists in healthy subjects [54], further research on the energy expenditure of people with stroke during activity at different stages in recovery is needed. Until then, activity classification, particularly of observed activity, will continue to rely on clinical judgment. 40

53 10 Stroke Research and Treatment Table 4: Therapy activity patient groups and therapy intensity. Study Therapy Patientgroup Setting n Minutes per session Minutes per day Ada et al. [45] PT and OT Full sample Rehabilitation Bernhardtetal.[46] PT PT Full sample Acute Bernhardtetal.[46] OT OT Full sample Acute Bernhardtetal.[32] PT Trondheim Rehabilitation Bode et al. [47] 2 wks PT PT 2 week admission Rehabilitation Bode et al. [47] 3 wks PT 3 week admission Rehabilitation Bode et al. [47] 4 wks PT 4 week admission Rehabilitation Bode et al. [47] 5 wks PT 5 week admission Rehabilitation Bode et al. [47] 2 wks OT OT 2 week admission Rehabilitation Bodeet al. [47] 3 wks OT 3 week admission Rehabilitation Bodeet al. [47] 4 wks OT 4 week admission Rehabilitation Bode et al. [47] 5 wks OT 5 week admission Rehabilitation De Wit et al. [48] B, PT PT Belgium Rehabilitation DeWitet al. [48] UK, PT United Kingdom Rehabilitation De Wit et al. [48] S, PT Switzerland Rehabilitation De Wit et al. [48] G, PT Germany Rehabilitation De Wit et al. [48] B, OT OT Belgium Rehabilitation DeWitet al. [48] UK, OT United Kingdom Rehabilitation De Wit et al. [48] S, OT Switzerland Rehabilitation De Wit et al. [48] G, OT Germany Rehabilitation Elson et al. [49] indiv PT PT Individual therapy Rehabilitation Elson et al. [49] group PT Group therapy Rehabilitation Jette et al. [50] PT Full sample Rehabilitation Kuys et al. [51] PT Full sample Rehabilitation Latham et al. [52] OT Full sample Rehabilitation McNaughton et al. [53] PT PT New Zealand Rehabilitation McNaughton et al. [53] OT OT New Zealand Rehabilitation OT: occupational therapy, PT: physiotherapy. Regardless of these limitations some consistent trends in patient activity were revealed across the studies reviewed. A large proportion of stroke inpatient time is spent inactive or involved in nontherapeutic activity. Comparatively little time appears spent involved in moderate to high level physical activities such as standing and walking. Additionally hospitalised stroke patients tend to spend most of their time alone and in their bedroom area. Although few studies investigated patients in the acute phase of their stroke, it appears that this lack of activity and isolation are especially prevalent for patients within 14 days of stroke compared to those at later stages of recovery. The current paper suggests that hospitalised stroke patients are involved in an average of approximately one hour per day of formal physiotherapy and one hour per day of formal occupational therapy. Even during this time it was reported in a number of studies that patients were involved in little or no physical activity for part of the session. Patients frequently spent less than half their therapy time involved in moderate to high physical activities such as standing and walking, and even less time was spent on therapy for the upper limb. It appears that patient activity may be influenced by the organisation of care. Patients admitted to conventional care units such as general medical wards, elderly care units, or general neurology wards appeared to be inactive, alone, and in their bedroom area for longer than patients admitted to stroke units or general rehabilitation units. Patients admitted to stroke units appeared to spend the most time involved in moderate to high physical activity and the least time located in bedside areas when compared with patients admitted to conventional care or general rehabilitation. These apparent differences however may be simply due to case-mix variation across the different samples studied. Further comparison across settings could provide insights into the barriers or facilitators to activity in different organisational settings. However this would require standard data to be available from each study to allow for adjustment for important patient and setting factors that may influence activity. The absence of even a common measure of stroke severity across studies hampered further exploration of these data. Patients did appear to be more active during formal therapy time, and it is tempting to suggest that increasing the time spent in formal therapy may help to increase physical activity in hospitalised stroke patients. Group therapy may be one approach to increasing formal therapy time. Patients participating in group therapy were found to be involved in more formal therapy and more physical activity [33, 34, 37, 49] and to spend less time alone [33, 34]; however 41

54 Stroke Research and Treatment 11 Ada et al. [45] Bernhardt et al. [46] PT Bernhardt et al. [46] OT Bode et al. [47] 2 wks PT Bode et al. [47] 3 wks PT Bode et al. [47] 4 wks PT Bode et al. [47] 5 wks PT Bode et al. [47] 2 wks OT Bode et al. [47] 3 wks OT Bode et al. [47] 4 wks OT Bode et al. [47] 5 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 Jette et al. [50] Kuys et al. [51] Latham et al. [52] McNaughton et al. [53] PT McNaughton et al. [53] OT Nil Low Proportion of time (%) Moderate to high Unobserved or unreported Figure 5: Therapy activity. Data pooled across sites by authors of original study. Ada et al. [45] 10.9 Bernhardt et al. [46] 21 Bernhardt et al. [32] 38.4 Kuys et al. [51] 5.6 Latham et al. [52] 22.9 McNaughton et al. [53] OT Proportion of therapy time (%) Figure 6: Upper limb therapy. Affected upper limb use across physiotherapy, occupational therapy, and speech therapy time. the proportion of time spent in high level activities such as walking was reported to be lower during group therapy than in individual sessions [49]. More structured therapy sessions withaformalschedulewerealsosuggestedasameansof increasing 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 intensity of activity that stroke patients should engage in during the hospitalised phase of their care to help their recovery. Nevertheless, the low levels of physical activity commonly found in these studies suggest that more could be done. Increasing formal therapy time is only one way in which physical activity could be improved. Greater involvement of nontherapy staff, particularly nursing staff, in facilitating patient activity may help to increase physical activity in hospitalised stroke patients [32, 43]. This may be promoted through the education and training of nontherapy staff in facilitating patient activity [32, 40] and through therapists working together with other staff [32]. The current paper found that a median of less than one quarter of patient time was spent with treating staff.a number of authors suggest that increasing self-directed patient activity could be another means of increasing physical activity [29, 30, 33, 39, 40, 43]. Greater self-directed activity may be encouraged with patient education and instruction in self-directed exercises [30, 35] and activity diaries [29, 43]. Environmental modifications to promote self-directed activity are recommended [32, 35 38]. In addition greater family involvement [29, 33, 36, 40, 43] and the introduction of an activities coordinator [29, 39] are also suggested to assist with self-directed activity. 5. Conclusions Physical activity is commonly monitored in hospitalised stroke patients using behavioural mapping which is easy to 42

55 12 Stroke Research and Treatment conduct and which provides a rich source of data across a day. The use of accelerometers, step counters, and other devices is becoming more frequent and may provide more accurate monitoring of activity after stroke, although their reliability, accuracy in very low functioning patients, ease of use, and the comfort of patients when wearing the device need to be considered. Unlike accelerometers, observation also provides the researcher with information about the location of patients when they are active and who was with them during the activity. This paper has shown however that considerable improvements to how activity is described and classified would greatly improve our ability to compare activity across populations, settings, or time points in the recovery pathway. 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57 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

58 4.1 Abstract Objective: To describe the physical activity undertaken by patients within 14 days poststroke 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

59 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 poststroke 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

60 during formal therapy; when patients first commenced physical activity out of bed and who initiated this. 4.3 Method 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 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

61 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 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] 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 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

62 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 Patient characteristics 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

63 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

64 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 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. 52

65 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

66 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 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

67 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

68 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

69 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 patientinitiated 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

70 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

71 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

72 4.7 References 1. Intercollegiate Stroke Working Party. National Clinical Guidelines for Stroke. 3rd ed. London: Royal College of Physicians: National Stroke Foundation. Clinical Guidelines for Stroke Management Melbourne: Scottish Intercollegiate Guidelines Network. Management of Patients with Stroke: Rehabilitation, Prevention and Management of Complications and Discharge Planning. A National Clinical Guideline. Edinburgh: 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): 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): 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): 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): 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): 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 trial of very early rehabilitation after stroke (AVERT). Cerebrovascular Diseases. 2008; 26(5): 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): West T, Bernhardt J. Physical activity in hospitalised stroke patients. Stroke Research and Treatment. 2012;

73 12. 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): 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): 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): 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): Stroke Unit Trialists Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews. 2007; (4): CD Langhorne P, Pollock A, Stroke Unit Trialists Collaboration. What are the components of effective stroke unit care? Age and Ageing. 2002; 31(5): West T, Langhorne P, Bernhardt J. How do comprehensive and acute stroke units differ? International Journal of Therapy and Rehabilitation. In Press, 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): 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): 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): 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): 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): 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):

74 25. 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): 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): 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): 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): 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): 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): 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): 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): 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):

75 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

76 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 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

77 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 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 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

78 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 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 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 Patient characteristics 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 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

79 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 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 (premorbid 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

80 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 Patient characteristics 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

81 Table 1. Patient characteristics ASU CSU N Age Median (IQR) 78.8 ( ) 75.5 ( ) 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 ( ) 7.0 ( ) 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 ( ) 6.0 ( ) 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

82 5.3.2 Behavioural mapping data 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 ) for the CSU patients compared to only 3.8% (IQR ) for the ASU patients. Conversely, ASU patients spent more time inactive or involved in nonphysical activities (ASU: median 58.8%, IQR ; CSU: median 42.0%, IQR ). 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 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 ; CSU: median 78.0%, IQR ) (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 ) of the day for the ASU patients compared to 16.0% (IQR ) of the day for CSU patients People present In both units, patients spent more than half the day alone (ASU: median 58.8%, IQR ; CSU: median 54.0%, IQR ) (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 ; CSU: 12.0%, ). 70

83 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 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

84 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 ) in the CSU compared to only 5.0 minutes (IQR ) 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 ( ) 36.0 ( ) Range Therapy minutes per session Median (IQR) 20.0 ( ) 40.0 ( ) Range Frequency of therapy sessions per day n (%) 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 ( ) 20.0 ( ) Range Therapy minutes per session Median (IQR) 29.5 ( ) 30.0 ( ) Range Frequency of therapy sessions per day n (%) None 57 (78.1) 25 (34.2) One 16 (21.9) 44 (60.3) Two 0 (0.0) 4 (5.5) 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

85 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 Median (IQR) 3.6 ( ) 6.4 ( ) Range Stroke to mobilisation (hours) N Median (IQR) 51.0 ( ) 32.0 ( ) Range Admission to mobilisation (hours) N Median (IQR) 28.4 ( ) 20.6 ( ) Range * Mann Whitney U test Discharge data The median length of stay was 13.0 days (IQR ) for the ASU patients and 14.0 days (IQR ) 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 ; 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 ; p=0.007). 73

86 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

87 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

88 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

89 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

90 5.6 References 1. Stroke Unit Trialists Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews. 2007; (4): CD 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): Stroke Unit Trialists Collaboration. How do stroke units improve patient outcomes? A collaborative systematic review of the randomized trials. Stroke. 1997; 28(11): Cavallini A, Micieli G, Marcheselli S, Quaglini S. Role of monitoring in management of acute ischemic stroke patients. Stroke. 2003; 34(11): 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 ischemic stroke. Journal of Neurology. 2008; 255(7): Silva Y, Puigdemont M, Castellanos M, Serena J, Suer R, Garca M, et al. Semiintensive monitoring in acute stroke and long-term outcome. Cerebrovascular Diseases. 2005; 19(1): Sulter G, Elting JW, Langedijk M, Maurits NM, De Keyser J. Admitting acute ischemic stroke patients to a stroke care monitoring unit versus a conventional stroke unit: a randomized pilot study. Stroke. 2003; 34(1): West T, Langhorne P, Bernhardt J. How do comprehensive and acute stroke units differ? International Journal of Therapy and Rehabilitation. In Press, 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): 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): 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): 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):

91 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): 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): 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): 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): 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): 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): 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 trial of very early rehabilitation after stroke (AVERT). Cerebrovascular Diseases. 2008; 26(5): 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):

92 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

93 6.2 Clinical implications 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 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

94 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 nontherapy 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

95 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 selfdirected 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

96 (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

97 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

98 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

99 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 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

100 evaluation of cost effectiveness, in order to provide more robust evidence for the benefits of one model of stroke unit care over another 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

101 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. 6.6 References 1. Foley N, Salter K, Teasell R. Specialized stroke services: a meta-analysis comparing three models of care. Cerebrovascular Diseases. 2007; 23(2-3): Stroke Unit Trialists Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews. 2007; (4): CD Chan DKY, Cordato D, O'Rourke F, Chan DL, Pollack M, Middleton S, et al. Comprehensive stroke units: a review of comparative evidence and experience. International Journal of Stroke. 2012; 4. Cavallini A, Micieli G, Marcheselli S, Quaglini S. Role of monitoring in management of acute ischemic stroke patients. Stroke. 2003; 34(11): 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 ischemic stroke. Journal of Neurology. 2008; 255(7): Silva Y, Puigdemont M, Castellanos M, Serena J, Suer R, Garca M, et al. Semiintensive monitoring in acute stroke and long-term outcome. Cerebrovascular Diseases. 2005; 19(1): Sulter G, Elting JW, Langedijk M, Maurits NM, De Keyser J. Admitting acute ischemic stroke patients to a stroke care monitoring unit versus a conventional stroke unit: a randomized pilot study. Stroke. 2003; 34(1): National Stroke Foundation. Clinical Guidelines for Stroke Management Melbourne: National Stroke Foundation. National Stroke Audit - Acute Services Organisational Survery Report Melbourne:

102 10. 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): 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): 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): 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): 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): 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): 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): King A, McCluskey A, Schurr K. The time use and activity levels of inpatients in a co-located acute and rehabilitation stroke unit: an observational study. Topics in Stroke Rehabilitation. 2011; 18(Suppl 1): 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): 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): Tinson DJ. How stroke patients spend their days. An observational study of the treatment regime offered to patients in hospital with movement disorders following stroke. International Disability Studies. 1989; 11(1):

103 21. Lincoln NB, Willis D, Philips SA, Juby LC, Berman P. Comparison of rehabilitation practice on hospital wards for stroke patients. Stroke. 1996; 27(1): Bear-Lehman J, Bassile CC, Gillen G. A comparison of time use on an acute rehabilitation unit: subjects with and without a stroke. Physical and Occupational Therapy in Geriatrics. 2001; 20(1): De Weerdt W, Selz B, Nuyens G, Staes F, Swinnen D, Winckel Avd, et al. Time use of stroke patients in an intensive rehabilitation unit: a comparison between a Belgian and a Swiss setting. Disability and Rehabilitation. 2000; 22(4): Lincoln NB, Gamlen R, Thomason H. Behavioural mapping of patients on a stroke unit. International Disability Studies. 1989; 11(4): Newall JT, Wood VA, Hewer RL, Tinson DJ. Development of a neurological rehabilitation environment: an observational study. Clinical Rehabilitation. 1997; 11(2): Esmonde T, McGinley J, Wittwer J, Goldie P, Martin C. Stroke rehabilitation: patient activity during non-therapy time. Journal of Physiotherapy. 1997; 43(1): Ada L, Dean CM, Mackey FH. Increasing the amount of physical activity undertaken after stroke. Physical Therapy Reviews. 2006; 11(2): De Wit L, Putman K, Dejaeger E, Baert I, Berman P, Bogaerts K, et al. Use of time by stroke patients: a comparison of four European rehabilitation centers. Stroke. 2005; 36(9): Keith RA. Activity patterns of a stroke rehabilitation unit. Social Science and Medicine. 1980; 14A(6): Keith RA, Cowell KS. Time use of stroke patients in three rehabilitation hospitals. Social Science and Medicine. 1987; 24(6): 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): Mackey F, Ada L, Heard R, Adams R. Stroke rehabilitation: are highly structured units more conducive to physical activity than less structured units? Archives of Physical Medicine and Rehabilitation. 1996; 77(10): National Stroke Foundation. Acute Stroke Services Framework Melbourne:

104 34. De Weerdt W, Nuyens G, Feys H, Vangronsveld P, Nieuwboer A, Osaer J, et al. Group physiotherapy improves time use by patients with stroke in rehabilitation. Australian Journal of Physiotherapy. 2001; 47(1): Elson T, English C, Hillier S. How much physical activity do people recovering from stroke do during physiotherapy sessions? International Journal of Therapy and Rehabilitation. 2009; 16(2): Kaur G, English C, Hillier S. How physically active are people with stroke in physiotherapy sessions aimed at improving motor function? A systematic review. Stroke Research and Treatment. 2012; Ada L, Mackey F, Heard R, Adams R. Stroke rehabilitation: does the therapy area provide a physical challenge? Journal of Physiotherapy. 1999; 45(1): Kuys S, Brauer S, Ada L. Routine physiotherapy does not induce a cardiorespiratory training effect post-stroke, regardless of walking ability. Physiotherapy Research International. 2006; 11(4): 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): 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): Langhorne P, Pollock A, Stroke Unit Trialists Collaboration. What are the components of effective stroke unit care? Age and Ageing. 2002; 31(5): 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): Cadilhac DA, Pearce DC, Levi CR, Donnan GA. Improvements in the quality of care and health outcomes with new stroke care units following implementation of a clinician-led, health system redesign programme in New South Wales, Australia. Quality and Safety in Health Care. 2008; 17(5): National Stroke Foundation. National Stroke Audit - Acute Services Clinical Audit Report Melbourne: DeJong G, Horn SD, Conroy B, Nichols D, Healton EB. Opening the black box of poststroke rehabilitation: stroke rehabilitation patients, processes, and outcomes. Archives of Physical Medicine and Rehabilitation. 2005; 86(12 Suppl 2): S1-S7. 92

105 46. Putman K, De Wit L. European comparison of stroke rehabilitation. Topics in Stroke Rehabilitation. 2009; 16(1): Diserens K, Michel P, Bogousslavsky J. Early mobilisation after stroke: review of the literature. Cerebrovascular Diseases. 2006; 22(2-3): 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): Dean CM, Rissel C, Sherrington C, Sharkey M, Cumming RG, Lord SR, et al. Exercise to enhance mobility and prevent falls after stroke: the community stroke club randomized trial. Neurorehabilitation and Neural Repair. 2012; 26(9): Tilson JK, Wu SS, Cen SY, Feng Q, Rose DR, Behrman AL, et al. Characterizing and identifying risk for falls in the LEAPS study: a randomized clinical trial of interventions to improve walking poststroke. Stroke. 2012; 43(2): 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):

106 APPENDIX A: Ethics approval - Royal Perth Hospital 94

107 APPENDIX B: Ethics approval - Austin Hospital 95

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

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

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112 APPENDIX E: Person responsible information and consent form, Royal Perth Hospital 100

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

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

121 109

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125 APPENDIX H: Observed motor activity case report form 113

126 APPENDIX I: Patient demographics case report form 114

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129 117