title: Access, timing and frequency of very early stroke rehabilitation - insights from the Baden-Wuerttemberg stroke registry.
abstract: BACKGROUND
  While the precise timing and intensity of very early rehabilitation (VER) after stroke onset is still under discussion, its beneficial effect on functional disability is generally accepted. The recently published randomized controlled AVERT trial indicated that patients with severe stroke might be more susceptible to harmful side effects of VER, which we hypothesized is contrary to current clinical practice. We analyzed the Baden-Wuerttemberg stroke registry to gain insight into the application of VER in acute ischemic stroke (IS) and intracerebral hemorrhage (ICH) in clinical practice.
  
  
  METHODS
  99,753 IS patients and 8824 patients with ICH hospitalized from January 2008 to December 2012 were analyzed. Data on the access to physical therapy (PT), occupational therapy (OT), and speech therapy (ST), the time from admission to first contact with a therapist and the average number of therapy sessions during the first 7 days of admission are reported. Multiple logistic regression models adjusted for patient and treatment characteristics were carried out to investigate the influence of VER on clinical outcome.
  
  
  RESULTS
  PT was applied in 90/87% (IS/ICH), OT in 63/57%, and ST in 70/65% of the study population. Therapy was mostly initiated within 24 h (PT 87/82%) or 48 h after admission (OT 91/89% and ST 93/90%). Percentages of patients under therapy and also the average number of therapy sessions were highest in those with a discharge modified Rankin Scale score of 2 to 5 and lowest in patients with complete recovery or death during hospitalization. The outcome analyses were fundamentally hindered due to biases by individual decision making regarding the application and frequency of VER.
  
  
  CONCLUSIONS
  While most patients had access to PT we noticed an undersupply of OT and ST. Only little differences were observed between patients with IS and ICH. The staff decisions for treatment seem to reflect attempts to optimize resources. Patients with either excellent or very unfavorable prognosis were less frequently assigned to VER and, if treated, received a lower average number of therapy sessions. On the contrary, severely disabled patients received VER at high frequency, although potentially harmful according to recent indications from the randomized controlled AVERT trial.
authors.affiliation: Department of Neurology and Neurophysiology, University Hospital Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany. bjoern.reuter@uniklinik-freiburg.de.
authors.forename: Björn
authors.identifier: http://orcid.org/0000-0001-7659-4165
authors.initials: B
authors.lastname: Reuter
authors.affiliation: Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany.
authors.forename: Christoph
authors.initials: C
authors.lastname: Gumbinger
authors.affiliation: Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany.
authors.forename: Tamara
authors.initials: T
authors.lastname: Sauer
authors.affiliation: formerly affiliated to Department of Neurology, Bürgerhospital, Stuttgart, Germany.
authors.forename: Horst
authors.initials: H
authors.lastname: Wiethölter
authors.affiliation: Office for Quality Assurance in Hospitals (GeQiK), Baden-Wuerttembergische Hospital Association, Stuttgart, Germany.
authors.forename: Ingo
authors.initials: I
authors.lastname: Bruder
authors.affiliation: Department of Internal/Vascular Medicine, Max-Grundig-Klinik, Bühl, Germany.
authors.forename: Curt
authors.initials: C
authors.lastname: Diehm
authors.affiliation: Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Ringleb
authors.affiliation: Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany.
authors.forename: Werner
authors.initials: W
authors.lastname: Hacke
authors.affiliation: Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany.
authors.forename: Michael G
authors.initials: MG
authors.lastname: Hennerici
authors.affiliation: Department of Neurology, Klinikum Kempten-Oberallgaeu, Kempten, Germany.
authors.forename: Rolf
authors.initials: R
authors.lastname: Kern
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009788:Occupational Therapy / Q000379:methods; D026741:Physical Therapy Modalities; D016032:Randomized Controlled Trials as Topic; D020127:Recovery of Function; D012042:Registries; D013070:Speech Therapy / Q000379:methods; D000071939:Stroke Rehabilitation / Q000379:methods*
keywords: Acute stroke; Occupational therapy; Physical therapy; Rehabilitation; Speech therapy; Stroke unit concept