Research Article| Volume 29, ISSUE 6, 104809, June 2020

Effectiveness of Stroke Rehabilitation Compared between Intensive and Nonintensive Rehabilitation Protocol: A Multicenter Study


      Background and aim

      Stroke is one of the leading causes of death, physical disability, and economic burden. Nowadays, various types of rehabilitation are available. Rehabilitation centers in Thailand provide services in different ways, including starting time, duration, and frequency of each therapy. In addition, many rehabilitation wards have a standing policy to reduce length of stay (LOS) due to economic considerations. This study aimed to compare the effectiveness and efficiency between intensive and nonintensive rehabilitation protocol for stroke patients.


      This prospective, multicenter cohort study was conducted among stroke patients who admitted to rehabilitation wards at 14 centers. All participants received either intensive or non-intensive rehabilitation program. Barthel Index (BI) at admission (BIad), BI at discharge (BIdc), and LOS were recorded. The effectiveness was difference in BIdc and BIad score (ΔBI), and the efficiency was ΔBI divided by LOS (ΔBI/LOS).


      Seven hundred and eighty stroke patients were included. Mean age was 61.9 ± 13.3 years, and 59.7% were male. The majority of patients (79.5%) were admitted for intensive rehabilitation. Effectiveness and efficiency were significantly higher in the intensive group than in the nonintensive group (4.5 ± 3.4 versus 2.6 ± 3.2 and .24 ± .30 versus .18 ± .33, respectively). LOS, intensive rehabilitation, and quality of life were significantly positively correlated with effectiveness; whereas, age, onset to admission interval (OAI), and BIad were significantly negatively correlated with the effectiveness of stroke rehabilitation.


      Stroke patients admitted for intensive rehabilitation had better effectiveness and efficiency than those admitted for non-intensive rehabilitation. Younger patients with shorter OAI, lower BIad, and longer LOS realized significantly enhanced effectiveness.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Stroke and Cerebrovascular Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Mozaffarian D.
        • Benjamin E.J.
        • Writing Group Members
        Heart disease and stroke statistics-2016 update: a report from the American Heart Association.
        Circulation. 2016; 133: e38-360
        • Miller E.L.
        • Murray L.
        • Richards L.
        • et al.
        Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association.
        Stroke. 2010; 41: 2402-2448
        • Anderson C.S.
        • Linto J.
        • Stewart-Wynne E.G.
        A population-based assessment of the impact and burden of caregiving for long-term stroke survivors.
        Stroke. 1995; 26: 843-849
        • Tian W.
        An All-Payer View of Hospital Discharge to Postacute Care, 2013: Statistical Brief #205.
        in: Healthcare Cost and Utilization Project) HCUP) Statistical Briefs [Internet]. Agency for Healthcare Research and Quality) US, RockvilleMD2006 ([cited 2017 Aug 21]. Available at:) (Accessed 21 August 2017)
        • Hachinski V.
        • Donnan G.A.
        • Gorelick P.B.
        • et al.
        Stroke: working toward a prioritized world agenda.
        Int J Stroke. 2010; 5: 238-256
        • Pollock A.
        • Baer G.
        • Campbell P.
        • et al.
        Physical rehabilitation approaches for the recovery of function and mobility following stroke.
        Cochrane Database Syst Rev. 2014; 4 (CD001920)
        • Denti L.
        • Artoni A.
        • Casella M.
        • et al.
        Validity of the modified Charlson Comorbidity Index as predictor of short-term outcome in older stroke patients.
        J Stroke Cerebrovasc Dis. 2015; 24: 330-336
        • Meyer M.J.
        • Pereira S.
        • McClure A.
        • et al.
        A systematic review of studies reporting multivariable models to predict functional outcomes after post-stroke inpatient rehabilitation.
        Disabil Rehabil. 2015; 37: 1316-1323
        • Langhorne P.
        • Pollock A.
        Stroke Unit Trialists’ Collaboration. What are the components of effective stroke unit care?.
        Age Ageing. 2002; 31: 365-371
        • Abilleira S.
        • Ribera A.
        • Sánchez E.
        • et al.
        The second stroke audit of catalonia shows improvements in many, but not all quality indicators.
        Int J Stroke. 2012; 7: 19-24
        • Biernaskie J.
        • Chernenko G.
        • Corbett D.
        Efficacy of rehabilitative experience declines with time after focal ischemic brain injury.
        J Neurosci. 2004; 24: 1245-1254
        • Langhorne P.
        • Wu O.
        • Rodgers H.
        • et al.
        A very early rehabilitation trial after stroke (AVERT): a phase III, multicentre, randomised controlled trial.
        Health Technol Assess. 2017; 21: 1-120
        • Yagi M.
        • Yasunaga H.
        • Matsui H.
        • et al.
        Impact of rehabilitation on outcomes in patients with ischemic stroke: a nationwide retrospective cohort study in Japan.
        Stroke. 2017; 48: 740-746
        • Kinoshita S.
        • Momosaki R.
        • Kakuda W.
        • et al.
        Association between 7 days per week rehabilitation and functional recovery of patients with acute stroke: A retrospective cohort study based on the Japan Rehabilitation Database.
        Arch Phys Med Rehabil. 2017; 98: 701-706
        • Kuptniratsaikul V.
        • Wattanapa P.
        • Wathanadilokul U.
        • et al.
        The effectiveness and efficiency of inpatient rehabilitation services in Thailand: a prospective multicenter study.
        Rehabilitation Process Outcome. 2016; 5: 13-18
        • Tongsiri S.
        • Cairns J.
        Estimating population-based values for EQ-5D health states in Thailand.
        Value Health. 2011; 14: 1142-1145
        • Wade D.T.
        • Hewer R.L.
        Functional abilities after stroke: measurement, natural history and prognosis.
        J Neurol Neurosurg Psychiatry. 1987; 50: 177-182
        • Chan B.
        Effect of increased intensity of physiotherapy on patient outcomes after stroke: an economic literature review and cost-effectiveness analysis.
        Ont Health Technol Assess Ser. 2015; 15: 1-43
        • Imura T.
        • Nagasawa Y.
        • Fukuyama H.
        • et al.
        Effect of early and intensive rehabilitation in acute stroke patients: retrospective pre-/post-comparison in Japanese hospital.
        Disabil Rehabil. 2018; 40: 1452-1455
        • Pattanasuwanna P.
        • Kuptniratsaikul V.
        Inpatient rehabilitation outcomes in patients with stroke at Thailand's largest tertiary referral center: a 5-year retrospective study.
        J Scientific Res Studies. 2017; 4: 208-216
        • Balu S.
        Differences in psychometric properties, cut-off scores, and outcomes between the Barthel Index and Modified Rankin Scale in pharmacotherapy-based stroke trials: systematic literature review.
        Curr Med Res Opin. 2009; 25: 1329-1341
        • Kwon S.
        • Hartzema A.G.
        • Duncan P.W.
        • et al.
        Disability measures in stroke: relationship among the Barthel Index, the Functional Independence Measure, and the Modified Rankin Scale.
        Stroke. 2004; 35: 918-923
        • Kuptniratsaikul V.
        • Kovindha A.
        • Dajpratham P.
        • et al.
        Main outcomes of stroke rehabilitation: a multi-centre study in Thailand.
        J Rehabil Med. 2009; 41: 54-58
        • Teasell R.W.
        • Foley N.C.
        • Bhogal S.K.
        • et al.
        A rehabilitation program for patients recovering from severe stroke.
        Can J Neurol Sci. 2005; 32: 512-517
        • Di Carlo A.
        • Lamassa M.
        • Baldereschi M.
        • et al.
        European BIOMED Study of Stroke Care Group. Risk factors and outcome of subtypes of ischemic stroke. Data from a multicenter multinational hospital-based registry. The European Community Stroke Project.
        J Neurol Sci. 2006; 244: 143-150
        • Jones S.
        • Nyberg L.
        • Sandblom J.
        • et al.
        Cognitive and neural plasticity in aging: general and task-specific limitations.
        Neurosci Biobehav Rev. 2006; 30: 864-871
        • Ruth P.
        Ageing and the brain.
        Postgrad Med J. 2006; 82: 84-88
        • Paolucci S.
        • Antonucci G.
        • Grasso M.G.
        • et al.
        Early versus delayed inpatient stroke rehabilitation: a matched comparison conducted in Italy.
        Arch Phys Med Rehabil. 2000; 81: 695-700
        • Maulden S.A.
        • Gassaway J.
        • Horn S.D.
        • et al.
        Timing of initiation of rehabilitation after stroke.
        Arch Phys Med Rehabil. 2005; 86: S34-S40
        • Manimmanakorn N.
        • Vichiansiri R.
        • Nuntharuksa C.
        • et al.
        Quality of life after stroke rehabilitation among urban vs. rural patients in Thailand.
        J Med Assoc Thai. 2008; 91: 394-399
        • Madden S.
        • Hopman W.M.
        • Bagg S.
        • et al.
        Functional status and health-related quality of life during inpatient stroke rehabilitation.
        Am J Phys Med Rehabil. 2006; 85: 831-838
        • Hopman W.M.
        • Verner J.
        Quality of life during and after inpatient stroke rehabilitation.
        Stroke. 2003; 34: 801-805