May 5, 2000 -- Patients are always anxious to get out of the hospital. Now there's a good reason why, at least for those who suffer a stroke. Home may be the best place for stroke victims to speed up their recovery. And, according to researchers, the sooner a patient is sent home, the better. However, it's not always affordable.
In a study in the May issue of the journal Stroke, researchers found that stroke patients who rehabilitated at home after only 10 days in the hospital had a faster recovery and, after three months, were farther advanced in assimilating back into their familiar surroundings then those who weren't sent home.
Lead researcher Nancy E. Mayo, PhD, tells WebMD that patients largely rehabilitated at home were able to perform activities of daily living at higher levels than those who received more traditional rehab. "Patients who received traditional care felt more isolated, more dependent, and showed less [control over their muscles]. We also found home care can cost less," Mayo says. She is an associate professor in the division of clinical epidemiology at Royal Victoria Hospital in Montreal.
One neurologist not surprised by the findings is Tim Lachman, MD, a neurologist in Philadelphia. "Most patients are happier and have better morale when they're in their home rather than in a hospital or a rehab center," Lachman tells WebMD. "A goal of stroke treatment is to get patients back into their own environment with the best amount of restored functioning."
According to the American Heart Association (AHA), a stroke occurs when a blood vessel bringing oxygen and nutrients to the brain bursts or is clogged by a blood clot or by thickening of the artery wall. Because of this rupture or blockage, part of the brain doesn't get the blood flow it needs. Without oxygen, nerve cells in the affected area of the brain stop functioning within minutes. Besides being the third leading cause of death in the U.S., stroke is a leading cause of serious, long-term disability -- both physical and mental.
Researchers at the Mayo Clinic in Rochester, Minn., recently reported there were 751,000 strokes in the U.S. in 1999 and another 500,000 transient ischemic attacks, or "mini-strokes," affecting a total of more than 1.2 million people.
The AHA says most gains in a person's ability to function in the first 30 days after a stroke are due to the body's natural recovery. The balance comes from rehabilitation. David Tong, MD, at the Stanford University Stroke Center, says the ultimate goal of rehabilitation is to return the patient to as independent a lifestyle as possible. "Successful stroke rehabilitation is dependent on many factors, including the severity of brain damage and the cooperation of family and friends. Not surprisingly, the attitude of the patient is a key factor in speed and degree of recovery. A positive outlook and high level of determination may facilitate recovery," he says.
Mayo, who has been conducting stroke research for the past 15 years in Canada, says while there are an increasing number of strokes in Canada, the rate of death due to stroke has dropped by about half in the past 20 years to 50 per 100,000 people. "The good news is that if you have a stroke, your probability of dying is lower," she says. "But the bad news is that you will live with the after-effects of stroke that can include impairments to your vision, perception, mood, [muscle use] and the ability to speak as well as a loss of control of basic bodily functions."
In the Canadian study, 114 stroke victims, 58 years old and up, were recruited from five hospitals in Montreal and put into two groups -- "home care" and "usual care." Four of the patients had suffered severe strokes, while only one had a mild stroke. About two-thirds were males.
In order to accept assignment in the home care group, patients -- who otherwise were randomly selected -- had to have caregivers at home willing to provide care over a four-week period. Patients were visited periodically by specialists offering various kinds of therapy from help with speech to advice about diet. The usual care patients received the same type of care but either while in a hospital or a rehab center.
Researchers found patients in both groups were the same when the study began as well as one month later, meaning the home care group was receiving the same level of care as the usual care patients. After three months, the home care group's health care rating -- based on tests indicating how well the patients were recovering -- was five points higher.
Mayo says a difference of this size can mean a 30% lower death rate and a 50% increase in a patient's ability to return to work. The results of the Canadian study were similar to three European studies conducted between 1997 and 1998, two in Great Britain and one in Sweden.
But while home seems to be the place to recover, it can turn into a nightmare if patients have trouble getting the kind of support services they need to improve their recovery. "Sometimes, the worst place for a stroke recovery is in the home," Jay Siegfried, MD, a rehab specialist in Philadelphia, tells WebMD. "People are working and aren't geared to stay home and become caregivers."
Mayo says Canadian stroke patients spend more days in hospitals than do their American counterparts. "That's largely because our health care system in Canada hasn't built facilities outside of acute-care hospitals," she says. "There's nowhere to send them to, so they either go home or to rehabilitation services."
Mayo says if people want therapy outside a hospital, they'd have to pay for it out of their own pocket, shifting the burden of care to families. "Now families are being asked to care for someone six or seven days [after a stroke] using up their own resources. That becomes very wearing for the family," she says.
In the U.S., home rehab is available on different levels depending on insurance. While some insurance policies will provide it for a limited time, some will provide it for months, says Siegfried. "Some insurance plans are delighted when a patient goes home rather than a rehab hospital, because it costs less money," Siegfried tells WebMD. "But whether they'll pay for the kind of rehab that is needed to get the patient functional depends on the plan."
Mayo says the take-home message the Canadian study showed was that people can be safely rehabilitated at home. She's hopeful it will one day become a model in Canada and elsewhere. "I know this is what the patients want. This is something you don't get from the data for a clinical study. You get it from talking to the people," she says.
- In the first 30 days after suffering a stroke, patients get some of their abilities back again spontaneously. But it takes a rehabilitation program to help the patient do everything else that he or she could do before the stroke.
- Canadian researchers report patients who spent their first 10 days in the hospital, then went home to complete their recovery, had better indications of recovery than those who were in a traditional hospital rehab program. The results are similar to studies conducted in other countries.
- Focusing a patient's recovery around his or her home could translate into improving patient morale and getting more patients back to their normal lives, researchers say. But not every patient has financial resources, insurance, and caregivers that could make home rehabilitation possible.