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ISSN: 2329-9096
International Journal of Physical Medicine & Rehabilitation
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The Clinical, Quality of Life and Economic Outcomes of Inpatient Rehabilitation: A Systematic Review

Maistreli Stefania1, Gourzoulidis George2*, Vellopoulou Katerina2, Kourlaba Georgia1,2, and Maniadakis Nikos3

1Collaborative Center of Clinical Epidemiology and Outcomes Research (CLEO), Non-Profit Civil Partenrship, Athens, Greece

2EVROSTON LP, Athens, Greece

3Department of Health Services Organization and Management, National School of Public Health, Athens, Greece

*Corresponding Author:
Gourzoulidis George
EVROSTON LP, Chatzigianni Mexi 5, 115 28, Athens, Greece
Tel: +30-216-900-1701
Fax: +30-216-900-1702
E-mail: [email protected]

Received date: March 15, 2017; Accepted date: April 03, 2017; Published date: April 04, 2017

Citation: Stefania M, George G, Katerina V, Georgia K, Nikos M (2017) The Clinical, Quality of Life and Economic Outcomes of Inpatient Rehabilitation: A Systematic Review. Int J Phys Med Rehabil 5: 399. doi: 10.4172/2329-9096.1000399

Copyright: © 2017 Stefania M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Objective: To systematically review the clinical, functional and economic benefits of Inpatient Rehabilitation for the most common disorders of the nervous system: stroke, spinal cord injury, and multiple sclerosis.

Methodology: PubMed, Embase, Scopus, CEA Registry, and NHS EED databases were searched using combinations of three sets of key words that included various terms for rehabilitation, benefits, and treatments. The outcomes considered included measures of independence in activities of daily living (ADL), motor function, disability, handicap, gait velocity, quality of life, and economics. Following the initial literature search, the abstracts and full texts of the identified studies were reviewed and assessed for inclusion by two independent researchers based on pre-determined criteria. The data of selected studies were extracted into a data extraction form and consequently were synthesized.

Results: Forty-six articles met the inclusion criteria. Particularly, 21 studies evaluated inpatient rehabilitation subsequently to stroke, 15 studies evaluated inpatient rehabilitation after SCI, and seven studies evaluated inpatient rehabilitation of MS patients. The remaining three studies referred to mixed patient population. The majority of studies indicated that inpatient rehabilitation can provide clinical and functional benefits for all patient groups under consideration. Moreover, economic evaluations indicate that rehabilitation may be cost saving or cost-effective in certain patient groups such as those with fractures and stroke.

Conclusion: The results of the present review demonstrate that existing studies in the literature indicate that inpatient rehabilitation may deliver significant health and economic benefits for patients suffering from stroke, spinal cord injury, or multiple sclerosis and for health systems. Further research is needed to improve the consistency and robustness of the available evidence.

Keywords

Inpatient rehabilitation; Clinical; Functional ability; Economic; Benefits

Introduction

Over a billion people, about 15% of the world’s population, have some form of disability either due to injury or acute and chronic diseases [1]. Between 110 million and 190 million adults have significant difficulties in functioning. Rates of disability are increasing due to population ageing and raises in the prevalence of chronic health conditions, among other causes. Disability has a negative impact on social development and economic development [1].

Rehabilitation is instrumental in enabling people with limitations in functioning, to remain in or return to their home or community, live independently, and participate in education, the labour market and civil life. Access to rehabilitation can decrease the consequences of disease or injury, improve health and quality of life and decrease the use of health services [2].

Physical rehabilitation is a medical specialty focused on prevention, diagnosis, and therapy for patients who experience functional limitations resulting from injury, disease, or malformation. The benefits of rehabilitation could be clinical- physical, neurological, and cognitive related improvements-, functional-motor related improvements and economic-including patient’s work productivity [3,4]. Rehabilitation programs can be provided in alternative settings including an acute hospital, sub-acute hospital, specialist facilities (inpatient or outpatient), or the patient’s home.

While many countries have started taking action to improve the lives of people with disabilities, much remains to be done [2]. Increased collaboration amongst rehabilitation professionals in developed and developing countries is essential to implement appropriate and sustainable rehabilitative services.

In Greece, rehabilitation services are provided mainly by private specialized institutions, even though, there are also some integrated services in general hospital care public facilities. However, the provided services are fragmented, underdeveloped, underfunded and in many cases inadequate and much more attention needs to be paid to this particular medical specialty.

In this light, the objective of the present study was to systematically review the literature reporting evaluations on the clinical, quality of life, and economic benefits of inpatient rehabilitation for patients suffering from stroke, spinal cord injury (SCI), and multiple sclerosis (MS).

Methods

This review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria [5,6] to search, retrieve, and synthesize the findings of selected studies.

Search strategy In order to identify eligible studies, PubMed, Embase, Scopus, CEA Registry, and NHS EED databases were searched using pre-determined keywords. The latter were elaborated by a group of experts with relevant methodological and clinical expertise. Τhe literature search was conducted using three different combinations of keywords for: rehabilitation; outcomes and health condition, as presented in Table 1. The terms in the three major categories were combined by the Boolean “AND”, whilst the terms utilized within each of the search categories were combined by the Boolean “OR”. The filters “English” and “Humans” were added as to restrict our search to the relevant studies. There was no search limitation in terms of time and geographical location of the original studies. The search was limited to studies published up to December 2015. The Appendix presents the full search strategy used for MEDLINE, which was adapted appropriately for the rest of the databases.

1.Type of rehabilitation 2.Outcomes 3.Condition/Treatment
rehabilitation center* benefit* Stroke
rehabilitation centre* outcome* SCI
rehabilitation hospital* cost* spinal cord injury
inpatient rehabilitation clinical multiple scleroses
hospital-based rehabilitation health  
hospital based rehabilitation economic  
  functional*  
  quality of life  
  quality-of-life  
  productiv*  
  capability  
  work  
  employment  
  hospitalization  
  barthel  
  mortality  
  cost-benefit  
  cost- effectiveness  
  cost-utility  
  cost-minimization  
  early discharge  
  cost-consequence  
  economic modeling  

Table 1: Search terms used in searches of electronic databases.

Study selection following the literature search, a check for double publications among the selected studies was undertaken to avoid double reporting. Consequently, the identified studies were reviewed and assessed for inclusion in the review by two independent researchers, based on the predetermined inclusion/exclusion criteria presented in Table 2. Clinical trials were excluded since the review was focused on real-world evidence data. Therefore, as presented in Table 2, observational studies were taken into consideration. The study selection procedure encompassed two stages: initially, all the identified studies were evaluated on the basis of titles and/or abstracts against the eligibility criteria; subsequently, in the second stage, when the information provided by titles/abstracts was insufficient to decide on inclusion/exclusion, or when the titles/abstracts indicated that the specific studies met the inclusion criteria, the full-papers were retrieved to be screened. In cases where the amount of information reported in the full-text continued to be insufficient to make a decision about inclusion, the studies were excluded. The study selection process was documented through a flow chart showing the number of studies/ papers remaining at each stage.

  Inclusion criteria Exclusion criteria
Studies Full prospective studies, retrospective studies, case-control studies, observational studies,economic evaluations Systematic reviews,   meta-analysis, case studies/reports, letters to the editor, abstracts
Outcomes Clinical, functional, quality of life,economic Other outcomes
Conditions Stroke,  Spinal Cord Injury, multiple scleroses  
Population Adults Pediatric
Countries Any -
Setting Inpatient (hospitals or centers) Outpatients

Table 2: Inclusion and exclusion criteria considered in the search strategy.

Data extraction

A standardized data extraction form for each health condition (stroke, SCI, MS), developed for the purpose of this review, was used by the two reviewers to extract the data independently. Any disagreement in the data extracted from the two reviewers was resolved by consensus among researchers or by arbitration by a third independent researcher. The aforementioned extraction form was designed to include data on the background information of the study, its methodological characteristics, and the key results.

Data synthesis

In this systematic review, the results are summarized in a qualitative manner collating data from studies. We synthesized the relevant and available data in a systematic manner following the review question, the inclusion and exclusion criteria.

Results

Study selection

After removing duplicate citations, 1,764 unique citations remained for screening. The manual screening of all titles and abstracts yielded 84 articles that contained information about the benefits of inpatient rehabilitation. Of the latter full articles retrieved and reviewed by the investigators, 40 met the inclusion criteria. The reference lists of all relevant papers originally selected for inclusion in the review and relevant reviews were also searched manually to identify potentially relevant articles which were not identified by the original electronic search. Consequently, six additional studies of interest were collected in full text with agreement for inclusion in the systematic review, taking the total to 46. Details of literature search strategy are shown in Figure 1.

physical-medicine-rehabilitation-Flowchart-systematic

Figure 1: Flowchart of systematic review.

Overall 41 out of the 46 studies examined the clinical benefits of inpatient rehabilitation (16 for stroke patients, 15 for SCI patients, seven for MS patients, and three for mixed population of stroke and SCI patients) and five studies assessed the economic benefits for post-stroke patients. Notably, there was significant heterogeneity in terms of study designs and in the way that functionality was measured.

Stroke

Overall, 24 studies examined the impact of inpatient rehabilitation on stroke patients (Table 3).

Study Background information of study Population characteristics Outcome measures Follow up Main results
Location Study design Sample size Age
Shah et al. [7] Australia prospective 258 mean age
Males:68
Females:71.6
BI: (0-100)   On admission to rehab vs. at discharge:
BI (mean): 44 vs. 78 s.s.
Sim et al. [8] Hong Kong retrospective/prospective 185 mean age ± SD
69 ± 11.1
BI: (0-100)
% of independent pts
1 year after discharge On admission to rehab vs. at discharge:
BI (median, IQR): 55 (30-75) vs. 90 (70-100) p<0.05
Discharge vs. 1 year follow-up (n=112):
BI (median, IQR): 90 (85-100) vs. 100 (85-100) p<0.05
% independent pts
74.1% vs. 83.9% walking
68.8% vs. 85.7% toileting p<0.05
Kuptniratsaikul et al. [9] Thailand prospective 327 mean age ± SD
62.1 ± 12.2
BI: (0-20)
HADS: % of pts with anxiety and depression
Thai WHOQOL-BRIEF:
QoL assessment (24-120)
  On admission to rehab vs. at discharge:
BI (mean ± SD): 7.48 ( ± 3.96) vs. 13.27 ( ± 4.86)  p<0.001
% of pts with anxiety:  25.5% vs. 6.8%  p<0.001
% of pts with depression: 37.8% vs. 16.3% p<0.001
QoL score (mean ± SD):69.74 ( ± 11.75) vs. 77.72 ( ± 10.69) p<0.001
Balaban et al. [10] Turkey retrospective 80 mean age ± SD
63.54 ± 13.62
BI: (0-100)
FIM: (18-126)
  On admission to rehab vs. at discharge:
BI (mean): 49.13 vs. 78  p<0.001
FIM (mean):  67.97 vs. 91.91  p<0.001
Yavuzer et al. [11] Turkey retrospective 67 mean age ± SD
60 ± 11.8
FIM: (18-126)   On admission to rehab vs. at discharge:
FIM (mean ± SD): 75.0 ( ± 24.9) vs. 86.7 ( ± 24.2)  p<0.001
Gökkaya et al. [12] Turkey prospective 83 mean age ± SD
58 ± 12
FIM: (18-126)   On admission to rehab vs. at discharge:
FIM (mean ± SD): 56.5 ( ± 18.6) vs. 74.6 ( ± 19.0)  p<0.01
Giaquinto et al. [13] Italy prospective 111   FIM: (18-126)   On admission to rehab vs. at discharge:
FIM (mean):  62 vs. 101  p<0.0001
Foley et al. [14] Canada retrospective 123 mean age ± SD
67 ± 15
FIM: (18-126)
Motor-FIM: (13-91)
Cognitive-FIM: (535)
% of pts discharged to community
  On admission to rehab vs. at discharge:
FIM (mean ± SD): 77 ( ± 25) vs. 103 ( ± 22)
Motor-FIM (mean ± SD): 52 ( ± 22) vs. 74 ( ± 19)
Cognitive-FIM (mean ± SD):25 ( ± 6) vs. 29 ( ± 5)
74% returned home upon discharge
Gagnon et al. [15] Canada retrospective 422 mean age ± SD
71.9 ± 10.5
FIM: (18-126)
Motor-FIM: (13-91)
Cognitive-FIM: (5-35)
% of pts discharged to community
  On admission to rehabvs. at discharge:
FIM (mean ± SD): 86.1 ( ± 21.7) vs. 107.7 ( ± 16.7)
Motor-FIM (mean ± SD): 58.8 ( ± 19.2) vs. 78.1 ( ± 13.5)
Cognitive-FIM (mean ± SD): 27.2 ( ± 6.4) vs. 29.6 ( ± 5.6)
84% returned to their prior living arrangement
Teasell et al. [16] United Kingdom retrospective 196 mean age ± SD
72 ± 11
FIM: (18-126)
% of pts with higher, lower, unchanged scores
% of pts discharged to community
  On admission to rehab vs. at discharge:
FIM (mean, IQR): 46 (IQR 20, range:19-96) vs. 70 (IQR 30, range:18-121)  p<0.0001
94.5% had higher discharge FIM scores /4.4% had lower FIM discharge scores /1.1% did not change
43.4% returned to their own home upon discharge
Hayward et al. [17] Australia prospective 239 mean age ± SD
70 ± 13
Motor-FIM: (13-91)
MCID:                                          (1-point change in MAS6)
shift in disability status (i.e. severe to mild-moderate)
  On admission to rehab vs. at discharge:
Motor-FIM (mean ± SD): 55 ( ± 23) vs. 76 ( ± 17)    p<0.001
83% achieved a MCID defined by a change of ≥ 17 points   85% shift from severe motor disability to mild-moderate motor disability at discharge
Hayward et al. [22] Australia prospective 226 mean age ± SD
71 ± 13
MAS6:
MAS6>2 mild moderate upper arm disability
MAS6 ≤ 2 severe upper arm disability
MCID: (1-point change in MAS6)shift in disability status (i.e. severe to mild-moderate)
  On admission to rehab vs. at discharge:
% of pts with MAS6 ≤ 2: 100% vs. 55%   p<0.001
68% of pts achieved MCID at discharge
45% of pts shifted from severe upper arm disability (MAS6<=2) to mild-moderate upper arm disability (MAS6>2) at discharge
Madden et al. [18] Canada retrospective 116 mean age ± SD
71 ± 13
FIM: (0-126)
Motor-FIM: (13-91)
Cognitive-FIM: (5-35)
SF-36: (0-100)                                    PCS
MCS
% of pts discharged to community
  On admission to rehab vs. at discharge:
FIM (mean ± SD): 79.0 ( ± 21.2) vs. 106.8 ( ± 20.4)  p<0.001
Motor-FIM (mean ± SD): 51.7 ( ± 18.1) vs. 77.1 ( ± 17.1) <0.001
Cognitive-FIM (mean ± SD):27.3 ( ± 6.4) vs. 29.8 ( ± 5.0) <0.001
PCS (mean ± SD): 28.4 ( ± 6.9) vs. 31.3 ( ± 7.3)  p<0.001
MCS (mean ± SD):48.8 ( ± 12.4) vs. 50.7 ( ± 10.8)
81% discharged home
Ee et al. [23] Singapore retrospective 100 mean age ± SD
72.7 ± 5.4
RPS: (ranges 0-5)
0-1  independent                           2-3 partially dependent
4-5 totally dependent
  On admission to rehab vs. at discharge:
(% of patients with RPS 4-5)
ADL:46% vs. 16%   p<0.001
Mobility: 76% vs. 35%   p<0.001
Gialanella et al. [24] Italy retrospective 72 mean age ± SD
46.5 ± 10
stroke severity
NIH: (0-42, 0=normal/ 42=patient in coma)
walking                                     Lindmark scale: (7-point scale, 0=cannot walk/ 6=can walk )
mobility                                   RMI: (0-15, 0=totally unable)
  On admission to rehab vs. at discharge:
NIH (mean ± SD): 5.20 ( ± 2.5) vs. 3.41 ( ± 2.2)  p<0.001
Lindmark (mean ± SD): 0.93 ( ± 0.9) vs. 4.22 ( ± 1.6)  p<0.001
RMI (mean ± SD): 2.69 ( ± 2.2) vs. 9.95 ( ± 2.2)  p<0.001
% pts walk independently: 1.4% vs. 80.5%
Mutai et al. [25] Japan retrospective 252 mean age ± SD
72.4 ± 10.8
mRS: (6 grades, 0=no symptoms/ 5=severe disability)
GDS ≥ 11 points (max 15 points) indicates depression
FAI: (scores from 15-60, higher score-higher level of activity)
1-3 years after discharge follow-up assessment:
52% of pts (n=159) were independent, mRS ≤ 2
21.6% of pts (n=153) scored GDS ≥ 11
FAI (mean ± SD): 26.5 ± 10.9 (n=156)
Mahler et al. [26] Switzerland retrospective, cost- analysis 131 mean age ± SD
73 ± 12
Direct insurance costs for year 2002-2003
(CHF-  Swiss franc)
BI gain (inpatient vs. no inpatient rehab)
% of independent pts after 1 year (inpatient vs. no inpatient rehab)
1 year after stroke -cost at 1 year inpatient vs. no inpatient rehab:
45.031 ( ± 13.492) vs. 25.908 ( ± 9.869) p<0.05
-mean cost of stroke/patient: 31.115 CHF
-mean cost of inpatient rehab/pts:11.471CHF (37% of the total cost)
BI gain (mean ± SD): 42 ( ± 29)  vs. 23 ( ± 26)   p<0.05
inpatient rehab (n=58) vs. no inpatient rehabilitation (n=73):
% of independent pts  after 1 year: 81% (47/58) vs. 51% (37/73) p<0.05
Moodie et al. [27] Australia economic evaluation 395 mean age ± SD
73 ± 14
Average cost per pts
Incremental cost –effectiveness
stroke unit vs. conventional care
28 weeks ICER of stroke unit vs. conventional care:A$9,867 per pts achieving thorough adherence to clinical process andA$ 16,372 per pts with severe complications avoided
Khiaocharoen et al. [28] Thailand economic evaluation 207   Total cost of hospitalization
ICER per QALYs gained
4 months Cost of hospitalization of rehab group and unexposed  group were 16,993 and 11,401 baht per case respectively
ICER per QALY gained from rehab was 24, 571 baht
Patel et al. [29] England economic evaluation 447   Total healthcare costs  of stroke unit, stroke team and domiciliary care
ICER per % point in deaths avoided and ICER per QALYs between the interventions
12 months Mean healthcare  cost :
Stroke unit : £11,450 ,
Stroke team: £9,527 ,
Domiciliary care: £6,840
ICER per% point in deaths avoided in the first year was £682  for the stroke unit over domiciliary care , ICER per QALY was £64,097
The stroke team was dominated by domiciliary care
Andersson et al. [30] Sweden cost-study 124   Total cost of inpatient & Home rehab. 12 months Total cost of inpatient rehab  126,000 sek
Total cost of  home based rehab 54,550 sek
Total days of inpatient rehab 28 days vs. home rehab 36 days
Bode et al. [19] USA retrospective 129 mean age ± SD
65.5 ± 12.3
Motor-FIM score: (0-100)
Cognitive-FIM score: (0-100)
  On admission to rehab vs. at discharge:
Motor-FIM (mean ± SD): 40.4 ( ± 12.6) vs. 63.0 ( ± 20.2)
Cognitive-FIM (mean ± SD): 54.7 ( ± 13.0) vs. 71.3 ( ± 16.8)
Ng et al. [20] Singapore prospective 865 mean age ± SD
61.3 ± 15
FIM: (18-126)
Motor-FIM score: (13-91)
Cognitive-FIM score: (5-35)
  On admission to rehab vs. at discharge:
total FIM (mean ± SD): 67.9 ( ± 23.1) vs. 85.9 ( ± 23.0)  p<0.01
Motor-FIM (mean ± SD): 43.2 ( ± 17.0) vs. 58.9 ( ± 17.5) p<0.01
Cognitive-FIM (mean ± SD): 24.7 ( ± 8.5) vs. 26.9 ( ± 7.7)p<0.01
Graham et al. [21] USA retrospective 93.925 66% aged    >65 years FIM: (18-126)
Motor-FIM score: (13-91)
Cognitive-FIM score: (5-35)
80-180 days post-discharge
(mean 104 days)
On admission to rehab vs. at discharge vs. at follow up:
Motor-FIM (mean ± SD): 39.2 ( ± 14) vs. 60.7 ( ± 16.6)  vs. 73.9 ( ± 18.1)
Cognitive-FIM (mean ± SD): 21.6 ( ± 7.6) vs. 25.7 ( ± 6.8) vs. 30.9 ( ± 5.4)
total FIM (mean ± SD): 60.8 ( ± 18.9) vs. 86.4 ( ± 21.0) vs. 104.8 ( ± 21.6)
vocation follow up:
4.6% employed
77.7% retired
79.7% maintained health follow up by their own
BI: Barthel Index (the individual's performance on 10 ADL functions for a total of 100 points-100 points for total independence), ADL: Activities of Daily Living, effectiveness: actual improvement over potential improvement, efficiency: mean improvement  per day, s. s.: statistically significant, SD: Standard Deviation, IQR: Inter Quartile Range, HADS: Hospital Anxiety and Depression Scale  Thai WHOQOL-BRIEF: Thai World Health Organization Quality of Life, the brief version, QoL assessment (ranges 24-120, 120 points-totally satisfied), QoL: Quality of Life, FIM: Functional Independent Measure (18-item, 7-level measure of patient's ability to perform several activities, 126 points-totally independent), Motor-FIM: (13 motor items on a 7-point scale each, 91 points-totally independent), Cognitive-FIM: (5-item, 7-level measure, ranges from 5-35 points, 5 points- cognitive disabled), MAS6: Motor Assessment Scale, Item 6 Upper Arm Function, MCID: Minimal Clinical Important Difference, SF-36: 36-item short form (8 domains HRQOL, scales from 0 to 100, higher values- better HRQOL), HRQOL: Health-Related Quality Of Life, PCS: Physical Component Summary, MCS: Mental Component Summary, RPS: Rehabilitation Profile System, NIH: National Institute of Health Stroke Scale, RMI: Rivermead Mobility Index, mRS: modified Rankin Scale, GDS: Geriatric Depression Scale, FAI: Frenchay Activities Index Rehab:rehabilitation, pts: patients

Table 3: Studies focusing on stroke patients

Clinical outcomes

Four studies [7-10] assessed functional disability in stroke patients using the Barthel Index (BI), which is a standardized and well validated method of measuring a patient’s level of physical independence. In all of these studies, patients demonstrated a statistically significant improvement in the BI score at discharge score relative to the one at admission.

Twelve studies used the Functional Independent Measure (FIM) for the evaluation of motor and cognitive disability in stroke patients [10-21]. All of these studies indicated significant improvement in the FIM score between rehabilitation admission to rehabilitation discharge. Notably, the majority of the studies highlighted that the improvement of patients’ functional ability was statistically significant [10-13,16-18,20,21].

Two studies used the Motor Assessment Scale, Item 6 Upper Arm Function (MAS6) to measure the upper arm disability [17,22]. In the first study, 83% of stroke patients demonstrated a statistically significant improvement in arm function at rehabilitation discharge, while 68% achieved a shift from severe to mild/moderate upper arm disability on discharge. The second study reported that 45% of patients had a statistically significant change in arm function recovery at rehabilitation discharge.

In addition, the study by Ee et al. [23] indicated that the percentage of totally dependent post stroke patients was statistically significantly lower in terms of the Rehabilitation Profile System (RPS) at discharge. Moreover, Gialanella et al. [24] demonstrated that patients had statistically significant improved mobility, measured by the Lindmark and the Rivermead Mobility Index (RMI), as well as neurological status, measured in terms of the National Institute of Health Stroke Scale (NIH). It is worth noting that 80.5% of patients were ambulatory independent at discharge contrary to 1.4% on admission, an impressive outcome improvement.

Four studies evaluated the long-term benefits of inpatient rehabilitation [8,21,25,26]. Sim et al. [8] demonstrated that the gains in patients’ functional status were generally maintained one year after discharge, with a further statistically significant improvement in toileting. Furthermore, Mutai et al. [25] reported that 51.9% were classified as independent in terms of their Activities of Daily Living (ADL), 1-5 years after discharge. According to Mahler et al. [26] the percentage of independent post stroke patients who underwent inpatient rehabilitation reached 81% as compared to 51% of the patients without inpatient rehabilitation, one year after stroke. Moreover, Graham et al. [21] indicated that 79.7% of patients were successfully maintaining their health status by themselves, 3-6 months after discharge.

Finally, Mahler et al. [26] assessed the effectiveness of inpatient rehabilitation as compared to traditional treatment on stroke patients. The patients who underwent the rehabilitation program had their BI score increased by 42 ± 29 points, as compared to patients without (inpatient) rehabilitation, whose functional level rose by 23 ± 26 points only (p<0.05).

Quality of life outcomes

Quality of life was assessed in three studies [9,18,25]. The study by Mutai et al. [25] indicated that 21.6% of patients suffered from depression 1-3 years after stroke. On the other hand, Kuptniratsaikul et al. [9] highlighted that the number of patients with anxiety and depression was statistically significant lower at discharge. More specifically, 25.5% of patients had anxiety and 37.8% had depression on admission. At discharge, the percentages of patients with anxiety and depression decreased to 6.8% and 16.3%, respectively. In addition, the same study reported that the quality of life scores at discharge were significantly higher than those on admission. Finally, the study by Madden et al. [18] reported that the mean improvement between admission and discharge at the SF-36 (patient-reported survey of patient health) scores was statistically significant.

Economic outcomes

It is worth noting the high percentage of patients who returned home after discharge. More specifically, four studies [14-16,18] reported that the percentages of patients who returned to their home (without further institutionalization or admission to nursing homes needed) after rehabilitation were 74%, 84%, 43.4%, and 81% respectively. The percentage of the third study [16] is much lower than the others because it referred to patients with severe stroke who were totally ambulatory dependent.

According to the cost analysis of Mahler et al. [26], inpatient rehabilitation is the most significant part of the total health insurance costs in the first year after stroke (37%). However, inpatient rehabilitation’s crucial benefit related to the high percentage of independent patients after one year (81%), which in turn may be associated with reduced health care long-term costs. Moodie et al. [27] compared costs and outcomes of stroke patients who received either conventional care or mobile service or stroke unit care. The study demonstrated that although acute Stroke Care Unit (SCU) costs were generally higher, they were more cost-effective than either a mobile service or conventional care. Khiaocharoen et al. [28] who conducted a cost-utility analysis of rehabilitation for stroke patients in Thailand, concluded that inpatient rehabilitation services for stroke survivors were cost-effective as compared with conventional care. Patel et al. [29] highlighted that the percentages of patients who avoided death/ institutionalization were 87%, 69%, and 78% in the stroke unit, stroke team, and domiciliary care groups, respectively. Finally, Andersson et al. [30] compared the outcomes of two rehabilitation groups, hospital-and home-based respectively. Although the home-based group had significantly lower costs, the number of acute care ward days after a decision about rehabilitation was made was three days in the hospital-based group and nine in the home-based group and the difference was significant. The hospital-based group thereafter had a mean duration of 28 in-hospital rehabilitation days and the home-based group had 36 days of home rehabilitation (Table 3).

SC

Overall 18 studies examined the impact of inpatient rehabilitation on SCI patients (Table 4).

Study Background information of study Population characteristics Outcome measures Follow up Main results
Location Study design Sample size Age
Yarkoni et al. [33] USA retrospective 711
(n=188) complete quadriplegia (n=201) incomplete quadriplegia
(n=211) complete paraplegia (n=111) incomplete paraplegia
(n=389) quadriplegia (n=322) paraplegia
mean age
incomplete lesions: 31
complete lesions: 26.2
MBI: (100-point scale)
-self-care subscore  (-2 to 53)  (higher score, higher independence)
-mobility subscore (0 to 47) (higher score, higher independence)
  On admission to rehab vs. at discharge:
complete quadriplegia MBI (mean): 7.7 vs. 21.1 s.s.
incomplete quadriplegia MBI (mean): 19.5 vs. 60.6 s.s.
complete paraplegia MBI (mean): 35.2 vs. 71.2 s.s.
incomplete paraplegia MBI (mean): 42.4 vs. 80.5 s.s.
quadriplegia total-MBI (mean): 13.8 vs. 46.1
paraplegia total-MBI (mean): 37.7 vs. 74.4
Ferdiana et al. [44] Netherlands prospective 114 mean age ± SD
42.1 ± 11.6
% of pts in paid employment for
-at least 1 h/week              -at least 12 h/week
5 years after discharge 50.9% returned to work for at least 1h/week
42.6% returned to work for at least 12h/week
median number of working hours before injury vs. 5 years follow-up: 44.1 vs. 22.6
Haisma et al. [31] Netherlands prospective 182 mean age ± SD
40 ± 14
Motor-FIM: (13-91)
SIP68: physical sum score: range 0-29 social sum score: range 0-22 (the higher the score, the more limited the functional status)
1 year after discharge On admission to rehab vs. at discharge:               
Motor-FIM (mean ± SD):44 ( ± 18) vs. 69 ( ± 17) p<0.01
At follow-up (n=133):
physical SIP68: 12 ( ± 7)
social SIP68: 6 ( ± 4)
New et al. [32] Australia retrospective 70 mean age
69
total RaschFIM
cognitive RaschFIM subscore:100-point scale
motor RaschFIM subscore:100-point scale
  On admission to rehab vs. at discharge:
cognitiveRasch score (mean): 80.6 ( ± 19.9) vs. 81.2 ( ± 20.1) not s.s.
motor Rasch score (mean): 39.6 ( ± 16.1) vs. 58.7 ( ± 15.8) p<0.001
raw motor RaschFIM gain (mean):
ASIA grade A,B,C paraplegia: 15.8 p=0.002
ASIA grade D paraplegia: 23.8  p<0.001
ASIA grade A,B,C tetraplegia: 8.3  not s.s.
ASIA grade D tetraplegia: 30.4  p<0.001
Schönherr et al.[35] Netherlands retrospective 55 mean age
33
Functional outcome:
9 activities of daily living, set of 3 skills (mean score per set 0-9 points)  -self-care skills                                            -ambulation skills                                         -bladder and bowel skills     (0=dependent  9=independent)
  On admission to rehab vs. at discharge:
self-care score (mean): 4.6  vs. 7.6   p<0.01
ambulation score (mean):3.2  vs. 6.3   p<0.01
bladder and bowel score (mean): 1.3  vs. 5.8   p<0.01
Sturt et al. [36] Australia prospective 62 mean age
67
Walking ability:                    TUG: time taken to complete the test and the seat height
10mWT: time taken to complete the test and the number of steps taken
6MWT: the distance the subject could complete in 6min and the number of rests during the test
  48% of pts regained some capacity to walk
On admission to rehab vs. at discharge:                 
TUG mean  (n=27): 57 s vs. 33 s  normal=8.5s   p<0.001
10mWT mean (n=27): 51 s vs. 29 s  normal=1.35ms for men/ 1.29ms for women
6MWT  mean (n=20): 129 m vs. 220 m  normal=659 ± 62 m
Yen et al. [37] Singapore retrospective 231 mean age ± SD
39 ± 17
Neurological outcome:
Frankel classification     (grades A-E, A: motor/sensory function absent  E: motor/sensory function normal)
Functional outcome:
Ambulatory status (independent/ non-ambulant)
ADL ability                     (independent/ requiring assistance)
Bladder outcome                (pts' method of voiding)
Vocational status                       (% of pts returned to some form of vocation)
  On admission to rehab vs. at discharge:                         
% of pts  with Frankel scale D/E :26.8% vs. 59.6%
% of pts upgraded Frankel scale from admission to discharge:
initially Frankel scale A:25.7%
initially Frankel scale B:23.1%
initially Frankel scale C:76.2%
initially Frankel scale D:16.7%
% of pts independent in ambulation: 5.3% vs. 45.2%
% of pts totally independent in ADL: 2.7% vs. 20%    
% of pts urinary-catheter totally dependent: 63.6% vs. 7.8%
48.9% of pts independent with aids in ADL at discharge
21.6% of pts returned to some form of vocation 1-year post injury
87.9% discharged home
Citterio et al. [45] Italy prospective 330 mean age
55.2
Neurological outcome:                   % of pts with AIS gain  (an increase at discharge of at least 1 grade on the scale above the grade recorded on admission)
% of pts returned home  % of pts with pressure ulcers
  30% of pts exhibited improvement in AIS
73% of pts returned home
On admission vs. at discharge:
% of pts with pressure ulcers:  19.7% vs. 8.8%
Franceschini et al. 2003 [38] Italy retrospective, prospective 251
(146 follow-up)
mean age
37.8
mortality rate
Quality of Life:              satisfaction with QoL questionnaire                        (two evaluation scales: autonomy and QoL,           range 0-10, the higher the score the more satisfied with QoL)
% of pts returned to work
6 years after discharge mortality rate from discharge to 6-years follow up: 9.96%
at follow up:                                
-autonomy mean score:6.5      
-QoL mean score:6.5
-29.5% was employed              
-61% left home on a daily basis  -64.4% could leave home without assistance                     
-48.6% was satisfied with partner relationships
Schonherr et al. [39] Netherlands retrospective 57 mean age ± SD
33 ± 11
LSQ: (1-6)                           (grades 5-6: ''satisfied''    
grades 1-4: ''not satisfied'')
hours spent on vocational and leisure activities
% of pts returned to work
2-12 years after injury 67% ''satisfied''
33% ''not satisfied'' with vocational & leisure participation
preinjuryvs. follow-up hours spent in:                                 
paid work: 41.6 vs. 19.5  p<0.05
small jobs at home: 5.1 vs. 3.3  p<0.05
total vocational participation: 57.2 vs. 33.5   p<0.05
sports: 4.0 vs. 1.2   p<0.05
total participation (vocational+leisure): 65.9 vs. 39.6  p<0.05
time for self-care:  3.3 vs. 8.1  p<0.05
% of pts worked at time of injury vs. at follow-up: 86% vs. 60%
28% of pts reported help from the rehab team in finding new hobbies or sports
van Asbeck et al. [40] Netherlands prospective 117 ≥ 18 housing status (% of pts)
work/household status (% of pts)
sport/hobbies status
(% of pts)
8-15 years after discharge 93% of pts were independent (own/rented house, adapted house)
32.4%  employed
36.7% household activities
41% were still active in sport (basketball, table tennis, wheelchair racing)
86.3% had at least one hobby
Franceschini et al.[41] Italy retrospective, prospective 403 mean age ± SD
41.8 ± 16.3
% of pts employed at the end of follow up 3.8 years after injury at the time of injury vs. at the end of follow-up:
% of employed:83.4% vs. 42.1%
employed vs. unemployed:
perceived quality of life:6.9 ± 2 vs. 5.3 ± 2.8   p<0.0001
satisfying sex life (%): 38% vs. 26.6% p=0.02
leave home for leisureness (%): 72.4 vs. 37.3  p<0.0001
practicing sports (%): 45.3 vs. 18.5  p<0.0001
van Velzen et al.[42] Netherlands prospective 118 mean age
38
% of pts returned to paid work for at least 1h/week 1 year after discharge 33% returned to work (all participants were in paid employment before injury)
median number of working hours before injury vs. 1-year follow-up: 40.63 vs. 20.69
van Velzen et al. [43] Netherlands prospective 103 range 18-65 % of pts returned to paid work for at least 1hour/week 5 years after discharge 44.7% returned to work (all participants were in paid employment before injury)
median number of working hours before injury vs. 5-years follow-up: 40 vs. 20
22% of RTW group were working full-time
78% of RTW group were working part-time
Bode et al. [19] USA retrospective 52 mean age ± SD
35.5 ± 15.7
Motor-FIM score: (0-100)
Cognitive-FIM score: (0-100)
  On admission to rehab vs. at discharge:
Motor-FIM (mean ± SD): 20.6 ( ± 16.7) vs. 86.5 ( ± 17.4)
Cognitive-FIM (mean ± SD): 45.6 ( ± 15.3) vs. 91.9 ( ± 13.3)
Ng et al, 2007 (20) Singapore prospective 145 mean age ± SD
61.3 ± 15
FIM: (18-126)
Motor-FIM score: (13-91)
Cognitive-FIM score: (5-35)
  On admission to rehab vs. at discharge:
total FIM (mean ± SD): 68.5 ( ± 21.1) vs. 86.6 ( ± 23.6)  p<0.01Motor-FIM (mean ± SD): 37.7 ( ± 18.8) vs. 54.9 ( ± 20.6)
Cognitive-FIM (mean ± SD): 30.8 ( ± 5.9) vs. 31.6 ( ± 5.7)  p<0.01
Graham et al. [21] USA retrospective 6.663 45% aged <45 years FIM: (18-126)
Motor-FIM score: (13-91)
Cognitive-FIM score: (5-35)
80-180 days post-discharge
(mean 104 days)
On admission to rehab vs. at discharge vs. at follow up:                                          Motor-FIM (mean ± SD):30.3 ( ± 14.0) vs. 55.0 ( ± 20.0)  vs. 66.6 ( ± 23.2)
Cognitive-FIM (mean ± SD):29.9 ( ± 5.6) vs. 32.3 ( ± 4.1) vs. 33.6 ( ± 3.0)
total FIM (mean ± SD):60.2 ( ± 16.1) vs. 87.3 ( ± 21.4) vs. 100.2 ( ± 24.3)
vocation follow up:
8.0% employed                 
45.1% retired
75.4% maintained health follow up by their own
Scivoletto et al. [34] Italy retrospective 117 mean age ± SD
55.1 ± 15.4
BI: (0-100)
RMI: (ranges 0-15, 0=totally unable)
WISCI: (ranges 0-20, 0=unable, 20=full autonomy)
ASIA motor score: (100-point scale, 100 points for no weakness)
% of pts walk independently
% of pts with normal bladder control
% of pts returned home
  On admission to rehab vs. at discharge:                        
BI (mean ± SD):29.4 ( ± 24.5) vs. 62.7 ( ± 30)  p<0.001
RMI (mean ± SD): 1.6 ( ± 3.1) vs. 5.6 ( ± 4.7)  p<0.001                                 WISCI (mean ± SD):1.6 ( ± 4.9) vs. 5.7 ( ± 7.7)  p<0.001                                  ASIA motor score (mean ± SD):56.3 ( ± 16.2) vs. 62.5 ( ± 20.5) <0.001
% of pts walk independently: 11% vs. 41% p<0.001
% of pts with normal bladder control: 0% vs. 42%
90% returned home
BI: Barthel Index (the individual's performance on 10 ADL functions for a total of 100 points-100 points for total independence), MBI: Modified Barthel Index, FIM: Functional Independent Measure (18-item, 7-level measure of patient's ability to perform several activities, 126 points-totally independent), Motor-FIM: (13 motor items on a 7-point scale each, 91 points-totally independent), s.s..: statistically significant, LOS: Length of Stay,  RMI: Rivermead Mobility Index, WISCI: Walking Index for Spinal Cord Injury, ASIA: American Spinal Injury Association standards, SIP68: Sickness Impact Profile 68, health-related functional status, Rasch:  psychometric model for analyzing categorical data, TUG: Timed Up and Go, 10mWT: 10-m walk test, 6MWT: 6-min walk test, ADL: Activities of Daily Living, AIS: Association Impairment Scale, QoL: Quality of Life, LSQ: Life Satisfaction Questionnaire, Rehab: rehabilitation, pts: patients

Table 4: Studies focusing on spinal cord injury patients.

Clinical outcomes

Five studies assessed physical and cognitive disability with the FIM scale [19-21,31,32]. Two of them reported a statistically significant improvement in patients’ functional status from rehabilitation admission to rehabilitation discharge [31,32]. The remaining three studies indicated that the patients’ total FIM score (physical and cognitive) was significantly higher at rehabilitation discharge [19-21]. Additionally, Graham et al. [21] reported that follow-up (3-6 months) FIM total ratings remained from table to slightly increased over time in 75.4% of patients.

Two studies indicated that the improvement of patients’ functional ability was statistically significant after admission to rehabilitation program, as measured by the BI scale [33,34]. Furthermore, the study by Scivoletto et al. [34] demonstrated that all functional and neurological scales showed statistically significant improvements in SCI patients, despite the delayed onset, of rehabilitation treatment.

Four studies reported that a great number of patients showed a significant improvement in ambulation and achieved independence or assisted dependence in walking at rehabilitation discharge [34-37]. More specifically, Scivoletto et al. [34] reported that at admission only 11% of patients were able to walk independently relative to 41% at discharge whereas the same percentages were reported to be 5.3% and 45.2% respectively in the study by Yen et al. [37]

With regard to bladder status [34,35,37] self-care [35], and activities of daily living [37], inpatient rehabilitation had a significantly positive impact on patients’ ability to perform independently the afore-mentioned activities.

Quality of life outcomes

Franceschini et al. [38] presented data indicating that SCI patients reported to be satisfied with their current quality of life (6,5 QoL score, 10 max score) and that 48.6% were satisfied with their partner relationships, 6 years after rehabilitation discharge. Additionally, 67% of patients were satisfied with their quality of life, 2-12 years after rehabilitation discharge, as reported by Schonherr et al. [39]. With regard to sports and hobbies, 86.3% of patients had at least one hobby 8-15 years after rehabilitation discharge whereas 41% of them were still active in sport, as reported by van Asbeck et al. [40].

Economic outcomes

As far as productivity loss is concerned, eight studies evaluated patients’ ability to return to some form of vocation within a reasonable period of time after injury [37-44]. More specifically, Yen et al. [37] indicated that 21.6% of SCI patients returned to some form of vocation one year post-injury while Franceschini et al. [38] showed that 29.5% were employed six years post-injury. The study by Schonherr et al. [39] demonstrated that most people with SCI were able to resume work 2-12 years after injury. In particular, 60% of patients had a job at the time of follow-up. Franceschini et al. [41] reported that 42.1% of SCI patients were employed at the time of follow-up (3.8 years). Finally, 32.4% of patients were employed and 36.7% were housekeeping 8-15 years after rehabilitation as reported by van Asbeck et al. [40].

Three studies in which all of the patients were [42-44] employed at the time of injury demonstrated that the percentages of them who were able to return to paid work for at least 1 hour/week within 5 years after discharge from inpatient rehabilitation were 33%, 44.7%, and 50.9% respectively.

According to the study by Scivoletto et al. [34] 90% of patients who underwent rehabilitation returned to their home while Citterio et al. [45] and Yen et al. [37] reported those percentages to be 73% and 87.9% respectively.

Finally, there were no economic evaluation studies identified that assessed inpatient rehabilitation’s outcomes for SCI patients (Table 4).

Multiple Sclerosis

Overall, seven studies examined the impact of inpatient rehabilitation on MS patients (Table 5).

Study Background information of study Population characteristics Outcome measures Follow up Main results
Location Study design Sample size Age
Kidd et al. [46] United Kingdom retrospective 79 mean age ± SD
48.8 ± 7.4
Impairment    DSS: (0-10)
Disability    BI: (0-20)
Handicap      ESS: (0-35)   (the higher the score the greater the handicap)
  On admission to rehab vs. at discharge:                   
DSS (mean ± SD): 7 ( ± 0.9) vs. 7 ( ± 1.1)
BI (mean ± SD): 14 ( ± 5.2) vs. 17 ( ± 4.9) p<0.0001
ESS (mean ± SD) n=52:
19 ( ± 7.5) vs. 19 ( ± 8.1)
20% improved DSS score
65% improved BI score
44% improved ESS score   
18% improved neurologically (as determined by clinical examination)
Freeman et al. [48] United Kingdom prospective 50 mean age ± SD
44.8 ± 9.7
EDSS: (0-10)
Motor-FIM: (13-91)
LHS: (0-100)
SF36: (0-100)
PCS max 50  MCS max 50
1 year after discharge On admission to rehab vs. at discharge (n=50) vs. at follow up (46):

EDSS (median):6.8 vs. 6.8 vs. 8.0
Motor-FIM (median):61.5 vs. 74 vs. 63.5
LHS (median):60.3 vs. 64.4 vs. 61.6
SF36-physical component (mean):27.8 vs. 46.1 vs. 28.4
SF36-mental component (mean):39.2 vs. 43.4 vs. 45.0
Khan et al. [52] Australia retrospective 110 mean age
52
FIM: (18-126)   On admission to rehab vs. at discharge:
FIM (mean): 85.6 vs. 97.0 p<0.001
Kidd et al. [49] United Kingdom prospective 47 mean age ± SD
40 ± 11
Impairment   DSS: (0-10)
Disability   Motor-FIM: (13-91)
Handicap ESS: (0-35)  (the higher the score the greater the handicap)
3 months after discharge On admission to rehab vs. at discharge vs. at follow up:   DSS median (range):7.5 (5.0-9.0) vs. 7.0 (4.0-9.0) vs. 7.0 (2.5-9.0)
Motor-FIM median (range):66 (13-85) vs. 80 (18-90) vs. 77 (18-90)ESS median (range): 19 (2-31) vs. 18.5 (4-30) vs. 17 (3-32)
On admission to rehab vs. at discharge:
17% improved EDSS score
87% improved motor FIM score p<0.001
47% improved ESS score
At follow up (n=44):
14% deteriorated in motor FIM
30% improved on ESS
86% maintained functional gains
Freeman et al. [51] United Kingdom randomized control study 66
treatment group:32
control group:34
mean age
treatment group: 43.2
control group: 44.6
EDSS: (0-10)
Motor-FIM: (13-91)
LHS: (0-100)
  treatment group vs. control group (at the end of 6 weeks of rehab/ no rehab):                 
EDSS (median): 6.5 vs. 6.5
Motor-FIM (median):67 vs. 69.5   p<0.001
LHS (median): 61.5 vs. 66.2
overall improvement in FIM motor (% of patients): 72% vs. 29% p<0.001
change in LHS (score)+2.9 vs. -2.7    p<0.01
change in LHS (% of patients): 53% vs. 23%  p<0.01
Aisen et al. [50] USA retrospective 37 mean age ± SD
46.87 ± 11.275
Impairment  EDSS: (0-10)  FS: (7 functional systems      ranging from 0 to 5 or 6-point scale, the higher the score the greater the disability)
Disability   FIM: (18-126)
6-36 months after discharge On admission to rehab vs. at discharge:
EDSS (mean): 7.47 vs. 6.92  p=0.0001
FS (mean): 14.73 vs. 13 p=0.0001
FIM (mean): 85.25 vs. 96.43 p=0.0001
s.s. improvements in FIM subgroups:
self-care (p=0.0001), locomotion (p=0.0001), sphincter control (p=0.0222)
81% improved in self-care  32.43% improved in sphincter control
s.s. improvements in FS domains:
pyramidal function (p=0.0001)
cerebellar function  (p=0.0033)
sphincter control (p=0.048)
Follow up 6-24 months after discharge: not significant change in mean FS or FIM
Follow up 24-36 months after discharge: (n=11) not significant change in mean FS
mean FIM significantly deteriorated (p=0.008) only due to deterioration in locomotion status (p=0.0133)
Grasso et al. [47] Italy retrospective 230
12.61%  'mild group' EDSS<6  (ambulation with no assistance)
30%      'moderate group'  EDSS 6-6.5  (ambulation with assistance)
57.39%  'severe group' EDSS>6.5  (loss of ambulation)
mean age ± SD
49.42 ± 11.5
Effectiveness
EDSS: (0-10)
BI: (0-100)
RMI: (0-15)
  On admission to rehab vs. at discharge:
EDSS (mean ± SD):6.93 ( ± 1.44) vs. 6.83 ( ± 1.45)
BI (mean ± SD): 54.06 ( ± 30.6) vs. 58.91 ( ± 31.09)   p<0.001
RMI (mean ± SD): 4.83 ( ± 4.41) vs. 5.49 ( ± 4.49)   p<0.001
Effectiveness on EDSS (mean ± SD): 1.95 ± 4.98
Effectiveness on BI (mean ± SD): 16.11 ± 25.36 Effectiveness on RMI (mean ± SD): 8.25 ± 14.42
19.6% improved on EDSS  
54% improved on BI           
49% improved on RMI
mild and moderate group-significant higher BI effectiveness than severe group
mild and moderate group-significant higher RMI effectiveness than severe group
DSS: Disability Status Scale, (10-point scale,0=no  impairment, 10=death due to MS), BI: Barthel Index (the individual's performance on 10 ADL functions for a total of 100 points-100 points for total independence), ESS: Environmental Status Scale, (35-point scale, the higher the score the greater the handicap)  EDSS: Expanded Disability Status Scale, FIM: Functional Independent Measure (18-item, 7-level measure of patient's ability to perform several activities, 126 points-totally independent), Motor-FIM: (13 motor items on a 7-point scale each, 91 points-totally independent), FS: Functional Systems, effectiveness: actual improvement over potential improvement, RMI: Rivermead Mobility Index, (ranges 0-15, 0=totally unable),  LHS: London Handicap Scale, (6 dimensions, 6-point scale, range 0-100, of increasing disadvantage), SF-36: 36-item short form (8 domains HRQOL, scales from 0 to 100, higher values- better HRQOL), HRQOL: Health-Related Quality Of Life, PCS: Physical Component Summary, MCS: Mental Component Summary, s.s.: statistically significant,rehab: rehabilitation

Table 5: Studies focusing on multiple sclerosis patients.

Clinical outcomes: Two studies found that the patients’ discharge neurological status was not significantly different from the admission’s as evaluated by means of Expanded Disability Status Scale (EDSS) [46,47]. According to the study by Freeman et al., improvements were maintained in disability (Functional Independent Measure) and handicap (London Handicap Scale) for 6 months after discharge but neurological status (EDSS) demonstrated a gradual deterioration within 1 year after discharge [48]. The study by Kiddetal indicated that 17% of MS patients improved on the EDSS [49], while Aisenetal reported that MS patients achieved statistically significant improvement between admission and discharge EDSS mean scores [50].

Two studies showed that statistically significant improvements occurred to MS patients as evaluated by means of the ΒΙ [46,47]. Five studies used the FIM to assess MS patients in terms of functional ability [48-52]. In four of the aforementioned studies (the fifth is a cohort study [51] the FIM score at discharge was higher than the one at admission, while in two of them [50,52] the FIM gain is statistically significant. It is worth noting that significant improvements also occurred in FIM subgroupings: self-care (eating, dressing, grooming, bathing), sphincter control (bladder, bowel), and locomotion (ambulation, stair climbing, wheel chair management) for all patients [50].

Additionally, two studies highlighted the statistically significant improvement that MS patients demonstrated in functional independence and disability, as evaluated by means of the Functional Systems, the Rivermead Mobility Index, and the London Handicap Scale [47,50].

Finally, according to Freeman et al. [51], MS patients with the same neurological status were randomized to a treatment or a control group. In terms of disability and handicap level improvements, there was a statistically significant difference between the two groups, 6 weeks later. In terms of the percentage of patients who improved, deteriorated, or remained the same, overall, 53%of the treatment group had improved their total handicap score, 3% remained the same, and 44% deteriorated. In contrast, 23% of the control group improved, 12% stayed the same, and 65% deteriorated.

Quality of life outcomes

With regard to health related quality of life measurement, in terms of the SF-36, Freeman et al. [48] reported that 54% of patients achieved maximum scores at 3 months after discharge and 28.2% at 6 months (in the physical dimension). In contrast, in the mental dimension, 21% of patients peaked at 3 months, with most (61%) peaking at 6 months.

Economic outcomes

Finally, there were no economic evaluation studies identified that assessed inpatient rehabilitation’s outcomes for MS patients (Table 5).

Discussion

We systematically reviewed the available literature containing studies that evaluated the clinical, functional, and economic benefits of inpatient rehabilitation for stroke, SCI, and MS patients. This study is important as it may provide insights into what is evident based on the evidence produced so far and what needs further research and future studies. We identified and included 46 articles in the review. Although the types of methodologies, measures and populations studied varied widely, we were able to identify clear health and economic benefits stemming from physical inpatient rehabilitation for patients and healthcare systems.

In particular, there was strong evidence supporting the functional and neurological benefits of post-acute inpatient rehabilitation for all patient groups and situations. Also, there was moderate evidence to report that patients had a statistically significant gain in health-related quality of life outcomes. Finally, it was shown that the gains in patients’ functional and disability status were generally maintained after discharge except for the MS patients in whom neurological status demonstrated a gradual deterioration after rehabilitation discharge over time. Moreover, the evidence indicates that the effectiveness of inpatient rehabilitation may be influenced by factors such the age of patients, their medical history, socio-economic status and onset of rehabilitation.

Our findings are in line with these presented in previously conducted systematic reviews which examined specifically the outcomes of inpatient rehabilitation on stroke [53,54], SCI [55], and MS [56] patients. More specifically, the study by Knecht et al. [54] reported that well-organized acute and intermediate rehabilitation after stroke can provide patients with the best functional results. Furthermore, the study by Lam et al. [55] showed that inpatient rehabilitation focused on gait training can offer the greatest benefits to functional ambulation in sub-acute or chronic spinal cord injury. Moreover, a study by Khan et al. [56] indicated that inpatient rehabilitation does not change the level of impairment, but can improve the experience of people with multiple sclerosis in terms of activity and participation.

In terms of the economics, there is very scarce evidence. Notwithstanding, the low number of studies, it appears that in certain settings rehabilitation may be cost-effective in patients with stroke and spinal injury. There are no studies available for multiple sclerosis patients.

In terms of the studies available, it appears effectiveness studies are prospective in nature, up to a year in the majority and there are no clinical trials. Moreover, there is no consistency in terms of how effectiveness is quantified as many different measures are utilized. Finally, it should be noted that programs are not standardized and are also delivered in different settings. In terms of the economic studies, from a methodological point of view, most of them are short term and they focus mainly on the health care system, based on cost-effectiveness or cost minimization modelling. Hence, they may underestimate the economic benefits of rehabilitation as it is associated with longer economic benefits for the health system due to resource utilization reductions and indirect benefits for the economy and society due to higher productivity, superior functioning and return to employment. Hence, long term cost-benefit analyses are more appropriate for evaluating it. Therefore, despite the availability of several studies in the field concerning the effectiveness of inpatient rehabilitation on the three health conditions of interest, it is evident that there is lack for economic evaluations and longer term studies in this field and there is also a lot of variability in terms of the outcomes considered and these justify further investigation and studies in order to establish more vividly the benefits of inpatient rehabilitation and influence decision making and patient management.

The results of this review must be interpreted in light of the methodological pitfalls of studies of this kind. We should acknowledge the possibility of publication bias due to the fact that only published studies, written in English language, were incorporated in our review. In addition, the search was limited to free databases. Moreover, the studies which were identified in this review covered a wide range of methodologies, outcome measures, and patient populations and consequently the heterogeneity of these studies prevented us from any quantitative estimates, of the overall benefits of inpatient rehabilitation and from performing a formal meta-analysis. Also, our review did not take into account information such as severity of disease, intensiveness of intervention, and length of stay. Furthermore, the information regarding the perspective of economic evaluation studies is not available. Finally, it should be also acknowledged that, unlike other treatments such as drugs, rehabilitation is not homogenous and standard therapy across different settings, and often data on the content and related information on rehabilitation programs evaluated is missing or differs across studies.

Conclusion

Despite the heterogeneity of outcomes and the limitations of this systematic review, there is abundant and clear evidence supporting the effectiveness and benefits of inpatient rehabilitation. In summary, inpatient rehabilitation improves clinical outcomes for patients with disability or impairment due to stroke, spinal cord injury, and multiple sclerosis. There is also scarce evidence that inpatient rehabilitation may be cost saving or highly cost-effective, especially for patients with stroke. Additional effectiveness and economic evaluation studies may contribute more to the evidence supporting the issue of rehabilitation for patients cost to inform policy and decision making and to improve patient access and outcomes of therapy.

Funding

This research received funding from the “ANAGENNISI” Recovery and Rehabilitation Center S.A.

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