Original article| Volume 95, ISSUE 2, P269-275, February 2014

Association Between the Volume of Inpatient Rehabilitation Therapy and the Risk of All-Cause and Cardiovascular Mortality in Patients With Ischemic Stroke

Published:September 09, 2013DOI:



      To investigate the relationship between the volume of inpatient rehabilitation therapy and mortality among patients with acute ischemic stroke, as well as to assess whether the association varies with respect to stroke severity.


      A retrospective study with a cohort of consecutive patients who had acute ischemic stroke between January 1, 2008, and June 30, 2009.


      Referral medical center.


      Adults with acute ischemic stroke (N=1277) who were admitted to a tertiary hospital.


      Not applicable.

      Main Outcome Measure

      Stroke-related mortality.


      During the median follow-up period of 12.3 months (ranging from January 1, 2008, to December 31, 2009), 163 deaths occurred. Greater volume of rehabilitation therapy was associated with a reduced risk of all-cause and cardiovascular mortality (P for trend <.001 for both). Compared with the first tertile, the third tertile of rehabilitation volume was associated with a 55% lower risk of all-cause mortality (hazard ratio [HR]=.45; 95% confidence interval [CI], .30–.65) and a 50% lower risk of cardiovascular mortality (HR=.50; 95% CI, .31–.82). The association did not vary with respect to stroke severity (P for interaction = .45 and .73 for all-cause and cardiovascular mortality, respectively).


      The volume of inpatient rehabilitation therapy and mortality were significantly inversely related in the patients with ischemic stroke. Thus, further programs aimed at promoting greater use of rehabilitation services are warranted.


      List of abbreviations:

      CI (confidence interval), HR (hazard ratio), NIHSS (National Institutes of Health Stroke Scale)
      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 Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. Department of Health, Executive Yuan, Taiwan. 2012 statistics of causes of death. Available at: Accessed June 25, 2013.

        • Hsieh F.I.
        • Lien L.M.
        • Chen S.T.
        • et al.
        • and Taiwan Stroke Registry Investigators
        Get With the Guidelines-Stroke performance indicators: surveillance of stroke care in the Taiwan Stroke Registry: Get With the Guidelines-Stroke in Taiwan.
        Circulation. 2010; 122: 1116-1123
        • Lichtman J.H.
        • Jones S.B.
        • Wang Y.
        • et al.
        Outcomes after ischemic stroke for hospitals with and without Joint Commission-certified primary stroke centers.
        Neurology. 2011; 76: 1976-1982
        • Prvu Bettger J.A.
        • Stineman M.G.
        Effectiveness of multidisciplinary rehabilitation services in postacute care: state-of-the-science. A review.
        Arch Phys Med Rehabil. 2007; 88: 1526-1534
        • Schwamm L.H.
        • Pancioli A.
        • Acker III, J.E.
        • et al.
        Recommendations for the establishment of stroke systems of care: recommendations from the American Stroke Association's Task Force on the Development of Stroke Systems.
        Stroke. 2005; 36: 690-703
        • Veerbeek J.M.
        • Koolstra M.
        • Ket J.C.
        • van Wegen E.E.
        • Kwakkel G.
        Effects of augmented exercise therapy on outcome of gait and gait-related activities in the first 6 months after stroke: a meta-analysis.
        Stroke. 2011; 42: 3311-3315
        • Bode R.K.
        • Heinemann A.W.
        • Semik P.
        • Mallinson T.
        Relative importance of rehabilitation therapy characteristics on functional outcomes for persons with stroke.
        Stroke. 2004; 35: 2537-2542
        • Chen C.C.
        • Heinemann A.W.
        • Granger C.V.
        • Linn R.T.
        Functional gains and therapy intensity during subacute rehabilitation: a study of 20 facilities.
        Arch Phys Med Rehabil. 2002; 83: 1514-1523
        • Chen M.D.
        • Rimmer J.H.
        Effects of exercise on quality of life in stroke survivors: a meta-analysis.
        Stroke. 2011; 42: 832-837
        • Hu G.C.
        • Hsieh S.F.
        • Chen Y.M.
        • Hsu H.H.
        • Hu Y.N.
        • Chien K.L.
        Relationship of initial glucose level and all-cause death in patients with ischaemic stroke: the roles of diabetes mellitus and glycated hemoglobin level.
        Eur J Neurol. 2012; 19: 884-891
        • Hu G.C.
        • Hsieh S.F.
        • Chen Y.M.
        • Hu Y.N.
        • Kang C.L.
        • Chien K.L.
        The prognostic roles of initial glucose level and functional outcomes in patients with ischemic stroke: difference between diabetic and nondiabetic patients.
        Disabil Rehabil. 2012; 34: 34-39
        • Kasner S.E.
        • Chalela J.A.
        • Luciano J.M.
        • et al.
        Reliability and validity of estimating the NIH Stroke Scale score from medical records.
        Stroke. 1999; 30: 1534-1537
        • Adams Jr., H.P.
        • Bendixen B.H.
        • Kappelle L.J.
        • et al.
        Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment.
        Stroke. 1993; 24: 35-41
        • Gassaway J.
        • Horn S.D.
        • DeJong G.
        • Smout R.J.
        • Clark C.
        • James R.
        Applying the clinical practice improvement approach to stroke rehabilitation: methods used and baseline results.
        Arch Phys Med Rehabil. 2005; 86: S16-S33
        • Hu M.H.
        • Hsu S.S.
        • Yip P.K.
        • Jeng J.S.
        • Wang Y.H.
        Early and intensive rehabilitation predicts good functional outcomes in patients admitted to the stroke intensive care unit.
        Disabil Rehabil. 2010; 32: 1251-1259
        • Vaartjes I.
        • van Dis I.
        • Grobbee D.E.
        • Bots M.L.
        The dynamics of mortality in follow-up time after an acute myocardial infarction, lower extremity arterial disease and ischemic stroke.
        BMC Cardiovasc Disord. 2010; 10: 57
        • Briggs D.E.
        • Felberg R.A.
        • Malkoff M.D.
        • Bratina P.
        • Grotta J.C.
        Should mild or moderate stroke patients be admitted to an intensive care unit?.
        Stroke. 2001; 32: 871-876
        • Kwakkel G.
        • van Peppen R.
        • Wagenaar R.C.
        • et al.
        Effects of augmented exercise therapy time after stroke: a meta-analysis.
        Stroke. 2004; 35: 2529-2539
        • Jette D.U.
        • Warren R.L.
        • Wirtalla C.
        The relation between therapy intensity and outcomes of rehabilitation in skilled nursing facilities.
        Arch Phys Med Rehabil. 2005; 86: 373-379
        • Bland S.T.
        • Schallert T.
        • Strong R.
        • Aronowski J.
        • Grotta J.C.
        • Feeney D.M.
        Early exclusive use of the affected forelimb after moderate transient focal ischemia in rats: functional and anatomic outcome.
        Stroke. 2000; 31: 1144-1152
        • Lincoln N.B.
        • Parry R.H.
        • Vass C.D.
        Randomized, controlled trial to evaluate increased intensity of physiotherapy treatment of arm function after stroke.
        Stroke. 1999; 30: 573-579
        • Parry R.H.
        • Lincoln N.B.
        • Vass C.D.
        Effect of severity of arm impairment on response to additional physiotherapy early after stroke.
        Clin Rehabil. 1999; 13: 187-198
        • Paolucci S.
        • Antonucci G.
        • Pratesi L.
        • Traballesi M.
        • Lubich S.
        • Grasso M.G.
        Functional outcome in stroke inpatient rehabilitation: predicting no, low and high response patients.
        Cerebrovasc Dis. 1998; 8: 228-234
        • Langhorne P.
        • Stott D.J.
        • Robertson L.
        • et al.
        Medical complications after stroke: a multicenter study.
        Stroke. 2000; 31: 1223-1229
        • Govan L.
        • Langhorne P.
        • Weir C.J.
        Does the prevention of complications explain the survival benefit of organized inpatient (stroke unit) care? Further analysis of a systematic review.
        Stroke. 2007; 38: 2536-2540
        • Johansson B.B.
        Brain plasticity and stroke rehabilitation. The Willis lecture.
        Stroke. 2000; 31: 223-230
        • Chiu H.T.
        • Wang Y.H.
        • Jeng J.S.
        • Chen B.B.
        • Pan S.L.
        Effect of functional status on survival in patients with stroke: is independent ambulation a key determinant?.
        Arch Phys Med Rehabil. 2012; 93: 527-531
        • De Wit L.
        • Putman K.
        • Devos H.
        • et al.
        Five-year mortality and related prognostic factors after inpatient stroke rehabilitation: a European multi-centre study.
        J Rehabil Med. 2012; 44: 547-552
        • Wade D.T.
        Research into the black box of rehabilitation: the risks of a type III error.
        Clin Rehabil. 2001; 15: 1-4
        • Wittwer J.E.
        • Goldie P.A.
        • Matyas T.A.
        • Galea M.P.
        Quantification of physiotherapy treatment time in stroke rehabilitation—criterion-related validity.
        Aust J Physiother. 2000; 46: 291-298
        • Lenze E.J.
        • Munin M.C.
        • Quear T.
        • et al.
        Significance of poor patient participation in physical and occupational therapy for functional outcome and length of stay.
        Arch Phys Med Rehabil. 2004; 85: 1599-1601
        • Lindsay P.
        • Bayley M.
        • McDonald A.
        • Graham I.D.
        • Warner G.
        • Phillips S.
        Toward a more effective approach to stroke: Canadian Best Practice Recommendations for Stroke Care.
        CMAJ. 2008; 178: 1418-1425
        • Foley N.
        • Pereira S.
        • Salter K.
        • Meyer M.
        • McClure J.A.
        • Teasell R.
        Are recommendations regarding inpatient therapy intensity following acute stroke really evidence-based?.
        Top Stroke Rehabil. 2012; 19: 96-103
        • Prvu Bettger J.A.
        • Kaltenbach L.
        • Reeves M.J.
        • et al.
        Assessing stroke patients for rehabilitation during the acute hospitalization: findings from the Get With The Guidelines-Stroke program.
        Arch Phys Med Rehabil. 2013; 94: 38-45