Two weeks of intensive sit-to-stand training in addition to usual care improves sit-to-stand ability in people who are unable to stand up independently after stroke: a randomised trial.

QUESTION: Does intensive sit-to-stand training in addition to usual care improve sit-to-stand ability in people who are unable to stand up independently after stroke? DESIGN: A multi-centre randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis. PARTICIPANTS: Thirty patients from two Sydney hospitals, < 3 months after stroke, with a mean Modified Rankin Scale score of 4 points (SD 0.5). INTERVENTION: All participants received usual care. Participants in the experimental group attended two additional sessions of physiotherapy per day for 2 weeks. These sessions were individualised to the needs of each participant in order to increase the amount and intensity of sit-to-stand training. OUTCOME MEASURES: Outcome measures were taken at baseline and at 2 weeks. The primary outcome was clinicians' impressions of sit-to-stand change, measured using videos and a 15-point Global Impressions of Change Scale. Secondary outcomes were sit-to-stand ability, composite strength of key muscles of the affected lower limb, gross lower limb extension strength, the Goal Attainment Scale, and ranking of change in ability to move from sitting to standing. RESULTS: All participants completed the trial. The mean between-group difference for clinicians' impressions of sit-to-stand change was 1.57/15 points (95% CI 0.02 to 3.11). The secondary outcomes that indicated a treatment effect were gross lower limb extension strength and ranking of change in ability to move from sitting to standing, with mean between-group differences of 6.2 deg (95% CI 0.5 to 11.8) and -7 (95% CI -1 to -13), respectively. CONCLUSION: Two weeks of intensive sit-to-stand training in addition to usual care improves sit-to-stand ability in people who are unable to stand up independently after stroke. TRIAL REGISTRATION: ANZCTR 12616001288415.

"In Safe Hands" - A costly integrated care program with limited benefits in stroke unit care.

Given reported favourable outcomes of accountable care unit models of health care delivery (Taylor et al., 2017; Stein et al., 2015; Kara et al., 2015), the Clinical Excellence Commission of NSW has embraced "In Safe Hands" (ISH) to enhance coordination of care. ISH embraces the structured interdisciplinary bedside round (SIBR) component, for which reported outcomes include reduced length of stay (Taylor et al., 2017; Stein et al., 2015; Kara et al., 2015), possible reduction in overall costs of care (Kara et al., 2015), and enhanced patient and staff satisfaction (O'Leary et al., 2011). It is not yet clear whether the benefits of such a model are translatable to the Australian Health Care System (Hunyh et al., 2016) and/or established units with an already strong multi-disciplinary approach to patient care. The purpose of this prospective cohort study of 200 participants was to assess the effect(s) of implementation of ISH in a stroke unit of a tertiary hospital in Sydney, Australia. Data on length of stay, re-admission rates, adverse events, as well as patient and nursing satisfaction, were collected pre and post implementation. There was no significant difference in length of stay in median days (5 (IQR 2-7) versus 4 (IQR 2-6), P = 0.55) or incidence of adverse events (10% versus 12%, P = 0.82). Stroke outcome disability scores were not affected by the intervention. There were no significant differences overall in reported patient and nursing satisfaction. Implementation of the ISH program cost approximately AUD$ 1805/week (USD$ 1365) in wages. The ISH program was a costly intervention of limited benefit in a well-established acute stroke unit. We here discuss potential reasons for the failure of this intervention to achieve its primary aim in this setting.