Original Study| Volume 22, ISSUE 2, P453-458.e3, February 2021

Download started.


Association of Therapy Time and Cognitive Recovery in Stroke Patients in Post-Acute Rehabilitation

Published:December 09, 2020DOI:



      Cognitive impairment is highly prevalent after stroke, with 77% of people having impairment in at least 2 cognitive domains. The purpose of this study is to describe the association between therapy minutes per length of stay (LOS) day and cognitive recovery in patients receiving rehabilitation services in inpatient post-acute care facilities following a stroke.


      Secondary analyses of data collected in inpatient rehabilitation and skilled nursing facilities from 2005 to 2010 for an observational cohort study.

      Setting and Participants

      Participants were adults aged ≥65 years with Medicare insurance and primary diagnosis of stroke (N = 100). Participants who met criteria for dementia (n = 5) were excluded from analyses. We calculated therapy minutes per LOS day for occupational therapy, physical therapy, speech-language pathology, and all therapies combined; therapy times were dichotomized into high or low minutes per LOS day (MLD). We used an ordinary least squares regression model for cognitive outcome at discharge to control for cognitive status at admission, therapy intensity by discipline, and LOS.


      At baseline, participants were classified as having severe (n = 11), moderate (n = 39), or mild (n = 45) cognitive impairment. Impairment groups were not significantly different on any demographic variables. The adjusted regression model showed that high occupational therapy MLD (>50 minutes per LOS day) (P = .028) was significantly associated with cognitive measure at discharge compared with low occupational therapy MLD when controlling for cognitive impairment group at baseline (P < .001). Neither high physical therapy MLD nor speech-language pathology MLD was significantly associated with cognitive outcome relative to their respective low TMLD groups.

      Conclusions and Implications

      Our results show that higher-intensity occupational therapy services were associated with better cognitive outcome at discharge from inpatient rehabilitation after stroke. Findings also suggest that volume of therapy alone does not necessarily produce optimal outcomes. Both amount and type of therapy should be tailored to meet the needs of individual patients.


      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 the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Morsund Å.H.
        • Ellekjær H.
        • Gramstad A.
        • et al.
        Cognitive and emotional impairment after minor stroke and non-ST-elevation myocardial infarction (NSTEMI): A prevalence study.
        Stroke Res Treat. 2019; 2019: 2527384
        • Cederfeldt M.
        • Gosman-Hedström G.
        • Pérez C.G.
        • et al.
        Recovery in personal care related to cognitive impairment before and after stroke—A 1-year follow-up.
        Acta Neurol Scand. 2010; 122: 430-437
        • Claesson L.
        • Lindén T.
        • Skoog I.
        • Blomstrand C.
        Cognitive impairment after stroke—Impact on activities of daily living and costs of care for elderly people.
        Cerebrovasc Dis. 2005; 19: 102-109
        • Jokinen H.
        • Melkas S.
        • Ylikoski R.
        • et al.
        Post-stroke cognitive impairment is common even after successful clinical recovery.
        Eur J Neurol. 2015; 22: 1288-1294
        • Cramer S.C.
        • Wolf S.L.
        • Adams H.P.
        • et al.
        Stroke recovery and rehabilitation research: Issues, opportunities, and the National Institutes of Health StrokeNet.
        Stroke. 2017; 48: 813-819
        • Foley N.
        • McClure J.
        • Meyer M.
        • et al.
        Inpatient rehabilitation following stroke: Amount of therapy received and associations with functional recovery.
        Disabil Rehabil. 2012; 34: 2132-2138
        • 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
        • Hong I.
        • Goodwin J.S.
        • Reistetter T.A.
        • et al.
        Comparison of functional status improvements among patients with stroke receiving postacute care in inpatient rehabilitation vs skilled nursing facilities.
        JAMA Netw Open. 2019; 2: e1916646
        • Coster W.
        • Haley S.M.
        • Jette A.
        • et al.
        Predictors of basic and instrumental activities of daily living performance in persons receiving rehabilitation services.
        Arch Phys Med Rehabil. 2007; 88: 928-935
        • Mallinson T.R.
        • Bateman J.
        • Tseng H.Y.
        • et al.
        A comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after lower-extremity joint replacement surgery.
        Arch Phys Med Rehabil. 2011; 92: 712-720
        • van der Steen J.T.
        • Volicer L.
        • Gerritsen D.L.
        • et al.
        Defining severe dementia with the Minimum Data Set.
        Int J Geriatr Psychiatry. 2006; 21: 1099-1106
      1. Weaver JA, Cogan AM, Mallinson T, Davidson L. Developing a cognition scale using items from three federally mandated assessments in post-acute care. GW University Research Days; 2019. Available at: Accessed June 25, 2020

        • Inouye S.K.
        • Studenski S.
        • Tinetti M.E.
        • Kuchel G.A.
        Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept.
        J AmGeriatr Soc. 2007; 55: 780-791
        • Cogan A.M.
        • Weaver J.A.
        • McHarg M.
        • et al.
        Association of length of stay, recovery rate, and therapy time per day with functional outcomes after hip fracture surgery.
        JAMA Netw Open. 2020; 3: e1919672
        • Park J.
        • Lee S.-U.
        • Jung S.H.
        Prediction of post-stroke functional mobility from the initial assessment of cognitive function.
        NeuroRehabilitation. 2017; 41: 169-177
        • Beauchet O.
        • Blumen H.M.
        • Callisaya M.L.
        • et al.
        Spatiotemporal gait characteristics associated with cognitive impairment: A multicenter cross-sectional study, the Intercontinental “Gait, cOgnitiOn & Decline” initiative.
        Curr Alzheimer Res. 2018; 15: 273-282
        • Abdi H.
        • Williams L.J.
        Tukey's Honestly Significant Difference (HSD) Test.
        in: Neil S. Encyclopedia of Research Design. Sage, Thousand Oaks, CA2010: 6
        • Sandhu S.
        • Furniss J.
        Functional cognition in the health care system.
        Functional Cognition and Occupational Therapy. AOTA Press, Inc, Bethesda, MD2019: 21-29
        • Winstein C.J.
        • Stein J.
        • Arena R.
        • et al.
        Guidelines for adult stroke rehabilitation and recovery: A guideline for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2016; 47: e98-e169
        • Hebert D.
        • Lindsay M.P.
        • McIntyre A.
        • et al.
        Canadian stroke best practice recommendations: Stroke rehabilitation practice guidelines, update 2015.
        Int J Stroke. 2016; 11: 459-484
        • National Institute for Health and Care Excellence
        Stroke rehabilitation in adults.
        National Institute for Health and Care Excellence, 2013 (2013. Available at:)
        Date accessed: February 13, 2020
        • Norrving B.
        • Barrick J.
        • Davalos A.
        • et al.
        Action plan for stroke in Europe 2018–2030.
        Eur Stroke J. 2018; 3: 309-336
        • Eskes G.A.
        • Lanctôt K.L.
        • Herrmann N.
        • et al.
        Canadian stroke best practice recommendations: Mood, cognition and fatigue following stroke practice guidelines, update 2015.
        Int J Stroke. 2015; 10: 1130-1140
        • Horn S.
        • DeJong G.
        • Smout R.
        • et al.
        Stroke rehabilitation patients, practice, and outcomes: Is earlier and more aggressive therapy better?.
        Arch Phys Med Rehabil. 2005; 86: 101-114