Interaction effect of rehabilitation initiation timing and hospitalization frequency on long-term functional outcomes after stroke in rural China: A retrospective cohort study

Juming Liu¹Luwen Zhang²Changyu Ju¹Xiping Jia³Chao Zhang¹Feng Wu¹Tao Qin^4*qianqian Sun^1,5*

• ¹Hubei University of Arts and Science Affiliated Xiangyang Central Hospital, Xiangyang, Hubei, China, Hubei, China
• ²School of Health Services Management, Southern Medical University, Guangzhou, Guangdong, China, Guangdong, China
• ³School of Computer Science, Guangdong Polytechnic Normal University, Guangzhou, China, Guangdong, China
• ⁴Hubei University of Arts and Science, Hubei, China, Hubei, China
• ⁵Rehabilitation Medicine and Rehabilitation Engineering Technology Xiangyang Key Laboratory, Xiangyang, Hubei, China, Hubei, China

Objective: To investigate the effects of rehabilitation-initiation timing and rehabilitation-hospitalization frequency(RHF) on activities of daily living (ADL) evaluated at 6 months post-stroke. Design: Retrospective cohort study. Setting: Convalescent rehabilitation wards in urban and suburban areas of Xiangyang, China. Participants: A total of 275 patients with ADL impairment following acute or subacute stroke who received inpatient comprehensive rehabilitation between 2021 and 2024. Interventions: Participants underwent inpatient multidisciplinary rehabilitation—including physical therapy, occupational therapy, and individualized functional exercises—during each hospitalization, with each inpatient rehabilitation episode lasting for 3 weeks.. The main exposures were the timing of rehabilitation initiation and the total number of inpatient rehabilitation episodes within the first 6 months post-stroke. Main Outcome Measures: The primary outcome was the change in ADL, assessed by the Barthel Index (BI), from baseline to the 6-month post-stroke follow-up. Results: At the 6-month (180-day) follow-up, the mean BI score increased by 12.59 points compared to baseline (95% CI, 5.53–19.65; P < 0.001). Compared to those who started rehabilitation at 61–90 days post-stroke, patients who initiated rehabilitation earlier—at 1–14, 15–30, and 31–60 days—showed greater BI improvements at 6 months, with mean differences of 15.48 (95% CI, 4.90–26.06; P = 0.004), 13.18 (95% CI, 3.85–22.51; P = 0.005), and 8.63 (95% CI, 0.40–16.86; P = 0.04) points, respectively. Among patients who started rehabilitation at 1–14 and 15–30 days, each additional systematic inpatient rehabilitation was associated with a further mean BI increase of 2.24 (95% CI, 0.98–5.46; P = 0.20) and 2.10 (95% CI, 0.87–5.07; P = 0.21) points, respectively, although these differences did not reach statistical significance. Subgroup analysis showed that early rehabilitation significantly improved BI in patients aged ≥65 and those with hemorrhagic stroke. Moreover, higher hospitalization frequency benefited patients with higher education and those with hemorrhagic stroke. Conclusion: Earlier initiation and greater frequency of inpatient rehabilitation were independently associated with better ADL outcomes at the 6-month mark in rural Chinese stroke survivors. Importantly, the benefit of each additional rehabilitation admission was amplified when therapy began within the first month post-stroke and diminished when initiation was delayed beyond two months.