Stroke rehabilitation: an international perspective.

There is a revolution underway in stroke rehabilitation. International comparative studies coupled with an impressive evidence base have provided a platform from which an ideal system for stroke rehabilitation can be envisioned. Using the concepts of structure and process of care, different systems of stroke rehabilitation can be compared and evaluated against best evidence. Two structures of care are examined: specialized interdisciplinary stroke rehabilitation units and outpatient programs. Although specialized interdisciplinary stroke rehabilitation units remain the "gold standard" of care, access to them is often limited. Outpatient programs are essential to stroke rehabilitation systems of care; however, while some countries are investing in outpatient programs, others are scaling back. Even though structures of care have been shown to affect processes of care, it is the processes of care that have proven to be more influential in altering patient outcomes. Four key processes of care are examined: time to admission, intensity of therapy, task-specific therapy, and discharge planning. Within international stroke rehabilitation systems, differences in these processes have resulted in significant differences in outcomes. This allows for "real-world" comparisons of how differing processes affect patient outcomes. Those systems whose structures and processes of care best reflect current best evidence appear to achieve better outcomes.