Supplementary Material for: Timing of initiation of acute stroke rehabilitation and management corresponding to complications at primary stroke centers in Japan: a nationwide cross-sectional web-based questionnaire survey

Introduction: Many guidelines now recommend early rehabilitation for acute stroke patients. However, evidence remains lacking regarding the specific timings for initiation of various rehabilitation steps and management when complications are encountered in acute stroke rehabilitation. This survey aimed to investigate actual clinical situations in acute stroke rehabilitation in Japan, to improve the medical systems for rehabilitation and plan further studies. Methods: This nationwide, cross-sectional, web-based questionnaire survey was administered between February 7, 2022 and April 21, 2022, targeting all primary stroke centers (PSCs) in Japan. Among several components of the survey, this paper focused on the timing of the initiation of three rehabilitation steps (passive bed exercise; head elevation; and out-of-bed mobilization), along with the management of rehabilitation (continued or suspended) in the event of complications during acute stroke rehabilitation. We also investigated the influence of facility features on these contents. Results: Responses were obtained from 639 of the 959 PSCs surveyed (response rate: 66.6%). In cases of ischemic stroke and intracerebral hemorrhage, most PSCs initiated passive bed exercise on Day 1, head elevation on Day 1 and out-of-bed mobilization on Day 2 (with day of admission defined as Day 1). In cases with subarachnoid hemorrhage, rehabilitation steps were delayed compared to other stroke subtypes or showed wide variation depending on the facility. Passive bed exercise was accelerated by the presence of protocols for rehabilitation and weekend rehabilitation. Out-of-bed mobilization was accelerated by the presence of a stroke care unit. Facilities with board-certified rehabilitation doctors were cautious regarding the initiation of head elevation. Most PSCs suspended rehabilitation training in the event of symptomatic systemic/neurological complications. Conclusion: Our survey revealed the actual situation of acute stroke rehabilitation in Japan and indicated that some facility features appear to influence early increases in physical activity levels and early mobilization. Our survey provides fundamental data to improve the medical systems for acute stroke rehabilitation in the future.

引言：如今多项临床指南均推荐对急性脑卒中患者实施早期康复干预，但目前仍缺乏针对急性期脑卒中康复各具体环节启动时机，以及出现并发症时康复管理方案的相关循证证据。本调查旨在调研日本急性脑卒中康复的实际临床现状，以优化康复医疗体系并为后续研究规划提供参考依据。
方法：本研究于2022年2月7日至2022年4月21日期间，针对日本所有初级卒中中心 (Primary Stroke Centers, PSCs) 开展了一项全国性横断面网络问卷调查。本次调查包含多个调研模块，本文聚焦于三项康复环节的启动时机：被动床上运动 (passive bed exercise)、床头抬高以及下床活动 (out-of-bed mobilization)，同时调研了急性脑卒中康复期间出现并发症时的康复管理策略（继续开展训练或暂停训练），此外还探讨了医疗机构特征对上述康复实践的影响。
结果：本次共向959家初级卒中中心发放问卷，回收有效问卷639份，有效回收率为66.6%。针对缺血性脑卒中及脑出血患者，多数初级卒中中心于入院当日（定义为第1日）启动被动床上运动与床头抬高，并于入院第2日开展下床活动。而针对蛛网膜下腔出血患者，其康复环节的启动时间相较其他卒中亚型有所延迟，且不同医疗机构间的实践差异较大。存在康复治疗规范及周末康复服务的机构，被动床上运动的启动时机更早；设有卒中护理单元 (stroke care unit) 的机构，下床活动的启动时机更早。配备经专科认证的康复医师的医疗机构，在启动床头抬高环节时更为谨慎。当出现症状性全身/神经系统并发症时，绝大多数初级卒中中心会暂停康复训练。
结论：本调研明确了日本急性脑卒中康复的临床实际现状，结果显示部分医疗机构特征会影响早期体能提升与早期下床活动的开展时机。本调查可为未来优化急性脑卒中康复医疗体系提供基础数据支撑。