Measures of activity limitation on admission to rehabilitation after stroke predict walking speed at discharge: an observational study

Determination of Five Sit-to-Stand Test Performance at Discharge of Stroke Patients

The early identification of performance in the five-repetition sit-to-stand test (5-STS) at discharge in stroke patients could be of interest because it can determine independence for community-based activities. This study aimed to determine whether the initial measurement of the 5-STS test can be a determinant of the performance level prediction and amount of change in the 5-STS test at discharge in stroke patients. A prospective cohort study was conducted with a sample of 56 patients aged ≤60 d post-stroke. The 5-STS test results, as well as changes in patient condition, were measured at admission (T0) to an outpatient rehabilitation program, after the first month (T1), and at discharge (T2). The mean age was 62.7 (SD = 13.0), 58.9% of the subjects were male, and 75% had suffered an ischemic stroke. A multivariate linear regression model using the 5-STS test at T0 explained 57.7% of the variance in the performance at discharge. Using the 5-STS at T1 increased the variance to 75.5% (p < 0.001). Only the time from stroke onset at T0 significantly contributed to the two models. The measurement of the 5-STS at T0 and the amount of change in its performance at T2 explained 60.2% (p < 0.001) of the variance, while reassessment at T1 explained only 19.3% (p < 0.001). The level of patient performance on the 5-STS test at discharge, as well as any potential change, can be predicted by the admission measure of 5-STS in stroke patients.

Predicting Discharge Walking Function With High-Intensity Stepping Training During Inpatient Rehabilitation in Nonambulatory Patients Poststroke

OBJECTIVE

This cohort investigation identified primary predictors of discharge walking function of nonambulatory individuals poststroke with high-intensity training (HIT) during inpatient rehabilitation.

DESIGN

Observational cohort investigation.

SETTING

Inpatient rehabilitation.

PARTICIPANTS

Data were collected from individuals (N=257) <6 months poststroke who required assistance to walk at admission.

INTERVENTION

Clinical physical therapy interventions attempted to maximize stepping practice at higher intensities.

MAIN OUTCOME MEASURES

Primary outcomes included the discharge level of assistance required during walking (minimal or no assistance) and attainment of specific gait speed thresholds (0.4 and 0.8 m/s) during the 10-m walk test. Independent predictors were demographics, training interventions (including steps/day), baseline Berg Balance Scale (BBS), and paretic leg strength.

RESULTS

Participants performed a median (interquartile range) of 1270 (533-2297) steps per day throughout inpatient rehabilitation, with significant differences between those who walked with versus without assistance at discharge. Logistic regressions indicate steps per day was a primary predictor of unassisted walking recovery; removal of steps per day resulted in primary predictors of baseline BBS and strength. Receiver operating characteristic (ROC) analyses indicate significant areas under the curve for BBS and relatively low cutoff scores of 5.5 points at admission to walk without assistance at any speed. ROC analyses performed using 1-week outcomes indicate BBS scores of 5-17 points were needed to achieve locomotor thresholds.

CONCLUSION

Stepping activity, BBS, and paretic leg strength were primary predictors of walking outcomes in patients performing HIT, and ROC analyses indicated recovery of independent walking could be achieved in low functioning patients early poststroke.

Prognostic value of balance performance for improvements of community ambulation among stroke patients: a cohort study

BACKGROUND

Despite the positive impact of improving the level of community ambulation among stroke patients, little prognostic research has focused on this indicator.

AIM

To investigate the prognostic value of the side-by-side, semi-tandem, and tandem standing balance positions and the five-sit-stand (5STS) test for discriminating patients undergoing physical rehabilitation who improve level of functional ambulation and predicting transition time.

DESIGN

A cohort study with assessments repeated monthly until discharge for classifying patients in a community ambulation class.

SETTING

A neurological rehabilitation unit of a hospital in Spain.

POPULATION

A consecutive sample of 109 stroke patients (68.5±12.0 years) was screened and included within four months post stroke. Of them no one refused, 3 died, and 5 were lost earlier to transition or discharge.

METHODS

Balance tests, the 5STS and gait speed were measured at the center at baseline and monthly until discharge. Transition from household or limited community ambulation to a higher ambulatory capacity or class. Area under the curve (AUC) were used to compare discriminative abilities of the tests and Cox regression analysis to evaluate the association between the tests and time of transition.

RESULTS

For household non-ambulators, the semi-tandem was the best discriminative test (AUC=0.850) and the three balance tests showed an association with time to transition. Among the limited community ambulators, the 5STS test also revealed discriminative ability (AUC: 0.822 [0.63-1.00]), with a good prognostic cut-off (14.8 seconds) and association with time to transition (Hazard Ratio: 1.22; 95%CI: 1.05-1.43).

CONCLUSIONS

Semi-tandem and the 5STS tests can discriminate patients who improve level of functional ambulation and predict transition times within three months in non-ambulators and limited community ambulation patients, respectively.

CLINICAL REHABILITATION IMPACT

The semi-tandem and the 5STS tests can be performed easily in clinical settings to predict improvement of functional ambulation level in patients following stroke.

Development of Gait Ability Assessment for hemiplegics (GAA) and verification of inter-rater reliability and validity

Tomida K, Tanino G, Sonoda S, Hirano S, Itoh N, Saitoh E, Kagaya H, Suzuki A, Kawakami K, Miyajima T, Takai M. Development of Gait Ability Assessment for hemiplegics (GAA) and verification of inter-rater reliability and validity. Jpn J Compr Rehabil Sci 2021; 12: 19-26.

Objective

To develop the Gait Ability Assessment for hemiplegics (GAA), and to verify its validity and inter-rater reliability.

Methods

We developed the GAA, a new method for the assessment of gait ability. Next, we examined the inter-rater reliability of GAA by assessing gait ability of post-stroke patients by two physical therapists. Then, we verified the validity of GAA by comparing with the existing assessments methods comprising Functional Ambulation Categories (FAC), Functional Independence Measure (FIM)-walk, maximum walking speed, motor subscore of the FIM (FIM-M), and total score of affected-side motor function of the Stroke Impairment Assessment Set (SIAS-L/E).

Results

Regarding the inter-rater reliability of GAA, κ coefficient was 0.76 and weighted κ coefficient was 0.96. The correlation coefficients between GAA scores and existing assessment methods were: 0.95 for FAC scores, 0.95 for FIM-walk scores, 0.82 for maximum walking speed, 0.89 for FIM-M, and 0.61 for SIAS-L/E, all of which showed a significant correlation (p<0.01).

Conclusion

GAA has high inter-rater reliability as well as high validity as a gait ability assessment method, suggesting that it can be applied to research and clinical settings.

Psychometric properties of measures of upper limb activity performance in adults with and without spasticity undergoing neurorehabilitation-A systematic review

Introduction

This systematic review appraises the measurement quality of tools which assess activity and/or participation in adults with upper limb spasticity arising from neurological impairment, including methodological quality of the psychometric studies. Differences in the measurement quality of the tools for adults with a neurological impairment, but without upper limb spasticity, is also presented.

Methods

29 measurement tools identified in a published review were appraised in this systematic review. For each identified tool, we searched 3 databases (Medline, Embase, CINAHL) to identify psychometric studies completed with neurorehabilitation samples. Methodological quality of instrument evaluations was assessed with use of the Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN) checklist. Synthesis of ratings allowed an overall rating of the psychometric evidence for each measurement tool to be calculated.

Results

149 articles describing the development or evaluation of psychometric properties of 22 activity and/or participation measurement tools were included. Evidence specific to tool use for adults with spasticity was identified within only 15 of the 149 articles and provided evidence for 9 measurement tools only. Overall, COSMIN appraisal highlighted a lack of evidence of measurement quality. Synthesis of ratings demonstrated all measures had psychometric weaknesses or gaps in evidence (particularly for use of tools with adults with spasticity).

Conclusions

The systematic search, appraisal and synthesis revealed that currently there is insufficient measurement quality evidence to recommend one tool over another. Notwithstanding this conclusion, newer tools specifically designed for use with people with neurological conditions who have upper limb spasticity, have emergent measurement properties that warrant further research.

Systematic review registration

PROSPERO CRD42014013190.

Inpatient stroke rehabilitation: prediction of clinical outcomes using a machine-learning approach

BACKGROUND

In clinical practice, therapists often rely on clinical outcome measures to quantify a patient's impairment and function. Predicting a patient's discharge outcome using baseline clinical information may help clinicians design more targeted treatment strategies and better anticipate the patient's assistive needs and discharge care plan. The objective of this study was to develop predictive models for four standardized clinical outcome measures (Functional Independence Measure, Ten-Meter Walk Test, Six-Minute Walk Test, Berg Balance Scale) during inpatient rehabilitation.

METHODS

Fifty stroke survivors admitted to a United States inpatient rehabilitation hospital participated in this study. Predictors chosen for the clinical discharge scores included demographics, stroke characteristics, and scores of clinical tests at admission. We used the Pearson product-moment and Spearman's rank correlation coefficients to calculate correlations among clinical outcome measures and predictors, a cross-validated Lasso regression to develop predictive equations for discharge scores of each clinical outcome measure, and a Random Forest based permutation analysis to compare the relative importance of the predictors.

RESULTS

The predictive equations explained 70-77% of the variance in discharge scores and resulted in a normalized error of 13-15% for predicting the outcomes of new patients. The most important predictors were clinical test scores at admission. Additional variables that affected the discharge score of at least one clinical outcome were time from stroke onset to rehabilitation admission, age, sex, body mass index, race, and diagnosis of dysphasia or speech impairment.

CONCLUSIONS

The models presented in this study could help clinicians and researchers to predict the discharge scores of clinical outcomes for individuals enrolled in an inpatient stroke rehabilitation program that adheres to U.S. Medicare standards.

Activity and participation in stroke survivors in a low-income setting: A cross-sectional study

OBJECTIVES

To describe patients' activity and participation levels and to compare these levels across different groups of stroke survivors according to their walking speed (WS).

METHODS

In this cross-sectional study, 67 stroke survivors (43 men, mean age: 58.4 ± 12.9 years old) were assessed using the stroke impairment assessment set (SIAS), ACTIVLIM-Stroke, 10-m walk test (10MWT), 6-min walk test (6MWT) and Reintegration to Normal Living Index (RNLI). The sample was afterwards split into three WS sub-groups (<0.4 m/s, 0.4-0.8 m/s and >0.8 m/s) based on 10MWT scores.

RESULTS

ACTIVLIM-Stroke, 10MWT and 6MWT mean scores (±SD) were, respectively, 69.4 ± 20.2%, 0.9 ± 0.6 m/s and 282.1 ± 182 m. RNLI median score (range) was 5 (0-20). Sub-group analyses indicated that 26.9% (n = 18) obtained WS < 0.4 m/s, 13.4% (n = 9) WS between 0.4 and 0.8 m/s, and 59.7% (n = 40) WS > 0.8 m/s. Significant differences (p < .001) were found between WS sub-groups for both activity and participation.

CONCLUSION

Stroke survivors in Kinshasa presented a good performance for basic-activities of daily life (basic-ADLs). However, some of them still had difficulties with some community activities. Differences in WS seemed to discriminate well stroke survivors in terms of activity and participation, since the higher WS, the more they performed in basic-ADLs, walking distance and participation, and inversely.

One-Quarter of People Leave Inpatient Stroke Rehabilitation with Physical Capacity for Community Ambulation

BACKGROUND AND PURPOSE

Ability to walk in the community is important for independence and participation in life roles, but is difficult for many people following stroke. The purpose of this study was to determine the proportion of people with stroke with the physical capacity to be independent community ambulators at discharge from a publicly funded inpatient rehabilitation setting.

METHOD

Consecutive medical records were audited to collate walking outcome at discharge, and to clarify if people with stroke had potential to walk independently in the community as defined by 4 criteria: independence with stairs; ability to traverse slopes and inclines; walking speed of .8m/s or more; and walking distance 367 m or higher on 6-Minute Walk Test.

RESULTS

While 80% of the 124 persons with stroke could walk indoors, only 27% could perform 4 essential skills needed to walk independently in the community at discharge from hospital. The proportion that met each criterion was 52% for stairs, 39% for slopes and inclines, 58% for speed, and 40% for distance. For the overall sample, mean (standard deviation) walking speed was .90 (.33) m/s, and distance for 6-Minute Walk Test was 349.6 (146.5) m.

DISCUSSION AND CONCLUSION

A retrospective review found that three quarters of stroke survivors lacked physical capacity for 4 skills required to walk independently in the community at the time of discharge from a public inpatient rehabilitation. Our findings recommend that people with stroke have access to outpatient physical rehabilitation to optimize walking outcome.

Comprehensive clinical sitting balance measures for individuals following stroke: a systematic review on the methodological quality

PURPOSE

The aim of this systematic review was to examine the psychometric properties of published clinical sitting measurement scales containing dynamic tasks in individuals following stroke.

METHOD

Databases, including Cumulative Index of Nursing and Allied Health Literature (CINAHL), MEDLINE, EMBASE, Cochrane, PubMed and Allied and Complementary Medicine Database (AMED) were searched from inception to December 2015. The search strategy included terms relating to sitting, balance and postural control. Two reviewers independently selected and extracted data from the identified articles and assessed the methodological quality of the papers using the COnsensus-based Standards for selection of health status Measurement INstruments (COSMIN) checklist.

RESULTS

Fourteen clinical sitting measurement scales (39 papers) containing dynamic tasks met the inclusion criteria and various measurement properties were evaluated. The methodological quality of the majority of the included studies was rated as poor to fair using the COSMIN checklist, with common limitations including small sample size and inappropriate use of statistical methods.

CONCLUSIONS

This review was unable to identify measures with sufficient psychometric properties to enable recommendation as preferred tools. However, measures were identified that warrant further specific psychometric investigations to fulfil requirements for a high quality measure. Implications for Rehabilitation Fourteen clinical sitting balance scales containing dynamic tasks are available to measure sitting balance with individuals following stroke. No single scale has sufficient psychometric properties to enable recommendation as a preferred tool for measuring sitting balance with stroke survivors. Use of a balance scale or dedicated sitting balance measure containing static and dynamic sitting items should be utilised to monitor progress for individuals following stroke with more severe deficits.

Activity limitations experienced by people with stroke who receive inpatient rehabilitation: differences between 2001, 2005, and 2011

OBJECTIVE

To determine whether there were differences in characteristics and activity limitations relevant to physiotherapists among people receiving inpatient rehabilitation after stroke in 2001, 2005, and 2011.

DESIGN

A multicenter observational study of 3 periods.

SETTING

Inpatient rehabilitation units (N=15).

PARTICIPANTS

Adult stroke survivors (N=738) admitted over 3 periods (2001, 2005, 2011).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Characteristics, hospital metrics, and Motor Assessment Scale (MAS) scores were recorded on admission and discharge.

RESULTS

All 3 cohorts were similar in terms of sex, side affected by stroke, and length of time from stroke onset to rehabilitation admission. Stroke participants in the 2005 cohort were older than those in the 2011 and 2001 cohorts. Participants in the 2011 cohort had a longer inpatient rehabilitation length of stay, experienced lower average MAS gains per day (F>3.298, P<.038), and experienced more activity limitations in basic functional tasks involving bed mobility, standing up, and sitting balance on admission and discharge, and in walking and arm function at discharge only compared with earlier cohorts.

CONCLUSIONS

In 2011, on average, people admitted for rehabilitation after stroke were approximately the same age as patients in 2005 and 2001 and it took approximately 2 weeks for all of these patients to be admitted to a rehabilitation unit, but patients in 2011 had a longer inpatient rehabilitation length of stay compared with patients in 2005 and 2001. In addition, activity limitations at inpatient rehabilitation admission and discharge appear to be worse, particularly for activities such as rolling, sitting up over the edge of the bed, and balanced sitting.

Amount of Exercise in the First Week After Stroke Predicts Walking Speed and Unassisted Walking

Background. Predicting walking outcomes poststroke is a challenge for clinicians. Objective. To identify the extent to which exercise dose (repetitions of leg movements) in the first week of a comprehensive stroke unit stay predicts discharge mobility. Methods. A cohort study was conducted on 200 consecutive people admitted to a comprehensive stroke unit who required physical therapy. Results. Discharge and predictor data were available for 191 survivors (99%). On admission, 86 participants were able to walk, and the average walking velocity was 0.42 m/s. On discharge, the average walking velocity was 0.77 m/s, and 152 participants were able to walk. A discharge walking velocity of greater than 0.8 m/s was predicted by the exercise dose achieved in the first week after admission. Adding other predictors did not significantly increase the predictive ability of the model. Completion of more than the median number of exercise repetitions (703) in the first week of admission was associated with a quicker recovery of unassisted walking. This effect persisted after adjustment for walking velocity on admission, cognition, and comorbidity. Conclusion. Exercise dose in the first week after admission for stroke is an important indicator of walking speed at discharge and the time to achieve unassisted walking.

Prediction of discharge walking ability from initial assessment in a stroke inpatient rehabilitation facility population

OBJECTIVES

To (1) determine which clinical assessments at admission to an inpatient rehabilitation facility (IRF) most simply predict discharge walking ability, and (2) identify a clinical decision rule to differentiate household versus community ambulators at discharge from an IRF.

DESIGN

Retrospective cohort study.

SETTING

IRF.

PARTICIPANTS

Two samples of participants (n=110 and 159) admitted with stroke.

INTERVENTIONS

A multiple regression determined which variables obtained at admission (age, time from stroke to assessment, Motricity Index, somatosensation, Modified Ashworth Scale, FIM, Berg Balance Scale, 10-m walk speed) could most simply predict discharge walking ability (10-m walk speed). A logistic regression determined the likelihood of a participant achieving household (<0.4m/s) versus community (≥0.4-0.8m/s; >0.8m/s) ambulation at the time of discharge. Validity of the results was evaluated on a second sample of participants.

MAIN OUTCOME MEASURE

Discharge 10-m walk speed.

RESULTS

Admission Berg Balance Scale and FIM walk item scores explained most of the variance in discharge walk speed. The odds ratio of achieving only household ambulation at discharge was 20 (95% confidence interval [CI], 6-63) for sample 1 and 32 (95% CI, 10-96) for sample 2 when the combination of having a Berg Balance Scale score of ≤20 and a FIM walk item score of 1 or 2 was present.

CONCLUSIONS

A Berg Balance Scale score of ≤20 and a FIM walk item score of 1 or 2 at admission indicates that a person with stroke is highly likely to only achieve household ambulation speeds at discharge from an IRF.

What is the Probability of Patients who are Nonambulatory after Stroke Regaining Independent Walking? a Systematic Review

Patients after stroke who are nonambulatory require resources, and independent walking becomes a major determinant of the ability to participate in activities of daily living. Our objective was to determine the probability of walking for patients who are nonambulatory in the first month after stroke. We performed a systematic review and meta-analysis of consecutive, prospective studies of nonambulatory patients within the first month after stroke in rehabilitation and acute units. The outcomes were the probability of achieving independent walking at three-, six- and 12 months after stroke. Twenty-six studies were included in the review. Seventeen studies comprising 2856 participants were entered into meta-analyses. For initially nonambulatory stroke patients managed in a rehabilitation unit, the probability of independent walking was 0·60 (95% CI 0·47–0·74, 1373 participants) at three-months, 0·65 (95% CI 0·53–0·77, 444 participants) at six-months and 0·91 (95% CI 0·81–1·00, 24 participants) at 12 months. For patients managed in an acute unit, the probability of independent walking was 0·39 (95% CI 0·27–0·52, 634 participants) at three-months, 0·69 (95% CI 0·46–0·92, 405 participants) at six-months and 0·74 (95% CI 0·59–0·88, 34 participants) at 12 months. 60% of patients managed in a rehabilitation unit who are nonambulatory in the first month after stroke will regain independent walking compared with 39% of those managed in an acute unit. This information can be used clinically to make decisions about allocation of rehabilitation resources, education of patients and carers, and for discharge planning.