Evaluating the effectiveness of stroke rehabilitation: choosing a discriminative measure

Admission and discharge profiles of people with MS accessing in-patient rehabilitation in Canada

BACKGROUND

Rehabilitation is the mainstay of management for people with disabilities of neurological origin to maximize function and reduce disability. Access to in-patient rehabilitation is usually reserved for people after crises or those who are discharged from acute care such as in stroke or trauma. Access to people with Multiple Sclerosis (MS) differs across countries and unknown for Canada. With the progression of MS, quality of life (QOL) becomes more closely coupled with independence and hence timely access to rehabilitation is important. The objectives of this paper are (i) to characterize the disability profiles of people with MS admitted to in-patient rehabilitation in Canada; and (ii) to estimate the extent to which disability profiles differ from admission to discharge.

METHODS

A longitudinal study of a rehabilitation admission-to-discharge cohort of 3500 people with MS was conducting using latent class analysis on the five Functional Independence Measure (FIM) subscales for Self-care, Transfers, Locomotion, Bladder/Bowel, and Cognition. The extent to which age, sex, and calendar time was associated with latent class membership, at both admission and discharge, was estimated using ordinal logistic regression, and proportional odds model was calculated for each age and sex.

RESULTS

At admission five classes were identified. The two most prevalent classes included people with total or moderate dependency in all FIM subscales except cognition (n = 1205 and n = 1099). The third most common was dependent in ambulation only (n = 523), followed by dependence in ambulation with varying degree of limitation in self-care and transfers (n = 465, and n = 208). At discharge four classes were identified with the largest class comprising of people dependent in ambulation and to a lesser degree in transfers (n = 1010). The second most prevalent class was no dependency (n = 946), followed by two classes with varying dependency in all subscales but cognition (n = 678 and n = 771).

CONCLUSION

Overall 62.3% of admissions transitioned to a more functional class by discharge. By discharge 28% of the population was characterized by no dependencies; however, 23% remained with dependencies in all areas. Those in the most dependent classes showed the greatest probability of transitioning to a better class at discharge highlighting the importance of reserving scarce rehabilitation services to those with more disability.

Effects of dynamic body weight support on functional independence measures in acute ischemic stroke: a retrospective cohort study

BACKGROUND

Stroke remains a major public health concern in the United States and a leading cause of long-term disability in adults. Dynamic body weight support (DBWS) systems are popular technology available for use in clinical settings such inpatient rehabilitation. However, there remains limited studies in such inpatient settings that compare DBWS to standard of care (SOC) using real world outcome measures. For survivors of acute ischemic stroke, we determine if incorporating a dynamic body weight support (DBWS) system into inpatient therapy offers greater improvement than standard of care (SOC).

METHODS

A retrospective chart review included 52 individuals with an acute ischemic stroke admitted to an inpatient rehabilitation facility. Functional Independence Measure (FIM) data, specifically changes in FIM at discharge, served as the primary outcome measure. Patient cohorts received either therapies per SOC or therapies incorporating DBWS. Regardless of cohort group, all patients underwent therapies for 3 h per day for 5 days a week.

RESULTS

For both groups, a statistically and clinically significant increase in total FIM (P < 0.0001) was observed at discharge compared to at admission. Improvements for the DBWS group were significantly greater than the SOC group as evidenced by higher gains in total FIM (p = 0.04) and this corresponded to a medium effect size (Cohen's d = 0.58). Among FIM subscores, the DBWS group achieved a significant increase in sphincter control while all other subscore changes remained non-significant.

CONCLUSIONS

This preliminary evidence supports the benefit of using DBWS during inpatient rehabilitation in individuals who have experienced an acute ischemic stroke. This may be due to the greater intensity and repetitions of tasks allowed by DBWS. These preliminary findings warrant further investigations on the use of DBWS in inpatient settings.

Psychometric Comparisons of Three Depression Measures for Patients With Stroke

IMPORTANCE

Psychometric examinations for patients with stroke remain insufficient. The Center for Epidemiologic Studies Depression Scale (CES-D), Beck Depression Inventory-II (BDI-II), and Geriatric Depression Scale (GDS) are promising outcome measures.

OBJECTIVE

To examine and compare the reliability and validity of three depression measures in a sample of patients with stroke.

DESIGN

Repeated-measures design.

SETTING

A hospital in southern Taiwan.

PARTICIPANTS

Fifty-nine outpatients, who completed three depression measures.

OUTCOMES AND MEASURES

Cronbach's α and intraclass correlation coefficients (ICCs) were used to examine the internal consistency and test-retest reliability, respectively, of the three measures. An independent-samples t test was conducted to compare two groups of patients with different levels of disability to investigate discriminative validity. Pearson's rs were calculated among the three measures to examine concurrent validity.

RESULTS

The three measures had good internal consistency (α = .85-.92) and sufficient test-retest reliability (ICC = .84-.91). The minimal detectable change (percentage of minimal detectable change) was 10.6 (63.3%), 13.5 (98.3%), and 5.8 (49.9%) for the CES-D, BDI-II, and GDS, respectively. There was a statistically significant difference between the two groups in CES-D score (p = .032) and no significant differences on the other two measures (p = .095-.187). The correlations among the three measures ranged from .79 to .89.

CONCLUSION AND RELEVANCE

All three depression measures had sound internal consistency, test-retest reliability, and concurrent validity in patients with stroke. What This Article Adds: Of the three measures, the CES-D had better discriminative validity, and the GDS demonstrated greater reliability and smaller random measurement error in patients with stroke.

Factors Related to Greater Functional Recovery after Suffering a Stroke

Background: In a stroke, the importance of initial functional status is fundamental for prognosis. The aim of the current study was to investigate functional status, assessed by the Functional Independence Measure (FIM) scale, and possible predictors of functional outcome at discharge from inpatient rehabilitation. Methods: This is a retrospective study that was carried out at the Physical Medicine and Rehabilitation Service in A Coruña (Spain). A total of 365 consecutive patients with primary diagnosis of stroke were enrolled. The functional assessments of all patients were performed through the FIM. A descriptive and a bivariate analysis of the variables included in the study was made and a succession of linear regression models was used to determine which variables were associated with the total FIM at discharge. Results: Prior to having the stroke, 76.7% were totally independent in activities of daily living. The FIM scale score was 52.5 ± 25.5 points at admission and 83.4 ± 26.3 at hospital discharge. The multivariate analysis showed that FIM scores on admission were the most important predictors of FIM outcomes. Conclusions: Our study indicates that the degree of independence prior to admission after suffering a stroke is the factor that will determine the functionality of patients at hospital discharge.

Ecological, convergent, and discriminative validities of the cognitive abilities screening instrument in people with dementia

BACKGROUND

The Cognitive Abilities Screening Instrument (CASI) assesses global cognitive function in people with dementia with 9 domains (i.e., long-term memory, short-term memory, concentration, orientation, attention, abstraction and judgment, language abilities, visual construction, and category fluency). However, the ecological, convergent, and discriminant validities of the CASI have not yet been examined.

PURPOSE

This study designed to investigate these 3 validities of the CASI in people with dementia.

METHODS

Fifty-eight participants underwent assessments with the CASI, 3 functional measures, and 3 cognitive measures. Pearson's r was used to estimate correlations among the CASI and 3 functional measures for examining ecological validity. We computed correlations (r) among the CASI and 3 functional measures for examining convergent validity. An independent t-test was applied to compare the levels of disability, and ceiling/floor effects were analyzed for examining discriminative validity.

RESULTS

The CASI total score and domains had moderate to high correlations with 3 functional measures (r = 0.42-0.80), except in 2 CASI domains (i.e., attention and language). The CASI total score and domains showed moderate to high correlations with 3 cognitive measures (r = 0.45-0.93). The t-test results revealed significant differences (P < .05) in the CASI total score and other domains except for the short-term memory domains. Four domains of the CASI showed noticeable ceiling effects (22.4-39.7%).

CONCLUSIONS

The CASI has adequate ecological validity, good convergent validity, and acceptable discriminative validity in people with dementia. The 5 domains with nonsignificant differences or ceiling effects should only be used with caution to distinguish people with dementia.

A Retrospective Cohort Comparing Left and Right Middle Cerebral Artery Ischemic Stroke Functional Outcomes in Acute Inpatient Rehabilitation

BACKGROUND

To date, no large population studies compare left and right middle cerebral artery (MCA) strokes and corresponding patient performance in acute rehabilitation as measured by the Functional Independence Measure (FIM).

OBJECTIVE

To compare granular performance data using the six FIM subcategories between left and right MCA territory strokes. This may foster development of individualized rehabilitation programs and affect rehabilitation policy based on phenotypic variations.

DESIGN

Retrospective cohort study.

SETTING

Inpatient rehabilitation facilities, using Uniform Data System for Medical Rehabilitation data from 2015 to 2017.

PATIENTS

Individuals with MCA strokes admitted to inpatient rehabilitation facilities (n = 38 812).

MAIN OUTCOME MEASURES

Mean FIM efficiency and FIM gain within the six FIM subcategories (self-care, sphincter control, transfers, locomotion, communication, and social cognition) were compared between left and right MCA strokes. All were stratified by admission FIM severity categories (<40, 40-80, >80). The study also examined length of stay and percentage discharged to home.

RESULTS

Mean FIM efficiency was significantly higher for left MCA strokes compared to right MCA strokes. Left MCA strokes with admission FIM <40 and 40-80 had significantly higher FIM efficiencies within the majority of FIM subcategories. However, left and right MCA strokes with admission FIM > 80 did not display any significant differences. Overall, patients with left MCA strokes were discharged to home at a significantly higher percentage. Patients with left MCA strokes with admission FIM 40-80 had on average a 2-day shorter length of stay than those with right MCA strokes.

CONCLUSIONS

Overall, patients with left MCA ischemic strokes had shorter length of stays, higher FIM efficiencies, and larger FIM gains than those with right MCA strokes. These results allow clinicians to counsel patients regarding functional gains based on diagnosis and to tailor rehabilitation programs to impairments encountered in left and right MCA territories. Including laterality of stroke and admission functional status would also improve algorithms for determining reimbursement.

Comprehensive ADL Outcome Measurement after Stroke: Rasch Validation of the Lucerne ICF-Based Multidisciplinary Observation Scale (LIMOS)

OBJECTIVE

To establish Rasch validation of the Lucerne International Classification of Functioning, Disability and Health (ICF)-based Multidisciplinary Observation Scale (LIMOS) in stroke. LIMOS measures the level of assistance in daily life activities related to motor function, communication, cognition, and domestic life. Rasch Measurement Theory (RMT) transforms an ordinal scale into an interval scale and thus the Rasch-based LIMOS scale captures a more accurate improvement of functional outcomes via Rasch-transformed scores.

DESIGN

Cross-sectional study design.

SETTING

Neurorehabilitation center, Luzerne, Switzerland.

PARTICIPANTS

We recruited participants with stroke (N=407; age=63.2±16.0y; n=157 women) through consecutive sampling.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participants were assessed with LIMOS at admission and discharge of rehabilitation. We used RMT to evaluate overall model fit, response dependency, floor and ceiling effect, reliability, and differential item functioning (DIF) for sex, age, type, and time of stroke on the 4 LIMOS subscales using the Rasch Unidimensional Measurement Model (RUMM) 2030 program.

RESULTS

The Rasch-based LIMOS subscales fit the Rasch model after reducing and rescoring items: motor (from 20 to 18 items), communication (5 items), cognition (from 15 to 13 items), and domestic life (5 items). There was no floor or ceiling effect. Some artificial DIF was identified. Scoring at discharge was dependent on the scoring responses at admission, which means that without applying a correction factor to the discharge scores, there was an underestimation of change in scores between admission and discharge, ranging from 0.24 to 0.97 logits (10.79%-49.24%) on the different subscales.

CONCLUSIONS

The Rasch-based LIMOS scale is recommended to measure functional outcome in people with acute or chronic stages of ischemic or hemorrhagic stroke.

Converting Functional Autonomy Measurement System Scores of Patients Post-Stroke to FIM Scores

Purpose: The Functional Independence Measure (FIM) is widely used to assess persons post-stroke. The Quebec government has selected the Functional Autonomy Measurement System (SMAF) for use in all care settings. In this article, we propose simple equations to convert SMAF scores to FIM scores for persons undergoing post-stroke rehabilitation. Method: Persons post-stroke (n=143) from three rehabilitation centres were assessed at admission and discharge using the FIM and SMAF. The sample was randomly split into derivation and validation data sets. Regression analysis was performed on the first data set to derive a conversion equation at each time point. The validity of the equations was measured using correlation coefficients, and differences between the observed and predicted FIM scores were computed from the second data set. Results: The relationship between the SMAF and FIM scores was linear at admission but quadratic at discharge. The proposed equations are, at admission, FIM=139-1.5×SMAF and, at discharge, FIM=118-0.018×SMAF². The observed and predicted FIM scores were highly correlated in the validation data set (rs=0.92 and 0.93 at admission and discharge, respectively). Furthermore, the equations performed well in classifying stroke severity compared with a classification based on the observed FIM scores. Conclusions: SMAF scores can be reliably converted to FIM scores using the proposed equations, thus facilitating international trials in stroke rehabilitation.

The Responsiveness of the Lucerne ICF-Based Multidisciplinary Observation Scale: A Comparison with the Functional Independence Measure and the Barthel Index

Background

Good responsive functional outcome measures are important to measure change in stroke patients. The aim of study was to compare the internal and external responsiveness, floor and ceiling effects of the motor, cognition, and communication subscales of the Lucerne ICF-based Multidisciplinary Observation Scale (LIMOS) with the motor and cognition subscales of the Functional Independence Measure (FIM), and the Barthel Index (BI), in a large cohort of stroke patients.

Methods

One hundred eighteen stroke patients participated in this study. Admission and discharge score distributions of the LIMOS motor, LIMOS cognition and communication, FIM motor and FIM cognition, and BI were analyzed based on skewness and kurtosis. Floor and ceiling effects of the scales were determined. Internal responsiveness was assessed with t-tests, effect sizes (ESs), and standardized response means (SRMs). External responsiveness was investigated with linear regression analyses.

Results

The LIMOS motor and LIMOS cognition and communication subscales were more responsive, expressed by higher ESs (ES = 0.65, SRM = 1.17 and ES = 0.52, SRM = 1.17, respectively) as compared with FIM motor (ES = 0.54, SRM = 0.96) and FIM cognition (ES = 0.41, SRM = 0.88) and the BI (ES = 0.41, SRM = 0.65). The LIMOS subscales showed neither floor nor ceiling effects at admission and discharge (all <15%). In contrast, ceiling effects were found for the FIM motor (16%), FIM cognition (15%) at discharge and the BI at admission (22%) and discharge (43%). LIMOS motor and LIMOS cognition and communication subscales significantly correlated (p < 0.0001) with a change in the FIM motor and FIM cognition subscales, suggesting good external responsiveness.

Conclusion

We found that the LIMOS motor and LIMOS cognition and communication, which are ICF-based multidisciplinary standardized observation scales, might have the potential to better detect changes in functional outcome of stroke patients, compared with the FIM motor and FIM cognition and the BI.

A Multidimensional Rasch Analysis of the Functional Independence Measure Based on the National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems National Database

A number of studies have evaluated the psychometric properties of the Functional Independence Measure (FIM™) using Rasch analysis, although none has done so using the National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems National Database, a longitudinal database that captures demographic and outcome information on persons with moderate to severe traumatic brain injury across the United States. In the current study, we examine the psychometric properties of the FIM as represented by persons within this database and demonstrate that the FIM comprises three subscales representing cognitive, self-care, and mobility domains. These subscales were analyzed simultaneously using a multivariate Rasch model in combination with a time dependent concurrent calibration scheme with the goal of creating a raw score-to-logit transformation that can be used to improve the accuracy of parametric statistical analyses. The bowel and bladder function items were removed because of misfit with the motor and cognitive items. Some motor items exhibited step disorder, which was addressed by collapsing Categories 1-3 for Toileting, Stairs, Locomotion, Tub/Shower Transfers; Categories 1 and 2 for Toilet and Bed Transfers; and Categories 2 and 3 for Grooming. The strong correlations (r = 0.82-0.96) among the three subscales suggest they should be modeled together. Coefficient alpha of 0.98 indicates high internal consistency. Keyform maps are provided to enhance clinical interpretation and application of study results.

Cross-cultural validation of the Persian version of the Functional Independence Measure for patients with stroke

PURPOSE

To translate and cross-culturally adapt the Functional Independence Measure (FIM) into the Persian language and to test the reliability and validity of the Persian FIM (PFIM) in patients with stroke.

METHOD

In this cross-sectional study carried out in an outpatient stroke rehabilitation center, 40 patients with stroke (mean age 60 years) were participated. A standard forward-backward translation method and expert panel validation was followed to develop the PFIM. Two experienced occupational therapists (OTs) assessed the patients independently in all items of the PFIM in a single session for inter-rater reliability. One of the OTs reassessed the patients after 1 week for intra-rater reliability.

RESULTS

There were no floor or ceiling effects for the PFIM. Excellent inter-rater and intra-rater reliability was noted for the PFIM total score, motor and cognitive subscales (ICC(agreement)0.88-0.98). According to the Bland-Altman agreement analysis, there was no systematic bias between raters and within raters. The internal consistency of the PFIM was with Cronbach's alpha from 0.70 to 0.96. The principal component analysis with varimax rotation indicated a three-factor structure: (1) self-care and mobility; (2) sphincter control and (3) cognitive that jointly accounted for 74.8% of the total variance. Construct validity was supported by a significant Pearson correlation between the PFIM and the Persian Barthel Index (r = 0.95; p < 0.001).

CONCLUSIONS

The PFIM is a highly reliable and valid instrument for measuring functional status of Persian patients with stroke.

IMPLICATIONS FOR REHABILITATION

The Functional Independence Measure (FIM) is an outcome measure for disability based on the International Classification of Functioning, Disability and Health (ICF). The FIM was cross-culturally adapted and validated into Persian language. The Persian version of the FIM (PFIM) is reliable and valid for assessing functional status of patients with stroke. The PFIM can be used in Persian speaking countries to assess the limitations in activities of daily living of patients with stroke.

Rehabilitation impact indices and their independent predictors: a systematic review

OBJECTIVES

To (1) identify all available rehabilitation impact indices (RIIs) based on their mathematical formula, (2) assess the evidence for independent predictors of each RII and (3) propose a nomenclature system to harmonise the names of RIIs.

DESIGN

Systematic review.

DATA SOURCES

PubMed and references in primary articles.

STUDY SELECTION

First, we identified all available RII through preliminary literature review. Then, various names of the same formula were used to identify studies, limited to articles in English and up to 31 December 2011, including case-control and cohort studies, and controlled interventional trials where RIIs were outcome variable and matching or multivariate analysis was performed.

RESULTS

The five RIIs identified were (1) absolute functional gain (AFG)/absolute efficacy/total gain, (2) rehabilitation effectiveness (REs)/Montebello Rehabilitation Factor Score (MRFS)/relative functional gain (RFG), (3) rehabilitation efficiency (REy)/length of stay-efficiency (LOS-EFF)/efficiency, (4) relative functional efficiency (RFE)/MRFS efficiency and (5) revised MRFS (MRFS-R). REy/LOS-EFF/efficiency had the most number of supporting studies, followed by REs and AFG. Although evidence for different predictors of RIIs varied according to the RII and study population, there is good evidence that older age, lower prerehabilitation functional status and cognitive impairment are predictive of poorer AFG, REs and REy.

CONCLUSIONS

5 RIIs have been developed in the past two decades as composite rehabilitation outcome measures controlling premorbid and prerehabilitation functional status, rate of functional improvement, each with varying levels of evidence for its predictors. To address the issue of multiple names for the same RII, a new nomenclature system is proposed to harmonise the names based on common mathematical formula and a first-named basis.

Reliability and validity of the evidence-based practice confidence (EPIC) scale

INTRODUCTION

The reliability, minimal detectable change (MDC), and construct validity of the evidence-based practice confidence (EPIC) scale were evaluated among physical therapists (PTs) in clinical practice.

METHODS

A longitudinal mail survey was conducted. Internal consistency and test-retest reliability were estimated using Cronbach's alpha and the intraclass correlation coefficient (ICC), respectively. The ICC was used to compute the MDC. We evaluated construct validity by testing hypotheses that EPIC scores would be positively associated with education level and frequency of searching, reading, and using research literature in clinical decision making.

RESULTS

At baseline, 275 PTs completed the EPIC scale and validity questionnaire and 187 completed the scale at retest (mean retest interval = 16 days). Internal consistency was 0.89 (95% confidence interval 0.86 to 0.91; N = 275). The ICC for test-retest reliability was 0.89 (95% confidence interval 0.85 to 0.91; N = 187). The MDC95 was 4.1 percentage points meaning that a change in an individual's score must be greater than 4.1 percentage points to exceed the limits of measurement error. The mean EPIC score was significantly higher among PTs holding a Masters or doctoral degree compared to those holding a bachelor's degree or diploma, and among PTs reporting searching online, reading, and using the research literature in clinical decision making 6 or more times compared to 0 to 5 times in a typical month.

DISCUSSION

Results provide evidence of excellent test-retest reliability and acceptable construct validity and minimal measurement error on repeated administration of the EPIC scale. The scale is recommended for use among PTs in clinical practice. Validation of the EPIC scale in other health professional groups is warranted.

Self-management: a systematic review of outcome measures adopted in self-management interventions for stroke

Purpose

To systematically review the psychometric properties of outcome measures used in stroke self-management interventions (SMIs) to (1) inform researchers, clinicians and commissioners about the properties of the measures in use and (2) make recommendations for the future development of self-management measurement in stroke.

Methods

Electronic databases, government websites, generic internet search engines and hand searches of reference lists. Abstracts were selected against inclusion criteria and retrieved for appraisal and systematically scored, using the COSMIN checklist.

Results

Thirteen studies of stroke self-management originating from six countries were identified. Forty-three different measures (mean 5.08/study, SD 2.19) were adopted to evaluate self-SMIs. No studies measured self-management as a discreet concept. Six (46%) studies included untested measures. Eleven (85%) studies included at least one measure without reported reliability and validity in stroke populations.

Conclusions

The use of outcome measures which are related, indirect or proxy indicators of self-management and that have questionable reliability and validity, contributes to an inability to sensitively evaluate the effectiveness of stroke self-SMIs. Further enquiry into how the concept of self-management in stroke operates, would help to clarify the nature and range of specific self-management activities to be targeted and aid the selection of existing appropriate measures or the development of new measures.

Outcome measures in neurological physical therapy practice: part I. Making sound decisions

Standardized outcome measures (OMs) are a vital part of evidence-based practice. Despite the recognition of the importance of OMs, recent evidence suggests that the use of OMs in clinical practice is limited. Selecting the most appropriate OM enhances clinical practice by (1) identifying and quantifying body function and structure limitations; (2) formulating the evaluation, diagnosis, and prognosis; (3) informing the plan of care; and (4) helping to evaluate the success of physical therapy interventions. This article (Part I) is the first of a 2-part series on the process of selecting OMs in neurological clinical practice. We introduce a decision-making framework to guide the selection of OMs and discuss 6 main factors-what to measure, the purpose of the measure, the type of measure, patient and clinic factors, psychometric factors, and feasibility-that should be considered when selecting OMs for clinical use. The framework will then be applied to a patient case in Part II of the series (see the article "Outcome Measures in Neurological Physical Therapy Practice: Part II. A Patient-Centered Process" in this issue).

From rehabilitation to recovery: protocol for a randomised controlled trial evaluating a goal-based intervention to reduce depression and facilitate participation post-stroke

BACKGROUND

There is much discourse in healthcare about the importance of client-centred rehabilitation, however in the realm of community-based therapy post-stroke there has been little investigation into the efficacy of goal-directed practice that reflects patients' valued activities. In addition, the effect of active involvement of carers in such a rehabilitation process and their subsequent contribution to functional and emotional recovery post-stroke is unclear. In community based rehabilitation, interventions based on patients' perceived needs may be more likely to alter such outcomes. In this paper, we describe the methodology of a randomised controlled trial of an integrated approach to facilitating patient goal achievement in the first year post-stroke. The effectiveness of this intervention in reducing the severity of post-stroke depression, improving participation status and health-related quality of life is examined. The impact on carers is also examined.

METHODS/DESIGN

Patients (and their primary carers, if available) are randomly allocated to an intervention or control arm of the study. The intervention is multimodal and aims to screen for adverse stroke sequelae and address ways to enhance participation in patient-valued activities. Intervention methods include: telephone contacts, written information provision, home visitation, and contact with treating health professionals, with further relevant health service referrals as required. The control involves treatment as usual, as determined by inpatient and community rehabilitation treating teams. Formal blinded assessments are conducted at discharge from inpatient rehabilitation, and at six and twelve months post-stroke. The primary outcome is depression. Secondary outcome measures include participation and activity status, health-related quality of life, and self-efficacy.

DISCUSSION

The results of this trial will assist with the development of a model for community-based rehabilitation management for stroke patients and their carers, with emphasis on goal-directed practice to enhance home and community participation status. Facilitation of participation in valued activities may be effective in reducing the incidence or severity of post-stroke depression, as well as enhancing the individual's perception of their health-related quality of life. The engagement of carers in the rehabilitation process will enable review of the influence of the broader social context on recovery.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12608000042347.

Evaluation of gait symmetry after stroke: a comparison of current methods and recommendations for standardization

Symmetry is a gait characteristic that is increasingly measured and reported, particularly in the stroke patient population. However, there is no accepted standard for assessing symmetry making it difficult to compare across studies and establish criteria to guide clinical decision making. This study compares the most common expressions of spatiotemporal gait symmetry to describe post-stroke gait and makes recommendations regarding the most suitable measure for standardization. The following symmetry equations were compared: symmetry ratio, symmetry index, gait asymmetry and symmetry angle using step length, swing time, stance time, double support time and an intra-limb ratio of swing: stance time. Comparisons were made within a group of 161 community-dwelling, ambulatory individuals with stroke and 81 healthy adults as a reference group. Our analysis supports the recommendations of the symmetry ratio as the equation for standardization and step length, swing time and stance time as the gait parameters to be used in the equation. Future work should focus on establishing the intra-individual variability of these measures and linking them to mechanisms of gait dysfunction.

Group physiotherapy provides similar outcomes for participants after joint replacement surgery as 1-to-1 physiotherapy: a sequential cohort study

Coulter CL, Weber JM, Scarvell JM. Group physiotherapy provides similar outcomes for participants after joint replacement surgery as 1-to-1 physiotherapy: a sequential cohort study.

OBJECTIVES

To compare effectiveness and time efficiency of physiotherapy rehabilitation provided within a group with an individualized program provided at home for improving participants' outcomes after total joint replacement surgery.

DESIGN

Quasiexperimental sequential cohort trial with 12-week follow-up.

SETTING

A tertiary acute care hospital.

PARTICIPANTS

Consecutive patients (N=51) having hip or knee replacement surgery in an 8-month period and who were able to weight-bear postoperatively.

INTERVENTIONS

The first group admitted to the study entered the exercise group, and patients in the following 4 months entered the home physiotherapy group.

MAIN OUTCOME MEASURES

Primary outcome measures included the Western Ontario McMaster's University Osteoarthritis Index (WOMAC), Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), Timed Up & Go (TUG) test, and knee range of motion (ROM). Secondary measures included the 6-m walk test and a patient evaluation questionnaire. Staff time costs were recorded. Outcomes were recorded preoperatively or at hospital discharge, and 5 and 12 weeks postoperatively.

RESULTS

There was no difference between the 2 groups for either the WOMAC or SF-36 scores, 6-m walk test, TUG test, or ROM measures at 12 weeks (P>.05), although both groups of patients improved between hospital discharge and 12 weeks. The class group accessed more frequent physiotherapy than the home group (mean, 7.5 and 3.96 visits, respectively). The physiotherapist's time was less per patient per visit for the class group (mean, 27min direct and 10min indirect) than for the home visits (mean, 38min direct and 26min indirect).

CONCLUSIONS

This trial suggests that the class-based exercise rehabilitation was the most efficient method of delivery of the physiotherapy service, without cost to patient outcomes.

Recovery plateau following stroke: Fact or fiction?

PURPOSE

'Plateau' is an expression frequently used in relation to decisions to discharge patients from physiotherapy following stroke. This paper critically considers the concept of recovery plateau in stroke, exploring (i) the evidence for plateau, (ii) potential contributing factors, and (iii) the consequences for patients, therapists and services.

SEARCH STRATEGY

The concept of recovery plateau in stroke was reviewed drawing on standard critical appraisal methodology for the search strategy and critique. Electronic searches using Web of Knowledge, MEDLINE, CINAHL, Department of Health Website and the Cochrane Library from the earliest dates of coverage until February 2005 identified quantitative and qualitative literature related to stroke, plateau, recovery, outcome, rehabilitation and physiotherapy.

DISCUSSION

The concept of plateau is ambiguous. Recovery has been considered to plateau within the first 6 months, yet recent studies indicate later recovery is possible. We suggest that 'plateau' relates not only to the patient's physical potential, but is influenced by how recovery is measured, the intensity and type of therapy, patients' actions and motivations, therapist values, and service limitations.

CONCLUSION

'Plateau' is conceptually more complex than previously considered. Current conceptualizations may limit potential recovery and hinder service development. Research into plateau which takes account of contextual issues of therapy provision is required.

Reliability, validity and factor structure of the upper limb subscale of the Motor Assessment Scale (UL-MAS) in adults following stroke

PURPOSE

The upper limb items of the Motor Assessment Scale (MAS) have been shown to be a sensitive, valid and reliable measure of upper limb function for adults following stroke, however the validity and reliability of summing these items into an independent subscale has not yet been evaluated. The stability, internal consistency and construct validity of the upper limb MAS subscale (UL-MAS) was assessed in this study.

METHOD

Twenty-seven inpatients following stroke (mean age = 67 years, range = 40 - 80) were sampled from an acute, inpatient rehabilitation setting. Patients were evaluated with 'Upper Arm Function', 'Hand Movements', and 'Advanced Hand Activities' items of the MAS by masked physiotherapists who had received standardized training in administration of the MAS.

RESULTS

All items were explained by one factor on confirmatory factor analysis and correlated significantly with one another and with the composite (summed total) score. Internal consistency analysis produced a Cronbach's alpha of 0.83 which did not benefit from removal of any items.

CONCLUSIONS

The acceptable internal consistency score obtained verifies the validity and reliability of using the UL-MAS as an independent scale. This study has also verified the construct validity of the UL-MAS subscale and provides a valuable extension of previous work, which together demonstrates the value of the UL-MAS as a responsive, valid and reliable measure of upper limb function in adults following stroke. The UL-MAS produced a single, composite score that could be interpreted as a total score for upper limb function in this population.

A new measure of hindlimb stepping ability in neonatally spinalized rats

One of the most widely used animal models for assessing recovery of locomotor functioning is the spinal rat. Although true differences in locomotor abilities of these animals are exhibited during treadmill testing, current measurement techniques often fail to detect them. The HiJK (Hillyer-Joynes Kinematics) scale was developed in an effort to distinguish more effectively between groups of spinal rats. Scale items were compiled after extensive review of the literature concerning development and analysis of rat locomotion and a thorough examination of the current tools. Treadmill tests for 137 Sprague-Dawley rats were taped and scored. The structure of the scale was tested with principle components and factor analysis, in which six of the eight items accounted for 59% of the variance, while all eight accounted for 78%. Validity tests demonstrate that HiJK is measuring locomotor performance accurately and powerfully. First, the HiJK scale correlates highly (>.8) with the widely used BBB scale and second, as shown with ANOVA, can distinguish between different groups of spinal rats. Reliability of the scale was also analyzed. Cronbach's alpha was shown to be .91, indicating considerable internal consistency. Additionally, inter-rater and intra-rater reliabilities were substantial, with correlations for most items reaching above .80. We believe that the HiJK scale will help researchers verify existing experimental differences, advance the field of spinal cord research, and, hopefully, lead to discovery of methods to enhance recovery of function.

Ideal timing to transfer from an acute care hospital to an interdisciplinary inpatient rehabilitation program following a stroke: an exploratory study

BACKGROUND

Timely accessibility to organized inpatient stroke rehabilitation services may become compromised since the demand for rehabilitation services following stroke is rapidly growing with no promise of additional resources. This often leads to prolonged lengths of stays in acute care facilities for individuals surviving a stroke. It is believed that this delay spent in acute care facilities may inhibit the crucial motor recovery process taking place shortly after a stroke. It is important to document the ideal timing to initiate intensive inpatient stroke rehabilitation after the neurological event. Therefore, the objective of this study was to examine the specific influence of short, moderate and long onset-admission intervals (OAI) on rehabilitation outcomes across homogeneous subgroups of patients who were admitted to a standardized interdisciplinary inpatient stroke rehabilitation program.

METHODS

A total of 418 patients discharged from the inpatient neurological rehabilitation program at the Montreal Rehabilitation Hospital Network after a first stroke (79% of all cases reviewed) were included in this retrospective study. After conducting a matching procedure across these patients based on the degree of disability, gender, and age, a total of 40 homogeneous triads (n = 120) were formed according to the three OAI subgroups: short (less than 20 days), moderate (between 20 and 40 days) or long (over 40 days; maximum of 70 days) OAI subgroups. The rehabilitation outcomes (admission and discharge Functional Independence Measure scores (FIM), absolute and relative FIM gain scores, rehabilitation length of stay, efficiency scores) were evaluated to test for differences between the three OAI subgroups.

RESULTS

Analysis revealed that the three OAI subgroups were comparable for all rehabilitation outcomes studied. No statistical difference was found for admission (P = 0.305-0.972) and discharge (P = 0.083-0.367) FIM scores, absolute (P = 0.533-0.647) and relative (P = 0.496-0.812) FIM gain scores, rehabilitation length of stay (P = 0.096), and efficiency scores (P = 0.103-0.674).

CONCLUSION

OAI does not seem to affect significantly inpatient stroke rehabilitation outcomes of patients referred from acute care facilities where rehabilitation services are rapidly initiated after the onset of the stroke and offered throughout their stay. However, other studies considering factors such as the type and intensity of the rehabilitation are required to support those results.

The Concurrent Validity and Responsiveness of the High-Level Mobility Assessment Tool for Measuring the Mobility Limitations of People With Traumatic Brain Injury

OBJECTIVE

To investigate the concurrent validity and responsiveness of the High-Level Mobility Assessment Tool (HiMAT) in people after traumatic brain injury (TBI).

DESIGN

This study compared the concurrent validity and responsiveness of the motor subsection of the FIM instrument and the gross function component of the Rivermead Motor Assessment (RMA) with the HiMAT, a new measure of high-level mobility developed for use in TBI.

SETTING

A major rehabilitation hospital.

PARTICIPANTS

A convenience sample of 103 participants with TBI were recruited from a major rehabilitation hospital.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

HiMAT, motor FIM, and the gross function RMA.

RESULTS

The correlation between the HiMAT and motor FIM was moderate (r=.53, P<.001), largely because of a ceiling effect in the motor FIM. The correlation between the HiMAT and gross function RMA was strong (r=.87, P<.001), yet the gross function RMA was also susceptible to a ceiling effect, with 51.5% of subjects achieving the maximum score. The HiMAT was more responsive than the motor FIM and the gross function RMA on all indices.

CONCLUSIONS

The HiMAT is a new unidimensional scale with moderate concurrent validity for measuring high-level mobility. The HiMAT is more responsive and has less of a ceiling effect than either the motor FIM or the gross function RMA.

Differential item functioning of the Functional Independence Measure in higher performing neurological patients

OBJECTIVE

When comparing outcomes of the Functional Independence Measure (FIM ) between patient groups, item characteristics of the FIM should be consistent across groups. The purpose of this study was to compare item difficulty of the FIM in 3 patient groups with neurological disorders.

SUBJECTS

Patients with stroke (n=295), multiple sclerosis (n=150), and traumatic brain injury (n=88).

METHODS

FIM scores were administered in each group. The FIM consists of a motor domain (13 items) and a cognitive domain (5 items). Rasch rating scale analysis was performed to investigate differences in item difficulty (differential item functioning) between groups.

RESULTS

Answering categories of the FIM items were reduced to 3 (from the original 7) because of disordered thresholds and low answering frequencies. Two items of the motor domain ("bladder" and "bowel") did not fit the Rasch model. For 7 out of the 11 fitting motor items, item difficulties were different between groups (i.e. showed differential item functioning). All cognitive items fitted the Rasch model, and 4 out of 5 cognitive items showed differential item functioning.

CONCLUSION

Differential item functioning is present in several items of both the motor and cognitive domain of the FIM. Adjustments for differential item functioning may be required when FIMdata will be compared between groups or will be used in a pooled data analysis.

Length of Stay, Discharge Destination, and Functional Improvement

Background and Purpose— Although implemented in 1998, no research has examined how well the Australian National Subacute and Nonacute Patient (AN-SNAP) Casemix Classification predicts length of stay (LOS), discharge destination, and functional improvement in public hospital stroke rehabilitation units in Australia.

Methods— 406 consecutive admissions to 3 stroke rehabilitation units in Queensland, Australia were studied. Sociodemographic, clinical, and functional data were collected. General linear modeling and logistic regression were used to assess the ability of AN-SNAP to predict outcomes.

Results— AN-SNAP significantly predicted each outcome. There were clear relationships between the outcomes of longer LOS, poorer functional improvement and discharge into care, and the AN-SNAP classes that reflected poorer functional ability and older age. Other predictors included living situation, acute LOS, comorbidity, and stroke type.

Conclusions— AN-SNAP is a consistent predictor of LOS, functional change and discharge destination, and has utility in assisting clinicians to set rehabilitation goals and plan discharge.

Modern stroke unit

The modern stroke unit is making significant contributions to the care of stroke victims and is proving to be an effective, cost-saving enterprise. The precise factors that contribute to the efficacy of these units have yet to be identified, but a combination of protocolized approaches to patient care, critical paths, a focus of expertise, and heightened index of suspicion for comorbidities all probably play a role. This article outlines the basic features of a modern stroke unit and surveys the literature on stroke unit outcomes.