An investigation of factors affecting progress of patients on a stroke unit

Efficacy of Corsi Block Tapping Task training for improving visuospatial skills: a non-randomized two-group study

Even though impaired visuospatial abilities can negatively affect daily functioning, there are very few training programs that attempt to improve visuospatial abilities. The purpose of this study was to examine if a single training session with a computerized version of the Corsi Block Tapping Task could improve mental rotation skills. Fifty-three young adults were assigned to one of two groups: (1) control group (mean age = 21.4; 10 females), who had 20 min of rest after their baseline assessment, or (2) training group (mean age = 21.5; 17 females), who had 20 min of training on the Corsi Block Tapping Task after their baseline assessment. The primary outcome was reaction time on a computer-based mental rotation task, and it was assessed both before and after the rest or training. There was a significant interaction between time (pre vs. post) and group (control vs. training) on mental rotation performance (p = 0.04), with the training group performing on average 124 ms faster on accurate trials than the control group at post-test. This preliminary study suggested that improving mental rotation may be feasible through targeted cognitive training. Future studies will consider multiple sessions of Corsi Block Tapping Task training to maximize training benefits (i.e., dose-response), as well as longer term retention in cognitively intact and impaired individuals.

Upper extremity motor abilities and cognitive capability mediate the causal dependency between somatosensory capability and daily function in stroke individuals

Stroke individuals’ daily function has been demonstrated to be influenced by their somatosensory capability, cognitive capability, and upper extremity (UE) motor abilities. However, the structural relationships among these abilities on stroke individuals’ independence in daily function remain unclear. We analyzed the pretest measures of 153 stroke individuals in outpatient rehabilitation settings by structural equation modeling to determine the structural relationship among somatosensory capability, UE muscle strength, UE motor function, and cognitive capability that influences independence in daily function. The standardized results indicated somatosensory capability negatively influenced UE muscle strength, but positively influenced UE muscle strength mediated by UE motor function. UE muscle strength, then, positively influenced individuals’ independence in daily function. On the other hand, somatosensory capability positively influenced cognitive capability, which marginally and positively affected the performance of independence in daily function. To the best of our knowledge, this is the first study to demonstrate the influence of somatosensory capability on the daily function is mediated mainly by motor functions and marginally by cognitive capability. This structural model may allow future clinical therapists to design more effective task-related training protocols to promote the independence in daily function for stroke individuals.

Factors predicting rehabilitation outcomes after severe acquired brain injury in trauma, stroke and anoxia populations: A cohort study

Severe acquired brain injury has long-term physical and cognitive effects. Identifying patient variables predictive of recovery in different brain injury populations would generate improved prognostic information and help rehabilitation teams set appropriate therapeutic goals. This cohort study of 447 NHS neurorehabilitation inpatients aimed to identify functional and cognitive predictors of recovery following severe acquired brain injury caused by trauma, stroke and anoxia. Motor and cognitive impairment ratings were collected at admission and discharge using the Functional Independence Measure and Functional Assessment Measure (FIM+FAM), and injury-related and demographic data were collated from medical records. Predictors of physical, cognitive and overall recovery were identified via hierarchical regression analyses. Several key findings emerged. Firstly, on-admission motor skills predicted functional and overall outcomes across groups. Secondly, on-admission social interaction skills predicted cognitive discharge outcomes in stroke and trauma, and overall outcomes for stroke, but did not predict anoxia outcomes. Thirdly, age predicted all forms of recovery for stroke only. Further group-specific factors were also identified as predicting motor and cognitive recovery, indicating that factors key to the rehabilitation trajectory may differ between populations. These variables should be considered in rehabilitation goal planning, although further research is required to explore their contributions to recovery.

The Relation between Perceptual Deficits after Stroke and Independence in Activities of Daily Living

The impact of perceptual difficulties on daily life was evaluated using standardised procedures. One hundred and fifty stroke patients (75 right hemiplegic and 75 left hemiplegic) of all ages, admitted consecutively to two general hospitals, were assessed one month after stroke. They were assessed on the Rivermead Perceptual Assessment Battery to identify perceptual difficulties and on an activities of daily living (ADL) scale. Patients without perceptual deficits were more often independent than those with perceptual deficits. On simple ADL tasks, left hemiplegic patients were more often independent than right hemiplegic patients, but not on more complex ones. There was a significant correlation between perceptual abilities and independence in all ADL scales. There was no correlation between visual neglect and independence in ADL in left hemiplegic patients.

The Rivermead Perceptual Assessment Battery: Its Relationship to Selected Functional Activities

Thirty-five stroke patients were assessed on the Rivermead Perceptual Assessment Battery (RPAB) and three functional activities. The activities chosen had reported constructional components. A checklist was developed to measure a person's performance on the constructional components of each activity objectively. The RPAB results were correlated with those of making a sandwich and packing a lunchbox, putting on a cardigan and setting a table. A statistically significant relationship was found between the RPAB and the selected functional tasks. The results also suggest that a clinical relationship exists between performance on the RPAB and the three tasks, therefore assumptions can be made about a person's performance on these tasks using the results from the RPAB.

Comparison of Stroke Unit and Non-Stroke Unit Inpatients on Independence in ADL

Independence in activities of daily living was compared between stroke patients on a stroke unit one month after onset and stroke patients in hospital but not on a stroke unit. The functional outcome at 2 years after onset was also compared. Generally, the results showed no significant difference in independence between the groups, at either one-month or 2-year assessments. The exceptions were in the household 1 section of the assessment.

Routine screening of brain-damaged patients: a comparison of the Rivermead Perceptual Assessment Battery and the Chessington Occupational Therapy Neurological Assessment Battery

Thirty-two brain damaged patients undergoing rehabilitation were assessed independently by the Rivermead Perceptual Assessment Battery (RPAB) and the Chessington Occupational Therapy Neurological Assessment Battery (COTNAB). The detection of perceptual deficits was similar with both batteries. The RPAB was quicker and slightly easier to use but the COTNAB was considered to give considerably more information. This led us to conclude that the COTNAB was the preferred battery for routine use in our clinical setting. Patients found both batteries acceptable with no particular preference for one over the other.

The recovery of perceptual problems after stroke and the impact on daily life

The frequency of perceptual problems in stroke patients and the impact of daily life, were assessed at one month and two years after onset of the stroke. Ninety patients were assessed on the Rivermead Perceptual Assessment Battery (RPAB) and an Activities of Daily Living (ADL) scale. Perceptual problems were identified in 69% of patients on the one month assessment and in 74% of patients on the two-year assessment. There was no significant difference in the frequency or severity of perceptual problems, between the two assessments. Significant improvement occurred in activities such as mobility, preparing a hot drink and crossing a road. There remained a significantly high correlation between perceptual problems and independence in activities of daily living.

The effects of a stroke unit on activities of daily living

Objective: To determine whether specific daily activities are improved more by treatment in a specialized stroke unit for patients seen after stroke.

Design: Randomized controlled study allocating patients to management in a stroke unit or on conventional hospital wards.

Setting: District general hospital medical or geriatric wards, or a hospital stroke unit.

Subjects: Patients who within five weeks of acute stroke were considered suitable for intensive stroke unit rehabilitation (if so randomized).

Interventions: Standard rehabilitation as delivered in the medical/geriatric wards or as delivered in the stroke unit.

Outcome measures: All individual items from the Barthel activities of daily living (ADL) scale, all items from the Rivermead ADL scales (self-care and household sections) and all items from the Nottingham Extended ADL scale were analysed.

Results: One hundred and seventy-six patients were seen in the stroke unit and 139 on the conventional wards. At entry the stroke unit had more women and stroke unit patients had less good arm function; otherwise the groups were comparable. The main differences were in the areas of feeding, dressing and household activities.

Conclusions: Stroke unit rehabilitation seems to improve feeding, dressing and household activities more than occurs on conventional wards; mobility was improved equally in both settings.

An extended activities of daily living scale for stroke patients

A ranked assessment of daily living (ADL) scale has been developed to assess activities which may be important to stroke patients who have been discharged home. A questionnaire incorporating 22 ADL activities in four sections was sent by post to 80 consecutively registered stroke patients. Gutmann scaling was carried out on the returned questionnaires, producing acceptable coefficients of reproducibility and scalability. The revised questionnaire was then sent to 20 stroke patients. The same patients were sent an identical questionnaire two weeks later. The overall level of agreement between the two assessments was satisfactory. The extended ADL scale could therefore be used as a postal questionnaire to assist in the follow-up of patients discharged home after a stroke. Due to the scaling properties of the assessment, patient's progress can be monitored and patients can also be compared on the basis of their scale score.

The experience of couples when one partner has a stroke at a young age: an interpretative phenomenological analysis

PURPOSE

Stroke is a major cause of disability worldwide and affects a significant number of working age adults each year. The consequences of stroke impact upon both young stroke survivors and their partners and this study aimed to qualitatively explore their joint experience.

METHODS

Eight joint semi-structured interviews were conducted and analysed using IPA.

RESULTS

Three themes were identified: (1) "How's this happened?"--Making sense of the stroke; (2) "Is this what life is going to be like now?"--From partners to carer and "cared for"; (3) "I lost being a man. I was a little boy, being looked after all the time"--From partners to parent and child.

CONCLUSIONS

Stroke at a young age can significantly disrupt couples' life biographies. The findings highlight the need for both partners to adapt to their reciprocal relationship role changes and the importance of addressing the couple as a focus for intervention. Implications for Rehabilitation Stroke at a young age is an abrupt event that impacts upon both partners in a relationship. The findings add insight to some of the issues faced by young stroke survivors and their partners, which can now be considered in tailoring treatment to this specific cohort within the context of services predominated by older adults. The findings highlight significant relationship role changes experienced within couples, which suggests a need for rehabilitation interventions to focus on the adjustment of both partners.

A systematic review of case-mix adjustment models for stroke

Objective:

To identify any externally validated prognostic model for predicting outcome in unselected populations following acute stroke comprising variables feasible for collection in routine care.

Data sources:

Searches were run in MEDLINE, EMBASE, CINAHL, PsycInfo, AMED and ISI Web of Science with no limits on publication date or language.

Review methods:

Any study describing the development or external validation of a discernible prognostic model to predict any valid outcome following acute stroke was included. Papers were retained if they met pre-specified inclusion criteria identified from previous reviews and pertinent discussion papers. Data extraction focused on methodological quality of model development, generalizability and feasibility of variable collection. Model performance was examined through consideration of external validation studies.

Results:

Seventeen externally validated models were identified from 43 papers fulfilling inclusion criteria. Quality of studies describing model development was variable and model performance in external validation studies was generally poor. Models were generally constructed through secondary use of randomized trial or stroke database data. Prognostic variables broadly encompassed markers of stroke severity, pre-stroke function and comorbidities. One model that fulfilled the review criteria and had extensive external validation in a range of post-stroke populations was identified (the Six Simple Variables model).

Conclusion:

The Six Simple Variables model performed well in six external validation studies, although prediction of outcome in patients with milder strokes was less reliable. Other models identified in this review have been developed using robust methodology but comprise more complex clinical variables which may limit their utility in routine stroke care.

Circuit Class Therapy Versus Individual Physiotherapy Sessions During Inpatient Stroke Rehabilitation: A Controlled Trial

OBJECTIVE

To compare the effectiveness of circuit class therapy and individual physiotherapy (PT) sessions in improving walking ability and functional balance for people recovering from stroke.

DESIGN

Nonrandomized, single-blind controlled trial.

SETTING

Medical rehabilitation ward of a rehabilitation hospital.

PARTICIPANTS

Sixty-eight persons receiving inpatient rehabilitation after a stroke.

INTERVENTIONS

Subjects received group circuit class therapy or individual treatment sessions as the sole method of PT service delivery for the duration of their inpatient stay.

MAIN OUTCOME MEASURES

Five-meter walk test (5MWT), two-minute walk test (2MWT), and the Berg Balance Scale (BBS) measured 4 weeks after admission. Secondary outcome measures included the Iowa Level of Assistance Scale, Motor Assessment Scale upper-limb items, and patient satisfaction. Measures were taken on admission and 4 weeks later.

RESULTS

Subjects in both groups showed significant improvements between admission and week 4 in all primary outcome measures. There were no significant between group differences in the primary outcome measures at week 4 (5MWT mean difference, .07m/s; 2MWT mean difference, 1.8m; BBS mean difference, 3.9 points). A significantly higher proportion of subjects in the circuit class therapy group were able to walk independently at discharge (P=.01) and were satisfied with the amount of therapy received (P=.007).

CONCLUSIONS

Circuit class therapy appeared as effective as individual PT sessions for this sample of subjects receiving inpatient rehabilitation poststroke. Favorable results for circuit classes in terms of increased walking independence and patient satisfaction suggest this model of service delivery warrants further investigation.

The impact of stroke on the well-being of the patient's spouse: an exploratory study

AIMS

The aim of this study was to investigate the impact of stroke on the patient's spouse, paying particular attention to psychiatric morbidity and the strain of caring, and correlating these with the degree of disability of the patient. The impact of impairment of speech was also investigated.

BACKGROUND

The impact of a stroke is not limited to the person who suffers it but also to the family, with the patient's spouse being particularly vulnerable. The literature suggests that the consequences for the spouse can be physical, psychological, economic and social.

METHODS

A quantitative approach was employed to investigate 44 couples who volunteered to participate in the study. A small battery of validated instruments was used to describe the patient's degree of disability, and psychiatric morbidity and the strain of caregiving in the spouse. Pearson's Correlation and Mann-Whitney U-test were used in data analysis.

RESULTS

The spouses were found to have a greater degree of psychiatric morbidity than a reference group and a large proportion of them found caregiving to be stressful. Psychiatric morbidity and strain in the spouses were not directly proportional to the extent of the patient's disability. Spouses whose partners' speech was affected by the stroke were more likely to experience strain than those who were unaffected in this way.

CONCLUSIONS

This study contributes to our knowledge of the relationship between patients' physical disability and the level of strain and psychiatric morbidity in spouses. The relationship is a complex one, in which it is not possible to predict with confidence which spouses will be most vulnerable.

RELEVANCE TO CLINICAL PRACTICE

Caring for a patient following a stroke is very stressful, particularly in cases where the patient's speech is affected and there is also likely to be a significant effect on the psychological well-being of the spouse. This information is relevant to all nurses caring for patients with stroke and the patients' spouses.

Memory Impairment Following Right Hemisphere Stroke: A Comparative Meta-Analytic and Narrative Review

We examined the evidence for widely held clinical beliefs about memory impairment following right hemisphere stroke (RHS), conducting both narrative and meta-analytic reviews of the literature [MEDLINE (1966-January 2003), PsycINFO (1974-January 2003), and CINAHL (1982-December 2002)]. We sought to determine whether RHS patients experience more problems with non-verbal memory than non-stroke controls (NSCs) and left hemisphere stroke (LHS) patients. Secondarily, we sought to determine whether RHS patients experience more problems with verbal memory than NSCs and fewer verbal memory problems than LHS patients. We also examined the effect of type of memory assessment (recall versus recognition) on reported findings. As regards non-verbal memory, narrative and meta-analytic reviews found that RHS patients had deficits relative to NSCs, on tests of both recall and recognition. The evidence for RHS non-verbal memory deficits relative to LHS was mixed in the narrative review, whereas the meta-analysis found RHS deficits on non-verbal recognition tests, but no difference between RHS and LHS patients on non-verbal recall tests. Deficits on recognition tests imply problems with early encoding of material or possibly its storage. Regarding verbal memory, the narrative review found that RHS patients performed more poorly than NSCs in about half of all studies. The meta-analytic review confirmed poorer RHS performance on tests of verbal recall, but none of the studies that compared RHS and NSCs on verbal recognition could be included in this type of review. The narrative review found mixed evidence as regards the performance of RHS and LHS patients on verbal memory tests, but the meta-analysis pointed to RHS superiority for both verbal recall and recognition. The relative strengths of both types of review are discussed.

Late motor recovery is influenced by muscle tone changes after stroke

OBJECTIVES

To evaluate the time course of motor recovery in a poststroke period ranging from 2 to 6 months and its correlation with both the severity of motor deficit and the muscle tone disturbances (flaccidity or spasticity) of the affected limbs.

DESIGN

Prospective cohort study.

SETTING

A comprehensive rehabilitation hospital.

PARTICIPANTS

Forty consecutive stroke patients (21 men, 19 women) with first ischemic stroke who met the inclusion criteria.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Change in motor deficit as evaluated by the Adams Hemispheric Stroke Scale.

RESULTS

Stepwise regression analysis indicated that the most significant factors influencing motor recovery were the time elapsed since stroke and muscle tone.

CONCLUSIONS

Rehabilitation of stroke patients is more effective in the first months after the event rather than later, considering the significant correlation observed between motor recovery and time elapsed since stroke. Flaccid patients appear to need 3 months or more before reaching the final plateau, because motor recovery occurs later and/or proceeds more slowly, whereas outcomes for spastic patients with spasticity appears to occur in the first months after stroke.

Working memory and mental practice outcomes after stroke

OBJECTIVE

To examine the relationship between working memory and motor improvement obtained after a single training session combining mental and physical practice.

DESIGN

Before-after trial.

SETTING

Laboratory of a university-affiliated research rehabilitation center.

PARTICIPANTS

A sample of 12 patients with stroke and 14 age- and gender-matched healthy subjects.

INTERVENTION

In a single session, patients were trained with combined mental and physical practice to increase the loading on the affected leg while standing up and sitting down.

MAIN OUTCOME MEASURES

Motor improvement as measured by the percentage change in limb loading on the affected limb after training and 24 hours later (follow-up), and the relationship between working memory and percentage motor improvement.

RESULTS

The loading on the affected leg was improved after training (P< .01) and at follow-up (P< .05), and working memory scores at follow-up correlated significantly (P< .004 to P< .007) with the level of improvement. The visuospatial domain yielded the strongest correlation (r= .83), followed by the verbal (r= .62) and kinesthetic (r= .59) domains.

CONCLUSIONS

These results suggest that the outcome (improved limb loading) of mental rehearsal with motor imagery depends on the ability to maintain and manipulate information in working memory.

Model of recovery of locomotor ability after sensorimotor cortex injury in rats

Animal models of locomotor recovery after brain injury provide tools for understanding the basic neurobiological processes that may underlie recovery after stroke in humans. Measurement of the ability of rats to traverse a narrow elevated beam has proven to be a particularly useful test of locomotor function. Repeated measurement of this behavior over time provides a simple method for quantifying the rate and degree of a rat's locomotor recovery after sensorimotor cortex injury and constitutes a tool for studying its mechanisms and possible treatment strategies. The model has proven particularly useful in predicting the effects of drugs on poststroke recovery in humans.

Subcortical vascular disease and functional decline: a 6-year predictor study

OBJECTIVES

To identify predictors of activity of daily living (ADL) and instrumental activity of daily living (IADL) decline in a population with subcortical vascular dementia (SVD) and to evaluate potential mechanism of decline.

DESIGN

Longitudinal.

SETTING

Hospital-based.

PARTICIPANTS

Computed tomographic (CT) scanning identified 77 participants as having subcortical infarction.

MEASUREMENTS

Participants were neurologically, neuropsychologically, behaviorally, and functionally assessed four times over 5.82 years. Baseline data were grouped into four modules: basic demographic and risk factor, CT scan, neurological and other clinical, and neuropsychological and behavioral. Multivariate analysis determined predictors of decline in ADLs and IADLs.

RESULTS

Predictors of ADL decline were age, alcohol consumption, coordination, snout reflex, and performance on a neuropsychological test (Block Design). Predictors of IADL decline were predominantly cognitive and included the presence of paratonia and performance on the two neuropsychological tests (attention and memory tasks).

CONCLUSION

These findings suggest that cognitive impairments are most likely to have an effect on IADL function, because the skills involved are complex and involve integrative activity, whereas physical and cognitive impairments combined are likely to compromise ADL function, given the more basic and physical nature of the functions involved. These findings indicate that in people with SVD, both ADL and IADL status should be monitored, because, for many, decline in function over time is likely, and thus the provision of appropriate support required.

Expression of the apolipoprotein E gene does not affect motor recovery after sensorimotor cortex injury in the mouse

Motor recovery after unilateral sensorimotor cortex ablation or sham-injury was measured in apolipoprotein E knockout and wild-type mice by testing their abilities to traverse a narrow beam. All mice trained without difficulty. Sham-operated mice performed perfectly regardless of genotype throughout testing. There was no difference in motor scores between lesioned apolipoprotein E knockout and wild-type mice on a first trial 24h after injury (P>0.05). There was a significant overall effect of lesion on motor performance (two-way repeated measures analysis of variance F(1,42)=304, P<0.0001), a significant time effect (F(17,714)=58, P<0.0001) and a lesion by time interaction (F(17,714)=58, P<0.0001). However, there was no effect of apolipoprotein E genotype group on recovery rate (i.e. there was no lesion group by genotype group by time interaction, F(17,714)=0.33, P=1.00) and no effect of genotype on the final level of motor performance 12 days after the lesion (Kruskal-Wallis H=5.79, P=0.12). These data suggest that motor recovery after unilateral injury to the sensorimotor cortex does not vary with apolipoprotein E genotype.

Predicting motor recovery of the upper limb after stroke rehabilitation: value of a clinical examination

BACKGROUND AND PURPOSE

Only a few studies have been conducted to predict motor recovery of the arm after stroke. The aims of this study were to identify which clinical variables, assessed at different points in time, were predictive of motor recovery, and to construct useful regression equations.

METHOD

One hundred consecutive stroke patients who had an obvious motor deficit of the upper limb were evaluated on entry to the study (two to five weeks post-stroke) and at two, six and 12 months after stroke. The Brunnström-Fugl-Meyer test was used as the outcome measure. Predictors included demographic data, overall disability, clinical neurological features, neuropsychological factors and secondary shoulder complications.

RESULTS

In multiple regression analyses, motor performance was invariably retained as the predictive factor with the highest R-square. Other significant predictive variables were overall disability, muscle tone, proprioception and hemi-inattention. Between 53% and 89% of the total amount of variance was accounted for in all selected models. The accuracy of prediction from clinical measurement in the acute phase diminished as the time span of measurement of outcome increased. Similarly, assessment of the variables at two and six months, rather than in the acute stage, resulted in a considerable improvement in the percentage variance explained at 12 months. The highest accuracy was obtained when predictions were made step-by-step in time.

CONCLUSIONS

It is possible to predict motor recovery of the upper limb accurately through the use of a few clinical measures. Predictive equations are proposed, the use of which are practicable in both clinical practice and research.

On the prognosis of outcome after stroke

OBJECTIVES

The study was aimed at improving the accuracy of prognosis for recovery of function in patients suffering a first stroke.

MATERIALS AND METHODS

Two-hundred and forty-eight patients were enrolled. The mean interval since the stroke was 23 days. Patients entered a rehabilitation program lasting 60 days. The predictive value of 12 factors were analysed, namely motor, cognitive and sphincter subitems of Functional Independence Measure at admission (FIM-a), age, sex, education, body mass index (BMI), depression, neglect, aphasia, ideomotor and constructive apraxia. FIM score at discharge was the dependent variable.

RESULTS

A multiple regression revealed that only age, cognitive and sphincter subitems of FIM-a, neglect and ideomotor apraxia were significantly associated with outcome. Moreover, these factors accounted for only 72% of the variance in outcome scores. A decision of unfavourable prognosis on the basis of a FIM-a value lower than 40 was incorrect in 2.8% of the patients in this study and in 8.2% of those having a FIM score lower than 40.

CONCLUSIONS

The use of statistical methods to examine the outcome after stroke is useful for expressing probability on a group basis but is unsuitable for determining the prognosis of individual patients. Such data should not be used for fiscal management. A significant minority of patients presenting with a FIM lower than 40 can regain a useful measure of independence. The errors in prognosis based upon available methods, although small, have unacceptable effects in human terms if they lead to the clinical decisions which deny patients rehabilitation. All of the patients should therefore be admitted for rehabilitation after their first stroke. Severe comorbidity requires special attention.

Prediction of gait velocity in ambulatory stroke patients during rehabilitation

OBJECTIVE

To quantify prediction of gait velocity in ambulatory stroke patients during rehabilitation.

DESIGN

Single group (n = 42) at the beginning of rehabilitation (Test 1) and 8 weeks later (Test 2).

SETTING

Inpatient rehabilitation.

PATIENTS

Unilateral first stroke; informed consent; able to walk 10 meters.

MEASURES

INDEPENDENT VARIABLES

Gait velocity at Test 1, age, time from stroke to Test 1, side of lesion, neglect.

DEPENDENT VARIABLES

Gait velocity at Test 2, gait velocity change.

RESULTS

The correlation between initial gait velocity and gait velocity outcome at Test 2 was of moderate strength (r2 = .62, p<.05). However, even at its lowest, the standard error of prediction for an individual patient was 9.4 m/min, with 95% confidence intervals extending over a range of 36.8 m/min. Age was a weak predictor of gait velocity at Test 2 (r2 = -.10, p<.05). Gait velocity change was poorly predicted. The only significant correlations were initial gait velocity (r2 = .10, p<.05) and age (r2 = .10, p<.05).

CONCLUSION

While the prediction of gait velocity at Test 2 was of moderate strength on a group basis, the error surrounding predicted values of gait velocity for a single patient was relatively high, indicating that this simple approach was imprecise on an individual basis. The prediction of gait velocity change was poor. A wide range of change scores was possible for patients, irrespective of their gait velocity score on admission to rehabilitation.

Newly developed short behavior scale for use in stroke outcome research

This study was designed to examine the scale quality of our newly developed short behavior scale and to identify its role in predicting the functional outcome of stroke patients. The short behavior scale consists of six items that assess cognitive function related to the daily behavioral status of a patient in activities of daily living and exercise. It can be scored quickly through observation of a patient's behavior. We assessed 190 stroke inpatients, who had a mean age of 61 years. The mean days and length of stay from onset were 47.3 and 138.2, respectively. We examined internal consistency with the Cronbach's alpha coefficient. Interrater reliability was tested by having two examiners evaluate 30 patients independently. We studied how the short behavior scale correlated with the admission Functional Independence Measure, Mini-Mental State Examination scores, and speech and visuospatial functions. We also studied how the short behavior scale contributed to the prediction of discharge Functional Independence Measure raw scores with stepwise multiple regression analysis. In another group of 116 patients, we cross-validated our predictive equation. The Cronbach's alpha coefficient was 0.88. The intraclass correlation coefficient was 0.84 for total score. The short behavior scale correlated significantly with cognitive Functional Independence Measure scores and Mini-Mental State Examination scores. We could explain 70.8% of the variance of discharge Functional Independence Measure scores from the Short Behavior Scale, days from onset to admission, age, speech scores, and admission Functional Independence Measure scores. Stability of the predictive equation was shown in cross-validation to a second sample of 116 patients. In conclusion, our newly developed short behavior scale proved reasonable and would be useful to enhance the precision of outcome prediction in stroke rehabilitation.

The influence of visual neglect on stroke rehabilitation

BACKGROUND AND PURPOSE

The poor outcome observed in stroke patients with visual neglect may be due to greater stroke severity or nonspecialist management.

METHODS

The effects of visual neglect were studied prospectively in 150 consecutive stroke patients with comparable stroke pathology and motor severity managed on a stroke unit. A randomized study was subsequently undertaken in 50 stroke patients with visual neglect to evaluate the effectiveness of spatial cueing during motor activity on functional outcome and resource use in these patients.

RESULTS

Visual neglect was present in 47 (32%) of a selected group of 146 patients (mean age, 77.0 +/- 8.2 years; 42% men) with moderate stroke severity. There were no differences in demography, prestroke function, or motor power in the arm (2.6 +/- 1.7 versus 2.3 +/- 2.1) or the leg (3.2 +/- 1.4 versus 3.0 +/- 1.6) on the affected side compared with 99 patients with no visual neglect. Although patients with visual neglect had lower median initial (4 versus 5, P < .01) and discharge (14 versus 16, P < .01) Barthel Index scores, equal proportions of patients were discharged home (60% versus 65%) or to institutions (34% versus 33%) in both groups. The durations of hospitalization (64 versus 36 days, P < .001) and therapy input (47.7 versus 27.8 hours; P < .01), however, were significantly greater in patients with visual neglect. The randomized controlled study showed a trend toward higher Barthel scores at 12 weeks (14 versus 12.5, P = NS) and significant reduction in median length of hospital stay (42 versus 66 days) in patients receiving spatiomotor cueing and early emphasis on functional rehabilitation.

CONCLUSIONS

Patients with visual neglect managed on a stroke unit have similar destination of discharge despite lower Barthel Index scores compared with patients of equal stroke severity who do not have this deficit. Spatiomotor cueing and early emphasis on function can improve outcome and reduce resource use in these patients.

Retrospective assessment of initial stroke severity with the Canadian Neurological Scale

BACKGROUND AND PURPOSE

The severity of the initial neurological deficit is a critical determinant of outcome after acute stroke. Retrospective outcome studies are generally limited by a lack of quantitative data relating to this initial stroke severity. We evaluated the validity and reliability of measuring initial stroke severity retrospectively with the Canadian Neurological Scale (CNS).

METHODS

The CNS was used to prospectively score the initial neurological deficit in a series of patients with acute ischemic stroke (n = 24). An algorithm was devised for applying the CNS retrospectively on the basis of information in the patient's hospital discharge summary. Those dictating the discharge summaries were not aware of the study, and the retrospective scoring was performed without reference to other scores. The level of agreement between the prospective and retrospective scores (validity) and both intraobserver and interobserver reliability for the retrospective scores were determined.

RESULTS

Agreement was high between retrospective and prospective scores (r = .84, R2 = .71, P < .0001), between two sets of retrospective scores obtained by one rater (r = .95, R2 = .91, P < .0001), and between retrospective scores obtained by different raters (r = .91, R2 = .82, P < .0001). Weighted kappa statistics (kappa w) for prospectively versus retrospectively scored items varied from almost perfect (kappa w > 0.81 for level of consciousness and orientation) to substantial (kappa w = 0.68 for speech) and moderate (kappa w = 0.41 to 0.60 for facial weakness, proximal arm, distal arm, proximal leg, and distal leg strength). Using the retrospective algorithm, there was almost perfect intraobserver and interobserver reliability for each of the individual CNS items (kappa w = 0.81 to 1.00).

CONCLUSIONS

These data show that retrospective scoring of initial stroke severity using an algorithm based on the CNS is valid and can be reliably performed using information available in hospital discharge summaries.

Deficit and change in gait velocity during rehabilitation after stroke

OBJECTIVE

To quantify the initial deficit, change, and outcome in gait velocity during inpatient rehabilitation following stroke.

DESIGN

The initial deficit on admission to rehabilitation was quantified by comparing 42 stroke patients with 42 controls matched by gender and age. The change in the stroke patients during the next 8 weeks was quantified and gait outcome was compared with functional and normal criteria.

SETTING

Patients were referred from four inpatient rehabilitation centers at the time of admission following a median of 16.5 days in the acute hospital.

PATIENTS

SELECTION CRITERIA

ability to give informed consent; unilateral first stroke; ability to walk 10 meters.

INTERVENTION

Patients participated in a median of 17.38 hours of individual physical therapy including a median of 6.92 hours of gait training during the 8 weeks.

MAIN OUTCOME MEASURE

Gait velocity.

RESULTS

Gait velocity was initially 38.6% (26.7m/min SD = 14.9) of the performance of controls and improved to 55.1% (38.1m/min). At outcome only 24% exceeded the 5th percentile of controls (48.1m/min) or the velocity required to cross the typical signalled intersection (46.2m/min). The change was only 26% of the initial deficit. Fifty-five percent of the patients improved beyond the 95% confidence intervals surrounding the error of measuring change. Indices of responsiveness indicated that there was a high signal-to-noise ratio and a robust effect size.

CONCLUSION

Gait velocity discriminated the effect of stroke and the change during rehabilitation.

Physical, psychological, and social outcomes in geriatric rehabilitation patients

OBJECTIVE

Previous research studies that addressed the relationship between age and functional outcome had limited generalizability because of small sample size, lack of an urban population, and limited variables that do not allow for a complete investigation of social, cognitive, psychological, and medical factors in geriatric rehabilitation. The present study attempted to assess the relationship between decade of geriatric life (60s, 70s, 80s, and 90+) and functional outcome.

DESIGN

Survey study of geriatric cohorts.

SETTING

Inpatient university-affiliated rehabilitation hospital.

PATIENTS

812 urban geriatric rehabilitation patients divided into four groups based on decade of life.

MAIN OUTCOME MEASURES

Index of comorbid disease, principal diagnoses, Functional Independence Measure, Mattis Dementia Rating Scale, Geriatric Depression Scale, CAGE alcohol questionnaire, and residential status at admittance and discharge.

RESULTS

Although there were no significant demographic differences between groups (apart from age), there were differences in functional outcome suggesting that the younger old (60s and 70s) and the older old (80s and 90+) patients may represent two different rehabilitation groups.

CONCLUSIONS

The younger old patients showed significantly higher alcohol abuse and comorbid physical disease, while the older-old patients demonstrated significantly poorer cognitive skills and more dependent social status on discharge from the rehabilitation facility. Despite the younger group's physical problems and alcohol use, they demonstrated better physical recovery. Implications for working with these two groups of urban geriatric patients in a rehabilitation setting are discussed.

Orientation in the acute and chronic stroke patient: impact on ADL and social activities. The Copenhagen Stroke Study

OBJECTIVES

To determine the influence of initially lowered orientation on rehabilitation outcome in stroke patients, and how decreased orientation 6 months after stroke influences ADL and social activities.

DESIGN

Prospective, consecutive, and community based.

SETTING

A stroke unit receiving all acute stroke patients from a well-defined catchment area. All stages of rehabilitation were completed within the unit.

PATIENTS

524 patients with acute stroke.

MAIN OUTCOME MEASURES

Basic ADL assessed by the Barthel Index (BI) at discharge; discharge placement; higher level ADL and social functions assessed by the Frenchay Activity Index(FAI) at a 6-month follow-up.

RESULTS

The independent influence of orientation in acute stroke on rehabilitation outcome was analyzed with multiple linear and logistic regression models, using initial stroke severity (Scandinavian Neurologic Stroke Scale), initial BI, age, sex, comorbidity, prior stroke, and marital status as covariates. A one-point decrease in orientation decreased BI with 9 points (coefficient b=8.66, SE(b)=1.02,p<.0001) and reduced the likelihood (1.49, 95% CI: 1.05 to 2.11) of discharge to independent living (b=.40, SE(b)=.18,p=.026). Follow-up examinations 6 month poststroke showed that decreased orientation at this point still exerted a marked, negative influence on ADL and social functions (BI: coefficient b=12.06, SE(b)=1.95,p<.0001; FAI: coefficient b=6.28, SE(b)=1.42,p<.0001).

CONCLUSION

The level of orientation influences basic ADL and higher level ADL and social activities in acute as well as chronic stroke. This finding suggests that rehabilitation of memory and attention might be relevant in stroke patients with impaired orientation.

Relationship between wheelchair propulsion and independent walking in hemiplegic stroke

BACKGROUND AND PURPOSE

We studied the relationship between wheelchair propulsion and final walking ability in hemiplegic stroke patients who were unable to walk independently 3 or more weeks after stroke.

METHODS

Sixty hemiplegic stroke patients unable to walk independently 3 weeks or more after stroke were entered in a study comparing independent walking and wheelchair propulsion. Eight patients were lost to follow-up. Of the remaining 52 patients, 29 were entered 3 weeks and 23 were entered 4 to 10 weeks after stroke. Assessments were performed on admission and 4 and 14 weeks later.

RESULTS

Fifteen of the 17 patients able to propel a wheelchair through a simple course at 3 weeks after stroke learned to walk independently (chi 2 = 9.94, P = .01), but none of the 12 who failed learned to walk (chi 2 = 12, P = .001). At the final assessment, the positive association between wheelchair propulsion and walking had been lost: 21 of 21 walkers and 18 of 31 nonwalkers could propel a wheelchair (chi 2 = 0.23, P = NS). The negative association remained: 13 of 31 nonwalkers failed the wheelchair test, but 0 of 21 walkers failed (chi 2 = 13.0, P = .001). Visual field deficits were significantly more common in patients unable to walk or propel a wheelchair than in walkers (chi 2 = 6.66, P = .01). Laterality had no effect on outcome.

CONCLUSIONS

Ability to propel a wheelchair 3 weeks after stroke in hemiplegic patients unable to walk is the most accurate guide to walking potential that has been reported to date.

Tactile extinction and functional status after stroke. A preliminary investigation

BACKGROUND AND PURPOSE

Research has identified a number of factors associated with poststroke recovery, but the prediction of long-term functional outcome remains an uncertain endeavor. In previous work, extinction to tactile, double-simultaneous stimulation has been shown to have short-term predictive utility. The present study was designed to examine its long-term prognostic value and to determine the relative importance of tactile extinction, cognitive functioning, and visual neglect as predictors of poststroke functional status.

METHODS

Successive admissions to an acute-care facility (n = 26) were assessed three times: 1 month, 3.5 months, and 6 months after stroke. Hierarchical multiple regression, a procedure that maximizes the effect of the variables first entered, was used to predict functional status. Cognitive functioning and visual neglect were forced into the equation on the first step; tactile extinction was entered on the second step. Multivariate analysis of variance was used to compare the functional status of subjects with no extinction versus those who demonstrated extinction at the first assessment and later improved and those who continued to manifest the deficit.

RESULTS

Tactile extinction on the left-hand side of the body was the most important predictor of functional outcome. A significant group-by-time interaction implied that the course of improvement in functional status differed between the groups.

CONCLUSIONS

Tactile extinction shows promise as a predictor of poststroke functional status, but further work is required to substantiate the present findings.

Stroke rehabilitation outcome. A potential use of predictive variables to establish levels of care

BACKGROUND AND PURPOSE

The most powerful predictors of functional recovery and eventual home discharge among stroke survivors are the initial severity of the stroke and the patient's age. We analyzed a large population of stroke rehabilitation admissions by stratifying subgroups with coherent outcomes in an attempt to define potentially more efficient patterns of providing rehabilitation care.

METHODS

We retrospectively analyzed 520 consecutive patients admitted to a rehabilitation hospital (1 calendar year) with cerebral infarction or hemorrhage. Side of index stroke, age, and functional disability at admission were the independent variables. Change in functional disability and home versus nursing home discharge were the dependent measures.

RESULTS

Recovery was overall most closely related to admission severity and age, but the relations between recovery and independent measures were complex. Patients aged < 55 years all were discharged home whatever their initial severity. Patients admitted with modest functional disability were almost all discharged home (96%), whatever their age. For the remainder of the patients, admission severity and age interacted to create two groups with very different prospects for home discharge (P < .0001). Within the groups that eventually returned home, there were very different rates of functional improvement that were directly related to length of hospital stay.

CONCLUSIONS

Standard clinical measures available at rehabilitation admission carry enough predictive power to define management strategies for stroke survivors. A management algorithm is proposed that might increase the efficiency of stroke rehabilitation programs and might allow comparisons of efficacy between different treatment settings.

Predicting length of stay, functional outcome, and aftercare in the rehabilitation of stroke patients. The dominant role of higher-order cognition

BACKGROUND AND PURPOSE

Research in recent years has revealed factors that are important predictors of physical and functional rehabilitation: demographic variables, visual and perceptual impairments, and psychological and cognitive factors. However, there is a remaining uncertainty about prediction of outcome and a need to clinically apply research findings. This study was designed to identify the relative importance of medical, functional, demographic, and cognitive factors in predicting length of stay in rehabilitation, functional outcome, and recommendations for postdischarge continuation of services.

METHODS

The influence of these factors was determined by comparing diagnostic, medical, demographic, functional, and neuropsychological information that was retrospectively obtained by reviewing the records of 86 patients admitted for comprehensive rehabilitation due to stroke (n = 36) or orthopedic injury (n = 50). Multiple linear regression with statistical adjustment to control for overprediction of variance was used to predict outcomes.

RESULTS

The study revealed the primary importance of higher-order cognitive impairments (comprehension, judgment, short-term verbal memory, and abstract thinking) in extending length of stay and increasing referrals for outpatient therapies and home services after discharge for the cerebrovascular accident patients in comparison with orthopedic cohorts.

CONCLUSIONS

The need is discussed for early, comprehensive assessment of deficits in cognition that affect a stroke survivor's ability to participate in a rehabilitation program and remediation that facilitates functional improvement by building on residuals of impaired abilities or teaching compensatory behaviors.

Measurement of motor recovery after stroke. Outcome assessment and sample size requirements

BACKGROUND AND PURPOSE

The purpose of this study was to analyze recovery of motor function in a cohort of patients presenting with an acute occlusion in the carotid distribution. Analysis of recovery patterns is important for estimating patient care needs, establishing therapeutic plans, and estimating sample sizes for clinical intervention trials.

METHODS

We prospectively measured the motor deficits of 104 stroke patients over a 6-month period to identify earliest measures that would predict subsequent motor recovery. Motor function was measured with the Fugl-Meyer Assessment. Fifty-four patients were randomly assigned to a training set for model development; 50 patients were assigned to a test set for model validation. In a second analysis, patients were stratified on basis of time and stroke severity. The sample size required to detect a 50% improvement in residual motor function was calculated for each level of impairment and at three points in time.

RESULTS

At baseline the initial Fugl-Meyer motor scores accounted for only half the variance in 6-month motor function (r2 = 0.53, p less than 0.001). After 5 days, both the 5-day motor and sensory scores explained 74% of the variance (p less than 0.001). After 30 days, the 30-day motor score explained 86% of the variance (p less than 0.001). Application of these best models to the test set confirmed the results obtained with the training set. Sample-size calculations revealed that as severity and time since stroke increased, sample sizes required to detect a 50% improvement in residual motor deficits decreased.

CONCLUSIONS

Most of the variability in motor recovery can be explained by 30 days after stroke. These findings have important implications for clinical practice and research.

The Extended Activities of Daily Living scale: a further validation

The Extended Activities of Daily Living scale was validated as an overall assessment of functional independence in stroke patients discharged from hospital. Analysis of results from 49 patients discharged from a stroke unit and 299 from a trial of domiciliary rehabilitation supported previous work indicating that the four subsections--mobility, kitchen, domestic, and leisure--each formed a unidimensional hierarchical scale. Results also indicated that the scores from the subsections could be added to provide an overall score. The scale is suggested as appropriate for studies evaluating rehabilitation outcome after stroke, and is suitable for postal surveys.

The accuracy of predictions about progress of patients on a stroke unit

The aim of the study was to check the accuracy of predictions about the factors which affect the progress, in physical abilities and activities of daily living, of patients admitted to a stroke unit. A series of 60 patients admitted consecutively to a stroke unit were assessed on tests of motor, functional and cognitive abilities at admission. On the basis of these assessments predictions were made about the abilities of the patients at discharge. Patients were assessed for level of motor abilities and activities of daily living at discharge and the accuracy of the predictions checked. Predictions were found to be significantly correlated with outcome but the relationships were not so close as to be useful for the clinical management of individual patients.

Gait recovery after hemiplegic stroke

We prospectively evaluated gait recovery in 197 elderly subjects after hemiplegic stroke by measuring serial walking speed. Fifty-seven per cent of subjects (113/197) could not walk without human assistance on day 7 post-stroke. About 40% of this group achieved gait independence at months 1, 2, 3, and 4 post-stroke. In contrast, about 95% of those walking on day 7 maintained gait independence 1, 2, 3, and 4 months post-stroke. Using multiple logistic regression, the best predictors of independent ambulation among the 113 subjects not walking on day 7 were age, line bisection error, and leg power.