Outcome after stroke in patients discharged to independent living

Italian translation and transcultural validation of an assessment tool for community ambulation in stroke survivors: the modified Functional Walking Categories (mFWC)

BACKGROUND

Community ambulation ability is one of the most important functional loss after stroke. The assessment of the level of community walking plays an important role in the multidimensional bio-psycho-social approach, to improve quality of life and social participation of stroke survivors. The modified Functional Walking Categories (mFWC) is a worldwide widely used tool to assess community ambulation in stroke survivors, but no Italian version is yet available.

OBJECTIVE

To cross-culturally adapt the mFWC into Italian and to assess its validity and reliability.

METHODS

According to the international guidelines, a multistep translation and cultural adaptation were conducted and revised by a committee of experts. Patients admitted to intensive inpatient rehabilitation with a sub-acute stroke were recruited. Inter- and intra-rater reliability and construct validity were studied.

RESULTS

Sixty patients with sub-acute stroke were prospectively enrolled in this study. Findings showed almost perfect intra- and inter-rater reliability (k = 1.000 [95% CI 1.000-1.000] and k = 0.984 [95% CI 0.955-1.000], respectively). The construct validity of the scale was satisfactory, as 100.0% a-priori hypotheses were met.

CONCLUSIONS

The Italian mFWC offers a valid tool for measuring community ambulation in stroke patients. Our work provides a validated and a cross-cultural adapted Italian version of the mFWC to accurately measure community ambulation both in clinical and research settings in Italy.

Association Between Ischemic Stroke Subtype and Stroke Severity: The Atherosclerosis Risk in Communities Study

BACKGROUND AND OBJECTIVES

Disability after stroke occurs across ischemic stroke subtypes, with a suggestion that embolic strokes are more devastating. Whether this difference is as a result of differences in comorbidities or differences in severity at the time of the stroke event is not known. The primary hypothesis was that participants with embolic stroke would have more severe stroke at the time of admission and a higher risk of mortality, compared with thrombotic stroke participants even with consideration of confounders over time, with a secondary hypothesis that this association would differ by race and sex.

METHODS

Atherosclerosis Risk in Communities (ARIC) study participants with incident adjudicated ischemic stroke, stroke severity and mortality data, and complete covariates were included. Multinomial logistic regression models determined the association between stroke subtype (embolic vs thrombotic) and admission NIH Stroke Scale (NIHSS) category (minor [≤5], mild [6-10], moderate [11-15], severe [16-20], and very severe [>20]) adjusted for covariates from visits most proximal to the stroke. Separate ordinal logistic models evaluated for interaction by race and sex. Adjusted Cox proportional hazard models estimated the association between stroke subtype and all-cause mortality (through December 31, 2019).

RESULTS

Participants (N = 940) were mean age 71 years (SD = 9) at incident stroke, 51% female, and 38% Black. Using adjusted multinomial logistic regression, the risk of having a more severe stroke (reference NIHSS ≤5) was higher among embolic stroke vs thrombotic stroke patients, with a step-wise increase for embolic stroke patients when moving from mild (odds ratio [OR] 1.95, 95% CI 1.14-3.35) to very severe strokes (OR 4.95, 95% CI 2.34-10.48). After adjusting for atrial fibrillation, there was still a higher risk of having a worse NIHSS among embolic vs thrombotic strokes but with attenuation of effect (very severe stroke OR 3.91, 95% CI 1.76-8.67). Sex modified the association between stroke subtype and severity (embolic vs thrombotic stroke, p interaction = 0.03, per severity category, females OR 2.38, 95% CI 1.55-3.66; males OR 1.75, 95% CI 1.09-2.82). The risk of death (median follow-up 5 years, interquartile range 1-12) was also increased for embolic vs thrombotic stroke patients (hazard ratio 1.66, 95% CI 1.41-1.97).

DISCUSSION

Embolic stroke was associated with greater stroke severity at the time of the event and a higher risk of death vs thrombotic stroke, even after careful adjustment for patient-level differences.

Predicting Independence 6 and 18 Months after Ischemic Stroke Considering Differences in 12 Countries: A Secondary Analysis of the IST-3 Trial

Objectives

This study is aimed at identifying the best clinical model to predict poststroke independence at 6 and 18 months, considering sociodemographic and clinical characteristics, and then identifying differences between countries.

Methods

Data was retrieved from the International Stroke Trial 3 study. Nine clinical variables (age, gender, severity, rt-PA, living alone, atrial fibrillation, history of transient ischemic attack/stroke, and abilities to lift arms and walk) were measured immediately after the stroke and considered to predict independence at 6 and 18 months poststroke. Independence was measured using the Oxford Handicap Scale. The adequacy, predictive capacity, and discriminative capacity of the models were checked. Countries were added to the final models.

Results

At 6 months poststroke, 35.8% (n = 1088) of participants were independent, and at 18 months, this proportion decreased to 29.9% (n = 747). Both 6 and 18 months poststroke predictive models obtained fair discriminatory capacities. Gender, living alone, and rt-PA only reached predictive significance at 18 months. Poststroke patients from Poland and Sweden showed greater chances to achieve independence at 6 months compared to the UK. Poland also achieved greater chances at 18 months. Italy had worse chances than the UK at both follow-ups. Discussion. Six and eight variables predicted poststroke independence at 6 and 18 months, respectively. Some variables only reached significance at 18 months, suggesting a late influence in stroke patients' rehabilitation. Differences found between countries in achieving independence may be related to healthcare system organization or cultural characteristics, a hypothesis that must be addressed in future studies. These results can allow the development of tailored interventions to improve the outcomes.

Walking speed changes in response to novel user-driven treadmill control

Implementing user-driven treadmill control in gait training programs for rehabilitation may be an effective means of enhancing motor learning and improving functional performance. This study aimed to determine the effect of a user-driven treadmill control scheme on walking speeds, anterior ground reaction forces (AGRF), and trailing limb angles (TLA) of healthy adults. Twenty-three participants completed a 10-m overground walking task to measure their overground self-selected (SS) walking speeds. Then, they walked at their SS and fastest comfortable walking speeds on an instrumented split-belt treadmill in its fixed speed and user-driven control modes. The user-driven treadmill controller combined inertial-force, gait parameter, and position based control to adjust the treadmill belt speed in real time. Walking speeds, peak AGRF, and TLA were compared among test conditions using paired t-tests (α = 0.05). Participants chose significantly faster SS and fast walking speeds in the user-driven mode than the fixed speed mode (p > 0.05). There was no significant difference between the overground SS walking speed and the SS speed from the user-driven trials (p < 0.05). Changes in AGRF and TLA were caused primarily by changes in walking speed, not the treadmill controller. Our findings show the user-driven treadmill controller allowed participants to select walking speeds faster than their chosen speeds on the fixed speed treadmill and similar to their overground speeds. Since user-driven treadmill walking increases cognitive activity and natural mobility, these results suggest user-driven treadmill control would be a beneficial addition to current gait training programs for rehabilitation.

Effectiveness of Client-Centered "Tune-Ups" on Community Reintegration, Mobility, and Quality of Life After Stroke: A Randomized Controlled Trial

OBJECTIVE

To explore the effectiveness of a 2-week client-centered rehabilitation intervention (tune-up) delivered 6 months after inpatient discharge on community reintegration at 1 year in people with stroke.

DESIGN

A multicenter randomized controlled trial with 2 groups: an intervention ("tune-up") group and a control group having the same exposure to assessment.

SETTING

Three research laboratories.

PARTICIPANTS

Participants (N=103) with hemiparetic stroke recruited from inpatient rehabilitation units at the time of discharge.

INTERVENTIONS

Participants randomized to the tune-up group received 1-hour therapy sessions in their home 3times/wk for 2 weeks at 6 months postdischarge focusing on identified mobility-related goals. A second tune-up was provided at 12 months.

MAIN OUTCOME MEASURES

Community reintegration measured by the Subjective Index of Physical and Social Outcome at 12 months and secondary outcomes included the Berg Balance Scale and measures of mobility and health-related quality of life up to 15 months.

RESULTS

At 12 months, both groups showed significant improvement in community reintegration (P<.05), a trend evident at all time points, with no difference between groups (mean difference, -0.5; 95% confidence interval, -1.8 to 2.7; P=.68). Similarly, a main effect of time reflected improvement in mobility-related and quality of life outcomes for both groups (P≤.0.5), but no group differences (P≥.30).

CONCLUSIONS

All participants in the tune-up group met or exceeded at least 1 mobility-related goal; however, the intervention did not differentially improve community reintegration. The improvements in mobility and quality of life over the 15-month postdischarge period may be secondary to high activity levels in both study groups and exposure to regular assessment.

A five-year follow-up of stroke survivors: motorfunction and activities of daily living

At the University Hospital, Uppsala, a study was conducted to assess and follow the changes in motor activities, primary activities of daily living (ADL) and instrumental ADL over a five-year period. The functional level of 280 acute stroke patients was assessed over five years.

One year after the stroke 193 patients (68%) were alive, and after five years 113 patients (40%). Of the latter, 101 patients were assessed. During the first year after the stroke, a significant improvement was shown in all the assessed variables. However, most of the variables had deteriorated significantly between one and five years post-stroke. The activities that were best preserved were primary ADL and locomotion. The ability to perform active movements, maintain balance, walk and perform some household tasks and some psychosocial activities had declined. Five years post-stroke approximately one-quarter had substantial motor loss and one-third were moderately impaired. Three-quarters managed their primary ADL without or almost without help. Differences were found between men and women in instrumental ADL behaviour, the women showing more deterioration post-stroke. In spite of this most of the patients felt satisfied with their health and life situation.

Measurement of lower limb joint kinematics using inertial sensors during stair ascent and descent in healthy older adults and stroke survivors

This study validated the feasibility of inertial sensors in estimating lower limb joint kinematics during stair ambulation in healthy older adults and stroke survivors. Three dimensional motion data were collected using an inertial sensor-based system from 9 persons with stroke and 9 healthy older adults as they ascended and descended a staircase at a self-selected pace. The measured joint angles were compared with a laboratory-based motion capture system by computing differences in range of motion (RoM), grand mean error, standard deviation, and coefficients of multiple correlations. For stroke survivors, differences in RoM measurements between these two systems were determined to be 3.3 ± 8.1°, while the highest correlations were found in the estimation of sagittal plane joint angles after offset correction. Results suggest that the inertial sensor system is suitable for estimating major joint angles in healthy older adults as well as the RoM for stroke survivors. New calibration procedures are necessary for applying the technology to a stroke population.

Complications following incident stroke resulting in readmissions: an analysis of data from three Scottish health surveys

BACKGROUND AND AIMS

Stroke is widely recognized as the major contributor to morbidity and mortality in the United Kingdom. We analyzed the data obtained from the three consecutive Scottish Health Surveys and the Scottish Morbidity records, with the aim of identifying risk factors for, and timing of, common poststroke complications.

METHODS

There were 19434 individuals sampled during three Scottish Health Surveys in 1995, 1998, and 2001. For these individuals their morbidity and mortality outcomes were obtained in 2007. Incident stroke prevalence, risk factors for a range of poststroke complications, and average times until such complications in the sample were established.

RESULTS

Of the total of 168 incident stroke admissions (0·86% of the survey), 16·1% people died during incident stroke hospitalization. Of the remaining 141 stroke survivors, 75·2% were rehospitalized at least once. The most frequent reason for readmission after stroke was a cardiovascular complication (28·6%), median time until event 1412 days, followed by infection (17·3%, median 1591 days). The risk of cardiovascular readmission was higher in those with 'poor' self-assessed health (odds ratio 7·70; 95% confidence interval 1·64-43·27), smokers (odds ratio 4·24; 95% confidence interval 1·11-21·59), and doubled with every five years increase in age (odds ratio 1·97; 95% confidence interval 1·46-2·65). 'Poor' self-assessed health increased chance of readmission for infection (odds ratio 14·11; 95% confidence interval 2·27-276·56).

CONCLUSIONS

Cardiovascular events and infections are the most frequent poststroke complications resulting in readmissions. The time period until event provides a possibility to focus monitoring on those people at risk of readmission and introduce preventative measures, thereby reducing readmission-associated costs.

A randomized controlled trial to determine the effect of a model of restorative home care on physical function and social support among older people

OBJECTIVE

To determine the impact of a restorative model of home care on social support and physical function among community-dwelling older people.

DESIGN

Cluster-randomized controlled trial.

SETTING

Home care in an urban area.

PARTICIPANTS

Participants (N=205) were randomly assigned to an intervention group (n=108; mean age, 79.1y; 71.3% women; 81.5% New Zealand European [NZE]; 50.8% residing in areas of the highest levels of social deprivation) or a usual care group (n=97; mean age, 76.9y; 60.8% women; 73.2% NZE; 53.5% in the highest levels of social deprivation).

INTERVENTION

Participants randomly assigned to the intervention group completed a goal facilitation tool with a needs assessor to determine their needs and to establish the aims for the episode of care. Services were structured according to the principles of restorative home care (independence focused with individually tailored activity programs). Usual care participants received a standard needs assessment that informed the delivery of home care services.

MAIN OUTCOME MEASURES

Short Physical Performance Battery (SPPB), Dukes Social Support Index (DSSI).

RESULTS

There was greater change over time in physical function (measured by SPPB: F=8.30, P=.003) but no associated increase in social support (as determined by DSSI: F=2.58, P=.09).

CONCLUSIONS

Significant improvements in physical function were observed after a period of restorative home care services. The absence of an associated change in social support may have been the result of a combination of factors, including the threshold of physical function required for community ambulation, the low rate of allied health service provision, and the time required to reestablish social ties. The findings contribute to a greater understanding of factors necessary to refocus home-based services to emphasize improvements in physical function and independence.

Kinematic and kinetic evaluation of the stance phase of stair ambulation in persons with stroke and healthy adults: a pilot study

This study describes and contrasts the kinematics and kinetics of stair ambulation in people with chronic stroke and healthy control subjects. Three-dimensional motion data were collected from 10 persons with stroke (7 males) and 10 sex and age-matched older adults as they ascended and descended an instrumented staircase at self-selected speed with and without a handrail. Ankle, knee and hip joint angle and moment profiles were generated during stance and range of motion and peak moments were contrasted between groups, sides (stroke only) and condition. Cadence was lower in stroke than controls, although the kinematic profiles appeared similar during ascent and decent. Notable differences in joint kinetics were evident as the peak extensor moments were typically lower on the affected side in stroke compared with controls and the less affected side. These differences accounted for the lower magnitude net extensor support moment. The lower affected side hip abductor moments likely limited lateral stability. Handrail use tended to reduce the peak moments on the affected side only leading to more side-to-side differences than occurred without the handrail. The findings reveal differences in task performance between stroke and healthy groups that help inform rehabilitation practice.

Association of care by hospitalists on discharge destination and 30-day outcomes after acute ischemic stroke

OBJECTIVES

The use of hospitalists is increasing. Hospitalists have been associated with reductions in length of stay and associated costs while not negatively impacting outcomes. We examine care for stroke patients because it requires complex care in the hospital and has high post discharge complications. We assessed the association of care provided by a hospitalist with length of stay, discharge destination, 30-day mortality, 30-day readmission, and 30-day emergency department visits.

METHODS

This study used the 5% Medicare sample from 2002 to 2006. Models included demographic variables, prior health status, type of admission and hospital, and region. Multinomial logit models, generalized estimating equations, Cox proportional hazard models, and propensity score analyses were explored in the analysis.

RESULTS

After adjusting models for covariates, hospitalists were associated with increased odds of discharge to inpatient rehabilitation or other facilities compared with discharge home (Odds Ratio, 1.24; 95% CI, 1.07-1.43 and Odds Ratio, 1.34; 95% CI 1.05-1.69, respectively). Mean length of stay was 0.37 days lower for patients in hospitalist care compared to nonhospitalist care. This reduction in length of stay was not appreciably changed after adjusting for discharge destination. Hospitalist care was not associated with differences in 30-day emergency department use or mortality. Readmission rates were higher for patients in hospitalist care (Hazard, 1.30; 95% CI, 1.11-1.52).

CONCLUSIONS

Hospitalists are associated with reduced length of stay and higher rates of discharge to inpatient rehabilitation. The higher readmission rates should be further explored.

The relationship of physical function to social integration after stroke

Stroke is a leading cause of death and a serious long-term disability in this country. Much of the research on stroke rehabilitation has focused on physical/functional recovery as the predominant measure of outcome. There is a gap in knowledge of social issues and integration into societal, family, and community roles after stroke. A descriptive, correlational survey design was used to examine the relationships of functional status, depression, and overall stroke recovery to social integration in a convenience sample of ischemic stroke survivors. The survey response rate was 21.4%. Results showed that functional status, overall stroke recovery, and depression are highly significant predictors of social integration, explaining 62% of the variance (adjusted R2). Comorbid depression was negatively (-.74) and significantly (.01, two-tailed) correlated to social integration, such that higher levels of depression are associated with lower levels of social integration. Finally, employment status after stroke dropped from 48% to 4.2%, and poststroke employment status was correlated to social integration (significance = .03). Care for patients with chronic conditions like stroke should address all domains of the individual-physical, psychosocial, and environmental. Factors including depression and perceptions of overall stroke recovery are significant and should be addressed in the rehabilitation process to better promote social integration. Social integration is an important and understudied aspect of stroke recovery that warrants further research.

Care for patients after stroke. Results of a two-year prospective observational study from Mazowieckie province in Poland

BACKGROUND AND PURPOSE

Little has been published about different elements of the health services in long-term follow-up in the countries of Central and Eastern Europe. The aim of this study was to explore the health services for stroke patients in Poland.

MATERIAL AND METHODS

Patients from 3 centres representing different levels of stroke care organization from Mazowieckie province were included. Data on first-ever stroke patients with "onset-to-door" time no longer than 7 days, consecutively admitted to participating centres between March 1 and June 30, 2002 were collected prospectively. Patients were assessed on admission, on discharge and 3, 6, 12, 18, and 24 months after discharge. Type of care, rehabilitation, readmissions, consultations and diagnostic procedures were evaluated.

RESULTS

One hundred and sixty-four patients with first-ever stroke were included. Twenty-one patients died during hospitalization, and 36 during the two-year follow-up. Most patients were discharged home, under family care. The total rate of readmission decreased over time, from 58% to 11%, and so did the rate of rehabilitation, from 41.5% to 15%. All patients had been seen by their general practitioners and neurologists.

CONCLUSIONS

Post-stroke care is provided mostly by family members. Access to rehabilitation is limited and decreases over time. This study could help the authorities in healthcare budget allocation in Poland.

A comparison of gait biomechanics and metabolic requirements of overground and treadmill walking in people with stroke

BACKGROUND

Comparisons of treadmill and overground walking following stroke indicate that symmetry in temporal-distance measures is better on the treadmill suggestive of better gait economy. We examined this issue by examining the kinematic, kinetic and metabolic demands associated with overground and treadmill walking at matched speeds and also explored the effect of increasing treadmill speed.

METHODS

Ten people with hemiparesis walked overground at their preferred speed which was matched on the treadmill. Belt speed was then increased 10% and 20% above preferred speed. Temporal-distance outcomes, angular kinematics and vertical ground reaction forces were recorded during steady state (stable heart rate and oxygen uptake).

FINDINGS

Step and stance times were longer when walking overground but the degree of symmetry was comparable for both surfaces. In contrast kinematic data revealed significant interlimb asymmetry with respect to all lower limb joint excursions during overground walking accompanied by higher vertical ground reaction forces at push-off. The metabolic demands, however, were lower when walking overground than on the treadmill. Increasing the belt speed increased angular displacements and the vertical forces associated with both limbs such that symmetry remained unchanged. Metabolic demands increased significantly.

INTERPRETATION

People with stroke adopt a more symmetrical kinematic walking pattern on the treadmill which is maintained at faster belt speeds. Surprisingly, at matched speed the metabolic cost was significantly higher with treadmill walking. We suggest further research to explore whether an increased reliance on the hip musculature to compensate lower push-off forces could explain the higher the energy cost.

Motor function and joint position sense in relation to gait performance in chronic stroke patients

OBJECTIVES

To determine the association between joint position sense (JPS) and motor function of the lower extremity and gait performance of patients with chronic stroke.

DESIGN

Single-group cross-sectional design.

SETTING

University gait laboratory.

PARTICIPANTS

Twenty-one patients with stroke onset of more than 6 months.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The isometric strength, Fugl-Meyer Assessment (FMA) motor status, and JPS of the lower extremity were tested. Spatiotemporal gait characteristics were measured using a 6-camera motion analysis system, with patients walking at their comfortable speeds while using their usual devices.

RESULTS

Lower-extremity muscle strength and FMA motor score correlated significantly with the spatiotemporal characteristics of gait and contributed significantly to the variance in gait velocity, stride length, and double-stance time. The JPS was not related to gait performance, except that the ankle JPS contributed significantly to the variance in gait velocity and stride length.

CONCLUSIONS

For patients with chronic stroke, motor function was significantly related to gait performance. Although the JPS was not, that of the ankle joint made a significant contribution. When enhancing gait performance is desired, improving the motor function is recommended, and the role of JPS should also be taken into consideration.

Association of physical functioning with same-hospital readmission after stroke

OBJECTIVE

Readmission after hospitalization for stroke is an important outcome. We sought to document the frequency of same-hospital readmission and to determine the relative value of physical functioning as a predictor of the outcome.

DESIGN

Consenting patients (n = 228) who were admitted for ischemic stroke were characterized according to demographics, stroke severity, and self-reported prestroke and postadmission physical functioning. The hospital's administrative database was used to track readmissions during the year after index hospitalization.

RESULTS

Same-hospital readmissions were experienced by 37.3% of the patients. The readmissions usually occurred within 100 days of discharge. The most common readmission diagnosis was stroke (14.1%). Lower prestroke and postadmission physical functioning (as reflected by dichotomous Barthel index scores) were weak but significant predictors of readmission (r = -0.165 and -0.268, respectively). Regression analysis showed that once postadmission physical functioning was accounted for, neither prestroke functioning nor any other measured variable added to the explanation of same-hospital readmission.

CONCLUSION

The importance of physical functioning goes beyond rehabilitation. It is a potentially modifiable variable with implications for readmission.

Evolution of the caregiving experience in the initial 2 years following stroke

Relationships between stroke survivor and family caregiver factors and the caregiver's health-related quality of life (HRQL) and overall quality of life (QoL) were examined in 97 dyads during the first and second years after stroke. Compared to age- and sex-matched population norms, caregivers scored significantly lower on the mental subscales of HRQL, and differences were greater for women than for men. Caregiver characteristics (older age, less burden, and fewer physical symptoms) were associated with better HRQL (mental summary scale) in the first year, with similar findings in the second year. Moderate stroke survivor physical impairment and caregiver characteristics (younger age and better HRQL) were associated with better QoL in the first year. During the second year poorer caregiver physical and mental health and caring for a stroke survivor with communication difficulties were associated with diminished QoL.

Comparison of changes in upper and lower extremity impairments and disabilities after stroke

The aims of this study were to determine if the changes in impairment and disability measures for the upper and lower extremities were equivalent during the post-stroke rehabilitation period and whether the rates of change were maintained 6 months after discharge from rehabilitation. A prospective cohort study design was used. One-hundred-and-thirty-two people who had sustained a stroke and who were enrolled in an intensive functional rehabilitation programme were recruited. Upper and lower extremity impairments and disabilities were evaluated at admission, at discharge from rehabilitation and 6 months later. During active rehabilitation, the changes in both extremities were smaller for the impairment measures (standardized response mean (SRM), 0.37-0.63) than the disability measures (SRM, 0.76-1.05). While the changes in upper and lower extremities were equivalent for impairment measures, they were larger in the lower extremity for disability measures, indicating that the rate of functional improvement was faster in the lower extremity during active rehabilitation. After discharge, however, while the rate of motor recovery in the lower extremity dropped (SRM, 0.54-0.18), it was maintained in the upper extremity (SRM, 0.45 and 0.42). Present findings indicate that functional (disability) measures improve faster than impairment measures in both extremities during the active rehabilitation period and suggest that motor recovery occurs at a different rate in the upper and lower extremities, with that of the upper extremity occurring later and extending into the period after discharge from active rehabilitation.

Activity, participation, and quality of life 6 months poststroke

OBJECTIVES

To estimate the extent of activity and participation of individuals 6 months poststroke and their influence on health-related quality of life (QOL) and overall QOL, information that would be useful in identifying services that stroke patients would need in the community.

DESIGN

Inception cohort study.

SETTING

Ten acute care hospitals in metropolitan areas of the province of Quebec.

PARTICIPANTS

Persons with first-ever stroke, either ischemic or hemorrhagic. In parallel, a population-based sample of community-dwelling individuals without stroke, frequency matched in age and city district, were also recruited.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Stroke subjects were interviewed by telephone at 6-month intervals for 2 years of follow-up. The community-dwelling individuals without stroke were also followed.

RESULTS

A total of 434 persons were interviewed approximately 6 months poststroke. Their average age +/- standard deviation was 68.4+/-12.5 years; the average age of the 486 controls was 61.7+/-12.4 years. The stroke group scored on average 90.6/100 on the Barthel Index; 39% reported a limitation in functional activities, 54% reported limitations with higher-level activities of daily living such as housework and shopping, and 65% reported restrictions in reintegration into community activities. By using the Medical Outcomes 36-Item Short-Form Health Survey (SF-36), persons with stroke rated their physical health 7 points lower than healthy peers; also, 7 of the 8 subscales of the SF-36 were affected by stroke.

CONCLUSION

Almost 50% of the community-dwelling stroke population lived with sequelae of stroke such that, unless there was a full-time and able-bodied caregiver at home, they needed some form of home help. A large proportion also reported lack of meaningful activity, indicating a need for organized support groups for people with stroke; otherwise, boredom will lead to depression and worsening of function, affect, health status, and QOL.

Development of a new mobility scale for people living in the community after stroke: content validity

Mobility inside and outside the home, and in the community, is important to independence of lifestyle after stroke. Existing measures lack content validity relating to these three environments. The aim of this study was to contribute to the content validity phase of developing a new scale for assessing mobility of people with stroke in these settings. An open-ended questionnaire was used to obtain responses from 15 physiotherapists with substantial experience in neurological physiotherapy. Responses were coded to provide a comprehensive list of tasks and destinations. A wide range of destinations was identified for i) inside the home: bedroom, bathroom/toilet, living room, kitchen; ii) outside the home: access to and from property, outside buildings, clothes line, garden and letterbox; iii) in the community: access to health and shopping facilities, leisure sites and public transport. Although a diverse range of tasks was identified, a common theme emerged to emphasise the impact of the environment on mobility. Responses were recorded in all dimensions of a recently published conceptual model of mobility that focused on environment. These dimensions included distance, time constraints, ambient conditions, terrain characteristics, external physical load, attentional demands, postural transitions and traffic level. Further work is required to quantify environmental dimensions which are relevant to the destinations identified in the three environmental settings of this study.

Characteristics of persons rehospitalized after stroke rehabilitation

OBJECTIVE

To develop classification models for risk of hospital readmission 80 to 180 days after discharge based the demographic and functional characteristics of persons discharged from acute inpatient rehabilitation after stroke.

DESIGN

Retrospective, using information from US facilities subscribing to the Uniform Data System for Medical Rehabilitation (UDS(MR)).

SETTING

Information submitted to the UDS(MR) from 1994 through 1996 by 167 hospital and rehabilitation facilities from 40 states was examined.

PARTICIPANTS

A total of 15,992 records of patients (mean age +/- standard deviation, 70.97 +/- 12.19yr) with a diagnosis of stroke were included in the final sample. The sample included 52.7% women and was 80% non-Hispanic white with an average length of stay (LOS) of 25.31 +/- 14.72 days.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Six subscales of the FIM instrument (self-care, sphincter control, transfers, locomotion, communication, social cognition), total FIM, and other predictor variables for regression analysis (gender, age, ethnicity, marital status, prehospital living setting, LOS, primary payer source, level of function-related group).

RESULTS

A logistic regression model included the following statistically significant variables (p <.05): ethnicity, sphincter control, self-care ability, gender, and LOS. The greatest variability occurred among men. Exactly 18.1% of non-Hispanic white men and 17.9% of African-American men were rehospitalized. In contrast, only 10.1% of Hispanic men and 11.4% of Asian men were rehospitalized. The odds of rehospitalization were lowest for Hispanic men.

CONCLUSION

As prospective payment systems are introduced for postacute care, it is important that the relationship among functional abilities, demographic characteristics, and incidence of hospital readmission following medical rehabilitation be examined.

Mobility status after inpatient stroke rehabilitation: 1-year follow-up and prognostic factors

OBJECTIVES

To evaluate the stability of mobility status achieved by stroke patients during hospital rehabilitation treatment over time and to identify reliable prognostic factors associated with mobility changes.

DESIGN

Follow-up evaluation in consecutive first-ever stroke patients 1 year after hospital discharge. Multiple logistic regressions were used to analyze increases and decreases in Rivermead Mobility Index (RMI) scores (dependent variables) between discharge and follow-up. Independent variables were medical, demographic, and social factors.

SETTING

Rehabilitation hospital.

PATIENTS

A cohort of 155 patients with sequelae of first stroke, with a final sample of 141.

MAIN OUTCOME MEASURES

Mobility status at 1-year follow-up, as measured by the RMI, and odds ratios (OR) for improvement and decline in mobility.

RESULTS

Functionally, 19.9% improved the mobility levels achieved during the inpatient rehabilitation treatment; levels of 42.6% worsened. Patients with global aphasia (OR = 5.66; 95% confidence interval [CI], 1.50-21.33), unilateral neglect (OR = 3.01; 95% CI, 1.21-7.50), and age 75 years or older (OR = 5.77; 95% CI, 1.42-23.34) had a higher probability of mobility decline than the remaining patients. Postdischarge rehabilitation treatment (PDT), received by 52.5% of the final sample, was significantly and positively associated with mobility improvement (OR = 5.86; 95% CI, 2.02-17.00). Absence of PDT was associated with a decline in mobility (OR = 3.73; 95% CI, 1.73-8.04).

CONCLUSIONS

In most cases, mobility status had not yet stabilized at hospital discharge. PDT was useful in preventing a deterioration in mobility improvement achieved during inpatient treatment and in helping increase the likelihood of further mobility improvement.

Investigating recovery from stroke: a qualitative study

A recent randomized controlled trial evaluated the effects of specialist nurses providing information, advice and support to caregivers and patients at home during the first year after a stroke. Reported here are the results of a complementary study which used qualitative methods to examine the experience of patients and caregivers during the year of recovery after a stroke. We used semi-structured interviews with a purposively selected sample of 30 patients and 15 caregivers at the end of a randomized controlled trial (13-16 months post-stroke). Patients and caregivers provided vivid descriptions of the recovery process. Recovery was perceived in terms of the degree of congruence patients identified between their lives before, and after, stroke. Patients therefore had individual and personal yardsticks for measuring their recovery. In conclusion, further research and interventions must consider the diverse, complex, dynamic and highly personal character of stroke recovery. Traditional outcome measures are too simplistic to capture patients' and caregivers' experiences. There do not appear to be single or simple solutions to the problems of facilitating psycho-social adjustment.

Age specific prevalence of impairment and disability relating to hemiplegic stroke in the Hai District of northern Tanzania. Adult Morbidity and Mortality Project

OBJECTIVES

To determine the age specific prevalence of impairment and disability relating to hemiplegic stroke in one rural area of Tanzania.

METHODS

During the yearly house to house census of the study population of 148 135 (85 152 aged 15 and over) in August 1994, specific questions were asked to identify those who might be disabled from stroke. People thus identified were subsequently interviewed and examined by one investigator. In those in whom the clinical diagnosis of stroke was confirmed a more detailed interview and examination relating to risk factors and recovery was carried out.

RESULTS

One hundred and eight patients, 61 men and 47 women, were identified with a median age of 70 (range 18-100). Median age at first stroke was 65 years. The age specific rates in this study were lower than previous studies in developed countries. All were cared for at home although 23 (21%) were bedbound.

CONCLUSIONS

Although prevalence of impairment and disability related to stroke in this population as a whole was low this is mainly explained by the age structure, with less than 6% being aged 65 and over. Age standardised rates for stroke with residual disability were about half those found in previous studies in developed countries. Death from stroke in Africa may be higher but data are limited. With the demographic transition stroke is likely to become a more important cause of disability in sub-Saharan Africa.

Unpacking the 'black box' of a nurse-led stroke support service

OBJECTIVES

To describe in detail the nature of the specialist nurse interventions; to increase understanding of the principal problems facing stroke patients and their care-givers in the first year following stroke and to demonstrate how these problems may change over time; and to investigate the value of qualitative research methodologies within the context of a randomized trial.

METHODS

Specialist nurses providing support in the year following stroke were asked to maintain comprehensive written records of their involvement with all patients and care-givers participating in a randomized controlled trial. Qualitative methods were used to examine the problems faced by stroke patients and their care-givers, and the actions taken by nurses in response.

RESULTS

Specialist nurses commenced 120 records. As 19 patients died or left the area during the year-long interventions, we obtained 101 complete records. The problems encountered by stroke patients and their care-givers were numerous, diverse, complex and changed over time. Initially, practical difficulties were noted; over time, these were accompanied by growing numbers of psychological needs. The nurses responded by providing information, advice, support and monitoring using a flexible, individualized approach. The nurses also collaborated or liaised with 17 other professional groups and provided direct support to care-givers.

CONCLUSION

The need for many stroke patients and their care-givers to be professionally supported during the stages of stroke adjustment, for at least the first year and probably beyond, was emphasized by this study.

Accuracy of physical and occupational therapists' early predictions of recovery after severe middle cerebral artery stroke

INTRODUCTION

The ability of physical therapists (PTs) and occupational therapists (OTs) to predict level of outcome accurately was investigated prospectively in 91 severely disabled stroke patients with a first-ever middle cerebral artery (MCA) stroke.

METHODS

Within the second and fifth week after stroke onset, 364 predictions were made by 59 PTs and 47 OTs about walking ability, dexterity, activities of daily living (ADL), need for additional care in ADL, time required to achieve independent walking ability and maximal level of ADL, and destination of discharge at six months after stroke. The functional recovery patterns of stroke patients were assessed by an independent observer. The accuracy of the therapists' predictions was compared with that of derived prediction models. In addition, the influence of characteristics of patients and therapists on the accuracy of the predictions was investigated.

RESULTS

Compared to observed outcomes at six months after stroke, therapists' lowest accuracies of prediction were found for the moment at which maximal ADL score was achieved (rs = 0.07; p = NS), and highest accuracy was for level of dexterity of the hemiplegic arm (rs = 0.78; p <0.01). Therapists' predictions of functional outcome at six months tended to be too pessimistic. No significant differences were observed for dexterity and walking ability when the predictions by PTs and OTs were compared with those of regression models, whereas significant differences were found for the accuracies of OTs' and PTs' first prediction of destination of discharge and second predictions of outcome in ADL and need for additional care in ADL. No significant differences were found between the accuracy of PTs' and OTs' predictions, and their ability to predict functional outcome was not significantly influenced by the characteristics of patient and therapists.

CONCLUSIONS

At two and five weeks after stroke, OTs and PTs can accurately predict level of walking ability and dexterity at six months. The prediction of time required for achieving maximal level of recovery, destination of discharge, outcome of ADL as well as need for additional care in ADL leaves room for improvement.

Etiology and incidence of rehospitalization after traumatic brain injury: a multicenter analysis

OBJECTIVE

To investigate incidence and etiology of rehospitalizations at 1, 2, and 3 years after traumatic brain injury.

DESIGN

Descriptive statistics were computed in a prospective study of etiology and incidence of rehospitalization at years 1, 2, and 3 postinjury. Analysis of variance (ANOVA) and chi2 were used to identify factors relating to rehospitalization; factors included length of stay, admission and discharge functional status, payer source, medical complications, injury severity, and demographics.

SETTING

Four medical centers in the federally sponsored Traumatic Brain Injury Model Systems. In each setting, the continuum of care includes emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services.

PARTICIPANTS

Six hundred sixty-five rehabilitation patients admitted to acute care within 24 hours of traumatic brain injury between 1989 and 1996.

MAIN OUTCOME MEASURES

Annual incidence and etiology of rehospitalization.

RESULTS

The annual incidence of rehospitalization ranged from 20% to 22.5%. Approximately half the rehospitalizations were for elective reasons. The most common reason for rehospitalization was for orthopedic or reconstructive surgery, followed by infectious disorders and general health maintenance. After the first year, the incidence of readmissions for seizures and psychiatric difficulties increased substantially. ANOVA and chi2 analyses were performed on data from the first year postinjury. No statistically significant associations were noted between incidence and etiology of rehospitalization and: demographics; injury severity; payer source for rehabilitation; concurrent injuries; acute care and rehabilitation length of stays; discharge Functional Assessment Measure; and discharge residence (p > .05).

CONCLUSIONS

There is a relatively stable but high rate of rehospitalization for at least 3 years after injury. The costs of rehospitalization should be considered when evaluating the long-term consequences of injury.

Rehabilitation needs of community stroke patients

PURPOSE

The aim was to identify stroke patients not admitted to hospital, to assess their disabilities and the rehabilitation provided.

METHOD

Stroke patients were notified by General Practitioners, assessed a month after stroke on measures of impairment and disability and the rehabilitation received was recorded. There were 124 patients notified and 93 assessed.

RESULTS

Patients showed an average decline of 1.7 on the Barthel Index and 3.6 on the Extended Activities of Daily Living scale from before to after stroke. There were 27% with severe mobility problems and 47% with clinically relevant arm impairment. Many patients had cognitive impairment with only 9% having no deficit. Mood problems were less common with 26% anxious and 13% depressed. Significant stress occurred in 15% of carers. The provision of rehabilitation was low and there was poor correspondence between impairments and services provided.

CONCLUSION

There is an unmet potential for rehabilitation in stroke patients not admitted to hospital.

A qualitative study of specialist nurse support for stroke patients and care-givers at home

BACKGROUND

The involvement of five specialist nurses in providing a stroke support service was evaluated quantitatively in a recent randomized controlled trial. This complementary study used qualitative methods to evaluate trial outcomes more comprehensively.

AIMS

To identify whether the nurses' intervention may have influenced the process of stroke recovery.

METHOD

A purposefully selected subsample of 30 patients and 15 care-givers were interviewed within 1-3 months of their final quantitative assessment (12 months after recruitment to the randomized trial). Fifteen of the patients and eight of the care-givers had received visits from a specialist nurse. A semistructured interview was designed to include questions on perceptions of the recovery process and evaluation of services received.

RESULTS

Some differences were evident between the accounts of control and intervention group subjects. The less tangible aspects of nurses' interventions--concern, attention, empathy and interest, when combined with sound professional knowledge, had identifiable value to the patients and care-givers. It appeared that the nurses had employed considerable sensitivity and skill in identifying and responding to particular needs at appropriate times.

CONCLUSION

The qualitative evaluation offers a different picture to the quantitative results of the randomized controlled trial. In general, the findings of the qualitative study are more positive and encouraging than the quantitative results. The majority of patients and care-givers in the intervention group believed that they had benefited from the specialist nurse's visits.

Post-stroke inpatient rehabilitation. II. Predicting discharge disposition

This study was undertaken to identify indicators that predict discharge disposition after an acute stroke rehabilitation program. A cohort of 152 incident cases suffering from stroke (76 women and 76 men) voluntarily participated in this study. They were recruited from a general hospital in which they were participating in a rehabilitation program. Post-stroke biologic, sociodemographic, and psychosocial characteristics were considered in our analyses. A polychotomous nominal logistic regression analysis was used to predict inpatient rehabilitation discharge disposition. The three discharge disposition categories were (1) private home, (2) rehabilitation center, and (3) long-term care facility. Significant predictors related to the discharge toward a rehabilitation center were functional status at admission, presence of social support, and gait status. Significant predictors for discharge to a long-term care facility were functional status at admission, presence of social support, gait status, and presence of medical complications. Functional status measured on rehabilitation admission should be considered, in conjunction with the patient's social support, gait status, and presence of medical complications, to be predictive of post-stroke rehabilitation discharge disposition.

Specialist nurse support for patients with stroke in the community: a randomised controlled trial

OBJECTIVE

To evaluate whether specialist nurse visits enhance the social integration and perceived health of patients with stroke or alleviate stress in carers in longer term stroke care.

DESIGN

Stratified randomised controlled trial; both groups assessed at time of recruitment and at 3, 6, and 12 months.

SETTING

Patients with disability related to new stroke who lived in their own homes in the Bradford Metropolitan District.

SUBJECTS

240 patients aged 60 years or over, randomly allocated to control group (n = 120) or intervention group (n = 120). Intervention--Visits by specialist outreach nurses over 12 months to provide information, advice, and support; minimum of six visits during the first six months. The control group received no visits.

MAIN OUTCOME MEASURES

The Barthel index (functional ability), the Frenchay activities index (social activity), the Nottingham health profile (perceived health status). Stress among carers was indicated by the general health questionnaire-28 (28 items). The nurses recorded their interventions in trial diaries.

RESULTS

There were no significant differences in perceived health, social activities, or stress among carers between the treatment and control groups at any of the assessments points. A subgroup of mildly disabled patients with stroke (Barthel index 15-19) had an improved social outcome at six months (Frenchay activities index, Median difference 3 (95% confidence interval 0 to 6; P = 0.03) and for the full 12 months of follow up (analysis of covariance P = 0.01) compared with the control group.

CONCLUSIONS

The specialist nurse intervention resulted in a small improvement in social activities only for the mildly disabled patients. No proved strategy yet exists that can be recommended to address the psychosocial difficulties of patients with stroke and their families.

Multidisciplinary rehabilitation versus medical care: a meta-analysis

Research studies in physical medicine have not demonstrated the effectiveness of inpatient rehabilitation services, primarily due to differences in methodological approaches which have led to inconsistent findings. Because of differing inclusion and outcome criteria, even meta-analyses have been inconclusive. To address this problem, research literature comparing the clinical effectiveness of rehabilitation programs with medical care was evaluated for three uniformly available outcome criteria: survival; functional ability; and discharge location. Published trials were obtained from citations in Index Medicus (Medicine) and Nursing and Allied Health Abstracts covering the recent 20 year period from 1974 to 1994. We used meta-analyses to test the hypotheses that specialized rehabilitative care (vs conventional medical care) improves health outcomes. Results of our meta-analyses indicated that rehabilitation services were significantly associated with better rates of survival and improved function during hospital stay (P < 0.01), but significance was not observed at follow-up. Also, rehabilitation patients returned to their homes and remained there more frequently than controls (P < 0.001). We concluded that patients who participate in inpatient rehabilitation programs function better at hospital discharge, have a better chance of short term survival, and return home more frequently than non-participants. However, long term survival and function were the same for experimental and control subjects. The sustaining benefit of returning home may suffice to justify the provision of inpatient rehabilitation. However, the lack of other long term benefits suggests that services may need to be continued at home or in subacute care settings to optimize their effectiveness.(ABSTRACT TRUNCATED AT 250 WORDS)

Stroke outcome in elderly people living alone

We prospectively followed 178 elderly people living alone prior to stroke who survived at least 30 days. At the time of hospital discharge and at months 2, 6 and 12 post-stroke one-third of survivors were living alone and half were living at home, either alone or with another person. Seventy-five per cent of survivors discharged to live alone were still living alone 6 months after stroke. Subjects discharged to live alone did not differ from other subjects with respect to age, gender or pre-stroke Barthel ADL score. The group discharged to live alone had less severe stroke deficits and higher ADL scores 1 week after stroke. This difference in ADL scores was maintained at hospital discharge and maximal recovery. Eleven variables were significant univariate predictors of discharge home to live alone. In multivariate models the strongest predictors of discharge home to live alone were high Barthel ADL score at day 7, high Mini-Mental State Score, high leg power and absence of homonymous hemianopia.

Rehabilitation of the elderly patient with stroke: an analysis of short-term and long-term results

All 104 patients, aged 65 years and older, admitted to our rehabilitation unit during the years 1984-1987 were studied. It was the objective to get data on the extent of hospital care, functional outcome and the situation of living 2-5 years after discharge. During inpatient rehabilitation, an equal improvement in activities of daily living (ADL) for patients 65-74 years of age as well as for patients older than 75 years was found. In spite of these findings, older patients had to be discharged to institutional care more often than younger patients. Furthermore, the old patient group had a greater drop of functional abilities at the time of follow-up than the young patient group. Of the 86 patients originally returning home, 84% were still living at home or had been living at home when death occurred, whereas only 16% had been admitted to institutional care during the follow-up period. At the time of follow-up, two-thirds of the surviving patients assessed their health status as equal or improved, compared with the time of discharge. In our patients, deterioration of health status was predominantly due to causes other than the original stroke.

Long-term prognosis of ischemic stroke in young adults

Prognostic information is provided for 74 young adults (age 16-40 yrs, mean age at stroke 29.5 yrs), who suffered from ischemic stroke and survived the first month after the stroke. The patients were followed for 13-26 yrs; in total for 1190 yrs after their stroke. At follow-up 12 of the patients were dead, mostly from severe underlying disease that was complicated by ischemic stroke. In 3 cases death was unrelated to cerebrovascular disease. Among the surviving 62 patients, 7 had experienced recurrent ischemic events (3 reinfarctions, 4 TIA:s). These 7 patients all had risk factors for cerebrovascular complications already at the time of their primary stroke. It is concluded that the long-term prognosis for ischemic stroke in the young adult is favourable. The recovery from neurological deficits is usually good (exceptions are occlusions within the internal carotid and middle cerebral arteries), the risk for recurrence is low (1.1-1.2% annually), and the social prognosis with respect to working capacity and family relation is fair.