Functional outcome of hemorrhagic and nonhemorrhagic stroke patients after in-patient rehabilitation

Effects of intensity of rehabilitation after stroke. A research synthesis

BACKGROUND AND PURPOSE

A research synthesis was performed to (1) critically review controlled studies evaluating effects of different intensities of stroke rehabilitation in terms of disabilities and impairments and (2) quantify patterns by calculating summary effect sizes. The influences of organizational setting of rehabilitation management, blind recording, and amount of rehabilitation on the summary effect sizes were calculated.

METHODS

A Medline literature search was performed for a critical review of the literature. The internal and external validity of the studies was evaluated. In addition, a meta-analysis was performed by applying the fixed (Hedges's g) effects model.

RESULTS

The effects of different intensities of rehabilitation were studied in nine controlled studies involving 1051 patients. Analysis of the methodological quality revealed scores varying from 14% to 47% of the maximum feasible score. Meta-analysis demonstrated a statistically significant summary effect size for activities of daily living (0.28 +/- 0.12). Lower summary effect sizes (0.19 +/- 0.17) were found for studies in which experimental and control groups were treated in the same setting compared with studies in which the two groups of patients were treated in different settings (0.40 +/- 0.19). Variables defined on a neuromuscular level (0.37 +/- 0.24) showed larger summary effect sizes than variables defined on a functional level (0.10 +/- 0.21). Weighting individual effect sizes for the difference in amount of rehabilitation between experimental and control groups resulted in larger summary effect sizes for activities of daily living and functional outcome parameters for studies that were not confounded by organizational setting.

CONCLUSIONS

A small but statistically significant intensity-effect relationship in the rehabilitation of stroke patients was found. Insufficient contrast in the amount of rehabilitation between experimental and control conditions, organizational setting of rehabilitation management, lack of blinding procedures, and heterogeneity of patient characteristics were major confounding factors.

Functional measures of first-stroke rehabilitation inpatients: usefulness of the Functional Independence Measure total score with a clinical rationale

OBJECTIVE

The Functional Independence Measure (FIM) was used to measure function in first-stroke patients on admission to and discharge from a rehabilitation center, and to determine gain; all data were analyzed by a clinically oriented approach.

DESIGN

All patients admitted after a first supratentorial stroke to a comprehensive rehabilitation facility over a 2-year period were examined prospectively with the FIM. Diagnosis was determined by neuroimaging. Data were collected continuously and stored in the departmental database. For analysis of data, the patients were divided by side of lesion (right or left hemisphere), main clinical syndrome (presence or absence of neglect or aphasic syndromes in those with damage to the right or left hemisphere, respectively), type of lesion (ischemic, hemorrhagic, etc), and site of lesion (cortical or subcortical).

SETTING

Neurological rehabilitation ward.

PATIENTS

The study population included 151 patients of average age 60.8 years; 60% were men. All were admitted an average of 28.9 days after stroke and rehabilitated for 109.3 days.

MAIN OUTCOME MEASURE

The raw FIM total score was determined at 48 to 72 hours after admission and at discharge. FIM gain was calculated by subtracting the FIM discharge score from the FIM admission score for each individual. Length of stay was also recorded.

RESULTS

There was no difference in average total FIM scores when patients were divided by side of damage (right or left hemisphere). Significant findings were obtained for the various parameters when the clinical criterion was applied. Patients with neglect or aphasia syndromes showed significantly higher gains despite their lower FIM admission scores, but they had a much longer in-hospital stay.

CONCLUSION

The raw FIM total score is a simple, practical, and efficient measure of function in first-stroke patients on admission for rehabilitation, provided an appropriate clinical approach is used during data analysis. Results can be used for comparison with similar measures, determination of admission and discharge policy, and program evaluation. The presence of neglect and aphasic syndromes has a significant effect on the various measures. Length of stay in rehabilitation is also of paramount importance in stroke patients with special clinical syndromes.