A longitudinal study investigating how stroke severity, disability, and physical function the first week post-stroke are associated with walking speed six months post-stroke

Cutoff values of motor and cognitive measures for predicting and discriminating levels of activities of daily living after stroke: a scoping review

The various assessments performed by rehabilitation professionals not only indicate the patient's current functional status but can also help determine the future status (prediction) or the ability to perform untested tasks (discrimination). In particular, the cutoff values are the simplest predictive and discriminative tool that can be widely used in clinical practice. The purpose of this scoping review was to summarize the current literature on cutoff values of motor and cognitive function for predicting or discriminating levels of activities of daily living after stroke. A literature search was conducted using the PubMed, CINAHL, and Scopus databases. The creation of the search criteria, primary screening of titles and abstract, and secondary screening by full-text review were performed by two rehabilitation professionals. A total of 54 articles were included. The summary of the cutoff values for prediction based on longitudinal studies revealed that an NIHSS score ≤8 and mRMI score ≥19 at acute hospitalization can predict good functional independence and walking independence, respectively, indicating reliable cutoff values. Cutoff values for predicting specific ADLs, such as toilet use or dressing, were not reported, which was a potential research gap identified in this review. Alternatively, the summary of the cutoff values for discrimination based on cross-sectional studies revealed that 288-367.5 m on the 6-min walk test and 25.5-27.6 points on the FMA-LL can discriminate community and noncommunity walkers. Considering the difference between prediction and discrimination, the reliable predicted cutoff values revealed in this review are useful for planning an intervention based on early prediction. Conversely, cutoff values for discrimination can estimate different performances with simpler test, or use as target values during rehabilitation.

R3-Walk and R6-Walk, Simple Clinical Equations to Accurately Predict Independent Walking at 3 and 6 Months After Stroke: A Prospective, Cohort Study

OBJECTIVE

To investigate if independent walking at 3 and 6 months poststroke can be accurately predicted within the first 72 hours, based on simple clinical bedside tests.

DESIGN

Prospective observational cohort study with 3-time measurements: immediately after stroke, and 3 and 6 months poststroke.

SETTING

Public hospital.

PARTICIPANTS

Adults with first-ever stroke evaluated at 3 (N=263) and 6 (N=212) months poststroke.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

The outcome of interest was independent walking at 3 and 6 months after stroke. Predictors were age, walking ability, lower limb strength, motor recovery, spatial neglect, continence, and independence in activities of daily living.

RESULTS

The equation for predicting walking 3 months poststroke was 3.040 + (0.283 × FAC baseline) + (0.021 × Modified Barthel Index), and for predicting walking 6 months poststroke was 3.644 + (-0.014 × age) + (0.014 × Modified Barthel Index). For walking ability 3 months after stroke, sensitivity was classified as high (91%; 95% CI: 81-96), specificity was moderate (57%; 95% CI: 45-69), positive predictive value was high (76%; 95% CI: 64-86), and negative predictive value was high (80%; 95% CI: 60-93). For walking ability 6 months after stroke, sensitivity was classified as moderate (54%; 95% CI: 47-61), specificity was high (81%; 95% CI: 61-92), positive predictive value was high (87%; 95% CI: 70-96), and negative predictive value was low (42%; 95% CI: 50-73).

CONCLUSIONS

This study provided 2 simple equations that predict walking ability 3 and 6 months after stroke. This represents an important step to accurately identify individuals, who are at high risk of walking dependence early after stroke.

Longitudinal changes in trunk acceleration and their relationship with gait parameters in post-stroke hemiplegic patients

OBJECTIVE

The purpose of this study was to examine the longitudinal changes in trunk acceleration, gait speed, and paretic leg motion in patients with post-stroke hemiparesis, the relationships between variables at each time point, and whether initial trunk acceleration and gait parameters were related to gait speed 2 months later.

METHODS

Gait was assessed monthly in patients who could walk under supervision after stroke onset. Gait parameters, including gait speed and trailing limb angle (TLA), were measured. Trunk acceleration was quantified using acceleration root mean square (RMS) and stride regularity (SR) indices.

RESULTS

This study found statistically significant longitudinal changes in gait speed (p < .001), acceleration RMS of the total axes (p < .001), and SR of the vertical axes (p < .001). Gait speed correlated significantly with the acceleration RMS of the mediolateral (r = -0.815 to -0.901), vertical (r = -0.541 to -0.747), and anteroposterior (r = -0.718 to -0.829) axes, as well as the SR of the vertical axes (r = 0.558 to 0.724) at all time points from T0 to T2. For the TLA, only the acceleration RMS of the mediolateral axis correlated significantly over the entire study period (r = -0.530 to -0.724). In addition, initial TLA correlated significantly with gait speed after 2 months (r = -0.572).

CONCLUSION

This study showed that assessing trunk acceleration helps estimate the improvement in gait status in patients with post-stroke hemiparesis. The magnitude and regularity of trunk acceleration varied longitudinally and were related to gait speed and paretic leg motion at each time point; however, they could not predict future changes in gait speed.

The 5-STS is a prognostic factor of sub-acute stroke patients who will not become community walkers at discharge from rehabilitation

BACKGROUND

The recovery of community ambulation is a common concern among individuals after stroke.

OBJECTIVES

(1) To develop a potential readily applicable prognostic model able to correctly discriminate stroke patients who will not become independent community walkers at discharge; (2) To investigate the effects of early reassessment during the first month of treatment on the prediction accuracy of this model.

METHODS

This was a prospective cohort study. A consecutive sample of 80 patients at ≤60 days poststroke were assessed at baseline of outpatient physical rehabilitation and reassessed one month later. Non-functional community ambulation was measured.

RESULTS

Seventy-four patients were followed until discharge. Of these, 47 patients were non-functional community walkers at discharge. A prediction model based on baseline performance in the five repetition sit-to-stand [5-STS] test was able to discriminate those patients of the sample (Area-under-curve = 0.956), and again with data from reassessment (AUC = 0.952). A time of 21 s at baseline was a highly prognostic cut-off point for discrimination (sensitivity = 87.2% and 85.1%). The combined use of baseline and reassessment data improved sensitivity (98.1%)CONCLUSION:Early findings of the 5-STS among stroke patients is an independent prognostic factor associated with independent community walking at discharge. It could discriminate individuals who will not become community walkers at discharge.

Postural Maintenance Is Associated With Walking Ability in People Receiving Acute Rehabilitation After a Stroke

OBJECTIVES

The Postural Assessment Scale for Stroke Patients (PASS) assesses the ability of people post stroke to maintain or change a given posture from lying to standing, and the items on which people with different walking status perform differently may suggest potential interventions. The purpose of this study was to (1) examine the association of PASS scores at admission for acute rehabilitation with walking status at admission and 3 months post stroke (3 M), and (2) identify PASS items that discriminate walking status.

METHODS

In this prospective observational study, 93 people post stroke were assessed with the PASS and a 2.44-m gait speed test at admission, with walking status assessed by telephone interview at 3 M. Those who could walk over a 2.44-m distance without the assistance of a walking aid or another person were considered to be independent in walking; others were considered to be dependent. Those who were dependent at admission were divided into the "regained independence" and "remained dependent" groups based on their status at 3 M. The association of the PASS at admission with 3 levels of walking status (independent at admission, regained independence, and remained dependent) was examined using the Kruskal-Wallis test. For those dependent at admission, the association of PASS score at admission with walking status at 3 M was examined using logistic regression and receiver operating curve analysis.

RESULTS

PASS scores at admission differed significantly across the 3 walking status groups and were significantly associated with walking status at 3 M (odds ratio = 0.864; 95% CI = 0.798-0.935) over and above length of stay. People post stroke who were dependent at admission and had PASS scores ≥22 were more likely to regain independence at 3 M. Nine PASS items differed among the 3 groups.

CONCLUSIONS

PASS score is significantly associated with walking status at admission and at 3 M. The identified 9 items suggest possible interventions for acute rehabilitation.

IMPACT

This study identified 9 PASS items that could guide clinicians in selecting interventions for acute rehabilitation.

Longitudinal Changes in Temporospatial Gait Characteristics during the First Year Post-Stroke

Given the paucity of longitudinal data in gait recovery after stroke, we compared temporospatial gait characteristics of stroke patients during subacute (<2 months post-onset, T0) and at approximately 6 and 12 months post-onset (T1 and T2, respectively) and explored the relationship between gait characteristics at T0 and the changes in gait speed from T0 to T1. Forty-six participants were assessed at T0 and a subsample of twenty-four participants were assessed at T2. Outcome measures included Fugl-Meyer lower-extremity motor score, 14 temporospatial gait parameters, and symmetry indices of 5 step parameters. Except for step width, all temporospatial parameters improved from T0 to T1 (p ≤ 0.0001). Additionally, significant improvements in symmetry were found for the initial double-support time and single-support time (p ≤ 0.0001). As a group, no significant differences were found between T1 and T2 in any of the temporospatial measures. However, the individual analysis revealed that 42% (10/24) of the subsample showed a significant increase in gait speed (Welch’s t-test, p ≤ 0.002). Yet, only 5/24 (21%) of the participants improved speed from T1 to T2 according to speed-based minimum detectable change criteria. The increase in gait speed from T0 to T1 was negatively correlated with gait speed and stride length and positively correlated with the symmetry indices of stance and single-support times at T0 (p ≤ 0.002). Temporospatial gait parameters and stance time symmetry improved over the first 6 months after stroke with an apparent plateau thereafter. A greater increase in gait speed during the first 6 months post-stroke is associated with initially slower walking, shorter stride length, and more pronounced asymmetry in stance and single-support times. The improvement in lower-extremity motor function and bilateral improvements in step parameters collectively suggest that gait changes over the first 6 months after stroke are likely due to a combination of neurological recovery, compensatory strategies, and physical therapy received during that time.

Prediction of Independent Walking in People Who Are Nonambulatory Early After Stroke: A Systematic Review

BACKGROUND AND PURPOSE

One systematic review has examined factors that predict walking outcome at one month in initially nonambulatory patients after stroke. The purpose of this systematic review was to examine, in nonambulatory people within a month of stroke, which factors predict independent walking at 3, 6, and 12 months.

METHODS

Prognostic factors: Any factors measured within one month after stroke with the aim of predicting independent walking. Outcome of interest: Independent walking defined as walking with or without an aid but with no human assistance.

RESULTS

Fifteen studies comprising 2344 nonambulatory participants after stroke were included. Risk of bias was low in 7 studies and moderate in 8 studies. Individual meta-analyses of 2 to 4 studies were performed to calculate the pooled estimate of the odds ratio for 12 prognostic factors. Younger age (odds ratio [OR], 3.4, P<0.001), an intact corticospinal tract (OR, 8.3, P<0.001), good leg strength (OR, 5.0, P<0.001), no cognitive impairment (OR, 3.5, P<0.001), no neglect (OR, 2.4, P=0.006), continence (OR, 2.3, P<0.001), good sitting (OR, 7.9, P<0.001), and independence in activities of daily living (OR 10.5, P<0.001) predicted independent walking at 3 months. Younger age (OR, 2.1, P<0.001), continence (OR, 13.8, P<0.001), and good sitting (OR, 19.1, P<0.001) predicted independent walking at 6 months. There were insufficient data at 12 months.

CONCLUSIONS

Younger age, an intact corticospinal tract, good leg strength, continence, no cognitive impairment, no neglect, good sitting, and independence in activities of daily living in patients who are nonambulatory early after stroke predict independent walking at 3 months. Registration: URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42018108794.

Factors associated with time to independent walking recovery post-stroke

BACKGROUND

Past studies have inconsistently identified factors associated with independent walking post-stroke. We investigated the relationship between pre-stroke factors and factors collected acutely after stroke and number of days to walking 50 m unassisted using data from A Very Early Rehabilitation Trial (AVERT).

METHODS

The outcome was recovery of 50 m independent walking, tested from 24 hours to 3 months post-stroke. A set of a priori defined factors (participant demographics: age, sex, handedness; pre-stroke: hypertension, ischaemic heart disease, hypercholesterolaemia, diabetes mellitus, atrial fibrillation; stroke-related: stroke severity, stroke type, ischaemic stroke location, stroke hemisphere, thrombolysis) were investigated for association with independent walking using a cause-specific competing risk Cox proportional hazards model. Respective effect sizes are reported as cause-specific adjusted HR (caHR) adjusted for age, stroke severity and AVERT intervention.

RESULTS

A total of 2100 participants (median age 73 years, National Institutes of Health Stroke Scale 7, <1% missing data) with stroke were included. The median time to walking 50 m unassisted was 6 days (IQR 2-63) and 75% achieved independent walking by 3 months. Adjusted Cox regression indicated that slower return to independent walking was associated with older age (caHR 0.651, 95% CI 0.569 to 0.746), diabetes (caHR 0.836, 95% CI 0.740 to 0.945), severe stroke (caHR 0.094, 95% CI 0.072 to 0.122), haemorrhagic stroke (caHR 0.790, 95% CI 0.675 to 0.925) and right hemisphere stroke (caHR 0.796, 95% CI 0.714 to 0.887).

CONCLUSION

Our analysis provides robust evidence for important factors associated with independent walking recovery. These findings highlight the need for tailored mobilisation programmes that target subgroups, in particular people with haemorrhagic and severe stroke.

Gait rehabilitation after stroke: review of the evidence of predictors, clinical outcomes and timing for interventions

The recovery of walking capacity is one of the main aims in stroke rehabilitation. Being able to predict if and when a patient is going to walk after stroke is of major interest in terms of management of the patients and their family's expectations and in terms of discharge destination and timing previsions. This article reviews the recent literature regarding the predictive factors for gait recovery and the best recommendations in terms of gait rehabilitation in stroke patients. Trunk control and lower limb motor control (e.g. hip extensor muscle force) seem to be the best predictors of gait recovery as shown by the TWIST algorithm, which is a simple tool that can be applied in clinical practice at 1 week post-stroke. In terms of walking performance, the 6-min walking test is the best predictor of community ambulation. Various techniques are available for gait rehabilitation, including treadmill training with or without body weight support, robotic-assisted therapy, virtual reality, circuit class training and self-rehabilitation programmes. These techniques should be applied at specific timing during post-stroke rehabilitation, according to patient's functional status.

Associations between walking speed and participation, according to walking status in individuals with chronic stroke

BACKGROUND

Reduced walking speed (WS) may lead to restrictions in participation of individuals with stroke, however, the relationships between WS and participation still need to better clarified.

OBJECTIVE

To evaluate the relationships between WS and participation and compare the levels of participation of individuals with chronic stroke, who were stratified according to their walking status.

METHODS

One-hundred and five individuals with stroke (58±12 years; 61 men) participated. WS was measured by the 10-meter walking test and reported in m/s. The participants were stratified into three walking status groups: household (WS <0.4 m/s), limited-community (0.4 m/s-0.8 m/s), and full-community ambulation (>0.8 m/s). Participation was assessed by the Brazilian version of the Assessment of Life Habits 3.1 (LIFE-H 3.1-Brazil).

RESULTS

Between-group analyses revealed statistically significant differences between the household, limited-community, and full-community ambulators regarding the LIFE-H 3.1 total (F = 17.5; p < 0.0001), as well the daily activity (F = 12.3; p < 0.0001) and social role (F = 19.0; p < 0.0001) domain scores. Measures of WS were correlated with the daily activity (r = 0.50, p < 0.0001), social role (r = 0.53, p < 0.0001), total LIFE-H scores (r = 0.53, p < 0.0001), and most of the LIFE-H categories (r = 0.23-0.56).

CONCLUSIONS

WS was significantly correlated with participation and was able to distinguish between individuals with stroke, who had different levels of participation.

Validity and interrater/intrarater reliability of the Turkish version of the postural assessment scale for stroke patients (PASS-Turk)

Background: There is no Turkish version of the Postural Assessment Scale for Stroke patients (PASS). Objectives: To translate and make the cross-cultural adaptation of the PASS into the Turkish language and evaluate the reliability and validity of the Turkish version (PASS-Turk). Methods: Sixty patients with stroke who had survived the three-week acute period were included in the study. The first researcher applied the scale to the participants twice with 5-day intervals. The second researcher applied the scale once at the same time with the first researcher. The reliability of PASS-Turk and its subsections was evaluated using Cronbach's alpha coefficient. In addition, item-total correlation and test-retest reliability were calculated. The interobserver agreement was assessed using the intraclass correlation coefficient. The construct validity of PASS-Turk was assessed using Pearson's product-moment correlation and principal component analyses. The Berg Balance Scale (BBS) and motor subscale of the Functional Independence Measure (FIM) were used for validity. Results: The Cronbach's alpha coefficients of the PASS-Turk scale were 0.903 for the subsection of "maintaining posture," 0.940 for the subsection of "changing a posture," and 0.953 for the total PASS-Turk scale. The first and second researcher evaluations were perfectly consistent with each other in terms of PASS-Turk total scores (ICC = 0.999, 95% CI: 0.998-0.999, and p < .001). A strong positive correlation was found between PASS-Turk and BBS and the motor subscale of FIM. Conclusion: PASS-Turk is a valid and reliable scale for the evaluation of posture and balance of patients with stroke.