Measure of functional independence dominates discharge outcome prediction after inpatient rehabilitation for stroke

Construction and application of a home exercise rehabilitation management program for elderly stroke patients based on the Functional Independence Measure score

OBJECTIVE

The objective of this study was to develop a home exercise rehabilitation management program for elderly stroke patients based on the Functional Independence Measure (FIM) score and assess its effectiveness through practical application.

METHODS

A prospective asynchronous controlled trial was conducted involving 290 elderly stroke patients, with 145 assigned to the control group and 145 to the intervention group. The control group received standard home rehabilitation instructions, while the intervention group followed a home exercise rehabilitation program guided by FIM scores. The program was developed through research group discussions, evidence-based literature review, and expert input. The efficacy of the program was evaluated by comparing self-care ability and exercise function between the two patient groups.

RESULTS

After 4 and 8 weeks of intervention, the motor assessment scale (MAS), Barthel Index scores and Mini-Mental State Examination (MMSE) of the intervention group were higher than those of the control group, and the modified Rankin scale (mRS) was lower than this of the control group (P < 0.05).

CONCLUSION

The home exercise rehabilitation management program for elderly stroke patients based on FIM scores was developed in a scientifically sound manner. This program holds significant theoretical implications for enhancing the home exercise regimen of elderly stroke patients and facilitating the rehabilitation of their limb functions.

The cutoff values of functional independence measure scores for predicting discharge destination in the early stroke phase

This study aimed to determine cutoff values of functional independence measure (FIM) scores to predict the discharge destinations of patients with acute stroke. The sample included 318 patients with acute stroke (mean age, 72.0 years; women, 39%). The discharge destination was categorized into three groups: home, postacute rehabilitation (hospital with convalescent rehabilitation wards), and postacute care (institution without convalescent rehabilitation wards). We assessed FIM after lifting bed restriction. Multinomial logistic regression analyses were used to estimate odds ratios (OR) and 95% confidence intervals (CI) of the FIM scores for predicting discharge destinations, with postacute rehabilitation as a reference. Cutoff values of motor and cognitive FIM scores for distinguishing home from postacute rehabilitation and postacute care from postacute rehabilitation were determined using receiver operating characteristic curves. The proportion of home, postacute rehabilitation, and postacute care were 34.6%, 41.8%, and 23.6%, respectively. After adjustments for clinical variables, the ORs (95% CIs) for motor and cognitive FIM scores for home versus postacute rehabilitation were 1.08 (1.04-1.11) and 1.05 (0.98-1.12). Furthermore, those for postacute care versus postacute rehabilitation were 1.01 (0.98-1.04) and 0.92 (0.87-0.98). The cutoff values of the motor and cognitive FIM scores for distinguishing home from postacute rehabilitation were 37.5 (sensitivity: 0.92; specificity: 0.64) and 23.5 (sensitivity: 0.78; specificity: 0.67). Furthermore, those for distinguishing postacute care from postacute rehabilitation were 15.5 (sensitivity, 0.81; specificity, 0.51) and 12.5 (sensitivity, 0.74; specificity, 0.64). The identified cutoff values may serve as early indicators for predicting discharge destinations from acute stroke care.

Turkish translation and transcultural validity and reliability of an assessment tool for spasticity: Leg Activity Measure (Leg A)

BACKGROUND

The Leg Activity Measure is the only self-report measure that has been published to date that takes into account both the influence on quality of life and passive and active function in the literature.

AIMS

The purpose is to examine the translation, cross-cultural adaptation validity and reliability of the Turkish version of the Leg Activity Measure (Tr-LegA).

METHODS

Neurological patients (n = 52) with lower limb spasticity (aged 47.09 ± 14.74 years) were enrolled. The study consisted of two stages. At the first stage, the scale was translated into Turkish and culturally adapted. Validity and reliability analyses were conducted at the second stage. Construct validity was evaluated by exploratory factor analysis (EFA). The Rivermead Mobility Index (RMI), Nottingham Health Profile (NHP), and Functional Independence Measure (FIM) were used for convergent validity. The reproducibility (test-retest reliability) was assessed by the intraclass correlation coefficient (ICC). Furthermore, the standard error of measurement (SEM) was calculated.

RESULTS

EFA suggested one factor for the Passive Function and two factors for the Active Function and Impact on Quality of Life Scales (QoL). Tr-LegA Passive and Active Function Scales were correlated with the total RMI, NHP, and FIM (p < 0.05). Tr-LegA Impact on Quality of Life Scale was correlated with the RMI and NHP (p < 0.05). Tr-LegA Passive Function Scale (ICC = 0.997), Tr-LegA Active Function Scale (ICC = 0.996), and Tr-LegA Impact on Quality of Life Scale (ICC = 0.976) had good reliability. Only Passive Function Scale had a significant floor effect (25%).

CONCLUSIONS

Tr-LegA is a valid and reliable multidimensional scale for passive and active function and quality of life in patients with lower limb spasticity.

THE CLINICAL TRIAL NUMBER

NCT05182411.

Comparative efficacy of non-invasive brain stimulation for post-stroke cognitive impairment: a network meta-analysis

BACKGROUND

Non-invasive brain stimulation (NIBS) is a burgeoning approach with the potential to significantly enhance cognition and functional abilities in individuals who have undergone a stroke. However, the current evidence lacks robust comparisons and rankings of various NIBS methods concerning the specific stimulation sites and parameters used. To address this knowledge gap, this systematic review and meta-analysis seek to offer conclusive evidence on the efficacy and safety of NIBS in treating post-stroke cognitive impairment.

METHODS

A systematic review of randomized control trials (RCT) was performed using Bayesian network meta-analysis. We searched RCT in the following databases until June 2022: Cochrane Central Register of Controlled Trials (CENTRAL), PUBMED, and EMBASE. We compared any active NIBS to control in terms of improving cognition function and activities of daily living (ADL) capacity following stroke.

RESULTS

After reviewing 1577 retrieved citations, a total of 26 RCTs were included. High-frequency (HF)-repetitive transcranial magnetic stimulation (rTMS) (mean difference 2.25 [95% credible interval 0.77, 3.66]) was identified as a recommended approach for alleviating the global severity of cognition. Dual-rTMS (27.61 [25.66, 29.57]) emerged as a favorable technique for enhancing ADL function. In terms of stimulation targets, the dorsolateral prefrontal cortex exhibited a higher ranking in relation to the global severity of cognition.

CONCLUSIONS

Among various NIBS techniques, HF-rTMS stands out as the most promising intervention for enhancing cognitive function. Meanwhile, Dual-rTMS is highly recommended for improving ADL capacity.

Development and Validation of a Decision Tree Analysis Model for Predicting Home Discharge in a Convalescent Ward: A Single Institution Study

OBJECTIVES

Accurately predicting the likelihood of inpatients' home discharge in a convalescent ward is crucial for assisting patients and families in decision-making. While logistic regression analysis has been commonly used, its complexity limits practicality in clinical settings. We focused on decision tree analysis, which is visually straightforward. This study aimed to develop and validate the accuracy of a prediction model for home discharge for inpatients in a convalescent ward using a decision tree analysis.

METHODS

The cohort consisted of 651 patients admitted to our convalescent ward from 2018 to 2020. We collected data from medical records, including disease classification, sex, age, duration of acute hospitalization, discharge destination (home or nonhome), and Functional Independence Measure (FIM) subitems at admission. We divided the cohort data into training and validation sets and developed a prediction model using decision tree analysis with discharge destination as the target and other variables as predictors. The model's accuracy was validated using the validation data set.

RESULTS

The decision tree model identified FIM grooming as the first single discriminator of home discharge, diverging at four points and identifying subsequent branching for the duration of acute hospitalization. The model's accuracy was 86.7%, with a sensitivity of 0.96, specificity of 0.52, positive predictive accuracy of 0.88, and negative predictive accuracy of 0.80. The area under the receiver operating characteristic curve was 0.75.

CONCLUSION

The predictive model demonstrated more than moderate predictive accuracy, suggesting its utility in clinical practice. Grooming emerged as a variable with the highest explanatory power for determining home discharge.

Effect of rehabilitation motivation on improving activities of daily living in subacute stroke patients

OBJECTIVES

To determine the effect of rehabilitation motivation on activities of daily living improvement in subacute stroke patients starting intensive rehabilitation.

MATERIALS AND METHODS

This was a single-center cohort study involving patients with a subacute stroke who were admitted to or discharged from a Recovery Rehabilitation Unit between February 2021 and August 2022. Improvement in Activity of Daily Living was evaluated using the Functional Independence Measure. We calculated the corrected motor Functional Independence Measure effectiveness using its motor-related items at admission and discharge. The Behavioral Regulation in Exercise Questionnaire 2 was used to evaluate admission rehabilitation motivation, and the Relative Autonomy index was calculated. Hierarchical multiple regression analysis was used to examine the relationship between the corrected motor Functional Independence Measure effectiveness and the Relative Autonomy Index.

RESULTS

Eighty-six of the 231 patients (37.2 %) were included in the analysis. Hierarchical multiple regression analysis adjusted for demographic and clinical variables demonstrated that age, comorbidities, and Relative Autonomy Index were significantly associated with corrected motor Functional Independence Measure effectiveness (R2 = 0.423, p ≺ .001).

CONCLUSION

Motivation at intensive rehabilitation initiation in patients with a subacute stroke influences Activities of Daily Living improvement. These results may help develop rehabilitation programs aimed at improving Activities of Daily Living in patients with subacute strokes.

Physical functioning factors predicting a return home after stroke rehabilitation: A systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis sought to identify the physical functioning factors associated with home discharge after inpatient stroke rehabilitation.

DATA SOURCES

A search of PubMed, Embase, CINHAL, The Cochrane Library (Trials), Web of Science, and PEDro were conducted up until May 2023.

METHODS

Two independent reviewers selected studies for population (patients with stroke), predictive factors (physical functioning), outcome (discharge destination), setting (inpatient rehabilitation), and study designs (observational and experimental studies). Predictive factors were identified among assessments of the "body function" and "activity" components of the International Classification of Functioning. Methodological quality was assessed with the Newcastle-Ottawa Scale. The findings used quantitative and narrative syntheses. Meta-analyses were performed with the inverse variance method and the random-effects model using included studies with sufficient data.

RESULTS

Forty-five studies were included with 204,787 participants. Included studies assessed the association of independence in activities of daily living, walking, rolling, transferring, and balance on admission with a probability of returning home. Motor (odds ratio = 1.23, 95% confidence interval: 1.12-1.35, p < .001) and total (odds ratio = 1.34, 95% confidence interval: 1.14-1.57, p < .001) Functional Independence Measure scores on admission were significantly associated with home discharge in meta-analyses. Additionally, included studies showed that independence in motor activities, such as sitting, transferring, and walking, and scores above thresholds for the Functional Independence Measure and Berg Balance Scale on admission were associated with discharge destination.

CONCLUSION

This review showed that higher independence in activities of daily living on admission is associated with home discharge after inpatient stroke rehabilitation.

Prediction of hospitalization time and independence level with functional outcomes for patients with acute stroke: a retrospective study

OBJECTIVES

The objective of this study was to develop predictive models for estimating the length of stay (LOS) with standardized clinical outcome measures (Functional Independence Measure, Trunk Impairment Scale, Postural Assessment Scale for Stroke Patients, Fugl Meyer Assessment Scale, and Functional Ambulation Category) during acute care setting.

METHODS

One hundred sixty-nine patients were included in the retrospective study. Predictors chosen for the LOS included scores of functional outcome measures at admission. We used Spearman's rank correlation coefficients to calculate correlations among clinical outcome measures and LOS, stepwise multiple regression analysis to develop a predictive model, and receiver operating characteristics curve to analyze the predictive value of explanatory factors obtained from the previous model for discharge Functional Independence Measure score.

RESULTS

The predictive equation explained 81% of the variance in LOS. The most important predictors were trunk impairment, motor function of the upper extremity, walking ability, and independence level at admission. The receiver operating characteristic curve was obtained with a cut-off score of 13 points for the Trunk Impairment Scale, 47 points for Fugl Meyer Assessment-Upper Extremity, and 2 points for Functional Ambulation Category, demonstrating the highest percentage of the accurately predicted ability of independence level at discharge.

DISCUSSION

The models presented in this study could help clinicians and researchers to predict the LOS and discharge independence level of clinical outcomes for patients with acute stroke enrolled in an acute care setting.

Improvements and Residual Limitations Experienced by Patients With Guillain-Barré Syndrome Undergoing Inpatient Rehabilitation

ABSTRACT

The purposes of this study were to (1) describe the level of functional independence of patients with Guillain-Barré syndrome before and after inpatient rehabilitation, (2) determine whether the level of functional independence increased in each functional domain during inpatient rehabilitation, and (3) determine whether independence at the end of inpatient rehabilitation differed significantly between domains. Data from patients with Guillain-Barré syndrome discharged from inpatient rehabilitation settings in 2019 were obtained from the Uniform Data System for Medical Rehabilitation database. The primary variables analyzed were paired, dichotomous variables of the number of patients who achieved full independence in the admission and discharge scores for the activities that comprise the domains, subscales, and total of the Functional Independence Measure. All patients admitted to inpatient rehabilitation required assistance with at least one if not several domains of function, motor, as well as cognitive. By the end of the inpatient rehabilitation stay, for each domain of function, significantly more patients were independent ( P < 0.0001). Independence at the end of inpatient rehabilitation differed significantly between domains ( P < 0.0001); more patients achieved independence in the communication (87.5%) and social cognition (74.8%) domains while fewer patients achieved independence in the self-care (35.9%), transfers (34.2%), and locomotion domains (24.7%).

Predicting models for arm impairment: External validation of the Scandinavian models and identification of new predictors in post-acute stroke settings

BACKGROUND

Post-stroke arm impairment at rehabilitation admission as predictor of discharge arm impairment was consistently reported as extremely useful. Several models for acute prediction exist (e.g. the Scandinavian), though lacking external validation and larger time-window admission assessments.

OBJECTIVES

(1) use the 33 Fugl-Meyer Assessment-Upper Extremity (FMA-UE) individual items to predict total FMA-UE score at discharge of patients with ischemic stroke admitted to rehabilitation within 90 days post-injury, (2) use eight individual items (seven from the Scandinavian study plus the top predictor item from objective 1) to predict mild impairment (FMA-UE≥48) at discharge and (3) adjust the top three models from objective 2 with known confounders.

METHODS

This was an observational study including 287 patients (from eight settings) admitted to rehabilitation (2009-2020). We applied regression models to candidate predictors, reporting adjusted R2, odds ratios and ROC-AUC using 10-fold cross-validation.

RESULTS

We achieved good predictive power for the eight item-level models (AUC: 0.70-0.82) and for the three adjusted models (AUC: 0.85-0.88). We identified finger mass flexion as new item-level top predictor (AUC:0.88) and time to admission (OR = 0.9(0.9;1.0)) as only common significant confounder.

CONCLUSION

Scandinavian item-level predictors are valid in a different context, finger mass flexion outperformed known predictors, days-to-admission predict discharge mild arm impairment.

Toward a cerebello-thalamo-cortical computational model of spinocerebellar ataxia

Computational neural network modelling is an emerging approach for optimization of drug treatment of neurological disorders and fine-tuning of rehabilitation strategies. In the current study, we constructed a cerebello-thalamo-cortical computational neural network model to simulate a mouse model of cerebellar ataxia (pcd^5J mice) by manipulating cerebellar bursts through reduction of GABAergic inhibitory input. Cerebellar output neurons were projected to the thalamus and bidirectionally connected with the cortical network. Our results showed that reduction of inhibitory input in the cerebellum orchestrated the cortical local field potential (LFP) dynamics to generate specific motor outputs of oscillations of the theta, alpha, and beta bands in the computational model as well as in mouse motor cortical neurons. The therapeutic potential of deep brain stimulation (DBS) was tested in the computational model by increasing the sensory input to restore cortical output. Ataxia mice showed normalization of the motor cortex LFP after cerebellum DBS. We provide a novel approach to computational modelling to investigate the effect of DBS by mimicking cerebellar ataxia involving degeneration of Purkinje cells. Simulated neural activity coincides with findings from neural recordings of ataxia mice. Our computational model could thus represent cerebellar pathologies and provide insight into how to improve disease symptoms by restoring neuronal electrophysiological properties using DBS.

Defining independence: A scoping review by the OMERACT patient perspective of remission in rheumatoid arthritis group

AIMS

The Outcome Measures in Rheumatology Trials (OMERACT) Remission in Rheumatoid Arthritis (RA) patient perspective working group has previously found that patients prioritised independence, pain, and fatigue as key domains of remission in RA. However, there is currently no clear definition of independence. Consequently, this scoping review aimed to explore how independence is represented in the RA literature.

METHODS

A comprehensive search of the EMBASE, Medline, and PsycInfo databases was performed for publications that used independence or autonomy as a disease activity measure, description of disease in remission or treatment outcome. Papers were included if they involved adult participants and were written in English, with no restrictions on study design or publication year. Two reviewers (TK and AC, AT or BJ) independently screened the abstracts. A thematic approach was applied to derive common definitions and descriptions of independence.

RESULTS

660 articles were identified, of which 58 (25 qualitative, 28 quantitative, one mixed, and four reviews) met the inclusion criteria. 86% of total participants were female. Ten publications referenced remission. Independence took many forms; in addition to physical and functional capability, it was described in relation to work, social activities, autonomy in healthcare, and household activities. Four common themes describing independence were identified: 1. A return to a state before arthritis. 2. Being physically and functionally able. 3. A sense of freedom without needing to rely on others. 4. Having control over the organisation of one's life.

CONCLUSION

Although independence is frequently mentioned in the RA literature, it has various meanings, lacks a consistent definition, and is a concept rarely applied to remission. It is multi-factorial, exceeding functional ability alone, and contextualised within sociodemographic and disease factors. This scoping review provides common descriptions of independence to inform future qualitative work towards the development of an outcome measure of independence for the assessment of RA in remission.

Predicting length of stay with assessment of motor and process skills in subjects with acquired brain injury

BACKGROUND

The Functional Independence Measure (FIM) is a well-established predictor of length of stay (LOS) for rehabilitation. The Assessment of Motor and Process Skills (AMPS) is a more in-depth construct for measuring activities of daily living (ADL) and may therefore be a valuable adjunct when predicting LOS. This paper aimed to investigate AMPS as a candidate predictor of LOS in a statistical model including FIM.

METHODS

A cohort study of 647 patients with acquired brain injuries admitted for rehabilitation. LOS was analyzed in a multiple regression model with the motor and process/cognitive domains of AMPS and FIM.

RESULTS

Independence in ADL process ability and FIM cognition were associated with 31% (p < 0.001) and 38% (p < 0.001) shorter LOS, respectively, relative to patients needing total assistance. Independence in ADL motor ability was associated with a 26% (p = 0.002) shorter LOS, whereas FIM motor was not a predictor.

CONCLUSIONS

The AMPS predicts LOS for rehabilitation at a level that is at least as good as that of FIM. Conducting the AMPS early in the course of inpatient rehabilitation provides clinicians and managers with valuable information for planning LOS.

Factors Associated With Time to Achieve Physical Functional Recovery in Patients With Severe Stroke After Inpatient Rehabilitation: A Retrospective Nationwide Cohort Study in Japan

Objective

To describe characteristics of patient with severe stroke (FIM motor score [FIM motor] 20-49 at admission) and examine association between pre-specified factors (age, sex, modified Rankin Scale before stroke onset, body mass index, FIM motor, and FIM cognitive) and time to achieve FIM motor ≥70, that is, self-independent level.

Design

Retrospective cohort study using a large database in Japan.

Setting

Rehabilitation wards.

Participants

Patients with severe stroke (N=1422) who received inpatient rehabilitation were included (median age: 76 years; interquartile range [IQR]: 68.0-84.0). A total of 54.6% were men, and 65.8% were ischemic stroke.

Interventions

Not applicable.

Main Outcome Measures

Time to achieve FIM motor ≥70.

Results

After inpatient rehabilitation, 40.4% (N=575) achieved FIM motor ≥70 (admission FIM motor 20-29, 30-39 and 40-49: 18.6%, 33.6%, and 47.8%, respectively). Patients who achieved FIM motor ≥70 stayed median 81.0 days [IQR, 51.0-120.0]) and received median: 6.94 units per day [IQR, 5.48-7.78], 1 unit=20 minutes). Adjusted Fine-Gray regression revealed that shorter time to achieve FIM motor ≥70 was associated with higher admission FIM motor (hazard ratio [HR] 2.87 [95% confidence interval [CI] 2.27-3.62]: 20-29 vs 40-49), higher admission FIM cognitive (HR 1.81 [95% CI: 1.39-2.35]: 5-14 vs 25-35), and younger (HR 3.20 [95% CI: 2.32-4.42]: ≥85 years vs 20-69 years).

Conclusions

Most patients with severe stroke did not achieve FIM motor ≥70 after inpatient rehabilitation. Older patients and patients with lower admission FIM motor require more attention. They should be prioritized for state-of-the-art rehabilitation therapy.

An exploratory descriptive cohort study of 90-day prognosis after acute ischaemic stroke with mechanical thrombectomy

AIM

To evaluate the relationship between nursing assessment findings at discharge and acute ischaemic stroke (AIS) patient prognosis after mechanical thrombectomy (MT).

METHODS

We analysed the characteristics of 144 AIS patients with MT treatment admitted to a university affiliated teaching hospital in Chengdu, Sichuan Province China, from January 2020 to December 2020. The modified Rankin Scale (mRS) score was used to assess outcomes 90-days after discharge. Exploratory analyses were undertaken using IBM SPSS Statistics (Version 26.0).

RESULTS

At 90-days, 47.9% (n = 69) had a good prognosis (mRS ≤ 2) including 22.2%(n = 32) fully recovered patients. There were 5 (3.5%) deceased patients and 48.6% (n =70) of patients had a poor prognosis (mRS ≥ 3). In univariate analysis, clinical prognosis correlated with the need for inpatient endotracheal intubation (p = 0.02), nasogastric tube (p＜0.001), indwelling urinary catheter (p＜0.001), central venous catheter (p = 0.03), health knowledge needs of pressure injury prevention (p = 0.03), National Institute of Health Stroke Scale (NIHSS) score (p＜0.001) and Activities of Daily Living (ADL) score (p＜0.001) at the time of discharge from hospital. The average hospitalisation time of the 144 patients was 12[IQR, 9-25] days, and the average cost of hospitalisation was $Y$21291.93 (SD 9165.01).

CONCLUSION

Almost half of the surviving patients had a poor prognosis. In our country, this surgery and rehabilitation impose a significant financial burden that needs to be addressed. However, the longer length of hospital stay and higher costs at discharge may be contributing factors to worse outcomes. The outcomes of comprehensive nursing assessment of the patients, including nursing needs, activities of daily living, and neurological function, can predict their outcome.

IMPACT STATEMENT

We recommend a comprehensive nursing assessment at discharge that predicts patient outcomes and can be used for subsequent targeted interventions. The prognosis of patients with acute ischaemic stroke after mechanical thrombectomy is poor, and the financial burden needs to be considered.

Clarification of Factors Determining Discharge Destination Among Elderly Patients After Stroke With Low Levels of Independence in Activities of Daily Living: A Retrospective Study

Objective

To determine factors influencing discharge destination of elderly patients after stroke with low levels of independence in activities of daily living (ADL).

Design

Cross-sectional study.

Setting

A community-based public hospital in a rural area in Japan.

Participants

A total of 67 patients with low daily function among 205 elderly patients with stroke screened for eligibility (N=67).

Interventions

Not applicable.

Main Outcome Measures

Motor component of functional independence measure (M-FIM) at discharge and discharge destination-home or long-term care facility (LCF).

Results

Among the 205 eligible patients, 147 were discharged home and 58 were discharged to LCFs. Patients with an M-FIM score of ≤30 at discharge were defined as patients deemed difficult to discharge home because of low independence levels in ADL. Of the 147 patients discharged home, 24 (16.3%) had M-FIM scores of ≤30. Of the 58 patients discharged to LCFs, 43 (74.1%) had M-FIM scores of ≤30. Patients with an M-FIM score of ≤30 at discharge significantly tended to be discharged home if they obtained oral intake vs tube feeding as a nutritional method (P=.047) and higher cognitive component of FIM scores at discharge (P=.002). All six patients who lived alone among patients with an M-FIM score of ≤30 were discharged to LCFs. Two patients on tube feeding were discharged home.

Conclusions

Nutritional method, cognitive function at discharge, and the prestroke living situation with or without household caregivers are important factors of discharge among elderly patients after stroke with low independence levels in ADL. However, only a small number of severely disabled patients were successfully discharged home.

Oral health status and its associated factors among post-stroke inpatients: a cross-sectional study in Hungary

Background

Post-stroke inpatients are at risk of poor oral health for a number of reasons. The aim of this study was to assess the oral health status of post-stroke patients and also to explore the factors that may influence it.

Methods

This cross-sectional study was organised at National Institute for Medical Rehabilitation in Hungary. Altogether 410 post-stroke patients were enrolled in the survey. Personal medical history and functional assessment was obtained from the final medical reports of the patients. The clinical examination and data collection were conducted according to the World Health Organization (2013) criteria. Socio-demographic background and behaviours related to oral health were assessed using a questionnaire. The dental status was explained by the number of Decayed, Missing and Filled Teeth (DMFT). The association of socio-demographic factors, stroke and functional assessment with oral health status and behaviour was evaluated. Chi-square test, Fisher’s exact test, Welch test, Mann–Whitney U test, Kruskal–Wallis test, ANOVA model and correlation analysis were used to analyse our data. The level of significance was set at p < 0.05.

Results

Mean age of stroke patients was 59.21(Standard Deviation [SD] 14.74) years. Mean DMFT score was 20.13 (8.08), including 3.28 (4.24) decayed teeth, 15.02 (10.29) missing teeth and 1.83 (2.94) filled teeth score. Factors that influenced the oral health status were gender, age, occupational status, level of education, type and risk factors for stroke. Significant correlation was found between the Functional Independence Measure and oral health-related behaviours with patients brushing their teeth once a month showing the lowest value.

Conclusion

According to the results, low socio-demographic and economic status, low level of education and the Functional Independence Measure score, unemployment, the combination of risk factors for stroke and residual dysfunctions are associated with poor oral health status. The data indicate that a series of changes are needed, for special attention and care in oral health for patients who have had a stroke. Based on the findings of this research, a new model of prevention and care can be developed, with an interdisciplinary collaboration, to promote the quality of life of these individuals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02259-2.

Is robot-assisted gait training intensity a determinant of functional recovery early after stroke? A pragmatic observational study of clinical care

Gait rehabilitation is a critical factor in functional recovery after a stroke. The aim of this pragmatic observational study was to identify the optimal dose and timing of robot-assisted gait training (RAGT) that can lead to a favourable outcome in a sample of subacute stroke survivors. Subacute patients with stroke who underwent a RAGT within a multidisciplinary rehabilitation program were enrolled. A set of clinical (i.e. age, type of stroke and time since stroke) and rehabilitation stay outcomes (length of stay and RAGT number of sessions) were recorded to evaluate their impact on functional outcome measures by functional independence measure (FIM) or functional ambulation category (FAC). We included 236 patients (62.73 ± 11.82 year old); 38.44% were females, and 59.32% were ischaemic stroke patients. Patients that received at least 14 RAGT sessions, had 15.83% more chance to be responders compared to those that receive less sessions (P = 0.006). Similarly, younger patients (≤60 years) were more prone to be responders (+15.1%). Lastly, an early rehabilitation (<6 weeks) was found to be more efficient (+21.09%) in determining responsiveness (P < 0.001). Becoming newly independent for gait, that refers to a FAC score ≥4, was related with age and RAGT sessions (P = 0.001). In conclusion, a younger age (≤60 years), an early rehabilitation (<6 weeks since stroke) and a higher RAGT dose (at least 14 sessions) were related to a favourable outcome in patients with subacute stroke.

Validation of a Disability Assessment Tool Based on the International Classification of Functioning, Disability, and Health in the Chinese Context

Background:

The common standards of disability assessment for long-term care (LTC) insurance are currently absent. The International Classification of Functioning, Disability and Health (ICF) was designed for a better description of health and functioning, which could fill the demand gap for the standards of disability assessment and be a promising tool for the development of LTC insurance system.

Objectives

To validate a disability assessment scale for disabled elderly individuals based on the ICF for LTC in the Chinese context.

Methods

The present study is a cross-sectional study. A disability assessment tool based on the ICF was developed by referring to other assessment tools and an expert consensus meeting in the initial phase of the study. The developed tool was used to evaluate 1,610 elderly individuals in the LTC institutions. The Cronbach's α coefficient and split-half reliability were applied to test the internal consistency of the tool, while the Interclass correlation coefficients (ICCs) were used to evaluate the interrater reliability (IRR). Factor analysis was performed to verify the construct validity of the tool. The scores from the Medical Outcomes Short Form-12 (SF-12) were correlated with that from the disability assessment tool, to assess the criterion-related validity.

Results

The Cronbach's α coefficient and split-half reliability of the disability assessment tool were 0.969 and 0.877, respectively. The ICCs of the sum scale was 0.85, and the ICCs of each of the 20 items in the scale ranged from 0.78 to 0.94. The items were divided into three factors through analysis, which is consistent with the structure expectation. The scores of each item and the sum score of the disability assessment scale were negatively correlated with the scores of the physical and psychological fields in SF-12 (p &lt; 0.001). Overall, the data indicated that the tool was characterized by good internal consistency, IRR, construct validity, and criterion-related validity.

Conclusions

The disability assessment tool based on the ICF is a reliable and valid tool for the collection of information on functioning across various LTC settings. The information of disability provided evidence for the distribution of LTC service and guided the development of LTC insurance standards.

Electroencephalogram (EEG) With or Without Transcranial Magnetic Stimulation (TMS) as Biomarkers for Post-stroke Recovery: A Narrative Review

Stroke is one of the leading causes of death and disability. Despite the high prevalence of stroke, characterizing the acute neural recovery patterns that follow stroke and predicting long-term recovery remains challenging. Objective methods to quantify and characterize neural injury are still lacking. Since neuroimaging methods have a poor temporal resolution, EEG has been used as a method for characterizing post-stroke recovery mechanisms for various deficits including motor, language, and cognition as well as predicting treatment response to experimental therapies. In addition, transcranial magnetic stimulation (TMS), a form of non-invasive brain stimulation, has been used in conjunction with EEG (TMS-EEG) to evaluate neurophysiology for a variety of indications. TMS-EEG has significant potential for exploring brain connectivity using focal TMS-evoked potentials and oscillations, which may allow for the system-specific delineation of recovery patterns after stroke. In this review, we summarize the use of EEG alone or in combination with TMS in post-stroke motor, language, cognition, and functional/global recovery. Overall, stroke leads to a reduction in higher frequency activity (≥8 Hz) and intra-hemispheric connectivity in the lesioned hemisphere, which creates an activity imbalance between non-lesioned and lesioned hemispheres. Compensatory activity in the non-lesioned hemisphere leads mostly to unfavorable outcomes and further aggravated interhemispheric imbalance. Balanced interhemispheric activity with increased intrahemispheric coherence in the lesioned networks correlates with improved post-stroke recovery. TMS-EEG studies reveal the clinical importance of cortical reactivity and functional connectivity within the sensorimotor cortex for motor recovery after stroke. Although post-stroke motor studies support the prognostic value of TMS-EEG, more studies are needed to determine its utility as a biomarker for recovery across domains including language, cognition, and hemispatial neglect. As a complement to MRI-based technologies, EEG-based technologies are accessible and valuable non-invasive clinical tools in stroke neurology.

Functional Independence predicts patients with stroke more likely to be discharged to the community after inpatient rehabilitation

BACKGROUND

Functional domain predictors of discharge destination following inpatient rehabilitation for stroke have not been thoroughly identified.

OBJECTIVES

1) Determine the relationships between intrinsic variables (demographic; comorbidities; functional independence at admission to and at discharge from an inpatient rehabilitation facility (IRF)) and discharge to home. 2) Determine cut scores for Functional Independence Measure® (FIM) subscales and domains that predict discharge to the community.

METHODS

This study was a secondary analysis of a large, multi-IRF dataset from the Uniform Data System for Medical Rehabilitation. Participants were adults with stroke who were discharged from an IRF in 2019 (n = 92,153).

RESULTS

Correlations with discharge to the community were strongest for discharge FIM scores (r = 0.330 to 0.580), followed by admission FIM scores (r = 0.245 to 0.411), which were stronger than the demographic and comorbidity variables (r = 0.005 to 0.110). Logistic regression analysis indicated 5 of 6 FIM domains (Social Cognition, Self-care, Sphincter, Transfer, and Locomotion) scored at admission and at discharge were predictive of discharge home. Receiver operating characteristic curve analyses determined the best cut point for each domain. For each FIM measure, the area under the curve was greater when the measure was obtained at discharge than it was at admission.

CONCLUSIONS

Clinicians may consider the cut points presented for each domain at admission and at discharge when setting goals or making recommendations for patients with stroke who aspire to a discharge from an IRF to a community setting.

Long-Term Rehabilitation Utilization Pattern Among Stroke Patients Under the National Health Insurance Program

OBJECTIVE

The aim of this study was to understand the frequency of patients receiving rehabilitation services at various periods after stroke and the possible medical barriers to receiving rehabilitation.

DESIGN

A retrospective cohort study was conducted using a nationally representative sample in Taiwan. A total of 14,600 stroke patients between 2005 and 2011 were included. Utilization of physical therapy or occupational therapy at different periods after stroke onset was the outcome variable. Individual and geographic characteristics were investigated to determine their effect on patients' probability of receiving rehabilitation.

RESULTS

More severe stroke or more comorbid diseases increased the odds of receiving physical therapy and occupational therapy; older age was associated with decreased odds. Notably, sex and stroke type influenced the odds of rehabilitation only in the early period. Copayment exemption lowered the odds of rehabilitation in the first 6 mos but increased the odds in later periods. Rural and suburban patients had significantly lower odds of receiving physical therapy and occupational therapy, as did patients living in areas with fewer rehabilitation therapists.

CONCLUSIONS

Besides personal factors, geographic factors such as urban-rural gaps and number of therapists were significantly associated with the utilization of post-stroke rehabilitation care. Furthermore, the influence of certain factors, such as sex, stroke type, and copayment exemption type, changed over time.

Precision medicine in stroke: towards personalized outcome predictions using artificial intelligence

Stroke ranks among the leading causes for morbidity and mortality worldwide. New and continuously improving treatment options such as thrombolysis and thrombectomy have revolutionized acute stroke treatment in recent years. Following modern rhythms, the next revolution might well be the strategic use of the steadily increasing amounts of patient-related data for generating models enabling individualized outcome predictions. Milestones have already been achieved in several health care domains, as big data and artificial intelligence have entered everyday life.

The aim of this review is to synoptically illustrate and discuss how artificial intelligence approaches may help to compute single-patient predictions in stroke outcome research in the acute, subacute and chronic stage. We will present approaches considering demographic, clinical and electrophysiological data, as well as data originating from various imaging modalities and combinations thereof. We will outline their advantages, disadvantages, their potential pitfalls and the promises they hold with a special focus on a clinical audience. Throughout the review we will highlight methodological aspects of novel machine-learning approaches as they are particularly crucial to realize precision medicine. We will finally provide an outlook on how artificial intelligence approaches might contribute to enhancing favourable outcomes after stroke.

Prevalence of Walking Limitation After Acute Stroke and Its Impact on Discharge to Home

OBJECTIVE

The purpose of this study was to provide contemporary estimates of the prevalence of lower extremity motor impairment and walking limitation after first-ever stroke and to characterize the predictive nature of early walking ability for being discharged home after acute hospitalization.

METHODS

In this cohort study, data were collected from a metropolitan acute care hospital in Canada at admission for 487 adults with first-ever acute ischemic or hemorrhagic stroke. Lower extremity motor impairment and walking limitation were measured using the National Institutes of Health Stroke Scale and AlphaFIM, respectively. Parallel multivariable logistic regression models were built to predict discharge home after acute hospitalization compared with further hospitalization.

RESULTS

For patients surviving a first-ever stroke, 44.1% presented with some degree of lower extremity motor impairment and 46.0% were unable to walk. In a multivariable model built around a binary classification of walking (Nagelkerke R2 = 0.41), those with any ability to walk at admission (with or without therapist assistance) had 9.48 times greater odds of being discharged home (odds ratio = 9.48, 95% CI = 6.11-14.92) than those who were unable. In a parallel multivariable model built around an ordinal classification of walking (Nagelkerke R2 = 0.49), patients had 2.07 times greater odds (odds ratio = 2.07, 95% CI = 1.82-2.38) of being discharged home for each increment on a 6-point walking scale (total dependence to complete independence) assessed at acute admission.

CONCLUSION

Approximately one-half of patients with first-ever stroke present with lower extremity weakness and walking limitation. Early walking ability is a significant predictor of returning home after acute hospitalization, independent of stroke severity. Discharge planning may be facilitated early after stroke with the familiar assessment of walking ability.

IMPACT

An early assessment of walking function within days of stroke admission can help to streamline discharge planning.

LAY SUMMARY

Nearly one-half of all individuals who experience a first-time stroke have walking difficulty when they arrive at the hospital. The severity of the walking limitation can predict whether a patient will eventually be discharged home or go on to further hospitalization.

Thirty-Day Post-Discharge Outcomes Following COVID-19 Infection

BACKGROUND

The clinical course of COVID-19 includes multiple disease phases. Data describing post-hospital discharge outcomes may provide insight into disease course. Studies describing post-hospitalization outcomes of adults following COVID-19 infection are limited to electronic medical record review, which may underestimate the incidence of outcomes.

OBJECTIVE

To determine 30-day post-hospitalization outcomes following COVID-19 infection.

DESIGN

Retrospective cohort study SETTING: Quaternary referral hospital and community hospital in New York City.

PARTICIPANTS

COVID-19 infected patients discharged alive from the emergency department (ED) or hospital between March 3 and May 15, 2020.

MEASUREMENT

Outcomes included return to an ED, re-hospitalization, and mortality within 30 days of hospital discharge.

RESULTS

Thirty-day follow-up data were successfully collected on 94.6% of eligible patients. Among 1344 patients, 16.5% returned to an ED, 9.8% were re-hospitalized, and 2.4% died. Among patients who returned to the ED, 50.0% (108/216) went to a different hospital from the hospital of the index presentation, and 61.1% (132/216) of those who returned were re-hospitalized. In Cox models adjusted for variables selected using the lasso method, age (HR 1.01 per year [95% CI 1.00-1.02]), diabetes (1.54 [1.06-2.23]), and the need for inpatient dialysis (3.78 [2.23-6.43]) during the index presentation were independently associated with a higher re-hospitalization rate. Older age (HR 1.08 [1.05-1.11]) and Asian race (2.89 [1.27-6.61]) were significantly associated with mortality.

CONCLUSIONS

Among patients discharged alive following their index presentation for COVID-19, risk for returning to a hospital within 30 days of discharge was substantial. These patients merit close post-discharge follow-up to optimize outcomes.

Outcome Prediction for Patients With Ischemic Stroke in Acute Care: New Three-Level Model by Eating and Bladder Functions

OBJECTIVE

To develop a new prediction model by combining independence in eating and bladder management functions, and to assess its utility in an acute care setting.

METHODS

Patients with ischemic stroke who were admitted in our acute stroke care unit (n=250) were enrolled in this study. Functional Independence Measure (FIM) scores for eating and bladder management on the initial day of rehabilitative treatment (median, 3 days) were collected as predictive variables. These scores were divided into low (<5) and high (≥5) and categorized as values 0 and 1, respectively. From the simple summation of these two-level model values, we derived a three-level model that categorized the scores as values 0, 1, and 2. The FIM-motor scores at discharge (median, 14 days) were collected as outcome measurements. The three-level model was assessed by observing the distribution patterns of the outcome FIM-motor scores and logistic regression analyses.

RESULTS

The median outcome FIM-motor score was 19 (interquartile range [IQR],13.8-45.3) for the value 0 category (n=14), 66.5 (IQR, 59.5-81.8) for the value 1 category (n=16), and 84 (IQR, 77-89) for the value 2 category (n=95) in the three-level model. Data fitting by logistic regression for FIM-motor scores of 41.3 and 61.4 reached 50% probability of values 1 and 2, respectively.

CONCLUSION

Despite the simplicity of the three-level model, it may be useful for predicting outcomes of patients with ischemic stroke in acute care.

Factors predicting clinically significant functional gain and discharge to home in stroke in-patients after rehabilitation - A retrospective cohort study

Objective

This study explored factors which predict stroke survivors who could achieve “clinically significant functional gain” and return home when being discharged from a local hospital after in-patient stroke rehabilitation programme.

Methods

This study included 562 inpatients with stroke who were residing at community dwellings before onset of stroke, and transferred to a convalescent hospital for rehabilitation from four acute hospitals over one year. The main outcome variables of prediction were (a) achieving “clinically significant functional gain” as measured by (a1) achievement of “minimal clinically important difference” (MCID) of improvement in Functional Independence Measure Motor Measure (FIM-MM)”, (a2) one or more level(s) of improvement in function group according to the patients’ FIM-MM, and (b) discharge to home. Sixteen predictor variables were identified and studied firstly with univariate binary logistic regression and those significant variables were then put into multivariate binary logistic regression.

Results

Based on multivariate regression, the significant predictors for “clinically significant functional gain” were: younger age <75 years old, higher Glasgow Coma Scale score at admission, with haemorrhagic stroke, intermediate FIM-MM function group. Those significant predictors for “discharge to home” were: living with family/caregivers before stroke, higher FIM score at admission, and one or more level(s) of improvement in FIM-MM function group.

Conclusions

This study identified findings consistent with overseas studies in additional to some new interesting findings. Early prediction of stroke discharge outcomes helps rehabilitation professionals and occupational therapists to focus on the use of appropriate intervention strategies and pre-discharge preparation.

Psychometric properties of measures of upper limb activity performance in adults with and without spasticity undergoing neurorehabilitation-A systematic review

Introduction

This systematic review appraises the measurement quality of tools which assess activity and/or participation in adults with upper limb spasticity arising from neurological impairment, including methodological quality of the psychometric studies. Differences in the measurement quality of the tools for adults with a neurological impairment, but without upper limb spasticity, is also presented.

Methods

29 measurement tools identified in a published review were appraised in this systematic review. For each identified tool, we searched 3 databases (Medline, Embase, CINAHL) to identify psychometric studies completed with neurorehabilitation samples. Methodological quality of instrument evaluations was assessed with use of the Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN) checklist. Synthesis of ratings allowed an overall rating of the psychometric evidence for each measurement tool to be calculated.

Results

149 articles describing the development or evaluation of psychometric properties of 22 activity and/or participation measurement tools were included. Evidence specific to tool use for adults with spasticity was identified within only 15 of the 149 articles and provided evidence for 9 measurement tools only. Overall, COSMIN appraisal highlighted a lack of evidence of measurement quality. Synthesis of ratings demonstrated all measures had psychometric weaknesses or gaps in evidence (particularly for use of tools with adults with spasticity).

Conclusions

The systematic search, appraisal and synthesis revealed that currently there is insufficient measurement quality evidence to recommend one tool over another. Notwithstanding this conclusion, newer tools specifically designed for use with people with neurological conditions who have upper limb spasticity, have emergent measurement properties that warrant further research.

Systematic review registration

PROSPERO CRD42014013190.

The tracheotomy tube weaning in patients with severe acquired brain injury: comparison of two operative procedures in a postacute rehabilitation hospital

BACKGROUND

Despite the high frequency of tracheotomy in severe acquired brain injury (sABI) patients, available literature about the weaning procedure is mainly represented by expert opinions with no standardized and evidence-based criteria.

AIM

The Institute of Physical and Rehabilitation Medicine "Gervasutta" adopted a new decannulation procedure, recommended by the Italian Society of Physical Medicine and Rehabilitation (SIMFER). This study evaluates whether the new procedure helps to improve the decannulation process of sABI patients.

DESIGN

A prospective observational with historical control was performed by dividing sABI patients into two groups depending on whether they were treated with or without the new procedure.

SETTING

The Department of Neurorehabilitation of the Institute of Physical and Rehabilitation Medicine "Gervasutta" in Udine, Italy.

POPULATION

sABI patients with tracheal cannula admitted to the Institute of Physical and Rehabilitation Medicine "Gervasutta" from January 2015 to March 2019.

METHODS

Clinical data were collected as both process and outcome indicators before and after the adoption of the new procedure. Data have been processed with Simple Interactive Statistical Analysis (SISA; Irving, TX, USA) software.

RESULTS

A sample of 141 patients was analysed. Among the 141 patients, 57 (40.4%) were treated with the new procedure. No differences were found between the two groups in terms of complications, functional independence measure (FIM), or level of cognitive functioning (LCF) at the admission. When the new procedure was applied, the decannulation rate was significantly higher (OR=1.8; 95% CI=1.2-9.8; P=0.01) and the time (days) between admission and oral feeding resumption was significantly lower (P<0.001; 95% CI=-10, -34 days).

CONCLUSIONS

The introduction of the new protocol allowed the safe achievement of both oral feeding resumption and decannulation, which are two of the main early rehabilitation goals.

CLINICAL REHABILITATION IMPACT

The standardization of the decannulation process has determined the achievement of a significantly faster oral feeding resumption and an increase in the decannulation rate during the rehabilitation of sABI patients.

Health related quality of life and satisfaction with care of stroke patients in Budapest: A substudy of the EuroHOPE project

BACKGROUND

Disadvantaged socioeconomic status is associated with higher stroke incidence and mortality, and higher readmission rate. We aimed to assess the effect of socioeconomic factors on case fatality, health related quality of life (HRQoL), and satisfaction with care of stroke survivors in the framework of the European Health Care Outcomes, Performance and Efficiency (EuroHOPE) study in Hungary, one of the leading countries regarding stroke mortality.

METHODS

We evaluated 200 consecutive patients admitted for first-ever ischemic stroke in a single center and performed a follow-up at 3 months after stroke. We recorded pre- and post-stroke socioeconomic factors, and assessed case fatality, HRQoL and patient satisfaction with the care received. Stroke severity at onset was scored by the National Institutes of Health Stroke scale (NIHSS), disability at discharge from acute care was evaluated by the modified Rankin Score (mRS). To evaluate HRQoL and patient satisfaction with care we used the EQ-5D-5L, 15D and EORTC IN PATSAT 32 questionnaires.

RESULTS

At 3 months after stroke the odds of death was significantly increased by stroke severity (NIHSS, OR = 1.209, 95%CI: 1.125-1.299, p<0.001) and age (OR = 1.045, 95%CI: 1.003-1.089, p = 0.038). In a multiple linear regression model, independent predictors of HRQoL were age, disability at discharge, satisfaction with care, type of social dwelling after stroke, length of acute hospital stay and rehospitalization. Satisfaction with care was influenced negatively by stroke severity (Coef. = -1.111, 95%C.I.: -2.159- -0.062, p = 0.040), and positively by having had thrombolysis (Coef. = 25.635, 95%C.I.: 5.212-46.058, p = 0.016) and better HRQoL (Coef. = 22.858, 95%C.I.: 6.007-39.708, p = 0.009).

CONCLUSION

In addition to age, disability, and satisfaction with care, length of hospital stay and type of social dwelling after stroke also predicted HRQoL. Long-term outcome after stroke could be improved by reducing time spent in hospital, i.e. by developing home care rehabilitation facilities thus reducing the need for readmission to inpatient care.

Factors Associated With Prolonged Length of Stay and Failed Lower Limb Prosthetic Fitting During Inpatient Rehabilitation

Objective

To identify variables associated with rehabilitation length of stay (LOS) and prosthetic fitting success for people with lower limb amputation (LLA).

Design

Retrospective analysis of clinically collected cohort.

Setting

Canadian inpatient rehabilitation hospital.

Participants

Consecutive individuals with LLA (N=103) admitted for prosthetic fitting (mean age, 65.3±10.6y).

Interventions

Not applicable.

Main Outcome Measures

Independent variables included the Lower Limb Amputee Measurement Scale (LLAMS), which is a 31-question tool to predict LOS with items in medical, cognitive, social, physical, activities of daily living, and other subsections; admission FIM; age; sex; level of amputation (below- or above-knee); and time from surgery to admission. LOS was measured as days from admission to discharge. Successful prosthetic fitting was defined as the ability to use a prosthesis on discharge.

Results

The mean LOS was 63.6 ± 33.3 days, and 21.4% of patients failed prosthetic fitting. Higher LLAMS, lower FIM, and above-knee amputation were significantly associated with longer LOS (P<.001, R²=0.36). Age, sex, and time from surgery were not significantly associated with LOS or prosthetic fitting. Higher LLAMS was significantly associated with unsuccessful prosthetic fitting (P=.032). Of the 31 items in the LLAMS, 5 were associated with prolonged LOS and 5 were associated with failed prosthetic fitting (P<.10).

Conclusions

The LLAMS, level of amputation, and admission FIM can be used to predict LOS in lower limb amputees admitted for prosthetic fitting. The LLAMS was weak in identifying patients who failed prosthetic fitting. Future research should consider shortening the LLAMS.

Relationship between Presence of Visceral Infarction and Functional Outcome among Patients with Acute Ischemic Stroke

INTRODUCTION

Evidence of visceral infarction is often found in patients with acute ischemic stroke. It remains uncertain whether there exists a relationship between visceral infarction and functional outcomes among patients with stroke.

OBJECTIVE

The aim of this study was to evaluate whether evidence of visceral infarction is associated with functional outcomes among patients with stroke.

METHODS

Among patients with acute ischemic stroke enrolled in the Cornell AcutE Stroke Academic Registry (CAESAR) from 2011 through 2016, we included those with a contrast-enhanced abdominal computed tomographic scan within 1 year of admission. Our outcome was ambulatory status at discharge from acute stroke hospitalization, categorized as walking without assistance, walking with assistance, and unable to walk. We used ordinal logistic regression to examine the association between visceral infarction and discharge ambulatory status after adjustment for demographics, stroke risk factors, stroke severity (NIH Stroke Scale), and stroke subtype.

RESULTS

Among 2,116 ischemic stroke patients registered in CAESAR from 2011 to 2016, 259 had contrast-enhanced abdominal computed tomographic imaging, of whom 48 (19%) had evidence of visceral infarction. After adjustment for demographics, stroke risk factors, stroke severity, and stroke subtype, the presence of visceral infarction was associated with a worse ambulatory status at discharge (global OR for better ambulatory status, 0.4; 95% CI, 0.2-1.0, p = 0.046).

CONCLUSIONS

We found that the presence of visceral infarction was associated with poor functional outcomes at the time of hospital discharge. These findings suggest that such findings are not necessarily benign and are at the least a marker of poor outcomes.

Inpatient stroke rehabilitation: prediction of clinical outcomes using a machine-learning approach

BACKGROUND

In clinical practice, therapists often rely on clinical outcome measures to quantify a patient's impairment and function. Predicting a patient's discharge outcome using baseline clinical information may help clinicians design more targeted treatment strategies and better anticipate the patient's assistive needs and discharge care plan. The objective of this study was to develop predictive models for four standardized clinical outcome measures (Functional Independence Measure, Ten-Meter Walk Test, Six-Minute Walk Test, Berg Balance Scale) during inpatient rehabilitation.

METHODS

Fifty stroke survivors admitted to a United States inpatient rehabilitation hospital participated in this study. Predictors chosen for the clinical discharge scores included demographics, stroke characteristics, and scores of clinical tests at admission. We used the Pearson product-moment and Spearman's rank correlation coefficients to calculate correlations among clinical outcome measures and predictors, a cross-validated Lasso regression to develop predictive equations for discharge scores of each clinical outcome measure, and a Random Forest based permutation analysis to compare the relative importance of the predictors.

RESULTS

The predictive equations explained 70-77% of the variance in discharge scores and resulted in a normalized error of 13-15% for predicting the outcomes of new patients. The most important predictors were clinical test scores at admission. Additional variables that affected the discharge score of at least one clinical outcome were time from stroke onset to rehabilitation admission, age, sex, body mass index, race, and diagnosis of dysphasia or speech impairment.

CONCLUSIONS

The models presented in this study could help clinicians and researchers to predict the discharge scores of clinical outcomes for individuals enrolled in an inpatient stroke rehabilitation program that adheres to U.S. Medicare standards.

Functional Performance and Discharge Setting Predict Outcomes 3 Months After Rehabilitation Hospitalization for Stroke

BACKGROUND

Some clinical features of patients after stroke may be modifiable and used to predict outcomes. Identifying these features may allow for refining plans of care and informing estimates of posthospital service needs. The purpose of this study was to identify key factors that predict functional independence and living setting 3 months after rehabilitation hospital discharge by using a large comprehensive national data set of patients with stroke.

METHODS

The Uniform Data System for Medical Rehabilitation was queried for the records of patients with a diagnosis of stroke who were hospitalized for inpatient rehabilitation from 2005 through 2007. The system includes demographic, administrative, and clinical variables collected at rehabilitation admission, discharge, and 3-month follow-up. Primary outcome measures were the Functional Independence Measure score and living setting 3 months after rehabilitation hospital discharge.

RESULTS

The sample included 16,346 patients (80% white; 50% women; mean [SD] age, 70.3 [13.1] years; 97% ischemic stroke). The strongest predictors of Functional Independence Measure score and living setting at 3 months were those same factors at rehabilitation discharge, despite considering multiple other predictor variables including age, lesion laterality, initial neurologic impairment, and stroke-related comorbid conditions.

CONCLUSIONS

These data can inform clinicians, patients with stroke, and their families about what to expect in the months after hospital discharge. The predictive power of these factors, however, was modest, indicating that other factors may influence postacute outcomes. Future predictive modeling may benefit from the inclusion of educational status, socioeconomic factors, and brain imaging to improve predictive power.

Sex Differences in Long-Term Mortality and Functional Outcome After Rehabilitation in Patients With Severe Stroke

Objective: We sought to determine sex differences in outcomes in patients with severe stroke who had been admitted to inpatient rehabilitation. Methods: We studied 1,316 patients aged 18 to 99 (mean 72) classified as case-mix groups 0108, 0109, and 0110 of the Medicare case-mix classification system. These groups encompass the most severe strokes. Three outcomes were analyzed: (1) 3-year mortality from admission to rehabilitation; (2) combined outcome of transfer to acute care or death within 90 days from admission to rehabilitation; (3) functional outcome, including proportional recovery in motor functioning and good functional outcome as defined by achievement of a Functional Independence Measure (FIM)-motor score ≥65 points at discharge. Multivariable regression analyses were used to assess sex-difference in each outcome between women and men. The covariates examined included age, marital status, comorbidities, time from stroke onset to rehabilitation admission <30 days, ischemic stroke, dysphagia, neglect, motor FIM score at admission, and cognitive FIM score at admission. Results: Kaplan-Meier estimated 3-year mortality rate was 20.7% in women and 22.0% in men. The crude hazard ratio (HR) of death for women compared with men was 0.94 (95% CI 0.74-1.20). After adjustment for significant covariates, the HR of 3-year mortality was 0.73 (95% CIs 0.56-0.96; p = 0.025). Comorbidity, including diabetes, anemia, coronary artery disease, atrial fibrillation, and chronic obstructive pulmonary disease, significantly increased mortality risk by 49-88%. The incidence of the combined outcome was 8.3% in women and 8.4% in men. The crude HR of the combined end-point for women compared with men was 1.05 (95% CI 0.72-1.53). After adjustment for significant covariates, the HR was 0.95 (95% CIs 0.65-1.40; p = 0.810). Likewise, no significant difference in proportional recovery or in the rate of achievement of a good functional outcome between women and men was observed. Conclusion: Among patients admitted to inpatient rehabilitation after severe stroke, women and men had comparable crude mortality rates at 3 years. After multivariable adjustment, however, women had lower mortality risk. No sex-differences in the risk of being transferred to acute care or dying within 90 days from admission to rehabilitation or in responsiveness to rehabilitation were observed.

BDNF Met allele Is Associated With Lower Cognitive Function in Poststroke Rehabilitation

Background and purpose. The identification of a genetic role for cognitive outcome could influence the design of individualized treatment in poststroke rehabilitation. The aim of this study is to determine whether brain-derived neurotrophic factor ( BDNF) Val66Met polymorphism is independently associated with poststroke functional outcome. Methods. A total of 775 stroke patients with genomic data were identified from the Partners HealthCare Biobank, which contains a large number of genotypes from Biobank’s consented patients. Of 775 stroke patients who met the inclusion/exclusion criteria, 86 were enrolled. Functional outcomes were assessed using the Functional Independence Measure scores at the time of admission and discharge. Logistic and linear regression models adjusted for covariate variables, including age, sex, and medical conditions, were used to evaluate the association between BDNF Val66Met and functional outcome. Results. We detected a significant correlation between Met alleles and lower cognitive function at discharge in both ischemic and hemorrhagic stroke patients. Genotyping findings confirmed that BDNF Met allele frequency was higher in contrast to Val/Val allele frequency in lower cognitive functional recovery. Furthermore, after adjusting for covariate variables, BDNF Met alleles were found to be associated with lower cognitive outcome [ P = .003; odds ratio (OR) = 5.95 (1.81-19.52)] and recovery [ P = .006; OR = 3.16 (1.4-7.15)], especially with lower problem solving, expression, and social recovery in all stroke patients. Conclusions. Met allele carriers exhibited impaired poststroke cognitive function. The BDNF genotype may be a useful predictor of cognitive function in inpatient poststroke rehabilitation.

Prediction of Prolonged Length of Stay for Stroke Patients on Admission for Inpatient Rehabilitation Based on the International Classification of Functioning, Disability, and Health (ICF) Generic Set: A Study from 50 Centers in China

Background

This study aimed to develop a risk prediction model for prolonged length of stay (LOS) in stroke patients in 50 inpatient rehabilitation centers in 20 provinces across mainland China based on the International Classification of Functioning, Disability, and Health (ICF) Generic Set case mix on admission.

Material/Methods

In this cohort study, 383 stroke patients were included from inpatient rehabilitation settings of 50 hospitals across mainland China. Independent predictors of prolonged LOS were identified using multivariate logistic regression analysis. A prediction model was established and then evaluated by receiver operating characteristic (ROC) curve analysis and the Hosmer-Lemeshow test.

Results

Multivariate logistic regression analysis showed that the type of medical insurance and the performance of daily activities (ICF, d230) were associated with prolonged LOS (P<0.05). Age and mobility level measured by the ICF Generic Set demonstrated no significant predictive value. The prediction model showed acceptable discrimination shown by an area under the curve (AUC) of 0.699 (95% CI, 0.646–0.752) and calibration (χ²=11.66; P=0.308).

Conclusions

The risk prediction model for prolonged LOS in stroke patients in 50 rehabilitation centers in China, based on the ICF Generic Set, showed that the scores for the type of medical insurance and the performance of daily activities (ICF, d230) on admission were independent predictors of prolonged LOS. This prediction model may allow stakeholders to estimate the risk of prolonged LOS on admission quantitatively, facilitate the financial planning, treatment regimens during hospitalization, referral after discharge, and reimbursement.

Referral patterns of stroke rehabilitation inpatients to a model system of outpatient services in Ontario, Canada: a 7-year retrospective analysis

Background

While several studies have tracked the care paths of patients in the early phases of stroke recovery, studies examining the transition from inpatient to outpatient rehabilitation are lacking. Examining this transition allows for improved understanding and refinement of the process whereby patients are referred and admitted to programs. The objective of this study was to examine the referral patterns of stroke rehabilitation inpatients to outpatient stroke therapy services, their demographics, and clinical profile.

Methods

This study examined patients who: (1) were admitted to an inpatient stroke rehabilitation unit between January 1, 2009 and March 1, 2016, (2) had a stroke diagnosis, (3) had an inpatient length of stay of > 1 day, and (4) lived within the geographical boundaries of the South West Local Health Integration Network which allowed them access to both hospital-based and home-based stroke rehabilitation outpatient programs. Patient data was collected from the National Rehabilitation Reporting System, as well as three hospital outpatient administrative databases. These databases were cross-referenced to determine each patient’s pathway. Those referred to an outpatient therapy program, and those who attended the outpatient programs, were compared to those who were not, and did not, respectively.

Results

1497 inpatients were included in the analysis. Upon discharge, 1037 (69.3%) of patients had an outpatient clinic, follow-up appointment scheduled; of those, 902 (87.0%) patients attended at least one outpatient clinic visit. 891 (59.5%) were referred to one of the interdisciplinary outpatient stroke rehabilitation programs; of those, an outpatient therapy program was attended by 80.9% of patients (n = 721). Of those receiving outpatient therapy services, the number of patients attending the in-hospital versus home-based program were equal, 360 and 361 individuals, respectively.

Conclusion

This study allows for a better understanding of the transition between inpatient and outpatient stroke care. There is a paucity of this type of information in stroke rehabilitation literature to date. This study acts as a starting point in improving rehabilitation planning across the continuum of care.

Prognostic Factors of Functional Outcome Assessed by Using the Modified Rankin Scale in Subacute Ischemic Stroke

Background

Most stroke survivors spent their lifetime with disability which not only affects the clients themselves and the family but also brings economic cost to the country. Therefore, this retrospective cohort study aimed to identify independent prognostic determinants associated with functional recovery in ischemic stroke within 6 months after onset.

Methods

Data from all first-onset ischemic stroke patients admitted to the acute stroke unit of the tertiary, university hospital were reviewed for 5 years consecutively. The functional outcome of the patients was recorded during 6-month follow-up by using the modified Rankin Scale (mRS). Baseline characteristics, motor assessment and all stroke-related variables were assessed during first week after stroke and 6-month follow-up. In order to derive clinical predictors, the backward stepwise multivariable risk regression analyses were used with the generalized linear model.

Results

The result revealed that in the 358 patients recruited into this study, 255 (71.2%) were in the functional recovery group (mRS score of 1 - 3) within 6 months after onset. The final model of multivariable risk regression analysis, with generalized linear model, demonstrated that the independent variables of functional recovery were leg score with a risk ratio (RR = 1.92, 95% confidence interval (CI): 1.14 - 3.21, P = 0.013), arm score (RR = 1.75, 95% CI: 1.02 - 3.01, P = 0.042) and age older than 75 years (RR = 1.36, 95% CI: 1.04 - 1.77, P = 0.025).

Conclusions

Achieving functional recovery during 6 months post stroke was related to age and motor improvement. With limited resources, continuity of rehabilitation training in the community system or allocation of caregiver training should be a part of discharge planning to promote recovery.

Leukoaraiosis Predicts Short-term Cognitive But not Motor Recovery in Ischemic Stroke Patients During Rehabilitation

BACKGROUND

Leukoaraiosis has been shown to impact functional outcomes after acute ischemic stroke. However, its association with domain specific recovery after ischemic stroke is uncertain. We sought to determine whether pre-existing leukoaraiosis is associated with short-term motor and cognitive recovery after stroke.

METHODS

We retrospectively studied ischemic stroke patients admitted to acute inpatient rehabilitation (AIR) between January 2013 and September 2015. Patient baseline characteristics, infarct volume, prestroke modified Rankin Scale, stroke cause, rehabilitation length of stay, and Functional Independence Measure (FIM) scores were recorded. Leukoaraiosis severity was graded on brain magnetic resonance imaging using the Fazekas scale. Multiple linear regression was used to determine factors independently associated with the total, cognitive, and motor FIM scores at AIR discharge, respectively.

RESULTS

Of 1600 ischemic stroke patients screened, 109 patients were included in the final analysis. After adjustment, the initial National Institute of Health Stroke Scale (β -0.541, confidence interval [CI] -0.993 to -0.888; P = 0.020) and pre-existing leukoaraiosis severity (β -1.448, CI -2.861 to -0.034; P = 0.045) independently predicted the total FIM score. Domain specific analysis showed that infarct volume (β -0.012, CI -0.019 to -0.005; P = 0.002) and leukoaraiosis severity (β -0.822, CI -1.223 to -0.410; P = 0.0001) independently predicted FIM cognitive scores at discharge from AIR. Leukoaraiosis did not predict FIM motor score (P = 0.17).

CONCLUSIONS

Leukoaraiosis severity is an independent predictor of total and cognitive, but not motor FIM scores after AIR for acute ischemic stroke. This highlights that leukoaraiosis affects poststroke recovery in a domain specific fashion, information that may aid counseling of patients and families as well as tailor rehabilitative efforts.

Applying bifactor modelling to improve the clinical interpretive values of Functional Independence Measure in adults with acquired brain injury

Purpose: To apply a modern robust approach, bifactor modeling, to critically examine psychometric properties of Functional Independence Measure (FIM) in adults with acquired brain injury and to propose a solution to improve the clinical interpretive values of the FIM to inform policy and clinical practice.Methods: The data came from a state-wide specialist in-patient brain injury rehabilitation service in Queensland, Australia for adults with acquired brain injury and discharged between 2012 and 2017. The sample included 457 people. Three measurement models (unidimensional, correlated first-order and bifactor) for FIM were tested using confirmatory factor analysis with structural equation modeling. Then, model-based reliability and incremental validity were assessed.Results: The bifactor model best fit the data. When operationalized as latent factors under structural equation modeling framework, general care burden had a large predictive effect, while Motor and Cognitive showed medium and small predictive effects respectively on rehabilitation length of stay.Conclusions: The total score of FIM was a reliable measure of general care burden, while the subscale scores were not. A solution is to apply a bifactor modeling approach based on structural equation modeling to disentangle the unique variance attributable to Motor and Cognitive factors. In the structural equation modeling framework, the FIM demonstrated good incremental validity to inform policy and clinical practice.Implications for rehabilitationClinicians and researchers can confidently use FIM total score in adults with acquired brain injury.The current study proposed an alternative solution to the poor reliability of Motor and Cognitive scores, that is, by applying a bifactor modeling approach, the unique contributions of the Motor and Cognitive factors can be examined.The current study has demonstrated the strengths of bifactor modeling in the robust validation and interpretation of FIM to better inform clinical practice and policy decision-making.The current study has the potential to make an important contribution to enhance more equitable decision-making in the areas of national benchmarking of rehabilitation outcomes and other program eligibility criteria and funding allocation.

Determination of the cut-off point of the Functional Independence Measure as a predictor of adverse events in patients with acute stroke

Objective

This study was performed to determine the cut-off point of the Functional Independence Measure (FIM) to discriminate patients with acute stroke who develop adverse events during their stay in a stroke care unit (SCU).

Methods

All consecutive patients with stroke admitted to a single institute from January to March 2015 were enrolled. They were divided into two groups according to their average daily energy intake in the SCU: ≥66% or <66% of the target (high- and low-energy group, respectively). A receiver operating characteristic curve was used to determine the cut-off point of the FIM to predict adverse events in patients with acute stroke.

Results

The length of stay in the SCU was significantly longer and the serum C-reactive protein level (CRP) was significantly higher in the low- than high-energy group (7 vs. 4 days and 2.15 vs. 0.20 mg/dL, respectively). The total FIM score cut-off value was 63 points.

Conclusions

An energy intake of <66% of the target was associated with a significantly longer stay in the SCU and a higher CRP level. A total FIM score cut-off value of 63 points is useful to discriminate patients with adverse events among those with acute stroke.

Neurocognitive functioning is associated with functional independence in newly diagnosed patients with temporal lobe glioma

BACKGROUND

Cancer and treatment-related neurocognitive dysfunction has the potential to significantly disrupt the lives of survivors. While neurocognitive functioning is known to predict aspects of patient-reported quality of life in individuals with glioma, little is known regarding the association between neurocognitive functioning and clinician-rated functional independence.

METHODS

Newly diagnosed patients with glioma in the left (n = 73; 49% glioblastoma) or right (n = 30; 57% glioblastoma) temporal lobe completed comprehensive neuropsychological testing. Clinicians rated patient functional independence using the Functional Independence Measure (FIM) and Karnofsky Performance Status (KPS) scale. Correlational and regression analyses were conducted to determine relationships between neurocognitive functioning and functional independence.

RESULTS

Tests of verbal learning, executive function, and language comprehension were moderately to strongly associated with clinician-rated functional independence, particularly for items pertaining to need for assistance with memory, problem-solving, and language functions. Stepwise linear regression showed that tests of verbal learning, executive functioning, and language comprehension predicted FIM ratings, together accounting for 40% of variance (P < .001). A test of executive functioning also predicted KPS scores and accounted for 19% of variance (P < .001).

CONCLUSIONS

In patients with newly diagnosed temporal lobe glioma, neurocognitive functioning is associated with functional independence. Verbal learning, executive functioning, and language comprehension demonstrated the strongest associations across both measures of functional independence. These findings provide support for the ecological validity of neuropsychological assessment by demonstrating the real-world clinical significance of objectively assessed neurocognitive functioning in glioma patients.

Rehabilitation Outcomes of Patients With Severe Disability Poststroke

OBJECTIVE

To characterize rehabilitation outcomes of patients with severe poststroke motor impairment (MI) and develop a predictive model for treatment failure.

DESIGN

Retrospective cohort study. Correlates of treatment failure, defined as the persistence of severe MI after rehabilitation, were identified using logistic regression analysis. Then, an integer-based scoring rule was developed from the logistic model.

SETTING

Three specialized inpatient rehabilitation facilities.

PARTICIPANTS

Patients (N=1265) classified as case-mix groups (CMGs) 0108, 0109, and 0110 of the Medicare classification system.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Change in the severity of MI, as assessed by the FIM, from admission to discharge.

RESULTS

Median FIM-motor (FIM-M) score increased from 17 (interquartile range [IQR] 14-23) to 38 (IQR, 25-55) points. Median proportional recovery, as expressed by FIM-M effectiveness, was 26% (IQR, 12-47). Median FIM-M change was 18 (IQR, 9-34) points. About 38.5% patients achieved the minimal clinically important difference. Eighteen point six percent and 32.0% of the patients recovered to a stage of either mild (FIM-M ≥62) or moderate (FIM-M 38-61) MI, respectively. All between-CMG differences were statistically significant. Outcomes have also been analyzed according to classification systems used in Australia and Canada. The scoring rule had an area under the curve of 0.833 (95% confidence interval, 0.808-0.858). Decision curve analysis displayed large net benefit of using the risk score compared with the treat all strategy.

CONCLUSIONS

This study provides a snapshot of rehabilitation outcomes in a large cohort of patients with severe poststroke MI, thus filling a gap in knowledge. The scoring rule accurately identified the patients at risk for treatment failure.

Association between older adults’ functional performance and their scores on the Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA)

Purpose

The paper aims to investigate if the performance of older adults on the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) were associated or predictive of their functional performance in a geriatric evaluation and management (GEM) inpatient hospital setting. This will inform the occupational therapy assessment and management of older adults admitted to sub-acute GEM settings.

Design/methodology/approach

In all, 20 participants (11 men, 9 women, mean age 82 years, SD = 6.93) were recruited from a GEM ward in an Australian hospital. Participants’ cognitive abilities were assessed using the MMSE and MoCA, and their functional performance were assessed using the Functional Independence Measure (FIM). Spearman’s rho correlations and linear regression analyses were completed. Bootstrapping was applied to the regression analyses to accommodate the small study sample size.

Findings

No statistically significant correlations were obtained between the total and subscale scores of the MMSE and FIM or between the total and subscale scores of the MoCA and FIM. In other words, the cognitive and functional abilities of older adults admitted to a GEM setting were not significantly associated in this study.

Originality/value

The findings suggest that the MoCA and the MMSE were not predictive of participants’ functional performance as measure by the FIM in a sub-acute GEM setting. Occupational therapists should be cautious when interpreting participants’ MMSE, MoCA and FIM results and not depend solely on these results in the goal setting and intervention planning processes for clients on GEM wards. Further studies are recommended to confirm these findings.

Length of Stay and Functional Outcomes Among Patients with Stroke Discharged from an Inpatient Rehabilitation Facility in Saudi Arabia

Background

In many countries, the length of stay (LOS) for inpatient rehabilitation following stroke has gradually decreased. It is unclear whether this trend is associated with differences in functional outcomes, especially in developing countries. This study aimed to examine associations between LOS and functional outcomes among patients with stroke discharged from an inpatient rehabilitation facility in Saudi Arabia.

Material/Methods

This retrospective study included all patients (N=409) aged ≥18 years who were admitted to an inpatient rehabilitation for stroke during 2008–2014. There were no deaths in the cohort during the study period. Patients were divided into 4 groups according to days of rehabilitation: ≤30 days (n=114), 31–60 days (n=199), 61–90 days (n=72), and >90 days (n=24). Multivariate regression analyses were used to evaluate functional outcomes using the functional independence measure (FIM).

Results

The fully adjusted model showed that higher total and subscale FIM scores were significantly associated with a LOS ≤30 days (total β: 18.2, standard error [SE]=4.43, P≤0.0001; motor-FIM: β=13.9, SE=3.70, P=0.0002; cognitive-FIM: β=4.3, SE=1.29, P=0.001), and 31–60 days (total β: 11.3, SE=4.07, P=0.005; motor-FIM: β=8.8, SE=3.40, P=0.009; cognitive-FIM: β=2.4, SE=1.19, P=0.038) compared with >90 days.

Conclusions

A short or intermediate LOS is not necessarily associated with worse outcomes, assuming adequate care is provided.