A new method for predicting functional recovery of stroke patients with hemiplegia: logarithmic modelling

Performance of a prediction method for activities of daily living scores using influence coefficients in patients with stroke

Introduction

Recently, a method was developed to predict the motor Functional Independence Measure (FIM) score at discharge in patients with stroke by stratifying the effects of factors such as age and cognitive function and multiplying those by the influence coefficients of these factors. However, an evaluation of the predictive performance of the method is required for clinical application. The present study aimed to evaluate the predictive performance of this prediction method.

Methods

Patients with stroke discharged from a rehabilitation ward between April 2021 and September 2022 were included. Predicted values of the motor FIM score at discharge were calculated after data collection from the hospital's patient database. The concordance between predicted and actual values was evaluated using the interclass correlation coefficient; moreover, the residual values were calculated.

Results

In total, 207 patients were included in the analysis. The median age was 79 (69-85) years, and 112 (54.1%) patients were male. The interclass correlation coefficient between predicted and actual values was 0.84 (95% confidence interval 0.75-0.89) for the motor FIM score at discharge. Meanwhile, the median residual value was 5.3 (-2.0-10.3) for the motor FIM score at discharge.

Discussion

The prediction method was validated with good performance. However, the residual values indicated that some cases deviated from the prediction. In future studies, it will be necessary to improve the predictive performance of the method by clarifying the characteristics of cases that deviate from the prediction.

Stroke Severity, Caregiver Feedback, and Cognition in the REGARDS-CARES Study

BACKGROUND

Cognitive impairment after stroke is common and is present in up to 60% of survivors. Stroke severity, indicated by both volume and location, is the most consequential predictor of cognitive impairment, with severe strokes predicting higher chances of cognitive impairment. The current investigation examines the associations of 2 stroke severity ratings and a caregiver-report of poststroke functioning with longitudinal cognitive outcomes.

METHODS AND RESULTS

One hundred fifty-seven caregivers and stroke survivor dyads participated in the CARES (Caring for Adults Recovering From the Effects of Stroke) project, an ancillary study of the REGARDS (Reasons for Geographic and Racial Differences in Stroke) national cohort study. The Glasgow Outcome Scale and modified Rankin Scale scores collected at hospitalization discharge were included as 2 primary predictors of cognitive impairment. The number of caregiver-reported problems and impairments at 9 months following stroke were included as a third predictor. Cognition was measured using a biennial telephone battery and included the domains of learning, memory, and executive functioning. Multiple cognitive assessments were analyzed up to 5 years poststroke, controlling for prestroke cognition and demographic variables of the stroke survivor. Separate mixed models showed significant main effects of the Glasgow Outcome Scale (b=0.3380 [95% CI, 0.14-0.5]; P=0.0009), modified Rankin Scale (b=-0.2119 [95% CI, -0.32 to -0.10]; P=0.0002), and caregiver-reported problems (b=-0.0671 [95% CI, -0.09 to -0.04]; P<0.0001) on longitudinal cognitive scores. In a combined model including all 3 predictors, only caregiver-reported problems significantly predicted cognition (b=-0.0480 [95% CI, -0.08 to -0.03]; P<0.0001).

CONCLUSIONS

These findings emphasize the importance of caregiver feedback in predicting cognitive consequences of stroke.

Stroke Severity, Caregiver Feedback, and Cognition in the REGARDS-CARES Study

Objective

Cognitive impairment after stroke is common, present up to 60% of survivors. Stroke severity, indicated by both volume and location, is the most consequential predictor of cognitive impairment, with severe strokes predicting higher chances of cognitive impairment. The current investigation examines the associations of two stroke severity ratings and a caregiver-report of post-stroke functioning with longitudinal cognitive outcomes.

Methods

The analysis was conducted on 157 caregivers and stroke survivor dyads who participated in the Caring for Adults Recovering from the Effects of Stroke (CARES) project, an ancillary study of the REasons for Geographic and Racial Differences in Stroke (REGARDS) national cohort study. Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS) collected at hospitalization discharge were included as two primary predictors of cognitive impairment. The number of caregiver-reported problems and impairments at nine months following stroke were included as a third predictor. Cognition was assessed using a biennial telephone battery, incorporating multiple cognitive assessments to assess learning, memory, and executive functioning. Longitudinal cognitive scores were analyzed up to five years post-stroke, controlling for baseline (pre-stroke) cognitive scores and demographic variables of each stroke survivor collected at CARES baseline.

Results

Separate mixed models showed significant main effects of GOS (b=0.3280, p=0.0009), mRS (b=-0.2119, p=0.0002), and caregiver-reported impairments (b=-0.0671, p<0.0001) on longitudinal cognitive scores. In a combined model including all three predictors, only caregiver-reported problems significantly predicted cognitive outcomes (b=-0.0480, p<0.0001).

Impact

These findings underscore the importance of incorporating caregivers feedback in understanding cognitive consequences of stroke.

Modeling outcome trajectories in patients with acquired brain injury using a non-linear dynamic evolution approach

This study describes a dynamic non-linear mathematical approach for modeling the course of disease in acquired brain injury (ABI) patients. Data from a multicentric study were used to evaluate the reliability of the Michaelis-Menten (MM) model applied to well-known clinical variables that assess the outcome of ABI patients. The sample consisted of 156 ABI patients admitted to eight neurorehabilitation subacute units and evaluated at baseline (T0), 4 months after the event (T1) and at discharge (T2). The MM model was used to characterize the trend of the first Principal Component Analysis (PCA) dimension (represented by the variables: feeding modality, RLAS, ERBI-A, Tracheostomy, CRS-r and ERBI-B) in order to predict the most plausible outcome, in terms of positive or negative Glasgow outcome score (GOS) at discharge. Exploring the evolution of the PCA dimension 1 over time, after day 86 the MM model better differentiated between the time course for individuals with a positive and negative GOS (accuracy: 85%; sensitivity: 90.6%; specificity: 62.5%). The non-linear dynamic mathematical model can be used to provide more comprehensive trajectories of the clinical evolution of ABI patients during the rehabilitation period. Our model can be used to address patients for interventions designed for a specific outcome trajectory.

Clinical Items for Geriatric Patients with Post-Stroke at Discharge or Transfer after Rehabilitation Therapy in a Chronic-Phase Hospital: A Retrospective Pilot Study

Clinical factors related to destination after rehabilitation therapy for geriatric patients with post-stroke in chronic-phase hospitals have not been elucidated. This study analyzed the clinical characteristics of geriatric patients with post-stroke at discharge/transfer after rehabilitation therapy in a chronic-phase hospital. Fifty-three patients (20 men, 33 women; mean age 81.36 ± 8.14 years) were recruited (the period analyzed: October 2013−March 2020). Clinical data were statistically analyzed among patients discharged to homes or facilities for older adults or transferred to another hospital. In addition, we analyzed the clinical items at discharge and transfer after rehabilitation therapy using a decision tree analysis. Twelve patients were discharged, eighteen were discharged to facilities for older adults, and twenty-three were transferred to another hospital. There were significant differences in the modified Rankin Scale, admission dates, functional independence measure (FIM) score, and Barthel Index score in the three groups (p < 0.05). Patients with motor subtotal functional independence scores of ≥14 (chronologically improved ≥5) after rehabilitation therapy for <291 days were more likely to be discharged home. Patients in a chronic-phase hospital who improved within a limited period were discharged to their homes, whereas those who were bedridden tended to be transferred to another hospital.

The addition of mirror therapy improved upper limb motor recovery and level of independence after stroke: a randomized controlled trial

Abstract Introduction In stroke survivors, the prevalence of upper motor disability remains high. There has not been much report on the success of post-stroke mirror therapy, especially in developing countries. Objective The focus of this research is to see how mirror therapy, in addition to standard rehabilitation for hand paresis, affects upper limb motor recovery and level of independence in self-care after stroke at an Indonesian teaching hospital. Method This was a randomized controlled trial with no assessor blinding. The study included 18 subacute stroke patients who did not have cognitive or visual impairment. The mirror group received a 20-minute mirror therapy session in addition to conventional rehabilitation, while the control group received only the standard program for 5 weeks (2 times per week). The Brunnstrom score and self-care level of independence elements of the Functional Independence Measure (FIM) were used as outcome measures. Results Baseline comparisons of lesion type and Brunnstrom score showed significant between-group differences. The ANACOVA test showed the difference had no effect on the FIM change in scores (P > 0.05). One patient (mirror group) was dropped out from the study. After 5 weeks (n=17), the mirror group showed improvement in both the Brunnstrom and FIM scores (P < 0.05) compared to the control group. Conclusions Mirror treatment improves upper limb motor recovery and level of independence in self-care after stroke when combined with standard hand paresis rehabilitation 2 times a week for 5 weeks.

Observation of others' actions during limb immobilization prevents the subsequent decay of motor performance

There is rich clinical evidence that observing normally executed actions promotes the recovery of the corresponding action execution in patients with motor deficits. In this study, we assessed the ability of action observation to prevent the decay of healthy individuals' motor abilities following upper-limb immobilization. To this end, upper-limb kinematics was recorded in healthy participants while they performed three reach-to-grasp movements before immobilization and the same movements after 16 h of immobilization. The participants were subdivided into two groups; the experimental group observed, during the immobilization, the same reach-to-grasp movements they had performed before immobilization, whereas the control group observed natural scenarios. After bandage removal, motor impairment in performing reach-to-grasp movements was milder in the experimental group. These findings support the hypothesis that action observation, via the mirror mechanism, plays a protective role against the decline of motor performance induced by limb nonuse. From this perspective, action observation therapy is a promising tool for anticipating rehabilitation onset in clinical conditions involving limb nonuse, thus reducing the burden of further rehabilitation.

Quality of Life and Negative Affectivity at the Patients with Stroke and Musculoskeletal Disorders

Introduction. Stroke can be a severe debilitating medical condition due to its medical consequences. When it occurs at an individual with pre-existent musculoskeletal disorders, the medical recovery becomes more problematic. Some consequences, like negative affectivity and a reduced quality of life intervene to varying degrees. Material and method. Our study included 150 outpatients who were diagnosed with stroke and one of five types of musculoskeletal disorders (low back pain, osteoporosis, hand disorders, hip osteoarthritis, knee osteoarthritis). We divided all the patients in five sub-groups. To assess the negative affectivity (anxiety) and quality of life we administered to the patients two scales: the State Trait Anxiety Inventory (STAI) form X1 (anxiety a s a state) and form X2 (anxiety as a trait) and The Quality of Life (QOL). Results. In patients diagnosed with stroke and osteoporosis, the quality of life was 83.92% of the maximum value. Anxiety as a state rated at an average of 50.5 and anxiety as a trait rated at an average of 45. In the case of stroke and degenerative diseases at the lower limbs, we registered the quality of life of 77.68% in knee osteoarthritis and 75.89% in hip osteoarthritis; anxiety as a condition had an average value of 65 and, as a trait, a value of 63 in knee osteoarthritis, while in hip osteoarthritis the anxiety as a condition, and, in the same time, as a trait, rated both at 49.5. Low back pain in stroke patients had a quality of life of 77.86% of the maximum value; anxiety as a condition was 48 and the anxiety trait has the value of 47. For the patients with stroke and hand disease, the quality of life was assessed at 88.83%. Anxiety as a condition recorded an average value of 48 and the average value of 51 for anxiety as a trait recorded an average value of 51. Conclusions. The lowest score of quality of life is recorded in the patient diagnosed with stroke and hip osteoarthritis (75.89% of the maximum value). This association converges with body dynamics, as the overlap of these two medical conditions may explain reduced functionality. The value of anxiety as a condition and also as a trait was higher in patients with stroke and osteoarthritis of the knee (65 and 63, respectively). The latter result is understandable, as intense pain and, therefore, discomfort related to osteoarthritis of the knee is well known. Keywords: stroke, anxiety, quality of life, musculoskeletal conditions,

The potential of prediction models of functioning remains to be fully exploited: A scoping review in the field of spinal cord injury rehabilitation

OBJECTIVE

The study aimed to explore existing prediction models of functioning in spinal cord injury (SCI).

STUDY DESIGN AND SETTING

The databases PubMed, EBSCOhost CINAHL Complete, and IEEE Xplore were searched for relevant literature. The search strategy included published search filters for prediction model and impact studies, index terms and keywords for SCI, and relevant outcome measures able to assess functioning as reflected in the International Classification of Functioning, Disability and Health (ICF). The search was completed in October 2020.

RESULTS

We identified seven prediction model studies reporting twelve prediction models of functioning. The identified prediction models were mainly envisioned to be used for rehabilitation planning, however, also other possible applications were stated. The method predominantly used was regression analysis and the investigated predictors covered mainly the ICF-components of body functions and activities and participation, next to characteristics of the health condition and health interventions.

CONCLUSION

Findings suggest that the development of prediction models of functioning for use in clinical practice remains to be fully exploited. By providing a comprehensive overview of what has been done, this review informs future research on prediction models of functioning in SCI and contributes to an efficient use of research evidence.

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.

The importance of balance and postural control in the recovery of stroke patients

Introduction.According to the criteria of WHO, stroke is a health condition that causes focal or global brain disorders (1), but without an apparent nonvascular cause. Stroke is considered the third leading cause of death in industrialized countries and accounts for 9% of all deaths, being considered one of the largest cases of disability in the world. Due to the medical, social and economic consequences that it causes, stroke is considered a public health issue. Purpose of research. The study starts from the idea that in the recovery of stroke patients it is important to have an individualized physiotherapy program adapted to the functional parts of each patient, having the role of improving the static and dynamic balance, of achieving postural control and finally functional independence. Material and method. The study included a number of 22 patients with sequelae stroke. They made physiotherapy, occupational therapy and occupational therapy sessions in the ambulatory, with the length of 1 hour, 3 times a week, in total 15 sessions. The evaluation of the patient was performed in the beginning of the treatment and at the end of it. Scales were used to assess mobility, static and dynamic balance, gait and functional independence. Results. The application of individualized treatment adapted to the functional body of each patient allowed a rapid recovery for the vast majority of the studied patients. The values obtained in the tests and evaluation scales are in accordance with the clinical evolution of the patients. Conclusions.The application of the treatment by kinetic therapy, work therapy and occupational therapy to the 22 patients, for a period of 3 weeks pointed out the reduction of pain, the improvement of movements, the recovery of transfers and gait, the postural improvement.

Effect of acetylcholinesterase inhibitors on post-stroke cognitive impairment and vascular dementia: A meta-analysis

Cognitive impairment is a common complication observed after a stroke. Currently there are no definitively proven pharmacologic therapies for recovery from post-stroke cognitive impairment and vascular dementia. In this meta-analysis, we evaluated the efficacy and safety of cholinesterase inhibitors in their improvement of cognition in patients with post-stroke cognitive impairment and vascular dementia. We conducted a meta-analysis using seven eligible studies from 305 published articles. We investigated the differences in Mini-Mental State Examination (MMSE) and Alzheimer's Disease Assessment Scale-Cognitive subscale (ADAS-Cog) scores, before and after cholinergic augmentation in patients with post-stroke cognitive impairment and vascular dementia. MMSE and ADAS-cog scores were also compared during the subsequent follow-up periods. MMSE score of patients with post-stroke cognitive impairment was increased after cholinergic augmentation throughout the 24 weeks with mean differences [MD] of 3.000, 1.732, 1.578 1.516, and 1.222, at 4, 4-8, 8-12, 12-18, and 18-24 weeks, respectively. In addition, ADAS-cog scores decreased at 6, 12, 18, and 24 weeks by pharmaceutical augmentation, but not with placebo with mean differences [MD] of -2.333, -2.913, -2.767, -2.416, and -1.859, respectively. This meta-analysis shows that acetylcholinesterase inhibitors maintain a stable pattern of improved cognitive function in patients with post stroke cognitive impairment and vascular dementia without the increased risk of side effects.

Association Between SCIM III Total Scores and Individual Item Scores to Predict Independence With ADLs in Persons With Spinal Cord Injury

Objective

To clarify the activities of daily living (ADL) structure of persons with spinal cord injury (SCI) by analyzing the associations between the Spinal Cord Independence Measure III (SCIM III) total score and individual SCIM III item scores.

Design

A retrospective survey.

Setting

A national hospital with 2 SCI units in Japan.

Participants

Inpatients (N=81) within 60 days of SCI onset were included (men, 84%). The mean age was 62 years. Of these, 63 persons had incomplete SCI (47 persons had tetraplegia).

Interventions

Not applicable.

Main Outcome Measure

SCIM III was used to assess the ADL independence level on a monthly basis during hospitalization. SCIM III data were analyzed with ordinal logistic analyses.

Results

The analyses revealed that SCIM III total scores accounted for the probabilities of individual SCIM III item scores. Goodness-of-fit of each logistic model by Wald test was significant (P<.001, R²_McFadden=0.183-0.598). Some items in the self-care domain showed a shallow (ie, less steep) logistic curve. Regarding the feeding item, a total score of 80 was needed to attain the complete independence level, while patients with a total score >10 attained modified independence level.

Conclusions

The SCIM III total score can provide information on the probability and degree of difficulty of attaining independence for each item. Therefore, the present total SCIM III scores could be the indication for ADL attainment. In addition, the higher total SCIM III score and the probability of individual items score are useful for planning efficient rehabilitative approaches, considering the degree of difficulty of attaining independence for each item. Moreover, our results show good generalizability across patients with complete and incomplete SCI.

Prediction of changes in functional ability of inpatients with schizophrenia using logarithmic and linear regression modelling

Background/Objective

Few studies have addressed the type of time course regression that can predict changes in functional ability in inpatients with schizophrenia. This study investigated the possibility of predicting changes in functional ability by logarithmic and linear regression modelling when treating schizophrenia.

Methods

This longitudinal study included two analysis rounds. Analysis 1 comprised 40 inpatients (male/female: 16/24, mean age: 39.7 ± 13.5 years) for the identification of the time course of changes in functional ability based on the Activity Profile Scale for Patients with Psychiatric Disorders score from the group data. Analysis 2 comprised 17 inpatients (male/female: 9/8, mean age: 38.5 ± 9.4 years) to ensure correlation of the group data with the prediction of each individual’s degree of functional ability.

Results

In Analysis 1, Activity Profile Scale for Patients with Psychiatric Disorders score was assessed at the initial occupational therapy visit, one week and one month thereafter, and at discharge; logarithmic modelling using the scores at the initial visit, one month later and at discharge was more suitable (R² = .506, p < .001) than the logarithmic and linear regression models using other score combinations. In Analysis 2, the individual’s predicted Activity Profile Scale for Patients with Psychiatric Disorders scores at discharge, as calculated by logarithmic modelling using scores from the initial visit and one month later, correlated moderately with actual Activity Profile Scale for Patients with Psychiatric Disorders scores (R² = .574, p < .001; ICC = .747, p < .001).

Conclusion

Logarithmic modelling based on Activity Profile Scale for Patients with Psychiatric Disorders score accurately predicted changes in the functional ability of inpatients with schizophrenia and is sufficiently uncomplicated to be adopted in daily clinical practice.

Long-Term Outcomes of FIM Motor Items Predicted From Acute Stage NIHSS of Patients With Middle Cerebral Artery Infarct

Objective

To outline the association between the National Institutes of Health Stroke Scale (NIHSS) in the acute stage and the Functional Independence Measure (FIM) of motor items several months later.

Methods

Seventy-nine infarct cases with middle-cerebral-artery region transferred to long-term rehabilitation facilities were analyzed. Patients were allocated to either the model-development group or the confirmatory group at a 2:1 ratio. Independent variables were based on the NIHSS during the acute care and on demographic factors such as age and modified Rankin Scale (mRS) before onset. Multivariate logistic analyses were performed to predict the independence of each FIM motor item. These models were evaluated in the confirmatory group.

Results

Multivariate logistic analyses in the model-development group (n=53) indicated that at least one NIHSS item was statistically significantly associated with the functional independence of a single FIM motor item. Of the NIHSS items, the affected lower extremity item was the most widely associated with 11 of the FIM motor items, except for eating and shower transfer. The affected upper extremity function was the second widely involved factor associated with 7 of the FIM motor items including eating, grooming, bathing, toileting, bed transfer, toilet transfer, and shower transfer. Age and mRS were also statistically significant contributing factors. The obtained predictive models were assessed in the confirmatory group (n=26); these were successful except for the stairs climb item.

Conclusion

In combination with age and pre-stroke status, the NIHSS items (especially the affected extremity items) may be useful for the prediction of long-term outcome in terms of activities in daily living.

Prediction of destination at discharge from a comprehensive rehabilitation hospital using the home care score

[Purpose] This study investigated whether it is possible to predict return to home at discharge from a rehabilitation hospital in Japan using the home care score of patients with cerebrovascular or osteoarticular disease and low activities of daily living at admission. [Subjects and Methods] The home care score and functional independent measurement were determined for 226 patients at admission and at discharge from five hospitals, and receiver operating characteristic analyses were conducted. [Results] The home care score cutoff point for the prediction of return to home at admission and at discharge was 11, and the area under the curve was more than 0.8. The area under the curve of the home care score was 0.77 for patients with low activities of daily living and within this group, the probability of return to home was approximately 50%, as predicted by the functional independent measurement. The home care score increased after receiving intervention at a rehabilitation hospital. [Conclusion] The home care score is useful for the prediction of return to home from a rehabilitation hospital, although prediction using the functional independent measurement is difficult for patients with low activities of daily living. Moreover, comprehensive interventions provided by the rehabilitation hospitals improve the ability to provide home care of the patient’s family, which is assessed by the home care score.

Post-stroke depression inhibits improvement in activities of daily living in patients in a convalescent rehabilitation ward

[Purpose] There have been no investigations into the improvement of activities of daily living among patients suffering from post-stroke depression on admission to convalescent rehabilitation wards in Japan. This study aimed to assess the improvement of activities in daily living in patients with or without post-stroke depression at the time of admission to a convalescent rehabilitation ward. [Subjects and Methods] This retrospective study included 108 stroke patients divided into two groups according to their Geriatric Depression Scale 15-item short form scores. Activities of daily living were assessed using the Functional Independence Measure. The degree of improvement on the Functional Independence Measure was defined as the difference between scores on admission and at discharge. [Results] The Functional Independence Measure gain score was significantly different from the Functional Independence Measure total score. There was a significant interaction between time period and post-stroke depression factors for the Functional Independence Measure total score. A multiple regression analysis revealed a significant association between Geriatric Depression Scale score and Functional Independence Measure total score. [Conclusion] The present study suggests that post-stroke depression has a negative impact on recovery of activities of daily living and on rehabilitation outcomes in a convalescent rehabilitation ward setting.

Outcome of Rehabilitation and Swallowing Therapy after Percutaneous Endoscopic Gastrostomy in Dysphagia Patients

The objective of this study was to investigate the outcomes of rehabilitation (with swallowing therapy) after percutaneous endoscopic gastrostomy (PEG) in patients with neurogenic dysphagia. Forty-seven patients (29 males and 18 females) who were transferred to the rehabilitation ward of our hospital after receiving PEG tube placements during a 5-year period were enrolled in this study. Patients' demographic data, comorbidities, nutritional statuses, and laboratory biomarkers before the PEG procedure were collected. Rehabilitation (with swallowing therapy) outcomes such as changes in Functional Independence Measure (FIM) and dysphagia grade (using Fujishima's classification) were evaluated. Significant improvements in FIM scores and dysphagia grades after rehabilitation therapy were observed. Twenty-seven patients (57.4 %) were discharged with some oral intake and 10 patients (21.3%) were discharged PEG-free (defined as the PEG tube not being used or removed). Factors associated with being discharged with some oral intake were increase in FIM score (adjusted OR 1.10, 95 % CI 1.02-1.19) and higher baseline dysphagia grade (adjusted OR 1.88, 95 % CI 1.04-3.39). Factors associated with being discharged PEG-free were longer rehabilitation period (OR 1.03, 95 % CI 1.01-1.04), absence of respiratory disorders (OR 0.12, 95 % CI 0.03-0.35), and increase in FIM score (OR 1.17, 95 % CI 1.08-1.28). Changes in dysphagia grade were significantly correlated with changes in FIM score (r ² = 0.46, p < 0.0001), indicating that improvement of FIM scores through general rehabilitation therapy may play an important role in the treatment of dysphagia.

Prediction of Advisability of Returning Home Using the Home Care Score

Purpose. The aim of this study was to assess whether the home care score (HCS), which was developed by the Ministry of Health and Welfare in Japan in 1992, is useful for the prediction of advisability of home care. Methods. Subjects living at home and in assisted-living facilities were analyzed. Binominal logistic regression analyses, using age, sex, the functional independence measure score, and the HCS, along with receiver operating characteristic curve analyses, were conducted. Findings/Conclusions. Only HCS was selected for the regression equation. Receiver operating characteristic curve analysis revealed that the area under the curve (0.9), sensitivity (0.82), specificity (0.83), and positive predictive value (0.84) for HCS were higher than those for the functional independence measure, indicating that the HCS is a powerful predictor for advisability of home care. Clinical Relevance. Comprehensive measurements of the condition of provided care and the activities of daily living of the subjects, which are included in the HCS, are required for the prediction of advisability of home care.

Development and Validation of Prognostic Indices for Recovery of Physical Functioning Following Stroke: Part 1

OBJECTIVE

To develop a prognostic index using Functional Independence Measure grades and stages that would enable clinicians to determine the likelihood of achieving a level of minimum assistance with physical functioning after a stroke. Grades define varying levels of physical function, and stages define varying levels of cognitive functioning.

DESIGN

Retrospective cohort study.

SETTING

Veterans Affairs Medical Centers throughout the United States.

PARTICIPANTS

Veterans with a diagnosis of a new stroke discharged between October 1, 2006, and September 30, 2008, who were below physical grade IV (requiring minimal assistance) at initial rehabilitation assessment.

MAIN OUTCOME MEASURE

Achievement of physical grade IV or above at final rehabilitation assessment.

RESULTS

Physical grade IV was reached by 25.8% of participants who were initially below this grade. Seven variables remained independently predictive of physical grade IV after adjustment. These variables were assigned the following points: age, ≤69 years = 2, 70-79 years = 1, ≥80 years = 0; initial physical grade, I = 0, II = 3, III = 4; initial cognitive stage, I or II = 0, III = 2, IV or V = 3, VI or VII = 4; absence of renal failure = 1; no serious nutritional compromise = 3; the type of rehabilitation services received, consultative = 0, comprehensive = 4; and recovery time between admission and discharge physical grade assessment, 1-2 days = 0, 3-7 days = 4, and ≥8 days = 5. The area under the receiver operating characteristic curve was 0.84 and 0.83 for the point system in the derivation and validation cohorts, respectively. The Hosmer-Lemeshow statistic was not significant (P = .93) in the derivation cohort, indicating that the regression model demonstrated adequate fit. The proportions of patients recovered to physical grade IV in the first (score ≥9), second (score = 10-12), third (score = 13-15), and fourth (score >15) score quartiles were 2.72%, 11.38%, 28.96%, and 60.34%, respectively.

CONCLUSION

By using a simple tool, clinicians can forecast the likelihood of recovery to or above the physical grade IV benchmark by the conclusion of rehabilitation services during the acute stroke hospitalization.

Revision of the predictive method improves precision in the prediction of stroke outcomes for patients admitted to rehabilitation hospitals

[Purpose] The purpose of this study was to confirm the accuracy of a revised method for predicting the Functional Independence Measure (FIM) at discharge when stroke patients are first admitted to a rehabilitation hospital. [Subjects and Methods] The predictive equation with logarithmic trend line was calculated based on the total score of the FIM at admission and discharge in 93 patients with cerebral infarction (CI) and 60 patients with intracerebral hemorrhage (ICH). In other patients with CI or ICH (validation group), the differences between the actual FIM and the predicted FIM at discharge calculated by the CI or ICH equation and the combined (CI + ICH) equation, as well as by the CI or ICH equation and combined equation used in a previous study, were calculated. [Results] The multiple correlation coefficients of the CI equation, ICH equation, and combined equation were 0.87, 0.71, and 0.8. The residual of the actual FIM and predicted FIM at discharge calculated by the CI equation was the smallest in the CI validation group. In the ICH validation group, the residual calculated for ICH patients alone was smaller than that calculated by the previous ICH equation. [Conclusion] This easy-to-use method using a new equation for prediction was more precise than the previous equation. Therefore, we should revise the equation for predicting stroke patient outcome strata according to data from within the governing medical administration system.

Predicting recovery of cognitive function soon after stroke: differential modeling of logarithmic and linear regression

Cognitive disorders in the acute stage of stroke are common and are important independent predictors of adverse outcome in the long term. Despite the impact of cognitive disorders on both patients and their families, it is still difficult to predict the extent or duration of cognitive impairments. The objective of the present study was, therefore, to provide data on predicting the recovery of cognitive function soon after stroke by differential modeling with logarithmic and linear regression. This study included two rounds of data collection comprising 57 stroke patients enrolled in the first round for the purpose of identifying the time course of cognitive recovery in the early-phase group data, and 43 stroke patients in the second round for the purpose of ensuring that the correlation of the early-phase group data applied to the prediction of each individual's degree of cognitive recovery. In the first round, Mini-Mental State Examination (MMSE) scores were assessed 3 times during hospitalization, and the scores were regressed on the logarithm and linear of time. In the second round, calculations of MMSE scores were made for the first two scoring times after admission to tailor the structures of logarithmic and linear regression formulae to fit an individual's degree of functional recovery. The time course of early-phase recovery for cognitive functions resembled both logarithmic and linear functions. However, MMSE scores sampled at two baseline points based on logarithmic regression modeling could estimate prediction of cognitive recovery more accurately than could linear regression modeling (logarithmic modeling, R(2) = 0.676, P<0.0001; linear regression modeling, R(2) = 0.598, P<0.0001). Logarithmic modeling based on MMSE scores could accurately predict the recovery of cognitive function soon after the occurrence of stroke. This logarithmic modeling with mathematical procedures is simple enough to be adopted in daily clinical practice.

Predicting Activities after Stroke: What is Clinically Relevant?

Knowledge about factors that determine the final outcome after stroke is important for early stroke management, rehabilitation goals, and discharge planning. This narrative review provides an overview of current knowledge about the prediction of activities after stroke. We reviewed the pattern of stroke recovery for functions and activities, the impact of spontaneous recovery on activities, and the measurement of improvement in general. We explored the activities profiles during the chronic phase and predictors for activities of daily living independence after stroke, and finally, we discussed where to from here? Mathematical regularities explain the nonlinear patterns of recovery, making the outcome of activities of daily living highly predictable. Initial severity of disability and extent of improvement observed within the first weeks poststroke are important indicators of the outcome at six-months. The sequence of progress in activities is almost fixed in time. Studies showed that most motor recovery is almost completed within 10 weeks poststroke. On average, stroke recovery plateaus three- to six-months after onset. Strong evidence was found that age and scores on scales assessing severity of neurological deficits in the early poststroke phase are strongly associated with the final basic activities of daily living outcome after three-months poststroke. The validated prediction models using simple algorithms, such as National Institutes of Health Stroke Scale or Barthel Index, need to be implemented in rehabilitation services and used for stratifying stroke patients in trials. Future studies should investigate the accuracy of dynamic models that includes time poststroke to optimize the application of prediction rules in individuals with stroke.