Functional outcomes by age after inpatient stroke rehabilitation in Saudi Arabia

Characterisation of young stroke presentations, pathways of care, and support for 'invisible' difficulties: a retrospective clinical audit study

Background Young stroke survivors are likely to be discharged home from acute hospital care without rehabilitation more quickly than older survivors, but it is not clear why. File-audit studies capturing real-world clinical practice are lacking for this cohort. We aimed to compare characteristics and care pathways of young and older survivors and describe stroke presentations and predictors of pathways of care in young survivors (≤45years), including a focus on care received for 'invisible' (cognitive, psychological) difficulties. Methods A retrospective audit of 847 medical records (67 young stroke survivors, mean age=36years; 780 older patients, mean age=70years) was completed for stroke survivors admitted to an Australian tertiary hospital. Stroke characteristics and presence of cognitive difficulties (identified through clinician opinion or cognitive screening) were used to predict length of stay and discharge destination in young stroke survivors. Results There were no differences in length of stay between young and older survivors, however, young stroke survivors were more likely to be discharged home without rehabilitation (though this may be due to milder strokes observed in young stroke survivors). For young stroke survivors, stroke severity and age predicted discharge destination, while cognitive difficulties predicted longer length of stay. While almost all young survivors were offered occupational therapy and physiotherapy, none received psychological input (clinical, health or neuropsychology). Conclusions Cognitive and psychological needs of young stroke survivors may remain largely unmet by a service model designed for older people. Findings can inform service development or models of care, such as the new Australian Young Stroke Service designed to better meet the needs of young survivors.

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.

The effects of rehabilitation therapy duration on functional recovery of patients with subacute stroke stratified by individual's age: a retrospective multicenter study

BACKGROUND

The duration of rehabilitation therapy is one of the key elements for promoting post-stroke functional recovery. However, whether an individual's age affects the effectiveness of the duration of rehabilitation therapy on post-stroke functional recovery remains unclear.

AIM

This study aimed to investigate whether age has an influence on the relationship between the duration of rehabilitation therapy and post-stroke functional recovery.

DESIGN

This is a retrospective observational study.

SETTING

Six convalescent inpatient rehabilitation hospitals in Japan.

POPULATION

The population of the study was represented by a total of 1186 participants with subacute stroke.

METHODS

Participants were stratified into four groups according to their age (≤59, 60-69, 70-79, and ≥80 years). The data of minutes involved in performing rehabilitation therapy for participants during hospitalization per day (extracted from the medical records of each hospital). The outcome measurement was the absolute change in the functional independence measure (FIM) score during hospitalization.

RESULTS

The mean FIM gains in the ≤59 years, 60-69 years, 70-79 years, and the ≥80 years groups were 38.7 (18.8), 32.8 (18.0), 29.7 (16.6), and 25.4 (17.2), respectively. The results of the multivariate regression analyses showed that there was a significant association between the duration of daily rehabilitation therapy and the FIM gain in the 70-79 years and the ≥80 years groups (-70-79 years group: B=1.289, β=0.290, 95% confidence intervals (CIs): 0.718-1.859, P<0.001; the ≥80 years group: B=2.375, β=0.371, 95% CIs: 1.644-3.107, P<0.001), but not in the other groups.

CONCLUSIONS

For patients with subacute stroke in rehabilitation hospitals, a higher duration of daily rehabilitation therapy was associated with better functional recovery in the 70-79 years group and ≥80 years groups. Understanding the responsiveness of patients with stroke to rehabilitation therapy by age group helps to better allocate medical resources and develop more effective approaches.

CLINICAL REHABILITATION IMPACT

An increased duration of daily rehabilitation therapy may be helpful in older adults with stroke selected for intensive rehabilitation for improvement of basic daily functioning.

Association of sarcopenia and physical activity with functional outcome in older Asian patients hospitalized for rehabilitation

BACKGROUND

Previous studies reported that sarcopenia and physical inactivity affected clinical outcome in older adults; however, the association with functional outcome has not been studied in a rehabilitation setting.

AIM

This study aimed to assess the association of sarcopenia and physical activity with the functional outcome in older hospitalized rehabilitation patients.

METHODS

A cross-sectional study was performed in older patients consecutively admitted to convalescent rehabilitation wards. Sarcopenia was diagnosed based on the Asia Working Group for Sarcopenia 2019 criteria, and physical activity time (light-intensity physical activity, LIPA; moderate-to-vigorous physical activity, MVPA) was measured using an activity monitor with a triaxial accelerometer. The association of sarcopenia and physical activity with functional outcome, measured by the Functional Independence Measure (FIM) motor function, was determined using multiple regression analysis adjusted for age, sex, primary disease diagnosis, length of acute hospital stay, Charlson comorbidity index, body mass index, and mini-nutritional assessment-short form score.

RESULTS

Out of 211 rehabilitation older inpatients [median (interquartile range) age 78 (11) years, 150 women (71%)], 104 patients (49%) were diagnosed with sarcopenia. Patients with sarcopenia had significantly lower LIPA (p < 0.001) and MVPA (p = 0.002) than those without sarcopenia. In multiple regression analysis, LIPA (β = 0.39, p < 0.001) and MVPA (β = 0.12, p = 0.02) were associated with FIM-motor function even after they were adjusted for confounding factors, including sarcopenia.

CONCLUSIONS

In rehabilitation older inpatients, sarcopenia and physical activity were independently associated with functional outcome, and physical activity was lower in sarcopenia patients than in those without sarcopenia.

The Berg Balance Scale at Admission Can Predict Community Ambulation at Discharge in Patients with Stroke

Background and Objectives: To regain the ability of community ambulation is a meaningful goal for stroke patients. Recent research recommended that the distance accomplished during the six-minute walk test (≥205 m in 6MWT) is the fittest for defining community ambulation. Until now, there are few studies that have used the updated definition to investigate the related predictors. The aim of this study was to investigate the association between the admission clinical parameters and community ambulation measured by the 6MWT at discharge. The other aim was to find the admission Berg Balance Scale (BBS) cut-off score to discriminate between household or community ambulators. Materials and Methods: This cohort study collected the data of patients who entered the post-acute Care Cerebrovascular Diseases program. Multivariate logistic regression was used to identify significant predictors measured at admission that are associated with community ambulation, and a receiver operating characteristic was adopted to calculate the cut-off value for admission status. There were 120 participants included in this study, and 25% (n = 30) of them regained the ability of community ambulation at discharge. The BBS on admission was identified as the only significant predictor for community ambulation (odds ratio 1.06). Results: The optimal cut-off score for the BBS at admission was 29, and the area under the curve for BBS scores on admission when discriminating between household and community ambulators at discharge was 0.74. Conclusions: The admission BBS scores could be used to predict household and community ambulators at discharge in stroke patients. The results of this study could help clinical physicians set appropriate discharge goals early.

Translational Block in Stroke: A Constructive and "Out-of-the-Box" Reappraisal

Why can we still not translate preclinical research to clinical treatments for acute strokes? Despite > 1000 successful preclinical studies, drugs, and concepts for acute stroke, only two have reached clinical translation. This is the translational block. Yet, we continue to routinely model strokes using almost the same concepts we have used for over 30 years. Methodological improvements and criteria from the last decade have shed some light but have not solved the problem. In this conceptual analysis, we review the current status and reappraise it by thinking "out-of-the-box" and over the edges. As such, we query why other scientific fields have also faced the same translational failures, to find common denominators. In parallel, we query how migraine, multiple sclerosis, and hypothermia in hypoxic encephalopathy have achieved significant translation successes. Should we view ischemic stroke as a "chronic, relapsing, vascular" disease, then secondary prevention strategies are also a successful translation. Finally, based on the lessons learned, we propose how stroke should be modeled, and how preclinical and clinical scientists, editors, grant reviewers, and industry should reconsider their routine way of conducting research. Translational success for stroke treatments may eventually require a bold change with solutions that are outside of the box.

Return to driving post stroke; patients' perspectives and challenges in Saudi Arabia

BackgroundReturning to driving remains one of the most important goals for stroke survivors. In Saudi Arabia, there are no structured processes to address the issue of return to driving in individuals with disabilities. There are increasing rates of strokes in the country and road traffic accidents are the highest in the region. Returning to driving among male stroke survivors in Saudi Arabia is of particular importance due to socio-economic and cultural reasons.AimsThe study aims to explore the factors involved in return to driving among stroke survivors in Saudi population.MethodsThis cross-sectional study was carried out on 100 male stroke survivors who had completed an inpatient rehabilitation program and had at least one follow-up assessment three months post-discharge. Information was collected regarding demographics, stroke characteristics, and factors related to pre and post-stroke driving. Data were analyzed using SPSS.ResultsMajority (60%) of patients were 51 years of age and above. Most commonly reported stroke impairments were weakness and spasticity with majority of participants having right-sided body involvement. Out of 94 stroke survivors who were driving prior to stroke, only 7 resumed driving. None of the stroke survivors who returned to driving reported receiving any formal driving assessment. Only one patient who reported being aware of the need of driving assessment did not resume driving after stroke.ConclusionsThere is a dire need to increase awareness and to develop a structured integrated system in Saudi Arabia to facilitate stroke survivors to return to driving.

Vitality index is a predictor of the improvement in the functional independence measure score in subacute stroke patients with cognitive impairment

OBJECTIVES

To investigate the effect of motivation on improvements in the Functional Independence Measure (FIM) scores in subacute stroke patients with cognitive impairment.

METHODS

This retrospective cohort study included 358 consecutive subacute stroke patients with first-ever stroke and Mini-Mental State Examination score ≤23 at admission. We determined motivation and rehabilitation outcome using the vitality index and FIM-motor gain, respectively. Stepwise multiple regression analysis was performed to identify the factors at admission related to FIM-motor gain.

RESULTS

Of 80 participants enrolled in this study (mean age: 74.2 ± 11.3 years). The median (interquartile range) vitality index at admission and FIM-motor gain were 7 (4) and 23 (22) points, respectively. Stepwise multiple regression analysis revealed that age (B, -0.43; 95% confidence interval [CI], -0.65-(-0.21); β, -0.31; P <.001), duration from stroke onset to admission (B, -0.18; 95% CI, -0.33-(-0.04); β, -0.20; P =.014) and Stroke Impairment Assessment Set-motor function (B, 1.27; 95% CI, 0.92-1.61; β, 0.78; P <.001), FIM-motor (B, -0.80; 95% CI, -1.01-(-0.60); β, -0.95; P <.001), and vitality index (B, 3.79; 95% CI, 2.37-5.21; β, 0.50; P <.001) scores at admission were significantly associated with the FIM-motor gain.

DISCUSSION

The vitality index was significantly associated with FIM improvement in subacute stroke patients with cognitive impairment.

Discharge Destination from a Rehabilitation Unit After Acute Ischemic Stroke

Background: We reviewed numerous variables for ischemic stroke patients admitted to a rehabilitation unit to determine those that were statistically associated with discharge destination. Methods: A retrospective chart review of patients with ischemic stroke discharged from the rehabilitation unit between January 1, 2005 and December 31, 2015. Variables were examined for their association with discharge destination (home versus long-term care (LTC)). Univariable relationships with discharge destination were assessed, and a multivariable logistic regression model was built. Results: Univariate predictors of discharge to LTC: advanced age, decreasing admission and discharge functional independence measure (FIM) scores, increasing change in FIM score from admission to discharge, dependency, residence outside of home before the stroke, absence of a caregiver, urinary and bowel incontinence, low Berg balance score at admission and discharge, low Montreal Cognitive Assessment scores, smoking, chronic heart failure, and an inability to transfer. Multivariable logistic regression: five factors remained significant predictors with LTC disposition: advanced age, bowel incontinence, residence outside of the home prior to stroke, right hemisphere site of the stroke, and absence of a caregiver. Conclusions: Several easily measured variables were significantly associated with discharge to LTC versus home following stroke rehabilitation.