In What Daily Activities Do Patients Achieve Independence after Stroke?

In What Daily Activities Do Patients Achieve Independence after Stroke? Giovanni Morone, MD, Stefano Paolucci, MD, and Marco Iosa, PhD

Background: The aim of the study is to determine the probability of achieving independence and the related prognostic factors with regard to single activities of daily living after 3 months of rehabilitation following stroke. Methods: This longitudinal observational study, conducted in a neurorehabilitation unit of a research and health care institute, involved 435 subjects who were affected by stroke (age, 68 6 14 years, 230 men). Barthel index (BI) scores were recorded at admission and dismissal 3 months later. Results: The highest improvement after rehabilitation was observed for bowel and bladder function and transfer and mobility, whereas the lowest improvement was seen in bathing, grooming, dressing, and stair climbing. Conclusions: Severity of stroke, presence of unilateral neglect, age, gender, and onset-to-admission interval (OAI) were significant prognostic factors for 6 of 10 activities, as assessed by BI subscores. Feeding was influenced only by neglect and OAI, whereas OAI did not affect bowel or bladder function recovery. Practice: Patients and their relatives could be informed about the specific activities in which patients will be expected to be independent after rehabilitation and the specific needs that they might have on returning home. Implication: Our results might help optimize the management of the rehabilitative process. Key Words: Stroke—rehabilitation—outcomes— prognostic factors—activity of daily living. Ó 2015 by National Stroke Association

After stroke, patients and their relatives have the prospect of recovery and independence when they return home and, eventually, to work.1 Several prognostic factors of rehabilitative outcomes after stroke have been identified.2 An early and accurate prediction of independence level after discharge is crucial in facilitating the return of stroke patients to their home3 with regard to

From the Clinical Laboratory of Experimental Neuorehabilitation, IRCCS Fondazione Santa Lucia, Rome, Italy. Received August 25, 2014; revision received March 17, 2015; accepted May 6, 2015. This work is supported by Italian Ministry of Health with the Grant Number (RC2013G). Address correspondence to Giovanni Morone, MD, IRCCS, Unit
a Operativa F, Clinical Laboratory of Experimental Neuorehabilitation Fondazione Santa Lucia, Via Ardeatina 306, 00179 Rome, Italy. E-mail: [email protected]. 1052-3057/$ - see front matter Ó 2015 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2015.05.006

planning eventual home and work adjustments in a timely manner, the presence of a professional caregiver, and familiar support.4 Clinically, the prediction of rehabilitative outcomes might aid allocating resources and identifying causes of unsuccessful rehabilitation, which has many implications for the cost of care. There are many tools that are used to determine the independence level of a person in activities of daily living (ADLs). The most common methods are 2 clinical scales: the Barthel index (BI) and the functional independence measure (FIM).5 Feeding, bathing, grooming, dressing, bowel function, bladder function, toilet use, transfers (bed to chair and back), mobility (walking on level surfaces), and stair climbing are the 10 activities that are assessed in the BI, which is the sum of the scores on each of these items. Similar activities are measured in the FIM: eating, bathing, grooming, dressing, personal hygiene, transfers, walking, and stair climbing.6 Older age and high initial grade of paresis are the most common negative prognostic factors for independence in ADLs.2,7-11 Severe impairment, hemineglect, global

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aphasia, and depression have been highlighted as other prognostic factors of low treatment efficacy by BI.12 Gender was found to be related primarily to mobility, wherein more men than women achieved independence in stair climbing (odds ratio [OR] 5 3.22) and ADLs (OR 5 1.90), experiencing greater response and effectiveness in terms of mobility. Conversely, more women usually needed a cane, even for level walking (OR 5 1.69).13 Furthermore, the side of hemiparesis—and hence, the contralateral side of the cerebrovascular accident—was related mainly to its potentially causing hemineglect or aphasia.14 At the end of rehabilitation, patients with neglect had significantly lower final motor scores and thus lower independence compared with those with aphasia, who had lower cognitive levels. The BI score at admission is a good predictor of independence in ADLs at dismissal.15,16 Functional status at 6 months is a predictor of mortality at 5 years,17 and the number of dependent ADLs at discharge is an independent risk of mortality at 1 year after stroke.18 However, the clinical value of the identification of these prognostic factors has been questioned: information about average recovery patterns might have little relevance for a patient or even an individual clinician.1 Past research has tended to focus on global scores rather than BI or FIM subscores on individual items, paying little attention to independence in single ADLs. But, patients and their relatives need individual and specific predictions of independence level in managing their return to home and, eventually, to work.1 For example, a patient who lives in a 2-storey house will know whether he is likely to recover the ability to climb stairs—a factor that is less important for other patients. Thus, beyond a general percentage of patients who become independent in ADLs, patients and their families are likely to know the tasks in which they risk remaining dependent or will be autonomous. Few studies have analyzed independence in single ADLs. Twenty-five years ago, Wade and Hewer reported good recovery for bowel and bladder function and grooming and poor recovery of bathing, stair climbing, and dressing. They found urinary incontinence, low initial BI score, older age, low mental function, reduced sitting balance, and decreased arm motor function at admission to be negative prognostic factors of global BI score.19 Recently, Gialanella et al examined the influence of single FIM subscores in 241 patients at admission as predictors of functional outcome after rehabilitation. They found that subscores on grooming and dressing, with Fugl-Meyer score at admission, presence of neglect, and social interaction level, predicted global FIM score at discharge, whereas bowel control and memory were predictors of discharge destination.20 Neither of these studies investigated factors that could be prognostic for independence in single ADLs.

The aims of our study were to measure improvements after rehabilitation in each of the 10 ADLs in the BI and identify their prognostic factors.

Materials and Methods Independence in ADLs was assessed in patients at admission and on discharge from our rehabilitation hospital by BI. Demographic data (age and gender) were collected at admission. Clinical data on etiology of stroke (ischemic versus hemorrhagic), side of hemiparesis (right versus left), and presence of unilateral spatial neglect (yes versus no) were also recorded. Unilateral spatial neglect was defined as scoring below the cutoff value in 3 of a standardized battery of 4 tests, comprising the letter cancellation test, the barrage test, the sentence-reading test, and the Wundt–Jastrow area illusion test.21 The inclusion criteria were patients who recovered in our rehabilitation hospital, first-ever stroke, and subacute phase of stroke. Exclusion criteria were missing data (eg, because the patient was transferred for a medical emergency before the end of the planned rehabilitative pathway or because of death) and the presence of severe comorbidities, independent of stroke. Patients received 2 daily sessions of neuromotor rehabilitation (each lasting 40 minutes) 5 days per week and 1 rehabilitative session on the sixth day, for approximately 3 months. When necessary, patients underwent a third hour of daily therapy that focused on speech, individual training for swallowing, recovery of bowel and bladder function, or recovery of spatial awareness if it was impaired by neglect. Assessments were performed by clinicians on admission and discharge from our hospital per the Minimal Protocol for Stroke, as defined by the Italian Society of Physical Medicine and Rehabilitation,15,22 including the administration of the BI23 and Canadian Neurological scales.24 The effectiveness of rehabilitative intervention on BI scores and each subitem, assessed at admission and discharge, was measured as the improvement that was achieved, expressed as a percentage of maximum improvement: effectiveness 5 (score at discharge2score at admission)/ (maximum possible score2score at admission) 3 100.25-28 Based on this formula, an effectiveness of 100% corresponds to the achievement of maximum improvement, which, with regard to the BI score and subscores, reflects independence. Because of the nominal or ordinal nature of the data, nonparametric statistics were used for inferential analyses. Wilcoxon signed-rank test was used to analyze the significance of changes between admission and dismissal subscores, and Friedman analysis was used to determine the significance of differences between these changes. Statistically significant results by Friedman

INDEPENDENCE IN ADL AFTER STROKE

analysis were followed by post hoc analyses using Wilcoxon signed-rank test, setting the threshold of significance at .005, applying Bonferroni correction (5.05/10) to avoid inflating the first-type statistical error. Then, we performed binary logistic regression (forward conditional algorithm, using SPSS 17.0, SPSS Inc, Chicago, IL, USA) to identify prognostic factors from information in the Minimum Protocol for Stroke.22 Potential binary factors, evaluated at admission, were expressed as 0 if they were potentially negative and 1 if they were potentially positive, per previous studies. Based on earlier reports, we examined age (0 if $ 65 years, 1 if , 65 years), gender (0 if female, 1 if male), etiology (0 if hemorrhagic, 1 if ischemic stroke), side of hemiparesis (0 if right, 1 if left), onset-to-admission interval (OAI; 0 if OAI.20, 1 if OAI#20), high severity of neurological impairment (0 if Canadian Neurological Scale [CNS] score #4, 1 if CNS score.4), and unilateral spatial neglect as factors. The dependent binary variable was the score of each item in the BI: 0 if maximum independence was not achieved and 1 if it was.

Results From February 2006 to February 2012, 612 patients with stroke were admitted to and screened in our hospital, and their data were recorded in our database. Seventy patients were excluded because of not having a first-ever stroke, 21 were omitted because they were not in the subacute phase, and 86 were excluded because of missing data (including patients who died or were transferred to an emergency hospital before the end of rehabilitative treatment). Ultimately, the data on 435 patients were analyzed. The demographic and clinical characteristics of these patients are shown in Table 1.

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At admission, approximately 19% of patients had a BI score of 0, and 78% of patients had a BI score of 40 or less. The average effectiveness of treatment was roughly 50%, as shown in Table 1. These improvements decreased these percentages (P , .001), with less than 3% of patients being discharged with a BI score of 0, 31% of patients with a BI score of 40 or less, and 17% of patients becoming completely independent on discharge (BI score 5 100, n 5 72). Next, we analyzed individual BI subscores. As shown in Figure 1, the BI subscores at admission approached 0 (the minimum), whereas on discharge, each subscore significantly approaches the maximum value (P , .001, Wilcoxon signed-rank tests). Figure 2 shows the effectiveness of rehabilitative treatment for each subscore. The effectiveness differed between the 10 subscores (c2 5 892.748, P , .001, Friedman analysis), with bathing being the lowest (23%, post hoc analysis: P , .001 versus all other subscores) and bowel function being the highest (68%). The effectiveness was also below 50% for dressing (40%), grooming (43%), and stair climbing (46%). Bowel and bladder scores showed the most improvement (68% and 64%, respectively, but not significantly lower than the .005 threshold for Bonferroni correction; P 5 .0199). The effectiveness exceeded 60 for transfers (62%) and mobility (61%). We noted a potential risk of worsening: 4 patients experienced negative effectiveness for transfers, and other sporadic cases were observed for feeding, dressing, and bowel and bladder function. The prognostic factors for achieving a BI score of 100 or the maximum BI subscore at discharge are reported in

Table 1. Median (first and third quartiles) or case ratio (percentages) for the sample characteristics

Sample characteristics

Median (first; third quartiles) or case ratio (%)

Age (y) 71 (59; 78) Gender (male/female) 236/199 (54%/46%) Time from stroke at admission (d) 14 (9; 25) Length of stay (d) 93 (73; 111) Hemiparesis (right/left) 248/187 (57%/43%) Etiology (ischemic/hemorrhagic) 357/78 (82%/18%) Presence of neglect (yes/no) 76/359 (17%/83%) Barthel index score at admission 15 (5; 40) Barthel index score at dismissal 60 (40; 90) Canadian Neurological score at 6.5 (4.5; 8.5) admission 8.5 (6.5; 10) Canadian Neurological score at dismissal Effectiveness Barthel index score 50 (30; 83)

Figure 1. Box-and-whisker plot for the Barthel index subscores (wide line, median; box extremes, first and third quartiles; whiskers, minimum and maximum of scores; dots, outliers).

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G. MORONE ET AL.

Figure 2. Box-and-whisker plot of effectiveness for the 10 activities of daily living included in Barthel index (wide line, median; box extremes, first and third quartiles; whiskers, minimum and maximum; dots, outliers).

Table 2. Approximately 83% of cases with a BI score of 100 at discharge were correctly predicted by 3 prognostic factors: male gender, age less than 65 years, and absence of neglect. The rate at which cases in which the maximum BI subscore was achieved were correctly identified ranged from 62.5% to 76.6%. The 3 prognostic factors above were the only significant features for 8 of 10 subscores (not for feeding and stairs). However, as with BI score, neglect was the most important prognostic factor in terms of significance and odds ratio (exp(b)) for all BI subscores except for bowel function, for which age was the main significant factor, followed by neglect. Presence of neglect was also the only factor that influenced feeding and, with age, affected independence in stair climbing. The etiology of stroke (ischemic versus hemorrhagic) and the affected side (right versus left) did not significantly affect any BI subscore. However, the affected side approached significance at the first iteration of regression for feeding (P 5 .076), bathing (P 5 .091), and mobility (P 5 .066), in terms of better outcomes for right hemiparesis. Conversely, etiology had no significant effects (P . .1).

Discussion In this study, we aimed at measuring improvements after rehabilitation in each of the 10 ADLs of the BI and identifying their prognostic factors. Our results demonstrated the highest recovery for bowel and bladder function, transfers, and walking and the lowest recovery for bathing, dressing, grooming, and stair climbing. These findings are consistent with those of Kong et al11, in which dressing, stair climbing, and bathing were reported to require longer recovery times. Our data are also in agreement with Wade and Hewer,19 despite our sample being more severely impaired.

The BI has only 2 possible scores for bathing and grooming: 0 for dependent and 5 for independent. The low sensitivity of these 2 subscores could have contributed to the minor improvement on these items. In general, scales that are more specific than BI subitems exist for assessing specific aspects of independence in ADLs, such as urinary incontinence scales.28 A modified version of the BI was proposed by Saha et al.25 that included more levels for bathing and grooming (from 0 to 5) and other subscores to increase the sensitivity of the scale and its subitems. Despite the potential risk of low sensitivity with respect to bathing and grooming, it is also possible that less attention is paid to these 2 activities by rehabilitative programs—for example, compared with feeding, mobility, and transfers. Our results showed that severity of stroke, presence of neglect, older age, female gender, and long interval between stroke event and admission to a rehabilitation hospital were prognostic factors for a greater risk of failing to achieve independence in ADLs. These factors were significant for general BI scores and for bathing, grooming, toilet use, transfers, and mobility. As expected, severity of stroke was the most important factor, followed by the presence of neglect, in 8 of 10 subitems. It is generally accepted that performance in ADLs and motricity correlate strongly11 and that motor recovery is largely influenced by the initial level of paresis, as demonstrated in a review of prognostic factors in stroke recovery.10 Similar results regarding the time of onset were reported by Stineman et al,29 in which admission to a rehabilitation hospital within 2 weeks from the event was associated with more favorable prognoses. Age had a more significant influence than neglect only for bowel and bladder function. For these activities, OAI did not have a significant value. Conversely, OAI was a prognostic factor for feeding with severity and neglect, whereas age and gender had little value. Gender had

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Table 2. Results of binary logistic regression 95% CI for exp(b) 100% At dismissal

Factors in the equation

Barthel index

Severity Neglect Age Gender OAI Severity Neglect OAI Severity Neglect Age Gender OAI Severity Neglect OAI Age Gender Severity Neglect Age OAI Severity Age Neglect Gender Severity Age Neglect Gender Severity Neglect Age OAI Gender Severity Neglect Age OAI Gender Severity Neglect Gender Age OAI Severity Neglect Age OAI

Feeding

Bathing

Grooming

Dressing

Bowels

Bladder

Toilette

Transfers

Mobility

Stairs

b

Standard error

P

exp(b)

Lower

Upper

2.497 2.282 1.152 .737 .744 3.390 1.446 .568 3.035 2.359 1.058 .703 .625 2.738 1.520 .947 .803 .618 3.290 1.441 .718 .663 2.395 1.448 1.088 .928 1.983 1.453 1.442 .909 2.988 1.869 1.307 .990 .691 2.433 1.856 .885 .741 .701 2.157 1.683 .854 .773 .520 2.215 1.701 .796 .559

.738 .746 .288 .310 .342 .600 .348 .247 .621 .621 .261 .272 .296 .423 .348 .254 .244 .236 .728 .407 .240 .271 .314 .277 .317 .242 .310 .255 .331 .232 .438 .374 .263 .263 .245 .385 .375 .885 .252 .236 .422 .414 .242 .240 .258 .481 .453 .240 .270

.001 .002 ,.001 .017 .029 ,.001 ,.001 .022 ,.001 ,.001 ,.001 .010 .035 ,.001 ,.001 ,.001 .001 .009 ,.001 ,.001 .003 .014 ,.001 ,.001 .001 ,.001 ,.001 ,.001 ,.001 ,.001 ,.001 ,.001 ,.001 ,.001 .005 ,.001 ,.001 ,.001 .003 .003 ,.001 ,.001 ,.001 .001 .044 ,.001 ,.001 .001 .038

12.148 9.799 3.164 2.089 2.104 29.677 4.247 1.765 20.792 10.575 2.880 2.019 1.868 15.454 4.574 2.577 2.231 1.855 26.834 4.223 2.050 1.941 10.966 4.255 2.967 2.528 7.262 4.275 4.229 2.482 19.853 6.482 3.694 2.692 1.995 11.389 6.400 2.422 2.098 2.016 8.641 5.384 2.349 2.166 1.681 9.164 5.477 2.217 1.749

2.859 2.272 1.799 1.138 1.077 9.160 2.146 1.087 4.923 3.132 1.726 1.184 1.046 6.746 2.311 1.568 1.382 1.167 6.442 1.902 1.281 1.142 5.931 2.474 1.593 1.573 3.951 2.593 2.210 1.576 8.421 3.113 2.208 1.608 1.235 5.350 3.067 1.501 1.281 1.270 3.778 2.392 1.461 1.354 1.014 3.570 2.252 1.386 1.031

51.263 42.261 5.563 3.835 4.109 96.156 8.403 2.865 87.806 35.708 4.808 3.442 3.337 35.403 9.056 4.237 3.602 2.949 111.777 9.379 3.282 3.299 20.276 7.318 5.526 4.063 13.345 7.049 8.093 3.909 46.805 13.500 6.181 4.508 3.222 24.243 13.353 3.908 3.435 3.201 19.761 12.118 3.778 3.464 2.789 23.522 13.318 3.545 2.968

Abbreviations: CI, confidence interval; OAI, onset-to-admission interval.

Nagelkerke R2

Overall percentage

.271

83.2%

.307

68.7%

.319

77.8%

.364

75.2%

.269

73.6%

.393

74.8%

.365

72.2%

.431

75.9%

.357

75.2%

.291

73.8%

.228

73.6%

G. MORONE ET AL.

1936

a small (exp(b) , 2) but significant (P , .02) function: females had a higher risk of being dependent in bathing, grooming, bowel and bladder function, toilet use, and mobility. Notably, unilateral neglect is a negative prognostic factor for all ADLs in the BI scale, which is consistent with previous studies that showed that unilateral neglect highly influences independence in ADLs with regard to motor abilities.14,30 Furthermore, patients with unilateral spatial neglect, compared with those without it, have significantly more severe baseline neurological and functional status at admission; experience lower effectiveness and efficiency of rehabilitative treatment on ADLs and mobility; and have a higher percentage of low responders, longer hospitalization, a higher percentage of persistent incontinence at discharge (20.5% versus 4.9%), and a lower percentage of high responders and patients returning home.29 Neglect was a prognostic factor for bowel and bladder function in our study. Previous studies have already highlighted a relationship between the presence of unilateral spatial neglect and urinary incontinence.30,31 We primarily examined unilateral spatial neglect; nevertheless, neglect is a multifactorial phenomenon with differences between spatial (external space) and personal (own body) neglect, as well as between sensory and motor disorders. Although the absence of this differentiation could be a limitation of our study and although the strictly neurological mechanisms of incontinence are unknown,32 our findings and previous results suggest that greater impairment in awareness of personal space is a significant factor in acute and chronic incontinence after stroke.30 Consequently, incontinence has been shown to be a prognostic factor of rehabilitative outcomes.2,7,33,34 The OAI to our hospital was a significant prognostic factor for all BI subitems except for bowel and bladder function. The importance of timing in rehabilitation outcomes has been highlighted as a prognostic factor: early rehabilitation treatment is associated with greater improvement in ADLs than delayed treatment.35 The value of OAI is critical, because it is the only factor in this study that can be modified. Although a shorter OAI reduces the risk of being dependent in certain ADLs on discharge, a patient can be admitted to a rehabilitation ward only if his medical conditions have stabilized, depending on his comorbidities.35 Johnston and Keiter36 concluded that the relationship between case severity and OAI is confounding in the analysis of rehabilitative outcomes. Nevertheless, it is apparent that early onset of rehabilitation (within 20 days from stroke event), when possible, doubles the likelihood of being independent in many ADLs on returning to one’s home. Side of hemiparesis and type of stroke were not found to be significant prognostic factors. The predominant

value of neglect may have mitigated the effect of side of lesion on the results, with outcomes correlating more to the presence of neglect. Regarding the etiology of stroke, previous studies have observed that patients with hemorrhagic stroke have better outcomes than those with ischemic strokes.37 The ratio between ischemic and hemorrhagic stroke cases in our study (82% versus 18%) is similar to reported values,38,39 but this difference is a potential bias in the data analysis, limiting the possibility of detecting a significant difference. We did not consider aphasia directly but merely assessed general neurological impairments with the Canadian Neurological Scale. Although aphasia is more of a prognostic factor for cognitive status at discharge than for independence in ADLs,14 our failure to consider aphasia directly could be considered another limitation of this study. In conclusion, after rehabilitation, patients with stroke have a low probability of recovering independence in bathing and grooming, whereas they experience a high likelihood of becoming independent with regard to bowel and bladder function and adequate probability of recovering independence in transfers and mobility. Severity of stroke, presence of unilateral neglect, female gender, older age, and long interval between the stroke event and beginning of rehabilitation are risk factors that decrease these probabilities. Thus, rehabilitative staff should pay particular attention to patients with these risk factors, informing their relatives about the expected level of independence at discharge and about their specific needs on returning home in a timely manner.

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