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      Six-month functional recovery of stroke patients: a multi-time-point study

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          Abstract

          The aim of this study is to compare the time-course changes in neurologic impairments (trunk control, motor function, sensory, and cognition) and recovery in functional impairments (activity of daily livings and gait) simultaneously from initiating rehabilitation to 6 months after stroke. Consecutive stroke patients were recruited from the department of nervous surgery, and transferred into the department of rehabilitation medicine and continued on treatment during the acute stage. Outcome measures were examined at the initial rehabilitation baseline, 1, 2, and 4 weeks after rehabilitation treatment, and 3, 4, 5, and 6 months after stroke. Patients were assessed using the Trunk Impairment Scale, the Fugl-Meyer Motor and Sensory Assessments for the upper and lower limbs, Mini-Mental State Examination, Functional Ambulation Category, and Modified Barthel Index. Twenty consecutive patients were analyzed in the study with complete assessments. The recovery was relatively rapid during the 4 weeks after treatment ( P value ranges from <0.001 to <0.007) and then to a lesser extent decelerated between 3 and 6 months after stroke ( P value between <0.001 and 0.080). Statistical comparison by repeated measures analysis showed a significant interaction between time points and measures of all recovery variables ( P<0.001). Significant differences in level of impairments and functional recovery were found at the different time points. In comparison with the lower leg and trunk control, the upper arm showed less recovery, with a significant difference. All variables except for leg motor function improved continuously over 6 months after stroke. Nevertheless, this study confirms the importance of the period within 3 months for recovery after stroke, during which most of the recovery occurred, ranging from 48 to 91%. Therefore, intensive treatment targeting motor and sensory functions early after stroke may be beneficial for recovery of impairments and functional performance.

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          Predictive validity and responsiveness of the functional ambulation category in hemiparetic patients after stroke.

          Jan Mehrholz, Katja Wagner, Katja Rutte … (2007)
          To determine the reliability, concurrent and predictive validity, and responsiveness of the Functional Ambulation Category (FAC) in hemiparetic patients after stroke. Prospective cohort. An early rehabilitation center for patients with neurologic disorders. Fifty-five nonambulatory patients after first-ever stroke, with duration of illness between 30 and 60 days, were included. Not applicable. FAC, Rivermead Mobility Index (RMI), walking velocity, step length, and six-minute walking test (6MWT) were assessed at the beginning, after 2 and 4 weeks of rehabilitation, and again 6 months later. After 6 months, community ambulation was also assessed. Test-retest and interrater reliability, concurrent, discriminant, and predictive validity and responsiveness of the FAC were calculated. Based on video examinations, high test-retest reliability (Cohen kappa=.950) and interrater reliability (kappa=.905) were found. FAC scores at the beginning and after 2 weeks, 3 weeks, and 6 months correlated highly with the RMI (Spearman rho=.686, rho=.787, rho=.825, rho=.893, respectively), distance walked in the 6MWT (rho=.949, rho=.937, rho=.931, rho=.906, respectively), walking velocity (rho=.952, rho=.939, rho=.902, rho=.901, respectively), and step length (rho=.952, rho=.932, rho=.896, rho=.877, respectively) at the same time points (all P<.001). The RMI, walking velocity, step length, and distance walked in the 6MWT differed for each FAC category (P<.001). After 4 weeks of rehabilitation, an FAC score of 4 or higher predicted community ambulation at 6 months with 100% sensitivity and 78% specificity. FAC scores changed significantly between the first 2 and second 2 weeks (Wilcoxon z=8.7, z=7.9, respectively; both P<.001) of the inpatient rehabilitation program. The FAC has excellent reliability, good concurrent and predictive validity, and good responsiveness in patients with hemiparesis after stroke.
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            Motor recovery after stroke: a systematic review of the literature.

            Henk T Hendricks, Jacques van Limbeek, Alexander C. H. Geurts … (2002)
            To collect and integrate existing data concerning the occurrence, extent, time course, and prognostic determinants of motor recovery after stroke using a systematic methodologic approach. A computer-aided search in bibliographic databases was done of longitudinal cohort studies, original prognostic studies, and randomized controlled trials published in the period 1966 to November 2001, which was expanded by references from retrieved articles and narrative reviews. After a preliminary screening, internal, external, and statistical validity was assessed by a priori methodologic criteria, with special emphasis on the internal validity. The studies finally selected were discussed, based on the quantitative analysis of the outcome measures and prognostic determinants. Meta-analysis was pursued, but was not possible because of substantial heterogeneity. The search resulted in 174 potentially relevant studies, of which 80 passed the preliminary screening and were subjected to further methodologic assessment; 14 studies were finally selected. Approximately 65% of the hospitalized stroke survivors with initial motor deficits of the lower extremity showed some degree of motor recovery. In the case of paralysis, complete motor recovery occurred in less than 15% of the patients, both for the upper and lower extremities. Hospitalized patients with small lacunar strokes showed relatively good motor recovery. The recovery period in patients with severe stroke was twice as long as in patients with mild stroke. The initial grade of paresis was the most important predictor for motor recovery (odds ratios [OR], >4). Objective analysis of the motor pathways by motor-evoked potentials (MEPs) showed even higher ORs (ORs, >20). Our knowledge of motor recovery after stroke in more accurate, quantitative, and qualitive terms is still limited. Nevertheless, our data synthesis and quantitative analysis comprises data from many methodologically robust studies, which may support the clinician in the management of stroke patients. With respect to early prognosis of motor recovery, our review confirms clinical experience that the initial grade of paresis (as measured on admission in the hospital) is the most important predictor, although the accuracy of prediction rapidly improves during the first few days after stroke. Initial paralysis implies the worst prognosis for subsequent motor recovery. Remarkably, the prognostic accuracy of MEPs appears much higher than that of clinical examination for different subgroups of patients. Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation
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              Outcome and time course of recovery in stroke. Part II: Time course of recovery. The Copenhagen Stroke Study.

              Henrik Jørgensen, Hirofumi Nakayama, Hans Raaschou … (1995)
              To determine the time course of both neurological and functional recovery from stroke. Prospective, consecutive, and community based. The stroke unit of a hospital in Copenhagen, Denmark. This setting receives all acute stroke patients admitted from a well-defined catchment area of 239,886 inhabitants within the city of Copenhagen. Acute treatment as well as all stages of rehabilitation are cared for within the stroke unit regardless of age, stroke severity, and premorbid condition. 1,197 patients with acute stroke. Weekly examinations of neurological deficits (using the Scandinavian Neurological Stroke Scale) and functional disabilities (Activity of Daily Living (ADL) measured by the Barthel Index) were performed from the time of acute admission to the end of rehabilitation. These evaluations were repeated 6 months poststroke. Time course of recovery was stratified according to initial stroke severity and disability. Functional recovery was completed within 12.5 weeks (95% confidence interval (CI) 11.6 to 13.4) from stroke onset in 95% of the patients. However, 80% of the patients had reached their best ADL function within 6 weeks (CI 5.3 to 6.7) from onset. The time course of functional recovery was strongly related to initial stroke severity. Best ADL function was reached within 8.5 weeks (CI 8 to 9) in patients with initially mild strokes, within 13 weeks (CI 12 to 14) in patients with moderate strokes, within 17 weeks (CI 15 to 19) in patients with severe strokes, and within 20 weeks (CI 16 to 24) in patients with very severe strokes. After these time-points, no significant changes occurred. However, a valid prognosis of functional outcome can be made much earlier. Best ADL function was reached by 80% of the patients with initially mild strokes within 3 weeks (CI 2.6 to 3.4), within 7 weeks (CI 6 to 8) of the patients with moderate strokes, and within 11.5 weeks (CI 10 to 13) of the patients with severe and very severe strokes. The time course of neurological recovery followed a pattern similar to that of functional recovery, but preceeded functional recovery by 2 weeks on average. A reliable prognosis can in all stroke patients be made within 12 weeks from stroke onset. Even in patients with severe and very severe strokes, neurological and functional recovery should not be expected after the first 5 months.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Int J Rehabil Res
                Journal ID (iso-abbrev): Int J Rehabil Res
                Journal ID (publisher-id): MRR
                Title: International Journal of Rehabilitation Research. Internationale Zeitschrift Fur Rehabilitationsforschung. Revue Internationale De Recherches De Readaptation
                Publisher: Lippincott Williams & Wilkins
                ISSN (Print): 0342-5282
                ISSN (Electronic): 1473-5660
                Publication date (Print): June 2015
                Publication date (Electronic): 06 May 2015
                Volume: 38
                Issue: 2
                Pages: 173-180
                Affiliations
                [a ]Department of Physical Therapy
                [b ]Department of Rehabilitation Medicine, St. Vincent Hospital, Suwon
                [c ]Department of Physical Therapy, Sahmyook University
                [d ]Department of Physical Therapy, Sam Hospital, Anyang
                [e ]Department of Physical Therapy, Severance Rehabilitation Hospital, Yonsei University, Seoul
                [f ]Department of Physical Therapy, Ilsan Paik Hospital, Inje University, Ilsan
                [g ]Human movement research center, Daejeon
                [h ]Department of Physical Therapy, Yongin University, Yongin, Republic of Korea
                Author notes
                Correspondence to Byong Yong Hwang, PT, PhD, Department of Physical Therapy, Yongin University, Samga-Dong, Yongin-Si 449-714, Republic of KoreaTel: +82 31 3230 2773; fax: +82 31 3230 3075; e-mail: bobathkorea@ 123456hanmail.net
                Article
                DOI: 10.1097/MRR.0000000000000108
                PMC ID: 4415968
                PubMed ID: 25603539
                SO-VID: ca94c0ab-727b-46e6-81dd-a669dc235832
                Copyright © Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NCND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. http://creativecommons.org/licenses/by-nc-nd/4.0/.

                History
                Date received : 1 September 2014
                Date accepted : 13 December 2014
                Categories
                Subject: Original Articles
                Custom metadata
                OPEN-ACCESS TRUE

                Keywords: recovery of function,recovery of neurologic impairment,stroke
                Data availability:
                Keywords: recovery of function, recovery of neurologic impairment, stroke

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