Post-Stroke Rehabilitation Outcomes Research Articles

Early Prediction of Poststroke Rehabilitation Outcomes Using Wearable Sensors.

Inpatient rehabilitation represents a critical setting for stroke treatment, providing intensive, targeted therapy and task-specific practice to minimize a patient's functional deficits and facilitate their reintegration into the community. However, impairment and recovery vary greatly after stroke, making it difficult to predict a patient's future outcomes or response to treatment. In this study, the authors examined the value of early-stage wearable sensor data to predict 3 functional outcomes (ambulation, independence, and risk of falling) at rehabilitation discharge. Fifty-five individuals undergoing inpatient stroke rehabilitation participated in this study. Supervised machine learning classifiers were retrospectively trained to predict discharge outcomes using data collected at hospital admission, including patient information, functional assessment scores, and inertial sensor data from the lower limbs during gait and/or balance tasks. Model performance was compared across different data combinations and was benchmarked against a traditional model trained without sensor data. For patients who were ambulatory at admission, sensor data improved the predictions of ambulation and risk of falling (with weighted F1 scores increasing by 19.6% and 23.4%, respectively) and maintained similar performance for predictions of independence, compared to a benchmark model without sensor data. The best-performing sensor-based models predicted discharge ambulation (community vs household), independence (high vs low), and risk of falling (normal vs high) with accuracies of 84.4%, 68.8%, and 65.9%, respectively. Most misclassifications occurred with admission or discharge scores near the classification boundary. For patients who were nonambulatory at admission, sensor data recorded during simple balance tasks did not offer predictive value over the benchmark models. These findings support the continued investigation of wearable sensors as an accessible, easy-to-use tool to predict the functional recovery after stroke. Accurate, early prediction of poststroke rehabilitation outcomes from wearable sensors would improve our ability to deliver personalized, effective care and discharge planning in the inpatient setting and beyond.

Lessons on Health Literacy and Communication in Post-Stroke Rehabilitation:: A Primer and Proposal.

Health literacy, or the ability to find, understand, and use information to make well-informed health decisions, has been linked to post-stroke rehabilitation outcomes. Importantly, barriers to health literacy stem from stroke survivor characteristics, clinician practices, institutional norms, as well as systemic variables. These barriers impact recovery and rehabilitation outcomes. To address these obstacles, clinicians can learn from the evidence-based practices used by speech-language pathologists in their work with stroke survivors with aphasia, a language impairment that can follow stroke. These methods to overcome communication barriers are appropriate and recommended for patients and family members regardless of stroke impairment, and include a transdisciplinary care model, multimodal approaches to patient education, along with consistent engagement with patients and their care partners. These strategies may be adopted for both personal and organizational health literacy efforts and help optimize the rehabilitation and recovery outcomes of stroke survivors with and without aphasia.

Construction and Validation of the 17-Item Stroke-Specific Quality of Life Scale (SS-QOL-17): A Comprehensive Short Scale to Assess the Functional, Psychosocial, and Therapeutic Factors of QOL among Stroke Survivors.

(1) Background: The exiting stroke-specific quality of life (SS-QOL) measure scales are limited by their excessive length, inconsistent validity, and restricted breadths of assessment. The objectives of this study were to construct and validate a comprehensive short SS-QOL scale to assess stroke-related outcomes and QOL and determine the socioeconomic, sociodemographic, and pharmacotherapeutic predictors of QOL among stroke survivors. (2) Methods: The novel 17-item SS-QOL scale (SS-QOL-17) was constructed with the aim of providing a well-balanced measuring tool to depict QOL widely while ensuring the simplicity of administration. (3) Results: The SS-QOL-17 structure was validated over a solution of three factors with a Kaiser-Meyer-Olkin measure of sampling adequacy = 0.894 and a significant Bartlett's test of sphericity (p < 0.001). The Cronbach's alpha of the SS-QOL-17 was 0.903. Better QOL was correlated to financial wellbeing (beta 0.093, p < 0.001), and medication adherence (beta 0.305, p = 0.004), whereas reduced QOL was correlated to older age (beta -0.117, p = 0.014), illiteracy (beta -6.428, p < 0.001), unemployment (beta -6.170, p < 0.001), and higher amount of prescribed medication (beta -1.148, p < 0.001). (4) Conclusions: The SS-QOL-17 is a valid and reliable tool with promising psychometric properties. It is useful in clinical practice and research settings to evaluate the post-stroke therapeutic and rehabilitation outcomes.

Post-stroke lateropulsion and rehabilitation outcomes: a retrospective analysis

Purpose A person with post-stroke lateropulsion actively pushes themselves toward their hemiplegic side, or resists moving onto their non-hemiplegic side. This study aimed to determine the association of lateropulsion severity with: • Change in function (Functional Independence Measure – FIM) and lateropulsion severity (Four-Point Pusher Score – 4PPS) during inpatient rehabilitation; • Inpatient rehabilitation length of stay (LOS); • Discharge destination from inpatient rehabilitation. Methods Retrospective data for 1,087 participants (aged ≥65 years) admitted to a stroke rehabilitation unit (2005–2018) were analysed using multivariable regression models. Results Complete resolution of lateropulsion was seen in 69.4% of those with mild lateropulsion on admission (n = 160), 49.3% of those with moderate lateropulsion (n = 142), and 18.8% of those with severe lateropulsion (n = 181). Average FIM change was lower in those with severe lateropulsion on admission than those with no lateropulsion (p < 0.001). Higher admission 4PPS was associated with reduced FIM efficiency (p < 0.001), longer LOS (p < 0.001), (adjusted mean LOS: 35.6 days for those with severe lateropulsion versus 27.0 days for those without), and reduced likelihood of discharge home (p < 0.001). Conclusion Post-stroke lateropulsion is associated with reduced functional improvement and likelihood of discharge home. However, given a longer rehabilitation duration, most stroke survivors with moderate to severe lateropulsion can achieve important functional improvement. Implications for Rehabilitation While people with post-stroke lateropulsion can be difficult to treat and require more resources than those without lateropulsion, the majority of those affected, even in severe cases, can make meaningful recovery with appropriate rehabilitation. Although those with moderate to severe post-stroke lateropulsion may have poorer outcomes (longer LOS and reduced likelihood of discharge home) it is still important to advocate for access to rehabilitation for this patient group to give them the opportunity for optimal functional recovery.

Race/Ethnicity Matters: Differences in Poststroke Inpatient Rehabilitation Outcomes.

To examine racial/ethnic differences in poststroke inpatient rehabilitation outcomes. Cross-sectional and retrospective study of administrative data across 2002-2018. An inpatient rehabilitation facility in Southern California. 3,876 racial/ethnic people aged ≥ 18 years. Functional Independence Measure (FIM®) and discharge disposition. Participants were non-Hispanic Whites (NHWs, 68.5%), Hispanics (17.1%), non-Hispanic Asians (NHAs, 7.4%), and non-Hispanic Blacks (NHBs, 6.4%) aged 18-102 years (Mage = 68.47±14.66 years; MLOS = 19.47±10.05 days). Above and beyond covariates, multivariate hierarchical regression analyses showed race/ethnicity significantly predicted admission, motor efficiency, and discharge FIM® scores. Compared with NHWs, the Hispanic and NHA groups were associated with lower cognitive, motor, and total FIM® scores at admission; the NHB group was associated with lower motor efficiency, lower discharge motor and total FIM® scores, whereas the Hispanic group was associated with higher discharge total FIM® scores. Lastly, Hispanics had higher odds of a discharge home compared with NHWs. Findings suggest racial/ethnic differences exist in poststroke rehabilitation outcomes.

Can initial sarcopenia affect poststroke rehabilitation outcome?

This study investigated the association between the presence of sarcopenia, measured by nonhemiplegic grip strength, and the level of functional recovery, measured by the modified Rankin Scale (mRS) at six months after stroke. We performed a retrospective cohort analysis of a prospectively maintained database of 194 hemiplegic poststroke patients, who had been admitted to the Department of Rehabilitation Medicine of a university-affiliated hospital. At 6 months after stroke, 72.2% of patients had mRS score >3, with more women (81.0% vs. 66.0%, p = 0.024) showing poor recovery. Both men (51.3% vs. 35.9%, p = 0.041) and women (42.2% vs. 6.7%, p = 0.022) with mRS score >3 had a higher rate of sarcopenia. Univariate analysis revealed that the presence of sarcopenia was associated with a 2.71-fold higher risk of poor recovery at six months. In addition, women had a 2.18-fold higher risk of poor outcome. Multivariable logistic regression analysis revealed that the presence of sarcopenia was associated with poor functional outcome (odds ratio [OR] = 2.61, 95% confidence interval [CI]: 1.14–5.98, p = 0.024) in men, but this association was notably stronger in women (OR = 9.93, 95% CI: 1.22–81.19, p = 0.032). This study suggests that the presence of sarcopenia two weeks after stroke may increase the risk of poor functional outcome six months after stroke. Most notably, women with sarcopenia within 2 weeks from stroke onset were more significantly likely to have a poor modified Rankin Scale after 6 months.

Assistive game controller for artificial intelligence-enhanced telerehabilitation post-stroke

ABSTRACT Off-the-shelf gaming technology is designed for young, fit, and motor intact individuals. Artificial intelligence (AI) has a role in making controllers and therapeutic games adaptable to the disabled. Post-stroke rehabilitation outcomes can be enhanced by gaming technology within the home to enable engaging telerehabilitation. BrightBrainer™ Grasp (BBG) is a novel therapeutic game controller designed to adapt to arm and hand impairments post-stroke. It mediates intensive arm reach, grasp and finger extension training and has the ability to track relevant outcomes. The newly designed controller uses BrightBrainer gamification system with AI technology to provide automatic adaptation, requiring minimal clinician input. This article describes the BBG design, hardware, force and movement detection and calibration, and its integration with the therapeutic games. The use of AI in adapting a library of custom therapeutic games is also described. Results of a usability study with healthy individuals and related design modifications are presented, with implications for future trials.

Examining the Inter-relations of Depression, Physical Function, and Cognition with Subjective Sleep Parameters among Stroke Survivors: A Cross-sectional Analysis

Goal: Stroke survivors commonly experience depression as well as deficits in physical and cognition function. Emerging evidence also suggests sleep quality is compromised poststroke. Our primary objective was to examine the association of subjective sleep parameters (ie, total PSQI score) with depression, health related quality of life, physical function, and cognition among stroke survivors. Materials and Methods: Cross-sectional analysis of 72 older adults with chronic stroke (≥6 months postischemic stroke) enrolled in a randomized controlled trial of exercise or cognitive enrichment. Subjective sleep parameters were assessed using the Pittsburgh Sleep Quality Index (PSQI). We report total PSQI score and specific PSQI parameter scores (ie, PSQI-subjective sleep quality, PSQI-sleep latency, PSQI-sleep duration, PSQI-habitual sleep efficiency, PSQI-sleep disturbances, PSQI-use of sleep medication, and PSQI-daytime dysfunction). Bivariate correlations and multivariate linear regression assessed associations between subjective sleep parameters and depression/health related quality of life, physical function, and cognition. Findings: For bivariate correlations, depression was significantly associated with global PSQI, PSQI-subjective sleep quality, PSQI-habitual sleep efficiency, and PSQI-daytime dysfunction. Health related quality of life was significantly associated with PSQI-sleep medication. Physical function and health was significantly associated with PSQI-subjective sleep quality, PSQI-sleep latency, PSQI-sleep duration, and PSQI-daytime dysfunction. Multivariate linear regression demonstrated that PSQI-daytime dysfunction predicted depression and physical function; PSQI-subjective sleep quality predicted depression. No significant associations between global PSQI subjective sleep parameters with cognition were observed. Conclusion: Poor subjective sleep parameters and PSQI-subjective sleep quality among stroke survivors were associated with depression; PSQI-daytime dysfunction was associated with physical function. Thus, sleep should be considered in the management of those who have suffered a stroke to optimize poststroke rehabilitation outcomes.

Self-Reported Body Weight Changes, Perceptions, and Weight Loss Techniques among Stroke Survivors

Background: Little is known about the body weight goals and trends of stroke survivors, despite evidence that overweight and obesity can negatively influence poststroke rehabilitation outcomes. Thus, the purpose of this study was to identify self-reported body weight trends over time in stroke survivors and nonstroke controls (>50 years old) and describe the methods used to attempt to achieve body weight goals. Methods: Self-reported body weight 1) at age 25 years, 2) 10 years prior to the current assessment, 3) 1 year prior to the current assessment, 4) current weight, and 5) age of heaviest body weight were collected from adults self-reporting a stroke in the 2011-2012 and 2013-2014 National Health and Nutrition Examination Surveys (stroke: N = 387 and nonstroke: N = 5085). Questionnaires were used to assess body weight goals and weight loss techniques during the previous year. Results: Of the stroke survivors, 54% reported that their heaviest weight occurred after their stroke. Approximately 70% of stroke and nonstroke were overweight or obese. Only 24% of stroke survivors reported trying to lose weight compared with 35% of nonstroke, with only 10%-15% successful (≥5% body weight loss), during the past year. Popular weight loss methods in both groups included eating less, exercising, and eating more fruits/vegetables. The majority of stroke survivors report their heaviest weight after their stroke and a desire to weigh less; however, few report successful weight loss. Conclusions: Future research is needed to identify optimal body weight and ways to incorporate preferred methods of lifestyle modification, including diet and exercise, to promote weight management in stroke survivors.

Post-stroke rehabilitation training with a brain-computer interface: a clinical and neuropsychological study

To evaluate the clinical efficacy of BCI-supported mental practice and to reveal specific cognitive impairment which determine mental practice ineffectiveness and inability to perform MI. Fifty-five hemiplegic patients after first-time stroke (median age 54. 0 [44.0; 61.0], time from onset 6.0 [3.0; 13.0] month) were randomized into two groups - BCI and sham-controlled. Severity of arm paresis was measured by Fugl-Meyer Assessment of Motor Recovery after Stroke (FMA) and Action Research Arm Test (ARAT). Twelve patients from the BCI group were examined using neuropsychological testing. After assessment, patients were trained to imagine kinesthetically a movement under control of BCI with the feedback presented via an exoskeleton. Patients underwent 12 training sessions lasting up to 30 min. In the end of the study, the scores on movement scales, electroencephalographic results obtained during training sessions were analyzed and compared to the results of neuropsychological testing. Evaluation of the UL clinical assessments indicated that both groups improved on ARAT and FMA (sections A-D, H, I) but only the BCI group showed an improvement in the ARAT's grasp score (p=0.012), pinch score (p=0.012), gross movement score (p=0,002). The significant correlation was revealed between particular neuropsychological tests (Taylor Figure test, choice reaction test, Head test) and online accuracy rate. These results suggest that adding BCI control to exoskeleton-assisted physical therapy can improve post-stroke rehabilitation outcomes. Neuropsychological testing can be used for screening before mental practice admission and promote personalized rehabilitation.

Post-stroke Rehabilitation Training with a Motor-Imagery-Based Brain-Computer Interface (BCI)-Controlled Hand Exoskeleton: A Randomized Controlled Multicenter Trial.

Repeated use of brain-computer interfaces (BCIs) providing contingent sensory feedback of brain activity was recently proposed as a rehabilitation approach to restore motor function after stroke or spinal cord lesions. However, there are only a few clinical studies that investigate feasibility and effectiveness of such an approach. Here we report on a placebo-controlled, multicenter clinical trial that investigated whether stroke survivors with severe upper limb (UL) paralysis benefit from 10 BCI training sessions each lasting up to 40 min. A total of 74 patients participated: median time since stroke is 8 months, 25 and 75% quartiles [3.0; 13.0]; median severity of UL paralysis is 4.5 points [0.0; 30.0] as measured by the Action Research Arm Test, ARAT, and 19.5 points [11.0; 40.0] as measured by the Fugl-Meyer Motor Assessment, FMMA. Patients in the BCI group (n = 55) performed motor imagery of opening their affected hand. Motor imagery-related brain electroencephalographic activity was translated into contingent hand exoskeleton-driven opening movements of the affected hand. In a control group (n = 19), hand exoskeleton-driven opening movements of the affected hand were independent of brain electroencephalographic activity. Evaluation of the UL clinical assessments indicated that both groups improved, but only the BCI group showed an improvement in the ARAT's grasp score from 0 [0.0; 14.0] to 3.0 [0.0; 15.0] points (p < 0.01) and pinch scores from 0.0 [0.0; 7.0] to 1.0 [0.0; 12.0] points (p < 0.01). Upon training completion, 21.8% and 36.4% of the patients in the BCI group improved their ARAT and FMMA scores respectively. The corresponding numbers for the control group were 5.1% (ARAT) and 15.8% (FMMA). These results suggests that adding BCI control to exoskeleton-assisted physical therapy can improve post-stroke rehabilitation outcomes. Both maximum and mean values of the percentage of successfully decoded imagery-related EEG activity, were higher than chance level. A correlation between the classification accuracy and the improvement in the upper extremity function was found. An improvement of motor function was found for patients with different duration, severity and location of the stroke.

Opportunities for Guided Multichannel Non-invasive Transcranial Current Stimulation in Poststroke Rehabilitation.

Stroke is a leading cause of serious long-term disability worldwide. Functional outcome depends on stroke location, severity, and early intervention. Conventional rehabilitation strategies have limited effectiveness, and new treatments still fail to keep pace, in part due to a lack of understanding of the different stages in brain recovery and the vast heterogeneity in the poststroke population. Innovative methodologies for restorative neurorehabilitation are required to reduce long-term disability and socioeconomic burden. Neuroplasticity is involved in poststroke functional disturbances and also during rehabilitation. Tackling poststroke neuroplasticity by non-invasive brain stimulation is regarded as promising, but efficacy might be limited because of rather uniform application across patients despite individual heterogeneity of lesions, symptoms, and other factors. Transcranial direct current stimulation (tDCS) induces and modulates neuroplasticity, and has been shown to be able to improve motor and cognitive functions. tDCS is suited to improve poststroke rehabilitation outcomes, but effect sizes are often moderate and suffer from variability. Indeed, the location, extent, and pattern of functional network connectivity disruption should be considered when determining the optimal location sites for tDCS therapies. Here, we present potential opportunities for neuroimaging-guided tDCS-based rehabilitation strategies after stroke that could be personalized. We introduce innovative multimodal intervention protocols based on multichannel tDCS montages, neuroimaging methods, and real-time closed-loop systems to guide therapy. This might help to overcome current treatment limitations in poststroke rehabilitation and increase our general understanding of adaptive neuroplasticity leading to neural reorganization after stroke.

Influence of both malnutrition and severity in stroke patients for length of independent ambulation verified by covariance structure analysis

Methods: 50 healthy controls (mean age = 67.3± 4.5; 27 males) and 48 elderlywith stroke (mean age = 67.3± 7.14; 32 males)were recruited. Fatiguewas assessedbyFatigueSeverity Scale (FSS). Age, gender, and chronicity were recorded as demographic information. Assessments of stroke severity (Fugl-Meyer), cognition (MoCA), independence level (modified Rankin Scale and Barthel Index), depression (PHQ-9) and presence of pain were administered. Quality of life was assessed using WHOQoL-BREF. Chi squared was used for comparison between the groups. Spearman rank correlation coefficient was used to determine relationship between fatigue and other outcome measures. Results: Twenty-two patient with stroke reported fatigue (46%)while only 5 non-stroke elderly (10%) reported fatigue (p< .001). The stroke group had a greater FSS score compared to the healthy controls (p< .001). There was no difference between male stroke and female stroke on the FSS score (p= .28). Similarly, age, presence of pain, cognition, and stroke severitywere not significantly correlatedwith post-stroke fatigue. In contrast, depression was significantly positively correlated with post-stroke fatigue (r = .37, p< .001). Post-stroke fatigue was not correlated with the levels of independence (BI p= .16; mRS p= .62). However, physical domain of quality of life was significantly negatively correlated with fatigue among individuals with stroke (r=−.46, p< .001). Conclusion(s): Prevalence of fatigue among individuals post-stroke was higher than the healthy elderly. Post-stroke fatigue was not associated with gender, pain, stroke severity, functional capacity, cognition and levels of independence. In contrast, post-stroke fatigue positively associated with depression and negatively correlated with physical domain of quality of life. Implications: Investigation of post-stroke fatigue and its correlates will assist to improve the post-stroke care and rehabilitation outcome.

Racial/Ethnic differences in poststroke rehabilitation outcomes.

Background. Significant racial and ethnic disparities in stroke incidence, severity, and morbidity have been consistently reported; however, less is known about potential differences in poststroke rehabilitation outcomes. Objective. To examine racial and ethnic differences in poststroke rehabilitation outcomes. Methods. We completed an in-depth search of Medline and several major journals dedicated to publishing research articles on stroke, rehabilitation, and racial-ethnic patterns of disease over a 10-year period (2003–2012). We identified studies that reported rehabilitation outcomes and the race or ethnicity of at least two groups. Results. 17 studies involving 429,108 stroke survivors met inclusion criteria for the review. The majority (94%) of studies examined outcomes between Blacks and Whites. Of those studies examining outcomes between Blacks and Whites, 59% showed that Blacks were generally less likely to achieve equivalent functional improvement following rehabilitation. Blacks were more likely to experience lower FIM gain or change scores (range: 1–60%) and more likely to have lower efficiency scores (range: 5–16%) than Whites. Conclusions. Black stroke survivors appear to generally achieve poorer functional outcomes than White stroke survivors. Future studies are warranted to evaluate the precise magnitude of these differences, whether they go beyond chance, and the underlying contributory mechanisms.

How does cognitive ability affect stroke rehabilitation outcomes?

Background: This paper discusses literature findings on the impact of pre-stroke degenerative cognitive impairments (pre-stroke dementia) on post-stroke rehabilitation outcomes. This association has practical implications for stroke rehabilitation services which are faced with the dilemma that pre-stroke cognitive impairment may be a cause of stroke and, on the other hand, stroke may cause cognitive deficits. Content: The link between pre-stroke dementia and stroke is described by explaining how vascular and neurodegenerative pathology contribute to stroke occurrence and to stroke related impairment. Stroke seems to be more closely related to dementia than previously thought and vascular factors appear to be at the core of a wide range of dementing disorders. The literature reviewed emphasises how cognitive performance at stroke onset can give indications about the anticipated level of post-stroke functional independence. Conclusion: The importance of assessing and monitoring cognitive performance of stroke survivors using reliable neuropsychological procedures is emphasised. The assessment results help to estimate rehabilitation potential, to plan the most effective interventions and to optimise post-hospital discharge arrangements. This helps clinicians on stroke units to make rehabilitation decisions addressing both cognitive variables and professional standards.

Skill transfer from symmetric and asymmetric bimanual training using a robotic system to single limb performance

BackgroundHumans are capable of fast adaptation to new unknown dynamics that affect their movements. Such motor learning is also believed to be an important part of motor rehabilitation. Bimanual training can improve post-stroke rehabilitation outcome and is associated with interlimb coordination between both limbs. Some studies indicate partial transfer of skills among limbs of healthy individuals. Another aspect of bimanual training is the (a)symmetry of bimanual movements and how these affect motor learning and possibly post-stroke rehabilitation.MethodsA novel bimanual 2-DOF robotic system was used for both bimanual and unimanual reaching movements. 35 young healthy adults participated in the study. They were divided into 5 test groups that performed movements under different conditions (bimanual or unimanual movements and symmetric or asymmetric bimanual arm loads). The subjects performed a simple tracking exercise with the bimanual system. The exercise was developed to stimulate motor learning by applying a velocity-dependent disturbance torque to the handlebar. Each subject performed 255 trials divided into three phases: baseline without disturbance torque, training phase with disturbance torque and evaluation phase with disturbance torque.ResultsPerformance was assessed with the maximal values of rotation errors of the handlebar. After exposure to disturbance torque, the errors decreased for both unimanual and bimanual training. Errors in unimanual evaluation following the bimanual training phase were not significantly different from errors in unimanual evaluation following unimanual training. There was no difference in performance following symmetric or asymmetric training. Changing the arm force symmetry during bimanual movements from asymmetric to symmetric had little influence on performance.ConclusionsSubjects could adapt to an unknown disturbance torque that was changing the dynamics of the movements. The learning effect was present during both unimanual and bimanual training. Transfer of learned skills from bimanual training to unimanual movements was also observed, as bimanual training also improved single limb performance with the dominant arm. Changes of force symmetry did not have an effect on motor learning. As motor learning is believed to be an important mechanism of rehabilitation, our findings could be tested for future post-stroke rehabilitation systems.

Poster 27: Black and White Disparities in Inpatient Stroke Rehabilitation Outcomes

Objective: To assess racial disparities in functional outcome on discharge from inpatient rehabilitation. Design: Multicenter prospective observational cohort study on inpatient stroke rehabilitation, the Post-Stroke Rehabilitation Outcomes Project (PSROP). Settings: 6 inpatient rehabilitation facilities from across the United States. Participants: 732 patients, subdivided in 2 case-mix groups (CMG classification). CMG groups 104 to 107 were grouped into the moderate group (n=397), and CMG groups 108 to 114 were defined as the severe stroke group (n=335).

Article 7: An International Comparison of the Characteristics of Inpatient Stroke Rehabilitation: Are We Talking About the Same Thing?

Objective: To compare inpatient rehabilitation following stroke. Design: Secondary analyses on the pooled dataset from 2 prospective cohort studies, one in Europe (Collaborative Evaluation of Rehabilitation In Stroke across Europe) and one in the United States (Post-Stroke Rehabilitation Outcomes Project). Setting: 6 inpatient rehabilitation facilities (IRFs) in the United States, 1 IRF in New Zealand, and 4 IRFs in Europe. Participants: 1214 patients suffering first ever-stroke (U.S.: n=622; N.Z.: n=60; E.U.: n=532). Interventions: Not applicable. Results: Median age was the highest in the N.Z. group and the lowest in the U.S. (75y, 67y, respectively; P<.001). Time between stroke onset and admission to the IRF varied significantly (median: U.S., 7d; N.Z., 9d; E.U., 16d; P<.001). Functional status on admission was significantly lower in the U.S. group compared with the E.U. group (median Barthel Index score, 7 and 11, respectively; P<.001). Additionally, length of stay showed large differences (median values: U.S., 16d; N.Z., 24d; E.U., 50d). Functional status at discharge was significantly higher in the E.U. group compared with the U.S. group (median Barthel Index score, 17 and 13, respectively; P<.001). Conclusions: Significant differences in case mix and processes of care were observed among the 3 regions. These differences provide a good basis for evaluating the effectiveness of different rehabilitation programs.

Poststroke Rehabilitation

To assess whether poststroke rehabilitation outcomes and reimbursement for Medicare beneficiaries differ across inpatient rehabilitation facilities (IRFs) and skilled nursing facility (SNF) subacute rehabilitation programs. Clinical data were linked with Medicare claims for 58,724 Medicare beneficiaries with a recent stroke who completed treatment in 1996 or 1997 in IRFs and subacute rehabilitation SNFs that subscribed to the Uniform Data System for Medical Rehabilitation. Outcome measures were discharge destination, discharge FIM ratings and Medicare Part A reimbursement during the institutional stay. IRF patients that were more likely to have a community-based discharge, compared with rehabilitation SNF patients, were patients with mild motor disabilities and FIM cognitive ratings of 23 or greater (adjusted odds ratio [AOR]=2.19; 95% CI: 1.52 to 3.14), patients with moderate motor disabilities (AOR=1.98; 95% CI: 1.49 to 2.61), patients with significant motor disabilities (AOR=1.26; 95% CI: 1.01 to 1.57) and patients younger than 82 with severe motor disabilities (AOR=1.43; 95% CI: 1.25 to 1.64). IRF patients with significant and severe motor disabilities achieved greater motor function of 2 or more FIM units compared with rehabilitation SNF patients. Medicare Part A payments for IRFs were higher than rehabilitation SNF payments across all subgroups. For most patients, poststroke rehabilitation in the more costly and intensive IRFs resulted in higher functional outcomes compared with care in a SNF-based rehabilitation program. IRF and SNF outcomes were similar for patients with minimal motor disabilities and patients with mild motor disabilities and significant cognitive disabilities. Cost-effectiveness analyses require considering the costs of the full episode of care.

Characterizing Speech and Language Pathology Outcomes in Stroke Rehabilitation

Hatfield B, Millet D, Coles J, Gassaway J, Conroy B, Smout RJ. Characterizing speech and language pathology outcomes in stroke rehabilitation. Objectives To describe a subset of speech-language pathology (SLP) patients in the Post-Stroke Rehabilitation Outcomes Project and to examine outcomes for patients with low admission FIM levels of auditory comprehension and verbal expression. Design Observational cohort study. Setting Five inpatient rehabilitation hospitals. Participants Patients (N=397) receiving poststroke SLP with admission FIM cognitive components at levels 1 through 5. Interventions Not applicable. Main Outcome Measure Increase in comprehension and expression FIM scores from admission to discharge. Results Cognitively and linguistically complex SLP activities (problem-solving and executive functioning skills) were associated with greater likelihood of success in low- to mid-level functioning communicators in the acute poststroke rehabilitation period. Conclusions The results challenge common clinical practice by suggesting that use of high-level cognitively and linguistically complex SLP activities early in a patient’s stay may result in more efficient practice and better outcomes regardless of the patient’s functional communication severity level on admission.