Predictors Of Functional Independence Research Articles

Abstract TP213: Predictors of Functional Independence Among Acute Ischemic Stroke Patients Treated With Intra-Arterial Thrombolysis as Adjunct to Mechanical Thrombectomy

Background and Purpose: Although intra-arterial thrombolysis (IAT) is widely used as adjunct with mechanical thrombectomy in acute ischemic stroke patients, the patients who are likely to benefit are not known. We analyzed real world data to identify acute ischemic stroke patients who are likely to benefit with IA as adjunct to mechanical thrombectomy. Methods: Acute ischemic stroke patients who underwent IAT with tissue plasminogen activator (tPA)/urokinase as adjunct to mechanical thrombectomy in the Trevo Retriever multicenter registry were analyzed. Primary endpoint was functional independence at 90 days post mechanical thrombectomy defined by a modified Rankin scale (mRS) of 0-2. We compared the variables including age, gender, pre-procedure National Institute of Health Stroke Scale (NIHSS) score, baseline Alberta Stroke Program Early CT (ASPECT) score, location of occlusion, procedure time, Thrombolysis in Cerebral Infarction (TICI) score pre- and post IAT, and number of thrombectomy passes. Results: A total of 145 patients treated with IAT tPA/urokinase after undergoing mechanical thrombectomy were analyzed. 74 patients (51%) had an mRS of 0-2 while 71 (49%) had an mRS of 3-6 (p=0.48). The procedure time for the patients in group A was 66.52±35.44 minutes as compared to group B, which was 99.01±62.97 (p=0.004). Pre-procedure NIHSS score, NIHSS at discharge, and baseline ASPECT scores were comparably lower for group A (p<0.001). Number of passes during thrombectomy correlated significantly with 90-day mRS with a value of 2.31±1.49 in group A and 3.25±2.01 in group B (p=0.002). Clot location, previous stroke, TICI scores, and stent location did not show any statistical significance. Conclusion: We did not identify any differences in mRS in patients who were treated with IAT after mechanical thrombectomy. Minimum procedure time and lesser number of passes for thrombectomy are related with good neurological outcomes at 90 days.

Comparison of 5-Item and 11-Item Modified Frailty Index as Predictors of Functional Independence in Patients With Spinal Cord Injury.

Retrospective Cohort Study. The 11-item modified Frailty index (mFI-11) by the ACS-NSQIP database was used to predict which patients are high risk for complications and inpatient mortality. ACS-NSQIP now has switched to the 5-item MFI. However, there are no studies on how these frailty indices fare against each other and their prognostic value of functional independence in patients with spinal cord injury (SCI). To compare the mFI-5 and mFI-11 in order to standardize frailty assessment in the SCI population. Retrospective analysis of 272,174 patients with SCI from 2010 to 2020 from the Pennsylvania Trauma Systems Foundation (PTSF) registry. Multivariable logistic regression was used to determine the predictive value of mFI for functional independence as determined by locomotion and transfer mobility. A total of 1907 patients were included with a mean age of 46.9 ± 15.1years. The 3 most common MFI factors were hypertension (32.2%), diabetes mellitus (13.7%) and chronic obstructive pulmonary disease (8.5%). Multivariable logistic regression analyses using MFI-5 and MFI-11 showed that a higher frailty score in MFI-5 (OR 1.375, P < .001) and in MFI-11 (OR 1.366, P < .001) were each predictive of poor functional status at discharge. ROC curves for the MFI-5 (AUC = .818, P < .001) and MFI-11 (AUC = .819, P < .001) demonstrated excellent diagnostic accuracy. The new MFI-5 is equivalent to its predecessor, the MFI-11, and predictive of functional outcomes in patients with SCI. MFI-5 can serve as the preferred frailty index at the point of care and in research contexts.

Cerebral blood volume index as a predictor of functional independence after basilar artery thrombectomy.

The role of CT perfusion (CTP)in the evaluation of acute basilar artery occlusion (aBAO) patients undergoing endovascular thrombectomy (EVT) is unclear. We investigated the association of individual CTP parameters with functional outcomes in aBAO patients undergoing EVT. A health system's prospectively collected code stroke registry was used in this retrospective analysis of aBAO patients treated with EVT presenting between January 2017 and February 2021 with pre-EVT CTP. The primary outcome measure was modified Rankin Scale (mRS) score 0-2 at 90 days. Factors with a univariate association (p < .05) with mRS 0-2 were combined in a multivariable regression model to determine independent predictors of 90-day favorable functional outcome. Forty-six subjects, with median age 67 years and median National Institutes of Health Stroke Scale 16, were included, of whom 17 (37%) achieved mRS 0-2 at 90 days. In the multivariable logistic regression model, CTP cerebral blood volume (CBV) index (per 0.1-point increase, odds ratio=1.843; 95% confidence interval: 1.039, 3.268; p-value .0365) was independently associated with a favorable 90-day outcome. CBV index was independently associated with a favorable 90-day outcome in aBAO patients treated with EVT, a novel finding in this patient population. CBV index may assist in treatment and prognosis discussions and inform future studies investigating the role of CTP in aBAO.

Rescue of Neglect and Language Impairment After Stroke Thrombectomy.

Although National Institutes of Health Stroke Scale scores provide an objective measure of clinical deficits, data regarding the impact of neglect or language impairment on outcomes after mechanical thrombectomy (MT) is lacking. We assessed the frequency of neglect and language impairment, rate of their rescue by MT, and impact of rescue on clinical outcomes. This is a retrospective analysis of a prospectively collected database from a comprehensive stroke center. We assessed right (RHS) and left hemispheric strokes (LHS) patients with anterior circulation large vessel occlusion undergoing MT to assess the impact of neglect and language impairment on clinical outcomes, respectively. Safety and efficacy outcomes were compared between patients with and without rescue of neglect or language impairment. Among 324 RHS and 210 LHS patients, 71% of patients presented with neglect whereas 93% of patients had language impairment, respectively. Mean age was 71±15, 56% were females, and median National Institutes of Health Stroke Scale score was 16 (12–20). At 24 hours, MT resulted in rescue of neglect in 31% of RHS and rescue of language impairment in 23% of LHS patients, respectively. RHS patients with rescue of neglect (56% versus 34%, P<0.001) and LHS patients with rescue of language impairment (64 % versus 25%, P<0.01) were observed to have a higher rate of functional independence compared to patients without rescue. After adjusting for confounders including 24-hour National Institutes of Health Stroke Scale, rescue of neglect among RHS patients was associated with functional independence (P=0.01) and lower mortality (P=0.01). Similarly, rescue of language impairment among LHS patients was associated with functional independence (P=0.02) and lower mortality (P=0.001). Majority of LHS-anterior circulation large vessel occlusion and of RHS-anterior circulation large vessel occlusion patients present with the impairment of language and neglect, respectively. In comparison to 24-hour National Institutes of Health Stroke Scale, rescue of these deficits by MT is an independent and a better predictor of functional independence and lower mortality.

Number of passes in mechanical thrombectomy: where is your limit?

Background and aims. Stent retriever based thrombectomy is the mainstay of treatment of acute ischemic stroke caused by large vessel occlusion. However, recanalization is sometimes not achieved even after multiple passes of the thrombectomy device. Whether revascularization becomes futile or harmful with an increasing number of passes as well as criteria for when to halt attempting recanalization remain unknown. The purpose of our work is to analyze literature data on this issue. Materials and methods. We performed a short review of the literature and summarized evidence on the impact of repeated stentriever attempts on outcome.Results. Despite some controversies, the published data indicate that up to 30 % of patients still reach favorable outcome even when ≥5 stentriever passes are performed. Probability of obtaining functional independence after multiple stentriever attempts is even higher in patients with lower baseline NIHSS score. Patients who achieve successful reperfusion after ≥5 passes have significantly higher rates of functional independence and significantly lower rates of hemorrhagic transformation compared with those who do not achieve reperfusion. Rate of target recanalization after ≥4 passes may reach 19 %. Number of passes alone is not an independent negative predictor of functional independence. The impact of multiple stentriever attempts on hemorrhagic transformation has not been well-established.Conclusions. Target vessel recanalization is an essential goal of mechanical thrombectomy, which should be pursued despite the additional number of passes and procedural time required. Number of stentriver attempts is not a game- changing factor in the decision to abort the procedure for technical futility. Treatment decisions need to be individualized for each patient based on operator’s experience and preferences, patient and clot-specific characteristics.

Sex Differences in Energetic Cost of Walking and Later-Life Function and Physical Activity Patterns

Aerobic fitness is a strong predictor of functional independence with aging. Variability in aerobic fitness is due, in part, to the efficiency of the movement of body mass while ambulating [energetic cost of walking (ECoW)]. ECoW may serve as a low burden measure of fitness compared to volitional treadmill tests. We assessed the predictive ability of ECoW with later-life function and physical activity participation in healthy adults. N=75 (age = 54.7 +/- 9.2; 52% female) completed a treadmill test with indirect calorimetry, during which time a warm-up of 1.5 mph at 0% grade was uniform. ECoW was quantified as steady state volume of oxygen consumption (ml/kg/min) subtracted by the calculated metabolic cost of walking at given speed and grade (=7.5 ml/kg/min). Later-life (median=9 years follow-up) function was assessed using the SF-36 physical functioning subscale, and the Baecke questionnaire for physical activity. Mean EcoW was similar to calculated cost (difference = -0.14 ml/kg/min) but had large variation (SD = 2.7; range = -4.4 to +17 ml/kg/min). In females, higher ECoW was predictive of better later-life function (b=1.9; p=0.04) and higher physical activity levels (b=0.09; p=0.001). In males, lower ECoW was predictive of higher physical activity levels only (b=-0.04; p=0.01). All models controlled for % body fat, age, and comorbidities. Surprisingly, in females, higher ECoW was associated with better later-life health outcomes. We hypothesize that this phenomenon may be similar to the obesity paradox, in that relatively higher non-metabolic tissue in females may serve as a stimulus for muscle and functional preservation.

Abstract TP387: Development of a Single System Activation Process to Reduce Time From Arrival to Skin Puncture in Endovascular Treatment

Background and Issues: Timely recanalization of intracerebral artery occlusions is a strong predictor of functional independence and reduced mortality in acute ischemic stroke patients. Our current stroke alert process did not address a way to assemble the neuro-interventional team rapidly for these emergent cases, resulting in lengthy times from arrival to skin puncture. In an effort to improve these times, with an ultimate goal of 90 minutes or less, we created a single system pager titled “Neuro IR 911”. With one phone call, we can now simultaneously activate the entire team. Purpose: The purpose of this project was to improve arrival to skin puncture times by eliminating overlap of multiple staff working separately to assemble the neuro-interventional team. Methods: We captured arrival to skin puncture times in 29 emergency department patients with a discharge diagnosis of ischemic stroke. Descriptive statistics (mean, standard deviation, median, 25 th and 75 th percentiles, minimum and maximum values for continuous variables) were calculated separately by group (pre-intervention and post-intervention). These two groups were compared using the Mann Whitney test for continuous data. A result was considered statistically significant at the p&lt;0.05 level of significance. Results: There was a reduction in arrival to skin puncture times but no statistical significance between pre-intervention and post-intervention groups was determined (126 minutes vs. 107 minutes respectively, p&lt;0.4785). Conclusions: Streamlining the activation process using a single system pager can reduce arrival to skin puncture times, but statistical significance remains to be determined.

Location of Intracerebral Hemorrhage Affects Outcome After Minimally Invasive Endoscopic Hematoma Evacuation

Abstract INTRODUCTION Treatment for intracerebral hemorrhage (ICH) has been largely medical after negative findings from trials evaluating open craniotomy for hematoma evacuation. Location of hemorrhage has always been a determinant of outcome in ICH. This has ramifications for outcomes after minimally invasive (MIS) evacuation. We present analysis of ICH outcome after endoscopic evacuation stratified by hemorrhage location. METHODS Minimally invasive endoscopic ICH evacuation was performed on patients with supratentorial ICH who fit previously published clinical criteria including age = 18, National Institutes of Health Stroke Scale (NIHSS) = 6, hematoma volume = 15, and baseline modified Rankin Score (mRS) = 3 with a computed tomography angiography (CTA) negative for vascular malformation. Retrospective review was performed on patients who were treated in a single health system from December 2015 to August 2018. Hematoma location was stratified as deep or lobar. Univariate analysis and multivariate logistic regression were performed on demographic, radiographic, and clinical outcomes including the location variable with 6 mo mRS as the primary outcome measure. RESULTS Univariate analysis revealed patients with lobar hemorrhage had significantly better initial admission Glasgow Coma Scale (GCS) (11.7 vs 8.9, P &lt; .0001) and NIHSS score (13.7 vs 19.6, P &lt; .0001) but significantly higher preoperative volume (64.1 vs 41.4, P = .001). Those with lobar hemorrhage also had significantly lower neurosurgical and hospital length of stay (8.1 vs 12.9, P = .003 and 16.9 vs 29.0, P = .02, respectively) and higher rate of 6 mo functional independence as defined by mRS 0 to 3 (68.6% vs 31.2%, P = .001). Multivariate analysis showed lobar location was a significant predictor of functional independence at 6 mo (OR 12.8, P = .003). CONCLUSION In our experience, lobar hemorrhage is a predictor of good outcome after endoscopic ICH evacuation. Current and future trials may benefit from stricter patient selection and further studies are needed to confirm the effect of hemorrhage location on outcome.

Abstract WP8: Global Real World Evidence of Balloon Guided Stent Retriever Thrombectomy

Background and Aims: Balloon Guide Catheter (BGC) use during thrombectomy treatment in Stroke patients has been reported to have positive effects on revascularization, procedural characteristics, and clinical outcomes. We evaluate the use of BGC in an open-label large prospective TREVO Retriever Registry of real world patients to determine predictors of good ‘clinical’ outcomes. Method: Consecutive Trevo Registry patients that had Balloon Guide Catheter (BGC) used during their thrombectomy procedure were identified; a subset of patients who fulfilled the criteria (ICA and/or MCA-M1/M2 occlusion with pre-morbid mRS 0-1, TLSW ≤6 hrs) within the cohort were also identified. Multivariate analysis was performed to identify the predictors of good outcomes in BGC thrombectomy patients. Results: A total of 1031 BGC treated Trevo Registry patients (overall enrolled, n=2010) qualified for analysis, of which 605 patients fulfilling the subset criteria were identified. The mean age of BGC/stent retriever patients was 67.5 with a median (IQR) baseline NIHSS of 15(11-19). Occlusion location of the BCG group was ICA -20.4%, M1- 57.1%, M2/M3-20.3%, and Posterior 1.8%. In the overall BGC cohort, the median (IQR) time to treatment was (4.2 (3.0,6.5)- hrs.) with conscious/local sedation used in 63.4% and general anesthesia used in 37.3% of cases. The median number of passes with Trevo stent retriever was 1 and revascularization (mTICI ≥ b) was achieved in 92.8% of cases. The sICH rate was low at 1.9% (20/1031) with a low rate of vessel perforation (0.2%). At 90 days post stroke, 56.0% of patients achieved functional independence (mRS 0-2) with 63.7% of the subset of “guidline “ BGC patients achieving functional independence at 90 days. Multivariate logistic regression showed age (aOR 0.97 [0.96, 0.99] P &lt;0.001), Diabetes (aOR 0.67, [0.18,0.98] P =0.03), conscious sedation vs general anesthesia ( aOR 1.7 [1.2,2.3], P= 0.002, number of passes (aOR 0.76 [0.66-0.88],P &lt;0.001), pre stroke mRS (aOR 0.54 [0.45-0.65], P &lt;0.0010 and NIHSS (aOR 0.93 [0.91-0.95], P &lt;0.001) as predictors of functional independence . Conclusion: Data from Trevo Registry demonstrate the use of BGC in thrombectomy procedure is safe, and leads to a reduction of disability in ischemic stroke patients.

Abstract WP309: Utilization of a Patient Selection Protocol for Mechanical Thrombectomy in Acute Ischemic Stroke Improves Outcomes

Introduction: The emergence of mechanical thrombectomy has extended the time window for treatment of acute ischemic stroke and improved patient outcomes. Our institution developed a patient selection protocol aimed to improve patient outcomes following the procedure. Hypothesis: Implementation of a patient selection protocol based on evidence-based best practices improves patient outcomes following endovascular intervention in acute ischemic stroke. Methods: In January 2015, our institution developed a patient selection protocol for anterior circulation stroke, including patients with a documented large vessel occlusion, an NIH stroke scale ≥6, a pre-morbid modified Rankin Scale (mRS) ≤2, and with the initial groin puncture within 6 hours of stroke onset. Patients were excluded if pre-morbid life expectancy was ≤90 days, CT perfusion demonstrated &lt;30% cerebral blood flow of 70 mL, ASPECTS score ≤6, presence of intracranial hemorrhage (ICH), INR ≥3 or platelet count ≤40. Age, sex, co-morbidities, treatment times and outcomes were retrospectively collected. Statistical analysis was performed using χ 2 test, unpaired t test, and multivariable logistic regression analysis where appropriate. Results: Forty patients underwent endovascular treatment prior to protocol implementation with 65 patients treated under the protocol. Protocol implementation resulted in improved rates of TICI 2B/3 revascularization (87.7% protocol, 57.5% pre-protocol; p&lt;0.001) and increased 90-day functional independence (41.5% protocol, 15.4% pre-protocol; p&lt;0.01), defined as mRS≤2 (Figure 1). There was no difference in symptomatic ICH or 90-day mortality. Use of a uniform patient selection protocol was an independent predictor of functional independence at 90 days (p&lt;0.01). Conclusions: The development and implementation of a patient selection protocol for endovascular treatment of large vessel occlusion improves revascularization rates and functional outcomes.

Predictors of functional independence, quality of life, and return to work in patients with burn injuries in mainland China.

BackgroundBurn injury may be associated with long-term rehabilitation and disability, while research studies on the functional performance after injuries, quality of life (QOL), and abilities to return to work of burn patients are limited. These outcomes are related not just to the degree and nature of injuries, but also to the socio-economical background of the society. This study aimed to identify the factors which might affect burn patients’ abilities to reintegrate back to the society based on a sample in mainland China.MethodsA retrospective study was conducted to collect data of demographic characteristics, medical data about burn injuries, physical and psychological status, and self-perceived QOL at the initial phase and upon discharge from a rehabilitation hospital, timing of rehabilitation, and duration of rehabilitation intervention. Four hundred fifteen patients with burn injuries were recruited in the study. Multiple linear regression and logistic regression were used to obtain a model to predict the functional abilities and the perceived QOL at discharge and their changes during rehabilitation, as well as the post-injury work status within 6 months after discharge.ResultsThe functional performance at discharge and its change were significantly predicted by the functional abilities and QOL at the admission, duration of treatment, timing of rehabilitation, payer source, and total body surface area burned. The perceived QOL at discharge and its change were significantly predicted by the baseline QOL at admission and duration of treatment. The significant predictors of work status within 6 months post-discharge included age, education, payer source, total body surface area burned, perceived QOL, and bodily pain at admission.ConclusionsThe present study identified a number of factors affecting the rehabilitation outcomes of people with burn injuries. Identification of these predictors may help clinicians assess the rehabilitation potential of burn survivors and assist in resource allocation. Policy makers should ensure that resources are adequate to improve the outcomes based on these factors.

Effects of Patient Preinjury and Injury Characteristics on Acute Rehabilitation Outcomes for Traumatic Brain Injury

ObjectiveTo examine associations of patient and injury characteristics with outcomes at inpatient rehabilitation discharge and 9 months postdischarge for patients with traumatic brain injury (TBI). DesignProspective, longitudinal observational study. SettingInpatient rehabilitation centers. ParticipantsConsecutive patients (N=2130) enrolled between 2008 and 2011, admitted for inpatient rehabilitation after index TBI, and divided into 5 subgroups based on rehabilitation admission FIM cognitive score. InterventionsNot applicable. Main Outcome MeasuresRehabilitation length of stay, discharge to home, and FIM at discharge and 9 months postdischarge. ResultsSeverity indices increased explained variation in outcomes beyond that accounted for by patient characteristics. FIM motor scores were generally the most predictable. Higher functioning subgroups had more predictable outcomes then subgroups with lower cognitive function at admission. Age at injury, time from injury to rehabilitation admission, and functional independence at rehabilitation admission were the most consistent predictors across all outcomes and subgroups. ConclusionsFindings from previous studies of the relations among patient and injury characteristics and rehabilitation outcomes were largely replicated. Discharge outcomes were most strongly associated with injury severity characteristics, whereas predictors of functional independence at 9 months postdischarge included both patient and injury characteristics.

Relationship between cognitive status and activities of daily living among the elderly of nursing homes

In recent years, increased life expectancy has caused the emergence of aging phenomenon in Iran. This study was conducted on 79 elderly in nursing homes. Data were collected by the demographic questionnaire, Abbreviated Mental Test Score (AMTs) and Barthel Activities of Daily Living (ADL) Index. The mean score of AMT was 4.06 (SD: 3.05) and the mean of Barthel Index was 66.15 (SD: 33.27). Results indicated a significantly positive correlation between cognitive status and activities of daily living (P=0.001, r=0.354). Accordingly, cognitive status can be a good predictor of functional independence in activities of daily living for the elderly.

Discounting preferences and response consistency as markers of functional ability in community-dwelling older adults

Introduction: Predictors of functional independence in older adults are in need. Based on findings that delay discounting, probability discounting, and the ability to respond consistently use cognitive abilities and neural systems with central relevance to functional ability, the present study evaluated whether these behavioral economic variables account for variance in everyday functioning in older adults. It was hypothesized that greater preference for immediate/probabilistic rewards and response inconsistency would independently predict decrements in instrumental activities of daily living (IADLs). Method: Participants included 64 community-dwelling older adults (65–85 years; mean age = 76.25 years; 76.60% female). Exclusionary criteria were neurological illness, illiteracy, substance dependence within the past 5 years, score of ≤20 on the Mini-Mental State Examination, and/or presence of dementia. Delay/probability discounting tasks consisted of a series of dichotomous selections between smaller, immediate/guaranteed and larger, delayed/probabilistic monetary values. Area under the curve (AUC) was used to index levels of discounting, while response (in)consistency was based on the percentage of contradictory responses. The Direct Assessment of Functional Status–Revised (DAFS–R) provided a performance-based assessment of IADLs. Hierarchical regression analyses were conducted to determine whether discounting preferences and response consistency accounted for variance in functional ability over and above relevant demographic characteristics. Results: Demographic characteristics accounted for significance variance in IADLs (p = .001, R2 = .237). Probability discounting AUC (p = .014, ΔR2 = .075) and response (in)consistency (p = .046, ΔR2 = .050) each accounted for significant additional variance in functional ability, as did delay discounting response (in)consistency (p = .010, ΔR2 = .081). Delay discounting AUC did not add significantly to the model (p = .861). Conclusions: Discounting preferences and choice consistency hold potential to serve as relatively fast and inexpensive markers of functional decline, likely due to neurocognitive deterioration relevant to both behavioral economic decision making and functional independence.

Temporal recovery of activities of daily living in the first year after ischemic stroke: a prospective study of patients admitted to a rehabilitation unit.

The ability to perform basic activities of daily living (ADL) independently is a marker of functional recovery after a stroke. However, there few studies documenting their long-term recovery. To document temporal recovery of activities of daily living (ADL) and establish predictors of ADL in a cohort of ischemic stroke patients in the first year after stroke. Prospective cohort study of 163 patients with first-ever ischemic stroke admitted to a rehabilitation centre. The Modified Barthel Index (MBI) was used to measure the patient's ability to perform the following 10 ADLs: feeding, grooming, dressing, bathing, toileting, bladder and bowel continence, transfers, ambulation and stair climbing. It was assessed on rehabilitation admission, discharge, and at 3, 6 and 12 months after stroke. The Motricity Index was used to measure motor power of the hemiplegic limb. The mean age was 63.8 (10.7) years, with 111 males and 52 females. The mean total MBI scores on rehabilitation admission, rehabilitation discharge, 3, 6 and 12 months after stroke were 41.3 (24.6), 72.9 (20.5), 88.4 (18.6), 90.5 (17.2) and 84.2 (20.4) respectively. Median scores of feeding, grooming, toileting, bladder/bowel continence, transfers and ambulation plateaued by 3 months after stroke. Median scores of dressing and stair climbing plateaued at 6 months and that for bathing, 12 months after stroke. None of the patients were functionally independent (defined as MBI score of 100) on rehabilitation admission, but this improved to 8.6% on discharge, and 32.1%, 41.4% and 50.3% at 3, 6 and 12 months after stroke respectively. The MBI and Motricity scores were strongly correlated at all periods of follow up (r = 0.67 to 0.69, p < 0.0001). Univariate analysis showed that age, neglect, a cortical stroke, admission MBI, NIHSS, Motricity Index and Abbreviated Mental Score scores were predictors of functional independence at 12 months after stroke. On logistic regression, only age remained significant, younger patients being more likely than older patients to be functionally independent. Most recovery of ADL occurs by 3 months after stroke. For individual ADLs, dressing, stair climbing and bathing appear to take a longer time to recover. Older age was a negative predictor of functional dependence at 12 months after stroke.

Increase in functional abilities following a residential educational and neurorehabilitation programme in young adults with acquired brain injury

To characterize and determine the pre-injury and injury-related variables that are linked to the extent of functional recovery following rehabilitation at a mixed therapy and educational residential programme and whether these variables differ for traumatic brain injury (TBI) and non traumatic brain injury (nonTBI). 106 young adults (age 16-36 years) with moderate-to-severe TBI who had attended and been discharged from the centre since 2002 were included. Clients received 5 hours of education and/or therapy each day. Functional level was assessed using the FIM + FAM. Regression analysis was used to determine possible predictors of functional independence at discharge. Clients with TBI and nonTBI made clinically and statistically significant improvements in their functional abilities during their neurorehabilitation. For the combined TBI and nonTBI group, FIM + FAM scores at discharge were predicted by FIM + FAM at admission and length of stay. These two predictors explained 80% of the variance in the FIM + FAM score at discharge. Both clients with TBI and nonTBI benefited from a mixed inpatient neurorehabilitation programme. This benefit was predicted by their functional abilities at admission and the length of stay. These findings are of importance as it becomes increasingly necessary to demonstrate who will benefit from residential intensive neurorehabilitation as opposed to community therapy.

Percent Change on the National Institutes of Health Stroke Scale: A Useful Acute Stroke Outcome Measure

A single optimal outcome measure in acute stroke has not been established. Changes in neurologic deficits might be useful outcome measures in acute stroke because they can measure within-subject changes on the entire spectrum of the scales starting at baseline. We tested the ability of percent National Institutes of Health Stroke Scale (NIHSS) score change (baseline-3 months) to predict the traditional functional outcomes in acute stroke (modified Rankin Scale [mRS], Barthel Index, Glasgow Outcome Scale, final NIHSS score). We analyzed data sets from two acute stroke clinical trials involving 44 clinical research centers throughout the United States and 1899 randomized patients. The percent NIHSS score change predicted functional outcomes very well, all areas under the curve of 0.90 or greater with all P values less than .001 in receiver operating characteristic analysis. In the National Institute of Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator (rt-PA) Acute Stroke Trial, benefit from rt-PA was confirmed by a greater improvement on the NIHSS score than with placebo (67% v 50%, P < .002). In moderate stroke severity (baseline NIHSS score 7-15) an improvement of at least 55% was the best predictor of functional independence at 3 months (mRS <or= 2). This novel approach to the NIHSS score as an outcome measure in acute stroke appears to be an additional useful analytic and communication tool.

Prediction of Functional Outcome in Patients With Primary Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is the most fatal and disabling stroke subtype. Widely used tools for prediction of mortality are fundamentally limited in that they do not account for effects of withdrawal of care and are not designed to predict functional recovery. We developed an acute clinical score to predict likelihood of functional independence. We prospectively characterized 629 consecutive patients with ICH at hospital presentation. Predictors of functional independence (Glasgow Outcome Score > or = 4) at 90 days were used to develop a logistic regression-based risk stratification scale in a random subset of two thirds and validated in the remaining one third of the cohort. At 90 days, 162 (26%) patients achieved independence. Age, Glasgow Coma Scale, ICH location, volume (all P<0.0001), and pre-ICH cognitive impairment (P=0.005) were independently associated with Glasgow Outcome Score > or = 4. The FUNC score was developed as a sum of individual points (0-11) based on strength of association with outcome. In both the development and validation cohorts, the proportion of patients who achieved Glasgow Outcome Score > or = 4 increased steadily with FUNC score. No patient assigned a FUNC score < or = 4 achieved functional independence, whereas > 80% with a score of 11 did. The predictive accuracy of the FUNC score remained unchanged when restricted to ICH survivors only, consistent with absence of confounding by early withdrawal of care. FUNC score is a valid clinical assessment tool that identifies patients with ICH who will attain functional independence and thus, can provide guidance in clinical decision-making and patient selection for clinical trials.

Predictors of functional independence in elderly patients with heart failure

Objective: The aim of this study was to identify the functional independence predictors in elderly patients with heart failure (HF). Design and Methods: Exploratory, descriptive and transversal study with 146 elderly outpatients with heart failure referred to hospitals in São Paulo. Two instruments were used for the data collection: the Sociodemographic and Clinical Instrument and The Functional Independence Measure (FIM). Descriptive and comparative statistical analyses were used (Kruskal-Wallis), as well as univariate and multiple regression analyses. Results: 52.0% of the patients were males, with a mean age of 68.6 (±6.9) years and 3.4(±2.8) years of education, with 3.9 (±1.7) comorbidities, 3.5 (±1.4) symptoms, with a predominance of NYHA class I or II (65%) and 67% with decreased left ventricular ejection fraction (LVEF). High FIM scores were observed, demonstrating the functional independence of the studied patients. The comparison between FIM scores and NYHA classes showed that a worse FIM score correlated with a progression in the NYHA class. The multiple regression analysis showed that the NYHA classes, years of education and age older than 80 years were predictors of functional independence, explaining 35.0% of the FIM variability. Conclusion: The variables NYHA class, age older than 80 years and higher level of education were predictors of functional independence and this fact suggests the importance of interventions that favor the detection

The Relationship of Functional Independence to Assistive Device Use of Elderly Persons Living at Home

This study explored the relationship between use of assistive devices and functional independence for noninstitutionalized elderly. Predictors of functional independence (including age, sex, education, mental status, physical disability, and visual impairment) were determined through correlation analysis on a sample of 364 subjects. From this sample, 117 pairs of subjects were matched on these predictors and compared for levels of functional independence relative to assistive device use. For 60 pairs, the subject who used more assistive devices was more functionally independent than the subject who used fewer devices. For 36 pairs, the opposite was found. For 21 pairs, the results were mixed: Within most pairs, the subject with more devices was more independent in ADL but less independent in IADL. Results suggest that increased use of assistive devices relates to increased functional independence.