[Stroke Patients After Inpatient Neurological Rehabilitation - A Prospective Study to Determine Predictors of Survival at Home up to Five Years After Discharge]. / Schlaganfallpatienten nach stationärer neurologischer Rehabilitation.

PURPOSE: To identify factors influencing the long-term survival at home in stroke patients after neurological inpatient rehabilitation. METHODS: The study was conducted as a prospective cohort study in 204 stroke patients who were treated in the course of one year in the Herzogenaurach Rehabilitation Hospital (rehabilitation phases C and B). The social data and clinical data were collected during inpatient rehabilitation. The outcome variable was assessed up to 5 years after discharge. Differences between groups were analysed with t-tests or chi-square tests. Binary logistic regression analyses were carried out for multivariate predictor analyses. RESULTS: The regression analysis resulted in a prediction model consisting of 5 variables for living at home 2.5 years after discharge (vs. institutionalization or death): a greater increase in health-related quality of life during inpatient rehabilitation, better health-relate quality of life at discharge, a greater increase in functional independence during inpatient rehabilitation, a higher body-mass index and fewer comorbidity conditions associated with a mortality risk. 5 years after discharge the prediction model consists of 3 variables: lower age, fewer comorbidity conditions associated with a mortality risk and lower risk for falls at discharge from neurological rehabilitation. CONCLUSION: Up to 2.5 years after discharge the extent of functional improvement and the improvement of health related quality of life, which are both correlated with therapeutic effects, are predictors for survival and living at home. On the other hand, 5 years after discharge biological factors as age and comorbidities are prognostically dominating.

Measuring stroke patients' exercise preferences using a discrete choice experiment.

Physical activity post stroke improves health, yet physical inactivity is highly prevalent. Tailored exercise programs considering physical activity preferences are a promising approach to promote physical activity. Therefore, this study seeks to measure exercise preferences of stroke survivors. Stroke survivors conducted a discrete choice experiment (DCE). DCE was presented in a face-to-face interview where patients had to choose eight times between two different exercise programs. Exercise programs differed by characteristics, with the six attributes under consideration being social situation, location, type of exercise, intensity, frequency, and duration. Utilities of the exercise attributes were estimated with a logit choice model. Stroke survivors (n=103, mean age: 67, SD=13.0; 60% male) show significant differences in the rated utilities of the exercise attributes (P<0.001). Participants had strong preferences for light and moderate intense physical activity and favored shorter exercise sessions. Stroke survivors have remarkable exercise preferences especially for intensity and duration of exercise. Results contribute to the tailoring of physical activity programs after stroke thereby facilitating maintenance of physical activity.

Visual feedback explains why propointing is better than antipointing in spatial neglect.

Rossit et al. (2011) showed that neglect patients perform normally in a propointing task but not in an antipointing task which requires pointing towards the mirrored position of a target. It is assumed that antipointing relies on information from the perceptual pathway of our visual brain. Therefore, this finding supports the notion that neglect is a disorder that primarily affects perceptual spatial representations within the brain leaving spatial maps used for visuomotor guidance intact. Alternatively, performance of patients might be compromised in both tasks, but only obviously so in tasks in which online corrections are made more difficult. It can be argued that online-corrections via visual feedback are less effective in antipointing because a direct comparison between hand and target is not possible in this condition. Secondly, it is also known that neglect patients have a pronounced egocentric bias which is assumed to be associated with a deviation of the perceived body midline. Since the midline is used to compute the end-position in the antipointing task this could also explain why patients are worse in antipointing. We investigated the influence of visual feedback on pro- and antipointing and the effect of providing a visual reference line for the antipointing task in right-brain damaged patients with neglect (n = 20), right-brain damaged patients without neglect (n = 23) and in a group of healthy participants (n = 22). The withdrawal of visual feedback had a stronger effect on propointing compared to antipointing. This effect was stronger in neglect patients than in patients without neglect or healthy controls. The introduction of a reference line reduced errors in antipointing performance, particularly in neglect patients with a strong egocentric bias. The results support our alternative account and challenge the hypothesis that the spatial disorder in neglect affects primarily perceptual maps within the visual system.

Long-term impact of stroke on patients' health-related quality of life.

PURPOSE: This international study aims to examine the size and determinants of the impact of stroke on five-year survivors' health-related quality of life (HRQoL) in four different European countries. METHOD: Patients were recruited consecutively in four European rehabilitation centers. Five years after stroke, the EuroQol-visual analog scale (EQ-VAS) was administered in 226 first-ever stroke patients. Impact of stroke was determined by calculating EQ-VAS z-norm scores (= deviation - expressed in SD - of patients' EQ-VAS level relative to their age-and gender-matched national population norms). Determinants of EQ-VAS z-norm scores were identified using multivariate linear regression analysis. RESULTS: Five years post-stroke, patients' mean EQ-VAS was 63.74 (SD = 19.33). Mean EQ-VAS z-norm score was -0.57 [95%CI: (-0.70)-(-0.42)]. Forty percent of the patients had an EQ-VAS z-norm score <-0.75 SD; 52% had an EQ-VAS z-norm score between -0.75 and +0.75 SD, only 8% scored >+0.75 SD. Higher patients' levels of depression, anxiety and disability were associated with increasingly negative EQ-VAS z-norm scores (adjusted R2 = 0.392). CONCLUSIONS: Five years after stroke, mean HRQoL of stroke survivors showed large variability and was more than ½ SD below population norm. Forty percent had a HRQoL level below, 52% on, and 8% above population norm. The variability could only partially be explained by the variables considered in this study. Longitudinal studies are needed to increase our understanding of the size and determinants of the impact of stroke on the HRQoL of long-term stroke survivors. Implications for rehabilitation The current European concept of stroke rehabilitation is focused on the acute and sub-acute rehabilitation phase, i.e., in the first months after stroke. The results of this study show that at five years after stroke, the mean level of HRQoL of stroke survivors remains below the healthy population level. This finding shows the need for continuation of rehabilitation in the chronic phase. At five years after stroke, higher patients' levels of depression, anxiety and disability were associated with lower scores for HRQoL. This finding implicates that chronic rehabilitation programs should be multi-faceted in order to increase long-term survivors' psychosocial outcomes.

A comparative study of medication use after stroke in four countries.

OBJECTIVES: The use of medication plays an important role in secondary stroke prevention and treatment of post-stroke comorbidities. The Collaborative Evaluation of Rehabilitation in Stroke across Europe (CERISE) was set up to investigate the inpatient stroke rehabilitation process in four centres, each in a different European country: Belgium, Germany, United Kingdom and Switzerland. PATIENTS AND METHODS: Patients' medication use 5 years post-stroke was compared between countries. Focus was put on cerebrovascular secondary prevention, including (a) adequate antithrombotic treatment, (b) treatment of cardiovascular comorbidities and diabetes, and (c) the use of lipid-lowering drugs; as well as on the treatment of stroke-related disorders such as depression, anxiety and pain. RESULTS: Medication data were available for 247 patients. Data about depression and anxiety were available for 233. CONCLUSION: There were no significant differences between the four centres in antithrombotic treatment and in the treatment of cardiovascular comorbidities and diabetes. However, significantly more patients from the UK were treated with lipid-lowering drugs compared to Belgian patients. Significant differences were also observed between the centres in the prevalence and treatment of depression. More Belgian patients suffered from depression compared to German patients and significantly more Belgian patients took antidepressants than patients in Germany. This was in contrast to the prevalence and treatment of anxiety and pain, for which no significant differences between the centres were seen. Related to pain treatment, it was observed that almost 40% of all patients suffering from pain, used no specific medication.

Effects of acupuncture and computer-assisted cognitive training for post-stroke attention deficits: study protocol for a randomized controlled trial.

BACKGROUND: A majority of stroke survivors present with cognitive impairments. Attention disturbance, which leads to impaired concentration and overall reduced cognitive functions, is strongly associated with stroke. The clinical efficacy of acupuncture with Baihui (GV20) and Shenting (GV24) as well as computer-assisted cognitive training in stroke and post-stroke cognitive impairment have both been demonstrated in previous studies. To date, no systematic comparison of these exists and the potential beneficial effects of a combined application are yet to be examined. The main objective of this pilot study is to evaluate the effects of computer-assisted cognitive training compared to acupuncture on the outcomes of attention assessments. The second objective is to test the effects of a combined cognitive intervention that incorporates computer-assisted cognitive training and acupuncture (ACoTrain). METHODS/DESIGN: An international multicentre, single-blinded, randomised controlled pilot trial will be conducted. In a 1:1:1 ratio, 60 inpatients with post-stroke cognitive dysfunction will be randomly allocated into either the acupuncture group, the computer-assisted cognitive training group, or the ACoTrain group in addition to their individual rehabilitation programme. The intervention period of this pilot trial will last 4 weeks (30 minutes per day, 5 days per week, Monday to Friday). The primary outcome is the test battery for attentional performance. The secondary outcomes include the Trail Making Test, Test des Deux Barrages, National Institute of Health Stroke Scale, and Modified Barthel Index for assessment of daily life competence, and the EuroQol Questionnaire for health-related quality of life. DISCUSSION: This trial mainly focuses on evaluating the effects of computer-assisted cognitive training compared to acupuncture on the outcomes of attention assessments. The results of this pilot trial are expected to provide new insights on how Eastern and Western medicine can complement one another and improve the treatment of cognitive impairments in early stroke rehabilitation. Including patients with different cultural backgrounds allows a more generalisable interpretation of the results but also poses risks of performance bias. Using standardised and well-described assessments, validated for each region, is pivotal to allow pooling of the data. TRIAL REGISTRATION: Clinical Trails.gov ID: NCT02324959 (8 December 2014).

Predictors of health-related quality of life in stroke patients after neurological inpatient rehabilitation: a prospective study.

BACKGROUND: The goal of the study was to investigate the long-term course of health-related quality of life (HRQoL) in stroke survivors during and up to 2.5 years after inpatient neurological rehabilitation and to identify predictors of HRQoL. METHODS: HRQoL was determined in 152 stroke survivors in a single-centre prospective cohort study at four time points: upon admission to inpatient rehabilitation, at discharge, and one and 2.5 years after discharge. Their HRQoL was determined by administering the EQ-5D at all four measurement points. During inpatient rehabilitation, the SF-36 was administered in addition to the EQ-5D. Predictors were identified through multiple regression analysis. RESULTS: During inpatient rehabilitation, the "European Index" of the EQ-5D rose significantly (p < 0.001) from 45.4 to 66.7. The change in HRQoL on the SF-36 was convergent. The HRQoL of the stroke patients living at home remained at the same level for 2.5 years following discharge. In the multiple regression analysis, the EQ-5D Index at discharge (p = 0.049), the risk of falls as defined by Runge and Rehfeld (p = 0.001), and the change in emotional quality of life on the SF-36 during inpatient rehabilitation (p = 0.048) predicted HRQoL 2.5 years following discharge. CONCLUSION: On the basis of our results, we conclude that the long-term health-related quality of life of stroke survivors can be positively influenced by reducing the risk of falls and improving emotional well-being during neurological inpatient rehabilitation.

Functional and motor outcome 5 years after stroke is equivalent to outcome at 2 months: follow-up of the collaborative evaluation of rehabilitation in stroke across Europe.

BACKGROUND AND PURPOSE: Recovery of patients within the first 6 months after stroke is well documented, but there has been little research on long-term recovery. The aim of this study was to analyze functional and motor recovery between admission to rehabilitation centres and 5 years after stroke. METHODS: This follow-up of the Collaborative Evaluation of Rehabilitation in Stroke Across Europe study, included patients from 4 European rehabilitation centres. Patients were assessed on admission, at 2 and 6 months, and 5 years after stroke, using the Barthel Index, Rivermead Motor Assessment Gross Function, Leg and Trunk function, and Arm function. Linear mixed models were used, corrected for baseline characteristics. To account for the drop-out during follow-up, the analysis is likelihood-based (assumption of missingness at random). RESULTS: A total of 532 patients were included in this study, of which 238 were followed up at 5 years post stroke. Mean age at stroke onset was 69 (±10 SD) years, 53% were men, 84% had ischemic strokes, and 53% had left-sided motor impairment. Linear mixed model analysis revealed a significant deterioration for all 4 outcomes between 6 months and 5 years (P<0.0001). Scores at 2 months were not statistically significant different from scores at 5 years after stroke. Higher age (P<0.0001) and increasing stroke severity on admission (P<0.0001) negatively affected long-term functional and motor recovery. CONCLUSIONS: Five-year follow-up revealed deterioration in functional and motor outcome, with a return to the level measured at 2 months. Increasing age and increasing stroke severity negatively affected recovery up to 5 years after stroke.

Stroke patients after neurological inpatient rehabilitation: a prospective study to determine whether functional status or health-related quality of life predict living at home 2.5 years after discharge.

We carried out a prospective study to determine whether stroke patients' functional status or health-related quality of life would predict whether they lived at home 2.5 years after discharge from neurological inpatient rehabilitation. We carried out a single-center prospective cohort study. The outcome 'home care' versus 'death' or 'institutionalization' (nursing home admission) was evaluated 30 months after discharge. A total of 204 stroke survivors with remaining moderate to severe functional deficits at admission to neurological inpatient rehabilitation were included. Clinical data were obtained at admission to and/or discharge from inpatient rehabilitation. Functional status was determined using the Barthel Index; health-related quality of life was assessed using the SF-36 and EQ-5D. The outcome was assessed by telephone interview. Predictors of living at home were calculated using binary logistic regression analysis. In total, 30 months after discharge, 75% of the stroke survivors were still living at home. Multivariate analysis showed that patients continued to live at home significantly more frequently when they had fewer mortality-relevant comorbidities (P=0.001), a higher BMI (P=0.040), a higher increase in functional independence during inpatient rehabilitation (P=0.017), and above all, a better health-related quality of life, measured using the EQ-5D (P<0.001), at discharge. Stroke survivors' health-related quality of life measured with the EQ-5D and the change in functional status during multimodal neurological rehabilitation appear to be the strongest clinically relevant long-term predictors of staying at home.

Long-term prediction of functional outcome after stroke using single items of the Barthel Index at discharge from rehabilitation centre.

PURPOSE: To determine the prognostic value of single items of the Barthel Index (BI) at discharge from rehabilitation, in predicting independence in personal activities of daily living (ADL) (BI score ≥ 95/100) at five years after stroke. METHOD: People with stroke were recruited consecutively from four European rehabilitation centres. BI was assessed on discharge and at five years after stroke. Stepwise multivariate logistic regression analysis was used to determine independent predictors of BI score ≥ 95/100 at five years after stroke. Thereupon, percentage chance of reaching BI ≥ 95/100 at five years after stroke was calculated. RESULTS: Data were available for 153 patients. Independence in dressing (odds ratio (OR)=5.22, 95% confidence interval (CI)=1.85-14.76, p=0.002) and bathing (OR=8.10, 95% CI=3.40-19.32, p<0.0001) were independent predictors. Independence in both items resulted in 74.1% (57.6-85.8) chance of reaching BI ≥ 95/100 at five years after stroke. Dependence in both items resulted in 6.3% (5.1-7.9) chance. Independence in bathing, but dependence in dressing resulted in 35.4% (30.7-40.4) chance whereas the opposite resulted in 26.1% (20.7-32.3) chance. CONCLUSION: Simple assessment of dressing and bathing on discharge from rehabilitation enables therapeutic staff to predict prognosis for long-term independence in personal ADL. This method can be used for early identification of persons with stroke who need intensive follow-up. Implications for Rehabilitation (In)dependence for dressing and bathing at discharge from a rehabilitation centre are significant factors in the prediction of (in)dependence in personal ADL at five years after stroke. This predictive tool can be used for targeting inpatient stroke rehabilitation and early identification of those patients who need intensive follow-up.

Five-year mortality and related prognostic factors after inpatient stroke rehabilitation: a European multi-centre study.

OBJECTIVE: To determine 5-year mortality and its association with baseline characteristics and functional status 6 months post-stroke for patients who received inpatient rehabilitation. DESIGN: A prospective rehabilitation-based cohort study. SUBJECTS: A total of 532 consecutive stroke patients from 4 European rehabilitation centres. METHODS: Predictors were recorded on admission. Barthel Index was assessed at 6 months (BI6mths) and patients were followed for 5 years post-stroke. Survival probability was computed using Kaplan-Meier analysis and compared across 3 BI6mths-classes (0-60, 65-90, 95-100) (log-rank test). Significant independent predictors were determined using multivariate Cox regression analysis (hazard ratio (HR)). RESULTS: Five-year cumulative risk of death was 29.12% (95% confidence interval (CI): 22.86-35.38). Age (HR=1.06, 95% CI: 1.04-1.09), cognitive impairment (HR=1.77, 95% CI: 1.21-2.57), diabetes mellitus (HR=1.68, 95% CI: 1.16-2.41) and atrial fibrillation (HR=1.52, 95% CI: 1.08-2.14) were independent predictors of increased mortality. Hyperlipidaemia (HR=0.66, 95% CI: 0.46-0.94), and higher BI6mths (HR=0.98, 95% CI: 0.97-0.99) were independent predictors of decreased mortality. Five-year survival probability was 0.85 (95% CI: 0.80-0.89) for patients in BI6mths-class: 95-100, 0.72 (95% CI: 0.63-0.79) in BI6mths-class: 65-90 and 0.50 (95% CI: 0.40-0.60) in BI6mths-class: 0-60 (p<0.0001). CONCLUSION: Nearly one-third of rehabilitation patients died during the first 5 years following stroke. Functional status at 6 months was a powerful predictor of long-term mortality. Maximum functional independence at 6 months post-stroke should be promoted through medical interventions and rehabilitation. Future studies are recommended to evaluate the direct effect of rehabilitation on long-term survival.

The use of a biplot in studying outcomes after stroke.

BACKGROUND AND PURPOSE: This study aimed to unravel the multidimensional profile of stroke outcomes by investigating the global correlation structure of motor, functional, and emotional problems of patients, as well as their caregivers' strain, at 6 months after stroke. Potential differential associations based on patients' level of functioning on admission to the rehabilitation center were analyzed. METHODS: Data were collected within the CERISE-study (Collaborative Evaluation of Rehabilitation in Stroke across Europe). Six months after stroke, the Rivermead Motor Assessment (RMA), Extended Activities of Daily Living (EADL), Hospital Anxiety and Depression Scale-Anxiety (HADS-A) and Hospital Anxiety and Depression Scale-Depression (HADS-D), EuroQol-Health State (EQ-HS), EuroQol-Visual Analogue Scale (EQ-VAS), and Caregiver Strain Index (CSI) were administered. Patients were classified into 3 categories according to their Barthel Index (BI) score on admission to the rehabilitation center. Principal component analysis was carried out, and a biplot was constructed. RESULTS: Data were available on 510 patients. One cluster was formed by RMA and EADL, and a second one by HADS-A, HADS-D, and EQ-VAS. EQ-HS was situated between these two. CSI formed a third dimension. Patients with low BI scores on admission to the rehabilitation center had higher HADS-A and HADS-D scores 6 months after stroke. High BI scores were associated with large variations in HADS-A and HADS-D scores. CONCLUSIONS: This novel biplot strategy for rehabilitation studies revealed 2 clusters: one of motor/functional problems and one of emotional problems. Patients with mild functional deficit measured on admission to the rehabilitation center can suffer from mild to severe anxiety and depression at 6 months poststroke. Screening for emotional disorders in all patients is recommended.

Anxiety and depression in the first six months after stroke. A longitudinal multicentre study.

PURPOSE: To document the prevalence, severity and time course of anxiety and depression in stroke rehabilitation patients in four European countries. METHOD: At two, four and six months post-stroke, the prevalence and severity of anxiety and depression were determined in 532 consecutively recruited patients, using the Hospital Anxiety and Depression Scale. Time course of prevalence and severity was examined, using Cochran-Q and Friedman-tests, respectively. We identified whether the numbers of anxious/depressed patients at each time point comprised the same individuals. RESULTS: Prevalence of anxiety ranged between 22% and 25%; depression between 24% and 30%. Median severity ranged between 4 and 5. No significant differences between centres occurred (p > 0.05). Prevalence of both disorders was not significantly different over time. Severity of anxiety decreased between four and six months; severity of depression remained stable. About 40% of the patients with initial anxiety remained anxious at six months. Some 11% and 7% of those initially not anxious became anxious at four or six months after stroke, respectively. Depression showed a similar pattern. CONCLUSIONS: Despite differences in patient profiles and intensity of rehabilitation, no significant differences occurred between centres in prevalence and severity of both disorders. Anxiety was almost as common as depression and additional patients became anxious/depressed at each time point.

Computer-aided therapy in aphasia therapy: evaluation of assignment criteria.

Recent studies in neurorehabilitation research show that success in aphasia therapy is linked to a high treatment frequency. Computer-aided therapy offers a solution to the dilemma of increasing therapy frequency while maintaining or reducing the load on therapists' resources. Until now it has, however, been unclear which patients can reasonably be treated with computer-aided therapy. The study investigates therapists' indication choices of a new computer-aided training programme designed to supplement conventional speech therapy for aphasics (EvoCare therapy, Dr Hein GmbH, Nuremberg, Germany). The goal was to ascertain which patients were suitable for the training and which (individual) allocation criteria played a role in the therapists' decision for or against the new therapy concept. The study is an explorative prospective application study in inpatient rehabilitation care. To determine the allocation criteria, comprehensive medical, psychosocial and neurolinguistic questionnaires were used. The speech therapists were surveyed separately. Forty-nine of the 75 patients were treated with EvoCare therapy; the others received purely conventional speech therapy. Patients chosen for computer-aided therapy suffered more frequently from problems with everyday mobility and serious neurolinguistic disorders. Type and extent of brain damage, degree of reliance on caregivers, sensomotoric and cognitive deficits and depression were irrelevant to the allocation.

Motor and functional recovery after stroke: a comparison of 4 European rehabilitation centers.

BACKGROUND AND PURPOSE: Outcome after first stroke varies significantly across Europe. This study was designed to compare motor and functional recovery after stroke between four European rehabilitation centers. METHODS: Consecutive stroke patients (532 patients) were recruited. They were assessed on admission and at 2, 4, and 6 months after stroke with the Barthel Index, Rivermead Motor Assessment of Gross Function, Rivermead Motor Assessment of Leg/Trunk, Rivermead Motor Assessment of Arm, and Nottingham Extended Activities of Daily Living (except on admission). Data were analyzed using random effects ordinal logistic models adjusting for case-mix and multiple testing. RESULTS: Patients in the UK center were more likely to stay in lower Rivermead Motor Assessment of Gross Function classes compared with patients in the German center (DeltaOR, 2.4; 95% CI, 1.3 to 4.3). In the Swiss center, patients were less likely to stay in lower Nottingham Extended Activities of Daily Living classes compared with patients in the UK center (DeltaOR, 0.7; 95% CI, 0.5 to 0.9). The latter were less likely to stay in lower Barthel Index classes compared with the patients in the German center (DeltaOR, 0.6; 95%CI, 0.4 to 0.8). Recovery patterns of Rivermead Motor Assessment of Leg/Trunk and Rivermead Motor Assessment of Arm were not significantly different between centers. CONCLUSIONS: Gross motor and functional recovery were better in the German and Swiss centers compared with the UK center, respectively. Personal self-care recovery was better in the UK compared with the German center. Previous studies in the same centers indicated that German and Swiss patients received more therapy per day. This was not the result of more staff but of a more efficient use of human resources. This study indicates potential for improving rehabilitation outcomes in the UK and Belgian centers.

Inpatient stroke rehabilitation: a comparative study of admission criteria to stroke rehabilitation units in four European centres.

OBJECTIVE: To explore the clinical and non-clinical factors involved in decision-making concerning admission to European stroke rehabilitation units. DESIGN: Observational study on case-mix at intake combined with questionnaires and semi-structured interviews with the medical consultants of each European stroke rehabilitation unit. PATIENTS AND SETTINGS: Clinical data on 532 first-ever patients after stroke. Medical consultants from 6 European stroke rehabilitation units in 4 European countries (UK, Belgium, Germany and Switzerland). METHODS: Standardized clinical assessments within 2 days after admission. Questionnaires to each medical consultants followed by a qualitative round of semi-structured interviews. RESULTS: Case-mix of patients after stroke was significantly different between European stroke rehabilitation units. Clinical criteria for admission were seldom explicit and were evaluated differently between the European stroke rehabilitation units. In the UK units, diagnosis of stroke was the only criterion for admission. In the Belgian, German and Swiss units, pre-morbid conditions were taken into account in admission decisions. The likelihood of discharge home was considered highly important in the Swiss units. CONCLUSION: Case-mix differences at intake could be linked to different appraisals of clinical and non-clinical factors of patients after stroke. The findings urge us to be more explicit about decision-making processes at admission in order to provide a more comprehensive insight into the interplay between context and process of care.

Effect of socioeconomic status on functional and motor recovery after stroke: a European multicentre study.

BACKGROUND: Previous studies have shown an inverse gradient in socioeconomic status for disability after stroke. However, no distinction has been made between the period in the stroke rehabilitation unit (SRU) and the period after discharge. The purpose of this study was to examine the impact of education and equivalent income on motor and functional recovery for both periods. METHODS: 419 consecutive patients were recruited from six SRUs across Europe. The Barthel Index (BI) and Rivermead Motor Assessment (RMA) were measured on admission, at discharge and 6 months after stroke. Ordinal logistic regression models were used, adjusting for case mix. Cumulative odds ratios (OR) were calculated to measure differences in recovery between educational levels and income groups with adjustments for case mix. RESULTS: Patients with a low educational level were less likely to improve on the BI (OR 0.53; 95% CI 0.32 to 0.87) and the RMA arm during inpatient stay (OR 0.54; 95% CI 0.31 to 0.94). For this period, no differences in recovery were found between income groups. After discharge, patients with a low equivalent income were less likely to improve on all three sections of the RMA: gross function (OR 0.20; 95% CI 0.06 to 0.66), leg and trunk (OR 0.22; 95% CI 0.09 to 0.55) and arm (OR 0.30; 95% CI 0.10 to 0.87). No differences were found for education. CONCLUSIONS: During inpatient rehabilitation, educational level was a determinant of recovery, while after discharge, equivalent income played an important role. This study suggests that it is important to develop a better understanding of how socioeconomic factors affect the recovery of stroke patients.

Trunk performance after stroke: an eye catching predictor of functional outcome.

BACKGROUND AND AIMS: Trunk performance is an important predictor of functional outcome after stroke. However, the percentage of explained variance varies considerably between studies. This may be explained by the stroke population examined, the different scales used to assess trunk performance and the time points used to measure outcome. The aim of this multicentre study was to examine the predictive validity of the Trunk Impairment Scale (TIS) and its subscales when predicting the Barthel Index score at 6 months after stroke. METHODS: A total of 102 subjects were recruited in three European rehabilitation centres. Participants were assessed on admission (median time since stroke onset 20 days) and 6 months after stroke. Correlation analysis and forward stepwise multiple regression analysis were used to model outcome. RESULTS: The best predictors of the Barthel Index scores at 6 months after stroke were total TIS score (partial R2 = 0.52, p<.0001) and static sitting balance subscale score (partial R2 = 0.50, p<.0001) on admission. The TIS score on admission and its static sitting balance subscale were stronger predictors of the Barthel Index score at 6 months than the Barthel Index score itself on admission. CONCLUSIONS: This study emphasises the importance of trunk performance, especially static sitting balance, when predicting functional outcome after stroke. The TIS is recommended as a prediction instrument in the rehabilitation setting when considering the prognosis of stroke patients. Future studies should address the evolution of trunk performance over time and the evaluation of treatment interventions to improve trunk performance.

Factors contributing to patient satisfaction with medical rehabilitation in German hospitals.

The objective of this study was to quantify overall patient satisfaction, through the identification of the particular aspects of patient satisfaction that were most likely to cause patients to recommend the rehabilitation hospital to others. The research entailed analysing secondary data from a quality improvement programme for medical rehabilitation, conducted from 1997 until 2004, in seven rehabilitation hospitals in Germany. Overall patient satisfaction and several potential predictors were examined in relation to 120,825 patients who had received inpatient medical rehabilitation. Recommending the rehabilitation hospital to others is a measure of overall patient satisfaction with the rehabilitation. Logistic regression was used to identify the factors that predicted patient satisfaction or dissatisfaction at discharge from the rehabilitation hospital. Overall satisfaction was mainly determined by the general atmosphere in the hospital, successful rehabilitation and the medical care. The general atmosphere was strongly associated with admission procedures, accommodation, catering, service, organisation and nursing care. In conclusion, the results suggest that in order to increase the rate of recommendation, rehabilitation hospitals should aim for not only high quality in medical care, but also the creation of a pleasant atmosphere.

Use of time by physiotherapists and occupational therapists in a stroke rehabilitation unit: a comparison between four European rehabilitation centres.

PURPOSE: The aim of this study was to compare the time allocated to therapeutic activities (TA) and non-therapeutic activities (NTA) of physiotherapists (PT) and occupational therapists (OT) in stroke rehabilitation units in four European countries. METHOD: Therapists documented their activities in 15-min periods for two weeks. They recorded: activity, number of patients, number of stroke patients, involvement of other people, location and frequency of each activity. Kruskal-Wallis tests and negative binomial regression models were used to compare activities between professional groups and between units. RESULTS: The average proportion of TA per day ranged between 32.9% and 66.1% and was higher for PT than for OT in each unit. For OT, significant differences emerged between the units in the proportion of time allocated to TA compared to NTA with British OTs spending significantly less time in TA. In the Belgian unit, three times less time was spent on patient-related co-ordination activities (e.g., administration, ward rounds) compared to the British and Swiss units. CONCLUSIONS: Time allocation differed between PT and OT and between units, affecting the time available for TA. Further investigation is necessary to study the effect of work organization in stroke rehabilitation units on the efficiency of rehabilitation regimes.