Professional Assignment Project
Early prediction of functional outcome by physiotherapists in post stroke
patients
A prospective cohort study
Nekpen T. Eghidemwivbie, Verena A. Schneeweis
European School of Physiotherapy, Hogeschool van Amsterdam, Tafelbergweg 51, Amsterdam, The Netherlands
Received 29 January 2010; accepted 6 February 2010
Abstract
The degree to which physical therapists can make an early accurate prediction of outcome of dexterity, gait and
activities of daily living at six months in stroke patients was investigated. Within 72 hours after stroke onset,
physiotherapists assessed 221 patients and made predictions. Measurements were repeated every three days and
a second prediction was made at hospital discharge. The second prediction also included a prediction about
place of living at three and six months. Final outcome was defined, using the action research arm test (ARAT)
for dexterity, the functional ambulation categories (FAC) for walking ability and the Barthel index (BI) for
ADL function. The level of accuracy predicted by the physiotherapists within 72 hours ranged from 51% to
65%, with prediction of gait as the most accurate and that of dexterity as the least. Predictions made at hospital
discharge were more accurate (63% to 71%), with prediction of gait as the most accurate and that of ADL
function as the least. These results suggest that the early predictions made by physiotherapists could prove
useful in informing patients and relatives, screening patients for rehabilitation and in planning treatment
strategies. Due to the facilitated discharge planning, length of stay in stroke units can be shortened.
Keywords: early prediction, stroke, recovery, functional outcome, dexterity, gait, ADL, discharge destination
Introduction
Stroke is the third leading cause of death in the
western world behind heart disease and cancer
(Department of Health and Human Services, 2009)
and causes 1 in 10 deaths worldwide each year
(Wolframalpha, 2009). About half of all stroke
survivors have a significant persisting neurological
impairment and disability (Tennant et al. 1997)
which causes dependency in performing activities of
daily living (ADL) (Schiemanck et al. 2006) and a
loss of arm (Kwakkel et al. 2003) and walking
function (Jørgensen et al. 1995).
In Dutch hospitals, about 30000 stroke patients are
admitted annually (van Peppen et al. 2004). Over the
past few years, the average length of stay in a
hospital stroke-unit has decreased to an average of 15
days (Zhu et al. 2009). The decrease of hospital stay
has consequence for the management of stroke
patients. The time to plan and wait for discharge
destination is reduced. Early initiated rehabilitation
post stroke is important, to optimize a patient’s
functional recovery by helping the patient relearn
skills that are lost, restitute or compensate for any
residual disabilities (van Peppen et al. 2004). Early
mobilization (within 72 hours post stroke) minimizes
the potential for secondary impairments (van Peppen
et al. 2004, Chaiyawat et al. 2009).
Therefore, preditions made within 72 hours of
functional recovery, in terms of ADL independency,
walking ability and dexterity is paramount for health
care management at stroke units, including discharge
planning and to set realistic goals (Loewen et al.
1990, Lai et al. 1998). Physiotherapists are often
involved in the rehabilitation and management of
stroke patients in stroke-units (van Peppen et al.
2004) and therefore it is important that
physiotherapists are able to make early and accurate
predictions about the functional recovery of stroke
patients.
It is clear that physiotherapists can accurately predict
the functional recovery in stroke patients at two and
five weeks (Kwakkel et al. 2000), but it is unknown
if physiotherapists can accurately predict the
functional recovery in stroke patients within 72
hours.
Up until now, there have been various prediction
made for discharge disposition (Henley et al. 1985,
Engberg et al. 1995), length of stay in the hospital
(Galski et al. 1993), motor recovery (Kwakkel et al.
2003, Loewen et al. 1990, Olson, 1990, Duncan et al.
1992) and degree of independence in activities of
daily living and mobility (Prescott et al. 1982, Wade
et al. 1983, Lincoln et al. 1989, Censori et al. 1993).
However, previous studies were done after 72 hours
and did not investigate the accuracy of
physiotherapists’ prediction. Hence, the present study
aims to investigate the accuracy of physiotherapists’
prediction within the first 72 hours and at hospital
discharge, of functional outcome in terms of
dexterity, walking ability, ADL function at six
months and place of living at three and six months
post stroke.
Netherlands as part of a prospective cohort study.
Stroke was defined according to the World Health
Organization (WHO, 1989) and patients were
included when they met the following criteria: (1)
clinical first-ever stroke in the anterior (carotid)
territory; (2) above 18 years of age; (3) a hemiparesis
within the first 72 hours; (4) able to follow
instructions (either verbally or non-verbally); (5) preexistent not limited in performing basic ADLs
(Barthel Index >18); and (6) informed consent.
During the first 72 hours, all patients were assessed
by a neurologist to confirm the diagnosis of stroke.
Patients were classified according to the Oxfordshire
Community Stroke Project (OCSP) into (1) Lacunar
Anterior Cerebral Infarction (LACI); (2) Total
Anterior Cerebral Infarction (TACI); and (3) Partial
Anterior Cerebral Infarction (PACI). Table 1 gives an
overview of the patients’ characteristics within 72
hours.
Methods
Subjects
Between March 2007 and April 2009, stroke patients
were recruited from ten hospitals across the
Measurements
Dexterity was measured with the ARAT (Lyle et al.
1981). This one-dimensional hierarchical scale
consists of 19 functional tasks that are divided into
Procedure
Based on clinical measurements within 72 hours post
stroke, 27 physiotherapists made a prediction of final
outcome. Final outcome was defined at six months
after stroke, with regard to dexterity, walking ability
and ADL, using the Action Research Arm Test
(ARAT), functional ambulation categories (FAC) and
Barthel index (BI) respectively. The clinical
measurements were repeated every three days up to
hospital discharge, with a maximum of three weeks.
At discharge, the physiotherapists made a second
prediction of final outcome as well as place of living
after three and six months. The number of days
between stroke onset and the time of first assessment
as well as the frequency of treatment received during
hospital stay were recorded. All 27 physiotherapists
were trained assessors from the ten participating
hospitals. Their characteristics were recorded and
included; years of experience in stroke rehabilitation
and additional education (table 2). Patients received
rehabilitation care according to the Dutch guidelines
of stroke rehabilitation (van Peppen et al. 2004). The
research protocol was approved by the ethics
committees of each participating hospital.
Table 1 Patients characteristics within 72 hours after stroke (N=186)
Sex (m/f)
Age, years (±SD) *
Hemisphere of stroke (L/R)
Type of stroke (OCSP)
TACI
PACI
LACI
CIRS (0-52) (±SD) *
MI (0-200) **
BFMT upper extremity (0-66) **
BFMT lower extremity (0-34) **
BFMT Total (0-100) **
BBS (0-56) **
TCT (0-100) **
FAT (0-5) **
NIHSS (0-69) **
MRS (0-5) **
BI (0-20) **
FAC (0-5) **
ARAT (0-57) **
Place of living at 3 months after stroke:
% home
% home with help for basic ADL
% rehabilitation center
% nursing home
82/104
66.3 (14.1)
81/105
36
62
88
2.56 (2.6)
100.5 (31.0, 151.0)
18.5 (4.0, 53.3)
20.0 (9.0, 29.0)
41.0 (13.8, 79.3)
9.0 (1.0, 39.0)
74 (37.0, 100.0)
0.0 (0.0, 4.0)
8.0 (4.0, 14.0)
4.0 (3.0, 5.0)
7.0 (3.0, 12.8)
1.0 (0.0, 3.0)
1.0 (0.0, 37.0)
47.3
12.4
16.7
23.1
Table 2 Characteristics of physiotherapists (N=27)
Sex (m/f)
Experience, years **
Type of courses
NDT (yes/no)
NPI (yes/no)
Others (yes/no)
5/22
18.0 (2.0, 25.0)
15/12
12/15
10/17
* Mean scores (standard deviations in parentheses).
**Median scores (25th and 75th quartile ranges in parentheses).
OCSP, classification following Oxfordshire Community Stroke Project; TACI, total anterior circulation infarct; PACI, partial anterior circulation
infarct; LACI, lacunar anterior circulation infarct; BI, Barthel Index; FAC, Functional Ambulation Categories; ARAT, Action Research Arm test;
ADLs, activities of daily living; MI, Motricity Index; BFMT, Brunnström Fugl-Meyer Test; BBS, Berg Balance Scale; TCT, Trunk Control Test;
FAT, Frenchay Arm Test; NIHSS, National Institutes of Health Stroke Scale; MRS, Modified Rankin Scale. NDT, Neurodevelopmental
treatment; NPI, clinimetrics after stroke
four domains: grasp, grip, pinch and gross
movement, with a maximum total score of 57 points.
The prediction for dexterity at six months was made
based on categorizing the ARAT into four categories:
non functional (0-9 points), some function (10-52
points), almost complete recovery (53-56 points) and
full function (57 points).
The FAC (Holden et al. 1984, Holden et al. 1986)
includes six ordinal levels (0-5) of support needed for
gait, but does not evaluate whether or not an aid was
used. A maximum score of five points on the FAC
represents the ability of the patient to walk safely and
independently. For the prediction of gait at six
months, the FAC was categorized into four
categories: can walk only with physical support
(score 0-2), can walk under supervision (score 3),
gait almost fully recovered, with the exception of the
ability to walk on uneven surfaces and stairs (score
Table 3 Percentage of patients at six months (N=186)
BI (0-20)
Very severely limited (0-3)
Is severely limited (4-9)
Is moderately limited (10-13)
Is mildly limited (14-18)
Is fully recovered (19-20)
FAC (0-5)
Patient is unable to walk/needs continuous support of 2 or more persons (0-2)
Patients needs supervision for safety and if necessary verbal guidance (3)
Patient is able to walk independently on flat grounds (4)
Patient is able to walk independently on flat base, irregular base, slopes (5)
ARAT (0-57)
Non-functional (0-9)
Some restored hand function (10-52)
Almost fully restored hand function (53-56)
Fully restored hand function (57)
3.8%
9.1%
4.8%
22.1%
60.2%
N=7
N=17
N=9
N=41
N=112
12.4%
4.8%
15.1%
67.7%
N=23
N=9
N=28
N=126
30.1%
26.9%
10.2%
32.8%
N=56
N=50
N=19
N=61
Table 4 Final score at 6 months after stroke (N=186)
MI (0-200) **
BFMT upper extremity (0-66) **
BFMT lower extremity (0-34) **
BFMT Total (0-100) **
BBS (0-56) **
TCT (0-100) **
FAT (0-5) **
NIHSS (0-69) **
MRS (0-5) **
BI (0-20) **
FAC (0-5) **
ARAT (0-57) **
Place of living at 6 months after stroke:
% home
% home with help for basal ADL
% rehabilitation center
% nursing home
169.5 (110.5, 191.0)
60.0 (21.8, 65.0)
29.0 (21.0, 33.0)
89.0 (42.0, 96.0)
51.0 (39.0, 55.0)
100.0 (100.0, 100.0)
5.0 (1.0, 5.0)
2.0 (1.0, 5.3)
2.0 (1.0, 3.0)
19.0 (16.0, 20.0)
5.0 (4.0, 5.0)
49.0 (2.8, 57.0)
61.8
14.5
4.3
18.8
* Mean scores (standard deviations in parentheses).
**Median scores (25th and 75th quartile ranges in parentheses).
OCSP, classification following Oxfordshire Community Stroke Project; TACI, total anterior circulation infarct; PACI, partial anterior circulation
infarct; LACI, lacunar anterior circulation infarct; BI, Barthel Index; FAC, Functional Ambulation Categories; ARAT, Action Research Arm test;
ADLs, activities of daily living; MI, Motricity Index; BFMT, Brunnström Fugl-Meyer Test; BBS, Berg Balance Scale; TCT, Trunk Control Test;
FAT, Frenchay Arm Test; NIHSS, National Institutes of Health Stroke Scale; MRS, Modified Rankin Scale. NDT, Neurodevelopmental
treatment; NPI, clinimetrics after stroke
4), gait fully recovered, able to walk safely on uneven
surfaces and stairs (score 5). The ability to perform
basic ADLs was assessed using the BI (Collin et al.
1988, Wade et al. 1988). This measurement was
applied in order to evaluate the ability of the patient
to perform ten different activities of daily living. The
BI was categorized into five categories to predict the
ability to perform basic ADL activities at six months:
very severely impaired (0-3 points), severely
impaired (4-9 points), moderately impaired (10-13
points), mildly impaired (14-18 points), and fully
recovered (19-20 points).
Statistics
Patients’ demographic and clinical characteristics
were summarized using central tendency and
variability statistics. Due to the ordinal nature of the
measurements, the Spearman rank correlation (rs)
was calculated to analyze the relationship between
(1) the prediction made by the physiotherapist within
72 hours post stroke and the observed outcome at six
months, and (2) the prediction made at hospital
discharge and the observed outcome at six months. A
correlation was considered as moderate to good if
rs =.05 to .75 and strong if rs =.75 to 1.0 (Colton,
1974). The Wilcoxon signed rank test was used to
evaluate the direction of difference between the
predictions made within 72 hours and at hospital
discharge and the final outcome. The level of
significance used was p < 0.05. SPSS version 15.0
for Microsoft Windows was used to perform the
analysis.
Results
Group definition
221 stroke patients were recruited. There were 35
drop outs excluded from the analysis, with reasons:
death (N=21), recurrent stroke (N=5), lack of
motivation (N=3), loadability too low (N=3),
relocated (N=1) and unknown (N=2). Thus, 186
patients completed the study and their characteristics
can be found in table 1.
At baseline (within 72 hours), the patient group was
severe in terms of ADL (BI median 7; 3.0, 12.8),
walking ability (FAC median 1; 0.0, 3.0), and
dexterity (ARAT median 1; 0.0, 37.0). At six months,
the group was mild in terms of ADL (BI median of
19; 16.0, 20.0) and walking ability (FAC median 5;
4.0, 5.0) and moderate in terms of dexterity (ARAT
median 49; 2.8, 57.0) as shown in table 4.
Prediction of physiotherapists and final outcome
Preliminary analyses were performed to ensure no
violation of the assumption of normality, linearity
and homescedasticity.
As shown in table 5, there was a moderate to strong
positive correlation (rs = .646 to .844) between all
predictions made about ADL, gait, dexterity, place of
Table 5 Predictions
Outcome
ADL
Gait
Dexterity
Place of
living at
3 months
Place of
living at
6 months
Prediction within
72 hours
rs
N
.646*
185
.653*
186
.725*
186
Prediction at
hospital discharge
rs
N
.755*
175
.750*
175
.844*
175
.768*
173
.735*
173
*p<0.05
living at three and six months and the actual observed
outcome. The Wilcoxon Signed Rank Test revealed a
positive statistical significant difference between the
prediction made about ADL (measured with BI)
within 72 hours and the final outcome and also
between the prediction made about dexterity
(measured with ARAT) at hospital discharge and the
final outcome (p < 0.05). However, there was a
positive non-statistical significant difference between
the prediction made about dexterity (measured with
ARAT) within 72 hours and the actual outcome, and
ADL functioning (measured with BI) at hospital
discharge compared to the actual outcome (p > 0.05).
It also revealed no statistically significant difference
between the prediction made about gait (measured
with FAC) within 72 hours and at hospital discharge
(p > 0.05).
There was also no statistical significant difference
regarding prediction made at hospital discharge about
the place of living at three and six months (p > 0.05).
As shown in table 6, higher percentages of accuracy
of predictions made at baseline and at hospital
discharge were found for the outcome of gait
(64.52% and 71.43%) and discharge destination
(70.52%) as compared to that of dexterity (50.54%
and 65.14%) and ADL functioning (58.92% and
63.43%).
Table 6 Accuracy of physiotherapists predictions at baseline and at hospital discharge
Outcome
ARAT (0-57)
FAC (0-5)
BI (0-20)
Place of living at 3
months
Place of living at 6
months
Chance
(%)
25.0
16.6
25.0
16.6
Prediction at Baseline
%accurate %optimistic %pessimistic
50.54**
28.49
20.97
64.52**
20.97
14.51
58.92*
26.49
14.59
16.6
Prediction at hospital discharge
%accurate %optimistic %pessimistic
65.14*
25.14
9.72
71.43**
17.14
11.43
63.43**
22.29
14.28
70.52**
16.76
12.72
70.52**
15.61
13.87
*p<0.05
**p>0.05
Discussion
The aim of this study was to find out if
physiotherapists are able to predict within 72 hours
and at hospital discharge the functional outcome in
terms of ADL functioning, gait and dexterity at six
months as well as the place of living at three and six
months.
Judging from the accuracy levels as shown in table 6,
physiotherapists are able to make early predictions.
The ability to make a prediction of outcome is
important for both clinical and scientific purposes.
An early and accurate prediction of functional
recovery in stroke patients is important for patient
management, rehabilitation, discharge planning, and
to provide reliable information to patients and their
relatives. It enables patients to prepare for eventual
functional limitation and plan for the future. The
short time period between the onset of stroke and the
prediction of outcome is crucial for an early
discharge planning, which should start right after
admission (Gresham et al. 1995). This goes in line
with Feys et al. (2000), who stated that predictions
should be done early as the accuracy of predictions
diminishes when done at a much later time in the
recovery process.
The most pressing question for stroke victims and
their families is the extent to which they are likely to
recover. The results of this study may help in giving
fairly accurate answers to this question.
Prediction of dexterity:
The present study indicates that physiotherapists are
able to accurately predict the outcome of dexterity.
The physiotherapists’ prediction about dexterity
within 72 hours showed an accuracy of 50.54%,
which increased at the second prediction (made at
hospital discharge) to 65.14%.
This finding is in agreement with Kwakkel et al.
(2000) who also found that physiotherapists are able
to accurately predict the outcome of dexterity six
months post-stroke. However, the level of accuracy
of physiotherapists in the present study reveals that
prediction made within 72 hours is more accurate
than predictions made within two weeks after stroke
onset, when compared to the study of Kwakkel et al.
(2000). Reasons for obtaining better results than
Kwakkel et al. (2000), but in a shorter period of time,
might be the strict inclusion and exclusion criteria, as
well as the change in physiotherapy practice. Over
the years, the physiotherapists probably gained
experience with stroke patients, and got more
familiar with the clinimetrics.
In predicting prognosis of arm recovery, it is
important to take into account the initial degree of
motor deficit in the arm (Feys et al. 2000). The group
in the present study was severe in terms of dexterity
at baseline; 114 patients (61.3%) were non-functional
(ARAT≤9 points). This number decreased to 56
patients (30.1%) at six months, whereas fully restored
hand function (ARAT=57 points) was present in nine
patients at baseline (4.8%) and in 61 patients (32.8%)
at final measurement. It has been said that the
prognosis for functional recovery of the hemiplegic
arm is poor; hence it is difficult to make an early
accurate prediction of dexterity (Kwakkel et al.
2003). This is in line with the lower accuracy level of
prediction made by the physiotherapists as regards
dexterity when compared to that of ADL and gait.
Prediction of gait:
A high percentage of recovery in terms of walking
ability was seen in patients at six months (Table 3).
At baseline, only 15 patients (8.1%) were able to
walk independently on flat base, irregular base and
slopes and at six months this number increased to 126
patients (67.7%). Predictions made about gait
appeared to be the most accurate (64.52 and 71.43%).
The prediction made by the physiotherapists can be
regarded as good; even though the predictions were
done early, they have a high accuracy level compared
to the study conducted by Jørgensen et al. (1995)
who stated that predictions about walking ability in
patient with initially no/mild/moderate leg paresis
can be made in three weeks after stroke onset. The
difference between the outcomes of these two studies
could be due to the fact that different measurement
tools were used to predict gait.
Prediction of ADL:
In 58.92% of cases, physiotherapists made an
accurate prediction about the outcome of ADL
functioning at baseline which increased to 63.43% at
hospital discharge. The numbers indicated a good
prognosis for return to ADL functioning. At six
months, 60.2% of the patients (N=112) had full
recovery which is slightly higher than the 58%
complete recovery as reported by Duncan et al.
(1992). Nevertheless, the percentage of accuracy of
ADL prediction in this present study is less than that
of gait which can be explained by the complex
character of ADL and the diversity of skills needed to
perform these ADLs (Kwakkel et al. 2000).
Prediction of discharge destination:
The physiotherapists accurately predicted the
discharge destination in 70.52% of cases at three and
six months. This percentage is lower than in the study
conducted by Olai et al. (2006) who had 78.4%
accuracy in predicting discharge destination at three
months. The higher percentage can be explained by a
large number of assessor on one occasion (3.6 per
patient), as well as a strict inclusion criteria regarding
age. It should be taken into account that discharge
destination differs amongst other cultures and social
circumstances and environment and therefore it
cannot be generalized (Kwakkel et al. 2000).
The physiotherapists’ predictions in this present
study were too optimistic and this can be compared to
the too optimistic predictions also found by KornerBitensky et al. (1989, 1990) and Kent et al. (1993).
For patients, this could indicate that there are
unfulfilled goals and hopes which could lead to a lack
of trust in the physiotherapist and a longer period of
acceptance of disability.
We recommend that predictions be based on
statistical models because they assist the practitioner
in making a proper prognosis and treatment plan for
an individual stroke patient (Kollen et al. 2006). We
therefore propose that predictions should be made
with caution, if they are not based on substantiated
prediction models and thus, goals should be chosen
carefully.
Limitations of this study:
One limitation of this study is the homogenous group
of patients, which might not be applicable to a great
variety of patients. All patients received therapy
according to the Dutch guidelines of stroke
rehabilitation (van Peppen et al. 2004), but individual
adaptations and exact treatment could not be
recorded, which could have an influence on the
recovery outcome. Also the influence of motivation,
mood and general health was not measured.
Eleven patients did not have a second prediction
because they were discharged from hospital within 72
hours and therefore the second prediction was
performed on a smaller patient group.
The physiotherapists used a great variety of
clinimetrics to have a complete overview of the
patient’s situation, which might not be possible in a
normal setting. This could have positively influenced
the accuracy level of predictions presented in this
study.
In addition, the influence of physiotherapists’
characteristics concerning years of experience in
stroke rehabilitation and additional education should
be investigated in order to deal with a possible
confounding effect on the accuracy of prediction.
This calls for an improvement in further studies to
enable the use and development of more accurate
prediction models, like those of Nijland et al.
(accepted 2009).
We recommend that further research should focus on
improving the accuracy of early predictions of
functional outcomes of stroke.
Conclusion
Accurate prediction about functional outcome at six
months in terms of dexterity, ADL function and gait,
can be made by physiotherapist within 72 hours post
stroke as well as place of discharge at three and six
months.
Acknowledgements
We would like to thank our client Prof. Dr. Gert
Kwakkel, as well as our internal coaches Janne
Veerbeek and Rinkse Nijland for their support,
advice and feedback. We acknowledge the support of
the Early Prediction of Stroke (EPOS) consortium
and the participating hospitals. We would also like to
thank our external coach Frank van Hartingsveld.
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