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Stroke Disability

Stroke is the third leading cause of death in the United States and a major causeof disability in the elderly. Although the incidence of stroke is decreasing, its preva-ence in the population is increasing because of enhanced survival and a grow-ng elderly population. Estimating and understanding disability following stroke

should be a high priority in health care. To better characterize stroke-related dis-ability, pbysical therapists should use a conceptual model of disablement andmeasure unctions across all domains of disablement (impaimtents, unctionallimitations, disability, and quality of life). Therapists need to use the measurementsobtained and knowledge of stroke recovery and of the variables that influencethis recovery to stage patients for prediction of outcomes. Using predicted out-comes to stage patients may result in efictive treatment plans and more accurateargeting of intensive rehabilitation to those patients most likely to benefit. [Dun-can PW. Stroke disability. Pbys Thm 1994;74:399407.]

Key Words: Cerebrovascular accident, Disability, Measurement, Outcomes, Stroke.

Incidence and Prevalenceof Stroke

Stroke is the third leading cause ofdeath in the United States and a major

cause of disability. Each year approxi-mately 500,000 Americans suffer anew or recurrent stroke. Of this num-ber, 350,000 will survive.' Althoughthe incidence of stroke is decreasing,its prevalence in the population ap-pears to be increasing because ofenhanced stroke survival and a grow-ing elderly population. The preva-lence of stroke survivors is currentlyover 2,000,000.l

Within the first 30 days followingstroke, the mortality rate is high(30%)).* t is more severe for hemor-rhagic stroke than for ischemicstroke.3 However, more than 50% ofstroke survivors are alive in 5 years.*Given this good survival rate and the

continuing high incidence of stroke,estimating and understanding disabil-ity following stroke becomes a highpriority in health care.

Dlsablllty Estlmates

Exact estimates of disability followingstroke are difficult to obtain becausepatients selected for study may bepopulation based o r referral based(acute hospitals or rehabilitation facili-ties), outcome measures may be in-consistent, and assessments may havebee n taken at different times duringthe recovery period. Patient-levelvariables such as severity and type ofstroke, age, and comorbid conditionswill also affect stroke disability andvary in different disability studies. Thebest estimates of disability followingstroke are provided by population-based studies. Stroke registries of allpatients referred to hospitals are the

PW Duncan, PhD,PT, s Associate Director for Research, Center for Health Policy Research andEducation, Duke University, and A ssociate Professor, Gradu ate P rogram in Physical Therapy, Duk eUniversity. Address all cor resp onde nceto Dr Duncan at Center for Health Policy Research an dEducation, Duke University, Erwin Sq , Ste 230, 2200 W Main St, Durham, NC 27705 (USA).

next best source, whereas studies ofpatients referred to rehabilitationfacilities tend to be the most biased.Patients who are selected for rehabili-tation are usually moderately to se-

verely impaired.

The incidence of dependence in activ-ities of daily living (ADL) is highestimmediately after a stroke and de-creases significantly thereafter, accord-ing to various auth01-s.~~ retrospec-tive analysis of data from 292 personsin Rochester, Minn, following theirfirst stroke indicated that 75% weredependent in ADL at onset of stroke.Only 57% of the survivors, however,were dependent at the time they weredischarged from the hospital.* In aprospective, population-based registryof 976 patients with stroke in theFrenchay Health District in England,Wade and Langton-Hewer7 found thatthe incidence of total dependence inADL decreased from 58% at 1 weekpoststroke to 9% at 6 months post-stroke. In a Japanese study, Kojima eta18 found similar results, with only25% of 5-year survivors totally depen-dent in ADL. Christie' repor ted

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6-month disability levels for 296persons who participated in apopulation-based study of stroke inMelbourne, Australia. Twenty-fivepercent of the subjects in that studywere independent in ADL, and 17 %could drive a car or use public trans-portation. Of those subjects under age7 5 years who did not lose conscious-ness immediately after the stroke,54% were independent in ADL and36% could drive a car or use publictransportation.

Several other factors may influencethese results . Selective survival of theleast seriously disabled individualsmay bias these findings. Also, depen-dencies in ADL may vary by function,making a summated ADL score lessrepresentative of limitations in indi-

vidual activities. For example, thedependence in more complex func-tions such as bathing is much greaterthan that in less complex activitiessuch as gr ~o mi ng .~

Population-based studies that assessneurological function following strokesupport an optimistic view of thepatient's prospects for recovery. Bo-nita and Beaglehole,lo who assessedthe natural history of motor recoveryfor patients with stroke in Auckland,New Zealand, reported that 88 % ofthe subjects had motor deficits. Theproportion of survivors who hadpersistent motor deficits at 6 monthspoststroke, however, had declined to62%, and the majority of these motordeficits were mild. Similarly, in aFinnish population-based study,6 73%of all patients with stroke had hemi-paresis, but only 37 % demonstratedhemiparesis at a 12-month follow-up.An assessment of 148 long-term

stroke survivors in the Framingham(Mass) community-based populationstudyn revealed that 67 had residualhemiparesis, 4 had bilateral motorweakness, and 77 had no motordeficit.

Although the inability to walk is oneof the no st common problems inacute stroke, most survivors achieveindependence in ambulation. In thepopulation-based Frenchay HealthDistrict: study, only 27% of patients

could functionally ambulate within 1week of stroke, but at 6 months 85 %were independent, although only 25%had regained normal speed of ambu-l a t i ~ n . ~ J ~resham et all1 reportedthat 78% of the stroke survivors in theFramingham study were ambulatory.

A few studies have examined instru-mental ADL and quality of life instroke survivors. In the Framinghamcohort, Gresham et all1 comparedstroke survivors with age-matchedcontrols and found that 90 % of thestroke survivors demonstrated o ne o rmor e disabilities, compared with 58%of the matched controls. Stroke survi-vors were more limited in severalareas, including household activities,recreational activities, social interac-tion, and public transportation usage.

In a matched control study using theSickness Impact Profile, Schuling etall3 found that stroke affected house-hold management, leisure activities,and mobility. Christie9 repor ted an"imperfect correlation" between re-sidual physical impairment and dis-ability. For example, of the strokesurvivors who were employed priorto stroke and who had no residualphysical impairments , only 60% re-turned to work and only 80% contin-ued their prior leisure activities. Ofpatients who had residual physicalimpairments, 40% continued to workand 60% engaged in leisure activities.9

Other conditions in addition to physi-cal disability undermine the quality oflife for persons following stroke.These conditions include depression ,dependency on others, and the inabil-ity to return to work.14 Many patientswith stroke also have other majorcomorbid disease, which contributes

to their disability. Based on the resultsof the Framingham disability study ofstroke survivors, Jette et all5 con-cluded that a history of stroke ex-plained only 12 % of the variance inphysical disability among m en livingin the community and only 3% of thevariance among women.

The overall prevalence of severedisability among stroke survivors maybe overestimated by clinicians whosecontact with patients with stroke has

been limited to early acute care man-agement, rehabilitation units, o r long-term care facilities. In any given pa-tient, the process of disablement maybe profound and complex. A broaderperspective is needed to understandthe nature of stroke-related disable-ment in the population.

Conceptual Models ofDisability

Several conceptual models of disabil-ity are available to facilitate the under-standing, assessment, measurement,and treatment of stroke-related dis-abilities. The World Health Organiza-tion's (WHO) International Classifica-tion of Impairments, Disabilities, andHandicaps (ICIDH)16 and the Nagi"functional limitation" model17 are

the most frequently presented modelsof the disablement process. The WHOmodel classifies disablement in termsof "disease, impairment, disability,and handicap." Nagi's model refers topathology, impairment, functionallimitation, and disability (Fig. 1).

In Nagi's model, pathology o r diseuserefers to the underlying pathologicstate that interferes with normal bodilyfunctions or structure.18 n stroke, thepathology may be due to thrombosis,emboli, or hemorrhage in a particularcerebrovascular distribution.

Impairments are the physiological orpsychological consequences, o r thesigns and symptoms, of the pathologyof the disease. Some common impair-ments after stroke are impaired motorfunction, sensory deficits, abnormaltone, perceptual deficits, cognitivelimitations, aphasia, and depression.Although some impairments are the

direct effects of stroke, others may beindirect. For example, shoulder painmay not be a direct effect of a strokebut may instead result from the com-posite effects of loss of shoulder mo-tor function, loss of range of motion,and altered biomechanics of theshoulder complex.

Functional limitations reflect thefunctional consequences of the pa-thology o r the abilities lost. Examplesof physical functional limitations fol-

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extremities. Neurological and func-tional recovery are often parallel,22-25

Flgure 1. The Nagi model of the disablij

lowing stroke are restriction in activi-ties such as transfers and walking.

Pathology

Disability represents the social and

societal consequences of functionallimitations. It is defined by a patient'sinability to perform ADL and maintainsocial and family relationships, tocontinue in a vocation, o r to pursueleisure activities.

+ mpairment

Assessment of the disablement ofstroke should capture not only thepatient's ability to perform basic orinstrurnental ADL, but also the pa-tient's perceptions of his or her emo-tional, social, and physical functionsand the ease with which these activi-ties are performed. This mor e com-plex and multidimensional concept ofwell-being and perception of health iscalled quality of life. Quality-of-lifeassessments try to capture how limita-tions in function affect emotional,social, and physical roles as well asperceptions of health. Interest inthese assessments is growing rapidly.Many measures have been devel-oped,l9,20 and one measure has been

used specifically with patients withs roke.21

The pathways from pathology to dis-ability are not necessarily unidirec-tional. For example, limitations infunctional activities can produce im-pairments such as increased weak-ness, restricted range of motion, anddeconditioning of the cardiovascularsystem. Moreover, the disablementprocess may be modified by many

4

29 process.

other factors (eg, social support, phys-ical environment, motivation, depres-sion). Figure 2 is a graphical repre-sentation of a modified version of the

Nagi model. It illustrates the complex-ity of the physical disablement ofpatients following a stroke and therelationships among impairment,functional limitation, disability, andquality of life. This model of physicaldisablement also makes a distinctionbetween functional performance thatis observed and functional perfor-mance that is self-reported. Under theideal circumstances often created inrehabilitation settings, the patient maybe able to perform a task, but thisachievement does not reflect his orhe r abilities in more variable environ-ments or represent his or her usualperformance.

Recovery Patterns

DisabilityFunctional

Limitation

Most patients experience some de-gree of recovery following a stroke. Itis difficult, however, to completelydistinguish between recovery fromimpairments and recovery from dis-

ability. The recovery of motor func-tion, sensation, and language arerepresentative of neurological recov-ery. Recovery of functional skills maybe attributable to neurological recov-ery o r behavioral compensation, orboth. For example, in behavioralcompensation, the unaffected extremi-ties may compensate for the reducedfunction of the affected extremities o rthe patient may learn to maximizeresidual motor control in the affected

+

but distinctions should be made be.tween neurological recovery andfunctional recovery.

Although it is often thought that theupper extremity does not recover aswell as the lower extremity followingstroke, the actual degree of neurologi-cal recovery of the upper and lowerextremities may be slmilar (DuncanPW, unpublished observations fromthe Durham County Stroke Study).The lower extremity, however, canfunction with less motor control thanthe upper extremity. Thus, partialmotor recovery in the lower extrem-ity may permit many patients withstroke to ambulate independently,although the pattern will not be "nor-

mal" in pattern o r velocity. Partialrecovery of upper-extremity functiondoes not usually translate into func-tional use.

In general, neurological recoveryoccurs within the first 1 to 3 monthsfollowing stroke. Further motor o rsensory recovery may continue tooccur 6 months to 1 year later; how-ever, these changes are generallylimited to individuals with some de-gree of volitional motor con-

t1-oll0.22~~~~7nd may not reach statisti-cal o r clinical ~ignificance.4,5,~7prospective study of recovery patternsin 104 patients with anterior circula-tion ischemic stroke demonstratedthat 86% of the variance in 6-monthmotor recovery can be predicted in 1month. The more severely impairedpatients continued to experiencesome measurable recovery of functionfrom 3 to 6 months poststroke, butthis recovery was not correlated withclinically meaningful ADL scores (>60on the Barthel Index).*5 In theFramingham cohort, recovery of mo-tor function and ADL occurred within3 months of stroke, then subsequentlyplateaued. Language and cognitivefunction improved over longer peri-ods of time."

The courses of recovery previouslydescribed d o not reflect the naturalhistory of recovery because patientswho received rehabilitation were not

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P s y c h o s o c i a l P a t ho lo g yFactors

-Ischemic-Hemorrhage

-Severity ofstroke

-Corn orbidities

-Sensory-Balance-Percep tual-Range of mot lon

-Tone-Pain-Cerdlovesculer

condl t loning

Env i ronmen ta lFac to r s

-Soclel support-Physical

envlronmant

Funct iona l Per formance\ [ Observed Sdf-reported I /

( (Qual i ty of Li fe) I

Figure 2. Model of physical disablement in stroke.

excluded from the population stud-ied. The profiles of recovery that arereported represent measures of cen-tral tendency. Individual recoverypatterns may be more variable, and

some individuals may show moreprotracted periods of recovery. Inspite of some variations in individuals,the terriporal pattern of recovery hasnow been well documented in severalindependent cohorts. These studiessupport the tenet that most neurologi-cal recovery occurs early. In addition,the time course of recovery is similarfor different levels of stroke severity(Duncan PW, unpublished observa-

tions from the Durham County StrokeStudy).

The prognosis for neurological andfunctional recovery following stroke is

influenced by a number of factors. Ina review of the literature, Dombovy eta128 identified the following factors aspredictors of poor functional outcc;meafter stroke: coma at onset, inconti-nence 2 weeks after stroke, poorcognitive function, severe hemipare-sis, no motor return within 1 month,previous stroke, perceptual-spatialdisorders, and significant cardiovascu-lar disease. In a similar review of 33

articles, Jongbloed2Vdentified older

age, history of prior stroke, inconti-nence, and visual-spatial deficits asprognosticators of poor recovery.Other studies have identified theinability to sit unsupported30 and anaccumulation of motor, sensory, andvisual deficits31 as factors that contrib-ute to m ore protracted recovery offunctional activities as well as poorer

functional outcomes. Depression andlack of social support have also beenassociated with longer and less exten-sive recovery of function followingstroke.32-3*

Staglng Patients

Understanding the patterns of recoveryand the predictors of outcome arecritical for establishing realistic g d sand planning appropriate interventionstrategies for each patient. Combinedwith the results of clinical assessments,this understanding can lead to moreaccurate and realistic patient staging.Staging of patients is useful as a meanscf dealing realistically with the pa-tient's and his o r her family's expecta-tions of recovery and outcome. Stagingis also useful as a way of selecting themost appropriate level of therapeuticintervention. For example, stagingcould be used to target limited re-sources for stroke rehabilitation so that

intensive rehabilitation would be pro-vided only for those for whom it ismost appropriate.

Staging of patients following stroke bydegr ee of motor impairment wasintroduced by Signe Brunnstrom over23 years agd5 and has more recentlybeen expanded by G0wland.3~ tagingof patients following stroke by ex-pected outcomes has not been a gen-eral practice, but it is currently beingattempted in some clinics. Table 1

outlines a classification system I usein clinical management of patientsafter stroke to stage them by expectedoutcomes.

The results of standardized assess-ments of cognitive function, sensation,motor control, perception, mobilitystatus, balance, continence, depres-sion, and comorbid diseases guide myclassification of the expected out-comes. Patients classified as being at

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-able 1. Stages of Expected outcomes ing impairments but rather on com-pensatory training in functional tasksand ADL. The Drogram for ~atients tExpected Outcome

Stage 1

lmpairment level

Disability level

Burden of careStage 2

lmpairment level

Disability level

Burden of care

Stage 3

lmpairment level

Disability level

Burden of care

Stage 4

lmpairment level

Disability level

Burden of care

No major neurological recovery

Patient will be dependent to semidependent in mostactivities

Caregiver will provide majority of assistance

Minimal neurological recovery

Patient will function semiindependently in mostactivities (eg, ambulate with assistance)

Caregiver will provide partial assistance

Moderate neurological recovery, but patient hasresidual impairments

Patient will function independently in most activities, butactivities may be performed with assistive device orat slower speed than before stroke; patient may needassistance for complex tasks

Caregiver will need to provide minimal or no assistance

Good to complete neurological recoveryPatient will function entirely independently with little, if

any, deficit noted

None

stage 1 of expected outcomes exhibittwo or more of the following factors:

moderate to severe cognitive deficits,hemiplegia (Brunnstrom stage 1 or2), severe sensory deficits, severeperceptual-motor deficits, impairedsitting balance, incontinence of boweland bladder, major comorbidities, anda Barthel ADL index of 6O on theBarthel Index. Patients at stage 4 willhave good cognition, slight hemipare-sis (Brunnstrom stage 5 or 6), nosensory deficits, good balance, and alimited number of comorbidities and

will be continent of bowel andbladder.

A study is in progress at HarmarvilleRehabilitation Center, Pittsburgh, Pa,to test the validity and reliability ofthis outcome staging scheme. Physi-cians, occupational therapists, andphysical therapists are participating inthis study. They are also investigatingthe optimal timing of assessments;that is, they are trying to ascertainhow soon after an event the outcomescan b e accurately predicted.

Staging, if demonstrated to be reliableand valid in the clinical setting, couldguide treatment goals and familyeducation of patients following astroke. For example, for patients instages 3 and 4, the therapeutic inter-vention program would be planned toremediate neurological impairmentsand to improve physical conditioning,as well as to promote independencein ADL. The program for patients instage 2 would not focus on remediat-

&-

stage 1 would emphasize family orcaregiver instruction and assistancewith basic ADL. The patient's stage ofexpected outcomes would b e consid-ered in conjunction with other influ-encing factors (time since stroke,social support, medical status, andpatient preferences) to help guideselection of the most appropriate sitefor postacute care. The proposedmethod of staging and the accuracy ofprediction are yet to be validated.Previous work by Korner-Bitensky eta137 suggests that physical therapistsdemonstrate a reasonable degree ofaccuracy in predicting rehabilitationdischarge outcomes in patients whohave had a stroke. When therapists

predicted dependency, they werealmost always correct (predictivevalue of dependence=91.3%-100%).The predictive value of independencewas not as great, but was good(70.5%-79.7%).

Recently, Kalra and Creme'" demon-strated that the Orpington PrognosticScore (Tab. 2) measured at 2 weekspoststroke was very useful in predict-ing outcomes in patients over 75years of age. The correlation (r2)between the Orpington score andfunctional outcome was 8 9. Patientswith an Orpington score of C3.2were discharged within 3 weeks ofstroke, whereas those scoring >5.2required long-term ~ a r e . 3 ~

The results of the previously men-tioned studies suggest that cliniciansare able to accurately predict out-comes in most patients. Initially, theremay be some hesitation to "stage"

patients. This resistance, however, willdecrease with recognition that stagingcan be accurate in predicting recoveryand response to specific rehabilitationservices. Early staging can serve as aguiding principle but will remainsubject to modification if th e patient'spotential changes.

Measurement

We will never be able to adequatelycapture the process of disablement

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-able 2. Orpington Prognostic Scord8Cllnlcal Feature ScoreMotor deficit in arm

MRCa grade 5

MRC grade 4

MRC grade 3

MRC grade 1-2

MRC grade 0

Proprioception (eyes closed)

Locates affected thumb:

Accurately

Slight difficulty

Finds thumb via arm

Unable to find thumb

Balance

Walks 3.05 m (10 ft) without help

Maintains standing positionMaintains sitting position

No sittir~g alance

Cognition

Mental rest score 10

Mental rest score E-9

Mental rest score !%7

Mental Test score 0 - 4

Total score= 1.6+motor+proprioception+balance + cognition

"MRC=Medical Research Council

following stroke, define the recoveryprocess, or develop predictive modelsof outcome unless we use well-characterized measures of impair-ment, functional performance, anddisability. The selected measures mustbe valid, reliable, and sensitive tochange. We should also use measuresthat do not have ceiling effects. Onemeasure that has been used in mostassessments of stroke-related disabilityis the Barthel Index. Although this

instrument may be an adequate mea-sure of basic ADL, it may not measuremore complex functional loss anddisablement, such as a decline in theperformance of more advanced ADLor in the patient's self-assessment ofquality of life.

Several factors appear to con tribute tothe current reluctance to utilize stan-dardized assessments in evaluatingpatients who have had a stroke.

Stroke differs widely in its clinicalmanifestations, and n o single assess-ment instrument can measure the fullrange of potential impairments, func-tional limitations, and disability. Ade-quate evaluation must rely on a bat-tery of instruments. These measuresare available, but only a few havedemonstrated clinimetric priorities ofreliability, validity, and sensitivity tochange. Probably the most importantbarrier, however, has been the reluc-

tance of clinicians to adopt standard-ized instruments. Recent reports thatsome formal assessments may bemore reliable than clinical impres-sions may help to overcome thisresistance.39

Table 3 represents a battery of mea-sures that I recommend for assess-ment of stroke.40-50 The list is notcomprehensive of all assessmentsavailable, but the measures included

are practical and have been assessedfor reliability and validity in studies ofpatients who have sustained a stroke.The assessments span the domains ofimpairments, functional limitations,and disability. Most of these measurescan be performed in the acute orpostacute care setting o r followingdischarge. Quality-of-life assessment,

however, is most relevant in the per-son's h ome setting and should prefer-ably be done there. Quality-of-lifemeasures have the specific advantageof capturing more complex functions,which may be compromised post-stroke even in the presence of goodrecovery of basic ADL.

The cognitive and sensorimotor mea-sures of impairment listed in Table 3

may need to be supplemented byassessments of depression, languagedeficits, and percep tual deficits be-cause these factors can also affect thelevel of disability. These assessmentscan be performed by ou r colleaguesin psychology, speech and languagepathology, and occupational therapy.For more comprehensive reviews ofthe measures available for characteriz-ing impai rments, functional limita-tions, and disability following stroke,the reader is referred to Wade.40

Modlfylng the DlsablementProcess

The goals of physical therapy instroke rehabilitation should be tomaximize function and minimizeimpairments within the constraints ofthe patient's pathology, comorbidities,and available resources. The ultimategoal is to reduce the physical contri-butions to disability.

A primary step in reducing disabilityis to examine the relationships be-tween impairment and disability.Exact measurements of both are obvi-ously preliminary to this process. Aphysical therapy evaluation shouldinvolve more than just compiling alist of patient impai rments o r func-tional deficits. The challenge to thephysical therapist is to evaluate find-ings and to analyze critically the inter-relationships among impairments,functional limitations, and disability.

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-able 3. Recommended Battery of Measures of Stroke Disablement Characterlstlcs of MeasureThal Have Been Assessed Tlme to AdministerImpairment measuresa

Folstein Mini-Mental examination4' Screens for memory, attention, language, Validityorientation, calculation

Reliability

c1 0 rnin

Sensitivity to change

Fugl-Meyer Sensorimotor AssessmenP2 Measures range of motion, pain, sensation, motor Validity 3 0 4 0 minfunction, balance

Reliability


Functional measures

Berg Balance Scale43.44

Disability measuresb

Basic activities of dai ly living

Barthel Index46

Measures 14 items of static and dynamic balance Validity

Reliability

Record time to walk 10 m


Validity

Reliability


Patient walks as far as he or she can at usual Validityself-paced rate

Measure distance walked in 6 min Reliability

Ordinal score of 10 items: feeding, bathing,grooming, dressing, bladder and bowel control,chairlbed transfer, ambulation, and stairclimbing

Functional Independence Measure7 Ordinal scale with seven levels including self-care,sphincter control, mobility, ocomotion,communication, and social cognition

Instrumental activities of daily living

Frenchay Activities Index48 Ordinal score of 15 items: preparing meals,washing up, washing clothes, light housework,heavy housework, ocal shopping, socialoutings, walking outside, pursuit of hobby,drivinglpubl ic transportation, outings, gardening,home maintenance, reading, gainful work

Quality of life

Sickness Impact Profile49 136 items with summated scores or 12 subscalesincluding ambulation, mobility, body care,emotional, social, communication, alertness,sleep, eating, home management, recreation,employment

Medical Outcomes Study 36-Item Short 36 items including physical functioning, roleForm= limitations due to physical or emotional

problems, social functioning, bodily pain, mentalhealth, vitality, general health perception


Validity

Reliability


Validity

Reliability


Validity

Reliability

Validity

Reliability


Validity

Reliability


c1 0 rnin

c l min

6 rnin

c2 0 rnin

c4 0 min

c10 min

2&3 0 min

10 min

"Other impairments such as perceptual and language dysfunction and depression should be screened and measured by other team members (psychol-ogists, speech pathologists, occupational therapists).

h~nstrumental-activities-of-daily-living nd quality-of-life measures are perform ed following hospital discharge in long-term follow-up.

In addition, the variables that moder- physical therapist is to observe the impairments can be remediated. If theate these relationships need to be patient's functional limitations and to impairments cannot be remediated,carefully considered. carefully assess the patient to deter- then the patient should be taught to

mine which impairments are contrib- compensate for the impairments.The movement deficits following uting to the functional limitations. Thestroke are extremely complex and physical therapist needs to adequately A primary question in all rehabilita-reflect the complexity of normal mo- diagnose the cause of the functional tion programs is: What constitutes ator control. One of the tasks for the limitations and to decide whether the clinically significant change in impair-

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ment? Many impairments may bemodified to some degree with aggres-sive programs, but ar e these changesin impairments clinically meaningful?Clinically meaningful changes in im-pairmen.ts are those associated withchanges in function. Therefore, theultimate goal in the rehabilitationprocess is to m odify function. Any

evaluation of the effectiveness of therehabilitation program should assessfunctional limitations and level ofdisability.

We all know patients who have simi-lar levels of impairment and similarfunctional abilities but quite differentlevels of disability. The quality of lifeof a pelson following a stroke is notdetermined solely by his or her physi-cal function but may be modified bymany oth er factors (eg, age, generalhealth state, psychosocial, personalmotivation, social suppo rt, and physi-cal envi.ronment). It is beyond thescope of physical therapy to alter o rcontrol all of these moderating vari-ables; however, we must considerthem in ou r plans to reduce the dis-ablement of stroke.

In order to better characterize stroke-

related disability, we should usepopulation-based studies to assess theextent of impairment, functional limi-tation, and disability in patients fol-lowing a stroke. Population-basedassessments of disability d o not sup-port the typically fatalistic attitude thatmost stroke survivors are profoundlydisabled and need long-term care.Many stroke survivors experiencesom e degree of neurological recov-ery; they are ambulatoly and nottotally depe nden t o r in nee d of long-term care.

Disability following stroke can beadequately characterized only if weuse measures across all the domainsof disa.blement (impairment, func-tional limitations , disability, and qual-ity of life). Impa irment-leve l measuresare important to define the factorsthat are contributing to functionallimitations and to guide treatment.Yet, the ultimate stroke outcom e mea-

sures are not at the impairment levelbut rather a re at the functional anddisability level. We ne ed to select o urmeasures of these domains carefully.

Finally, we nee d to use the m easuresobtained to reasonably predict ou t-comes, making allowance in o ur pre-dictions for the patient's own percep-

tions and the many variables outsidethe clinical sphere that may affect thepatient's recovery. Using predictedoutcom es to stage patients may resultin m ore effective treatment plans an da hopefully enhanced quality of lifefor the ever-increasing numb ers ofstroke survivors in the population weserve.

Acknowledgments

I thank Annette Jurgelski, MAT, foreditorial assistance andFikri Yucel forassistance in prep aring graphics.

References

1 1992 Stroke Facts. Dallas, Tew: AmericanHean Association; 1992.2 Garraway WM , Whisnant JP, Dmry I. Thechanging pattern of sunival following stroke.Stroke. 1983;14:699-703.

3 Soltero 1, Liu K, Cooper R, et al. Trends inmortality from cerebrovascular diseases in theUnited States, 1960 to 1975. Stroke. 1978;9:

549-558.4 Dombovy ML, Basford JR, Whisnant JP, Berg -stralh EJ. Disability and use of rehabilitationsen ices following stroke in Rochester, Minne-sota, 1975-1979. Stroke. 1987;18:83&836.5 Ahlsio B, Britton M, Murray V, Theore ll TDisablement and quality of life after stroke .Stroke. 1984;15:886-890.6 Kotila M, Waltimo 0 , Niemi M-L, et al. Theprofile of recovery from stroke and factorsinfluencing outcome. Stroke. 1984;15:1039-1044.7 Wade DT, Iangton-Hewer R. Functional abil-ities after stroke: measurement, natural history.and prognosis. J Neurol Ne u~ os ur g sychiatly.1987;50:177-182.

8 Kojima S, Omura T, Wakamatsu W, et al.Prognosis and disability of stroke patients after5 years in Akita, Japan. Stroke. 1990;21:72-77.

9 Christie D. Aftermath of stroke: an epidemi-ological study in Melbourne, Australia.

J Epiderniol Community Health. 1982;36: 23-126.10 Bonita R, Beaglehole R. Recovery of moto rfunction after stroke . Stroke. 1988;19:1497-1500.11 Gresham GE, Phillips TF, Wolf PA, et al.Epidemiologic profile of long-term stroke dis-ability: the Framingharn Study. Arch Phys MedRebabil 1979;60:487-491.

12 Wade DT, Wood VA, Helle r A, et al. Walk-ing after stroke: measurement and recoveryover the first three months. Scand J RehabilMed. 1987;19:25-30.13 Schuling J, Greidanus J, Meyboom-de JongB. Measuring functional status of st roke pa-tients with the Sickness Impact Profile. DisabilRehabil. 1993;15:19-23.

14 Viitanen M, Fugl-Meyer KS, Bernspang BFugl-Meyer AR. Life satisfaction in long-termsurvivors after stroke. Scan d J Rehabil Med.1988;20:17-24.15 Jette AM, Pinsky JL, Branch LG, et al. TheFramingham disability study: physical disabilityamong community-dwelling sun ivors ofstroke. J Clin Epidemiol. 1988;41:719-726.16 In te rnat iona l Classzfcation of Impair-ments, Disabilities, a n d Handicaps. Geneva,Switzerland: World Health Organization; 1980.17 Nagi SZ. Disabiliry a n d Rehabilitation. Co-lumbus, Ohio: Ohio State University Press;1969.18 Nagi S. Disability concepts revis ited: impli-cations for prevention. In: Pope AM, Traloveds . Disability in America: Toward a NationaAgenda for Prevention. Washington, DC: Na-tional Academy Press; 1991.

19 DeHaan R, Aaronson N, Limbun M, et al.Measuring quality of life in stroke. Stroke.1993;24:320-327.20 Jette AM. Using health-related quality of lifemeasures in physical therapy outcomes re-search. Phys Ther. 1993;73:52%537.21 Holbrook M, Skilbeck CE. An activities in-dex for use with stroke patients. 4ge Ageing.1983;12:166-170.22 Wade DT, Iang ton-Hewer R, Wood VA,et al. The hemiplegic arm after stroke: mea-surement and recovery. J Neurol NeurosurgPsychiatry. 1983;46:521-524,23 Wade DT, Wood VA, Iangt on-Hewer R Re-covery after stroke: the first three months.J Neurologv. 1985;48:7-13.24 Skilbeck CE, Wade DT, Iangton-Hewer R,Wood VA. Recovery after stroke. J Neurol Neu-rosurg Psychiatry. 1983;46:5-8.25 Duncan PW, Goldstein LB, Matchar D, et al.Measurement of motor recovery after stroke:outcome assessment and sample size require-ments. Stroke. 1992;23:1084-1089,26 Kinsella G, Ford B. Acute recovery patternsin stroke. Med J A W 1980;2:662-666.

27 Andrews K, Brocklehurst JC, Richards B,Iaycock PJ. The rate of recovery from strokeand its measurement. Inter nat ion al Rehabilita-tion Medicine. 1981;3:155-161.

2 8 Dombovy ML, Sandok B4 Basford JR. Re-habilitation for stroke: a review. Stroke. 1986;17:363-369.

29 Jongbloed L. Prediction of function afterstroke : a critical review. Stroke. 1986;17:765-776.30 Sandin KJ, Smith BS. The measure of bal-ance in sitting in stroke rehabilitation progno-sis. Stroke. 1990;21:82-86.31 Reding MJ, Potes E. Rehabilitation outcomefollowing initial unilateral hemispheric stroke:life table analysis approach. Stroke. 1988;19:U541358.32 Parikh RM , Robinson RG, Lipsey JR, et al.The impact of post-stroke depression on re-covery in activities of daily living over a two-year follow-up. Arch Neurol. 1990;47:785-789,

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33 Schuben DS, Taylor C, Lee S, et al. Physicalconsequences of depression in the stroke pa-tient. Gen Hosp P M i a t v 1992;14:69-76.34 Glass TA, Matchar DB, Belyea M, FeussnerJR. lmpact of social suppon on outcome infirst stroke. Stroke. 1993;24:6470.3 5 Brunns t rom S.Mot'ement Therapy inHemiplegia: A NeuropLysiological Approach.New York, NY: Harper & Row; 1970.3 6 G o w la n d CA. Staging motor impairmentafter stroke. Stroke. 199 0;2 1(s upp l IQ.1119-1121.37 Korner-Bitensky N, Mayo N, CabotR, et al.Motor and functional recovery after stroke:accuracy of physical therapists' predictions.Arch Pb s Med Rehabil. 1989;70:95-99.3 8 Kalra L. Crome P. The role of prognosticscores in targeting stroke rehabilitation in el-derly patients.]A m Geriatr Soc. 1993;41:396400.39 Tinetti ME, Ginter SF. Identifying mobilitydysfunctions in elderly patients.JAMA 1988;259.119G1193.

40 Wade DT. Measurement in NeurologicalRehabilitation. Oxford, England: Oxford Uni-versity Press; 1992.41 Folstein MF, Folstein SE, McHugh PR."Mini-mental state": a practical m ethod forgradin g the cognitive state of patients for th eclinician.J P.ychiatr Res. 1975;12:189-198.42 Fugl-Meyer AR, Jaasko L, Leyman I, et al.The post-stroke hem iplegic patient, I: amethod for evaluation of physical perfor-mance. Scand J Rehabil Med 1975;7:13-314 3 B e rg K, Wood -Dauphinee S, Williams JI,Gayton D. Measuring balance in the elderly:preliminary developm ent of an instrument.Physiotherapy Canada. 1989;41:30431144 Berg K, Wood -Dauphinee S, Williams J1,Maki B. Measuring balance in the elderly: vali-dation of an instrument. Can J Public Health.1992;2:S7-Sll.4 5 Butland RJA, Pang J, Gross ER, et al. Two-,six-, and twelve-minute walking test in respira-tory disease. Br Med J . 1982;284:16041608.

4 6 Mahoney F1, Banhel DW. Functional evalu-ation: the Ban hel Index. Md State Med J 1965;1 4 : 6 1 4 5 .47 Hamilton BB, Laughlin J& Granger CV,Kayton RM. Interrater agreement of the seven-level Functional Independence Measure (FIM).Arch PLys Med Rehabil 1991;72:790.4 8 Schuling J, de Haan R, Limburg M, Groe-nier KH . The Frenchay activities index: assess-men t of functional status in stro ke patients.Stroke. 1993;24:1173-1177.49 Bergner M, Bobbitt RA, C a n e r WB , GilsonBS. The Sickness lmpact Profile: developmentand revision of a health status measure.MedCare. 1981;19:275-289.50 Stewan A, Ware JE, eds. Measuring Func-tioning and Well-Being: The Medical Out-comes Study Approach. Durham , NC: DukeUniversity Press; 1992.

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1994; 74:399-407.PHYS THER.Pamela W DuncanStroke Disability

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Stroke Disability PHYS THER 1994 Duncan 399 407

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