Stroke recovery profile and the Modified Rankin assessment

BACKGROUND AND PURPOSE: The purpose of this study was to examine the relationship between the Modified Rankin Scale (MRS) and poststroke recovery in neurological deficits, activities of daily living (ADL), higher level of physical and social functioning and the patients' preference for health state. METHODS: Four hundred and fifty-nine participants in the Kansas City Stroke Study were prospectively assessed for measures of MRS, NIH Stroke Scale (NIHSS), Barthel ADL, SF-36 physical functioning, SF-36 social functioning, and Time Trade-Off (TTO). ANOVA and Bonferroni multiple comparisons were used to examine any differences in 3-month scores of NIHSS, Barthel ADL, SF-36 physical functioning, SF-36 social functioning and TTO between levels of the MRS. In addition, SF-36 physical functioning, SF-36 social functioning and TTO were characterized in patients who demonstrated improvement in global MRS outcome and also achieved a Barthel Index (BI) > or = 95 at 3 months after stroke. RESULTS: Two hundred and eighty patients (62%) shifted at least one grade in MRS from baseline to 3 months after stroke. Only 67 or 194 patients were considered to have a favorable outcome using MRS 0/1 or MRS 0/1/2, respectively, as criteria. Mean 3-month NIHSS and Barthel ADL scores were not significantly different between Rankin 0/1 and 2, but they were significantly different among Rankin 3, 4 and 5 (all p < 0.05). Mean 3-month scores of physical functioning and SF-36 social functioning were significantly different among Rankin 0/1, 2, 3 and 4 (all pairwise p < 0.05). Proportions of patients who achieved NIHSS < or = 1 or BI > or = 95 decreased as MRS grades worsened. In patients who showed improvement in MRS global outcome and also achieved BI > or = 95, mean scores on TTO were similar. CONCLUSIONS: Definition of favorable outcomes should include transition in the Modified Rankin score rather than MRS dichotomized as 0/1 or 0/1/2 because patients with transition in MRS scores have improvement in ADL, increased higher level of functioning and higher utility for health state.     

Relationship of Barthel Index and its Short Form with the Modified Rankin Scale in acute stroke patients

BackgroundModified Rankin Scale and Barthel Index are the most common scales for assessing stroke outcomes in clinical practice and trials. Concordance between the Barthel Index scores and the modified Rankin Scale grades is important to define favorable outcome in clinical practice and stroke trials consistently. The purpose of this study was to examine the relationship between the scores of Barthel Index and 3-item Barthel Index Short Form with the modified Rankin Scale grades of acute stroke patients.MethodsBarthel Index, Barthel Index Short Form scores and modified Rankin Scale grades of 516 stroke patients were obtained from a follow-up study of the Longshi Scale in China. A study showed that the assignment of modified Rankin Scale grades to stroke patients was prone to misclassification. Therefore, the recorded modified Rankin Scale grades were compared with the Barthel Index scores of each patient to produce the adjusted modified Rankin Scale grades. Receiver operating characteristics curve analyses were performed to determine the optimal cutoff scores, respective sensitivities and specificities of Barthel Index and Barthel Index Short Form with the corresponding adjusted modified Rankin Scale grades ≤1, ≤2 and ≤3.FindingsAbout 44% of the recorded modified Rankin Scale grades of patients required adjustment. The optimal cutoff scores were ≥100 (sensitivity 100%; specificity 95.3%), ≥100 (sensitivity 98.1%; specificity 100%) and ≥75 (sensitivity 93.8%; specificity, 91.9%) for the Barthel Index and ≥40 (sensitivity 100%; specificity 78.9%), ≥40 (sensitivity 98.1%; specificity 82.8%), and ≥35 (sensitivity 99.3%; specificity, 91.6%) for the Barthel Index Short Form corresponding to the adjusted modified Rankin Scale grade ≤1, ≤2, and ≤3 respectively. The areas under the receiver operating characteristic curves were nearly all above 0.9.ConclusionsThe optimal cutoff scores of Barthel Index and Barthel Index Short Form corresponding to the modified Rankin Scale grades ≤1, ≤2 and ≤3 were recommended to be ≥100 and ≥40, ≥100 and ≥40, and ≥75 and ≥35 respectively for determining the favorable and unfavorable outcome of stroke patients within three months of onset in clinical practice and trials.     

Assessment scales for the evaluation of stroke patients.

The approval of tissue plasminogen activator to treat acute ischemic stroke and the continuing need to evaluate new neuroprotective drugs and thrombolytic agents in clinical trials have focused interest on the quantitative evaluation of stroke patients. Emphasizing outcomes management in clinical practice has also heightened the importance of quantitative evaluation using assessment scales. Investigators who evaluate, revise, and use assessment scales for the measurement of stroke impairment, disabilites, and handicaps face many challenges. These problems include the heterogeneity of stroke and the need to determine appropriate outcome measures, to use neurological deficit scales that can accurately predict disability, to ensure adequate follow-up, and to use scales that can be used outside of clinical trials by all health care professionals. Such scales should be easily and quickly administered, responsive, valid, and reliable. The most important categories of stroke scales are neurological deficit scales (e.g., Canadian Neurological Scale, European Stroke Scale, and National Institutes of Health [NIH] Stroke Scale), functional outcome scales (e.g., Barthel Index), and global outcome scales (e.g., Modified Rankin Scale). Although stroke-specific, health-related quality-of-life (HRQL) scales have yet to be developed and validated, general HRQL scales such as the Nottingham Health Profile, the Medical Outcomes Study Short Form-36, the Sickness Impact Profile, and the Health Utilities Index may be used to assess stroke patients. Lacking the ideal single stroke outcome scale, we continue to recomend a combination of scales: the NIH Stroke Scale (or similar deficit scale), the Barthel Index, and the Rankin Scale.     

The impact of cardiac complications on outcome in the SAH population

OBJECTIVES: To determine the impact of cardiac complications (CdCs) on outcomes in patients with acute subarachnoid hemorrhage (SAH). PATIENTS AND METHODS: Eighty-one adult aneurysmal SAH patients with a fisher grade >1 and/or a Hunt and Hess grade >2 were recruited for this study. CdCs were defined as electrocardiogram (ECG) changes, myocardial necrosis, arrythmias, or pulmonary edema. Outcomes were assessed at 3, 6 and 12 months by telephone interview using the Modified Rankin Scale (MRS), Glasgow Outcome Scale (GOS), Barthel Index and Medical Outcome study Short Form-36 (SF-36). RESULTS: The CdCs occurred in 33% of patients. The most common CdCs were arrythmias and pulmonary edema (30%). There was no significant difference in mortality between the two groups. At 3 months there was a significant difference in the Barthel (P = 0.007) and the SF-36 (P = 0.014) with trends in the GOS (P = 0.049) and the MRS (P = 0.063). At 6 months a significant difference remained in the SF-36 (P = 0.028) and a trend in the Barthel (P = 0.069). CONCLUSION: Results show that CdCs may negatively impact outcomes in SAH patients up to 6 months following hemorrhage.     

The impact of pain on health-related quality of life 3 months after stroke

Abstract

Background:

Pain is common in stroke; however, its impacts on health-related quality of life (HRQoL) are unclear due to the limitations of previous studies.

Objectives:

The current study aims to examine and compare the demographic and clinical characteristics of Chinese stroke patients with and without pain and explore the correlations between poststroke pain and HRQoL.

Method:

Four hundreds and forty-one participants recruited in an acute stroke unit in a regional hospital. They were assessed 3 months after the index stroke with the following instruments. HRQoL was measured using the Short Form-12 (SF-12). The Chinese version of the Faces Pain Rating Scale-Revised (FPS-R) was used to determine the presence and intensity of pain. The demographic and clinical characteristics of patients were obtained using Barthel Index (BI), Fatigue Severity Scale (FSS), Geriatric Depression Scale (GDS), Anxiety subscale of the Hospital Anxiety and Depression Scale (HADSA), Instrumental Activities of Daily Living (IADL), Mini Mental State Examination (MMSE), Modified Rankin Scale (MRS), and National Institutes of Health Stroke Scale (NIHSS).

Results:

Of all participants screened, 167 reported pain and 69 had novel pain. The pain group had significantly lower physical component summary (PCS) scores after adjusting for sex, education, DSM-IV depression and BI, GDS, HADSA, and FSS scores. The FPS score was negatively correlated with a lower PCS score in patients with pain and with novel pain.

Conclusion:

The presence and intensity of pain have significant negative effects on HRQoL in stroke survivors. Interventions for pain could make a valuable contribution to improving HRQoL in stroke survivors.     

Spasticity and its association with functioning and health-related quality of life 18 months after stroke

BACKGROUND: There is no consensus concerning the presence of spasticity or the relationship between spasticity and functioning and spasticity and health-related quality of life (HRQL) in the stable phase after stroke. OBJECTIVE: The aim of the present study was to describe, 18 months after stroke, the frequency of spasticity and its association with functioning and HRQL. METHODS: In a cohort of 66 consecutive patients with first-ever stroke, studied prospectively, the following parameters were assessed 18 months after stroke: spasticity, by the Modified Ashworth Scale (0-4 points with 1+ as the modification), muscle stiffness, by self-report, abnormal tendon reflexes, by physical examination, motor performance, by the Lindmark Motor Assessment Scale, mobility, by the Rivermead Mobility Index, activities of daily living, by the Barthel Index, and HRQL, by the Swedish Short Form 36 Health Survey Questionnaire (SF-36). RESULTS: Of 66 patients studied, 38 were hemiparetic; of these, 13 displayed spasticity, 12 had increased tendon reflexes, and 7 reported muscle stiffness 18 months after stroke. Weak (r < 0.5) to moderate (r = 0.5-0.75) correlations were seen between spasticity and functioning scores. Correlations between spasticity and HRQL were generally weak (r < 0.5). Hemiparetic patients without spasticity had significantly better functioning scores and significantly better HRQL on 1 of the 8 SF-36 health scales (physical functioning) than patients with spasticity. CONCLUSIONS: Few patients displayed spasticity 18 months after stroke. Spasticity might contribute to impairment of movement function and to limitation of activity, but seems to have a less pronounced effect on HRQL.     

Functional outcome and quality of life after angiography and operation for unruptured intracranial aneurysms. On behalf of the MARS Study Group

OBJECTIVES: To assess outcome after elective treatment for unruptured intracranial aneurysms. METHODS: Of 193 consecutive patients with subarachnoid haemorrhage 626 first degree relatives (parents, siblings, children) were screened with magnetic resonance angiography. Subsequently, 18 relatives underwent elective angiography and operation. Outcome was assessed in terms of impairments (neurological examination), disabilities (Barthel index), handicaps (Rankin scale), and quality of life (sickness impact profile (SIP) and short form-36 (SF-36)) 3 months and 1 year after operation; it was compared with baseline measurements. RESULTS: Before angiography all patients had a normal neurological examination, optimal Barthel and Rankin scores, and a quality of life similar to that in a reference population. Three months postoperatively five patients (28%; 95% confidence interval (95% CI) 10-54%) had neurological impairments (one after angiography), two (11%; 95% CI 1-35%) had a decrease in Barthel index, and 15 (83%; 95% CI 59-96%) had suboptimal Rankin scores (none was dependent in daily living). Quality of life (SIP and SF-36) was reduced for most domains. After 1 year, five patients still had neurological impairments, all had an optimal Barthel index, and eight (47%; 95% CI 23-72%) had suboptimal Rankin scores. Quality of life returned to baseline levels for all SIP and most SF-36 domains. CONCLUSIONS: Treatment of unruptured aneurysms has a considerable short term negative impact on functional health and quality of life in most patients, despite the low rate of impairments. Outcome improves markedly but not completely within 1 year after operation.     

Impact of low mini-mental status on health outcome up to 5?years after stroke: the Erlangen Stroke Project

Cognitive deficits are frequent stroke sequelae. Data from population-based stroke cohorts on the impact of cognitive deficits on long-term outcome are scarce. The purpose of this study was to investigate the impact of low mini-mental status on health outcome up to 5 years after first-ever stroke. Data were collected from the Erlangen Stroke Project, a population-based stroke registry covering a source population of 103,000 inhabitants. The Mini-Mental State Examination (MMSE) was used to assess global cognitive function. Health outcome included limitations in instrumental activities of daily living (IADL, Frenchay Activities Index), low independence in activities of daily living (ADL, Barthel Index), depressive symptoms (Zung Self Rating Depression Scale), and institutionalization. Using multivariate logistic regression analysis, association of an education-adjusted MMSE score ≤ 24 with these health outcomes was investigated within distinct models at 12, 36, and 60 months after stroke as well as predictors at 3 months for low IADL. A total of 705 patients with first-ever stroke were included. Institutionalization, low levels of ADL and IADL (p < 0.001) are associated with a MMSE score ≤ 24 over 5 years after stroke. Predictors at 3 months for low IADL are low mini-mental status up to 3 years after stroke (OR 2.69, 95% CI 1.2-5.8) as well as older age (p < 0.001), and stroke severity (p < 0.001) up to 5 years. A low mini-mental status has an independent impact on long-term health outcome after stroke. Our results emphasize the importance of cognitive status screening to identify stroke survivors at risk and manage and treat these patients more efficiently.     

Measuring quality of life in a way that is meaningful to stroke patients

OBJECTIVE: To identify predictors of poststroke quality of life. BACKGROUND: Health-related quality of life (HRQOL) measures assess the impact of disease on the physical, emotional, and social aspects of patients' lives. Although HRQOL measures are used increasingly, factors associated with HRQOL poststroke and the ability of stroke-specific versus generic HRQOL measures to predict patient-reported HRQOL are not well known. METHODS: A total of 71 patients were evaluated 1 month postischemic stroke with a new stroke-specific HRQOL measure-the SS-QOL-and the SF-36, a generic HRQOL measure. Stroke severity, impairments, and functional limitations were also measured. Demographic variables and outcome measure scores were compared between patients rating their overall HRQOL the same as pre-stroke versus those with overall HRQOL worse than prestroke. Independent predictors of overall HRQOL were identified using multivariable modeling. RESULTS: Variables associated with better overall HRQOL were higher (better) SS-QOL and Barthel Index scores, and lower (better) NIH Stroke Scale and Beck Depression Inventory scores. Independent predictors of good overall HRQOL were the SS-QOL score (odds ratio [OR], 2.97; 95% CI, 1.3, 7.1; p = 0.01) and NIH Stroke Scale score (OR, 0.69; 95% CI, 0.47, 0.99; p = 0.05). Demographic factors and SF-36 scores were not associated with overall HRQOL ratings. CONCLUSIONS: Stroke-specific quality of life score and patient impairments predict patient-reported overall health-related quality of life (HRQOL) poststroke. SF-36 scores were not associated with overall HRQOL ratings. Disease-specific HRQOL measures are more sensitive to meaningful changes in poststroke HRQOL and may thus aid in identifying specific aspects of poststroke function that clinicians and "trialists" can target to improve patients' HRQOL after stroke.     

Effect of smoking status on outcome after acute ischemic stroke

BACKGROUND: The status of smoking as a risk factor for the occurrence of stroke is well established. However, there is a paucity of data on the relationship between smoking status and acute stroke outcomes. We evaluated the role of recent smoking as a prognostic factor following acute ischemic stroke. METHODS: We analyzed data from patients enrolled in the Intravenous Magnesium Efficacy in Stroke (IMAGES) trial. Outcome measures studied included change in IMAGES stroke score, poor functional outcomes at day 30 and 90 (defined as Rankin Scale >1 and Barthel Index <95), and survival over the first 3 months after stroke. The independent effect of smoking status (subjects who had smoked in the past year) on outcome was evaluated by logistic regression analysis and Cox's proportional hazards model, adjusting for variables known to predict outcome after ischemic stroke. RESULTS: There were 2,386 subjects in the IMAGES efficacy dataset, including 615 recent or current smokers and 1,771 nonsmokers, among whom smokers were younger (p < 0.0001). After adjusting for covariates, smokers had increased odds of poor 90-day functional outcome independently of other statistically significant predictor variables, as assessed by Rankin Scale (odds ratio 1.38; 95% confidence interval 1.09-1.75) and Barthel Index (odds ratio 1.42; 95% confidence interval 1.13-1.79) at day 90. Smoking status did not affect survival at day 90. CONCLUSIONS: Current or recent smokers experience poorer functional outcomes than nonsmokers 3 months after acute ischemic stroke.     

Stroke outcome in patients already taking aspirin

Background Although aspirin (ASA) has been shown to be effective for secondary (but not primary) stroke prevention and to have some beneficial influence on outcome when taken early after stroke onset, studies regarding the impact of prior use of ASA on stroke severity are conflicting. Objectives: To determine whether ASA therapy begun before stroke onset lessens the severity of stroke. Methods: Prospective clinical information was collected for all patients admitted with their first acute ischemic stroke between July 1996 and July 1998. National Institutes of Health Stroke Scale (NIHSS) scores were noted on admission and at discharge. Barthel Index (BI), Modified Rankin Scale (MRS), and Glasgow Outcome Scale (GOS) scores were also noted at discharge. Stroke severity was classified as severe if the NIHSS score was 9 or greater, BI score was 55 or less, the MRS score was 4 or greater, or the GOS score was 3 or greater. Group comparisons were performed by using the X(2) tests. Results: 178 patients were evaluated. Forty-two were taking ASA and 136 were not taking ASA or any other anti-thrombotic drug. There were no differences between the 2 groups in terms of age, gender, baseline hematocrit or blood glucose, history of hypertension, diabetes, atrial fibrillation, smoking, or stroke subtype. There were no significant differences between the 2 groups on any of the scales, either on admission or at discharge. Conclusion: Our data do not suggest that ASA use before stroke onset lessens the severity of first stroke. Until this question is definitively settled, however, it would be prudent to ensure balanced distribution of recent ASA use in acute stroke treatment trials.     

Barthel index in a Middle-East country: translation, validity and reliability

BACKGROUND: In Iran, a Middle-East country, no disability scale has been translated and validated for use in stroke clinical trials. This study was designed to translate the Barthel Index and make its Persian translated form valid and reliable. METHODS: All items of the Barthel Index were translated into Persian. Also, the Modified Rankin Scale (MRS) was also translated to Persian. Telephone interview was used as the method of data acquisition. Two interviewers were chosen for this means in order to accelerate data gathering and measure interrater agreement. Samples were selected from Isfahan Cardiovascular Research Center's Stroke Registry Unit, a WHO collaborating center in the center of Iran. All the patients were registered as stroke or intracerebral hemorrhage (ICH). These patients were inhabitants of Isfahan Province who had suffered from stroke or ICH between 12 and 24 months before data acquisition. Chronbach's alpha, test-retest reliability, concurrent validity with MRS, interrater agreement and item analysis were done for the translated questionnaire. RESULTS: Translated questionnaires were filled by interview from 459 stroke patients. Their mean age was 68.11 +/- 11.59 years. 243 of them were male (52.9%). Cronbach's alpha was 0.9354. Spearman's correlation coefficient between translated Barthel Index scores and MRS scores was -0.912. Spearman's correlation coefficient between 2 scores, to determine test-retest reliability was 0.989. Concordance correlation to determine interrater agreement was 0.994. All corrected item-total correlations were greater than 0.5. CONCLUSIONS: The Persian translated version of the Barthel Index is a reliable and valid questionnaire for use in stroke clinical trials.     

Assessment of scales of disability and handicap for stroke patients.

BACKGROUND AND PURPOSE: The purpose of the study is to compare the reliability of the Barthel activities of daily living score, which assesses disability, with the Rankin scale, which assesses handicap, and to determine their mutual agreement. METHODS: Fifty patients with stroke of varying severity were identified by a community-based stroke register and interviewed by two of three research nurses on two occasions that were 2-3 weeks apart. RESULTS: There was no evidence of a systematic difference between the first and second measurements. Repeatability was assessed using a kappa statistic with quadratic disagreement weights (kappa w) to take account of extreme differences. This measure was very good for both Barthel (kappa w = 0.98) and Rankin (kappa w = 0.95) scales. There was also excellent agreement between raters for the Barthel scale (kappa w greater than or equal to 0.88), but some indication of disagreement (kappa w = 0.75) between raters for the Rankin scale. Analysis of variance confirmed these findings. A conversion from the Barthel to the Rankin scale can be derived by assigning the most common Rankin score for the subjects with a given Barthel score, producing a kappa w of 0.91 for agreement. CONCLUSIONS: The Barthel scale is a more reliable and less subjective scale for assessing disability, from which a Rankin handicap score can then be derived to enable those managing stroke patients to assess aspects of handicap as well as disability.     

卒中单元护理模式对卒中后抑郁患者疗效的影响

目的 探讨卒中单元护理模式对卒中后抑郁患者的影响。方法 将52例卒中后抑郁患者,随机分为治疗组和对照组,对所有患者均进行常规护理和常规治疗,治疗组在此基础上加用卒中单元护理模式,对两组患者的神经功能和精神状态进行对照研究。结果 按照卒中单元护理模式进行护理干预的患者汉密尔顿抑郁量表（Hamilton Rating Scale forDepression,HRSD）评分、Barthel指数（Barthel index,BI）和神经功能改良Rankin量表（The ModifiedRankin Scales,mRS）评分较常规护理组得到明显改善（P <0.01）。结论 对卒中后抑郁的患者,早期实施卒中单元模式护理,是减轻患者的抑郁情绪、提高康复效果的有效护理方法。     

Stroke magnetic resonance imaging within 6 hours after onset of hyperacute cerebral ischemia

We studied the diagnostic and prognostic value of diffusion- and perfusion-weighted magnetic resonancce imaging (DWI and PWI) for the initial evaluation and follow-up monitoring of patients with stroke that had ensued less than 6 hours previously. Further, we examined the role of vessel patency or occlusion and subsequent recanalization or persistent occlusion for further clinical and morphological stroke progression so as to define categories of patients and facilitate treatment decisions. Fifty-one patients underwent stroke magnetic resonance imaging (DWI, PWI, magnetic resonance angiography, and T2-weighted imaging) within 3.3 +/- 1.29 hours, and, of those, 41 underwent follow-up magnetic resonance imaging on day 2 and 28 on day 5. In addition, we assessed clinical scores (on the National Institutes of Health Stroke Scale, Scandinavian Stroke Scale, Barthel Index, and Modified Rankin Scale) on days 1, 2, 5, 30, and 90 and performed volumetric analysis of lesion volumes. In all, 25 patients had a proximal, 18 a distal, and 8 no vessel occlusion. Furthermore, 15 of 43 patients exhibited recanalization on day 2. Vessel occlusion was associated with a PWI-DWI mismatch on the initial magnetic resonance imaging, vessel patency with a PWI-DWI match (p < 0.0001). Outcome scores and lesion volumes differed significantly between patients experiencing recanalization and those who did not (all p < 0.0001). Acute DWI and PWI lesion volumes correlated poorly with acute clinical scores and only modestly with outcome scores. We have concluded on the basis of this study that early recanalization saves tissue at risk of ischemic infarction and results in significantly smaller infarcts and a significantly better clinical outcome. Patients with proximal vessel occlusions have a larger amount of tissue at risk, a lower recanalization rate, and a worse outcome. Urgent recanalization seems to be of utmost importance for these patients.     

Activities of daily living performance in dementia

OBJECTIVE: To explore the activities of daily living ADL performance profile of community-living people with dementia and to investigate its relationship with dementia severity. MATERIALS & METHODS: ADL performance of 86 subjects were evaluated using Barthel Index (BI), Lawton and Brody's Instrumental Activities Daily Living (IADL) and Assessment of Motor and Process Skills (AMPS). Dementia severity was measured by Clinical Dementia Rating (CDR). RESULTS: Subjects were able to perform most basic ADL (BI mean = 16.4) and some IADL (Lawton and Brody's IADL mean = 4.3). The AMPS process ability measure and the Lawton and Brody's IADL were significantly correlated with CDR (P < 0.01). CONCLUSIONS: Subjects with mild dementia were able to perform mostly all basic ADL and some IADL. The AMPS process ability measure and the Lawton and Brody's IADL could provide useful information on their ability to live independently in the community.     

Predictive variables on disability and quality of life in stroke outpatients undergoing rehabilitation

Abstract The purposes of this study were: (1) to evaluate the relationship between disability and Quality of Life (QoL) in stroke outpatients undergoing rehabilitation and (2) to determine whether and how demographic and social features of the patient, duration of disease and concomitant diseases influence the disability and QoL of the stroke outpatients. We performed a prospective study using several conventional disability measurements (Barthel Index, Functional Independence Measure, Modified Rankin Scale and Deambulation Index) and a validated patient-oriented measurement of QoL (SF-36). Sixty-eight outpatients were evaluated consecutively. As expected, all disability measurements were related to Physical Function: patients with higher disability, according to the physician’s perspective, complained of higher deterioration of physical performance. Unexpectedly, patients with higher disability from the physician’s point of view perceive that they were not able to do some daily activities not only because of physical problems but also because of emotional problems, and complained of higher deterioration of mental health. Multivariate analysis showed that higher disability is associated with higher age, depression and lower educational level. Physical Composite Score appeared to be deteriorated in patients with lower educational level who lived with family; on the contrary, Mental Composite Score appeared deteriorated in patients with higher educational level who lived alone. The current study provides interesting data about the relationship, not always expected, between disability and QoL for stroke patients and about the influence of patients’ characteristics on disability and QoL. Our results showed that in a rehabilitation programme we should consider not only disability assessment but also QoL, which is more relevant for the patient.     

Timecourse of health-related quality of life as determined 3, 6 and 12 months after stroke. Relationship to neurological deficit,disability and depression

Objective: To study the timecourse of health-related global and domain-specific quality of life (QOL) in patients presenting with stroke or transient ischemic attacks (TIA) up to one year after the ischemic event. Variables were identified that may predict poststroke life satisfaction. Patients and Methods: In this prospective study, a cohort of 183 stroke/TIA patients was followed up at 3, 6, and 12 months. A total of 144 survivors completed the follow-up (65 women, 79 men, mean age 65.3 years). Health-related QOL was assessed by the Short Form 36 (SF-36) questionnaire, the neurological status by the European Stroke Scale (ESS). Disability was evaluated by using the Barthel index and the modified Swedish Stroke Registry Follow-up Form; depression was scored by the Montgomery-Asberg Depression Rating Scale (MADRS). Results: One year after stroke/TIA, 66 % of patients reported a worsening of life satisfaction compared with the prestroke level. The SF-36 physical component summary was reduced throughout the observation period. The SF-36 mental component summary deteriorated between the 6- and 12-months follow-up from 52.2 ± 7.1 to 50.6 ± 7.1 (p < 0.05). The SF-36 domains “physical functioning”, “social functioning” and the MADRS scores both showed a significant deterioration between 6 and 12 months poststroke (p < 0.05). In contrast, the neurological status and the degree of disability remained stable. Male sex, absence of diabetes, and normal MADRS scores at 3 and 6 months postinsult were identified as predictors of favorable QOL after 1 year (p < 0.05). Conclusions: Despite stable neurologic function and disability, global as well as domain-specific measures of QOL deteriorated over the 12-months observation period in a cohort of stroke survivors. Received: 18 September 2001, Received in revised form: 14 February 2002, Accepted: 20 February 2002     

There's no place like home : an evaluation of early supported discharge for stroke

BACKGROUND AND PURPOSE: Because stroke management is aimed at facilitating community reintegration, it would be logical that the sooner the patient can be discharged home, the sooner reintegration can commence. The purpose of this study was to determine the effectiveness of prompt discharge combined with home rehabilitation on function, community reintegration, and health-related quality of life during the first 3 months after stroke. METHODS: A randomized trial was carried out involving patients who required rehabilitation services and who had a caregiver at home. When medically ready for discharge, persons with stroke were randomized to either the home intervention group (n=58) or the usual care group (n=56). The home group received a 4-week, tailor-made home program of rehabilitation and nursing services; persons randomized to the usual care group received services provided through a variety of mechanisms, depending on institutional, care provider, and personal preference. The main outcome measure was the Physical Health component of the Measuring Outcomes Study Short-Form-36 (SF-36). Associated outcomes measures included the Timed Up & Go (TUG), Barthel Index (BI), the Older Americans Resource Scale for instrumental activities of daily living (OARS-IADL), Reintegration to Normal Living (RNL), and the SF-36 Mental Health component. RESULTS: The total length of stay for the home group was, on average, 10 days, 6 days shorter than that for the usual care group. There were no differences between the 2 groups on the BI or on the TUG at either 1 or 3 months after stroke; however, there was a significantly beneficial impact of the home intervention on IADL and reintegration (RNL). By 3 months after stroke, the home intervention group showed a significantly higher score on the SF-36 Physical Health component than the usual care group. The total number of services received by the home group was actually lower than that received by the usual care group. CONCLUSIONS: Prompt discharge combined with home rehabilitation appeared to translate motor and functional gains that occur through natural recovery and rehabilitation into a greater degree of higher-level function and satisfaction with community reintegration, and these in turn were translated into a better physical health.