Part 2Prognostic Indicators Post Stroke and

Outcome Measures

Michelle Collier, DPTApril 12, 2014

PART 2Prognostic Indicators Post Stroke and Outcome Measures• Objectives• Synthesize examination findings to determine an accurate PT prognosis• Choose and administer appropriate outcome tools in different practice

settings, including acute care, inpatient rehabilitation and outpatient rehabilitation• Explain the results of the outcome measures to the medical team and third

party payers

Prognosis to Determine OutcomesWhy does it matter?

• Stroke- Leading cause of Disability4

• Burden to the System 1

• Pressure from Insurance Companies• Guidance for Clinicians

Prognosis to Determine OutcomesFactors that Influence Prognosis 4, 5, 6

• Type of stroke• Gender/Age• Premorbid health, activity, function• Cognition• Urinary Incontinence• Psychosocial and Socioeconomic Factors

Prognosis to Determine OutcomesFactors Influencing Prognosis and Functional Outcomes18

AFTER ONE YEAR• Improvement neurologic deficits: motor and sensory• No improvement in autonomy and quality of life• Determinants to improvement: aphasia, hemianopia, incontinence

• QoL remained altered 1 year after hospital d/c

BOTTOM LINE- improved neurological deficits does not equate to improved function or quality of life. Functional improvement related to family support.

Prognosis to Determine OutcomesYoung Adult; Long Term Functional Outcome21

• After 10 years 1 of 8 young adults still dependent • Strongest predictor- severity of initial CVA• Poorer outcomes correlated with ≥ 1 CVA• Preventative Strategies*

Factors that Influence PrognosisUnilateral spatial neglect 7, 8

• Slower functional progress• Longer LOS• Increased risk of falls• Decreased likelihood of discharge to home

Overall Negative Outcomes

Factors that Influence PrognosisCognition 9

• Attention deficit (48.5%)*• Aphasia (27%)• STM deficit (24.5%)• Executive Dysfunction (18.5%)**• LTM deficit (13%)• Apraxia (8.5%)• Disorientation to Time (7%)• Hemi-Neglect (5.5%)

Factors that Influence PrognosisAmbulation 10, 11, 13

• Specific Prognostic Indicators • Sensory and motor impairments (↑ severity, ↓ prognosis)• Visuospatial Impairment (-)• Time (-)• Sit balance between 2nd-4th week post CVA (↑ severity, ↓ prognosis)• Standing balance (+) *

• Compensatory strategies and postural control important• 6 Minute Walk Test- best indicator for return to community

ambulation

Factors that Influence PrognosisFunctional use of the Upper Extremity 12, 13

• 1 month AROM measures → function at 3 months• Shoulder

• Early synergistic movements in the UE→ increased Action Research Arm Test (ARAT) score• Most important predictor for General UE recovery• Initial severity of motor impairment or function

• Most powerful predictor for regaining dexterity• Voluntary finger extension

Factors that Influence PrognosisSomatosensory Deficit and the Upper Extremity19

• Predictor of recovery and return of function• 2 point discrimination- predictor of dexterity• Proprioception- predictor for quality of functional movements• Light touch + proprioception- motor recovery, ADL’s, social roles• Important assessment: Nottingham Sensory Assessment• To provide appropriate interventions and goal setting

Factors that Influence PrognosisADL Independence 13

• Increased severity of hemiplegia (-)• Consciousness at admission, more alert (+)• Depression (-)• Older age, Increased severity of neurological deficits (-) *• Predicts outcomes at 3 months

Factors that Influence PrognosisFatigue Post Stroke20

• Prevalence in those 18-50 years old- 41%• No difference on location or duration from stroke onset

• Risk Factors• Anxiety, depression, recurrent CVA’s, female

• Negative effect on Functional Outcomes• Higher demands: work, young family, social roles

Factors that Influence PrognosisPredictors of Return to Driving After Stroke 14

• Functional Ability needed: • motor- turning wheel, step on pedal, signals, windshield wipers• visual-perceptual: reading signs, events in periphery, parking

between lines• cognitive: awareness of speed limit, route finding, merging and

switching lanes- planning and safety

Factors that Influence PrognosisPredictors of Return to Driving After Stroke 14

• Related to Driving Ability• Pre-stroke driving frequency• Post Stroke Barthel Index

• Return to Driving• 31% return to driving (inpatient setting)• Predicting Factors: FIM Cognition and Motricity Index LE (admission)

• Motricity Index UE/ARAT highly correlate with Motricity Index LE

• Car Modifications• Knowledge• Learning• Cost

Factors that Influence PrognosisReturn to Work 15, 16

• Negative Factors• nonwhite ethnicity, pre stroke part-time employment, depression

• Degree of limitations*• Job contextual factors• Admission to rehab- poorer outcomes with return to work• Return to home at 1 month (+)

About 50% return to work

Factors that Influence PrognosisActivity Limitation and Participation Restriction22

• A patient’s perception of recovery is poor• Activity limitation directly effects participation• Predictors: age and level of post stroke functional ability

• Objective and subjective measures not congruent• Benefit to measuring activity limitation AND participation restriction• Community Services for the elderly• more severely impacted group

Outcome MeasuresICF Model 1, 17

• Body Structure and Function• Motor Function• Sensation

• Activity• Gait and Balance• Arm function• Trunk Control• Posture• ADL/IADL

• Participation

• Resources• rehabmeasures.org• StrokEngine • Stroke Edge Task Force

Outcome Measures: Body Structure and FunctionICF Model 1

• Ashworth Test (Modified Ashworth Scale)• Chedoke McMaster Stroke

Assessment• Dynamometry• Fugl-Meyer Assessment of Motor

Performance• Fugl-Meyer Sensory Assessment• Motricity Index• NIH Stroke Scale• Nottingham Assessment of

Somatosensation• Orpington Prognostic Scale• Rate of Perceived Exertion• Rivermead Motor Assessment• Semmes Weinstein Monofilaments• Limb Movement Subscale of the

Stroke Rehabilitation Assessment of Movement• Tardieu Spasticity Scale (Modified

Tardieu)• VO2 Max

Ashworth Test (Modified Ashworth Scale)performance based. Recommended for all settings. • A tool to measure the degree of

spasticity 1, 3

• Influencing Factors: dystonia, contractures, joint stiffness3

• Velocity is not standardized 3

• Repeated measure decreases accuracy1

http://www.rehabmeasures.org/PDF%20Library/Modified%20Ashworth%20Scale%20Instructions.pdf

Fugl-Meyer Assessmentperformance based. Highly recommended for all settings: sensation, UE and LE motor 1

• Stroke specific. Evaluates recovery in a person with hemiplegia 2, 3

• Score 0 (cannot perform) to 2 (performs fully) 3

• Max score UE motor- 66, LE motor- 34

• Equipment: chair, bed, tennis ball, small spherical shaped container, reflex tool, adequate space with few distractions 3

http://www.neurophys.gu.se/digitalAssets/1332/1332679_fm-le-english.pdfhttp://www.neurophys.gu.se/digitalAssets/1328/1328946_fma-ue-english.pdf

Outcome Measures: ActivityICF Model 1

• 5 times sit to stand• 6 minute walk test• 9 hole peg test• 10 meter walk• Action Research Arm Test (ARAT)• Activities-Specific Balance Confidence Scale

(ABC)• Arm Motor Ability Test• Balance Evaluation Systems Test (BEST Test)• Berg Balance Scale• Box and Blocks Test• Brunnel Balance Test• Canadian Occupation Performance Measure• Chedoke Arm Hand Inventory• Dynamic Gait Index

• Functional Ambulation Categories• Functional Independence Measure• Functional Reach• HiMat• Jebsen Taylor Arm Function Test• Motor Activity Log• Postural Assessment Scale for Stroke Patients• Stroke Rehabilitation Assessment of Movement-

Mobility Subscale• Timed Up and Go• Tinetti Up and Go• Trunk Control Test• Trunk Impairment Scale• Wolf Motor Function Scale• Functional Gait Assessment3

5 Times Sit to Stand performance based. Recommended use in all settings 1

• Timed test 5 repetitions from chair 43cm high 1

• Designed for LE strength test 1,3

• Performance more related to balance1

• Need ability to rise from a chair no arm rests 1

• Cut-off- 12 seconds1, 3

• Mean Norms 3

• 50-59: 7.1(+/-)1.5• 60-69: 8.1(+/-)3.1• 70-79: 10.0(+/-)3.1• 80-89: 10.6(+/-)3.4 http://geriatrictoolkit.missouri.edu/

6 Minute Walk Test performance based. Highly recommended for use in all settings 1

• Ambulation distance measured over 6 minutes 3

• Assesses sub maximal aerobic capacity 3

• Measures gait velocity and endurance (various timed versions)1

• Limitations- no balance assessment or movement quality1

• Norms: 3

• 60-69 (M)572m (F)538m• 70-79 (M)527m (F)471m• 80-89 (M)417m (F)392m

http://www.cscc.unc.edu/spir/public/UNLICOMMSMWSixMinuteWalkTestFormQxQ08252011.pdf

10 Meter Walk Testperformance based. Highly recommended for use in all settings 1

• Assesses walking speed in meters per second over a short distance 3

• 6, 8, 10, 12 meters in length

• Considerations3

• Assistive devices can be used• Not appropriate if assist needed• Can be performed at preferred speed and fast walking speed

• Repeated 3 times3

• Cut-Off Scores: ambulation ability correlated with gait speed3

• < 0.4 m/s household ambulator• 0.4-0.8 m/s limited community ambulator• > 0.8 m/s community ambulator

Berg Balance Scaleperformance based. Highly recommended in most settings (except acute) 1

• Used to assess balance in older adults2

• For stroke 45 is the cut-off3

• Limitations• Time to administer 15-20 minutes3

• Poor ceiling effect; Poor floor effects 14 days post CVA3

http://www.fallpreventiontaskforce.org/pdf/BergBalanceScale.pdf

Timed Up and Goperformance based. Highly recommended in all settings. 1

• A test of mobility, balance and locomotor performance1

• Unable to perform without assist but can use a device1,3

• Instructions: stand from a chair, walk 3 meters as quickly and safely as possible, cross a line on the floor, turn around, walk back and sit down3

• Standard height chair with arm rests, not against a wall. 3 meters1

• Cut-Off scores3 TUG cognitive ≥ 15 seconds- fallers• Normative Data3 mean time TUG 8.39 seconds

Functional Gait Assessmentperformance based. Highly recommended in all settings. 1

• Modification from DGI• Looks at postural stability with

ambulation tasks• 10 items• Scores• 0-severe impairment• 1-moderate impairment• 2- mild impairment• 3- normal ambulation

FGA is found in the original article:http://physicaltherapyjournal.com/content/84/10/906.full.pdf

Outcome Measures: ParticipationICF Model 1

• Assessment of Life Habits• EuroQOL• Falls Efficacy Scale• Goal Attainment Scale• Modified Fatigue Impact Scale• Modified Rankin Scale• Reintegration to Normal Living

• Satisfaction with Life Scale• Stroke-Adapted Sickness

Impact Scale-30• SF-36• Stroke Impact Scale • Stroke-Specific Quality of Life

Scale

Falls Efficacy Scaleself report. Studies found only for inpatient rehab Swedish Version (additional questions stroke specific) 1

• Assesses confidence, balance, perception with daily activities 1

• Visual Analog Scale3

• 1- very confident• 10- not confident at all• Score: 10 (+) to 100 (-)• >80 falls risk, >70 fear of fall

• Those with aphasia may have difficulty1

Original: http://www.rehabmeasures.org/PDF%20Library/Falls%20Efficacy%20Scale.pdf Swedish Version: http://www.biomedcentral.com/content/supplementary/1743-0003-6-13-s1.pdf

Stroke Impact Scale self report. Highly Recommended for SNF, home health and outpatient only if patient has been in the community post stroke 1

• Assessment of health status post stroke3

• Scoring 1-5: (1)could not do → (5)not difficult at all• Items of home living can be omitted- use as a percentage1,3

• Simple training, cost is free to non profit users3

• www.mapi-trust.org or www.kumc.edu

http://www.northeastrehab.com/Forms/NRH_Forms/SIS_Handout.pdf

Summary• Predictors of Poor Outcomes: comorbidities, dependence,

incontinence, support system, gender, age.• Predictors of Return to Ambulation: Stand balance and 6MWT• Predictors of Return of UE function: 1 month AROM (shoulder), finger

extension• Capture the full patient profile when choosing outcome measures• body function/structure• activity• participation

Questions

A Special Thank You• Phil Blatt PT, PhD, NCS• Laura Krych PT, MPT, NCS• Sarah Grusemeyer PT, MPT, NCS• Julie Mount PT, PhD• Neera Prabhakar PT, DPT, NCS

References1. StrokEDGE Taskforce.

http://www.neuropt.org/docs/stroke-sig/strokeedge_taskforce_summary_document.pdf?sfvrsn=2. Accessed March 23, 2015.

2. Strokengine.ca. http://strokengine.ca. Accessed January 9, 2014.3. RehabMeasures.org. http://www.rehabmeasures.org/default.aspx. Accessed March 23, 2015.4. Wei JW, Heeley EL, Wang J, Huang Y, Wong LKS, Li Z, Heritier S, Arima H, Anderson C S. Comparison Of Recovery

Patterns and Prognostic Indicators for Ischemic and Hemorrhagic Stroke in China: The ChinaQUEST (Quality Evaluation of Stroke Care and Treatment) Registry Study. Stroke. 2010; 41(9): 1877-83. Tan, W.S.,

5. Tan, W.S., Heng, B.H., Chua, K.S., Chan, K.F. Factors Predicting Inpatient Rehabilitation Length of Stay of Acute Stroke Patients in Singapore. Arch Phys Med Rehabil. 2009; 90(7):1202-7.

6. Hakkenned SJ, Brock K, Hill KD. Selection for Inpatient Rehabilitation After Acute Stroke: A Systematic Review of the Literature. Arch Phys Med Rehabil. 2011; 92(12):2057-70.

7. Di Monaco M, Schintu S, Dotta M, Barba S, Tappero R, Gindri P. Severity of Unilateral Spatial Neglect Is an Independent Predictor of functional Outcome After Acute Inpatient rehabilitation in Individuals with Right Hemisphere Stroke. Arch Phys Med Rehabil. 2011; 92(8):1250-6.

8. Bernardo G, Cristina F. Functional Outcome after Stroke in Patients with Aphasia and Neglect: Assessment by the Motor and Cognitive Functional Independence Measure Instrument. Cerebrovasc Dis. 2010; 30(5):440-7.

References9. Leśniak M, Bak T, Czepiel W, Seniów J, Członkowska A. Frequency and Prognostic Value of Cognitive Disorders in

Stroke Patients. Dement Geriatr Cogn Disord. 2008; 26(4):356-63. 10. Kollen B, van de Port I, Lindeman E, Twisk J, Kwakkel G. Predicting Improvement in Gait After Stroke: A Longitudinal

Prospective Study. Stroke. 2005 Dec; 36(12):2676-80.11. Fulk GD, Reynolds C, Mondal S, Deutsch JE. Predicting Home and Community Walking Activity in People With Stroke.

Arch Phys Med Rehabil. 2010 Oct; 91(10):1582-6. 12. Beebe JA, Lang CE. Active Range of Motion Predicts Upper Extremity Function 3 Months After Stroke. Stroke. 2009

May; 40(5):1772-9.13. Kwakkel G, Kollen BJ. Predicting Activities After Stroke: What is Clinically Relevant? Int J Stroke. 2013 Jan; 8(1):25-32. 14. The Aufman EL, Bland MD, Barco PP, Carr DB, Lang CE. Predictors of Return to Driving After Stroke. Am J Phys Med

Rehabil. 2013 Jul; 92(7):627-34.15. Glozier N, Hackett ML, Parag V, Anderson CS. Influence of Psychiatric morbidity on Return to Paid Work After Stroke

in Younger Adults. Stroke. 2008 May; 39(5):1526-32.16. Wozniak MA, Kittner SJ. Return to Work After Ischemic Stroke: A Methological Review (abstract).

Neuroepidemiology. 2002 Jul-Aug; 21(4):159-66.17. ICF Model. http://www.who.int/classifications/icf/en/. Accessed on March 24, 2014

References18. Galanth S, Tressieres B, Lannuzel A, Foucan P, Alecu C. Factors

Influencing Prognosis and Functional Outcome One Year After a First Time Stroke in a Caribbean Population. Arch Phys Med Rehabil. 2014 Nov; 95 (11): 2134-9