Body function and activity after acute stroke : physiotherapy perspectives

Abstract

The overall aim of the thesis was to describe body function and activity from a physiotherapy perspective in patients with stroke. Further aim was to look for feasible prognostic instruments for the length of stay in hospital or nursing home so as to facilitate planning of the subsequent level of care after acute stroke in patients 65 years and older.

The thesis is based on the assessments of the patients in 3 study populations presented in 5 papers.

I. We assessed 115 patients 65 years and older 10 days after stroke and at discharge for language, somatosensory and urination function; mobility: Rivermead Mobility Index (RMI); and activities of daily living (ADL): Barthel Index (BI) to find feasible prognostic instruments for the institutional length of stay (LOS), so as to facilitate planning of the subsequent level of care. Study population 1.

II. We assessed 115 patients 65 years and older 10 days after stroke and at discharge to investigate the relationship between clinically assessed somatosensory function, to activity (RMI and BI), and to the LOS. Study population 1.

III. We analysed those 100 patients, 65 years and older, still in hospital 10 days after stroke, at days 5 and 10 after stroke for consciousness, mental, perceptive, language, somatosensory and urination function; mobility; and ADL so as to describe and to compare functioning between days 5 and 10 after stroke. Study population 2.

IV. We assessed 115 patients 65 years and older, at day 5, and if still in hospital also at day 10 (n= 100) after stroke for consciousness (Glasgow Coma Scale [GCS]), mental, emotional, perceptive, language, somatosensory and urination function; mobility; and ADL to find feasible prognostic instruments for the LOS, so as to facilitate planning of the subsequent level of care. Study population 2.

V. We assessed 95 patients initially (when diagnosed to have a stroke) and 3 months after stroke so as to analyse and describe the extent to which spasticity occurs and is associated with disabilities (movement-related impairments and activity limitations). Study population 3.

Results: According to multiple survival analyses the best positive predictors of LOS, i.e. a short LOS, registered 10 days after stroke, were RMI >4 points corresponding to the ability to raise from a chair in less than 15 seconds and stand there for 15 seconds with or without aid; BI >35 points; normal somatosensory function; urinary continence; and living with another person (paper 1).

Normal or almost normal somatosensory function was related to high activity level and short LOS. Impaired somatosensory function was not that closely related to low activity levels and long LOS (paper II).

Only consciousness and urination functions; mobility; and ADL were assessable in all patients. Small, but systematic changes (p<0.05) were seen between days 5 and 10 after stroke for most functions and activities. Of all 875 assessments registered 5 days after stroke, 72% remained unchanged by day 10, while 24% improved and 4% deteriorated (paper 111).

The best positive predictors of LOS at day 10 after stroke were BI >35 points and no previous stroke. The best positive predictors of LOS at day 5 after stroke were GCS >13 points, corresponding to mild brain injury; RMI >4 points; and no previous stroke (paper IV).

Spasticity was present in 19% of the patients investigated 3 months after stroke. Among the patients with severe disabilities we saw almost the same number of non-spastic as spastic patients (paper V).

Conclusions: Small changes in functioning were seen between days 5 and 10 after stroke. Preferable outcome measures are at the activity level, though mental functions always have to be considered. Beside medical appraisal the "RMI >4" could be useful when deciding the subsequent level of care 5 days after acute stroke. Only a very small number of spastic patients were seen, suggesting that the focus on spasticity in stroke rehabilitation is out of step with its clinical importance. Further studies in this field are needed.