Predicting the functional outcome of intensive inpatient rehabilitation after stroke: results from the RIPS Study.

BACKGROUND: The complexity of stroke sequelae, the heterogeneity of outcome measures and rehabilitation pathways, and the lack of extensively validated prediction models represent a challenge in predicting stroke rehabilitation outcomes. AIM: To prospectively investigate a multidimensional set of variables collected at admission to inpatient post-stroke rehabilitation as potential predictors of the functional level at discharge. DESIGN: Multicentric prospective observational study. SETTING: Patients were enrolled in four Intensive Rehabilitation Units (IRUs). POPULATION: Patients were consecutively recruited in the period December 2019-December 2020 with the following inclusion criteria: aged 18+, with ischemic/haemorrhagic stroke, and undergoing inpatient rehabilitation within 30 days from stroke. METHODS: This is a multicentric prospective observational study. The rehabilitation pathway was reproducible and evidence-based. The functional outcome was disability in activities of daily living, measured by the modified Barthel Index (mBI) at discharge. Potential multidimensional predictors, assessed at admission, included demographics, event description, clinical assessment, functional and cognitive profile, and psycho-social domains. The variables statistically associated with the outcome in the univariate analysis were fed into a multivariable model using multiple linear regression. RESULTS: A total of 220 patients were included (median [IQR] age: 80 [15], 112 women, 175 ischemic). Median mBI was 26 (43) at admission and 62.5 (52) at discharge. In the multivariable analysis younger age, along with better functioning, fewer comorbidities, higher cognitive abilities, reduced stroke severity, and higher motor functions at admission, remained independently associated with higher discharge mBI. The final model allowed a reliable prediction of discharge functional outcome (adjusted R2=77.2%). CONCLUSIONS: The model presented in this study, based on easily collectable, reliable admission variables, could help clinicians and researchers to predict the discharge scores of the global functional outcome for persons enrolled in an evidence-based inpatient stroke rehabilitation program. CLINICAL REHABILITATION IMPACT: A reliable outcome prediction derived from standardized assessment measures and validated treatment protocols could guide clinicians in the management of patients in the subacute phase of stroke and help improve the planning of the rehabilitation individualized project.

Correlates of participation six months after stroke in an Italian population: results from the RIPS (Post-Stroke Intensive Rehabilitation) Study.

BACKGROUND: Stroke survivors report physical, cognitive, and psychological impairments, with a consequent limitation of participation. Participation is the most context-related dimension of functioning, but the literature on participation in Italian stroke patients is scant. AIM: This study aimed to describe the recovery of participation six months after stroke with a validated Italian version of the Frenchay Activity Index (FAI) and to investigate potential correlates with higher participation scores. DESIGN: The study is a prospective observational study. SETTING: The cohort of patients was enrolled in four intensive inpatient rehabilitation units of IRCCS Fondazione Don Carlo Gnocchi Onlus, Florence, Italy. POPULATION: Adults addressing postacute intensive inpatient rehabilitation after an ischemic or hemorrhagic stroke occurred within 30 days from recruitment were prospectively enrolled. METHODS: Data were collected at admission to intensive inpatient rehabilitation, and a six-month follow-up. The primary outcome was participation, measured by a validated Italian version of the FAI; only patients whose data included both anamnestic FAI and FAI at six months follow-up were included in this analysis. The data were analyzed by univariate and multivariate linear regressions. RESULTS: A cohort of 105 patients (median age 78 years [interquartile range, IQR=21]; 46.7% males) with completed FAI at follow-up were included in this study. The sample reported a FAI median score of 28 (IQR=8) at admission (referred to the participation in the 3-6 months before the stroke) and 13 (IQR=20) at follow-up. All items were significantly affected, with the exception of reading and making trips. The multivariate regression for all patients with good participation before the stroke (N.=101), showed that 6 months after the stroke a higher FAI Score was independently associated with better functioning in activities of daily living (modified Barthel Index) (B=0.133; P=0.015), and absence of cognitive impairment (B=4.755; P=0.027); a lower stroke severity in the postacute phase (NIHSS B=-0.832; P=0.001) and a higher prestroke FAI Score (B=0.410; P=0.028) were also independently related to follow-up FAI Score. CONCLUSIONS: In our cohort of patients addressing postacute stroke rehabilitation, prestroke participation levels were on average good, while they were severely reduced six months after stroke for all the considered items except reading and making trips. Higher FAI at follow-up was independently associated with a higher functional level and no cognitive impairment at follow-up, with lower stroke severity in the postacute phase, as well as a higher anamnestic participation score. CLINICAL REHABILITATION IMPACT: Our results suggest that investigating prestroke participation may be highly relevant to predict, and possibly address, participation recovery after stroke.

Factors influencing trunk control recovery after intensive rehabilitation in post-stroke patients: a multicentre prospective study.

BACKGROUND: Trunk control plays a crucial role in the stroke rehabilitation, but it is unclear which factors could influence the trunk control after an intensive rehabilitation treatment. OBJECTIVES: To study which demographic, clinical and functional variables could predict the recovery of trunk control after intensive post-stroke inpatient rehabilitation. METHODS: Subjects with acute, first-ever stroke were enrolled and clinical and data were collected at admission and discharge. The primary outcome was considered the trunk control measured by the Trunk Control Test (TCT). The data were analyzed by a univariate and multivariate logistic regressions. RESULTS: Two hundred forty-one post-stroke patients were included. All baseline variables significantly associated to TCT at discharge in the univariate analysis (i.e. gender, NIHSS neglect item at admission, presence of several complexity markers, TCT total score at admission, NIHSS total score, pre-stroke modified Rankin Scale, Fugl-Meyer Assessment motor and sensitivity score) were entered in the multivariate analysis. The multivariate regression showed that age (p = .003), admission NIHSS total score (p = .001), admission TCT total score (p < .001) and presence of depression (p = .027) independently influenced the TCT total score at discharge (R2 = 61.2%). CONCLUSIONS: Age, admission neurological impairment (NIHSS total score), trunk control at the admission (TCT total score), and presence of depression independently influenced the TCT at discharge. These factors should be carefully assessed at the baseline to plan a tailoring rehabilitation treatment achieving the best trunk control performance at discharge.

Design and implementation of a Stroke Rehabilitation Registry for the systematic assessment of processes and outcomes and the development of data-driven prediction models: The STRATEGY study protocol.

Background: Stroke represents the second preventable cause of death after cardiovascular disease and the third global cause of disability. In countries where national registries of the clinical quality of stroke care have been established, the publication and sharing of the collected data have led to an improvement in the quality of care and survival of patients. However, information on rehabilitation processes and outcomes is often lacking, and predictors of functional outcomes remain poorly explored. This paper describes a multicenter study protocol to implement a Stroke rehabilitation Registry, mainly based on a multidimensional assessment proposed by the Italian Society of Physical and Rehabilitation Medicine (PMIC2020), in a pilot Italian cohort of stroke survivors undergoing post-acute inpatient rehabilitation, to provide a systematic assessment of processes and outcomes and develop data-driven prediction models of functional outcomes. Methods: All patients with a diagnosis of ischemic or haemorrhagic stroke confirmed by clinical assessment, admitted to intensive rehabilitation units within 30 days from the acute event, aged 18+, and providing informed consent will be enrolled. Measures will be taken at admission (T0), at discharge (T1), and at follow-up, 3 months (T2) and 6 months (T3) after the stroke. Assessment variables include anamnestic data, clinical and nursing complexity information and measures of body structures and function, activity and participation (PMIC2020), rehabilitation interventions, adverse events and discharge data. The modified Barthel Index will be our primary outcome. In addition to classical biostatistical analysis, learning algorithms will be cross-validated to achieve data-driven prognosis prediction models. Conclusions: This study will test the feasibility of a stroke rehabilitation registry in the Italian health context and provide a systematic assessment of processes and outcomes for quality assessment and benchmarking. By the development of data-driven prediction models in stroke rehabilitation, this study will pave the way for the development of decision support tools for patient-oriented therapy planning and rehabilitation outcomes maximization. Clinical tial registration: The registration on ClinicalTrials.gov is ongoing and under review. The identification number will be provided when the review process will be completed.