Characteristics of subacute stroke patients who achieve earlier independence in real-life walking performance during hospitalization
DOI:
https://doi.org/10.2340/jrm.v57.41993Keywords:
cerebrovascular disorders, hemiplegia, inpatient, walkingAbstract
Objective: To identify factors associated with earlier independence in “real-life walking” during hospitalization in subacute stroke patients.
Design: Retrospective cohort study.
Subjects/Patients: Two hundred and six hemiplegic patients.
Methods: Functional Independence Measure (FIM) walking items were measured biweekly from admission to discharge. Patients were grouped by achieving independent “real-life walking” (FIM-walking score ≥6). Time to independence, stratified by age, FIM motor score (FIM-M), FIM cognitive score (FIM-C), and Functional Ambulation Categories (FAC) scores were compared using Kaplan–
Meier plots and log-rank tests. Hazard ratios were calculated via multivariable Cox proportional hazard models.
Results: The median time to independence was 4 weeks, with significant differences (p < 0.05) by age, FIM-M, FIM-C, and FAC stratification. Age ≤64 years (hazard ratio 1.92, 95% confidence interval 1.21–3.06), FIM-C ≥25 (hazard ratio 2.42, 95% confidence interval 1.52–3.86), and FAC ≥3 (hazard ratio 1.98, 95% confidence interval 1.22–3.21) significantly affected earlier walking independence (all p < 0.01). Impeding factors were FIM-M ≤38 (hazard ratio 0.23, 95% confidence interval 0.13–0.40; p < 0.01) and FAC = 0 (hazard ratio 0.184, 95% confidence interval 0.06–0.62; p < 0.01).
Conclusion: Early improvement in “real-life walking” was associated with younger age, greater cognitive function, and greater “test-setting walking” ability on admission. Low activities of daily living independence and “test-setting walking” ability hindered early progress.
Downloads
References
Faria-Fortini I, Polese JC, Faria CDCM, Teixeira-Salmela LF. Associations between walking speed and participation, according to walking status in individuals with chronic stroke. NeuroRehabilitation 2019; 45: 341-348.
https://doi.org/10.3233/NRE-192805 DOI: https://doi.org/10.3233/NRE-192805
Smith MC, Barber PA, Stinear CM. The TWIST algorithm predicts time to walking independently after stroke. Neurorehabil Neural Repair 2017; 31: 955-964.
https://doi.org/10.1177/1545968317736820 DOI: https://doi.org/10.1177/1545968317736820
Aaslund MK, Moe-Nilssen R, Gjelsvik BB, Bogen B, Næss H, Hofstad H, et al. A longitudinal study investigating how stroke severity, disability, and physical function the first week post-stroke are associated with walking speed six months post-stroke. Physiother Theor Pract 2017; 33: 932-942.
https://doi.org/10.1080/09593985.2017.1360424 DOI: https://doi.org/10.1080/09593985.2017.1360424
Park J, Lee SU, Jung SH. Prediction of post-stroke functional mobility from the initial assessment of cognitive function. NeuroRehabilitation 2017; 41: 169-177.
https://doi.org/10.3233/NRE-171469 DOI: https://doi.org/10.3233/NRE-171469
Paolucci S, Bragoni M, Coiro P, De Angelis D, Fusco FR, Morelli D, et al. Quantification of the probability of reaching mobility independence at discharge from a rehabilitation hospital in nonwalking early ischemic stroke patients: a multivariate study. Cerebrovasc Dis 2008; 26: 16-22.
https://doi.org/10.1159/000135648 DOI: https://doi.org/10.1159/000135648
Kennedy C, Bernhardt J, Churilov L, Collier JM, Ellery F, Rethnam V, et al. Factors associated with time to independent walking recovery post-stroke. J Neurol Neurosurg Psychiatry 2021; 92: 702-708.
https://doi.org/10.1136/jnnp-2020-325125 DOI: https://doi.org/10.1136/jnnp-2020-325125
Holden MK, Gill KM, Magliozzi MR, Nathan J, Piehl-Baker L. Clinical gait assessment in the neurologically impaired. Reliability and meaningfulness. Phys Ther 1984; 64: 35-40.
https://doi.org/10.1093/ptj/64.1.35 DOI: https://doi.org/10.1093/ptj/64.1.35
Collen FM, Wade DT, Bradshaw CM. Mobility after stroke: reliability of measures of impairment and disability. Int Disabil Stud 1990; 12: 6-9.
https://doi.org/10.3109/03790799009166594 DOI: https://doi.org/10.3109/03790799009166594
Moore SA, Boyne P, Fulk G, Verheyden G, Fini NA. Walk the talk: current evidence for walking recovery after stroke, future pathways and a mission for research and clinical practice. Stroke 2022; 53: 3494-3505.
https://doi.org/10.1161/STROKEAHA.122.038956 DOI: https://doi.org/10.1161/STROKEAHA.122.038956
Data management service of the Uniform Data System for Medical Rehabilitation and the Center for Functional Assessment Research: guide for use of the uniform data set for medical rehabilitation (ver.3.0). New York: State University of New York at Buffalo; 1990.
Makizako H, Kabe N, Takano A, Isobe K. Use of the Berg Balance Scale to predict independent gait after stroke: a study of an inpatient population in Japan. PM R 2015; 7: 392-399.
https://doi.org/10.1016/j.pmrj.2015.01.009 DOI: https://doi.org/10.1016/j.pmrj.2015.01.009
Blum L, Korner-Bitensky N. Usefulness of the Berg Balance Scale in stroke rehabilitation: A systematic review. Phys Ther 2008; 88: 559-566.
https://doi.org/10.2522/ptj.20070205 DOI: https://doi.org/10.2522/ptj.20070205
Ishiwatari M, Tani M, Isayama R, Honaga K, Hayakawa M, Takakura T, et al. Prediction of gait independence using the Trunk Impairment Scale in patients with acute stroke. Ther Adv Neurol Disord 2022; 15: 17562864221140180.
https://doi.org/10.1177/17562864221140180 DOI: https://doi.org/10.1177/17562864221140180
Meyer MJ, Pereira S, McClure A, Teasell R, Thind A, Koval J, et al. Systematic review of studies reporting multivariable models to predict functional outcomes after post-stroke inpatient rehabilitation. Disabil Rehabil 2015; 37: 1316–1323. https://doi.org/10.3109/09638288.2014.963706 DOI: https://doi.org/10.3109/09638288.2014.963706
Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG, Biller J, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke 1989; 20: 864–870. https://doi.org/10.1161/01.STR.20.7.864 DOI: https://doi.org/10.1161/01.STR.20.7.864
Chevalley O, Truijen S, Opsommer E, Saeys W. Physical functioning factors predicting a return home after stroke rehabilitation: A systematic review and meta-analysis. Clin Rehabil 2023; 37: 1698-1716.
https://doi.org/10.1177/02692155231185446 DOI: https://doi.org/10.1177/02692155231185446
Sonoda S, Saitoh E, Nagai S, Kawakita M, Kanada Y. Full-time integrated treatment program, a new system for stroke rehabilitation in Japan: comparison with conventional rehabilitation. Am J Phys Med Rehabil 2004; 83: 88-93.
https://doi.org/10.1097/01.PHM.0000107481.69424.E1 DOI: https://doi.org/10.1097/01.PHM.0000107481.69424.E1
Chino N, Sonoda S, Domen K, Saitoh E, Kimura A. Stroke impairment assessment set(SIAS): a new evaluation instrument for stroke patients. Jpn J Rehabil Med 1994; 31: 119-125.
https://doi.org/10.2490/jjrm1963.31.119 DOI: https://doi.org/10.2490/jjrm1963.31.119
Ottenbacher KJ, Hsu Y, Granger CV, Fiedler RC. The reliability of the functional independence measure: a quantitative review. Arch Phys Med Rehabil 1996; 77: 1226-1232.
https://doi.org/10.1016/S0003-9993(96)90184-7 DOI: https://doi.org/10.1016/S0003-9993(96)90184-7
Petrilli S, Durufle A, Nicolas B, Pinel JF, Kerdoncuff V, Gallien P. Prognostic factors in the recovery of the ability to walk after stroke. J Stroke Cerebrovasc Dis 2002; 11: 330-335.
https://doi.org/10.1053/jscd.2002.130124 DOI: https://doi.org/10.1053/jscd.2002.130124
Itoh S, Ogino T, Kawakami K, Miyake K, Iyoda H, Imaizumi H, et al. Gait evaluation in stroke hemiplegic patients using short physical performance battery. J Stroke Cerebrovasc Dis 2022; 31: 106704.
https://doi.org/10.1016/j.jstrokecerebrovasdis.2022.106704 DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2022.106704
Imada Y, Tokunaga M, Fukunaga K, Sannomiya K, Inoue R, Hamasaki H, et al. Relationship between cognitive FIM score and motor FIM gain in patients with stroke in a Kaifukuki rehabilitation ward. Jpn J Compr Rehabil Sci 2014; 5: 12-18.
https://doi.org/10.11336/jjcrs.5.12 DOI: https://doi.org/10.11336/jjcrs.5.12
Rodrigues NAG, da Silva SLA, Nascimento LR, de Paula Magalhães J, Sant'Anna RV, de Morais Faria CDC, et al. R3-walk and R6-walk, simple clinical equations to accurately predict independent walking at 3 and 6 months after stroke: A prospective, cohort study. Arch Phys Med Rehabil 2024; 105: 1116-1123.
https://doi.org/10.1016/j.apmr.2024.01.013 DOI: https://doi.org/10.1016/j.apmr.2024.01.013
Grimmer M, Riener R, Walsh CJ, Seyfarth A. Mobility related physical and functional losses due to aging and disease - a motivation for lower limb exoskeletons. J Neuroeng Rehabil 2019; 16: 2.
https://doi.org/10.1186/s12984-018-0458-8 DOI: https://doi.org/10.1186/s12984-018-0458-8
Geyskens L, Jeuris A, Deschodt M, Van Grootven B, Gielen E, Flamaing J. Patient-related risk factors for in-hospital functional decline in older adults: A systematic review and meta-analysis. Age Ageing 2022; 51: afac007.
https://doi.org/10.1093/ageing/afac007 DOI: https://doi.org/10.1093/ageing/afac007
Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12: 189-198.
https://doi.org/10.1016/0022-3956(75)90026-6 DOI: https://doi.org/10.1016/0022-3956(75)90026-6
Askenasy JJ, Rahmani L. Neuropsycho-social rehabilitation of head injury. Am J Phys Med 1987; 66: 315-327.
https://doi.org/10.1097/00002060-198812000-00001 DOI: https://doi.org/10.1097/00002060-198812000-00001
Zwecker M, Levenkrohn S, Fleisig Y, Zeilig G, Ohry A, Adunsky A. Mini-Mental State Examination, cognitive FIM instrument, and the Loewenstein occupational therapy Cognitive Assessment: relation to functional outcome of stroke patients. Arch Phys Med Rehabil 2002; 83: 342-345.
https://doi.org/10.1053/apmr.2002.29641 DOI: https://doi.org/10.1053/apmr.2002.29641
Oros RI, Popescu CA, Iova CA, Mihancea P, Iova SO. The impact of cognitive impairment after stroke on activities of daily living. HumanVet Med 2016; 8: 41-44.
Suda S, Nishimura T, Ishiwata A, Muraga K, Aoki J, Kanamaru T, et al. Early cognitive impairment after minor stroke: associated factors and functional outcome. J Stroke Cerebrovasc Dis 2020; 29: 104749.
https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104749 DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104749
Persson CU, Hansson PO, Sunnerhagen KS. Clinical tests performed in acute stroke identify the risk of falling during the first year: postural stroke study in Gothenburg (POSTGOT). J Rehabil Med 2011; 43: 348-353.
https://doi.org/10.2340/16501977-0677 DOI: https://doi.org/10.2340/16501977-0677
Kose N, Cuvalci S, Ekici G, Otman AS, Karakaya MG. The risk factors of fall and their correlation with balance, depression, cognitive impairment and mobility skills in elderly nursing home residents. Saudi Med J 2005; 26: 978-981.
Mehrholz J, Wagner K, Rutte K, Meissner D, Pohl M. Predictive validity and responsiveness of the functional ambulation category in hemiparetic patients after stroke. Arch Phys Med Rehabil 2007; 88: 1314-1319.
https://doi.org/10.1016/j.apmr.2007.06.764 DOI: https://doi.org/10.1016/j.apmr.2007.06.764
Wandel A, Jørgensen HS, Nakayama H, Raaschou HO, Olsen TS. Prediction of walking function in stroke patients with initial lower extremity paralysis: the Copenhagen Stroke Study. Arch Phys Med Rehabil 2000; 81: 736-738.
https://doi.org/10.1016/S0003-9993(00)90102-3 DOI: https://doi.org/10.1016/S0003-9993(00)90102-3
Bansal K, Morgan-Daniel J, Chatterjee SA, Rose DK. Factors affecting community ambulation post-stroke: a mapping review protocol. F1000Res 2024; 13: 166.
https://doi.org/10.12688/f1000research.144582.2 DOI: https://doi.org/10.12688/f1000research.144582.2
Kawakami K, Miyasaka H, Hioki Y, Furumoto A, Sonoda S. Gait training with a safety suspension device accelerates the achievement of supervision level walking in subacute stroke: a randomized controlled trial. Int J Rehabil Res 2024; 47: 75-80.
https://doi.org/10.1097/MRR.0000000000000625 DOI: https://doi.org/10.1097/MRR.0000000000000625
Kawakami K, Tanino G, Tomida K, Kato Y, Watanabe M, Okuyama Y, et al. Influence of increased amount of exercise on improvements in walking ability of convalescent patients with post-stroke hemiplegia. J Phys Ther Sci 2016; 28: 602-606.
https://doi.org/10.1589/jpts.28.602 DOI: https://doi.org/10.1589/jpts.28.602
Tapp A, Griswold D, Dray D, Landgraff N, Learman K. High-intensity locomotor training during inpatient rehabilitation improves the discharge ambulation function of patients with stroke. A systematic review with meta-analysis. Top Stroke Rehabil 2024; 31: 431-445.
https://doi.org/10.1080/10749357.2024.2304960 DOI: https://doi.org/10.1080/10749357.2024.2304960
Mulder M, Nijland RHM, Vloothuis JDM, van den Berg M, Crotty M, Kwakkel G, et al. Comparing two identically protocolized, multicentre, randomized controlled trials on caregiver-mediated exercises poststroke: Any differences across countries? PLoS One 2022; 25: e0263013.
https://doi.org/10.1371/journal.pone.0263013 DOI: https://doi.org/10.1371/journal.pone.0263013
Hombali A, Mahmood A, Gandhi DBC, Kamalakannan S, Chawla NS, D'souza J, et al. Clinical practice guidelines (CPGs) for stroke rehabilitation from low- and middle-income countries (LMICs): Protocol for systematic review. PLoS One 2023; 18: e0293733.
https://doi.org/10.1371/journal.pone.0293733 DOI: https://doi.org/10.1371/journal.pone.0293733
Published
How to Cite
License
Copyright (c) 2025 Kenji Kawakami, Shigeo Tanabe, Daiki Kinoshita, Ryo Kitabatake, Hiroo Koshisaki, Kenta Fujimura, Yoshikiyo Kanada, Hiroaki Sakurai
This work is licensed under a Creative Commons Attribution 4.0 International License.
All digitalized JRM contents is available freely online. The Foundation for Rehabilitation Medicine owns the copyright for all material published until volume 40 (2008), as from volume 41 (2009) authors retain copyright to their work and as from volume 49 (2017) the journal has been published Open Access, under CC-BY-NC licences (unless otherwise specified). The CC-BY-NC licenses allow third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for non-commercial purposes, provided proper attribution to the original work.
From 2024, articles are published under the CC-BY licence. This license permits sharing, adapting, and using the material for any purpose, including commercial use, with the condition of providing full attribution to the original publication.
