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Introduction
In the rehabilitative treatment of stroke patients
with hemiplegia, prediction of functional recovery
is crucial. Accurate prediction facilitates proper
definition of goals of intervention for individual
patients, thus improving the quality and efficiency
of rehabilitation service.1 For providers of services
Address for correspondence: Tetsuo Koyama, Department of
Rehabilitation Medicine, Nishinomiya Kyoritsu Rehabilitation
Hospital, Jurinji-Minamimachi 2-13, Nishinomiya, Hyogo,
Japan 662-0002. e-mail: ytkoyama@bd6.so-net.ne.jp
# 2005 Edward Arnold (Publishers) Ltd
Figure 1 Model formula and predictive curve. (A) shows a generic structure; (B) shows mathematical procedures to tailor the
generic structure to fit individual degree of recovery. For this, actual FIM scores recorded at two time points (Day A and Day B)
are required. DFIM indicates change in FIM scores between Day A and Day B. Constant in (A) is countervailed in this procedure.
(C) shows the final form of the model formula. Predicted value for Day X can be calculated with this form. FIM, Functional
Independence Measure; ln, natural logarithm.
Methods
Patients
Stroke patients with hemiplegia who were admitted to our long-term rehabilitation hospital
during August 2003 to April 2004 were recruited
into the study. Criteria for inclusion were:
no past history of hemiplegia; capable of independent ADL (activities of daily life) before stroke;
wheelchair required for locomotion at admission.
As a result of Japanese health insurance procedures, patients were referred from local community
acute medical services, typically 30/60 days after
the stroke occurred, and received inpatient care in
our long-term rehabilitation hospital for 30 /180
days. During the prior period of acute medical
hospitalization they received physical therapy.
During long-term rehabilitation hospitalization
they received physical therapy, occupational therapy and speech therapy for a joint total of 120 min
every day. To minimize the influence of variability
of therapeutic regimen, we also limited recruitment
to patients who received treatment from the same
rehabilitation team directed by a single physiatrist
(first author of this article). The protocol was
reviewed and approved by our hospitals ethical
committee and informed consent was obtained
from all patients.
Assessment of functional recovery
To assess functional recovery, we employed the
Functional Independence Measure (FIM), which
has been widely used in rehabilitation medicine.22
The FIM is derived from scoring 18 items according to a seven-point scale (1 /totally dependent,
7/completely independent) to assess functional
independence in ADL. These 18 items are
categorized as self-care (6 items), sphincter
control (2 items), transfers (3 items), locomotion
(2 items), communication (2 items), and social
cognition (3 items). The first four categories
781
Figure 2 Time-course of actually obtained and predicted FIM scores for patients with left hemisphere lesions (cases 1 /10).
Closed circles show actually obtained FIM-total scores, closed triangles show actually obtained FIM-motor scores, closed
squares show actually obtained FIM-cognition scores and open circles show predictive values derived from the model formula
(Figure 1). Arrowheads indicate initial two sampling time-points for data to tailor the model formula for each individual.
FIM, Functional Independence Measure.
783
Figure 3 Time-course of actually obtained and predicted FIM scores for patients with right hemisphere lesions (cases 11 /18).
Closed circles show actually obtained FIM-total scores, closed triangles show actually obtained FIM-motor scores, closed
squares show actually obtained FIM-cognition scores and open circles show predictive values derived from the model formula
(Figure 1). Arrowheads indicate initial two sampling time-points for data to tailor the model formula for each individual.
FIM, Functional Independence Measure.
Results
Patients
We collected and manipulated data for 18
patients (12 male, 6 female; 10 left, 8 right,
Age
Gender
Hemisphere
Lesion
Cause of stroke
Ope.
Intervention
Comorbidity
No.
No.
No.
No.
No.
No.
No.
No.
No.
No.
No.
No.
No.
No.
No.
No.
No.
No.
82
63
53
33
62
73
78
74
74
65
74
50
73
70
70
54
65
54
M
F
M
F
M
F
F
F
M
M
M
M
M
F
M
M
M
M
Left
Left
Left
Left
Left
Left
Left
Left
Left
Left
Right
Right
Right
Right
Right
Right
Right
Right
Corona radiata
Putamen
Corona radiata
Putamen
Putamen
Putamen
Corona radiata
MCA
Putamen
Prefrontal cortex
Prefrontal cortex
Corona radiata
Corona radiata
MCA
MCA
Thalamus
MCA
Putamen
Infarct
Hemorrhage
Infarct
Hemorrhage
Hemorrhage
Infarct
Infarct
Infarct
Hemorrhage
Hemorrhage
Hemorrhage
Infarct
Infarct
Infarct
Infarct
Hemorrhage
Infarct
Hemorrhage
(/)
(/)
(/)
(/)
(/)
(/)
(/)
(/)
(/)
(/)
(/)
(/)
(/)
(/)
(/)
(/)
(/)
(/)
OT,
OT,
OT,
OT,
OT,
OT,
OT,
OT,
OT,
OT,
OT,
OT,
OT,
OT,
OT,
OT,
OT,
OT,
CAD
HT
HT
HT, HL
( /)
DM, HT
( /)
Af, CAD, HT
HCC
( /)
( /)
DM, HT
DM, HT
( /)
CAD, DM
HT
HT
HT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
PT
PT,
PT,
PT,
PT,
PT,
PT
PT,
PT,
PT
PT,
PT
PT
PT
PT
PT,
PT
PT
ST
ST
ST
ST
ST
ST
ST
ST
ST
CAD, coronary artery disease; DM, diabetes mellitus; HCC, hepatic cell carcinoma (post operation); HL, hyperlipidaemia; HT,
hypertension; MCA, middle cerebral artery; Ope., operation (open-skull) during acute medical hospitalization; OT, occupational
therapy; PT, physical therapy; ST, speech therapy.
Figure 4 Scatterplots showing the relationships between actually obtained FIM-total scores and predicted values derived
from the model formula (see Figures 2 and 3). Data from the two initial sampling time-points for each patient (indicated by
arrowheads in Figures 2 and 3) were excluded from the scatterplots. FIM, Functional Independence Measure.
Discussion
A logarithmic function was applied to simulate the
time-course of functional recovery of stroke patients with hemiplegia. Based on this, we developed
a new model formula that, using FIM results
sampled from two points in time during recovery,
could be applied accurately to predict the pattern
of functional recovery in individual recovery.
Among patients with a wide variety of motor and
cognitive disability, the model formula accurately
predicted actual functional recovery during hospi-
785
Clinical messages
/
11
12
13
14
References
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Fermoso-Garcia J. Predictive model of functional
15
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x
1.0
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
2.0
2.2
2.4
2.6
2.8
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
ln, natural logarithm.
Ln (x )
0.000
0.095
0.182
0.262
0.336
0.405
0.470
0.531
0.588
0.642
0.693
0.788
0.875
0.956
1.030
1.099
1.386
1.609
1.792
1.946
2.079
2.197
2.303
789
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.