Geriatricrehabilitationofstroke

patientsinnursinghomes:astudy
protocol
MonicaSpruitvanEijk1,2 ,BiancaIBuijck1,3 ,SytseUZuidema1
,AlexanderCHGeurts4 andRaymondTCMKoopmans1

,FransLMVoncken3

DepartmentofPrimaryandCommunityCare,CentreforFamilyMedicine,GeriatricCareandPublic
Health,RadboudUniversityNijmegenMedicalCentre,GeertGrooteplein21Nijmegen6525EZ,the
Netherlands
2

SVRZ,Koudekerkseweg143,Middelburg4335SM,theNetherlands

DeZorgboog,Roessel3,Bakel5761RP,theNetherlands

DepartmentofRehabilitation,NijmegenCentreforEvidenceBasedPractice,RadboudUniversity
NijmegenMedicalCentre,GeertGrooteplein21,Nijmegen6525EZ,theNetherlands
authoremail

correspondingauthoremail

BMCGeriatrics2010,10:15doi:10.1186/147123181015
Theelectronicversionofthisarticleisthecompleteoneandcanbefoundonlineat:
http://www.biomedcentral.com/14712318/10/15
Received:
Accepted:
Published:

20January2010
27March2010
27March2010

2010Eijketal;licenseeBioMedCentralLtd.
ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommonsAttribution
License(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and
reproductioninanymedium,providedtheoriginalworkisproperlycited.

Abstract
Background
Geriatricpatientsaretypicallyunderrepresentedinstudiesonthefunctionaloutcomeofrehabilitation
afterstroke.Moreover,mostgeriatricstrokepatientsdoprobablynotparticipateinintensive
rehabilitationprogramsasofferedbyrehabilitationcenters.Asaresult,veryfewstudieshave
describedthesuccessfulnessofgeriatricstrokerehabilitationinnursinghomepatients,althoughit
appearsthatthemajorityofthesepatientsarebeingdischargedbacktothecommunity,ratherthan
beingtransferredtoresidentialcare.Nevertheless,factorsassociatedwiththesuccessfulnessofstroke
rehabilitationinnursinghomesorskillednursingfacilitiesarelargelyunknown.Theprimarygoalof
thisstudyis,therefore,toassessthefactorsthatuniquelycontributetothesuccessfulnessof
rehabilitationingeriatricstrokepatientsthatundergorehabilitationinnursinghomes.Asecondarygoal

istoinvestigatewhetherthesefactorsaresimilartothoseassociatedwiththeoutcomeofstroke
rehabilitationintheliterature.

Methods/Design
ThisstudyispartoftheGeriatricRehabilitationinAMPutationandStroke(GRAMPS)studyinthe
Netherlands.Itisalongitudinal,observational,multicenterstudyin15nursinghomesintheSouthern
partoftheNetherlandsthataimstoincludeatleast200patients.Allparticipatingnursinghomesare
selectedbasedontheexistenceofaspecializedrehabilitationunitandtheprovisionofdedicated
multidisciplinarycare.Patientcharacteristics,diseasecharacteristics,functionalstatus,cognition,
behavior,andcaregiverinformation,arecollectedwithintwoweeksafteradmissiontothenursing
home.Thefirstfollowupisatdischargefromthenursinghomeoroneyearafterinclusion,and
focusesonfunctionalstatusandbehavior.Successfulrehabilitationisdefinedasdischargefromthe
nursinghometoanindependentlivingsituationwithinoneyearafteradmission.Thesecondfollowup
isthreemonthsafterdischargeinpatientswhorehabilitatedsuccessfully,andassessesfunctional
status,behavior,andqualityoflife.Allinstrumentsusedinthisstudyhaveshowntobevalidand
reliableinrehabilitationresearchorarerecommendedbytheNetherlandsHeartFoundationguidelines
forstrokerehabilitation.
DatawillbeanalyzedusingSPSS16.0.Besidesdescriptiveanalyses,bothunivariateandmultivariate
analyseswillbeperformedwiththepurposeofidentifyingassociatedfactorsaswellastheirunique
contributiontodeterminingsuccessfulrehabilitation.

Discussion
ThisstudywillprovidemoreinformationaboutgeriatricstrokerehabilitationinDutchnursinghomes.
Toourknowledge,thisisthefirstlargestudythatfocusesonthedeterminantsofsuccessofgeriatric
strokerehabilitationinnursinghomepatients.

Background
AccordingtotheWorldHealthOrganization,15millionpeopleworldwidesufferedastrokein2004
[1].IthasbeenreportedthatthemeanstrokeincidencerateinWesterncountriesis94per100.000
personyears[2].Althoughmenaremoreoftenaffectedthanwomenduetoayoungerageofonset,this
genderdifferencebecomessmallerwithincreasingage[3].Strokeincidencetypicallyincreaseswith
ageand,duetotheageingofthepopulation,strokeincidenceratesareexpectedtorise.Highageand
lowlevelofphysicalendurance,duetosignificantcomorbidity,arecharacteristicofthegeriatricstroke
population.Althoughrehabilitationafterstrokeisanimportantactivityinmanyrehabilitationcenters
worldwide,mostgeriatricstrokepatientsareprobablynotadmittedtothesecentersand,thus,donot
participateinintensiverehabilitationprograms[4].Thesepatientsmaybereferredtonursinghomesor
skillednursingfacilities(SNF)thatprovideadaptedrehabilitationprogramscombinedwithresidential
care,whereasothersmaynotreceiveanyformaltypeofmultidisciplinaryrehabilitationatall.Asa
result,geriatricstrokepatientsaregreatlyunderrepresentedinoutcomestudiesandfactorsassociated
withthesuccessfulnessoftheirrehabilitationarelargelyunknown.
Fewstudieshavedealtwiththeinfluenceofcomorbidityandageontheoutcomeofstroke
rehabilitation.AtalayandTurhan[5]foundthatelderlystrokepatients(olderthan65yearsofage)
werelesslikelytobesuccessfullyrehabilitateddespitesimilarFunctionalIndependenceMeasure
(FIM)scoresonadmission,comparedtopatientsyoungerthan65years.Yet,comorbidityandage
werenotassociatedwithprolongedlengthofstayintherehabilitationcenter.Inthesamevein,Fischer
etal.[6]foundthatcomorbidityandagedidnotuniquelycontributetopredictinglengthofhospital
stay.Ontheotherhand,thereisevidencethatcomorbidityandageareimportantfactorsindetermining
functionaloutcomeafterstroke[7].Severaladditionalstudieshaveemphasizedtheimportanceofage
forfunctionaloutcomeafterstroke,butestimatesofthetrueimpactofageseemtovarygreatly.

Whereassomestudiesreportedarelativelysmallinfluenceofage[8,9],otherstudiesfoundthatvery
oldage,definedas85yearsandolder,wasaconsistentlystrongpredictorofpooroutcome[10].
Interestingly,Teaselletal.[4]havereportedthatrehabilitationin'lowerband'patientsrecoveringfrom
severestroke,whowereconsideredinappropriateforconventionalinpatientrehabilitationprograms,
maystillbequitesuccessfulintermsofgaininindependencyofselfcareandambulation.However,
althoughthepatientswereonaverage72yearsofage,thisstudydidnotspecificallyfocusongeriatric
rehabilitationanddidnotexaminetheinfluenceofcomorbidityorageonrehabilitationoutcome.
Severalotherstudieshaveshownthatasubstantialnumberofstrokepatientsthatreceiverehabilitation
inSNFsornursinghomescanbesuccessfullydischargedtothecommunity[1113].Theprobabilityof
dischargegreatlydependsonindividualrehabilitationpotential,whichisrelatedtostrokeseverityand
physicalcapacities.Besides,itappearsthatadmissiontoSNFsincreasesthelikelihoodofsuccessful
rehabilitationintermsofdischargetothecommunity[11,12].
Ingeneral,manystudieshaveinvestigatedtheclinical,biologicalanddemographicfactorsassociated
withtheoutcomeafterstroke[410,1425].Alargenumberofsuchfactorshasbeenassociatedwith
theoutcomeafterstrokerehabilitation(table1),butprobablymanyofthesefactorsareinterrelated.
Thisimplicatesthattheuniquecontributionofthesefactorstostrokeoutcome,correctedfor
associationwithotherfactors,stillhastobedeterminedinordertobeofvalueforclinicalpredictionin
dailypractice.Inshort,initialdisabilityandageseemtobethemostpromisingpredictorsoflongterm
activitiesofdailyliving(ADL)anddischargedestinationafterrehabilitation.
Table1.Factorsassociatedwithstrokeoutcomedisabilityanddischargedestinationintheliterature
Againstthisbackground,theprimarygoalofthisstudyistoassessthefactorsthatuniquelycontribute
tothesuccessfulnessofrehabilitationingeriatricstrokepatientsthatundergorehabilitationinnursing
homes.Functionaloutcomeisprimarilyassessedbydischargetoanindependentlivingsituationand,
secondarily,byvariousfunctionalscales.Asecondarygoalistoinvestigatewhetherthefactorsthatare
uniquelyassociatedwithsuccessfulnessofrehabilitationinthisgeriatricpopulationaresimilartothose
associatedwiththeoutcomeofstrokerehabilitationintheliterature.Tothisend,wehavesetupa
multicenterstudyin15nursinghomesintheSouthernpartoftheNetherlands.Allparticipatingnursing
homesareselectedbasedontheexistenceofaspecializedstrokerehabilitationunitandtheprovision
ofdedicatedmultidisciplinarycare.Toourknowledge,thisisthefirststudythatfocusesonthe
determinantsofsuccessofgeriatricrehabilitationinnursinghomepatients.

Methods/Design
Studydesign
ThisprospectivestudyispartoftheNijmegenGeriatricRehabilitationinAMPutationandStroke
(GRAMPS)studyandcomprisesthreemeasurements.Baselinedata(T0)arecollectedwithintwo
weeksafteradmissiontothenursinghome.Patientsanddiseasecharacteristics,functionalstatus,
cognition,behaviorandcaregiverinformationareregistered(table2).Thefirstfollowup(T1)isat
dischargefromthenursinghome,andfocusesonfunctionalstatusandbehavior.Successful
rehabilitationisdefinedasdischargefromthenursinghometoanindependentlivingsituationwithin
oneyearafteradmission.Thesecondfollowup(T2)isatthreemonthsafterdischargeinpatientswho
rehabilitatedsuccessfullyandfocusesonfunctionalstatus,behaviorandqualityoflife.
Table2.Researchinstruments
DatacollectionhasstartedinJanuary2008,andwillendinJuly2010.

Patients

Allpatientswhoareconsecutivelyadmittedtooneofthespecializedrehabilitationwardsofthe15
participatingnursinghomesareeligibletoparticipateinthisstudy.Nootherinclusioncriteriawere
applied.Inabilitytogiveinformedconsentisanexclusioncriterion.Allparticipatingnursinghomes
collaborateintheNijmegenUniversityNursingHomeNetworkoftheRadboudUniversityNijmegen
MedicalCenter.Afteradmissionpatientsareprovidedwithoralinformationfromthetreating
physicianornurse.Inaddition,allpatientsandtheircaregiversreceivewritteninformationaboutthe
study.Thepatientsindicatethemselveswhethertheyareinterestedtoparticipate.Theattending
physicianjudgesthelegalcapacityofhis/herpatients.Inthecaseofdoubtshe/sheconsultsthe
caregivers.Inaddition,theGRAMPSwebsitehttp://www.gramps.nlwebciteprovidesextra
informationforinterestedpatientsandtheircaregivers.

Ethicalapproval
ThisresearchprotocolwaspresentedtothemedicalethicscommitteeofthedistrictNijmegen
Arnhem,theNetherlands.Ethicsapprovalwasnotdeemednecessary,becausethedesignis
observationalandbecauselegallyincapablepatientsareexcluded.

Assessmentinstruments
Dataarecollectedbythemultidisciplinaryteamsworkingintheparticipatingnursinghomes.Each
disciplinehastheobligationtoperformspecificassessments.Theselectedoutcomemeasureshave
beenselectedbasedonpreviouslyestablishedreliabilityandvalidityorbasedonrecommendationsby
theNetherlandsHeartFoundationguidelinesforstrokerehabilitation(table2)[26].

Patientcharacteristics
Generalpatientcharacteristicsaswellasdiseasecharacteristics,medicationlists,andinformation
aboutcomorbidity,usingtheCharlsonIndex(CI),areregistered.TheCIcomprises19categoriesof
diagnosesfromtheInternationalClassificationofDiseases,(9threvisionClinicalModificationICD
9CM)andisbasedonasetofriskfactorsforoneyearmortalityrisk[27].TheCIcontainsaweighted
indexforeachdiseaseatwhichthescoreisasignificantpredictorofoneyearsurvival.Oneyear
mortalityrateforthedifferentscoresare:"0"12%,"12"26%,"34"52%and">5"85%.

Functionalstatus
TheBarthelIndex(BI),modifiedbyCollinetal.in1988[28],measuresdependencyinactivitiesof
dailyliving(ADL).TheBIisavalidandreliableinstrumentinstrokeresearch[2831].Thetotalscore
rangesfrom020,with20representingcompletefunctionalindependence.TheFrenchayactivities
index(FAI)isusedforassessmentofextendedADL.TheFAI[32]scorestheactualactivities
undertakenbypatientsandcanbedividedinthreedomains:domestichousework,indooractivitiesand
outdooractivities.The15itemquestionnaireisareliableandvalidinstrumentformeasuringfunctional
outcomeinstrokepatients[33,34].EvenproxiesgivereliableinformationaboutFAIitems[35,36].
TheFrenchayArmTest(FAT)isusedtoevaluatearmfunctionafterstroke.Thepatientisaskedto
performfiveactivitieswithhisaffectedarm,forwhichhereceivesonepointifsuccessfullycomplete.
TheFATisavalidandreliableinstrumentforuseinstrokeresearch[37].
TheMotricityIndex[38]isusedtoevaluatemotorimpairmentofthelimbs.Sixmovements,dividedin
armandlegmovements,areobserved.Threescorescanbemeasured:armscore,legscoreandside
score.Botharmandlegscoreshavegoodcriterionvalidityandarereliableifusedbydifferent
observers[3941].
ItemthreeoftheTrunkControlTest(TCT)isusedtoassessstaticsittingbalance:sittinginabalanced
positionontheedgeofthebedforatleast30seconds,withthefeetabovetheground.TheTrunk

ImpairmentScale(TIS),developedbyVerheydenandcolleagues[42],evaluatesmotorimpairmentof
thetrunkafterstroke.TIStakesmovementandcoordinationaswellasstaticsittingbalanceinto
account.TheTCTandTISbothshowgoodvalidityandreliability[40,42].
TheBergBalanceScale(BBS)isanordinal14itemscale(056points)developedbyBergetal.[43]to
measurebalanceinstrokepatients.ValidityandreliabilityoftheBBSisgood[4447],howeverthe
scaleisnotsuitableforpatientswithverysevereimpairments,whocannotmaintainabalancedsitting
position[44].CeilingeffectshavealsobeendescribedbyMao[44]at90180dayspoststroke.The
onelegstandingbalancetest,firstusedbySchoppenetal.[48],isusedtoassessstandingbalanceon
theunaffectedleg.
TheFunctionalAmbulationCategories(FAC)[49]isameasureofthe(in)dependencyofgait.The
FACisanordinalsixpointscalewith0indicatingtotaldependencyforwalkingand5indicating
independentwalking.Theuseofawalkingdeviceisallowed.Bergetal.[43]foundhighcorrelations
betweentheBBSandFACscores.
TheTenMeterWalkingSpeedtest(TMWStest)timesthewalkingspeedalongadistanceoften
metersandcanbeperformedatacomfortableormaximumwalkingspeed[50].Becausethe
comfortablewalkingspeedseemstobemoreresponsivetofunctionalrecoveryafterstroke[51]and
becausethemaximumwalkingspeedcanbeestimatedbymultiplyingcomfortablewalkingspeedby
1.32[52],theTMWStestisperformedatcomfortablewalkingspeed,onlybypatientswithaFAC
scoreof3orhigher.
Thewaterswallowingtest[26]isasimplebedsidetestandresemblesthewaterswallowingtest
proposedbySmithardandcoworkers[21].Afterdrinkingthreespoonsofwatersafely,halfaglassof
waterisgiventothepatient.Thepatientfailsincaseofsignsofchoking.Thespeechtherapistassesses
foodconsistencyafterthepatientsafelydrinksthewater.

Cognition
TheMiniMentalStateExamination(MMSE),developedbyFolsteinandMcHugh[53],isa
screeninginstrumentforcognitiveimpairment,andhasafairreliabilityandconstructvalidity,witha
highsensitivityformoderatelyseverecognitiveimpairmentandalowersensitivityformildcognitive
impairment[54].Itcomprisesitemstestingorientation,attention,memory,languageandconstructive
abilities.Bottomandceilingeffectshavebeendescribed[55].AnimportantbiasinusingtheMMSEin
strokeresearchistheextensiveuseoflanguage,whichleadstounreliableresultsinaphasicpatients.
Forthisreason,wewillnotusetheMMSEinpatientswithsevereaphasia.TheHeteroAnamnestic
Cognitionlist(HAClist),derivedfromtheMMSEbyMeijerinhisAMDASstudy[56],isusedto
explorethepresenceofpremorbidcognitivedisabilities.Theproxy,preferablyapartnerifpresent,is
askedafewsimple'yes'or'no'questionsconcerningorientation,attentionandcalculation,language,
memory,andexecutiveskills.Severityisjudgedonthebasisofneedofassistanceorprofessional
therapyrequired.
TheStarCancellationTest(SCT),anitemoftheBehavioralInattentionTest(BIT)[57],isascreening
instrumentfordetectingunilateralvisuospatialneglect.TheSCTconsistsof52largestars,13
characters,10words,and56smallstars.Allsmallstarsaretobeeliminated.Theresearchergivesa
demonstrationbycrossingoutthetwosmallstarsinthemiddle.Thecutoffpointis52[57].Rough
scorescanbeusedtointerprettheoutcomeoftheSCT,ratherthanthevisuallateralizationscores[58].
ThereissufficientevidenceforgoodvalidityoftheSCT[5961].
VanHeugtenetal.developedadiagnostictoolforapraxiainstroke,basedonanexistinginstrument
[62].ThisApraxiatest,differentiatingbetweenapraxiaandnonapraxia,involvesdemonstrationof
objectuseandimitationsofgestures.Ithasgoodvalidityandreliability[62,63].
TheSAN(StichtingAfasieNederland=DutchAphasiaFoundation)scoreisusedtoquantify
communicativeimpairmentinstrokepatientsandispartoftheAachenAphasiaTest(AAT)[64].The

SANscoreisanordinal7pointscalewith'1'indicatingnocommunicationpossibleand'7'indicating
normallanguageskills[65].

Behavior
TheNeuroPsychiatricInventory(NPI),originallydevelopedfordementiapatients[66],givesaglobal
impressionofbehavioralproblemsandisapplicableinotherpatientgroupsaswell.TheNPIcomprises
12categoriesofproblembehaviors:delusions,hallucinations,agitation/aggression,depression,
anxiety,euphoria,disinhibition,irritability/lability,apathy,aberrantmotoractivity,sleepingdisorder
andeatingdisorder.Iftheinterviewedperson,eitheranurseintheNPINursingHome(NPINH)
versionorapartnerorcloserelativeinthequestionnaireversion(NPIq),positivelyanswersthe
screeningquestion,bothfrequencyandseverity(onlyintheNPINHversion)aredetermined.TheNPI
closeseachcategorywithenquiringaboutemotionalburden.TheNPIisavalidandreliableinstrument
[66],hasbeentranslatedintoDutch,andhaspreviouslybeenusedinstrokeresearch[67,68].
TheeightitemversionoftheGeriatricDepressionScale(GDS8)isashortenedpatientfriendlytest
derivedfromtheGDS15version,andhasbeendevelopedspecificallyforthenursinghomepopulation
[69].Itindicatesthepresenceofdepressionatacutoffof3outof8.

Qualityoflife
TheRAND36,developedtomeasurehealthrelatedqualityoflifeinchronicallyillpatients,
compriseseightdimensions:physicalfunctioning,rolelimitationsduetophysicalhealthproblems,
bodilypain,generalhealth,vitality,socialfunctioning,rolelimitationsduetoemotionalproblems,and
generalmentalhealth.Italsocontainsanadditionalitemaboutperceivedhealthchange[70].Theitem
scoresofalldimensionsneedtoberecodedaccordingtotheRANDhealthsciencesprogramstandards
[71].TheRAND36hasbeentranslatedintoDutchbyvanderZeeetal.,andwasfoundtobeavalid,
reliable,andsensitivemeasurementofgeneralhealth[72].

Caregivers
TheDartmouthCOOPFunctionalHealthAssessmentCharts/WONCA(COOP/WONCA)subscales
[7375]physicalfitness,dailyactivities,feelingsandoverallhealthareusedtomeasureproxy's
functionalstatus.Eachsubscaleconsistsofashorttitleandanillustratedfivepointresponsescale:
scores16andupareindicativeofhighstrain[56].
TheCaregiverStrainIndex(CSI)isonlyusedafterdischargefromthenursinghome,when
participationlevelofthepatientplaysakeyrole[76].Optimalreintegrationreducestheexperienced
strainofthecaregivers.TheCSIconsistsof13'yes'and'no'questions,isaneasyusedinstrumentto
identifystrain,andshowsvalidity[77].Ascoreof7ormorepositiveresponsesindicatesahighlevel
ofstrain[78].TheCSIhasbeenusedinresearchonvariousdiseases[7981].

Dataanalysis
AlldataisprocessedusingtheStatisticalPackageforSocialScience16.0(SPSS16.0).Different
techniqueswillbeusedtoanalyzethedata,dependingontheresearchquestion.
Descriptiveanalysiswillbeusedforgeneralpatientcharacteristics,diseasecharacteristics,treatment,
successfulnessofrehabilitation,andfunctionaloutcomes.
Univariateanalyses,parametricaswellasnonparametric,willbeperformedforidentifyingthe
demographicandclinicalfactorsthatareassociatedwithsuccessfulrehabilitation(p<0.1).

Associatedfactorswillthenbetestedinamultivariatelogisticregressionanalysistodeterminetheir
uniquecontributionandoverallexplainedvarianceofsuccessfulnessofrehabilitation.

Power
TherequiredsamplesizewasestimatedusingtheruleofthumbaccordingtoPeduzzietal.[82]:At
least10patientsperfactorinthesmallestgroup,inthecaseofadichotomousoutcome.Basedonour
experience,approximately35%ofthestrokepatients,admittedtonursinghomesforrehabilitation,
cannotbedischargedtoanindependentlivingsituation.Whentestingamaximumofsevenfactorsin
themultivariatemodel,70patientsneedtobeincludedinthesmallestgroup(35%).Consequently,a
totalof200strokepatientswillbeincluded.

Discussion
Toourknowledge,thisisthefirstlargestudythatfocusesonthedeterminantsofsuccessofgeriatric
strokepatientsadmittedtonursinghomes.Itwillprovidemoredetailedinformationaboutthefactors
thatareuniquelyassociatedtothesuccessfulnessofgeriatricstrokerehabilitationandthatcan,thus,be
usedinbuildingaclinicalpredictionmodelofdischargedestinationfromnursinghomes.
Allselectedoutcomemeasureshaveproventobereliableandvalid,orarerecommendedbythe
NetherlandsHeartFoundation.
Becauselegallyincapablepatientsareexcludedfromthisstudy,itsexternalvaliditymaybeslightly
affected.Therefore,generalpatientcharacteristicsoftheexcludedpatientsareregisteredandcompared
tothoseoftheincludedpatients.Besidesage,lengthofstayinthenursinghome,anddischarge
destinationarerecordedtocomparebothgroups.Thismulticenterresearchusesmultidisciplinary
teamstocollectthedataoveraperiodoftwoandahalfyearsand,thus,maysufferfromsome
measurementinaccuracies.Tominimizesuchinaccuracies,over90peopleworkingin15Dutch
nursinghomesreceivedthesameinstructionsaboutperformingtheoutcomemeasuresduring
collectivemeetingsbeforethestartofthestudy.Toensurethequalityofdatacollectionduringthe
study,eachnursinghomehas2to3speciallyassignedprofessionalswhomaintaincontactwiththe
mainresearchers.Inaddition,anewsletterisprovidedevery68weekstokeepeverybodyinvolved,
informed,andmotivatedwithregardtotheprogressofthestudy.

Competinginterests
Theauthorsdeclarethattheyhavenocompetinginterests.

Authors'contributions
MSandBBaretheprimaryinvestigatorsoftheGRAMPSstudy,theydesignedthestudyandwrotethe
manuscript.ThecollecteddatawillbeprocessedandanalyzedbyMSandBB.SZwillhelpinthe
analysisofthedata,andheparticipatedinwritingthemanuscript.FVparticipatedinthedesignofthe
study,andhereviewedthisstudyprotocol.AGparticipatedindesigningthisstudy,writingthe
manuscript,andhewillhelpintheanalysisofthedata.RKparticipatedinthedesignofthestudy,and
writingthemanuscript,andhewillhelpwiththeanalysisofthedata.Allauthorshavegivenfinal
approvaloftheversiontobepublished.

Acknowledgements
Thisstudyisfundedby"Zorgboog"and"SVRZ"andthesciencepromotionfoundationfornursing
homes(SWBV).TheresearchersoftheGRAMPSstudywouldliketoacknowledgedrH.vander
Lindeforhisadvice.

References
1.

WHO:TheAtlasofHeartdiseaseandStroke.WHO,Geneva;2004.

2.

FeiginVL,etal.:Worldwidestrokeincidenceandearlycasefatalityreportedin56
populationbasedstudies:asystematicreview.
LancetNeurol2009,8(4):35569.PubMed

Abstract|Publisher

FullText

3.

AppelrosP,StegmayrB,TerentA:Sexdifferencesinstrokeepidemiology:asystematic
review.
Stroke2009,40(4):108290.PubMed

Abstract|Publisher

FullText

4.

TeasellRW,etal.:Arehabilitationprogramforpatientsrecoveringfromseverestroke.
CanJNeurolSci2005,32(4):5127.PubMed

Abstract|Publisher

FullText

5.

AtalayA,TurhanN:Determinantsoflengthofstayinstrokepatients:ageriatric
rehabilitationunitexperience.
IntJRehabilRes2009,32(1):4852.PubMed

Abstract|Publisher

FullText

6.

FischerU,etal.:Impactofcomorbidityonischemicstrokeoutcome.
ActaNeurolScand2006,113(2):10813.PubMed

Abstract|Publisher

FullText

7.

TurhanN,AtalayA,MuderrisogluH:Predictorsoffunctionaloutcomeinfirstever
ischemicstroke:aspecialinteresttoischemicsubtypes,comorbidityandage.
NeuroRehabilitation2009,24(4):3216.PubMed

Abstract|Publisher

FullText

8.

DentiL,AgostiM,FranceschiniM:Outcomepredictorsofrehabilitationforfirststrokein
theelderly.
EurJPhysRehabilMed2008,44(1):311.PubMed

Abstract|Publisher

FullText

9.

BaggS,PomboAP,HopmanW:Effectofageonfunctionaloutcomesafterstroke
rehabilitation.
Stroke2002,33(1):17985.PubMed

Abstract|Publisher

FullText

10. KammersgaardLP,etal.:Shortandlongtermprognosisforveryoldstrokepatients.
TheCopenhagenStrokeStudy.
AgeAgeing2004,33(2):14954.PubMed

Abstract|Publisher

FullText
11. WodchisWP,etal.:Skillednursingfacilityrehabilitationanddischargetohomeafter
stroke.
ArchPhysMedRehabil2005,86(3):4428.PubMed

Abstract|Publisher

FullText

12. JetteDU,WarrenRL,WirtallaC:Therelationbetweentherapyintensityandoutcomesof
rehabilitationinskillednursingfacilities.
ArchPhysMedRehabil2005,86(3):3739.PubMed

Abstract|Publisher

FullText
13. NijmeijerNM,etal.:EfficacyofagreementswithintheEnchedeStrokeServicetorefer
patientswithastrokefromthestrokeunitinthehospitaltoanursinghomeforshort
termrehabilitation.
NedTijdschrGeneeskd2005,149(42):23449.PubMed

Abstract
14. KwakkelG,KollenB,LindemanE:Understandingthepatternoffunctionalrecovery
afterstroke:factsandtheories.
RestorNeurolNeurosci2004,22(35):28199.PubMed

Abstract|Publisher

FullText
15. JohnstonKC,etal.:Apredictiveriskmodelforoutcomesofischemicstroke.
Stroke2000,31(2):44855.PubMed

Abstract|Publisher

FullText
16. VerheydenG,etal.:Trunkperformanceafterstroke:aneyecatchingpredictorof
functionaloutcome.
JNeurolNeurosurgPsychiatry2007,78(7):6948.PubMed

Abstract|Publisher

FullText
17. SmithPM,etal.:Predictingfollowuplivingsettinginpatientswithstroke.
ArchPhysMedRehabil2002,83(6):76470.PubMed

Abstract|Publisher

FullText
18. ThommessenB,BautzHolterE,LaakeK:Predictorsofoutcomeofrehabilitationof
elderlystrokepatientsinageriatricward.
ClinRehabil1999,13(2):1238.PubMed

Abstract|Publisher

FullText
19. AgarwalV,etal.:Amodeltoaidinthepredictionofdischargelocationforstroke
rehabilitationpatients.
ArchPhysMedRehabil2003,84(11):17039.PubMed

Abstract|Publisher

FullText
20. PortelliR,etal.:Institutionalizationafterstroke.
ClinRehabil2005,19(1):97108.PubMed

Abstract|Publisher

FullText
21. SmithardDG,SmeetonNC,WolfeCD:Longtermoutcomeafterstroke:doesdysphagia
matter?
AgeAgeing2007,36(1):904.PubMed

Abstract|Publisher

FullText
22. MeijerR,etal.:Prognosticfactorsforambulationandactivitiesofdailylivinginthe
subacutephaseafterstroke.Asystematicreviewoftheliterature.
ClinRehabil2003,17(2):11929.PubMed

Abstract|Publisher

FullText

23. MeijerR,etal.:Prognosticfactorsinthesubacutephaseafterstrokeforthefuture
residenceaftersixmonthstooneyear.Asystematicreviewoftheliterature.
ClinRehabil2003,17(5):51220.PubMed

Abstract|Publisher

FullText
24. MeijerR,etal.:Prognosticsocialfactorsinthesubacutephaseafterastrokeforthe
dischargedestinationfromthehospitalstrokeunit.Asystematicreviewoftheliterature.
DisabilRehabil2004,26(4):1917.PubMed

Abstract|Publisher

FullText
25. KwakkelG,etal.:Predictingdisabilityinstrokeacriticalreviewoftheliterature.
AgeAgeing1996,25(6):47989.PubMed

Abstract|Publisher

FullText
26. RehabilitationC.s.:Rahabilitationafterstroke;guidelinesandrecommendationsfor
caregivers.NetherlandsHeartFoundation:TheHague;2001.
27. CharlsonME,etal.:Anewmethodofclassifyingprognosticcomorbidityinlongitudinal
studies:developmentandvalidation.
JChronicDis1987,40(5):37383.PubMed

Abstract|Publisher

FullText
28. CollinC,etal.:TheBarthelADLIndex:areliabilitystudy.
IntDisabilStud1988,10(2):613.PubMed

Abstract
29. WadeDT,HewerRL:Functionalabilitiesafterstroke:measurement,naturalhistoryand
prognosis.
JNeurolNeurosurgPsychiatry1987,50(2):17782.PubMed

Abstract|Publisher

FullText|
PubMedCentralFullText
30. LoewenSC,AndersonBA:ReliabilityoftheModifiedMotorAssessmentScaleandthe
BarthelIndex.
PhysTher1988,68(7):107781.PubMed

Abstract|Publisher

FullText
31. PostMW,etal.:DutchinterviewversionoftheBarthelIndexevaluatedinpatientswith
spinalcordinjuries.
NedTijdschrGeneeskd1995,139(27):137680.PubMed

Abstract
32. HolbrookM,SkilbeckCE:Anactivitiesindexforusewithstrokepatients.
AgeAgeing1983,12(2):16670.PubMed

Abstract|Publisher

FullText
33. PiercyM,etal.:InterraterreliabilityoftheFrenchayactivitiesindexinpatientswith
strokeandtheircareers.
ClinRehabil2000,14(4):43340.PubMed

Abstract|Publisher

FullText

34. PostMW,deWitteLP:GoodinterraterreliabilityoftheFrenchayActivitiesIndexin
strokepatients.
ClinRehabil2003,17(5):54852.PubMed

Abstract|Publisher

FullText
35. ChenMH,etal.:Differencesbetweenpatientandproxyreportsintheassessmentof
disabilityafterstroke.
ClinRehabil2007,21(4):3516.PubMed

Abstract|Publisher

FullText
36. SegalME,SchallRR:Determiningfunctional/healthstatusanditsrelationtodisabilityin
strokesurvivors.
Stroke1994,25(12):23917.PubMed

Abstract
37. HellerA,etal.:Armfunctionafterstroke:measurementandrecoveryoverthefirst
threemonths.
JNeurolNeurosurgPsychiatry1987,50(6):7149.PubMed

Abstract|Publisher

FullText|
PubMedCentralFullText
38. DemeurisseG,DemolO,RobayeE:Motorevaluationinvascularhemiplegia.
EurNeurol1980,19(6):3829.PubMed

Abstract|Publisher

FullText
39. CameronD,BohannonRW:CriterionvalidityoflowerextremityMotricityIndexscores.
ClinRehabil2000,14(2):20811.PubMed

Abstract|Publisher

FullText
40. CollinC,WadeD:Assessingmotorimpairmentafterstroke:apilotreliabilitystudy.
JNeurolNeurosurgPsychiatry1990,53(7):5769.PubMed

Abstract|Publisher

FullText|
PubMedCentralFullText
41. KoppB,etal.:TheArmMotorAbilityTest:reliability,validity,andsensitivitytochange
ofaninstrumentforassessingdisabilitiesinactivitiesofdailyliving.
ArchPhysMedRehabil1997,78(6):61520.PubMed

Abstract|Publisher

FullText
42. VerheydenG,etal.:TheTrunkImpairmentScale:anewtooltomeasuremotor
impairmentofthetrunkafterstroke.
ClinRehabil2004,18(3):32634.PubMed

Abstract|Publisher

FullText
43. BergKO,etal.:Measuringbalanceintheelderly:validationofaninstrument.
CanJPublicHealth1992,83(Suppl2):S711.PubMed

Abstract
44. MaoHF,etal.:Analysisandcomparisonofthepsychometricpropertiesofthreebalance
measuresforstrokepatients.
Stroke2002,33(4):10227.PubMed

Abstract|Publisher

FullText

45. StevensonTJ,GarlandSJ:Standingbalanceduringinternallyproducedperturbationsin
subjectswithhemiplegia:validationofthebalancescale.
ArchPhysMedRehabil1996,77(7):65662.PubMed

Abstract|Publisher

FullText
46. BlumL,KornerBitenskyN:UsefulnessoftheBergBalanceScaleinstrokerehabilitation:
asystematicreview.
PhysTher2008,88(5):55966.PubMed

Abstract|Publisher

FullText
47. BergK,WoodDauphineeS,WilliamsJI:TheBalanceScale:reliabilityassessmentwith
elderlyresidentsandpatientswithanacutestroke.
ScandJRehabilMed1995,27(1):2736.PubMed

Abstract
48. SchoppenT,etal.:Physical,mental,andsocialpredictorsoffunctionaloutcomein
unilaterallowerlimbamputees.
ArchPhysMedRehabil2003,84(6):80311.PubMed

Abstract|Publisher

FullText
49. HoldenMK,etal.:Clinicalgaitassessmentintheneurologicallyimpaired.Reliabilityand
meaningfulness.
PhysTher1984,64(1):3540.PubMed

Abstract|Publisher

FullText
50. VosVromansDC,etal.:Theresponsivenessofthetenmeterwalkingtestandother
measuresinpatientswithhemiparesisintheacutephase.
PhysiotherTheoryPract2005,21(3):17380.PubMed

Abstract|Publisher

FullText
51. SalbachNM,etal.:Responsivenessandpredictabilityofgaitspeedandotherdisability
measuresinacutestroke.
ArchPhysMedRehabil2001,82(9):120412.PubMed

Abstract|Publisher

FullText
52. KollenB,KwakkelG,LindemanE:Hemiplegicgaitafterstroke:ismeasurementof
maximumspeedrequired?
ArchPhysMedRehabil2006,87(3):35863.PubMed

Abstract|Publisher

FullText
53. FolsteinMF,FolsteinSE,McHughPR:"Minimentalstate".Apracticalmethodfor
gradingthecognitivestateofpatientsfortheclinician.
JPsychiatrRes1975,12(3):18998.PubMed

Abstract|Publisher

FullText
54. TombaughTN,McIntyreNJ:Theminimentalstateexamination:acomprehensive
review.
JAmGeriatrSoc1992,40(9):92235.PubMed

Abstract
55. AppelrosP,AnderssonAG:ChangesinMiniMentalStateExaminationscoreafter
stroke:lacunarinfarctionpredictscognitivedecline.

EurJNeurol2006,13(5):4915.PubMed

Abstract|Publisher

FullText
56. MeijerR,vanLimbeekJ,deHaanR:DevelopmentoftheStrokeunitDischargeGuideline:
choiceofassessmentinstrumentsforpredictioninthesubacutephasepoststroke.
IntJRehabilRes2006,29(1):18.PubMed

Abstract|Publisher

FullText
57. WilsonB,CockburnJ,HalliganP:Developmentofabehavioraltestofvisuospatial
neglect.
ArchPhysMedRehabil1987,68(2):98102.PubMed

Abstract
58. vanKesselME,etal.:Visuospatialasymmetryandnonspatialattentioninsubacute
strokepatientswithandwithoutneglect.
Cortex2010,46(5):602612.PubMed

Abstract|Publisher

FullText
59. AgrellBM,DehlinOI,DahlgrenCJ:Neglectinelderlystrokepatients:acomparisonof
fivetests.
PsychiatryClinNeurosci1997,51(5):295300.PubMed

Abstract|Publisher

FullText
60. BaileyMJ,RiddochMJ,CromeP:Evaluationofatestbatteryforhemineglectinelderly
strokepatientsforusebytherapistsinclinicalpractice.
NeuroRehabilitation2000,14(3):139150.PubMed

Abstract|Publisher

FullText
61. JehkonenM,etal.:Howtodetectvisualneglectinacutestroke.
Lancet1998,351(9104):7278.PubMed

Abstract|Publisher

FullText
62. vanHeugtenCM,etal.:Adiagnostictestforapraxiainstrokepatients:internal
consistencyanddiagnosticvalue.
ClinNeuropsychol1999,13(2):18292.PubMed

Abstract
63. ZwinkelsA,etal.:Assessmentofapraxia:interraterreliabilityofanewapraxiatest,
associationbetweenapraxiaandothercognitivedeficitsandprevalenceofapraxiaina
rehabilitationsetting.
ClinRehabil2004,18(7):81927.PubMed

Abstract|Publisher

FullText
64. HuberW,PoeckK,WillmesK:TheAachenAphasiaTest.
AdvNeurol1984,42:291303.PubMed

Abstract
65. DeelmanBG,etal.:Measurementsofaphasicdisorders.AbriefdescriptionoftheSAN
battery.
Gerontologie1980,11(1):1721.PubMed

Abstract

66. CummingsJL,etal.:TheNeuropsychiatricInventory:comprehensiveassessmentof
psychopathologyindementia.
Neurology1994,44(12):230814.PubMed

Abstract
67. AngelelliP,etal.:Developmentofneuropsychiatricsymptomsinpoststrokepatients:a
crosssectionalstudy.
ActaPsychiatrScand2004,110(1):5563.PubMed

Abstract|Publisher

FullText
68. HamaS,etal.:Depressionorapathyandfunctionalrecoveryafterstroke.
IntJGeriatrPsychiatry2007,22(10):104651.PubMed

Abstract|Publisher

FullText
69. JongenelisK,etal.:Constructionandvalidationofapatientanduserfriendlynursing
homeversionoftheGeriatricDepressionScale.
IntJGeriatrPsychiatry2007,22(9):83742.PubMed

Abstract|Publisher

FullText
70. HaysRD,SherbourneCD,MazelRM:TheRAND36ItemHealthSurvey1.0.
HealthEcon1993,2(3):21727.PubMed

Abstract|Publisher

FullText
71. RAND:RAND36itemHealthSurveyscoringinstructions.
[http://www.rand.org/health/surveys_tools/mos/mos_core_36item.html]webcite
1992.
72. VanderZeeKI,etal.:PsychometricqualitiesoftheRAND36ItemHealthSurvey1.0:a
multidimensionalmeasureofgeneralhealthstatus.
IntJBehavMed1996,3(2):10422.PubMed

Abstract|Publisher

FullText
73. ScholtenJHG,WCv:Functionalstatusassessmentinfamilypractice:theDartmouthCOOP
FunctionalHealthAssessmentCharts/WONCA.EditedbyMeditekst.Lelystad;1992.
74. NelsonE,etal.:Assessmentoffunctioninroutineclinicalpractice:descriptionofthe
COOPChartmethodandpreliminaryfindings.
JChronicDis1987,40(Suppl1):55S69S.PubMed

Abstract|Publisher

FullText
75. vanWeelC,KZC,TouwOttenFWMM,vanDuijnNP,MeyboomdeJongB:Measuring
functionalhealthstatuswiththeCOOP/WONCAcharts,amanual.
Groningen1995.
76. IlseIB,etal.:Strokecaregivers'strain:prevalenceanddeterminantsinthefirstsix
monthsafterstroke.
DisabilRehabil2008,30(7):52330.PubMed

Abstract|Publisher

FullText
77. RobinsonBC:ValidationofaCaregiverStrainIndex.

JGerontol1983,38(3):3448.PubMed

Abstract|Publisher

FullText
78. WilkinsonPR,etal.:Alongtermfollowupofstrokepatients.
Stroke1997,28(3):50712.PubMed

Abstract|Publisher

FullText
79. TanjiH,etal.:MutualityofthemaritalrelationshipinParkinson'sdisease.
MovDisord2008,23(13):18439.PubMed

Abstract|Publisher

FullText
80. TsaiSM,WangHH:Therelationshipbetweencaregiver'sstrainandsocialsupport
amongmotherswithintellectuallydisabledchildren.
JClinNurs2009,18(4):53948.PubMed

Abstract|Publisher

FullText
81. DonnellyM,etal.:Oesophagealcancer:caregivermentalhealthandstrain.
Psychooncology2008,17(12):1196201.PubMed

Abstract|Publisher

FullText
82. PeduzziP,etal.:Asimulationstudyofthenumberofeventspervariableinlogistic
regressionanalysis.
JClinEpidemiol1996,49(12):13739.PubMed

Abstract|Publisher

FullText