2021-9-Oct-Stroke Predictores

European Journal of Physical and Rehabilitation Medicine
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Prognostic value of balance performance for improvements

of community ambulation among stroke patients: a cohort
study.
Francesc MEDINA-MIRAPEIX, Mª José CRISOSTOMO, Rodrigo MARTíN-SAN
AGUSTíN, Mª Piedad SáNCHEZ-MARTíNEZ
European Journal of Physical and Rehabilitation Medicine 2021 Sep 09

DOI: 10.23736/S1973-9087.21.06996-3
Article type: Original Article
© 2021 EDIZIONI MINERVA MEDICA
Article first published online: September 9, 2021

Manuscript accepted: August 31, 2021
Manuscript revised: July 20, 2021
Manuscript received: April 8, 2021
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Title: Prognostic value of balance performance for improvements of community

ambulation among stroke patients: a cohort study.
Running title: Prognostic value of balance performance
Francesc Medina-Mirapeix1, Mª José Crisostomo2, Rodrigo Martín San Agustín3*,

Mª Piedad Sánchez-Martínez1.
1
Department of Physical Therapy, University of Murcia, 30100 Murcia, Spain;
mirapeix@um.es; mariapiedad.sanchez1@um.es
2
Department of Rehabilitation, Jerez Hospital, Jerez de la Frontera, Spain;
mjcriso@gmail.com
3
Department of Physical Therapy, University of Valencia, 46010 Valencia, Spain;
rodrigo.martin@uv.es
* Corresponding author: Rodrigo Martín-San Agustín, Department of Physiotherapy,

Calle Gascó Oliag, 5. PC: 46010, Valencia (Spain). E-mail: rodrigo.martin@uv.es Tel.
+34 963 983 853 Fax +34 963 983 852
ABSTRACT
BACKGROUND: Despite the positive impact of improving the level of community
ambulation among stroke patients, little prognostic research has focused on this indicator.
AIM: To investigate the prognostic value of the side-by-side, semi-tandem, and tandem
standing balance positions and the five-sit-stand (5STS) test for discriminating patients
undergoing physical rehabilitation who improve level of functional ambulation and
predicting transition time.
DESIGN: A cohort study with assessments repeated monthly until discharge for classifying
patients in a community ambulation class.
SETTING: A neurological rehabilitation unit of a hospital in Spain.
POPULATION: A consecutive sample of 109 stroke patients (68.5 ±12.0 years) was
screened and included within four months post stroke. Of them no one refused, 3 died, and
5 were lost earlier to transition or discharge.
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METHODS: Balance tests, the 5STS and gait speed were measured at the center at baseline
and monthly until discharge. Transition from household or limited community ambulation
to a higher ambulatory capacity or class. Area under the curve (AUC) were used to compare
discriminative abilities of the tests and Cox regression analysis to evaluate the association
between the tests and time of transition.
RESULTS: For household non-ambulators, the semi-tandem was the best discriminative
test (AUC=0.850) and the three balance tests showed an association with time to transition.
Among the limited community ambulators, the 5STS test also revealed discriminative
ability (AUC: 0.822 [0.63-1.00]), with a good prognostic cut-off (14.8 seconds) and
association with time to transition (Hazard Ratio: 1.22; 95%CI: 1.05-1.43).
CONCLUSIONS: Semi-tandem and the 5STS tests can discriminate patients who improve
level of functional ambulation and predict transition times within three months in non-
ambulators and limited community ambulation patients, respectively.
CLINICAL REHABILITATION IMPACT: The semi-tandem and the 5STS tests can be
performed easily in clinical settings to predict improvement of functional ambulation level
in patients following stroke.
Key Words: Postural Balance; Stroke Rehabilitation; Walking; Transitions.
Introduction
For rehabilitation professionals and stroke patients undergoing physical rehabilitation, the
restoration of community ambulation is the most important goal.1,2 In spite of efforts, many
patients who are classified as non-ambulators, household ambulators (<0.4 m/s) or limited
community ambulators (between 0.4 and 0.8 m/s) at the beginning of physical rehabilitation
are not able to be full community ambulators (>0.8 m/s) again.1,3–5 Nevertheless, some
studies reported that about half of these patients improved to a higher level of ambulation
within three months (e.g., from household ambulation to limited community ambulation),
and that transitioning was associated with substantially better function and quality of life.5
Despite the positive impact of improving the level of community ambulation among stroke
patients, little is known about transition rates that take place later than three months in
physical rehabilitation. Often more attention is paid to known rates of other indicators of
gait recovery such as gait speed, walking distance or asymmetrical gait parameters.1,6–11
Likewise, prognostic research has also focused on these gait recovery indicators,12–16 for
identifying prognostic factors such as balance12,13 and muscle strength of lower
extremities,14 regardless of age12 and the initial gait speed.5,13,15 Nevertheless, there is still
no confirmation as to whether these factors also have value for transition to a higher class
of ambulation. This paper wanted to test prognostic ability of the five-sit-to-stand (5STS)
test and the three balance tests included in the Short Physical Performance Battery (SPPB).17
We selected the 5STS because it evaluates a functional task that requires both lower limb
strength and efficient balance control.18–21 We deemed those three isolated balance tests
because multi-item scales (eg. Berg balance scale) have floor effects among household
ambulators.22
The main aim of this study was to investigate the prognostic value of three isolated standing
balance positions17 and the 5STS test for discriminating patients undergoing physical
rehabilitation who improve level of functional ambulation and predicting transition time. A
secondary aim was to determine transition rates over time beyond three months. We
hypothesized that (1) the prognostic value of these tests would differ according to the
baseline level of community ambulation; (2) within each baseline ambulation class, patients
with good balance performance will transition faster than patients with poor balance
performance.
Materials and methods
Study design
A cohort study was conducted including patients with a first episode of stroke admitted to
the Rehabilitation Service of the Jerez Hospital (Spain) between October 2016 and October
2018 to participate in a physical rehabilitation after receiving acute stroke care at that
hospital or nearby. Assessments were made within two days of admission and repeated
monthly until the patient transitioned to the level of full community ambulation or
discharge. The study protocol was approved by the Ethical Committee of the Jerez Hospital
(approval number: EST-42/16).
Participants
Participants were prospectively recruited and screened. The inclusion criteria included:
patients who (1) were at least 30 years, (2) and were screened within four months post
stroke. The following exclusion criteria were applied: patients who were full community
ambulators at baseline (>0.8 m/s), those who remembered having a gait speed lower than
0.8 m/s (e.g., more than 8 s for 10 m) during the month before the stroke, or subjects who
displayed cognitive or language impairments (in the subscales of the Cognistat).23 The first
exclusion criterion was established because no transitioning would be possible. The pre-
stroke gait speed criterion was established to avoid the possibility of limited recovery of
ambulation due to a poor ambulation status or additional neurological impairments prior to
the stroke. The cognitive and language criteria were based on the need to ensure that patients
could provide reasonable answers. All study patients provided written informed consent.
Outcome measure
The primary outcome measurement used was the first improvement transition, without
relapse before discharge, to a higher class of ambulation in the Perry’s classification, which
established three categories: household ambulators (<0.4 m/s), limited community
ambulators (between >0.4 m/s and <0.8 m/s) and full community ambulators (>0.8m/s).3
Transition (yes/no) was defined when participants shifted from household to limited
community, and from limited ambulation to full community ambulation. Time (months)
from the beginning of physical rehabilitation to transition was also recorded. We canceled
transitions with relapse, i.e., when they were followed by a transition to a lower class before
discharge.
Tests and other characteristics

Balance tests, the 5STS and gait speed were measured at the center at baseline and monthly
until discharge. In addition, at baseline, five characteristics (age, sex, type of the stroke, side
affected and time from stroke to admission) were collected from medical records in order
to describe participants. Moreover, because age and time from stroke have been associated
with gait speed,12–14 they were also used to control the association of the examined tests
with the time to transitioning.
The balance tests included different standing positions. Standing positions were evaluated
in three progressively more difficult stances regarding the SPPB: (a) feet side-by-side,
touching; (b) semi-tandem, the side of the heel of one foot touching the big toe of the other
foot; and (c) tandem, the heel of one foot directly in front of and touching the toes of the
other foot. If the participant held a stance for 10 seconds, he/she was asked to try the next
more difficult position.17,24
The 5STS test was measured as the time taken to complete 5 repetitions of the sit-to-stand
task. All sit-to-stand tasks were performed from a chair without an arm rest.18 Participants
unable to complete five repetitions within 1 min were given a score of 60 s, as in previous
research.25
Gait velocity was assessed with a 4-m gait speed test and reported in m/s. Subjects were
asked to complete the 4-m walk at their ‘‘most comfortable speed’’,26 and a stopwatch
recorded the time. Timing began after an acceleration distance of 1m and ceased as they
crossed a finish line. Subjects performed two trials, and the faster time was recorded.27
Patients unable to walk were classified as household non-ambulators.
Statistical analysis
Participants’ characteristics at admission were summarized for the whole sample and by
each level of community ambulation. In total, three groups were established: household
ambulator, non-ambulators and limited community ambulators (Table 1). Chi-square and
ANOVA tests were used to compare baseline characteristics between these three groups.
The percentages of transitioning of these three groups to a higher ambulation class, and time
to transitioning was described by Kaplan-Meier survival curves and compared by the log
rank test.
Subsequently, we tested the prognostic value of the examined tests in each group (household
ambulator, non-ambulators and limited community ambulators). First, the area under the
ROC curve (AUC) and predictive likelihood ratios (LRs) were used to assess the ability of
balance tests and 5STS to discriminate individual participant’s transition to a higher
ambulation class at two points in time: at three months and at discharge.28 The AUCs were
compared by DeLong’s test. The LRs were based on the optimal cut-off point of the ROC
curve, which was identified by the maximal Youden Index calculated as (sensitivity +
specificity - 1) and compared. Second, multivariate Cox regression analysis adjusted by the
selected covariates (age and time since stroke) were performed to estimate the hazard ratios
(HRs) and 95% confidence intervals (CIs) of the balance tests and 5STS for each level of
community ambulation.
Finally, for those groups with a discriminative test (AUC>0.8), we also calculated Kaplan-
Meier survival curves and compared with the log rank test whether patients with high
balance performance (defined by the optimal cut-off point identified previously)
transitioned faster than patients with poor balance performance. All analyses were
performed using the Statistical Package for the Social Sciences (SPSS) version 24.0 (IBM
SPSS, Chicago, IL, USA). A two-sided P<0.05 was considered significant.
Results
Patient characteristics
In total, 123 stroke patients were screened for inclusion. Figure 1 shows the reasons for
exclusion of 14 patients. Table 1 summarizes relevant patient characteristics and baseline
balance measurements of the 109 patients according to ambulation class. The mean age was
68.5 (SD=12.0), 55% of the subjects were male and 83.5% had an ischemic stroke. The
mean time since stroke onset was 52.1 days (SD=31.4). Only a percentage of patients were
able to complete the balance tests (range 70.7% for side-by-side to 40.4% for tandem stand)
and/or the 5STS test (46.8%).
Figure 1.⎯ Flowchart of patients who met inclusion/exclusion criteria for the study
population.
Table I.⎯ Baseline demographics and overall stroke patient characteristics in total and separated by level
of community ambulation.
Level of community ambulation
Household Limited
All Community P-
Variable
(n=109) Non- (n=32) Value
Ambulators
ambulators
(n=33)
(n=44)
Demographics
Age, y 68,5(12,0) 69,45(12,3) 71,0(10,7) 64,6(12,2) 0,079
Male, n(%) 60(55) 24(54,5) 16(48,5) 20(62,5) 0,523
Stroke characteristics
Side affected (right), n(%) 57(52,3) 27(61,4) 12(36,4) 18(56,3) 0,082
Type of stroke (ischemic), n(%) 91(83,5) 37(84,1) 27(81,8) 27(84,4) 0,953
Time from stroke to admission, 52,1(31,4) 50,8(31,5) 56,0(32,7) 50,0(30,6) 0,709
days
Standing balance tests
Side-by-side position
Patients able to stand ≥1s, n(%) 77(70,7) 13(29,5) 32(97) 32(100) <0.001
time (s) 6,86(4,55) 2,75(4,39) 9,3(2,15) 10,0(0) <0.001
Semi-tandem position
Patients able to stand ≥1s, n(%) 69(63,3) 9(20,5) 29(87,9) 31(98,9) <0.001
time (s) 5,83(4,73) 1,57(3,42) 7,9(3,63) 9,56(1,88) <0.001
Tandem position
Patients able to stand ≥1s, n(%) 44(40,4) 2(4,6) 14(42,4) 28(87,5) <0.001
time (s) 3,2(4,38) 0,40(1,89) 3,39(4,38) 6,85(4,16) <0.001
5STS
Patients able to do it, n(%) 51(46,8) 4(9,1) 18(54,5) 29(90,6) <0.001
time (s) 40,34(21,63) 56,65(10,77) 39,19(20,35) 19,11(14,06) <0.001
Gait speed, m/s 0,31(0,2) 0(0) 0,29(0,06) 0,59(0,12) <0.001
5STS indicates five-repetition sit-to-stand. Values are mean (SD) where appropriate.
A total of 44 (40.36%) patients were classified as household non-ambulators, and 32 of the
65 ambulators were limited community ambulators. These patient groups did not display
significant differences in demographic and clinical characteristics, although they did present
significant differences in their assessments. For the four examined tests, the three groups
showed significant differences regarding both mean time (P-values <0.001) and number of
patients able to do them (P-values <0.001).
Of the 109 patients who were enrolled at admission, 55 (50.5%) transitioned to a higher
ambulation class before discharge, and 8 (7.4%) dropped out earlier (7 dropped out in the
first three months). The demographic and stroke baseline characteristics of these 8 patients
did not significantly differ from the 101 patients who continued throughout the study until
discharge (P-value ranged between 0.208 and 0.814).
Transition rates in patients of each ambulation class

The Kaplan-Meier plot (Figure 2) shows that the level of community ambulation was
associated with a reduction of transition time (X2[2]=28.92 log rank; P<0.001). The
cumulative percentage of transitions in household non-ambulators increased more slowly
over time, and their rates of transitioning at three months and at discharge were 26.1% and
45.1%, respectively. Among ambulators the cumulative percentage of transitions for
household ambulators increased slightly faster than limited community ambulators upon the
three months, and this percentage was also higher for household patients at this time (85.3%
and 63.2%, respectively).
Figure 2.⎯ Cumulative percentage of transitioning to a higher ambulation class by months:

household non-ambulators (dashed line), household ambulators (solid line) and limited community
ambulators (dotted line).
Prognostic value of the tests in patients of each ambulation class

Table 2 shows AUCs and cut-off values of balance tests and the 5STS for discriminating
transitions at three months and at discharge. For household non-ambulators, side-by-side
standing and semi-tandem standing positions showed discriminative ability (AUCs>0.7) for
the ability to transition at these two time-points, however the semi-tandem position showed
better AUCs. The optimal cut-off points of this test (stand for 1s), which was the same at
three months and at discharge, also provided more positive LRs than the cut-off points of
the side-by-side standing position for transitioning at these two points in time (7.46 vs. 5.71
at discharge; >10 vs. 4.67 at three months). For household ambulators, all tests showed
AUCs<0.7 (values not showed in table 3). In contrast, for limited community ambulators
the 5STS test showed AUCs>0.8 at three months and again at discharge. The cut-off rates
for the 5-STS test (14.8s) were the same at two points in time, because they had similar
rates.
Table II.⎯Areas under curve (AUC) and cut-off values of standing balance tests and the 5STS for discriminating transitioning at
3-months and at discharge, and their statistics indicators.
Baseline
ambulation Time Tests AUC* 95% CI Cut-off Sensitivity Specificity LR + 1/LR-
class
Side-by-side position(s) 0,779 0,54-1,00 5 0,70 0,85 4,67 2,84
At 3-months Semi-tandem position(s) 0,850 0,66-1,00 1 0,70 1,00 >10 3,33
Household Tandem position(s) 0,600 0,32-0,87 3,9 0,20 1,00 >10 1,25
non-
ambulators Side-by-side position(s) 0,721 0,54-0,89 8,5 0,57 0,9 5,71 2,12
At discharge Semi-tandem position(s) 0,726 0,54-0,90 1 0,50 0,93 7,46 1,88
Tandem position(s) 0,571 0,38-0,76 3,9 0,14 1,00 >10 1,16
Limited At 3-months 5STS (s) 0,822 0,63-1,00 14,8 0,78 0,80 3,90 3,63
community
ambulators At discharge 5STS (s) 0,857 0,71-1,00 14,8 0,78 0,86 5,44 4,00
AUC indicates area under the curve; CI, confidence interval; LR, likelihood ratio; 5STS: five-repetition sit-to-stand.
*Only tests con AUC>0.55 are shown (Tests for household ambulators are not shown because this reason).
Figure 3 shows a forest plot of the HRs and their 95%CI -adjusted by age and time since
stroke- of the balance tests and 5STS with time to transitioning in participants of each
ambulation class. For household non-ambulator patients, the three standing balance
positions revealed lower limits of 95%CI of their HRs higher than 1 (P<0.05) and were
associated to transitioning to a higher class of ambulation. The 5STS test was not associated
with time to transitioning in this group. In contrast, the 5STS test was associated with limited
community ambulators (HR: 1.22; 95%CI: 1.05-1.43), although the standing balance
positions did not. None of the four tests showed an association with transition time among
household ambulators.
Figure 3 .⎯ Hazard ratios (and 95%CI) of the standing balance tests and the 5STS with
time to transitioning according to ambulation class at baseline (adjusted by age and time
since stroke). *HRs could not be calculated because all patients did the test.
Rates of improvement in patients with good and poor balance performance

Figure 4a shows how those household non-ambulators able to stand >1s in semi-tandem
positions (the best discriminative test) transitioned to a higher ambulation class at a
significantly faster rate compared to these unable to perform this test (X2(1)=15.75 log rank;
P<0.001). At three months patients with a better performance in this test had higher rates of
improvements than patients with poor performance (77.8% vs 26.1%). Figure 4b shows how
limited community ambulators who were able to complete the 5STS test <14.8s required
significantly less time to transition to full community ambulators than those unable to do so
(X2(1)=15.98 log rank; P<0.001).
Figure 4 .⎯ Cumulative percentage of transitioning to a higher ambulation class by months:

4a) household non-ambulators patients able (solid line) or not (dotted line) to standing in
the semi-tandem position ≥1s; 4b) limited community patients able (solid line) or not (dotted
line) to complete the 5STS in ≤14.8 s.
Discussion
We found that many patients from the household ambulators and limited community class
transitioned at around three months after admission to the physical rehabilitation, however,
only a quarter of household non-ambulators transitioned at that time. After three months,
only household non-ambulators increased their transition rates. For these patients, the semi-
tandem was the best test for discriminating patients who improve level of functional
ambulation at three months and again at discharge, but all standing balance tests showed an
association with transition time. The 5STS test also had good these discriminative and
predictive properties among limited community ambulators.
Balance, age and days since stroke onset were previously reported as key determinants of
certain gait recovery indicators after stroke.13,19,29–33 Our study confirmed that these factors
are also determinants for discriminative and predictive purposes with transitions of
functional ambulation. On the one hand, we found that by using a cut-off point in side-by-
side and semi-tandem stance positions it is possible to discriminate between household non-
ambulators who are able to transition at three months and at the discharge and those who
fail to transition. Our indicators of sensitivity and specificity at three months were similar
or higher than those reported for the Berg balance scale for discriminating non-ambulator
stroke patients who achieved unassisted walking.24,29
As expected, our study also found that the 5STS test was not relevant for household
ambulators and non-ambulators because many of these patients were not able to perform
the test on admission. In contrast, as expected, the 5STS had a greater discriminative
capacity among the limited community ambulators. To our knowledge, this is the first study
that shows the discriminative value of the 5STS on the appearance of certain events over
time for stroke patients. Previous studies have only reported the cross-sectional ability for
discriminating patients with differing ambulatory capacity (e.g., discriminating limited or
full community ambulators), with similar values of sensitivity and specificity to our study.19
Another novelty of our study is that we found that the 5STS in the case of limited community
ambulators had a prognostic value for achieving earlier transitioning to a higher ambulation
class.
At three months, we found higher cumulative percentages of transitions to a higher
ambulation class for household ambulators and limited community ambulators compared to
those previously reported by Schmid et al.5 Beyond three months, our study showed that
hardly any transitions took place among both household ambulators and limited community
ambulators. Our results are consistent with previous studies that reported that the maximum
walking improvement after a stroke is achieved during the first three months.1,6,7
Previous studies showed that a quarter of non-ambulators can achieve unassisted walking at
three months.24,29,30 Because unassisted walking is theoretically a less difficult task for non-
ambulator stroke patients than transitioning to the limited community ambulation category,
we expected the cumulative percentage of transitions at three months to be lower than 25%.
Surprisingly, our study showed that a quarter of those patients were able to transition at
three months.
Implications for practice and research

Previous literature has reported that gait speed can continue to improve over the first six
months when undergoing a physical rehabilitation.6,30 In spite of this overall evidence, our
results added that it is unexpected for household ambulators and limited community patients
to attain a higher level of ambulation beyond the first three months.
Furthermore, our findings reveal that the side-by-side and semi-tandem stance positions,
and the 5STS had prognostic value for household non-ambulators and limited community
ambulators, respectively. This supports the use of these tests. They are also very useful when
time and space is limited in clinical settings as they can be performed rapidly. Given the
prognostic relevance of these tests, future research is necessary to analyze whether they
could be incorporated into predictive models.
Strengths and limitations

This study has several strengths. First, we explored the prognostic value of multiple tests on
three groups with differing ambulatory abilities. One of the positive consequences of this
design was that it enabled us to observe how the tests had different prognostic values for
each group, which, to our knowledge is a novel finding to date. Second, we used different
indicators to analyze the discriminative ability of tests (AUCs, sensitivity, specificity and
positive and negative LRs).
This study also has some limitations. First, as our study was developed at a single hospital
and included a small number of patients, generalizations should be made with caution.
Second, we imputed times for patients who failed to complete the 5STS. Thus, we did not
compare unable vs. able to complete the 5STS. Third, other measures that may impact
improvement during rehabilitation and overall walking function were not included as
covariates. For example, lower extremity impairment (somatosensorial, spasticity) was not
specifically measured yet may impact balance and walking ability.29 Finally, the lack of a
validation of our results in other independent sample of stroke patients and/or with another
additional method for measuring gait speed. While other researchers used the 10 m walking
test timed with a stopwatch for analyzing transition to a higher class of ambulation,5 we
used the 4-m gait speed test. Until that validation, our results should be considered
provisional. Given our current good results and the reasons for our test selection, we would
expect that new studies will provide validity and enough adequacy of the 4-m gait speed
test to sub-acute patients. On the one hand, we selected this test because shorter distances
(e.g., 5m) are more recommended to detect longitudinal change over time than longer
distances (e.g., 10m) in sub-acute stroke patients,34 which were our study aim and study
population, respectively. Reasons for a lower responsiveness of the 10m walking test may
be due to the fact that some of these patients were unable to maintain speed over those
distances because of reduced active movement or muscular endurance.34 On the other hand,
instead of the frequently used 5-m gait speed test,27,34 the 4-m test was chosen because it is
a component of the SPPB, which includes the balance test and the 5-STS test as components
as well.17
Conclusions
In summary, only a few of the household non-ambulators transitioned beyond the three
months. Semi-tandem and the 5STS tests can discriminate patients who improve level of
functional ambulation and predict transition times within three months in non-ambulators
and limited community ambulation patients, respectively. However, further studies are
required to determine the prognostic value of these tests for household ambulators.
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Conflicts of interest.⎯ The authors certify that there is no conflict of interest with any
financial organization regarding the material discussed in the manuscript.
Funding.⎯ The authors report no involvement in the research by the sponsor that could
have influenced the outcome of this work.
Authors’ contributions.⎯ Author F.M.-M. and author M.J.C have given substantial
contributions to the conception or the design of the manuscript, author M.P.S.M and author
R.M.-S to acquisition, analysis and interpretation of the data. All authors have participated
to drafting the manuscript, author F.M.-M. revised it critically. All authors read and
approved the final version of the manuscript.
Acknowledgements.⎯ The authors acknowledge the neurology team of the Rehabilitation

Service of the Jerez Hospital for proofreading activity.

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European Journal of Physical and Rehabilitation Medicine

EDIZIONI MINERVA MEDICA

Prognostic value of balance performance for improvements

European Journal of Physical and Rehabilitation Medicine 2021 Sep 09

Article type: Original Article

© 2021 EDIZIONI MINERVA MEDICA

Article first published online: September 9, 2021

Subscription: Information about subscribing to Minerva Medica journals is online at:

EDIZIONI MINERVA MEDICA

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Title: Prognostic value of balance performance for improvements of community

Running title: Prognostic value of balance performance

Francesc Medina-Mirapeix1, Mª José Crisostomo2, Rodrigo Martín San Agustín3*,

* Corresponding author: Rodrigo Martín-San Agustín, Department of Physiotherapy,

BACKGROUND: Despite the positive impact of improving the level of community

undergoing physical rehabilitation who improve level of functional ambulation and

predicting transition time.

patients in a community ambulation class.

SETTING: A neurological rehabilitation unit of a hospital in Spain.

5 were lost earlier to transition or discharge.

between the tests and time of transition.

association with time to transition (Hazard Ratio: 1.22; 95%CI: 1.05-1.43).

ambulators and limited community ambulation patients, respectively.

performed easily in clinical settings to predict improvement of functional ambulation level

in patients following stroke.

Key Words: Postural Balance; Stroke Rehabilitation; Walking; Transitions.

identifying prognostic factors such as balance12,13 and muscle strength of lower

Materials and methods

(approval number: EST-42/16).

ambulation due to a poor ambulation status or additional neurological impairments prior to

established three categories: household ambulators (<0.4 m/s), limited community

Tests and other characteristics

with the time to transitioning.

more difficult position.17,24

Patients unable to walk were classified as household non-ambulators.

balance tests and 5STS to discriminate individual participant’s transition to a higher

balance performance (defined by the optimal cut-off point identified previously)

SPSS, Chicago, IL, USA). A two-sided P<0.05 was considered significant.

exclusion of 14 patients. Table 1 summarizes relevant patient characteristics and baseline

and/or the 5STS test (46.8%).

A total of 44 (40.36%) patients were classified as household non-ambulators, and 32 of the

patients able to do them (P-values <0.001).

discharge (P-value ranged between 0.208 and 0.814).

Transition rates in patients of each ambulation class

cumulative percentage of transitions in household non-ambulators increased more slowly

45.1%, respectively. Among ambulators the cumulative percentage of transitions for

and 63.2%, respectively).

Figure 2.⎯ Cumulative percentage of transitioning to a higher ambulation class by months:

Prognostic value of the tests in patients of each ambulation class

transitions at three months and at discharge. For household non-ambulators, side-by-side

Rates of improvement in patients with good and poor balance performance

positions (the best discriminative test) transitioned to a higher ambulation class at a

(X2(1)=15.98 log rank; P<0.001).

Figure 4 .⎯ Cumulative percentage of transitioning to a higher ambulation class by months:

predictive properties among limited community ambulators.

stroke patients who achieved unassisted walking.24,29

discriminating patients with differing ambulatory capacity (e.g., discriminating limited or

At three months, we found higher cumulative percentages of transitions to a higher

Implications for practice and research

to attain a higher level of ambulation beyond the first three months.

could be incorporated into predictive models.

Strengths and limitations

positive and negative LRs).