Journal of the Formosan Medical Association 121 (2022) 670e678

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Original Article

Prognostic factors of functional outcome in

post-acute stroke in the rehabilitation unit
Wei-Chieh Chen b, Ming-Yen Hsiao a,b,*, Tyng-Guey Wang a,b

a
Department of Physical Medicine and Rehabilitation, College of Medicine, National Taiwan
University, Taipei, Taiwan
b
Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei,
Taiwan

Received 28 September 2020; received in revised form 2 July 2021; accepted 5 July 2021

KEYWORDS Background/Purpose: This retrospective study aimed to determine which factors, such as
Stroke; cognition, motor recovery, swallowing function, and bladder and bowel functions, significantly
Rehabilitation ward; predicted independence in the activities of daily living (ADL) at hospital discharge in a domes-
Prognostic factor; tic population of patients experiencing post-acute stroke who received in-hospital
Functional outcome; rehabilitation.
Neurorehabilitation Methods: We reviewed medical records that were retrieved from the Integrated Medical Data-
base, National Taiwan University Hospital (NTUH-iMD) of 3000 patients who suffered from
stroke and were admitted to NTUH from 2014 to 2017. The main outcome measure was inde-
pendence in the basic ADL (modified Barthel index [mBI]) at discharge. Regression analyses
were used to identify prognostic factors for the basic ADL (mBI).
Results: The total mBI improved from 40.7  33.0 to 63.1  34.1 in eligible 2538 patients dur-
ing their hospital stay. The baseline daily activity function (R2 change Z 0.042) was the most
important prognostic factor associated with independence at discharge, followed by depen-
dence in sitting up (R2 change Z 0.014), impaired sitting balance (R2 change Z 0.010), the
Brunnstrom stage of hemiplegic lower limb (R2 change Z 0.006), and the presence of bladder
incontinence (R 2 change Z 0.006) assessed by physician upon rehabilitation admission
(R2 Z 0.53, p < 0.05). Dependency in sitting up, impaired sitting balance, and the presence
of urinary incontinence were negative prognostic factors of ADL independence at discharge
(p < 0.05). By contrast, the Brunnstrom stage of hemiplegic lower limb and baseline mBI scores
at rehabilitation admission were positive prognostic factors of ADL independence at discharge
(p < 0.05).
Conclusion: Baseline ADL function was the most important prognostic factor of functional in-
dependence in post-acute stroke. Moreover, the activity limitation of dependency on sitting up
and motor function impairment of hemiplegic lower limb prognosticated functional indepen-
dence.

* Corresponding author. Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital and National Taiwan
University College of Medicine, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City 100, Taiwan.
E-mail address: myferrant@gmail.com (M.-Y. Hsiao).

https://doi.org/10.1016/j.jfma.2021.07.009
0929-6646/Copyright ª 2021, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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 Journal of the Formosan Medical Association 121 (2022) 670e678
Copyright ª 2021, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
Introduction
Stroke leads to limitations in daily functional activities and
is a frequent cause of death in the adult population
worldwide.1e3 It results in significant impairment in multi-
ple systems, including motor, sensory, swallowing, balance
and gait, visualespatial processing, cognition and psychia-
try, and bladder and bowel functions.4 Early and intensive
inpatient rehabilitation during the acute and subacute
stages has shown evidence for better functional outcomes
and is, hence, strongly recommended.1,3,5 Systemic reviews
and meta-analyses indicated the positive effect of reducing
death and facilitating independence in the stroke unit.
However, most studies had small patient numbers and
moderate heterogeneity.6,7 Moreover, several studies could
not identify the most important prognostic factors of the
functional outcome because of methodological flaws and
patient group heterogeneity. It is challenging to improve
functional status and achieve independence and discharge
disposition in such a limited time after stroke onset.1 From
the viewpoint of both patient care quality and cost-
effectiveness, there is an urgent need to identify charac-
teristics that define patients with a high potential for
functional improvement and possibly classify them based
on their particular treatment modality needs.
Most research on stroke patients is based on the Western
population.6,8 There is limited domestic data that provides
such prognostic information. Differences in ethnicity could
potentially have a significant influence on disease courses
and treatment responses. Stroke types also vary between
Asians and Caucasians, with a higher incidence of hemor-
rhagic stroke in Asian countries.9 Thus, the applicability of
results from Western literature to the Asian stroke popu-
lation is questionable. Most outcome studies were con-
ducted from the 1970s to the 1990s. With advances in
medical care, therapeutic interventions, and assistive
technologies, one might expect current stroke patients’
functional outcomes to be different from those observed
previously.
This study aimed to identify prognostic factors, such as
motor recovery, swallowing function, and functional ac-
tivity level evaluated clinically at bedside, and their asso-
ciation with the functional outcomes of activities of daily
living (ADL) after acute stroke in domestic population by
retrospectively reviewing the medical records of patients
who suffered from stroke and were admitted to the Na-
tional Taiwan University Hospital (NTUH). The International
Classification of Functioning, Disability, and Health (ICF)10
model was used to identify scales with relevant domains
for possible prognostic factors. The clinical evaluations of
body function impairment (cognition, motor, sensory,
swallowing, and sphincter function) and activity limitation
(functional activity level and ADL) in the ICF model were
selected as possible prognostic factors in patients with
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post-acute stroke, which are evaluated routinely at bedside
at our hospital.
Materials and methods
Study population
This study is part of a retrospective review study comprising
approximately 10,000 patients from 2007 to 2017 who were
diagnosed with cerebrovascular diseases and admitted to
the NTUH. The study was approved by the NTUH’s Research
Ethics Committee (Institutional Review Board: NTUH-REC
No.: 201806049RINC). The present study included the
medical records of 3000 patients from the latest admission
from 2014 to 2017.
The inclusion criteria were as follows:
1. Patients diagnosed with stroke, including ischemic and
hemorrhagic stroke.
2. Stroke onset within 3e6 months.
3. Patients admitted to the rehabilitation ward, neurology
ward, neurosurgery ward, internal medicine ward, or
family medicine ward.
4. Patients aged 20 years.
The exclusion criteria were as follows:
1. Previous stroke history, including infarction/hemor-
rhage/lacunar infarction.
2. Presence or history of intracranial tumor, with/without
tumor bleeding.
3. Presence or history of traumatic brain injury.
4. Presence or history of encephalopathy/myelopathy.
5. Presence or history of central nervous system infection/
inflammation.
6. Presence or history of degenerative central or peripheral
nervous system disease, including neuropathy, neuron-
opathy, or myopathy.
The data retrieved from the NTUH-iMD included basic
data (age and gender), diagnosis, and nursing records. As
most functional outcome information is recorded in the
abovementioned medical records, including the admission
and discharge notes, were reviewed.
The NTUH rehabilitation ward is a 60-bed general ward
with a multidisciplinary stroke care team. Indications for
admission to the rehabilitation ward included post-acute
stroke patients (time from the onset of stroke within 3e6
months), stable vital signs, clear consciousness (Glasgow
coma scale > 12), stationary neurological deficits for >2
days, and severe functional deficits with a modified Rankin
Scale of 4e5. Patients in the rehabilitation ward received
organized and intensive medical, nursing, and
 W.-C. Chen, M.-Y. Hsiao and T.-G. Wang
rehabilitative care. After a detailed history review, phys-
ical and neurological examinations; functional assess-
ment; physical, occupational, and speech rehabilitation;
and swallowing therapy were prescribed depending on the
patient’s condition. Each patient received 30e40 min of
each therapy per day, five times per week.
Clinical variables and measurement of outcome
On the first day of admission, each patient underwent a
thorough medical history resubmission, physical examina-
tion, and a series of clinical evaluations, including cogni-
tive,11,12 swallowing,13 sphincter,14,15 motor,3,16 sensory,
balance function, functional activity level,3 and ADL using
the modified Barthel index (mBI), by a physician. The total
hospitalization length and inpatient rehabilitation in the
rehabilitation ward were also documented.
Cognition
Each patient received the Mini-Mental Status Examination
(MMSE). MMSE is a simple, practical, and general screen for
dementia,11 which tests orientation, memory, attention,
language, and construction functions. Total scores range
from 0 to 30. MMSE is limited in evaluating mild cognitive
dysfunction and is influenced by age and education level.12
Swallowing and sphincter function
Swallowing function was evaluated and categorized into
the presence/absence of a nasogastric tube. The categories
of presence/absence of a nasogastric tube were further
transformed into numeric variables (“presence” to “1” and
“absence” to “0”) to enter univariate correlation anal-
ysis.13 Sphincter function was evaluated and categorized
into the presence/absence of Foley tube/urinary inconti-
nence and stool incontinence. The categories of presence/
absence of Foley tube/urinary incontinence/stool inconti-
nence were further transformed into numeric variables
(“presence” to “1” and “absence” to “0”).13,15
Motor function
The manual muscle test (0e5)16 and Brunnstrom motor re-
covery stage (stages IeVI)1,3 of the proximal and distal
parts of the paretic upper and lower limb were docu-
mented. Spasticity was measured using the modified
Asworth scale.
Sensory function
Sensory function was evaluated and categorized into intact
or impaired based on clinical evaluation. The categories of
intact or impaired sensory function were further trans-
formed into numeric variables (“intact” to “0” and
“impaired” to “1”).3
Functional activity level and balance function
Functional status, including supine-to-sit and sit-to-stand,
was measured by ranking independency from 0 to 5 (0:
totally independent, 1: supervision, 2: 0%e25% assistance,
3: 25%e50%, 4: 50%e75%, and 5: 75%e100%), modified
from functional independency measure.1 Sitting and
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standing balance was measured using the ranking from 0 to
4 (0: normal, 1: good, 2: fair, 3: poor, and 4: absent).
ADL
To evaluate the dependency of ADL, a 5-point mBI system
was used. The total score ranges from 0 to 100, with higher
scores representing more independence and >90 scores
indicating independence. mBI encompasses 10 different
ADL functional domains, including feeding, grooming, toi-
leting, bathing, dressing, bladder and bowel control,
transfer, ambulation, and stair climbing.12,17 On the day the
patients were discharged, mBI was re-evaluated by a
physician. mBI scores at discharge were defined as the
primary outcome for ADL function recovery.
Statistical analysis
This study focused on prognostic variables in patients with
post-acute stroke who were admitted to the rehabilitation
specialty ward. Descriptive statistics were used to analyze
demographic data along with all the collected variables.
Univariable linear regression was performed to determine
which variables during admission were associated with the
outcome variable mBI at discharge. Clinical variables with
significant associations were then entered into multiple
regression analysis. The independent variables used were
age, length of stay in the intensive care unit (ICU), MMSE,
dysphagia, bladder/bowel incontinence, sensory impair-
ment, manual muscle testing, Brunnstrom stage, hemi-
plegic limb spasticity, and functional activity level. The
dependent variables were ADL outcomes at discharge.
Statistically significant variables (p < 0.05) with Pearson
correlation coefficients (R) > 0.318,19 from the univariable
linear regression were considered potential prognostic
factors with significant correlation and were entered into
multiple regression analyses. A retrograde stepwise se-
lection method was used to build the final prognostic
model for independence at discharge. All statistical ana-
lyses were performed using SPSS for Windows version 22.0.
Statistical significance was recognized when the p-value
was <0.05.
Results
Of the 3000 patients, 123 patients had missing or incom-
plete data. Thus, 2877 patients were recruited for eligi-
bility screening. A total of 2538 patients met the inclusion
criteria, whereas 254 patients were excluded because of
previous stroke history and 85 patients were excluded for
the presence or history of central or peripheral nervous
system diseases (Fig. 1).
Of the 2538 patients, 1142 patients received intensive
inpatient rehabilitation in the NTUH rehabilitation ward.
The average age of the patients admitted to the rehabili-
tation ward was 65.5  14.5 years. Males comprised 56.7%
of patients admitted to the rehabilitation ward. The reha-
bilitation group’s body mass index (BMI) was 26.0  23.4 kg/
m2. Regarding stroke type, 40.2% of the patients suffered
from hemorrhagic stroke in the rehabilitation ward. The
 Journal of the Formosan Medical Association 121 (2022) 670e678

Figure 1 Patient selection procedure and flowchart of inclusion.

Table 1 Demographic data of all patients.

General characteristics Total (n Z 2538) Rehabilitation ward (n Z 1142)
Age at admission (Mean  SD ) c
66.3  15.2 65.5  14.5
Sex (Male/Female) 1504/1034 647/495
BMIa (Mean  SDc) 25.6  19.4 26.0  23.4
Stroke type (Ischemic/hemorrhage) 1807/731 683/459
Total hospitalization (days) (Mean  SDc) 28.8  21.8 40.9  19.7
Stay in ICUb(days) (Mean  SDc) 6.9  7.8 8.1  7.2
a
BMI, body mass index.
b
ICU, intensive care unit.
c
SD, standard deviation.

average length of hospital stay and ICU stay of the reha-
bilitation ward admitted patients were 40.9  19.7 days
and 8.1  7.2 days, respectively (Table 1).
For patients admitted to the rehabilitation unit, the
mean length of rehabilitation ward stay was 35.6  17.6
days, and the average MMSE scores were 21.3  7.2 at
admission. The percentage of patients with nasogastric
tubes was 36.3%. In motor function, the percentage of
patients with a manual muscle testing (MMT) score of >3 at
the proximal upper limb, distal upper limb, proximal lower
limb, and distal lower limb of the hemiplegic limb was
39.2%, 37.6%, 39.7%, and 40.4%, respectively. The per-
centage of patients with a Brunnstrom stage of >III at the
hemiplegic proximal upper limb, distal upper limb, and
lower limb was 54.6%, 55.0%, and 61.3%, respectively. The
percentage of patients with a modified Ashworth scale of

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 W.-C. Chen, M.-Y. Hsiao and T.-G. Wang

2 was 6.3%. Sensory impairment was observed in 35.2% of
the patients. Moreover, 47.6% and 34.6% of the patients had
urinary and stool incontinence, respectively. Because of
functional activity level and balance function, 42.8% and
54.8% of the patients needed more than minimal assistance
with sitting up and standing up, respectively. In addition,
23.8% and 62.8% of the patients had poor sitting and
standing balance, respectively (Table 2).
Recovery of ADL
The mBI of both the rehabilitation and other ward groups
are listed in Table 3 and Fig. 2.
Univariate associations with discharge outcome in
the inpatient rehabilitation group
The associations between each candidate’s prognostic
factors and discharge mBI are provided in Supplementary
Table 1. The functional activity level and balance func-
tion had a moderate correlation with independence (R be-
tween 0.5 and 0.7, p < 0.05). Age, BMI, stroke types, length
of stay in ICU, MMSE, dysphagia, bladder and bowel incon-
tinence, Brunnstrom stage, and hemiplegic limb spasticity
were also associated with independence at discharge
(R < 0.5, p < 0.05). However, age (R Z 0.281), BMI
(R Z 0.091), stroke types (R Z 0.021), MMSE (R Z 0.272),
spasticity (R Z 0.134), and ICU stay (R Z 0.163) had less
relevance because R was <0.3; hence, they were not
selected for multiple regression analysis.
Multivariate associations between candidate
prognostic factors and outcome measures in the
inpatient rehabilitation group
A multivariate stepwise linear regression analysis was
performed to determine which variables were the best
prognostic factors of independence. We chose Brunnstrom
stage in the regression analysis rather than MMT because
of the underlying collinearity between MMT and Brunn-
strom stage. Although MMT is a universal comparison, it
cannot be precisely measured when Brunnstrom stage is
<V. Results showed that baseline mBI scores at rehabili-
tation ward admission received the strongest weight (R
square change Z 0.042) in the model, followed by de-
pendency in sitting up (R square change Z 0.014),
impaired sitting balance (R square change Z 0.010), the
Brunnstrom stage of hemiplegic lower limb (R square
change Z 0.006), and the presence of bladder inconti-
nence (R square change Z 0.006). Baseline mBI scores
(standardized coefficients Z 0.359) and the Brunnstrom
stage of hemiplegic lower limb (standardized
coefficients Z 0.091) were positive prognostic factors. By
contrast, dependency in sitting up (standardized
coefficients Z 0.182), impaired sitting balance (stan-
dardized coefficients Z 0.139), and the presence of
urinary incontinence (standardized coefficients Z 0.097)

Table 2 Demographic and clinical characteristics at rehabilitation admission.

Stay in rehabilitation (days) (Mean  SDb) 35.6  17.6
MMSEa (Mean  SDb) 21.4  7.2
Dysphagia With NGc/without 414/728
Bladder incontinence Presence/absence 544/598
Bowel incontinence Presence/absence 395/747
Motor function
Manual muscle test (hemiplegic limb)
Upper proximal limb 3/>3 694/448
Upper distal limb 3/>3 713/429
Lower proximal limb 3/>3 689/453
Lower distal limb 3/>3 681/461
Brunnstrom stage (hemiplegic limb)
Upper proximal limb III/>III 519/623
Upper distal limb III/>III 514/628
Lower limb III/>III 442/700
Modified Ashworth scale <2/2 1071/72
Sensory impairment Presence/absence 402/740
Functional activity level
Sitting up More than minimal assistance 489 (42.8%)
Standing up More than minimal assistance 626 (54.8%)
Sitting balance Poor or absent 272 (23.8%)
Standing balance Poor or absent 717 (62.8%)
a
MMSE, mini-mental state examination.
b
SD, standard deviation.
c
NG, nasogastric tube.

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 Journal of the Formosan Medical Association 121 (2022) 670e678

prognostic factor associated with independence at

Table 3 Modified Barthel index score during inpatient
discharge, followed by dependency in sitting up, impaired
rehabilitation.
sitting balance, the Brunnstrom stage of hemiplegic lower
mBIa Rehabilitation Total (n limb, and the presence of bladder incontinence. Baseline
ward (n Z 1142) Z 2538) mBI scores and the Brunnstrom stage of hemiplegic lower
Admission 28.5  23.1 40.7  33.0 limb were positive prognostic factors. However, de-
Discharge 57.0  27.7 63.1  34.1 pendency in sitting up, impaired sitting balance, and the
mBI gain 28.4  29.3 22.2  25.7 presence of urinary incontinence were negative prognostic
a factors.
mBI, modified Barthel index.
Independence of ADL is one of the major goals of reha-
bilitation. Our study showed that baseline ADLs at admis-
sion to the rehabilitation ward was positively correlated
with ADL independence recovery, which is similar to a
previous study.20 A higher mBI after acute stroke repre-
sented more preserved function. The main reason of pre-
served function is the provision of unique organized care to
facilitate both neurological and functional recovery more
effectively in the stroke unit compared with the general
medical ward.21 In addition, the increased activation of
uninjured ipsilateral and intact contralateral brain areas
after stroke is possible with increasing therapeutic intensity
in the stroke unit.21,22 This increased activation correlates
with the level of recovery as supported by neuroimaging
studies.21,23 mBI increments during rehabilitation admission
reflected the intensive rehabilitation benefits conferred by
the specialty unit resulting from the integrated care and
efficient communication, which is similar to a previous
study.21 Physiatrists are well-trained in managing stroke-
Figure 2 Modified Barthel index score during inpatient specific medical conditions, and the nursing staff is adept
rehabilitation. at rehabilitation nursing care and could assess stroke-
specific conditions (such as detecting aspiration risk and
were negative prognostic factors (R2 Z 0.53, p < 0.05). infection) more comprehensively. Besides increased ther-
The stepwise multiple regression models are presented in apy duration, interdisciplinary rehabilitation was provided
Table 4 and Supplementary Table 2. in the rehabilitation ward, in contrast to multidisciplinary
rehabilitation in other wards. Clear functional goals were
provided to the involved family members and caregivers to
Discussion educate them to some extent. Literature showed that the
interdisciplinary setting was superior to the multidisci-
The present study revealed that the baseline daily activity plinary setting regarding improvement in the functional
function following acute stroke is the most important outcome and quality of life, leading to possible discharge

Table 4 Multiple linear regression model for the prognosis of the modified Barthel index score at discharge in inpatient
rehabilitation group (final model).
Model Variables at admission Ba Betab Pearson R R-squared change p-value
6 (Constant) 56.584 0.000
Modified Barthel index 0.421 0.359 0.683 0.042 <0.001**
Sitting upc 2.763 0.182 0.601 0.014 <0.001**
Sitting balanced 4.373 0.139 0.553 0.010 <0.001**
Lower limbe 1.777 0.091 0.432 0.006 <0.001**
Bladder incontinencef 5.298 0.097 0.45 0.006 <0.001**
Dysphagiag 1.903 0.039 0.359 0.001 0.093
*p < 0.05 **p < 0.01.
a
B, unstandardized coefficients.
b
Beta, standardized coefficients.
c
Functional activity level of supine-to-sit and sit-to-stand modified from functional independency measure from 0 to 5 (0: totally
independent, 1: supervision, 2: 0%e25% assistance, 3: 25%e50%, 4: 50%e75%, and 5: 75%e100%).
d
Sitting and standing balance ranking from 0 to 4 (0: normal, 1: good, 2: fair, 3: poor, and 4: absent).
e
Brunnstrom stage from 0 to 6 of proximal and distal part at hemiplegic upper and lower limb.
f
Sphincter function: Foley tube or incontinence, 0 Z absence and presence Z 1.
g
Swallowing function was evaluated by the presence of nasogastric tube, 0 Z absence and 1 Z presence.

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 W.-C. Chen, M.-Y. Hsiao and T.-G. Wang
home instead of an institution and reduced hospitalization
time and costs.20 In our rehabilitation ward, regular case
conferences involving a physiatrist; physical, occupational,
speech, and swallowing therapists; a nurse; a psychologist;
and a social worker were held every 2 weeks to provide
rehabilitation services and set common goals. Medical
problems, rehabilitation progress, and positive and nega-
tive rehabilitation factors were evaluated during these
conferences. The primary medical team and therapists set
common functional goals and planned discharge disposition
together with social workers. The nursing staff also helped
the family understand rehabilitation goals and disposition
preparation.
Our study showed dependency on sitting up as a prog-
nostic factor for functional independence at discharge,
which was more weighted than sitting balance in the
regression model. In literature, the sitting balance24e26 was
shown to have a proven relationship with functional out-
comes in patients with stroke. Without the ability to sit up,
activities, including eating, dressing, toileting, and bath-
ing, are difficult to complete.25 To sit up, one might need to
grasp objects located beyond arm’s length and accordingly
adjust the muscles of trunk and lower limbs. Sitting up is a
dynamic process of elevating upper body against gravity.
After stroke, the ability to sit up might be interfered by
cognitive dysfunction, sensorimotor deficits, and spas-
ticity.25 To facilitate functional recovery, physical therapy
of the trunk and limb muscles training exercise could be
applied.
Sitting balance is necessary to perform ADLs, such as
eating in a seated position and dressing.26 Trunk balance is
the cornerstone of advanced transfer and mobility
training.24 The ability to balance is a delicate interplay
between cognitive, motor, and sensory functions, which
could be disturbed in stroke.26 Therefore, the complete
evaluation and early identification of balance function
deficits and arranging training in the rehabilitation ward are
crucial for patients who suffered from stroke to make initial
gains in basic mobility function.27
Our study showed that the Brunnstrom stage of the
hemiplegic lower limb was a positive prognostic factor for
functional recovery. In a previous study,16 a multivariable
regression model demonstrated that the hemiplegic leg
motor function, which represented strength from MMT, is
the strongest prognostic factor of functional recovery,
beyond other clinical variables, including cognition,
communication, and swallowing. By contrast, one study
stated that the Brunnstrom stage of hemiplegic limbs was
not a prognostic factor of functional outcome at discharge.1
However, this study summed up the hemiplegic proximal
and distal upper limb and lower limb scores as a single
score. Another study showed a positive association between
Brunnstrom acute stroke stage in ICU and mBI at discharge.3
To our knowledge, this is the first study that proved that the
Brunnstrom stage of the hemiparetic lower limb in post-
acute stroke showed a positive prognosis of functional in-
dependence. It is reasonable that most mBI items, including
heavy hygiene, transfer, ambulation, and stair climbing,
required lower limb motor recovery. Of note, one of the
major goals in the rehabilitation ward is transfer and
ambulation training before discharge to facilitate the pa-
tient’s mobility. One study showed a correlation of hip
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abductor strength with ambulation ability instead of hip
flexors in patients with chronic stroke.28 Therefore, the
motor function of the hemiplegic lower limb should be
evaluated. It could provide clinicians with information on
better functional outcomes.
In our study, bladder incontinence was also associated
with functional recovery, which is similar to a previous
study.14 In acute stroke with <7 days post-onset, >50% of
patients with first-ever stroke had urinary incontinence.29
The causes of urinary incontinence include direct damage
to the neuromicturition pathways by stroke lesion,
impaired awareness, indirect stroke-related causes of
mobility difficulties, and transient causes of fecal impac-
tion or delirium.30 Urinary incontinence is included in the
bladder control domain in mBI. Therefore, it might have
collinearity with mBI on admission and at discharge.31 The
score of bladder control accounts of only 10% in mBI and it
might explain the reason of urinary incontinence being the
last ranking in our model.
Limitations
There are some limitations in the current study. First,
comorbidities, including prior myocardial infarction, atrial
fibrillation, chronic heart failure, prior stroke, and chronic
pulmonary diseases, are already known to have a negative
effect on functional recovery after stroke.32e35 However,
they were not included in the analysis in this study because
our aim was focused on the potential prognostic factors in
the clinical evaluation of body function impairment and
activity limitation. Moreover, some important variables,
such as premorbid functional status3,36,37 and the time from
onset to first rehabilitation,3 were not retrievable in the
database. Other prognostic factors, such as the initial
severity of stroke (documented as National Institute of
Health Stroke Scale scores), whether patients received
thrombolysis or thrombectomy, or complications during
admission, could also influence the final functional
outcome. However, these were not included in the analysis
because of data unavailability. A detailed manual review of
the medical records is required to provide further insight.
Finally, although mBI was documented routinely in all pa-
tients with stroke who were admitted to non-rehabilitation
wards, it was recorded by the nursing staff who might be
unfamiliar with it, leading to increased uncertainty.
Conclusion
Baseline ADL function was the most important prognostic
factor of functional independence in post-acute stroke.
Moreover, the activity limitation of dependency on sitting
up and motor function impairment of hemiplegic lower limb
prognosticated functional independence.
Funding statement
This research received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
 Journal of the Formosan Medical Association 121 (2022) 670e678
Declaration of competing interest
The authors have no conflicts of interest relevant to this
article.
Acknowledgments
We thank the staff of the Department of Medical Research,
National Taiwan University Hospital for the Integrated
Medical Database (NTUH-iMD).
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jfma.2021.07.009.
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