Factors predictive of stroke outcome

in a rehabilitation setting
Jon Erik Ween, MD; Michael P. Alexander, MD; Mark D'Esposito, MD; and Mary Roberts, MS

Article abstract-Accurate outcome prediction following stroke is important for proper delivery of poststroke care. It has
been difficult to determine specific factors that provide reliable and accurate predictions of outcome, particularly for
patients with intermediate deficit severities. Age and severity of deficit have repeatedly been found to be most reliable, but
only as rough estimates and for patients at either extreme of the disability spectrum. This paper reports a prospective
study of consecutive rehabilitation admissions (N = 536) to determine the influence of preselected factors. Outcome was
analyzed in terms of functional improvement and disposition. Patients younger than 55 years or with an admission
Functional Independence Measure (FIM) greater than 80 almost universally went home. Admission FIMs less than 40
were associated with nearly certain nursing home discharge. The comprehensive FIM score was a stronger predictor of'
outcome than motor impairment in isolation. An admission FIM of 60 or greater was associated with a higher probability
of functional improvement during rehabilitation. Small-vessel strokes had the best outcome. Intracerebral hemorrhages
improved more than ischemic strokes but more slowly. Right hemisphere lesions did worse than left. Comorbidities
influenced outcome only when several conditions accumulated. The absence of a committed caregiver at home increased
the risk of nursing home discharge. Suggestions for rehabilitation triage are given.
NEUROLOGY 1996;47:388-392

There are approximately 600,000 new cases of stroke tion programs that is both cost effective and amena-
in the United States every year. A sizable proportion ble to rational quality-and cost-control would be
of these cases will survive with significant residual to stratify stroke survivors by easily identifiable clin-
deficits. Most of these survivors will automatically be ical factors a n d determine which subgroups show
offered early rehabilitation in a n effort to improve predictable and acceptable improvements at differ-
their functional abilities. This practice h a s come un- e n t levels of care within a spectrum of care delivery
der increasing fire as the escalation of health care options, ranging from acute rehabilitation to custo-
costs has forced greater scrutiny on the entire range dial care. This would reduce both acute- and long-
of health care delivery. Although t h e efficacy of term costs and afford optimum individual care in a
stroke rehabilitation now seems clear,l-"t h e question clinically principled manner. Such a system would
h a s become whether or not the effort is worth the require a reliable way of predicting functional out-
cost. come i n stroke survivors. Numerous studies (re-
Attempts to clarify this question have raised sev- viewed by Alexander") have utilized different ap-
eral, still unresolved issues: What is an acceptable proaches:
level of functional ability? Are all types of interven- Single-variable predictors tend to be sensitive but
tion equally effective in attaining this level of func- nonspecific, while multivariate algorithm^"^ are spe-
tion? Is a given intervention equally effective at all cific b u t insensitive, i n addition to being difficult to
levels of deficit severity? Which setting i s optimal for use.s Alexander" suggested a multi-layered approach
a cost-effective delivery of the rehabilitation effort? based on constellations of single variables i n stratify-
How much functional improvement is worth how ing poststroke care delivery. Advanced age had a
many health care dollars? Changes in health care very high likelihood of nursing home placement re-
economics seem to be driving rehabilitation care rap- gardless of admission Functional Independence Mea-
idly to less costly treatment settings without ade- sure (AFIM) and FIM change, while the youngest,
quate answers to the above questions. Furthermore, subjects tended to go home regardless of functional
none of these unresolved clinical or economic ques- outcome. In the remaining cases, those with low
tions affect the basic assumptions of rehabilitation: AFIM had a high likelihood of nursing home place-
Improved function leads to less disability for the in- ment, and had lower FIM change and FIM efficiency
dividual patient and ultimately to lower costs to so- (FIM change by length of stay), while cases in a
ciety through less long-term supportive care and "middle band" of AFIM showed good FIM change and
fewer poststroke complications. FIM efficiency. The goal of the present paper is to
One step toward defining a system of rehabilita- study individual factors more closely, to help elabo-
From The Rehabilitation Hospital of Rhode Island (Dr. Ween), N. Smithfield, RI; Braintree Hospital (Drs. Ween and Alexander), Braintree, MA; LJniversity
Hospital (Dr. D'Esposito), Philadelphia, PA, and Miriam Hospital (Dr. Roberts), Providence, RI.
Presented in part a t the 46th annual meeting of the American Academy of Neurology, Washington, DC, May 1994.
Received October 6, 1995. Accepted in final form February 9, 1996.
Address correspondence and reprint requests to Dr. Jon Erik Ween, Department of Neurology, Braintree Hospital, 250 Pond St., Braintree, MA 02184.
388 Copyright 0 1996 by the American Academy of Neurology
rate clinically applicable rules for optimal triage of Table I Population description
poststroke care. Mean age (years) 73 5 12”
Days postonset on admission 16 f 30”
Subjects and methods. Consecutive admissions t o Mean length of stay 33 f 22*
Braintree Hospital with a primary diagnosis of stroke (in-
Female/male 55/45
farction, hemorrhage) in the calendar year 1993 were in-
cluded. Subarachnoid hemorrhages and strokes requiring Incontinent of urine 41%
cerebral surgical interventions were excluded because of Incontinent of bowel 31%
their complex constellation of comorbidities. Subjects dis- Dysphagic 20%
charged to acute care hospitals for intercurrent acute
events during rehabilitation or subjects who died during Diabetic 19%
the course of rehabilitation were not included in the out- UTI (diagnosed by discharge) 12%
come analyses. Patients with remote histories of stroke but Cumulative comorbidities None 22%, Few 49%, Many 29%
admitted for other reasons were also not included. Stroke types LGV 6096, SMV 25%
There were 536 admissions with primary diagnosis of
cerebrovascular accidents. Eighty-six cases were not eval- ( N = 376) ICH 970, UK 6%
uated for various logistical reasons. A post hoc review of Stroke site Right 37%, Left 41%
this latter group found no systematic differences from the (N = 376) Bilateral 3%,Brainstem 796,
study group. Twenty-nine cases were properly excluded Cerebellum 4%, UK 8%
and 42 1 patients were evaluated. Thirty-eight patients
died or were transferred back t o acute care hospitals, 7 :!:Mean2 SD.
cases had “other” dispositions, and 376 cases were included UTI = urinary tract infection; LGV = large-vessel infarct;
in the outcome analysis. All subjects were provided reha- SMV = small-vessel infarct; ICH = intracerebral hemorrhage;
bilitation on general rehabilitation units in the standard, UK = unknown.
multi-disciplinary fashion.
Independent measures suspected of influencing out-
come were assessed within 2 or 3 days of admission to bidities, a weighted, aggregate sum of comorbidities was
Braintree Hospital: computed. We arbitrarily weighted previous strokes 3
(1)Age (age groups: <55, 55-64, 65-74, 75-85, >85). points, other neurologic comorbidities 2, and all other de-
(2) Severity of deficit, measured either by (a) the Func- fined comorbidities 1 point each. Maximum score was
tional Independence Measure (FIM, an 18-item functional twelve. Patients were grouped as having none (O), few (1to
measure with maximum score of 126,”AFIM groups: <40, 31, or many (24)comorbidities.
40-60, 61-80, H O ) , or by (b) the severity of hemiparesis, (6) Incontinence of bladder and bowel and presence of
determined on clinical evaluation by staff neurologists and dysphagia on admission were assessed singly and as an
rated on a scale of 0 to 9 (Modified Brunnstr~m’~’: 0 = no aggregate sum, each deficit contributing 1 point. Maxi-
spontaneous movement, 1 = proximal leg synergies only, mum score was three.
2 = full leg synergies, no or early arm synergies, 3 = (7) Socioeconomic constraints were estimated in two
isolated leg movements with arm synergies, 4 = proximal ways: (a) based on the presence or absence of a committed
leg and arm weakness only, 5 = leg weakness only, 6 = caregiver; (b) presence of significant financial limitations
isolated proximal arm motion with distal synergies, 7 = for home care (usually absence of detectable insurance cov-
isolated distal arm motion, 8 = hand clumsiness only, 9 = erage for home services)- both determined by the admis-
no weakness. Synergistic movement across joints arises sion social service assessment.
from release of brainstem or spinal integration with the Dependent measures were determined upon discharge:
loss of higher order motor control necessary for isolated (a) FIM change (discharge FIM minus admission FIM); (b)
joint motion in the extremities. See Gowlandl” and her FIM efficiency (FIM change divided by length of stay); (c)
references for details). disposition (to home or skilled nursing facility).
(3) Lesion types were classified based on review of his- Group averages were compared (df in parentheses) us-
tory, clinical examination and head imaging studies (when ing analysis of variance for continuous variables and the x2
available) as large vessel, small vessel (lacunes), intracere- test for discontinuous variables. All analyses were per-
bra1 hemorrhage, or “unknown.” No attempt was made to formed on a Macintosh microcomputer using Statview and
distinguish etiologies (carotid vascular, cardiac, coagulopa- Superanova software from Abacus Concepts.
thies, etc.).
(4) Lesion site (lefthight hemisphere, brainstem, cere- Results. Table 1 gives a summary description of our pop-
bellum) was determined by clinical deficit profile and neu- ulation. Of the 421 patients evaluated, the group of acute
roimaging, when available. Impact of lesion side (left, transfers and in-house deaths (combined n = 33) had a
right, bilateral, or unknown) was also evaluated. significantly lower AFIM than the group going home (48.4
(5) Existence of comorbidities such as neurologic, car- vs 69.8, p < 0.05) and a higher cumulative incontinence/
diac, pulmonary, peripheral vascular, or arthritic disease, dysphagia score (1.6 vs 0.68, p < 0.05). They were not
hypertension, diabetes mellitus, and obesity were deter- significantly different in age, severity of hemiparesis, or
mined. Apart from hypertension and diabetes mellitus, cumulative number of comorbidities. Seven patients had
only comorbidities that were previously documented and “other” dispositions (subacute units, other rehabilitation
functionally limiting were scored to keep the assessment facilities, etc.), and outcome analyses were performed on
conservative. To account for possible interactions of comor- the remaining 376 subjects (326 for lesion type, site, and
August 1996 NEUROLOGY 47 389
Table 2 Outcome by descriptive groups 35 -I
~~ ~

FIM change FIM efficiency

- -
Disposition 30 -
Mean (SD) Mean (SD) (‘#I home)
___
~~ ~

25 -
Age groups
Q)
U
J
(55 27.2 (16.3) 1.39 (1.30) 91 2 20-
55-64 28.2 (13.6) 1.30 (1.24) 76
5
65-74 25.0 (13.3) 1.36 (1.50) 77 5 15-
G /-
I ==: I
75-85 24.7 (12.4) 1.05 (.85) 68
>85 21.1 (13.6) 1.02 (.88) 57
Admission FIM groups l:] v: :
40 19.9 (19.0) .49 (.55) 38
40-60 24.4 (13.4) .79 (.70) 63 0
81
c40 40-60 61-80 >80
61-80 28.4 (12.0) 1.21 (.83)
AFIM
>80 24.8 (8.3) 2.13 (1.68) 98
Figure. FIM change by admission FIM.
Lesion type
LGV 21.2 (16.4) 1.19 (1.31) 69
(F[1,374] = 132.94, p = 0.0001), with all group compari-
ICH 25.4 (12.4) 1.22 (1.32) 74 sons significant. The same was found for disposition, (x2[31
SMV 26.8 (20.2) 1.33 (.93) 82 = 81.44, p = 0.0001). AFIM >80 had a 98% rate of home
Lesion side discharge; 60-80, 81%; 40-59, 64%~;and <40, 38%, all
comparisons significant. Severity of hemiparesis influ-
Right 23.1 (13.7) .91 (.79) 69
enced FIM change less strongly (F[1,3671 = 3.77, p =
Left 27.3 (12.4) 1.46 (1.41) 78 0.053) but FIM efficiency quite strongly (F[1,3671 = 71.10,
Bilateral 19.1 (17.1) 1.22 (1.22) 63 p = 0.0001).
Bladder incontinence on admission (3) Lesion type correlated with outcome. Large-vessel
strokes (LGV) did significantly worse than small-vessel
Yes 21.8 (16.6) .71 (.74) 39
strokes ( S M V ) o r hemorrhages (ICH)(F13,3721= 5.56, p =
NO 27.1 (10.6) 1.52 (1.32) 82 0.001). As can be seen from the figure, this effect is due to
Admission s t a t u s for bowel, bladder, and swallowing disability, the most impaired LGV strokes performing much worse
cumulative score* than ICH or SMV. While ICH were significantly less im-
0 27.4 (10.0) 1.62 (1.37) 88 paired on admission than the other two groups (AFIM
72 -+ 16 vs 59 -+ 22 for LGV and 57 2 25 for SMV, F[3,4171
1 24.9 (12.4) 1.03 (.go) 63
= 10.8, p < 0.0001), there was no difference in duration of
2 25.5 (16.0) .76 (.62) 60 acute stay prior to rehabilitation admission (F[3,418] =
3 15.4 (18.1) .40 (53) 45 0.50) nor was FIM efficiency during rehabilitation signifi-
cantly different between groups (F13,372] = 1.06). This
:!. See text for details. suggests that although ICH were less impaired on admis-
FIM = Functional Independence Measure; LGV = large vessel; sion and improved more than ischemic strokes, they expe-
ICH = intracerebral hemorrhage; SMV = small vessel. rienced their recovery more slowly. There was no differ-
ence in disposition between the groups (x2[31= 5.77).
(4)Lesion site influenced FIM change with bilateral and
side comparisons). Table 2 gives group means and stan- right-sided lesions doing worse than left-sided (F[3,371I =
dard deviations for the most important factors. 4.36, p < 0.005). Right-sided lesions also had less FIM
( 1)Age had a strong influence on FIM change across the efficiency than left-sided (F[3,3711 = 6.74, p < 0.0005), but
whole population (F[1,374] = 8.70, p < 0.0031, while only lesion side did not influence disposition (x2[3]= 7.59).
the 55-64 vs >85 group comparison reached significance Since lesion site and lesion type may have confounding
on post hoc testing. A similar influence was found for FIM influences on each other, the population was broken down
efficiency across the whole population (F[1,374] = 10.05, according to type and side of stroke for a more careful
p = 0.002). Only the 65-74 vs 75-85 group comparisons comparison. Lesion side plus type still had significant in-
reached significance. Age also affected disposition (x2[4] = fluence on FIM change (F[12,3621 = 2.68, p < 0.005). I n
14.44, p = 0.006). Ninety percent of cases <55, 77% of post hoc comparisons, left-sided ICH had the most FIM
cases 55-75, 68% of cases 75-85, and 57% of subjects older change (average = 33. l), bilateral large-vessel lesions the
than 85 went home. The disposition comparisons for >85 least (average = 19.5). Right-sided lesions did worse than
and <55 reached significance. left-sided whether they were large-vessel or small-vessel,
(2) Severity of deficit had a strong influence on all out- but right-sided hemorrhages did no worse than left-sided.
come measures. AFIM influenced FIM change across the FIM efficiency was also influenced by lesion side plus type
population (F[1,3741= 8.39, p = 0.004) and <40 vs 40-59, (F[12,363] = 2.86, p < 0.001), right-sided large-vessel
<40 vs 60-80 and <40 vs >80 group comparisons were strokes did the worst (average = 0.70) and cerebellar le-
significant. FIM efficiency was also strongly influenced sions the best (average = 2.09). Large-vessel strokes had
390 NEUROLOGY 47 August 1996
better FIM efficiency if they were on the left. Outcome for
small-vessel strokes and hemorrhages was the same
whichever side was affected.
( 5 ) No single comorbidity had an isolated effect on any
dependent measure. This, surprisingly, was true also for
existence of prior strokes (FIM change: F[1,368] = 2.73;
FIM efficiency: F[1,3681 = 1.23; and discharge: x2[11 =
0.93). Taken as an aggregate sum, patients with a higher
comorbidity score had less FIM change (F[1,374] = 6.36,
p < 0.05) and worse FIM efficiency (F[1,374] = 6.15, p <
0.05) but were no more likely to be discharged to nursing
homes than to home (x2[2] = 0.42).
(6) Both incontinence and dysphagia had effects on all
outcome measures. Urinary incontinence on admission was
strongly associated with FIM change (t[374] = 3.81, p <
0.0005) and FIM efficiency (t[3741 = 6.75, p < 0.0001).
However, in a two-factor ANOVA with AFIM, this effect
was not apparent (F[1,3681 = 0.33, p = 0.561, suggesting
that incontinence reflects severity of deficit. Incontinence
on discharge had a strong correlation with FIM change
(t[3741 = 10.76, p < 0.0001) that persisted regardless of
overall functional seventy (F[1,369] = 94.51, p < 0.0001).
Continence on admission was associated with a n 84% rate
of home discharge, while incontinence on admission re-
duced this rate t o 55%, a significant difference (x2[11 =
38.78, p < 0.0001). Persistence of incontinence on dis-
charge reduced the rate of home discharge to 39% versus
an 82% rate for continent patients (x2[1] = 61.17, p <
0.0001). Dysphagia alone was associated with diminished
FIM change (26 vs 20, t[3671 = 3.62, p < 0.0005), less FIM
efficiency (0.60 vs 1.3, t[3671 = 4.80, p < 0.0001, and less
likelihood of home discharge (50% vs 78%, x2[1] = 21.26,
p < 0.0001).
(7) Of the socioeconomic factors considered, the absence
of a committed caregiver identified on admission to reha-
bilitation significantly reduced the rate of home discharge
from 77% to 65% (x2[1] = 5.75, p < 0.05). Admission as-
sessment of financial status was not reliably reported, in
part because financial difficulties identified on admission
were addressed t o case managers and subject to ongoing
remediation efforts during the course of rehabilitation.
Discussion. The results of the current study again
emphasize the influence of ageI1-I3and degree of im-
pairment on stroke The influence of age
probably reflects the impact of many comorbid fac-
tors (such as senescent brain changes, diminished
physical endurance, and various medical problems),
while specific medical comorbidities (including prior
strokes) individually did not have the same influ-
ence. Only when comorbidities were assessed in ag-
gregate did an effect emerge for those patients with
many comorbidities, probably in a manner that par-
allels the impact of age. Although patients with truly
devastating medical comorbidities are often not con-
sidered acceptable candidates for rehabilitation, our
inclusion criteria for functionally limiting comorbidi-
ties in the population under study were still quite
conservative. Thus, the presence of prior, function-
ally limiting medical conditions does not preclude a
good outcome from neurologic rehabilitation. The in-
fluence of initial severity, as measured by the AFIM
(also a comprehensive measure), was more powerful
in predicting outcome than a measure of motor func-
tion alone (hemiparesis severity). When FIM effl-
ciency (rate of improvement) was the dependent
measure, hemiparesis severity was a much stronger
predictive factor.
Effects of lesion type have been less well stud-
ied.17J8 I n our study, small-vessel infarctions (la-
cunes) did better than other stroke types. Patients
with hemorrhages experienced more FIM change
than those with large ischemic strokes but improved
a t a slower rate despite coming to rehabilitation with
less impairment (i.e., higher AFIM and FIM change
with the same FIM efficiency). A recent study by
Jwgensen et a1.I8 found ICH to be related to more
severe deficits, but found no difference in outcome or
rate of recovery between ICH and ischemic strokes
when severity was accounted for. The discrepancy
between our findings and those of Jergensen et al.IS
may be due to the different populations in the two
studies o r to methodology. Ours was a subacute re-
habilitation population; theirs was community
based. Thus, the more devastating ICHs may not
have come to rehabilitation in our environment. As
in the other study,ls we accounted for severity when
comparing ICH with ischemic stroke and still found
ICHs to do better. The study of Jprrgensen e t a1.18
however, did not fractionate ischemic strokes into
small- or large-vessel infarcts. Given the better prog-
nosis for SMV infarcts when compared with LGV in
our study, consolidating SMV and LGV strokes may
have improved the outcome for the ischemic group in
their study and brought the composite outcome up to
that of ICHs.
Right hemisphere lesions did more poorly than
left hemisphere lesions, even across degrees of sever-
ity, a finding similar to that of a n earlier r e p ~ r t . ' ~
While it may be easier for patients with left hemi-
sphere lesions to gain rehabilitation admission due
to their aphasia and thus bias rehabilitation admis-
sions of right hemisphere damage toward more se-
verely impaired patients (there was a nonsignificant
trend in this direction in our data), the poorer out-
comes in right hemisphere damaged patients may
relate to specific cognitive abilities, such as neglect
and agnosia,20:21
Incontinence was strongly associated with poor
outcomes and nursing home discharge as noted by
, ~ J as
~ t h e r ~perhaps ~ ~a reflection
~ ~ ~ ~ of~impairment
severity rather than isolated damage to CNS mic-
turition control. Dysphagia on admission had a simi-
lar influence, probably for the same reasons. Dis-
charge continence correlated more strongly with
disposition than did continence status on admission,
probably a s much due to home caregiver concerns as
to severity issues. While discharge continence itself
is of no value in predicting outcome, these results
suggest that there may be a point in time after admis-
sion, but prior to discharge, where persistent inconti-
nence may be a valuable predictor of final disposition.
The absence of a committed caregiver did reduce
the likelihood of home discharge significantly, but
August 1996 NEUROLOGY 47 391
even without a clear potential caregiver most pa-
tients went home (65%).
There are plausible conclusions for systems of
care. Patients with early hospital improvement (our
AFIM >80 group) could be managed at home directly
from acute care, if appropriate outpatient services
are available. Othersz4 have also proposed this. Pa-
tients with low FIM (<40) in the early subacute
phase should be treated a t a lower level of intensity
(skilled nursing facility with basic therapies), but
monitored closely for any delayed recovery, particu-
larly patients with hemorrhages. All other stroke
survivors will probably benefit from intensive, inpa-
tient rehabilitation. The presence of medical comor-
bidities should not influence rehabilitation admis-
sions beyond the need for a medically stable
condition allowing for participation in therapies, un-
less they are multiple and seen in the setting of
sphincter dyscontrol.
The form of stratification we are suggesting con-
tributes to answering some of the unresolved ques-
tions regarding poststroke care. The acceptable level
of functional ability, and hence the improvement de-
sired through rehabilitation, is determined in part
by the improvement and disposition expected. Af-
fording a patient a home discharge with outpatient
services represents large savings vis-a-vis nursing
home care. By the same token, reducing a nursing
home patient’s need for care, for example from max-
imum assistance by three caretakers 8 hours a day
to maximum assistance by two caretakers 2 hours a
day, also represents a significant real-dollar savings
over the life of that patient and should also be con-
sidered a successful intervention even though the
absolute FIM change may be small. All treatments
are probably not equally effective a t all impairment
levels, and thus functional stratification is important
in determining not only which treatments are effec-
tive but also which treatment setting is most appro-
priate. Keith et al.,25in one of the few studies avail-
able comparing levels of care, found a clear cost
inefficiency in the acute rehabilitation setting. How-
ever, they did not stratify their analysis by clinical
factors as we have done, nor did they factor in inci-
dental expenses for intercurrent medical complica-
tions, known t o be lower in specialized stroke reha-
bilitation units than in other settings.26Our results
strongly suggest a role for acute rehabilitation while
arguing for a principled triage of patients into such
facilities. If this can be coupled with a relaxation in
CARF mandated treatment levels for acute inpatient
rehabilitation, so that one is freer to tailor the treat-
ment program to each patient’s specific need, the
overall cost of acute rehabilitation will be dramati-
cally reduced, thus improving the cost/efficacy ratio
vis-a-vis other “less costly” settings. Better insight
into stroke outcome and rehabilitation triage may
thus place us in a better position to determine how
much of our health care dollar we are willing to
spend for functional improvements in stroke survi-
vors,
392 NEUROLOGY 47 August 1996
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Neurology 1996;47;388-392
DOI 10.1212/WNL.47.2.388

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