2. PART 2
Prognostic Indicators Post Stroke and Outcome Measures
• Objectives
• Synthesize examination findings to determine an accurate PT prognosis
• Choose and administer appropriate outcome tools in different practice
settings, including acute care, inpatient rehabilitation and outpatient
rehabilitation
• Explain the results of the outcome measures to the medical team and third
party payers
3. Prognosis to Determine Outcomes
Why does it matter?
• Stroke- Leading cause of Disability4
• Burden to the System 1
• Pressure from Insurance Companies
• Guidance for Clinicians
4. Prognosis to Determine Outcomes
Factors that Influence Prognosis 4, 5, 6
• Type of stroke
• Gender/Age
• Premorbid health, activity, function
• Cognition
• Urinary Incontinence
• Psychosocial and Socioeconomic Factors
5. Prognosis to Determine Outcomes
Factors Influencing Prognosis and Functional Outcomes18
AFTER ONE YEAR
• Improvement neurologic deficits: motor and sensory
• No improvement in autonomy and quality of life
• Determinants to improvement: aphasia, hemianopia, incontinence
• QoL remained altered 1 year after hospital d/c
BOTTOM LINE- improved neurological deficits does not equate to
improved function or quality of life. Functional improvement related to
family support.
6. Prognosis to Determine Outcomes
Young Adult; Long Term Functional Outcome21
• After 10 years 1 of 8 young adults still dependent
• Strongest predictor- severity of initial CVA
• Poorer outcomes correlated with ≥ 1 CVA
• Preventative Strategies*
7. Factors that Influence Prognosis
Unilateral spatial neglect 7, 8
• Slower functional progress
• Longer LOS
• Increased risk of falls
• Decreased likelihood of discharge to home
Overall Negative Outcomes
9. Factors that Influence Prognosis
Ambulation 10, 11, 13
• Specific Prognostic Indicators
• Sensory and motor impairments (↑ severity, ↓ prognosis)
• Visuospatial Impairment (-)
• Time (-)
• Sit balance between 2nd-4th week post CVA (↑ severity, ↓ prognosis)
• Standing balance (+) *
• Compensatory strategies and postural control important
• 6 Minute Walk Test- best indicator for return to community
ambulation
10. Factors that Influence Prognosis
Functional use of the Upper Extremity 12, 13
• 1 month AROM measures → function at 3 months
• Shoulder
• Early synergistic movements in the UE→ increased Action Research
Arm Test (ARAT) score
• Most important predictor for General UE recovery
• Initial severity of motor impairment or function
• Most powerful predictor for regaining dexterity
• Voluntary finger extension
11. Factors that Influence Prognosis
Somatosensory Deficit and the Upper Extremity19
• Predictor of recovery and return of function
• 2 point discrimination- predictor of dexterity
• Proprioception- predictor for quality of functional movements
• Light touch + proprioception- motor recovery, ADL’s, social roles
• Important assessment: Nottingham Sensory Assessment
• To provide appropriate interventions and goal setting
12. Factors that Influence Prognosis
ADL Independence 13
• Increased severity of hemiplegia (-)
• Consciousness at admission, more alert (+)
• Depression (-)
• Older age, Increased severity of neurological deficits (-) *
• Predicts outcomes at 3 months
13. Factors that Influence Prognosis
Fatigue Post Stroke20
• Prevalence in those 18-50 years old- 41%
• No difference on location or duration from stroke onset
• Risk Factors
• Anxiety, depression, recurrent CVA’s, female
• Negative effect on Functional Outcomes
• Higher demands: work, young family, social roles
14. Factors that Influence Prognosis
Predictors of Return to Driving After Stroke 14
• Functional Ability needed:
• motor- turning wheel, step on pedal, signals, windshield wipers
• visual-perceptual: reading signs, events in periphery, parking
between lines
• cognitive: awareness of speed limit, route finding, merging and
switching lanes- planning and safety
15. Factors that Influence Prognosis
Predictors of Return to Driving After Stroke 14
• Related to Driving Ability
• Pre-stroke driving frequency
• Post Stroke Barthel Index
• Return to Driving
• 31% return to driving (inpatient setting)
• Predicting Factors: FIM Cognition and Motricity Index LE (admission)
• Motricity Index UE/ARAT highly correlate with Motricity Index LE
• Car Modifications
• Knowledge
• Learning
• Cost
16. Factors that Influence Prognosis
Return to Work 15, 16
• Negative Factors
• nonwhite ethnicity, pre stroke part-time employment, depression
• Degree of limitations*
• Job contextual factors
• Admission to rehab- poorer outcomes with return to work
• Return to home at 1 month (+)
About 50% return to work
17. Factors that Influence Prognosis
Activity Limitation and Participation Restriction22
• A patient’s perception of recovery is poor
• Activity limitation directly effects participation
• Predictors: age and level of post stroke functional ability
• Objective and subjective measures not congruent
• Benefit to measuring activity limitation AND participation restriction
• Community Services for the elderly
• more severely impacted group
18. Outcome Measures
ICF Model 1, 17
• Body Structure and Function
• Motor Function
• Sensation
• Activity
• Gait and Balance
• Arm function
• Trunk Control
• Posture
• ADL/IADL
• Participation
• Resources
• rehabmeasures.org
• StrokEngine
• Stroke Edge Task Force
19. Outcome Measures: Body Structure and Function
ICF Model 1
• Ashworth Test (Modified Ashworth
Scale)
• Chedoke McMaster Stroke
Assessment
• Dynamometry
• Fugl-Meyer Assessment of Motor
Performance
• Fugl-Meyer Sensory Assessment
• Motricity Index
• NIH Stroke Scale
• Nottingham Assessment of
Somatosensation
• Orpington Prognostic Scale
• Rate of Perceived Exertion
• Rivermead Motor Assessment
• Semmes Weinstein Monofilaments
• Limb Movement Subscale of the
Stroke Rehabilitation Assessment of
Movement
• Tardieu Spasticity Scale (Modified
Tardieu)
• VO2 Max
20. Ashworth Test (Modified Ashworth Scale)
performance based. Recommended for all settings.
• A tool to measure the degree of
spasticity 1, 3
• Influencing Factors: dystonia,
contractures, joint stiffness3
• Velocity is not standardized 3
• Repeated measure decreases
accuracy1
http://www.rehabmeasures.org/PDF%20Library/Modi
fied%20Ashworth%20Scale%20Instructions.pdf
21. Fugl-Meyer Assessment
performance based. Highly recommended for all settings: sensation, UE and LE motor 1
• Stroke specific. Evaluates recovery in a person with hemiplegia 2, 3
• Score 0 (cannot perform) to 2 (performs fully) 3
• Max score UE motor- 66, LE motor- 34
• Equipment: chair, bed, tennis ball, small spherical shaped
container, reflex tool, adequate space with few distractions 3
http://www.neurophys.gu.se/digitalAssets/1332/1332679_fm-le-english.pdf
http://www.neurophys.gu.se/digitalAssets/1328/1328946_fma-ue-english.pdf
22. Outcome Measures: Activity
ICF Model 1
• 5 times sit to stand
• 6 minute walk test
• 9 hole peg test
• 10 meter walk
• Action Research Arm Test (ARAT)
• Activities-Specific Balance Confidence Scale
(ABC)
• Arm Motor Ability Test
• Balance Evaluation Systems Test (BEST Test)
• Berg Balance Scale
• Box and Blocks Test
• Brunnel Balance Test
• Canadian Occupation Performance Measure
• Chedoke Arm Hand Inventory
• Dynamic Gait Index
• Functional Ambulation Categories
• Functional Independence Measure
• Functional Reach
• HiMat
• Jebsen Taylor Arm Function Test
• Motor Activity Log
• Postural Assessment Scale for Stroke Patients
• Stroke Rehabilitation Assessment of
Movement- Mobility Subscale
• Timed Up and Go
• Tinetti Up and Go
• Trunk Control Test
• Trunk Impairment Scale
• Wolf Motor Function Scale
• Functional Gait Assessment3
23. 5 Times Sit to Stand
performance based. Recommended use in all settings1
• Timed test 5 repetitions from chair 43cm high 1
• Designed for LE strength test 1,3
• Performance more related to balance1
• Need ability to rise from a chair no arm rests 1
• Cut-off- 12 seconds1, 3
• Mean Norms 3
• 50-59: 7.1(+/-)1.5
• 60-69: 8.1(+/-)3.1
• 70-79: 10.0(+/-)3.1
• 80-89: 10.6(+/-)3.4
http://geriatrictoolkit.missouri.edu/
24. 6 Minute Walk Test
performance based. Highly recommended for use in all settings1
• Ambulation distance measured over 6 minutes 3
• Assesses sub maximal aerobic capacity 3
• Measures gait velocity and endurance (various timed versions)1
• Limitations- no balance assessment or movement quality1
• Norms: 3
• 60-69 (M)572m (F)538m
• 70-79 (M)527m (F)471m
• 80-89 (M)417m (F)392m
http://www.cscc.unc.edu/spir/public/UNLICOMMSMWSixMinuteWalkTestFormQxQ08252011.pdf
25. 10 Meter Walk Test
performance based. Highly recommended for use in all settings 1
• Assesses walking speed in meters per second over a short distance 3
• 6, 8, 10, 12 meters in length
• Considerations3
• Assistive devices can be used
• Not appropriate if assist needed
• Can be performed at preferred speed and fast walking speed
• Repeated 3 times3
• Cut-Off Scores: ambulation ability correlated with gait speed3
• < 0.4 m/s household ambulator
• 0.4-0.8 m/s limited community ambulator
• > 0.8 m/s community ambulator
26. Berg Balance Scale
performance based. Highly recommended in most settings (except acute) 1
• Used to assess balance in older
adults2
• For stroke 45 is the cut-off3
• Limitations
• Time to administer 15-20 minutes3
• Poor ceiling effect; Poor floor effects
14 days post CVA3
http://www.fallpreventiontaskforce.org/pdf/BergBalanceScale.pdf
27. Timed Up and Go
performance based. Highly recommended in all settings. 1
• A test of mobility, balance and locomotor performance1
• Unable to perform without assist but can use a device1,3
• Instructions: stand from a chair, walk 3 meters as quickly and safely as
possible, cross a line on the floor, turn around, walk back and sit
down3
• Standard height chair with arm rests, not against a wall. 3 meters1
• Cut-Off scores3 TUG cognitive ≥ 15 seconds- fallers
• Normative Data3 mean time TUG 8.39 seconds
28. Functional Gait Assessment
performance based. Highly recommended in all settings. 1
• Modification from DGI
• Looks at postural stability with
ambulation tasks
• 10 items
• Scores
• 0-severe impairment
• 1-moderate impairment
• 2- mild impairment
• 3- normal ambulation
FGA is found in the original article:
http://physicaltherapyjournal.com/content/84/10/906.full.pdf
29. Outcome Measures: Participation
ICF Model 1
• Assessment of Life Habits
• EuroQOL
• Falls Efficacy Scale
• Goal Attainment Scale
• Modified Fatigue Impact Scale
• Modified Rankin Scale
• Reintegration to Normal Living
• Satisfaction with Life Scale
• Stroke-Adapted Sickness
Impact Scale-30
• SF-36
• Stroke Impact Scale
• Stroke-Specific Quality of Life
Scale
30. Falls Efficacy Scale
self report. Studies found only for inpatient rehab Swedish Version (additional
questions stroke specific) 1
• Assesses confidence, balance,
perception with daily activities 1
• Visual Analog Scale3
• 1- very confident
• 10- not confident at all
• Score: 10 (+) to 100 (-)
• >80 falls risk, >70 fear of fall
• Those with aphasia may have difficulty1
Original: http://www.rehabmeasures.org/PDF%20Library/Falls%20Efficacy%20Scale.pdf
Swedish Version: http://www.biomedcentral.com/content/supplementary/1743-0003-6-13-s1.pdf
31. Stroke Impact Scale
self report. Highly Recommended for SNF, home health and outpatient only if patient
has been in the community post stroke 1
• Assessment of health status post stroke3
• Scoring 1-5: (1)could not do → (5)not difficult at all
• Items of home living can be omitted- use as a percentage1,3
• Simple training, cost is free to non
profit users3
• www.mapi-trust.org or www.kumc.edu
http://www.northeastrehab.com/Forms/NRH_Forms/SIS_Handout.pdf
32. Summary
• Predictors of Poor Outcomes: comorbidities, dependence,
incontinence, support system, gender, age.
• Predictors of Return to Ambulation: Stand balance and 6MWT
• Predictors of Return of UE function: 1 month AROM (shoulder), finger
extension
• Capture the full patient profile when choosing outcome measures
• body function/structure
• activity
• participation
34. A Special Thank You
• Phil Blatt PT, PhD, NCS
• Laura Krych PT, MPT, NCS
• Sarah Grusemeyer PT, MPT, NCS
• Julie Mount PT, PhD
• Neera Prabhakar PT, DPT, NCS
35. References
1. StrokEDGE Taskforce. http://www.neuropt.org/docs/stroke-sig/strokeedge_taskforce_summary_document.pdf?sfvrsn=2.
Accessed March 23, 2015.
2. Strokengine.ca. http://strokengine.ca. Accessed January 9, 2014.
3. RehabMeasures.org. http://www.rehabmeasures.org/default.aspx. Accessed March 23, 2015.
4. Wei JW, Heeley EL, Wang J, Huang Y, Wong LKS, Li Z, Heritier S, Arima H, Anderson C S. Comparison Of Recovery Patterns and
Prognostic Indicators for Ischemic and Hemorrhagic Stroke in China: The ChinaQUEST (Quality Evaluation of Stroke Care and
Treatment) Registry Study. Stroke. 2010; 41(9): 1877-83. Tan, W.S.,
5. Tan, W.S., Heng, B.H., Chua, K.S., Chan, K.F. Factors Predicting Inpatient Rehabilitation Length of Stay of Acute Stroke Patients in
Singapore. Arch Phys Med Rehabil. 2009; 90(7):1202-7.
6. Hakkenned SJ, Brock K, Hill KD. Selection for Inpatient Rehabilitation After Acute Stroke: A Systematic Review of the Literature.
Arch Phys Med Rehabil. 2011; 92(12):2057-70.
7. Di Monaco M, Schintu S, Dotta M, Barba S, Tappero R, Gindri P. Severity of Unilateral Spatial Neglect Is an Independent
Predictor of functional Outcome After Acute Inpatient rehabilitation in Individuals with Right Hemisphere Stroke. Arch Phys
Med Rehabil. 2011; 92(8):1250-6.
8. Bernardo G, Cristina F. Functional Outcome after Stroke in Patients with Aphasia and Neglect: Assessment by the Motor and
Cognitive Functional Independence Measure Instrument. Cerebrovasc Dis. 2010; 30(5):440-7.
36. References
9. Leśniak M, Bak T, Czepiel W, Seniów J, Członkowska A. Frequency and Prognostic Value of Cognitive Disorders in Stroke
Patients. Dement Geriatr Cogn Disord. 2008; 26(4):356-63.
10. Kollen B, van de Port I, Lindeman E, Twisk J, Kwakkel G. Predicting Improvement in Gait After Stroke: A Longitudinal Prospective
Study. Stroke. 2005 Dec; 36(12):2676-80.
11. Fulk GD, Reynolds C, Mondal S, Deutsch JE. Predicting Home and Community Walking Activity in People With Stroke. Arch Phys
Med Rehabil. 2010 Oct; 91(10):1582-6.
12. Beebe JA, Lang CE. Active Range of Motion Predicts Upper Extremity Function 3 Months After Stroke. Stroke. 2009 May;
40(5):1772-9.
13. Kwakkel G, Kollen BJ. Predicting Activities After Stroke: What is Clinically Relevant? Int J Stroke. 2013 Jan; 8(1):25-32.
14. The Aufman EL, Bland MD, Barco PP, Carr DB, Lang CE. Predictors of Return to Driving After Stroke. Am J Phys Med Rehabil.
2013 Jul; 92(7):627-34.
15. Glozier N, Hackett ML, Parag V, Anderson CS. Influence of Psychiatric morbidity on Return to Paid Work After Stroke in Younger
Adults. Stroke. 2008 May; 39(5):1526-32.
16. Wozniak MA, Kittner SJ. Return to Work After Ischemic Stroke: A Methological Review (abstract). Neuroepidemiology. 2002 Jul-
Aug; 21(4):159-66.
17. ICF Model. http://www.who.int/classifications/icf/en/. Accessed on March 24, 2014
37. References
18. Galanth S, Tressieres B, Lannuzel A, Foucan P, Alecu C. Factors
Influencing Prognosis and Functional Outcome One Year After a
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