Influence of the amount of rehabilitation and the disease phase on recovering independence in patients with cerebral stroke

  • Y.V. Flomin MC «Universal Clinic “Oberig”», Kyiv, Ukraine
  • V.G. Gurianov Bogomolets National Medical University, Kyiv, Ukraine
  • M.V. Guliaieva MC «Universal Clinic “Oberig”», Kyiv, Ukraine
  • L.I. Sokolova Bogomolets National Medical University, Kyiv, Ukraine
Keywords: stroke; outcome; stroke phase; rehabilitation; prognosis; prognostic model.


Objective ‒ to determine independent predictors and develop a prognostic model for asses-sing the likelihood of lack of a good outcome (dependence) in cerebral stroke patients with severe disabilities who were admitted to a comprehensive stroke unit in a subacute or chronic phase.
Materials and methods. A retrospective observational study enrolled patients with a verified cerebral stroke, who were admitted to the Stroke Center (SC) over 2010‒2018 in the early subacute (from Day 8 to Day 90 from onset), the late subacute (from Day 91 to Day 180 from onset) or chronic (after 180 days from onset) phase of the disease and had severe disabilities upon admission (i.e. a modified Rankin scale (mRS) 4 or 5). There were included 290 patients (38.7 % of women) aged from 20.4 to 91.2 years (median ‒ 64.9 years, interquartile range ‒ 56.6‒74.6). Care in the SC was provided in accordance with guidelines and included active interdiscipli-nary rehabilitation. The restoration of independence in daily living at discharge was considered a good outcome (mRS 0‒2). We assessed the relationship of the risk of failure to achieve a good outcome with five clinical variables: age, sex, stroke period, and baseline mRS score and the amount (dose) of rehabilitation (total time of physical therapy, ergotherapy or mechanotherapy).
Results. 81 (28.0 %) participant had intracerebral hemorrhage, whereas 209 (72.0 %) had cerebral infarction. The total National Institutes of Health stroke scale (NIHSS) score on admission ranged from 1 to 36 (median 14 points, interquartile range 10–20). While 188 (64.8 %) of the patients were hospitalized to the SC during the early subacute, 34 (11.8 %) and 68 (23.4 %) study participants were admitted only in the late subacute and chronic phase of stroke, respectively. In the analysis of generalized linear regression models, three features had a significant relationship with a decrease in the mRS score: sex, time from stroke onset to SC admission, and the total time of mechanotherapy. According to the multivariate analysis, four factors were significantly associated with a need for assistance in activities of daily living at SC discharge: the risk of dependence was significantly (p = 0.004) lower in men, was directly depended on the initial mRS score and the time elapsed from the estimated stroke onset to the SC admission, but was inversely related to the amount (dose) of certain rehabilitation interventions (the odds ratio of not achieving a good outcome was 0.93 (95 % CI 0.89‒0.97) for every additional 100 minutes of mechanotherapy). The logistic regression model based on the selected set of features turned out to be adequate (χ2 = 60.7 at 7 degrees of freedom, p <0.001). The area under the curve of operational characteristics AUC = 0.82 (95 % CI 0.77‒0.86) indicates good internal prognostic model agreement, and its sensitivity and specificity were good with 76.1 % (95 % CI 70.1‒81.4 %) and 75.0 % (95 % CI 61.6‒85.6 %), respectively.
Conclusions. In a cohort of patients with cerebral stroke, independent predictors of dependency after in-patient rehabilitation were identified and a predictive model was developed to assess the likelihood of a good treatment outcome. If its external validity is confirmed in other settings, the developed model may be useful for optimizing treatment strategies and providing patients and their families with prognostic evaluations.


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Lindsay MP, Norrving B, Sacco RL et al. World Stroke Organization (WSO): Global Stroke Fact Sheet 2019. Int J Stroke. 2019 Oct;14(8):806-17.

GBD 2016 Stroke Collaborators. Global, regional, and national burden of stroke, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol 2019 May;18(5):439-58.

Luengo-Fernandez R, Violato M, Candio P, Leal J. Economic burden of stroke across Europe: A population-based cost analysis. Eur Stroke J. 2020 Mar;5(1):17-25.

Global Burden of Disease Study 2017 (GBD 2017). Seattle, WA: Institute for Health Metrics and Eva-luation (IHME), University of Washington, 2018 (онлайн-доступ за посиланням:

Timmis A, Townsend N, Gale CP, Torbica A, Lettino M, Petersen SE, et al.; European Society of Cardio-logy. European Society of Cardiology: Cardiovascular Disease Statistics 2019. Eur Heart J. 2020 Jan 1;41(1):12-85.

Anaya MA, Branscheidt M. Neurorehabilitation after stroke. Stroke. 2019 Jul;50(7):e180-e182.

Feng W, Belagaje SR. Recent advances in stroke recovery and rehabilitation. Semin Neurol. 2013 Nov;33(5):498-506.

Hankey GJ, Spiesser J, Hakimi Z, Bego G, Carita P, Gabriel S. Rate, degree, and predictors of recovery from disability following ischemic stroke. Neuro-logy. 2007 May 8;68(19):1583-7.

Andersen KK, Andersen ZJ, Olsen TS. Predictors of early and late case-fatality in a nationwide Danish study of 26,818 patients with first-ever ischemic stroke. Stroke. 2011 Oct;42(10):2806-12.

Saver JL, Altman H. Relationship between neurologic deficit severity and final functional outcome shifts and strengthens during first hours after onset. Stroke. 2012 Jun;43(6):1537-41.

Koennecke HC, Belz W, Berfelde D et al.; Berlin Stroke Register Investigators. Factors influencing in-hospital mortality and morbidity in patients treated on a stroke unit. Neurology. 2011 Sep 6;77(10):965-72.

Béjot Y, Troisgros O, Gremeaux V et al. Poststroke disposition and associated factors in a population-based study: the Dijon Stroke Registry. Stroke. 2012 Aug;43(8):2071-7.

Saposnik G, Johnston SC. Decision making in acute stroke care: learning from neuroeconomics, neuromarketing, and poker players. Stroke. 2014 Jul;45(7):2144-50.

Harvey RL. Predictors of functional outcome following stroke. Phys Med Rehabil Clin N Am. 2015 Nov;26(4):583-98.

Auriel E, Bornstein NM. Early mobilisation following stroke. European Neurological Review. 2013;8(2):141–3.

Sun Y, Paulus D, Eyssen M, Maervoet J, Saka O. A systematic review and meta-analysis of acute stroke unit care: what’s beyond the statistical significance? BMC Med. Res. Methodol. 2013 Oct 28;13:132.

Bernhardt J, Hayward KS, Kwakkel G et al. Agreed definitions and a shared vision for new standards in stroke recovery research: The Stroke Recovery and Rehabilitation Roundtable taskforce. Int J Stroke. 2017 Jul;12(5):444-50.

Prabhakaran S, Zarahn E, Riley C et al. Inter-individual variability in the capacity for motor recovery after ischemic stroke. Neurorehabil Neural Repair. 2008 Jan-Feb;22(1):64-71.

Stinear CM, Byblow WD, Ackerley SJ, Smith MC, Borges VM, Barber PA. proportional motor recovery after stroke: implications for trial design. Stroke. 2017 Mar;48(3):795-8.

Cooke EV, Mares K, Clark A, Tallis RC, Pomeroy VM. The effects of increased dose of exercise-based therapies to enhance motor recovery after stroke: A systematic review and meta-analysis. BMC Med. 2010 Oct 13;8:60.

Peiris CL, Taylor NF, Shields N. Extra physical therapy reduces patient length of stay and improves functional outcomes and quality of life in people with acute or subacute conditions: A systematic review. Arch Phys Med Rehabil. 2011 Sep;92(9):1490-500.

Krakauer JW, Carmichael ST, Corbett D, Wittenberg GF. Getting neurorehabilitation right: what can be learned from animal models? Neurorehabil Neural Repair 2012 Oct;26(8):923-31.

Host HH, Lang CE, Hildebrand MW et al. Patient active time during therapy sessions in postacute rehabilitation: Development and validation of a new measure. Phys Occup Ther Geriatr. 2014 Jun;32(2):169-178.

Lohse KR, Lang CE, Boyd LA. Is more better? Using metadata to explore dose-response relationships in stroke rehabilitation. Stroke. 2014 Jul;45(7):2053-8.

Lang CE, Lohse KR, Birkenmeier RL. Dose and timing in neurorehabilitation: prescribing motor therapy after stroke. Curr Opin Neurol. 2015 Dec;28(6):549-55.

Lang CE, Strube MJ, Bland MD et al. Dose response of task-specific upper limb training in people at least 6 months poststroke: a phase II, single-blind, randomized, controlled trial. Ann Neurol. 2016;80:342-54.

Stinear CM, Lang CE, Zeiler S, Byblow WD. Advances and challenges in stroke rehabilitation. Lancet Neurol. 2020 Apr;19(4):348-60.

Veerbeek JM, Kwakkel G, van Wegen EE, Ket JC, Heymans MW. Early prediction of outcome of activities of daily living after stroke: a syste-matic review. Stroke. 2011 May;42(5):1482-8.

Park J, Lee SU, Jung SH. Prediction of post-stroke functional mobility from the initial assessment of cognitive function. NeuroRehabilitation. 2017;41(1):169-177.

de Ridder IR, Dijkland SA, Scheele M et al. Development and validation of the Dutch Stroke Score for predicting disability and functional outcome after ischemic stroke: a tool to support efficient discharge planning. Eur Stroke J. 2018 Jun;3(2):165-73.

Kim TJ, Lee JS, Oh M-S et al. Predicting functional outcome based on linked data after acute ischemic stroke: S-SMART Score. Transl Stroke Res. 2020 Apr 18.

Ntaios G, Gioulekas F, Papavasileiou V, Strbian D, Michel P. ASTRAL, DRAGON and SEDAN scores predict stroke outcome more accurately than physicians. Eur J Neurol. 2016 Nov;23(11):1651-7.

Quinn TJ, Singh S, Lees KR, Bath PM, Myint PK; VISTA Collaborators. Validating and comparing stroke prognosis scales. Neurology. 2017 Sep 5;89(10):997-1002. h

Gao MM, Wang J, Saposnik G. The art and science of stroke outcome prognostication. Stroke. 2020 May;51(5):1358-60.

Bates BE, Xie D, Kwong PL et al. Development and validation of prognostic indices for recovery of physical functioning following stroke: Part 1. PMR. 2015 Jul;7(7):685-98.

Petrie A, Sabin C. Medical Statistics at a Glance, 3rd ed. Oxford, UK: Wiley-Blackwell; 2009. 180 p.

Myint PK, Clark AB, Kwok CS et al. The SOAR (Stroke subtype, Oxford Community Stroke Pro-ject classification, Age, prestroke modified Rankin) score strongly predicts early outcomes in acute stroke. Int J Stroke. 2014 Apr;9(3):278-83.

Flint AC, Rao VA, Chan SL et al.; SITS International and VISTA-plus investigators. Improved ischemic stroke outcome prediction using model estimation of outcome probability: the THRIVE-c calculation. Int J Stroke. 2015 Aug;10(6):815-21.

European Medicines Agency. Clinical investigation of medicinal products for the treatment of acute stroke. CPMP/EWP/560/1998 (онлайн-доступ за посиланням:

Galvin R, Murphy B, Cusack T, Stokes E. The impact of increased duration of exercise therapy on functional recovery following stroke ‒ what is the evidence? Top Stroke Rehabil. 2008 Jul-Aug;15(4):365-77.

Veerbeek JM, Koolstra M, Ket JC, van Wegen EE, Kwakkel G. Effects of augmented exercise therapy on outcome of gait and gait-related activities in the first 6 months after stroke: A meta-analysis. Stroke. 2011 Nov;42(11):3311-5.

Duncan PW, Sullivan KJ, Behrman AL et al. Body-weight-supported treadmill rehabilitation after stroke. N Engl J Med. 2011 May 26;364(21):2026-36.

Hsieh YW, Wu CY, Lin KC et al. Dose-response relationship of robot-assisted stroke motor rehabilitation: The impact of initial motor status. Stroke. 2012 Oct;43(10):2729-34.

How to Cite
Flomin, Y., Gurianov, V., Guliaieva, M., & Sokolova, L. (2020). Influence of the amount of rehabilitation and the disease phase on recovering independence in patients with cerebral stroke. Ukrainian Interventional Neuroradiology and Surgery, 32(2), 35-46.