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

Abstract

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.