Research Report
Population: Adult
Marghuretta D Bland, PT, DPT, NCS, MSCI, Assistant Professor, Washington University in St. Louis School of Medicine blandm@wustl.edu
Keith Lohse, PhD, Assistant Professor, Auburn University kelopelli@gmail.com
Catherine Lang, PT, PhD, Professor, Washington University in St. Louis School of Medicine lang@wustl.edu
Keywords: Prediction, Stroke, Outpatient Rehabilitation, Functional Change
Purpose/Hypothesis: To examine overall change and individual trajectories across the activity domains of upper extremity motor capacity, balance limitations, and mobility in people post-stroke who are receiving outpatient therapy services.
Number of Subjects: 366 records stored in the Brain Recovery Core database for patients admitted to outpatient physical and/or occupational therapy between March 2010 and September 2014.
Material/Methods: Multi-level linear modeling was used to quantify changes across activity domains. The Berg Balance Scale (BBS) was used as a measure of balance limitations, the Action Research Arm Test (ARAT) was used as a measure of upper extremity motor capacity, and walking speed as a measure of mobility. Additional variables modeled as fixed-effects were: Duration (months of outpatient therapy), Time (days post-stroke at the start of outpatient therapy), Age (years), and Inpatient status (if the patient went to an inpatient rehabilitation facility (IRF)) as a proxy for functional severity. Initial scores at the start of outpatient therapy (intercepts), rate of change during outpatient therapy (slopes), and the covariance between slopes and intercepts were modeled as random-effects.
Results: A patient with average Age and Time started at 37 points on the BBS with a change of +1.9 points per month, at 34 points on the ARAT with a change of +1.9 points per month, and with a walking speed of 0.59 m/s with a change of +0.08 m/s per month. When controlling for other variables, patients started with lower scores on the BBS and ARAT or had slower walking speeds at admission if they started outpatient therapy later than average or went to an IRF. For the BBS, the rate of change during outpatient therapy was the same regardless of Age, Time, or Inpatient status. For the ARAT and walking speed, rate of change was slower if they started outpatient therapy later or were older than average.
Conclusions: Patients generally improved during outpatient therapy across the measured activity domains, but there was considerable variability in individual trajectories. Time post-stroke and inpatient status negatively impacted initial scores at admission to outpatient services. Time post-stroke and age also negatively impacted rate of change for upper extremity motor capacity and walking speed. Surprisingly, the rates of change across all three domains for the duration of outpatient therapy were rather small; average changes per month were below estimates of minimal clinically-important differences.
Clinical Relevance: Because these data come from outpatients and not a research population, they are immediately useful for assisting clinicians in prediction of expected changes and outcomes for individual patients receiving outpatient stroke rehabilitation services. Knowing how much change and the anticipated duration of outpatient services will enable therapists to better match individual goals and prognoses to the most appropriate interventions.
Citation:
Bland, Marghuretta D, PT, DPT, NCS, MSCI; Lohse, Keith R, PhD; Lang, Catherine E, PT, PhD. Predicting change during outpatient stroke rehabilitation: A retrospective regression analysis.. Poster Presentation. IV STEP Conference, American Physical Therapy Association, Columbus, OH, July 17, 2016. Online. https://u.osu.edu/ivstep/poster/abstracts/077_bland-et-al/