Physiatrists have struggled to define the relation

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1 8 The Measure of Balace i Sittig i Stroke ehabilitatio Progosis Karl J. Sadi, MD, ad Barry S. Smith, MD To test the hypothesis that recoverig stroke patiets with iitially good sittig balace or those who develop good sittig balace durig rehabilitatio have better Barthel Idex-based fuctioal assessmet outcomes tha recoverig stroke patiets with poor sittig balace, we prospectively studied of 5 cosecutive stroke patiets admitted to a tertiary-care hospital rehabilitatio uit Sittig balace, a prerequisite for most fuctioal activities, was scored usig a four-poit scale evaluatig static ad dyamic sittig balace o admissio to the rehabilitatio uit ad weekly util discharge. Fuctioal status was assessed usig the Barthel Idex or weeks after the stroke. We foud a strog positive correlatio betwee Barthel Idex score ad each weekly sittig balace score. Multiple evaluatios over time idetified those patiets whose sittig balace improved durig rehabilitatio i our uit; after groupig the patiets ito those with ormal, improved, ad poor sittig balace, we foud a sigificat differece i the Barthel Idex scores amog the three groups. The group of patiets whose sittig balace improved had higher Barthel Idex scores tha the group whose sittig balace did ot improve. Ogoig evaluatio of sittig balace ca be helpful i aticipatig fuctioal status at discharge i stroke patiets udergoig comprehesive rehabilitatio. (Stroke ^:8-86) Dowloaded from by o Jauary, Physiatrists have struggled to defie the relatio betwee various aspects of fuctioal status ad overall rehabilitatio outcome i stroke patiets. May studies have correlated patiet characteristics preset at the iitial examiatio with log-term fuctioal improvemet; other studies have bee uable to documet a sufficietly high correlatio to precisely predict outcome. Aderso et al showed that perceptual loss, low motivatio, cofused ad disorieted thikig, withdraw ad apathetic behavior, a exteded time sice stroke oset, previous stroke, low blood pressure, ad a exteded period of ucosciousess at the time of the stroke are importat variables related to improvemet. ehma et al showed that family icome ad family ivolvemet supportig the patiet predicted discharge dispositio. There is a paucity of data cocerig the value of specific, ogoig fuctioal assessmet techiques i idetifyig those stroke victims who will do well i ipatiet rehabilitatio uits. We report the results of a prospective study of of 5 cosecutive stroke patiets admitted to the rehabilitatio uit of a acute-care hospital. We From the Departmet of Physical Medicie, Baylor College of Medicie (K.J.S., B.S.S.) ad the Departmet of Physical Medicie ad ehabilitatio, St. uke's Episcopal Hospital (B.S.S.), Housto, Texas. Address for correspodece: Dr. Sadi, Departmet of Physical Medicie, Baylor College of Medicie, Moursud, A-, Housto, TX 77. eceived April, 8; accepted August, 8. serially evaluated sittig balace to test the hypothesis that recoverig stroke patiets with iitially good sittig balace or those who develop good sittig balace durig rehabilitatio do better o a Barthel idex-based fuctioal assessmet of outcome tha recoverig stroke patiets with cosistetly poor sittig balace. Subjects ad Methods Twety-five patiets who had had a stroke were admitted to the rehabilitatio uit from May to September 5, 88. Twety-four were referred from St. uke's Episcopal Hospital, a large tertiary-care teachig hospital emphasizig medical ad surgical treatmet of cardiovascular disease ad the site of the rehabilitatio uit. The other patiet was referred from the outpatiet cliic of our departmet. Oe patiet had a hip fracture i additio to a stroke ad he was required to wear a thigh abductio split at all times. Because his sittig balace could have bee affected by his fracture, his stroke, or his postoperative orthopedic equipmet, this patiet was deleted from the cohort. The same physiatrist obtaied iformed coset from each patiet or a family member, tested the patiet's sittig balace, ad assessed the patiet's Barthel Idex score (see below). Sittig balace was tested usig the stadard techique for evaluatig static ad dyamic sittig balace. The patiet sat o the side of a hospital

2 Dowloaded from by o Jauary, bed, feet o the floor, back usupported, ad hads o the lap. If the patiet could hold this positio without assistace for 5 secods, he was udged by the physiatrist ateriorly, posteriorly, ad laterally usig approximately 5- foot-pouds of force. The physiatrist guarded the patiet from fallig with his free had. The patiet's sittig balace was scored as, ormal: able to perform the above testig without ay physical assistace;, good: able to maitai a static positio without difficulty but requirig assistace i rightig from the hemiplegic side;, fair: able to maitai a static positio without difficulty but requirig assistace i all rightig tasks; or, poor: uable to maitai a static positio. Sittig balace was evaluated o admissio to the rehabilitatio uit ad every week while the patiet was i the hospital. The Barthel Idex, a ordial scale that comprises scores for feedig, mobility, persoal care, ambulatio or wheelchair skills, bowel ad bladder abilities, ad dressig skills, was used to assess each patiet's rehabilitatio outcome. The Barthel Idex was selected because of its ease of admiistratio, its prove reliability, ad its good track record i the fuctioal evaluatio of patiets with stroke. 5 " 7 The Barthel Idex score was geerated by physiatric examiatio i cojuctio with rehabilitatio ursig evaluatio exactly weeks after the oset of hemiparesis due to stroke i of the patiets ad weeks after stroke oset i three patiets with extremely log hospital stays before admissio to the rehabilitatio uit. Each patiet's discharge dispositio (to home without or with assistace, to retiremet home, to exteded-care facility/ursig home, or back to the acute-care hospital) was recorded. The percetage of the cohort with give demographic ad cliical characteristics was calculated. The mea, stadard deviatio (SD), rage, media, ad mode were calculated for the time variables age, time from stroke oset to admissio to rehabilitatio uit, time to iitial sittig balace evaluatio, ad time i rehabilitatio uit. The correlatio coefficiet (r) for sittig balace score versus Barthel Idex score was calculated ad evaluated usig the two-tailed t test. The mea±sd Barthel Idex scores for defied groups of patiets were calculated ad compared usig the two-tailed t test. esults Of the patiets, 6 (66.7, five me ad wome) had left hemiparesis ad eight (., four me ad four wome) had right hemiparesis; (.7) strokes were thromboembolic ad two (8.) cosisted of capsular hemorrhage that resulted i left hemiparesis. This was the first stroke i patiets. The patiet who had already had several mior strokes was fuctioig ormally at the time of the stroke uder cosideratio. The mea±sd age of the patiets was 7.7±8. (rage 5-8) years. The demographic ad cliical data are summarized i Table. Sadi ad Smith Serial Evaluatio of Sittig Balace 8 The patiets were admitted to the rehabilitatio uit a average of 7. (SD., rage -6) days after their stroke (Table ); the media ad mode were days. Sittig balace was iitially evaluated a average of.5 (SD., rage -) days after admissio to the rehabilitatio uit; the media was days. The time from the oset of stroke to the iitial sittig balace evaluatio averaged.5 (SD.8) days; the media was 6.5 ad the mode 6 days. The patiets uderwet a media of two (rage -) sittig balace evaluatios while i the rehabilitatio uit (Table ). Table gives the frequecy distributios of the sittig balace scores for each evaluatio. Because the Barthel Idex scores for three patiets were obtaied weeks after the stroke, the statistical aalyses were performed first by icludig ad the by omittig the results from those three patiets. Because there was o sigificat differece i the results betwee aalyses, we report the aalysis of all patiets. The Barthel Idex score averaged 75 (SD 7, rage 5-); the media ad mode were 8. Of the patiets, 8 (75) were discharged to home with help, icludig stad-by assistace, ad oe (.) was discharged to idepedet home care. Two patiets (8.) were discharged to exteded-care facilities ad oe (.) to a retiremet home. Two patiets (8.) retured to the acute-care hospital, where oe later died. Correlatio aalysis of the Barthel Idex score ad the first sittig balace scores yielded r=.6; (p<.). Similar correlatio aalyses of Barthel Idex score ad the secod ad third sittig balace scores gave r=. (p<.) adr=.8 (/?<.), respectively. There was o sigificat differece i Barthel Idex scores betwee the patiets discharged to home (mea±sd score 77 ±6) ad the five patiets discharged to retiremet or ursig homes or to the acute-care hospital (mea±sd score 65±) (Table ). We grouped the patiets by their sittig balace scores at each evaluatio; the ormal group comprised patiets with a score of, ad the lesstha-ormal group comprised those scorig,, or. Comparig the Barthel Idex scores of the two groups revealed a sigificat differece. As show i Figure, mea Barthel Idex score at the first sittig balace evaluatio was for the ormal group ad 68 for the less-tha-ormal group (p<.). At the secod evaluatio the meas were 87 ad 55, respectively (/><.), ad at the third they were 8 ad 5, respectively (p<.). For additioal aalysis the patiets were divided ito three groups: Group A, patiets with sittig balace scores of or at the first evaluatio ad at discharge (=5, 6.5); Group B, patiets with sittig balace scores of or at the first evaluatio who improved by at least two poits so that their sittig balace score at discharge was or («=,

3 8 Stroke Vol, No, Jauary TABE. Summary of Demographic ad Cliical Data for Stroke Patiets Admitted to ehabilitatio Uit Dowloaded from by o Jauary, Age/sex Group A 5/F 6/M 7/M 67/M 8/F 5/F 7/F 8/F 6/M 8/F 76/M 6/F 7/F 7/M 8/F Group B 7/M 6/F 8/F 7/M Group C 7/M 68/F 68/F 7/F 7/F Side t t Stroke oset to rehabilitatio Tue (days) ehabilitatio stay Sittig balace score First Secod Third Fourth F, female; M, male;, left;, right;, ormal;, good;, fair,, poor. Assessmet at weeks after stroke. tcapsular hemorrhage. 6.7); ad Group C, patiets with sittig balace scores of or at the iitial evaluatio who failed to improve at least two poits or those whose sittig balace scores declied while o the rehabilitatio uit ad were discharged with sittig balace scores of or (=5,.8) (Table ). The mea±sd Barthel Idex score was ± for Group A, 6 ± for Group B, ad 8 ±8 for Group C. There was a sigificat differece i mea Barthel Idex score betwee Groups A ad B (/J<.), betwee Groups B ad C (/?<.5), ad betwee Groups A ad C Barthel idex score 8' * 8* Discharge dispositio Nursig home Home (idepedet) etiremet home Nursig home Acute-care hospital Acute-care hospital (/?<.) (Figure ). The rehabilitatio stay averaged 7.5 (SD 7.5, rage -6) days; the media was 6 days. Mea±SD legth of stay for Groups A, B, ad C was ,.8±7., ad 7.±. days, respectively (Table ). There was o sigificat differece betwee these times. Discussio We plaed this study withi the framework of the usual cliical situatio, usig oly routiely available assessmet tools. Because patiets come to a reha- TABE. Sittig Balace Scores for Serial Evaiatios of Stroke Patiets Sittig balace score l(poor) (fair) (good) Evaluatio First Secod Third Fourth N (ormal) 7!

4 Sadi ad Smith Serial Evaluatio of Sittig Balace - I EVMiMTICM NUWB FIGUE. Bar graph. Barthel Idex score for stroke patiets with ormal sittig balace (ope bars) compared with those with poor, fair, or good sittig balace (shaded bars) o three weekly evaluatios. Probability of differece betwee groups assessed by two-tailed t test P<JO p< 5 Dowloaded from by o Jauary, bilitatio uit at various times after their stroke, the oset of the stroke rather tha admissio to the rehabilitatio uit was used as time t=. Four weeks after the stroke was arbitrarily chose as the time for the Barthel Idex assessmet (except i those patiets with very log prerehabilitatio hospital stays). Give a average of 7 days from stroke oset to rehabilitatio uit admissio ad a average rehabilitatio stay of 7.5 days (total.5 days), the Barthel Idex scores represet the patiet's fuctioal status week before discharge. This time frame seems to be cliically relevat sice discharge plaig frequetly begis i earest approximately week before discharge. Our cohort may have bee slightly less impaired tha patiets i other rehabilitatio uits. The average legth of stay (7.5 days) was somewhat less tha that i the rehabilitatio uit of a similar private, academic hospital elsewhere i our medical ceter (upublished data). Similarly, the average Barthel Idex score (75) was somewhat higher tha that i other stroke patiets udergoig rehabilitatio. A strog correlatio betwee Barthel Idex score ad ay weekly sittig balace score is ot surprisig. The Barthel Idex is weighed heavily toward activities (dressig, bowel ad bladder abilities, ad wheelchair skills) that require good sittig ad trasfer skills. Wade et al 8 idetified sittig balace alog with age, hemiaopsia, uriary icotiece, ad arm motor deficit as variables that related to 6-moth Barthel Idex score i a study of 8 patiets with stroke. Additioal iformatio about this cohort is derived from our serial evaluatio of sittig balace. Our stroke patiets' sittig balace scores improved POTTO (Grot* A) - 5 kprovod (GroipB) - Poor (Grape) -5 FIGUE. Bar graph. Barthel Idex scores for Groups A, B, ad C. Probability of differece from Group B assessed by two-tailed t test. betwee the first ad secod evaluatios, but the the rate of improvemet leveled off. Most likely, sittig balace improved from the first to the secod evaluatios because of eurologic ad fuctioal recovery i the cohort, but there also may have bee some practice effect. It is of particular iterest that there was a sigificat differece i Barthel Idex score amog the three groups of patiets. Certaily patiets with good sittig balace are expected to do well o the Barthel Idex. There was also a group of patiets with iitially poor sittig balace whose scores improved while o the rehabilitatio uit. From the data available, however, we foud o sigificat variables (such as age or legth of rehabilitatio stay) that differed betwee those patiets whose sittig balace scores improved ad those whose scores remaied poor or fair. Oly serial sittig balace evaluatios idetified those patiets whose sittig balace scores improved ad i tur had higher Barthel Idex scores. Additioal work eeds to be doe to idetify other serially evaluable fuctioal tasks that may idicate which patiets will do well durig stroke rehabilitatio. Serial assessmet of other fuctioal activities such as toiletig ability, cookig, etc., rather tha a oe-time assessmet, may better highlight those who will do well after stroke rehabilitatio. Oe such

5 86 Stroke Vol, No, Jauary study of truk cotrol i stroke patiets is i progress (S. Moore, persoal commuicatio). Ackowledgmets Special thaks to aura M. Motgomery, PhD, for expert assistace with computer aalysis, to Thomas Krouskop, PhD, for editig assistace, ad to the ursig staff of the rehabilitatio uit of St. uke's Episcopal Hospital. efereces. Aderso TP, Bourestom, N, Greeberg F, Hildyard VG: Predictive factors i stroke rehabilitatio. Arch Phys Med ehabil 7;55: ehma JF, Deateur BJ, Fowler S, Warre CG, Arhold, Schertzer G, Hurka, Whitmore JJ, Masock AJ, Chambers KH: Stroke rehabilitatio: Outcome ad predictio. Arch Phys Med ehabil 75;56:8-8. Stolov WC: Evaluatio of the patiet, i Kottke FJ, Stillwell GK, ehma JF (eds): Kruse's Hadbook of Physical Medicie ad ehabilitatio, ed. Philadelphia, WB Sauders Co, 8, pl. Mahoey FI, Barthel DW: Fuctioal evaluatio: The Barthel Idex. Md Med J 65;: Grager CV, Albrecht G, Hamilto BB: Outcome of comprehesive medical rehabilitatio: Measuremet by PUSES profile ad the Barthel Idex. Arch Phys Med ehabil 7; 6: Grager CV, Dewis S, Peters NC, Sherwood CC, Barrett JE: Stroke rehabilitatio: Aalysis of repeated Barthel Idex measures. Arch Phys Med ehabil 7;6:-7 7. Grager CV, Sherwood CC, Greer DS: Fuctioal status measures i a comprehesive stroke care program. Arch Phys Med ehabil 77;58: Wade DT, Skilbeck CE, Hewer : Predictig Barthel AD score at 6 moths after a acute stroke. Arch Phys Med ehabil 8;6:-8 KEY WODS cerebrovascular disorders rehabilitatio Dowloaded from by o Jauary,