MINERVA MEDICA COPYRIGHT. Stroke is the most common cause of disability or

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1 Background. Very few studies have investigated the influence of single activities of daily living (ADL) at admission as possible predictors of functional outcome after rehabilitation. Aim. The aim of the current study was to investigate admission functional status and performance of basic ADLs as assessed by Functional Independence Measure (FIM) scale as possible predictors of motor and functional outcome after stroke during inpatient rehabilitation. Design. This is a prospective and observational study. Setting. Inpatients of our Department of Physical Medicine and Rehabilitation. Population. Two hundred sixty consecutive patients with primary diagnosis of stroke were enrolled and 241 patients were used in the final analyses. Methods. Two backward stepwise regression analyses were applied to predict outcome. The first backward stepwise regression had age, gender, stroke type, stroke-lesion size, aphasia, neglect, onset to admission interval, Cumulative Illness Rating Scale, National Institute of Health Stroke Scale (NIHSS), Fugl-Meyer Scale, Trunk Control Test, and FIM (total, motor and cognitive scores) as independent variables. The second analyses included the above variables plus FIM items as an independent variable. The dependent variables were the discharge scores and effectiveness in total and motor-fim, and discharge destination. Results. The first multivariate analysis showed that admission Fugl-Meyer, neglect, total, motor and cognitive FIM scores were the most important predictors of FIM outcomes, while admission NIHSS score was the only predictor of discharge destination. Conversely, when admission single FIM items were included in EUR J PHYS REHABIL MED 2013;49: Predicting outcome after stroke: the role of basic activities of daily living B., R. SANTORO, C. FERLUCCI Operative Unit of Recovery and Functional Re-education Salvatore Maugeri Foundation, Lumezzane, Brescia, Italy the statistical model, admission Fugl-Meyer, neglect, grooming, dressing upper body, and social interaction scores were the most important predictors of FIM outcomes, while admission memory and bowel control scores were the only predictors of discharge destination. Conclusion. Our study indicates that performances of basic ADLs are important stroke outcome predictors and among which social interaction, grooming, upper body dressing, and bowel control are the most important. Clinical rehabilitation impact. The results of this study suggests that, when designing other studies on stroke outcome predictions, researchers should also include tests which assess performances of basic ADLs as independent variables, because this may allow identification of new prognostic indicators that can be helpful for the physician for managing stroke patients at the end of the rehabilitation period. Key words.stroke - Rehabilitation - Treatment outcome - Activities of daily living. Corresponding author: B. Gialanella, MD, Operative Unit for Recovery and Functional Rehabilitation, Fondazione Salvatore Maugeri, IRCCS, Via G Mazzini 129, Lumezzane, Brescia, Italy. bernardo.gialanella@fsm.it Stroke is the most common cause of disability or dependence in activities of daily living (ADL) among the elderly, having an enormous physical, psychological and financial impact on patients, families and health care system. 1 Therefore, reducing the degree of dependence in performance of basic ADLs is often a central aim of rehabilitation programmes and of other related interventions for stroke patients. 2 Response to rehabilitation and pre- Vol No. 5 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 629

2 diction of outcome in stroke patients can be difficult to ascertain. Early accurate prediction of outcome for stroke is crucial to facilitate proper discharge planning and to anticipate the need for home adjustments and community support. 3 Several studies have shown that functional status at admission, stroke severity, motor function and trunk movements are the most important outcome predictors in stroke patients. 2, 4-9 These endpoints have been used in studies employing multiple regression analysis to predict outcomes on a variety of clinical variables. Functional status at admission, discharge, and sometimes after discharge is assessed by several scales and instruments. The most widely used is the Functional Independence Measure (FIM) Scale. 10 This functional scale describes the stroke patient limitations in various ADLs: eating, grooming, bathing, dressing, personal hygiene, transfer to bed/ chair, walking, and stair seating. Very few studies have investigated the influence of single ADL at admission as predictors of functional outcome after rehabilitation Taub et al. 12 and Thommessen et al. 13 found that urinary incontinence at admission is the best single predictor of disability after stroke. On the other hand, Singh et al. 14 and Osberg et al. 16 pointed out that wheelchair use is a significant predictor of limitations in walking 14 and functional outcome, 16 while Weh and Ramb 11 and Suzuki et al. 15 showed that dressing/undressing and walking/riding in wheelchair have the highest predictive outcome value. In all the above studies, only some performance of basic ADLs such as urinary incontinence, or body dressing, or walking, or riding in wheelchair have been evaluated, thus these studies do not clearly point out the role of performance of basic ADLs in predicting functional outcome in stroke patients. The score of the performance of basic ADLs indicates disability in a specific ADL, while functional status score is a measure of total disability of the patient. Both single ADL and functional status at admission are predictors of stroke outcome but so far it has not been verified if in stroke patients, initial functional status is a more important outcome predictor than the single ADL. If this association was known, it would have allowed us to create more appropriate predictive models of outcome in stroke plus help in identifying other potential prognostic factors. The aim of this prospective study was to investigate functional status and single-item ADL at admission, measured by FIM, as predictors of motor and functional outcomes after stroke during inpatient rehabilitation. Patients Materials and methods The study was conducted at the Rehabilitation Centre of Lumezzane, where stroke patients are referred from medical emergency departments and stroke units in the province of Brescia (Italy). The Rehabilitation centre of Lumezzane is an accredited structure by the National Health System and all funding sources are driven by the NHS. Between January 2001 and April 2008, consecutive patients admitted to our Rehabilitation Unit with primary diagnosis of stroke were considered for study inclusion. Patients referred from other departments for concomitant acute events during rehabilitation or patients who died during rehabilitation were not included in the outcome analyses. Patients with previous history of stroke and dementia, presence of other ongoing neurological diseases or confusion states, and onset to admission interval (OAI) 29 days were also excluded. The Ethics Committee of our Institution approved the study protocol and all patients gave their written informed consent to participate. The study was conducted in accordance with the principles of the Declaration of Helsinki. Computed tomography (CT) scans were performed on all patients. On the basis of their largest CT diameter, lesions were classified as small, medium or large (<3 cm, from 3 to 5 cm, or >5 cm, respectively). 17 Types of evaluations Evaluation of all patients was based on a standard neurological examination using scales of demonstrated reliability, validity and sensitivity that have been used in past studies during post-stroke recovery. The Aachen Aphasia Test (AAT), 18 the Albert s and Bisiach s tests, 19, 20 the Cumulative Illness Rating Scale (CIRS), 21 the National Institute of Health Stroke 630 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE October 2013

3 Scale (NIHSS), 22 the Fugl-Meyer Scale, 23 the Trunk Control Test (TCT), 24 FIM, 10 and discharge destination were evaluated. The presence and severity of aphasia was assessed using the Italian version of the Aachen Aphasia Test (AAT). 18 AAT assesses the main linguistic modalities (spontaneous speech, repetition, written language, confrontation naming and comprehension) and identifies five aphasic syndromes (motor, sensory, mixed, anomic, and unclassified aphasia). According to deficits of linguistic modalities, we classified aphasia severity using a 5-step ordinal scale (no Aphasia; slight= anomic Aphasia; mild= motor Aphasia; moderate= sensory Aphasia; severe=motor-sensory Aphasia). 25 The presence and severity of Neglect was assessed by Albert s and Bisiach s tests: 19, 20 we then classified Neglect severity using a 4-step ordinal arbitrary scale (no neglect; slight= neglect; moderate= hemisomatoagnosia + neglect; severe= anosognosia + hemisomatoagnosia + neglect). 25 Comorbidity was assessed by CIRS. 21 This is an instrument that measures disease burden in individuals with various chronic diseases. CIRS is a comprehensive review of medical problems of 14-organ systems. It is based on a 0 to 4 rating of each organ system. The instrument gives information about severity and comorbidity of chronic diseases. The current study evaluated comorbidity only. 26 Stroke severity was assessed by NIHSS. 22 The scale consists of 15 items exploring level of consciousness (questions and commands), gaze, visual fields, facial palsy, motor arm and leg, limb ataxia, sensitivity, language, dysarthria, and inattention. The total score ranges from 0 (normal) to 42 (patient in coma, unresponsive to external stimuli). Fugl-Meyer Scale was used to assess limb motricity, balance, some sensory details and joint dysfunction in hemiplegic patients. 23 We evaluated only motor function. A total of 50 items are included. A 3-step (0-1-2) ordinal scale is applied to each item (0= details cannot be performed; 1= details can be performed only partly; 2= details are performed throughout the total range of motion of the joint). This gives a total maximum score of 100, i.e. normal motor-function (66 and 34 for upper and lower extremity, respectively). TCT examines four simple aspects of trunk movement. 24 The patient lies supine in bed and is asked to roll on their weak and strong sides, sit up from lying down, and sit in a balanced position on the edge of the bed, with the feet off the ground for a minimum of 30 seconds. The scoring is as follows: 0= unable to perform movement without assistance; 12= able to perform movement, but in an abnormal way; and 25= able to complete movement normally. TCT score is the sum of the scores obtained on the four tests (range 0 to 100). FIM 10 was performed to measure the degree of independence and need-of-assistance in the performance of basic ADLs. It is an 18-item ordinal scale with seven levels ranging from 1 (total dependence) to 7 (total independence). FIM can be subdivided into a 13-item motor sub-scale (eating, grooming, bathing, dressing upper body, dressing lower body, personal hygiene, bladder control, bowel control, transfer to bed/chair/wheelchair, transfer to toilet, transfer to tub/shower, walk or wheelchair, stairs) and a 5-item cognitive sub-scale (comprehension, expression, social interaction, problem solving, memory). The motor and cognitive sub-scales scores range from 13 to 91 (motor-fim) and from 5 to 35 (cognitive-fim). The maximum total score is 126. Patients were tested by a qualified physiatrist. Discharge destination from our Rehabilitation Unit was classified in four categories (nursing homes, home with caregiver, home with relatives, home alone). Rehabilitation programme All patients included in the study underwent a rehabilitation programme. The need for and type of rehabilitation for each patient was assessed by a team of specialists (physicians, speech therapists, and physiotherapists). Rehabilitation started the day after admission. Needs, specific goal set and rehabilitation achievement were discussed by the rehabilitation team on a patient-by-patient basis, before the start of the study. All patients underwent an average of 330 min/ week of motor rehabilitation (6 days/week) and if needed 200 min (4 days/week) of neuropsychological rehabilitation. In addition, all patients underwent a 15-h cycle of occupational therapy (5 h/week) during the last 3 weeks of hospitalization. Motor rehabilitation was based on the Bobath concept. 27 Patients were not discharged until additional in-hospital improvement was considered unlikely to occur by the rehabilitation team. Vol No. 5 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 631

4 Statistical analysis Statistical analysis was performed using descriptive statistic tests (mathematical mean, SD, percentage) and Student s t-test for comparison of paired data. Moreover, univariate and multivariate regression analyses were applied. All statistically significant variables at the univariate regression analysis were submitted to the multivariate analysis. Backward stepwise regression analyses were used to predict outcome. Age, gender, stroke type, strokelesion size, aphasia, neglect, OAI, CIRS, NIHSS, admission Fugl-Meyer score, TCT at admission and total-, motor- and cognitive-fim scores at admission are independent variables at the first backward stepwise regression. The independent variables were chosen on clinical grounds and on the basis of previous studies, where these variables were valid independent predictor of outcome in stroke discharge destination. 29 All statistical analyses were performed with the software application Statistica Version 6 (StatSoft, Tulsa, OK, 2001). P-values <0.05 were considered statistically significant. Results During the study period, 376 patients with primary diagnosis of acute cerebrovascular accident were screened. Of these, 56 patients had previous history of stroke and 60 had OAI 29 days. Therefore, 260 patients were included in the study. During the in-hospital rehabilitation, 19 patients died or were transferred back to acute care hospitals. As a result, 241 patients were included in the outcome analysis. Table I shows the demographical and clinical characteristics of patient population. Table II shows the initial and final scores and the gain in single FIM items. Gain involves all activities. Among motor-fim items, gain was highest in walking (2.7±1.6), transfer to toilet (2.4±1.6) and transfer to bed/chair (2.4±1.5). Gain on cognitive-fim items was the lowest. Table III reports the data of the univariate linear MEDICA patients. 12, 28 The second backward stepwise regression included, as independent variables, single FIM items and all variables included in the first backward stepwise regression. The dependent variables were the discharge scores and effectiveness in total and motor-fim, and Table I. Demographical and Clinical Characteristics of Patients (N.=241). Admission Discharge P-value Age (years) 71.1±10 Sex (male/female) 117/124 Stroke type (infarct/haemorrhage) 195/46 Stroke lesion size (small/medium/large) 67/90/84 Side of stroke lesion (right/left) 102/139 Aphasia (severe/moderate/mild/slight) 33/17/23/15 Neglect (severe/moderate/slight) 15/7/14 OAI (days) 17.6±5.9 LOS (days) 49.4±16 CIRS 3.3±1.2 NIHSS 9.0± ±4.1 P=0.000*** TCT 25.0± ±26 P=0.000*** ***P<0.001MINERVA Fugl-Meyer 37.5± ±31 P=0.000*** Total-FIM 54.0± ±27 P=0.000*** Motor-FIM 33.2± ±21 P=0.000*** Cognitive-FIM 20.8± ±8.0 P=0.060 Effectiveness in total-fim (%) 44.3±25 Effectiveness in motor-fim (%) 49.4±28 Discharge destination (home/nursing home) 205/36 CIRS: Cumulative Illness Rating Scale; FIM: Functional Independence Measures; LOS: length of stay; NIHSS: National Institute of Health Stroke Scale; OAI: onset to admission interval; SD: standard deviation; TCT: trunk control test. Data are shown as mean±sd, or number. Comparison was performed by Student s t-test. 632 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE October 2013

5 Table II. Profiles of activities of daily living (ADL) at admission and discharge (N.=241). regression analysis and summarises the relationships among admission independent variables and outcome, while Table IV shows the results of the two multivariate linear regression analyses both with and without FIM items. Discussion ADL at admission The aim of this study was to evaluate the role of functional status and performance of basic ADLs, assessed by single FIM items, at the point of admission, in predicting functional outcome after stroke inpatient rehabilitation. Outcome measures were discharge scores and effectiveness in total and motor-fim, and discharge destination. The results showed that total, motor and cognitive-fim at admission were predictors of functional outcome. However, when single FIM items were included in the statistical model, FIM items were the most important outcome predictors, compared to FIM sub-scales at admission. Social interaction, problem solving, grooming, and upper-body dressing were significant predictors of FIM outcomes, while memory and bowel Control were predictors of discharge destination. Our results on predictive value of functional status at admission are consistent with those by Ng et ADL at discharge Gain P-value Eating 3.7± ± ±1.1 P=0.000*** Grooming 2.9± ± ±1.2 P=0.000*** Bathing 2.2± ± ±1.3 P=0.000*** Dressing (upper body) 2.3± ± ±1.3 P=0.000*** Dressing (lower body) 2.0± ± ±1.5 P=0.000*** Lower toileting 1.9± ± ±1.6 P=0.000*** Bladder control (management) 3.8± ± ±2.1 P=0.000*** Bowel control (management) 4.8± ± ±1.4 P=0.000*** Transfer to bed/chair/wheelchair 2.4± ± ±1.5 P=0.000*** Transfer to toilet 2.2± ± ±1.6 P=0.000*** Transfer to tub/shower 1.6± ± ±1.6 P=0.000*** Walk or wheelchair 2.1± ± ±1.6 P=0.000*** Stairs 1.4± ± ±1.9 P=0.000*** Comprehension 5.0± ± ±1.0 P=0.000*** Expression 4.4± ± ±1.0 P=0.000*** Social interaction 4.5.1± ± ±1.0 P=0.000*** Problem solving 3.1± ± ±0.9 P=0.003** Memory 3.8± ± ±0.9 P=0.017* Comparison was performed by Student s t-test *P<0.05; **P<0.01; ***P<0.001 al., 8 who showed that admission motor-fim is an important outcome predictor. On the contrary, there are no data in the literature that parallel our data on the predictive role of performance of single ADLs. There are few studies on this issue which report contradictory results. Taub et al. 12 and Thommessen et al. 13 showed that urinary incontinence at admission is the best single predictor of disability. Singh et al. 14 pointed out that, after stroke, wheelchair use is a significant predictor of walking (FIM) 14 and functional outcome. 16 On the contrary, Weh and Ramb 11 and Suzuki et al. 15 found that dressing and walking/riding in wheelchair have the highest outcome predictive value. However, there are differences between our study and studies conducted by other authors. All the above mentioned studies analysed only certain ADL components (commonly, urinary incontinence, or body dressing, or walking, or riding in wheelchair) and followed different study designs Our study analysed performance of basic ADLs, as measured by FIM items, and we included in the statistical model not only single FIM items and FIM sub-scales, as independent variables, but also other variables which in previous studies were shown to be valid predictors of outcome in stroke patient. We have found out that performances of single ADLs are stronger predictors of the final functional status. Vol No. 5 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 633

6 Table III. Univariate linear regression analysis (N.=241). Discharge total-fim The explanation can be that initial functional status represents the sum of scores of performances of single ADLs, both of those with stronger relationship with outcome as well as for those with poorer relationship. Therefore, the initial functional status is not a predictor when the statistical model includes one or more ADLs with stronger relationship with the outcome measures. Moreover, performance of basic ADLs can have a predictive value higher than that of TCT, CT, OAI, CIRS, aphasia since the scores of these indicators express and evaluate specific aspect of the stroke, while the scores of performance of basic ADLs are the cumulative effect of motor, cognitive and psychological components which are actually present in the outcome measures considered. Discharge motor-fim Effectiveness in total-fim Effectiveness in motor-fim Discharge destination Age Sex (male/female) * Stroke type (infarct/haemorrhage) Stroke lesion size (small/medium/large) * CIRS Aphasia 0.37* 0.20* 0.26* 0.17* 0.17* Neglect 0.36* 0.42* 0.38* 0.40* 0.10 Admission NIHSS -0.70* -0.64* -0.59* -0.57* -0.28* Admission TCT 0.64* 0.67* 0.52* 0.58* 0.23* Admission Fugl-Meyer 0.68* 0.72* 0.60* 0.65* 0.19* Admission total-fim 0.79* 0.73* 0.58* 0.60* Admission motor-fim 0.71* 0.73* 0.52* 0.59* 0.22* Admission cognitive-fim 0.60* 0.41* 0.44* 0.35* 0.27* Admission eating 0.62* 0.62* 0.45* 0.50* 0.25* Admission grooming 0.69* 0.68* 0.52* 0.55* 0.23* Admission bathing 0.67* 0.68* 0.52* 0.58* 0.19* Admission dressing -upper body 0.69* 0.71* 0.55* 0.61* 0.16* Admission dressing-lower body 0.64* 0.66* 0.49* 0.56* 0.14* Admission lower toileting 0.56* 0.56* 0.43* 0.48* 0.08 Admission bladder control 0.55* 0.57* 0.40* 0.45* 0.15* Admission bowel control 0.38* 0.42* 0.23* 0.31* 0.26* Admission transfer to bed/chair/wheelchair 0.67* 0.69* 0.52* 0.52* 0.17* Admission transfer to toilet 0.60* 0.63* 0.46* 0.52* 0.18* Admission transfer to tub/shower 0.46* 0.47* 0.35* 0.39* 0.12 Admission walk or wheelchair 0.59* 0.62* 0.45* 0.51* 0.16* Admission stairs 0.38* 0.42* 0.28* 0.36* 0.13* Admission comprehension 0.41* 0.23* 0.25* 0.19* 0.24* Admission expression 0.44* 0.26* 0.29* 0.40* 0.20* Admission social interaction 0.60* 0.45* 0.48* 0.45* 0.24* Admission problem solving 0.63* 0.48* 0.52* 0.42* 0.25* Admission memory 0.52* 0.34* 0.37* 0.28* 0.29* CIRS: Cumulative Illness Rating Scale; FIM: Functional Independence Measures; LOS: length of stay; NIHSS: National Institute of Health Stroke Scale; OAI: onset to admission interval; TCT: trunk control test. Significant data are marked with * In the current study, upper-body dressing was of greater predictive value for effectiveness in motor- FIM, while grooming was for total and motor-fim. To be independent in upper-body dressing, people have to maintain their balance, move their trunk, arm and leg in coordinated sequence, recognise and orient clothes on both sides of the body; donning clothes in the correct sequence are also required for dressing. 30 Upper-body dressing requires also more advanced recognition if compared with lower-body dressing. 30 Walker and Lincoln found that difficulty in lower-body dressing was associated with physical impairment and that difficulty in upper-body dressing was associated with visual inattention and sensory disturbance. 31 In addition, the assessment 634 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE October 2013

7 Table IV. Multivariate linear regression analyses (N.=241). Dependent variables First multivariate analysis of upper-body dressing by FIM scale also necessitates patient performing preparatory operations, represented by the patient getting clothes from their usual locations. The complexity of the activities can influence the dressing ability and also explain the relationship between this ADL and efficiency in motor-fim score found in the current study. Grooming is a predictor of discharge scores in total- and motor-fim. In the FIM scale, grooming includes washing hands, face and teeth, combing hair, wear makeup or shave. Performing activities of upper-body dressing necessitates not only motor but also cognitive requirements. However, the cognitive requisites needed for grooming are more advanced than those of dressing, since the patient must also use devices or instruments (sometimes dangerous, such as a razor for shaving), and this may explain why grooming is a predictor of total-fim which includes both motor and cognitive-fim. In the first multivariate analysis, NIHSS only was Second multivariate analysis * Independent variables R 2 Independent variables R 2 Discharge Total-FIM Cognitive-FIM 0.39 Fugl-Meyer 0.32 Fugl-Meyer 0.30 Grooming 0.27 Motor-FIM 0.29 Social interaction 0.23 Neglect 0.18 Problem solving 0.19 Neglect 0.15 Discharge Motor-FIM Motor-FIM 0.40 Fugl-Meyer 0.31 Fugl-Meyer 0.23 Grooming 0.24 Neglect 0.21 Neglect 0.22 NIHSS TCT 0.19 Social interaction 0.17 Effectiveness in total-fim Fugl-Meyer 0.43 Fugl-Meyer 0.43 Cognitive-FIM 0.31 Social interaction 0.32 Neglect 0.26 Neglect 0.24 Effectiveness in motor-fim Fugl-Meyer 0.39 Fugl-Meyer 0.37 Total-FIM 0.30 Neglect 0.23 Neglect 0.23 Upper -body dressing 0.22 Social interaction 0.20 Discharge Destination NIHSS 0.28 Memory 0.25 Bowel control 0.22 FIM: Functional Independence Measures; NIHSS: National Institute of Health Stroke Scale; TCT: trunk control test. =regression coefficient; first multivariate analysis without FIM items; *second multivariate analysis with FIM item; All the independent variables are admission scores a predictor of discharge destination. However, when single FIM items were included in the statistical model memory and bowel control were the only predictors of discharge destination. This finding is in keeping with that of Mokler et al. who found that bladder management, toilet transfers, and memory were associated with discharge destination. 32 Bowel incontinence on admission is an unfavourable sign. Patients with bowel incontinence improve less or have lower functional abilities on discharge than those who possess bowel control. 33 The study indicates that bowel incontinence on admission is also an unfavourable prognostic factor for home destination at discharge, supporting the finding of Mokler et al. 32 Bowel incontinence in patients with stroke is particularly important to the personal dignity of stroke survivors and to those who care for them 34 and this may be the reason for their transfer to nursing homes at the end of the rehabilitation programme. Vol No. 5 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 635

8 Memory is needed to learn new skills and to regain lost function during the rehabilitation process. The ability to remember and to learn new tasks has been demonstrated to be an important prerequisite for success in the rehabilitation environment. 35 The impossibility to acquire new memories and the difficulty in remembering recent events can be the first signs of dementia which can be an important variable in determining the destination of stroke patients to nursing home. 36 These data suggest that in the first planning of destination of the stroke patient at the end of the rehabilitation period, memory and bowel control must also be considered together with the presence of caregiver and social support that are recognised to be more important determinants of this outcome measure. 28, 37 Among the FIM items, social-interaction is the one which has relationship with the majority of outcome measures considered, in particular with discharge scores and effectiveness in total and motor-fim. It measures patient capacity to interact with others in social relationships or therapeutic situations and this may affect the rehabilitative programme 38 and social reintegration. 39 There is growing evidence that rehabilitation is most effective when active participation in the rehabilitation process is fully promoted by therapists and committed to by patients. 40 Despite these considerations, the current study has some limitations. First of all, this was not a population-based study (patients were referred by general hospitals) and therefore not all patients who survived stroke were enrolled. Furthermore, the study was performed in a population admitted to rehabilitation hospitals in need of physical rehabilitation. Therefore, our population does not reflect the actual functional disability of every stroke patient: those with slight impairment did not require inpatient rehabilitation while extremely disabled patients would have been transferred directly to skilled nursing facilities after acute care. 8 Another important limitation of our study is that we did not include in the regression analysis all possible predictors. Nevertheless, we have included in the regression analysis those independent variables that in previous studies were shown to be important predictors of outcome in stroke patient. 12, 28 We included in the statistical model also aphasia and neglect, but from the samples we have excluded patients with confusion states and history of dementia. In our study, both the dependent and the inde- pendent variables were represented by FIM, and by its subtests and single items. This statistical approach has already been used in other studies 41, 42 and should not have influenced the main results of the current study since both initial functional status and performance of basic ADLs are included in the statistical model as independent variable. The number of independent variables considered in the study is large, but the sample size is relatively large and some of the independent variables were not included in the multivariate analysis since they had no relations with the outcome measures in the univariate analysis. Conclusions Our study found that total, motor and cognitive- FIM at admission are predictors of functional outcome after stroke inpatient rehabilitation. However, when single FIM items were included in the statistical model, social-interaction, grooming, upper body dressing, and bowel control were the most important outcome predictors, compared to FIM sub-scales at admission. These data indicate that performances of basic ADLs are important outcome predictors after stroke during inpatient rehabilitation. In addition, they show that the use of performance of single ADLs in the predictive model allows identifying new prognostic indicators which can be helpful for the physician in managing stroke patients at the end of the rehabilitation period. Thus, we suggest that, in designing studies on stroke outcome prediction, researchers should also include tests which assess performances of basic ADLs as independent variables. References 1. Roth EJ. Trends in stroke rehabilitation. Eur J Phys Rehabil Med 2009;45: Hsieh CL, Sheu CF, Hsueh IP, Wang CH. Trunk control as an early predictor of comprehensive activities of daily living function in stroke patients. Stroke 2002;33: Kwakkel G, Wagenaar RC, Kollen BJ, Lankhorst GJ. Predicting disability in stroke-a critical review of the literature. Age Ageing 1996;25: Adams J HP, Davis PH, Leira EC. Baseline NIH Stroke Scale score strongly predicts outcome after stroke. A report of the trial of Org in acute stroke treatment (TOAST). Neurology 1999;3: Demchuk AM, Buchan AM. Predictors of stroke outcome. Neurologic Clinics 2000;19: EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE October 2013

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There were no financial relationships between the authors and any commercial interest related to the outcome of the study. Received on September 12, Accepted for publication on April 12, Epub ahead of print on May 28, Vol No. 5 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 637