Predicting outcome in patients with chronic stroke: findings of a 3-year follow-up study

Abstract

This thesis is based on the findings of the FuPro-Stroke study (the Stroke section of the Functional Prognostification and disability study on neurological disorders), which is a multicentre, prospective cohort study among patients with stroke, who were included during inpatient rehabilitation. The aim of the research reported on in the present thesis was to investigate the long-term prognosis of chronic stroke outcome up to 3 years after onset. Poor mobility status is a key concern in chronic stroke patients, especially since it may lead to ADL dependence and affect social reintegration. We found that mobility at one-year post stroke could be predicted by functional status, sitting balance, time between stroke onset and measurement, and age. We also investigated determinants that could predict decline in mobility status in chronic stroke patients. Inactivity in terms of instrumental activities of daily living (IADL), cognitive problems, fatigue and depressive symptoms at one year post stroke were the main predictors for deterioration in mobility. Community ambulation is an important outcome for stroke patients and we found that this variable was closely related to gait speed. The optimal cut-off point for community ambulation was 0.66 m/s. Balance, endurance and the use of an assistive walking device were determinants that confounded the relation between community ambulation and gait speed. The effectiveness of training programmes focusing on lower limb strengthening, cardio-respiratory fitness or gait-oriented tasks, in terms of the outcome of gait, gait-related activities and health-related quality of life (HRQoL) after stroke were also investigated. Twenty-one high quality RCTs were included, five of which focused on lower limb strengthening, two on cardio-respiratory fitness training and 14 on gait-oriented training. After conducting a meta-analysis we suggested that gait-oriented training is the most successful method to improve walking competency after stroke. Depression and fatigue are both well-known sequels after stroke. At three years post stroke, 19% of the patients showed depressive symptoms. Depression was best predicted by one-year IADL activity and fatigue. It was also shown that 68%, 74% and 58% of the patients experienced fatigue at 6, 12 and 36 months post stroke, respectively. Fatigue was significantly related to IADL and HRQoL, but not to ADL. Depression and motor impairment were important confounders in the relationship between fatigue and IADL and HRQoL. Since the number of stroke patients is rising and it is a chronic disease, it is important that appropriate care is provided to suit the needs of all these patients. We suggest in our study that 33% of the patients perceived at least one unmet care demand at three years after stroke. Younger age, motor impairment, fatigue and depressive symptoms were significantly related to the presence of unmet demands. These results suggest that our health care system is as yet not fully meeting the demands of patients with chronic stroke. Our advise is that the focus of care and research should be on improving our understanding of the course of functional recovery by monitoring patients over time, introducing innovative intervention strategies and exploring the underlying mechanisms of functional improvement after stroke.