Kazuhisa Domen

Comorbidity measures for stroke outcome research: A preliminary study

OBJECTIVE To develop standardized comorbidity measures for use in stroke outcome research. DESIGN Retrospective review of medical records to analyze comorbidities and to study reliability and validity of the newly developed measures, comorbidity index (CI), and weighted comorbidity index (w-CI). SETTING Tertiary rehabilitation center in Japan. PATIENTS 106 stroke patients, age 56.5 +/- 13.2 yr, admitted and discharged during the year from May 1994 to December 1995. The median days of duration of stroke, onset to admission, and length of stay (LOS) were 199, 83, and 105.5, respectively. The median admission and discharge Functional Independence Measure (FIM) raw scores were 85 and 110, respectively. MAIN OUTCOME MEASURES Assessment of interrater reliability with intraclass correlation coefficient (ICC) for total scores and weighted kappa for subscores; assessment of concurrent validity by relating the measures to Charlsons comorbidity index, total numbers of medications, laboratory studies, therapeutic interventions, consultations, and days of interruption (Spearmans rank correlation method); study of predictive validity with discharge FIM score and LOS as dependent variables. RESULTS The ICCs were .896 for CI and .997 for w-CI, and weighted kappa ranged from .615 to 1.00. CI and w-CI correlated significantly with Charlson index and the above indices of validity. They also correlated negatively with discharge FIM scores and positively with LOS. With stepwise multiple regression analysis, 79.8% of the variance of discharge FIM scores could be explained by w-CI, days from onset to admission, admission FIM score, and deviation in tape bisection task. CONCLUSION The newly developed comorbidity measures are reliable and valid for use in stroke outcome research.

ADL structure for stroke patients in Japan based on the functional independence measure

Tsuji T, Sonoda S, Domen K, Saitoh E, Liu M, Chino N: ADL structure for stroke patients in Japan based on the Functional Independence Measure. Am J Phys Med Rehabil 1995;74:432—438 The difficulty patterns of FIM (Functional Independence Measure) in Japan were determined and compared with patterns found in the United States to assess whether FIM can be used for worldwide comparisons of ADL (the activities of daily living). The FIM was measured for 190 stroke patients in several hospitals throughout Japan. The scores at admission and discharge were converted to an interval scale by Rasch analysis. Right and left brain lesion patients were analyzed separately. The FIM items were divided into two groups: motor items and cognitive items to minimize misfit. A degree of misfit was acceptable, except for bowel and bladder management, stairs, bathing, and expression. Motor items, eating, and bowel and bladder management were the easiest; stairs, bathing, and tub/shower transfers were the most difficult. The difficulty patterns of patients with left and right hemisphere lesions were almost identical. Bathing and tub/shower transfer were more difficult for Japanese patients than for those studied in the United States. Concerning the cognitive items, expression was easiest for patients with right hemisphere lesions but most difficult for those with left hemisphere lesions. Social interaction was easier for Japanese patients with left hemisphere lesions than the other patients. The item difficulty patterns in Japan differs slightly from those in the United States because of cultural differences. As countries show different patterns of difficulty, we must be careful when making international comparisons of FIM data converted by Rasch analysis.

Osteoporosis in hemiplegic stroke patients as studied with dual-energy x-ray absorptiometry

OBJECTIVES To compare bone mineral densities (BMDs) of the affected and unaffected limbs in stroke patients at multiple sites; to study longitudinal changes during a 3-month rehabilitation program; and to relate BMDs to demographic, impairment, and disability variables. DESIGN Descriptive study. SETTING Tertiary rehabilitation center. PATIENTS One hundred four consecutive hemiplegic inpatients, 69 men, age 56.5 +/- 13.2 yrs, 47 with left-sided brain lesion. Median days from onset to admission and median length of stay days were 83 and 105.5, respectively. MAIN OUTCOME MEASURES BMDs of proximal humerus, distal radius, femoral neck, and calcaneus bilaterally, and third lumbar vertebra, measured with dual-energy x-ray absorptiometry (DXA), were compared between affected and unaffected sides at admission and discharge. RESULTS Stroke Impairment Assessment Set (SIAS) motor scores, Functional Independence Measure (FIM) scores, grip strength, and awake/sleep heart rate counts (activity index) improved significantly at discharge. Affected/unaffected BMD ratios were 88.3% to 98.4% at admission and 79.6% to 98.8% at discharge, lowest for the humerus. Discharge/admission ratios were 89.1% to 97.8% for the affected and 97.4% to 100% for the unaffected side. All BMDs were intercorrelated (R = .438 to .873). They correlated significantly with age, body weight, grip strength, FIM scores, and activity index. Factors selected to explain BMD with multiple regression analysis differed according to the site and timing of the measurement. CONCLUSIONS BMDs of the affected side were lower and most marked in the humerus. Longitudinally, not only the affected but the unaffected BMDs decreased. Age, sex, duration of stroke, anthropometric measurements, motor paralysis, muscle strength, and activity level contributed differently to bone loss according to the site and timing of the measurement.

Changes in impairment and disability from the third to the sixth month after stroke and its relationship evaluated by an artificial neural network

Functional recovery in a rather late stage after stroke was examined in 70 stroke patients using the Stroke Impairment Assessment Set (SIAS) and the Functional Independence Measure (FIM). The SIAS and the FIM were administered at three and six months after the onset of stroke. Motor items and the abdominal manual muscle testing item improved in more than 30 percent of patients. The motor subscore of the FIM changed from 60.8 to 73.4, and the cognitive subscore changed from 28.4 to 30.4. The relationship between impairment and disability was evaluated using the neural network method with the software, Skiltran. The change of the FIM motor subscore from three months to six months was used as an output variable, and the change in the SIAS items and the FIM motor subscore were included as input variables. As a result of the connection weight obtained from this network, the change in the fifth motor item (one of the tone items, abdominal manual muscle testing) and the unaffected side grip as well as the FIM at three months had a strong connection to the change of the FIM. It is compatible with ordinary experience that function of both the affected and unaffected side influences the level of disability. Contribution of the impairment to the disability indicates the importance of taking into consideration the impairment for predicting prognosis and selecting adequate treatment when we carry out stroke rehabilitation. In conclusion, we described the relationship between the SIAS and the FIM using the neural network in stroke patients and proved the importance of the impairment to predict the outcome of disability.

Evaluation of Motor Function in Stroke Patients Using the Stroke Impairment Assessment Set (SIAS)

We have developed the Stroke Impairment Assessment Set (SIAS) as a global measure of stroke impairment. This chapter reviews our recent research on motor function in stroke patients using the SIAS. The affected-side motor assessment items of the SIAS were found to be reliable and valid for evaluating hemiplegia by employing the concepts of both synergy and muscle strength. The motor SIAS score was strongly correlated with the Brunnstrom stage (Spearman’s r =. 694−.939) and the manual muscle testing score (Spearman’s r =.870−.958). However, some dispersion was caused by differences in the definitions employed by these scales. A longitudinal study indicated that motor SIAS items were more sensitive for detecting motor recovery after stroke than the Brunnstrom stage or manual muscle testing. The recovery of motor function at discharge could be predicted by the SIAS depending on whether the score on admission was 0 (no voluntary movement) or 1 (minimal voluntary movement). A cross-sectional study showed that unaffected-side function was an important factor in relation to disability, while a longitudinal study demonstrated that unaffected-side function also improves during rehabilitation (grip strength was 23.51kg on admission and 25.54kg on discharge; n = 75, P <. 01). Therefore, unaffected-side function should also be measured when assessing stroke impairment.

Clinical application of the modified medially-mounted motor-driven hip gear joint for paraplegics.

Purpose: This paper describes a motor-driven orthosis for paraplegics which has been developed. This orthosis is composed of a medially-mounted motor-driven hip joint and bilateral knee-ankle-foot orthosis. With the gear mechanism, the virtual axis of the hip joint of this orthosis is almost as high as the anatomical hip joint. Method: A paraplegic patient with an injury level of T10/11 walked using bilateral lofstrand crutches and this new orthosis with or without the motor system. The motor is initiated by pushing a button attached at the edge of the grab of the crutches. Result: Faster cadence and speed and smaller rotation angle of the trunk was obtained in motor walking compared with nonmotor walking. The patient did not feel fearful of falling. Conclusion: The benefit of motor orthosis is that it can be used even in patients with lower motor lesions and that it provides stable regulation of hip flexion movement in spastic patients. In conclusion, this motor orthosis will enhance paraplegic walking.

Prognostication of Stroke Patients Using the Stroke Impairment Assessment Set and the Functional Independence Measure

Outcome prediction is one of the main issues in stroke rehabilitation. Although many predictors have been tested and a considerable number of statistical methods employed, none to date has resulted in a satisfactory method for prognosis. We have successfully predicted stroke outcome using regression analysis with the Stroke Impairment Assessment Set (SIAS), which we have developed, and the Functional Independence Measure (FIM). Our subjects were 192 stroke patients who had completed rehabilitation whose average number of days from stroke onset was 53.0; their mean length of hospital stay was 94.9 days. Subjects were divided into two groups according to the total FIM score on admission: less than 80 compared to 80 or more. Patterns of correlation coefficients between admission parameters and the discharge FIM score differed between the two groups. Regression equations were separately made in each group with independent variables of the SIAS, the FIM, and several other parameters (piecewise regression analysis). Adding the impairment scale, the SIAS, and related items to the disability scale as independent variables enhanced the correlation coefficient of piecewise regression from. 85 to.93. Stroke outcome can be successfully predicted using piecewise regression with the SIAS and the FIM. Stratification of stroke patients by their admission FIM scores is effective for making a good prognosis. The SIAS proved to be an adequate set to score impairment.

Stroke Impairment Assessment Set (SIAS). (2). Reliability and Validity of Motor Function Assessment Items of SIAS.

脳卒中の総合的機能障害評価法Stroke Impairment Assessment Setの麻痺側運動機能評価項目群(SIAS-M)の信頼性と妥当性を検討した.脳血管障害20例での検討の結果,一致係数(weighted kappa)はSIAS-M, Brunnstrom stage (BS)およびMotricity Index (MI)いずれも0.80以上であり,3者とも同程度の信頼性を有すると思われた.脳血管障害65例における検討から,SIAS-MとMIおよびSIAS-MとBSとの相関は高く,SIAS-Mの併存的妥当性が示された.しかし散布図から,同一BSにおけるSIAS-Mのばらつきが目立ち,SIAS-Mの方がBSより麻痺の回復をより鋭敏に反映することが推察された.