Neurorehabilitation and its impact on functional status in patients who have suffered a stroke

www.elsevier.es/rcsedene

ORIGINAL

ARTICLE

Neurorehabilitation

and

its

impact

on

functional

status

in

patients

who

have

suffered

a

stroke

夽

Susana

Catarina

Sarmento

Banrezes

Salselas

,

Fidel

López-Espuela

,

Maria

José

Almendra

Gomes

_,

_Leonel

_São

_Romão

_Preto

_,

_Sergio

_Rico-Martin

a_{UnidadedeAVC,UnidadeLocaldeSaúdedoNordesteEPE,Braganc¸a,Portugal}

b_{DepartamentodeEnfermería,FacultaddeEnfermeríayTerapiaOcupacional,Cáceres,Spain}

c_{EscolaSuperiordeSaúde,InstitutoPolitécnicodeBraganc¸a,UnidadedeInvestigac¸ãoemCiênciasdaSaúde:Enfermagem}

(UICISA:E),Braganc¸a,Portugal

Received5November2019;accepted21January2020

KEYWORDS Elderly; Dependency; Disability; Stroke; Neurorehabilitation

Abstract StrokerepresentsthemaincauseoffunctionaldependenceandinthePortuguese adultpopulation.

Objective: toanalysetheimpactofrehabilitationonfunctionalstateandbasicactivitiesof dailylife(ABVD),8weeksfollowingastroke,inapopulationofelderlypeopleinnorth-western Portugal.

Methodology: Observational,longitudinalandretrospectivestudy.Thepatientsweregrouped into3groupsaccordingtotherehabilitationtreatmentreceived:Non-rehabilitation(NR),light rehabilitation(RL)andintenserehabilitation(RI).

Sociodemographicdata,clinicalvariables(onstroke),hospitalstay,rehabilitativetreatment, andfunctionalstatus(BarthelIndex)werecollected.

Results:350patients,withameanageof75.83(±8.02)years.Thehospitalstaywaslonger in the group of RL (19.7 (±8.69)), RI (17.67 (±10.05)) and ofthose who didnot undergo rehabilitation(10.97(_±6.96)),(p=.001).

Asignificantincrease(p<.001)wasobservedintheBarthelindexscoresfromadmissionto8 weeksafterthestroke.

Age(p=.003)andhospitalstay(p=.013) wereshownasriskfactorsforfunctional depen-dence.Similarly, takingasareference thepatientswhodidnotundergorehabilitation,the subjects who underwent light rehabilitation(OR (95%CI): 6.37(1.74−23.25), p=.005) and intensiverehabilitation(OR(95%CI):2.28(1.08−4.82,p=.030),hadasignificantlyhigherrisk ofpresentingfunctionaldependence

PIIoforiginalarticle:S2013-5246(20)30005-2

夽 _{Pleasecitethisarticleas:SalselasSCSB,López-EspuelaF,GomesMJA,Preto LSR,Rico-MartinS.Neurorrehabilitaciónysu impacto} en el estado funcional en pacientes que han sufrido un ictus. Rev Cient Soc Esp Enferm Neurol. 2020. https://doi.org/10.1016/ j.sedene.2020.01.003

∗_{Correspondingauthor.}

E-mailaddress:fidellopez@unex.es(F.López-Espuela).

2530-299X/©2020SociedadEspa˜noladeEnfermer´ıaNeurol´ogica.PublishedbyElsevierEspa˜na,S.L.U.Allrightsreserved.

Conclusion:undergoingintensiverehabilitationimprovesfunctionalstateandABVDcompared tolightrehabilitation,8weeksfollowingastrokeinelderlypatients.

©2020SociedadEspa˜noladeEnfermer´ıaNeurol´ogica.PublishedbyElsevierEspa˜na,S.L.U.All rightsreserved. PALABRASCLAVE Anciano; Dependencia; Discapacidad; Ictus; Neurorrehabilitación

Neurorrehabilitaciónysuimpactoenelestadofuncionalenpacientesquehan sufridounictus

Resumen Elictusrepresentalaprincipalcausadedependenciafuncionalyenlapoblación adultaPortuguesa.

Objetivo:Aanalizarelimpactodelarehabilitaciónenelestadofuncionalyenlasactividades básicasdelavidadiaria(ABVD),tras8semanasdesufrirunictus,enunapoblacióndeancianos delnoroestedePortugal.

Metodología:Estudioobservacional,longitudinalyretrospectivo.Lospacientesfueron agrupa-dosen3gruposdeacuerdoconeltratamientorehabilitadorrecibido:Norehabilitación(NR), rehabilitaciónligera(RL)yrehabilitaciónintensa(RI).

Serecogierondatossociodemográficos,variablesclínicas(sobreelictus),estancia hospita-laria,tratamientorehabilitador,yestadofuncional(ÍndiceBarthel).

Resultados: 350pacientesconedadmediade75,83(_±8,02)a˜nos.Laestanciahospitalariafue mayorenelgrupodeRL(19,7(±8,69)),RI(17,67(±10,05))ydelquenorealizórehabilitación (10,97(_±6,96)),(p=0,001).

Seobservó unaumentosignificativo (p<0.001) enlaspuntuaciones delíndice de Barthel desdeelingresohastalas8semanastraselictus

Laedad(p=0,003)y la estancia hospitalaria(p=0,013)sepresentaron como factoresde riesgodepresentardependenciafuncional.Deigualmanera,teniendocomoreferenciaalos pacientesquenosesometieronarehabilitación,aquellossujetosquerealizaronrehabilitación ligera(OR(IC95%):6,37(1,74−23,25),p=0,005)yrehabilitaciónintensa(OR(IC95%):2,28 (1,08_−4,82,p=0,030),tuvieronunriesgosignificativamentemayordepresentardependencia funcional

Conclusión:larealizacióndeunarehabilitaciónintensamejoraelestadofuncionalylasABVD conrespectoalarehabilitaciónligera,alas8semanasdesufrirunictusenpacientesancianos. ©2020SociedadEspa˜noladeEnfermer´ıa Neurol´ogica. PublicadoporElsevierEspa˜na,S.L.U. Todoslosderechosreservados.

Introduction

Stroke is presentlyone of the majorcauses worldwideof disabilityanddeath.1_{In Europe,1.3million peoplesuffer}

fromafirststrokeeveryyear,andthesocioeconomicimpact ishigh: estimatedat approximately45 billionEuros.2 _Itis

likelythatthesefigureswillrisesinceprojectionsshowthat strokeswillincreaseby35%inEuropein2050,mainlydue totheageingofthepopulation.3_{InPortugalthisscenariois}

evenworse,andithasbecometheprimarycauseofdeath.4

Althoughdeathfromstrokehasdecreasedoverrecentyears, itcontinuestobeamajorhealthprobleminthenorthofthe country.5,6

The decrease in mortalityis partlydue toadvances in thetreatment ofstrokeandthemeasuresusedduringthe lastfew yearsfor early diagnosis and treatment of cere-brovasculardisease.7_{Theseadvancementsinthetreatment}

ofstrokeareessentiallybasedonearlyneurologicalcare, admittancetostroke units, the application of fibrinolytic treatmentinstrokeandrehabilitiontherapy.Ofallofthese,

rehabilitation therapy has the broadest therapeutic win-dow:itmaybeappliedbothtoischaemicandhaemorrhagic stroke, improve functional prognosis evenseveral months afterthe strokehasoccurred andreduce costsassociated withthedisease.8

Strokeisthemostimportantcauseofinvalidityor disabil-ityintheadult.Sixmonthsafterastoke26.1%ofpatients willhavedied,41.5%areindependentand32.4%are depen-dent,withaglobalestimationamongstrokesurvivorsof44% sufferingfromfunctionaldependence.9

Theapproachtoneurologicaldysfunctionsshouldbe ini-tiated inthe acutephaseandbemaintained,ensuringan appropriatetransitiontootherresourcesinthepatientswith functionalobjectiveswhendysfunctionsareprolongedover timeandrequiremediumtolong-termtreatment.10,11_This

typeofapproachisachallengeforthepatientswith moder-ate/severedysfunctionsbecauseduetotheirseveritymore timeandmoretechnicalandhumanresourcesarerequired thanwouldnormallybeadministeredtopatientswithmild dysfunctions.12_{Thisfact,combinedwiththefactthatoneof}

themostrecognizedpredictorsoffinalpost-stroke disabil-ityis theinitial disability, meansthat many patientswith moderate/severestrokeareconsidered‘‘poorcandidates’’ interms of efficacyand costtobeincluded in rehabilita-tionprogrammes.11 _{Ifaddedtothis is thefact thatthere}

isa prevalenceof patientswhopresent withmoderateto severelongtermdisabilitywemayunderstandhowstroke isagenuineproblemforhealthandsocialstructures.

Afterastroke,recoveryandreturntoafulllifearethe main aims of the survivors, their families and the health professionalswhomakeeveryefforttoprovidethebest pos-siblecare.10,12 _{Thisis achieved,amongother means,with}

neurorrehabilitation.

Neurorrehabilitationhasbeendefinedasacombination ofmethodsaimedatrecoveringlostorreduced neurologi-calfunctionsresultingfromcerebralor medullardamage. In patients whohave suffered a stroke the methods used inneurorrehabilitationtakeadvantageofthecerebral plas-ticitytoimproveornormalizeneurologicaland functional impairment.8 _{It istime-limited process,the aim ofwhich}

is to prevent complications and reduce the neurological impairment to achieve the maximum functional capacity possibletofacilitate personalautonomyandreintegration intofamily,socialandworkinglife.Thisrehabilitationmust bebegunearlyandinacoordinatedfashionandmaintained duringthedifferencephasesofhealthcare.13

Theliteratureestablishesthatforstrokesurvivorsthere isanassociationbetweendelayininitiatingtreatmentand poorer functional evolution compared withan early start to treatment and a better prognosis. The processes of cerebral plasticity are optimized with rehabilitation pro-grammeswhichbeginintheearlystages,thetimededicated daily totreatment andthe prolongation inmonths of the rehabilitation.8,14

Theneedforeffectiverehabilitationafterastrokeisan essentialelementincarecontinuityandcarewhichmustbe administeredtothese patients.10 _{The aimof this studyis}

toanalysetheimpactofrehabilitationonfunctionalstatus andbasic activities ofdaily life(BADL), 8weeksfollowing astrokeinapopulationofelderlypeopleinnorth-eastern Portugal.

Methodology

Observational, longitudinal and retrospective study, with a consecutivesample of patientsadmitted tohospitalfor acute stroke in a hospital in north-eastern Portugal (Bra-ganza)betweentheyears2013and2017.

ThestudywasapprovedbytheResearchEthics Commit-teeoftheLocalUnitofSaúdedoNordesteEPE(ULSNe)and developed in accordancewith theprinciples expressedin theDeclaration of Helsinki.The main researcher signed a documentofconfidentialityandwasguaranteeddata confi-dentialityandcustodyofthedatabase.

Theparticipantpatientsfulfilledthefollowinginclusion criteria: over 65years of age who had suffered from an ischaemicorhemorrhagicstroke,andwhohadcompleteda functionalassessmentwiththeBarthelindexonadmittance, ondischarge and8 weeksfollowing the stroke. Exclusion criteriawere:patientswithtransitoryischaemicstrokeand patientswhohaddiedbeforethe8weekshadpassed.

The flow diagram of participants is shown in Fig.1. It showsthe538patientswhowerehospitalised,afterapplying criteriaoffinalsampleparticipation,whichwas350.

Patients were classified into 3 groups in accordance withthe rehabilitationtreatment received: No rehabilita-tion(NR),Lightrehabilitation(LR)andIntenserehabilitation (IR).We considered ‘‘no rehabilitation’’asthosepatients whodid not receive any typeof rehabilitation treatment from the health system; ‘‘light rehabilitation’’ as those patientswhohad3daysorless perweek ofrehabilitation treatment and ‘‘Intenserehabilitation’’ asthose patients whoreceived4ormoredaysofrehabilitationperweekor onhospitaldischargetheywenttocentresconsideredtobe ofintensiverehabilitation.

Sociodemographicdatawerecollected,suchasage,sex, andclinical stroke type and subtype variables, laterality, hospitalstay andrehabilitatingtreatment received. Func-tionalstatuswasassessedwiththeBarthelindex.

Datacollectionwascarriedoutbythemainresearchers. Datawere collected from the patients’ medical filesand werecomputerizedonadifferentiatedandanonymousbasis torespectpatientconfidentialityandanonymity.Themain researchersalonehadaccesstothesedata.

Instrumentsofmeasurement

Thetypesofischaemicstrokeswereclassifiedaccordingto criteriaoftheOxfordCommunityStrokeProject(OCSP).15_In

1991,theOxfordshireCommunityStrokeProjectproposed aclassificationwhichenabledthelocationandsizeofthe injurytobeassessed,aswellasofferingearly,fastand sim-pleprognosticinformationonclinicaloutcome.Thepatients wereclassifiedas:

• TACS(totalanteriorcirculationstroke).Theseincludethe combination or alterationin cortical functions (aphaisa or dysphasia, discalculia or visual-spatial alteration), homonymoushemianopsia andmotor or sensory impair-mentwhichincludesatleasttwoareasofthefollowing: face,upperlimbandlowerlimb.

• PACI(partialanteriorcirculationinfarction).Thesemeet withtwoofthethreecharacteristicsoftheTACSoronly onedysfunctionofthehigherbrainfunctions.

• POCI(posteriorcirculationinfarction).Thisisafocal neu-rologicalimpairmentwhichincludes:ipsilateralparalysis ofcranialwallswithmotorand/orcontralateralsensory impairment,motorand/orbilateralsensoryimpairment, alterationofcombinedmovementsoftheeyes,cerebellar dysfunctionoranisolatedalterationofthefieldofvision. • LACI (lacunarinfarction). These strokes present witha typical lacunar syndrome (pure motor or pure sensory stroke,hemiparesis-ataxiaordysarthriaunsteadyhand).

ToassessfunctionalstatustheBarthelindex16_wasused,

whichassesses thedegree of dependencein BADL;scores rangebetween0(greater dependence)and 100 (indepen-dence).Theiroverallresults weregroupedintocategories ofdependence:totaldependence(scorebetween0and20); severedependence (21---40points);moderate dependence (41---60points);slightdependence(61---90points); indepen-dence(91---100points).

Patients hospitalized during the study period

433 Patients

Patients without diagnosis or with AITI

(n = 105)

83 patients excluded without assessment on admittance,

on discharge or 8 week follow-up visit

Total patients n = 350

Figure1 Flowdiagramofthestudy.

Dataanalysis

A descriptive analysis of all collected variables was performed. Categorical variables were described using percentages and quantitative variables, using mean, and standarddeviation(SD).

Relationshipsbetweenvariableswasestablished.Forthis theChi-square test was usedfor qualitative variables. To compare quantitative variables a normality test was per-formed (Kolmogorov Smirnov) and depending on whether normalitywasfollowedornot,parametric(ANOVA)andnon parametric(Kruskal-Wallis)testswereused.

Theoddsratioofdifferentvariableswerealsocalculated usingbinarylogistic regression.Firstly a univariate analy-siswasperformed followedbymultivariateanalysisofthe significantvariables.

DatawereanalysedwiththestatisticalprogrammeSPSS forWindowsv.22.Forall statisticaltests thethresholdof significancewasp<.05.

Results

A total of 350 patients were included, with a mean age of 75.83 (±8.02) years. The main clinical characteristics accordingtopoststrokerehabilitationcarriedoutareshown in Table 1. The length of hospital stay was longer in the groupof patients whoreceived lightrehabilitation (19.76 [±8.69]), followed by the group of Intense rehabilitation (17.67[±10.05])andthosewhodidnotcarryout rehabili-tation(10.97[±6.96]),withsignificantdifferencesexisting betweenthem(p=.001).Regardingthetypeofstroke, sig-nificant differences were observed in the proportion of TACS and LACI between the groups (p<.05). No statisti-callysignificantdifferenceswerefoundintheotheranalysed variables.

Table2showsthestatusoffunctionaldependenceat hos-pitaladmittance,hospitaldischargeand8weeksafterthe strokeinaccordancewiththepoststroke levelof rehabil-itation. Significant differences werefound between the 3 rehabilitation groups receivedat the 3 momentsof func-tionaldependenceassessment(p<.001),withthepatients who received light rehabilitation in all cases being those withthelowestscores, followedbythoseofintense reha-bilitation andno rehabilitation.In the intragroupanalysis animprovementinthescoreoffunctionaldependencewas appreciatedinthe3groupsofrehabilitation(p<.001),the highestbeingwhentheBarthelindexwasanalysed8weeks afterthestoke.

FunctionalstatusinperformingBADLwasanalysedwith theBarthelindexathospitaladmittance,hospitaldischarge and8weeksafterthestrokeineachofthegroupsof rehabili-tationreceived(Table3).Asignificantincreasewasobserved (p<.001)inthescoresoftheBarthelindexfromadmittance upuntilthe8weeksafterthestroke,withtheexceptionof theitemofbathing/showeringinthegroupoflight rehabil-itation(p=.368).

Finally,univariateandbivariateanalysiswasperformed withthebaselinefactorswhichcouldpredictobtaining func-tional dependence 8 weeks after the stroke (Table 4). In the univariateanalysis age (OR:1.07; 95% CI:1.02−1.12; p=.003) and mean hospital stay (OR: 1.06; 95% CI: 1.01−1.11;p=.013)werepresentedasriskfactorsfor pre-senting with functional dependence. Similarly, taking as reference patientswho hadnot undergone rehabilitation, thesubjectswhocarriedoutlightrehabilitation(OR:6,37; 95%CI:1.74−23.25;p=.005)andIntenserehabilitation(OR: 2.28; 95%CI:1.08−4.82;p=.030)hadasignificantlyhigher riskofpresentingwithfunctionaldependence.Inthe mul-tivariate analysis similar results were obtained, with the exception ofmeanhospitalstay,whichdidnot presentas ariskfactor(OR:(1,04;95%CI:.99−1.09;p=.096).

Table1 Baselinecharacteristicsofthestudypopulation. Norehabilitation (n=141) Lightrehabilitation (n=58) Intenserehabilitation (n=151) p Age(years) 75.02(±8.36) 78.05(±9.01) 75.74(±7.14) .052 Sex(woman) 57(40.4%) 24(41.4%) 61(40.4%) .991

Hospitalstayduration(days) 10.97(_±6.96) 19.76(_±8.69) 17.67(_±10.05) .001 Laterality

Lefthemispheredamage 68(48.2%) 28(48.3%) 68(45.0%) .837

Righthemispheredamage 59(41.8%) 24(41.4%) 75(49.7%) .333

Unknown(POCIincluded) 14(10.0%) 6(10.3%) 8(5.3%) .267

Classificationofthestroke

Haemorrhagic 19(13.5%) 12(20.7%) 30(19.9%) .275 POCI 24(17.0%) 7(12.1%) 16(10.6%) .260 TACS 12(8.5%) 19(32.8%) 34(22.5%) <.001 LACI 45(31.9%) 8(13.8%) 39(25.8%) .030 PACI 41(29.1%) 12(20.7%) 32(21.2%) .794 Ischaemic 122(86.5%) 46(79.3%) 121(80.1%) .275

LACI:Lacunarstroke;PACI:partialanteriorcirculationstroke;POCI:posteriorcirculationstroke;TACS:totalanteriorcirculationstroke. Dataexpressedasmean±standarddeviationandfrequencies(percentages).

Table2 Evolutionofthefunctionalstatusaccordingtothedegreeofpoststrokerehabilitation. Norehabilitation (n=141) Lightrehabilitation (n=58) Intenserehabilitation (n=151) pa Barthelindexonadmittance 41.88(±29.7)1 6.12(±14.33) 17.72(±20.30) <.001 Barthelindexondischarge 84.15(_±25.41) 19.66(_±18.70) 46.59(_±27.56) <.001 Barthelindex8weeksafterstroke 85.89(±25.28) 27.84(±27.32) 59.57(±31.42) <.001

pb _{<.001 <.001 <.001}

Dataexpressedasamean(standarddeviation).

a _{Comparisonbetweentypeofrehabilitation.}

b _{Comparisononadmittance,ondischargeand8weeksafterstroke.}

Discussion

Themainfindingsofourstudyindicatethatintense rehabil-itationinpatientswhohavesufferedfromastrokeprevents functionaldependence,comparedwiththosewhohavelight rehabilitation.

The impairment of motor ability, with its subsequent lossoffunctionalcapacityisoneofthemainconsequences of stroke.17,18 _{Recovery, together with the return to a}

full and significant life after the stroke is the main goal of survivors, their families and the health professionals in charge of providing them with the best care possi-ble. Rehabilitation services are the primary mechanisms by which functional recovery is promoted and indepen-dence is achieved in patients with acute stroke.10 _After

hospital admittance and prior to hospital discharge, the patients undergo exhaustive assessment to evaluate the damage totheir bodyand the functionalimpairment suf-fered after the stroke.19 _{As a result,health professionals}

are able to take a decision regarding the type of reha-bilitation they should receive. However, in Portugal the rangeofrehabilitationservicesofferedtothepatientswith stroke is broad and highly varied, with regard to typeof caresettings,duration,andintensity andintypeof inter-ventions administered,degree of participationof medical

specialists,nursesandotherspecificrehabilitation special-ists.This lack ofhomogeneity leads tothe creationof no commonpattern tofollow inpost-stroke patient rehabili-tation.Thishasbeenreflectedinourstudy,sincepatients whohadreceivedlightrehabilitationpresentedwithalower meanscoreintheBarthelindexathospitaladmittanceand dischargethan those whoreceivedIntense rehabilitation, and when assessed at 8 weeks their recovery was lower. Thissuggeststhatperhapspatientsshouldhavebeengiven moreintenseandindividualisedrehabilitationearlier. The resultsoftheclinicaltrialAVeryEarlyRehabilitationTrial

(AVERT)suggestthatearlyandintensiverehabilitationmay improvefunctional recovery and accelerate thereturn of unaidedambulation.20,21_{However,thequestionofwhattype}

ofIntenserehabilitationshouldbecarriedoutremains unre-solved. Beyondthe relevant results of the AVERT clinical trial, at present there are very few controlled and ran-domizedstudiesthatassessthe efficacyandsafetyofthe different rehabilitation techniques.22,23 _{These results are}

controversial due in part totheir diversityand the small size of the samples included. In our study, ourreference wasthepatientswhodidnothaverehabilitation(sincethey werethosewhohadfunctionalindependenceondischarge). Thepatientswhohadlightrehabilitationpresentedwitha higherprobabilityoffunctionaldependenceafter8weeks

Table3 Associationbetweeneachactivity/itemoftheBarthelindex.Onadmittance,dischargeand8weeksafterstroke. HospitalAdmittance Hospitaldischarge 8weeksafterstroke p Feeding Norehabilitation 5.39(3.64) 8.87(2.42) 9.18(2.36) <.001 Lightrehabilitation .78(2.05) 2.59(2.99) 4.14(3.98) <.001 Intenserehabilitation 2.62(2.93) 5.56(3.19) 6.92(3.64) <.001 Bathing Norehabilitation .28(1.61) 2.66(2.50) 3.23(2.40) <.001 Lightrehabilitation .00(.00) .09(.66) .00(.00) .368 Intenserehabilitation .03(.41) .23(1.05) 1.29(2.20) <.001 Washing Norehabilitation .35(1.29) 3.33(2.36) 3.65(2.23) <.001 Lightrehabilitation .00(.00) .00(.00) .43(1.42) <.001 Intenserehabilitation .10(.70) .46(1.45) 1.52(2.31) <.001 Dressing Norehabilitation 3.76(3.39) 7.77(3.24) 8.16(3.24) <.001 Lightrehabilitation .52(1,54) 1,03(2,04) 1,64(2,55) <.001 Intenserehabilitation 1,29(2,27) 3,48(3,37) 5,03(3,67) <.001 Bowelcontrol Norehabilitation 6.13(4.11) 8.94(2.85) 9.08(2.71) <.001 Lightrehabilitation .78(2.26) 1.98(3.37) 3.36(4.33) <.001 Intenserehabilitation 2.95(3.71) 6.19(3.95) 7.19(3.89) <.001 Urinecontrol Norehabilitation 6.03(4.16) 8.90(2.81) 8.79(2.92) <.001 Lightrehabilitation .78(2.26) 1.90(3.22) 3.19(4.36) <.001 Intenserehabilitation 2.85(3.63) 5.99(3.96) 6.99(3.96) <.001 Useofbathroom Norehabilitation 3.76(3.83) 8.76(2.88) 8.69(3.03) <.001 Lightrehabilitation .34(1.28) 1.29(2.21) 2.16(3.76) <.001 Intenserehabilitation 1.19(2.63) 4.37(3.89) 5.86(4.19) <.001 Transference(bed-armchair) Norehabilitation 7.02(4.85) 13.48(3.04) 13.48(3.38) <.001 Lightrehabilitation 1.47(2.96) 6.21(2.70) 6.21(3.66) <.001 Intenserehabilitation 3.44(3.61) 9.07(3.85) 10.07(4.43) <.001 Mobility Norehabilitation 6.67(5.94) 13.58(3.79) 13.72(3.65) <.001 Lightrehabilitation 1.29(3.45) 3.97(4.66) 5.09(5.17) <.001 Intenserehabilitation 2.72(4.27) 8.74(5.36) 10.73(5.33) <.001 Goingupanddownstairs

Norehabilitation 2.48(3.31) 7.87(3.39) 7.94(3.33) <.001

Lightrehabilitation .17(.92) .60(1.64) .95(1.98) <.001

Intenserehabilitation .53(1.65) 2.48(3.26) 4.34(3.82) <.001

Kruskal---Wallistest.

than those who had intense rehabilitation. These results weresimilar both in the univariate analysisand the mul-tivariateanalysis.Furthermore,early initiation ofintense rehabilitation after the stroke appears to have a greater importancethanthe typeofrehabilitation made.24,25 _Due

tothestudycharacteristicsdataregardingtheperiodfrom theeventtothestartofrehabilitationarenotavailableand forthisreasonwewereunabletoshowtheminourresults. Age is associated witha poorerprognosis after suffer-ingfromstroke,especiallyin theelderlyover 85yearsof age, where comorbidities are greater and their previous

functional status is further impaired than in younger patients.26_{Inourstudyagewasshowntobeariskfactorof}

functionaldependence8weeksafterthestrokebothinthe univariateanalysis(OR:1.07; 95%CI:1.02−1.12)andinthe multivariateanalysis(OR:1.09; 95%CI:1.04−1.15). Some studies27,28_{demonstratealowerrecoveryinolderpatients,}

leading in some cases to the indication to participate in specificrehabilitationprogrammes.However,otherstudies havebeen publishedinwhichjustificationfornotcarrying out arehabilitation treatment wasnot found,since func-tionalimprovementafterthestrokewasproven,29_withage

Table4 PredictivebaselineFactorsoffunctionaldependence8weeksafterstroke(n=264).

Univariateanalysis Multivariateanalysis

Variable OR(IC95%) p OR(IC95%) P

Age 1.07(1.02−1.12) .003 1.09(1.04−1.15) <.001

Malesex .73(.36−1.49) .395

----Meanhospitalstay 1.06(1.01−1.11) .013 1.04(.99−1.09) .096

Typeofstroke

Haemorrhagic 1.00Ref 1.00Ref

Ischaemic 1.32(.58_−2.99) .505 ----POCI .94(.0−.94) .918 ----TACS 2.98(.86−10.33) .085 ----LACI .61(.23−1.57) .308 ----PACI 2.42(.75−7.76) .135 ----Laterality

left 1.00Ref 1.00Ref

right 1.37(.65−2.86) .401

----Rehabilitation

Norehabilitation 1.00Ref 1.00Ref

Lightrehabilitation 6.37(1.74−23.25) .005 7.74(1.91−31.30) .004 Intenserehabilitation 2.28(1.08−4.82) .030 3.14(1.35−7.31) .008 LACI:Lacunarstroke;PACI:partialanteriorcirculationstroke;POCI:posteriorcirculationstroke;TACS:totalanteriorcirculationstroke.

notbeingadeterminingfactorforentrytotherehabilitation programmesafterastroke.30 _{Duetothecharacteristicsof}

ourstudy,weareunawareofthereasonswhysomepatients carriedoutlightrehabilitationandothersintense rehabili-tation.

Ourstudyhadseverallimitations.Firstly,thestudydesign wasobservational andtherefore only involved association butnot causality.Duetotheretrospective characteristics ofthe study,severalvariables whichcouldhaveimpacted thefinaloutcomewerenotcollected,suchasthetimefrom thebeginning ofthestroke torehabilitationand thetype carriedout,orthepresenceofcomorbidities.Furthermore, onegroupwassmallerthantheothers(141vs.58vs.151 patientsrespectively).Finally,onlythefunctionalstatusof patientswasconsidered,notcognitiveorlanguagerecovery. Toconclude,ourfindingssuggestthatinelderlypatients carryingoutintenserehabilitationimprovesthefunctional statusandBADL,comparedwithlightrehabilitation,8weeks after suffering from a stroke. We therefore believe it is essential to increase efforts made in the health systems sothatneurorrehabilitationservicesareavailabletothese patients,offeringthem appropriaterehabilitationtherapy toimprovetheirfunctionalstatusafterthestroke.

Financing

None.

Conflict

of

interests

S.R.Mand F.L.E state that this study hasbeen conducted withinthecontextofaresearchvisitintheDepartmentof NursingofthepolytechnicInstituteofBraganza.

Theotherauthorshavenoconflictofintereststodeclare.

Acknowledgements

Ourthanks to the Escola Superior de Saúde del instituto PolitécnicodeBraganc¸aforwelcomingthelecturersSergio RicoandFidelLópezintheirresearchstay.

Thisstudywaspossiblethankstothemobilitygrantsto theteachingpersonnelawardedbytheCouncilofEducation andEmploymentoftheGovernmentofExtremadura.

ToIrene,JaimeandElena.

References

1.Bushnell C, McCullough LD, Awad IA, Chireau MV, Fedder WN, FurieKL, et al.Guidelines forthe preventionofstroke in women: a statement for healthcare professionals from theAmericanHeartAssociation/AmericanStrokeAssociation. Stroke.2014;45(5):1545---88.

2.WilkinsE,WilsonL,WickramasingheK,BhatnagarP,RaynerM, TownsendN.European CardiovascularDiseaseStatistics2017 edition.EuropeanHeartNetwork.2017.

3.UnitedNations,DepartmentofEconomicandSocialAffiars

Pop-ulation Division. World Population Ageing 2017 - Highlights.

UnitedNations.2017;.

4.Portugal. Ministério da Saúde. Direc¸ão-Geral da Saúde.

Pro-grama Nacional Para as Doenc¸as Cérebro-Cardiovasculares

2017 [Internet]. Lisboa: Direc¸ão-Geral da Saúde; 2017.

Availablefrom:https://www.dgs.pt/ficheiros-de-upload-2013/

aaaaaaaaaaapndccv-2017-temp-pdf.aspx.

5.Correia M,Magalhaes R,Felgueiras R, Quintas C,Guimaraes L,SilvaMC.Changesinstrokeincidence,outcome,and asso-ciatedfactors inPorto between1998and2011. IntJStroke. 2017;12(2):169---79.

6.BaptistaD,AbreuP,AzevedoE,MagalhaesR,CorreiaM.Sex dif-ferencesinstrokeincidenceinaPortuguesecommunity-based study.JStrokeCerebrovascDis.2018;27(11):3115---23.

7.Avellaneda-GomezC,RodriguezCampelloA,GiraltSteinhauer E,GomezGonzalezA,SerraMartinezM,deCeballosCerrajeria

P,etal.Descriptionofstrokemimicsaftercomplete neurovas-cularassessment.Neurologia.2019;34(1):7---13.

8.Murie-Fernandez M, Irimia P, Martinez-Vila E, John Meyer M,TeasellR. [Neuro-rehabilitationafterstroke].Neurologia. 2010;25(3):189---96.

9.CondeEspejoP.Evaluacióndelaeficienciademodelos

organi-zativosparaelabordajedelictus(unidadesdeictus)[Internet].

Madrid: Ministerio de Sanidad Servicios Sociales e Igualdad.

UnidaddeEvaluacióndeTecnologíasSanitariasdelaComunidad

deMadrid.2013.InformesdeEvaluacióndeTecnologías

Sani-tarias.;2013.Availablefrom:http://www.comunidad.madrid/

sites/default/files/aud/sanidad/evaluacion de laeficiencia de modelosorganizativosparaelabordajedelictusunidades deictus.pdf.

10.WinsteinCJ,SteinJ,ArenaR,BatesB,CherneyLR,CramerSC, etal.Guidelinesforadultstrokerehabilitationandrecovery: a guideline for healthcare professionals from the Ameri-can Heart Association/American Stroke Association. Stroke. 2016;47(6):e98---169.

11.Noe-SebastianE,Balasch-BernatM,Colomer-FontC, Moliner-MunozB,RodriguezSanchez-LeivaC,UgartP,etal.[Disability afterstroke:alongitudinalstudyinmoderateandseverestroke patientsincludedinamultidisciplinaryrehabilitationprogram]. RevNeurol.2017;64(9):385---92.

12.PereiraS,GrahamJR,ShahabazA,SalterK,FoleyN,MeyerM, etal.Rehabilitationofindividualswithseverestroke:synthesis ofbestevidenceandchallengesinimplementation.TopStroke Rehabil.2012;19(2):122---31.

13.WalkerMF,HoffmannTC,BradyMC,DeanCM,EngJJ,Farrin AJ,etal.Improvingthedevelopment,monitoringandreporting of stroke rehabilitation research: Consensus-basedcore rec-ommendations from the Stroke Recovery and Rehabilitation Roundtable.IntJStroke.2017;12(5):472---9.

14.Alcusky M, Ulbricht CM, Lapane KL. Postacute care setting, facilitycharacteristics,andpoststrokeoutcomes:asystematic review.ArchPhysMedRehabil.2018;99(6):1124---40,e9.

15.Sung S-F, Chen SC-C, Lin H-J, Chen C-H, Tseng M-C, Wu C-S, etal. OxfordshireCommunityStrokeProjectclassification improvespredictionofpost-thrombolysissymptomatic intrac-erebralhemorrhage.BMCNeurol.2014;14:39.

16.Baztán J, Pérez del Molino J, Alarcón T, San Cristonal E, Izquierdo G, Manzarbeitia J. Indice de Barthel: instrumento válido parala valoración functional de pacientes con enfer-medadcerebrovascular.RevEspGeriatrGerontol.1993.

17.DimyanMA,CohenLG.Neuroplasticityinthecontextofmotor rehabilitationafterstroke.NatRevNeurol.2011;7(2):76---85.

18.Grefkes C, Ward NS. Cortical reorganization after stroke: how much and how functional? Neuroscientist. 2014;20(1): 56---70.

19.MillerEL, Murray L, RichardsL, ZorowitzRD, BakasT, Clark P, et al. Comprehensiveoverview of nursing and interdisci-plinaryrehabilitation care ofthestroke patient: a scientific statement from the American Heart Association. Stroke. 2010;41(10):2402---48.

20.CummingTB,ThriftAG,CollierJM,ChurilovL,DeweyHM, Don-nanGA,etal.Veryearlymobilizationafterstrokefast-tracks returntowalking:furtherresultsfromthephaseIIAVERT ran-domizedcontrolledtrial.Stroke.2011;42(1):153---8.

21.VanWijkR, Cumming T, ChurilovL, DonnanG, Bernhardt J. Anearlymobilizationprotocolsuccessfullydeliversmoreand earliertherapytoacutestrokepatients:furtherresultsfrom phaseIIofAVERT.NeurorehabilNeuralRepair.2012;26(1):20---6.

22.StinearC,AckerleyS,ByblowW.Rehabilitationisinitiatedearly afterstroke,but mostmotor rehabilitation trials are not: a systematicreview.Stroke.2013;44(7):2039---45.

23.DobkinBH,DorschA.Newevidencefortherapiesinstroke reha-bilitation.CurrAtherosclerRep.2013;15(6):331.

24.Morreale M,Marchione P,Pili A, LautaA, CastigliaSF, Spal-lone A, et al. Early versus delayed rehabilitation treatment inhemiplegicpatientswithischemicstroke:proprioceptiveor cognitiveapproach?EurJPhysRehabilMed.2016;52(1):81---9.

25.Langhorne P, Collier JM, Bate PJ, Thuy MN, Bernhardt J. Veryearlyversusdelayedmobilisationafterstroke.Cochrane DatabaseSystRev.2018;10:CD006187.

26.MorenoPalaciosJA,MorenoMartínezI,PintorOjedaA, Nu˜no EstebezME,CasadoBlancoC,MorenoLópezJ.Evolución fun-cionaltrasunictusenmayoresde85a˜nos.Rehabilitación.2018.

27.PaolucciS,AntonucciG,TroisiE,BragoniM,CoiroP,De Ange-lisD,etal.Agingandstrokerehabilitation.acase-comparison study.CerebrovascDis.2003;15(1---2):98---105.

28.LiebermanD,LiebermanD.Rehabilitationfollowingstrokein patientsaged85andabove.JRehabilResDev.2005.

29.Baztan JJ,Perez-Martinez DA, Fernandez-Alonso M, Aguado-Ortego R, Bellando-Alvarez G, et al. [Prognostic factors of functionalrecoveryinveryelderlystrokepatients.Aone-year follow-upstudy].RevNeurol.2007;44(10):577---83.

30.BaggS,PomboAP,HopmanW.Effectofageonfunctional out-comesafterstrokerehabilitation.Stroke.2002;33(1):179---85.