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NeuroRehabilitation 34 (2014) 391–399 DOI:10.3233/NRE-141060 IOS Press

Where are we in terms of poststroke functional outcomes and risk factors Nil Sayiner Caglar, Turkan Akin∗ , Ibrahim Halil Erdem, Levent Ozgonenel, Ebru Aytekin, Sule Tutun, Nezihe Akar and Ozcan Aysar Department of Physical Medicine and Rehabilitation, Istanbul Training and Research Hospital, Istanbul, Turkey

Abstract. BACKGROUND: Stroke is acute vascular deterioration of cerebral functions and 2nd leading cause of death. As population gets older, as well as the increasing prevalence of stroke and disability from chronic disease, the demand for rehabilitation care will continue to rise. There is need for evidence based rehabilitation approaches and rehabilitation outcomes should be proved by objective questionnairres to qualify the process. OBJECTIVE: To present the functional outcomes of stroke rehabilitation process among functional impairment measure evaluation. Determine the contributing factors on functional gain. MATERIAL-METHODS: Retrospectively assessment of data of 142 posttroke patients performed. In addition to demographical and clinical properties, functional outcomes with functional impairment measurement (FIM) and motor evaluation by Brunnstrom Motricitiy Index were recorded. Risk factors for stroke were questionned also. RESULTS: The mean of ages was 64.30 ± 11.9 years, male/female ratios were 47.2%/ 52.8%. The functional gain was 20.4% in M-FIM, 14.7% in C-FIM. Better outcomes gained by the patients who stayed longer than 15 days (ANOVA, p: 0.000) and who had hemorrhagic etiology (MannWhitney U, p: 0.048), meanwhile there was no significant difference in gender and plegic side groups on both Motor-FIM and Cognitive-FIM gains (p > 0.05, MannWhitney U). Regression models exhibited highest impact on the M-FIM gain were the admission M-FIM scores and DM (adjusted Rsquare: 0.173, p: 0.000). Admission C-FIM scores had positive correlation with discharge C-FIM scores (r: 0.917, p: 0.000). Although older age was the negative determinant of C-FIM gain (r: −0.202, p: 0.016). We obtained the risk factor distribution 71.8% for HT, 29.6%for CAD, 25.6% for smoking, 16.2% for TIA and 33.1% for DM. All had negative impact on functional outcomes but DM had significantly (regression analysis p < 0.05). CONCLUSION: Improvement by rehabilitation programme determined by FIM scores. Data provided about the poststroke patients and present risk factors. Still there exists similar ratios of risk factors as studies before eventhough prevention recommendations. Keywords: Stroke, rehabilitation, functional independence measure

1. Introduction Stroke is acute vascular deterioration of cerebral functions longer than 24 hours (Brandstater, 2005). It is a common syndrome, and care of the stroke patient ∗ Address for correspondence: Turkan Akin, MD, Department of Physical Medicine and Rehabilitation, Istanbul Training and Research Hospital, 34098 Istanbul, Turkey. Tel.: +90 5448849911; Fax: +90 212 632 00 60; E-mail: [email protected].

is often thought of as a prototype rehabilitation effort because of its high frequency and its reliance on actually all members of the typical rehabilitation team (Harvey, 2011). Worldwide, stroke is the 2nd leading cause of death. As our population ages, the incidence and prevalence of stroke will continue to increase. Recently proceeds exist in stroke prevention and management; however, it is still a widespread condition, especially among the elderly. Known as the most disabling chronic disease, stroke affects not only the individual but also

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his/her family and society completely (Ingall, 2004; Mayo, 2002). The main causes of atherothromboembolic ischemic stroke are increasing blood pressure (BP), increasing cholesterol, cigarette smoking and diabetes; and the main risk factors for cardiogenic ischemic stroke are atrial fibrillation (AF) and ischemic heart disease (Hankey, 2005). Despite the changable ones, age, gender, family history of stroke and ethnicity are unchangable risk factors (Karatepe, 2007). On account of functional outcomes are affected by the comorbidities to be aware of risk factors may help prevention and management of stroke. Poststroke functional outcomes demonstrate improvement by rehabilitation. It is now evident both clinically and scientifically that improvement in motor control after stroke is training dependent and continuous training praogramme recquired. As population gets older particularly in developed countries, as well as the increasing prevalence of disability from chronic disease, the demand for rehabilitation care will continue to rise (Harvey, 2011; Ng, 2007; Ottenbacher, 2004). There is need for rehabilitation approaches which are evidence-based, to verify the efficacy of inpatient rehabilitation and also to select processes that best improve functional outcome cost-effectively (Ng, 2007; Thomson, 2005). Rehabilitation outcomes should be proved by objective questionnairres to qualify the process. In well developed rehabilitation units like United States, Australia and Europe, some databases specific to rehabilitation outcomes have been established (Ng 2007). Measures of disability and activities of daily living (ADL) are mainly Barthel Index (BI) and Functional Independence Measure (FIM). The FIM as the common primary functional outcome measure is the most widely used general measure of disability in North America and Australia (Ng, 2007; Sangha, 2005). The Agency for Health Care Policy and Research Post-Stroke Rehabilitation Panel suggests using wellvalidated and standardized instruments for reliable documentation of poststroke disabilities and prognoses over time. The panel recommended 2 instruments; the BI and the M-FIM, for measuring poststroke disability. The FIM is also subject to continuous review and progress to maintain standards and allows more accurate analysis of change (Kidd, 1995; Kwon, 2004). The aims of this study were to demonstrate demographics, clinical characteristics and functional outcomes, using the FIM, of the patients admitted to an inpatient rehabilitation unit and determine the factors significantly associated with functional scores.

2. Materials-methods Follow-up records of 142 hemiplegic patients rehabilitated at inpatient clinic within years of 2008 – 2011 were reviewed. Known etiology other than cerebrovascular attack (CVA), existing another central or peripherical neurological disease, unstabil vital functions, cognitive failure, walking impairment because of hip or knee disorders were exclusion criteria. We included patients with previous CVA to determine the functional status of them also. Sociodemographic and clinical factors existing in this study were the age, gender, etiology, affected side, duration of disease, length of stay (LOS) in hospital, risk factors and functional outcomes. Age was categorised into three groups, 75 years. LOS was upto 15 days, 1 month and longer than 1 month. Disease duration was also classified as 6 months. Functional outcome diffferences between groups were evaluated. At hospitalisation and discharge patients were examined and assessed for mobility and functional status. FIM forms were filled for all patients. FIM consists of 13 motor (M-FIM) and 5 cognitive (C-FIM) items. The M-FIM consists of 13 items: eating, grooming, bathing, dressing upper body, dressing lower body, toileting, managing bladder, managing bowel, transferring to bed/chair/wheelchair, transferring to toilet, transferring to tub/shower, locomotion by walk/wheelchair, and locomotion on stairs. Each item is rated with a score from 1 to 7 (1-complete assistance to perform basic ADL through 7-complete independence in performing basic ADL). Cognitive items assess communication, social interaction, problem-solving and memory. Results is between minimum score of 18 and maximum score of 126 indicating total functional independence (Ng, 2007; Kwon, 2004). We used FIM for functional measurement before and after treatment though validation and adaptation of FIM in Turkish population have done (Kucukdeveci, 2001). Form was filled by observation of the patient or interview with his/her companion. Primary measure for motor evaluation was Brunnstrom Motor Recovery Status assessing hand, upper extremity and lower extremity over 6 stages (Safaz, 2009). Patients underwent conventional rehabilitation program including range of motion (ROM) exercises, posture and balance training, walking, climbing stairs and transfer exercises with/without aids. Stretching exercises, coldpacks and neuromuscular electrical

N.S. Caglar et al. / Where are we in terms of poststroke functional outcomes

stimulation (NMES) were used for limited joints and spasticity. For weak muscles progressive resistive exercises and NMES were needed. Some physical therapy modalities as hotpack, coldpack, trancutaneous electrical nerve stimulation (TENS) and basic analgesics were applied for pain management. Therapy sessions were 5 days a week with a physiotherapist. Other factors were assessed during the baseline included smoking habits, hypertension (HT), transient ischemic attack (TIA), diabetes mellitus (DM) and coronary artery disease (CAD). After retrospectively review of the folders descriptive and frequency analyses were done. For functional improvement FIM scores before and after treatment evaluated. The functional gain was calculated by the formula below. functional gain =

(FIM after treatment − FIM before treatment) FIM before treatment

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Table 1 Demographical and clinical properties Age (years) 75 Gender Male Female Affected side Dominant Non-dominant Etiology Ischemic Hemorrhagic Disease duration (months) 6 Length of Stay (days) 30

%

n (142)

48.6 27.5 23.9

69 39 34

47.2 52.8

67 75

52.1 47.9

74 68

88.0 12.0

125 17

11.3 38.0 29.6 21.1

16 54 42 30

44.3 43.0 12.7

63 61 18

× 100 The contributing affects of age, gender, etiology, duration of disease and LOS, comorbid diseases on functional gain were assessed. Statistical analysis were done by using SPSS 16.0 for Windows. Descriptive analyses, paired – T test, non-parametric Mann Whitney – U analyses, one way analysis of variance (one-way ANOVA) and lineer regression models were performed, p < 0.05 was accepted as significant result.

Table 2 Comorbid conditions TIA DM HT CAD Cigarette smoking

N

%

23 47 102 42 36

16.2 33.1 71.8 29.6 25.4

TIA: transient ischemic attack, DM: diabetes Mellitus, HT: hypertension, CAD: coronary artery disease.

3. Results 142 hemiplegic patients rehabilitated within years of 2008 – 2011 were enrolled into study. Table 1 presents the demographical and clinical properties of patients. The mean of ages was 64.30 ± 11.9 years. As cathegorized age distribution was 48.6%–27.5%–23.9% (75 years respectively). 47.2% of them were male and 52.8% were female. In 68 patients (47.9%) affected side was non dominant, in 74 patients (52.1%) it was dominant side. Etiologic reasons were ischemic (88%) and hemorrhagic (12%) cerebrovascular attack mainly. The mean of LOS was 17.38 ± 8.76 days. 38.0% of the patients attained to rehabilitation unit after while of 1–3 months, 29.6% had after 3–6 months of duration. Subgroups of LOS and disease duration exist in Table 1. Descriptives of actual comorbidities such as cigarette smoking, DM, HT and CAD are presented in Table 2.

FIM and Brunnstrom motor recovery scores improved significantly as determined by paired-T test analysis after rehabilitation. Calculated by the formula given in methods 20.4% functional gain was apparent in M-FIM and 14.5% was in C-FIM. Details are shown in Table 3. Before searching the affects of parameters such as age, gender, etc. on functional outcomes, kolmogorov – smirnov test was performed and exhibited nonhomogenius distribution, so non-parametric analyses were done. Age, LOS in hospital and duration of disease subgroups were evaluated and significantly more gain was assigned in whom duration of disease is shorter and significantly less gain was assigned in whom LOS is shorter due to one way ANOVA statistics (Table 4). We found M-FIM gain better in hemorrhagic etiology (p: 0.048) than the ischemic ones, meanwhile there was no significant difference in gender and plegic side groups

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N.S. Caglar et al. / Where are we in terms of poststroke functional outcomes Table 3 Motor and functional evaluation Before treatment (means)

After treatment (means)

p*

72.49 ± 25.93 43.89 ± 20.98 28.59 ± 8.88 2.98 ± 2.03 2.81 ± 1.71 3.24 ± 1.46

79.65 ± 26.06 49.81 ± 20.86 29.84 ± 9.63 3.27 ± 1.95 3.12 ± 1.72 3.58 ± 1.42

0.000 0.000 0.025 0.000 0.000 0.000

T-FIM scores M-FIM scores C-FIM scores Brunnstrom hand Brunnstrom upper extremity Brunnstrom lower extremity

FIM: Functional Independence Measure (range from 18, most disability to126, no disability). T: total, M: motor, C: cognitive. *paired t-test, all are statistically significant, confidence interval is %95. Table 4 ANOVA analysis of some parameters on functional gain M-FIM gain Age groups 1 2 3 LOS 1 2 3 Disease duration 1 2 3 4

F

p

C-FIM gain

F

p

22.44 16.27 21.31

0.335

0.716

28.97 0.89 0.77

1.477

0.232

6.31* 32.1 30.6

8.7

0.000

4.16 11.29 61.61

2.524

0.084

33.85* 28.71* 12.10 10.24

3.025

0.032

92.94* 2.68 4.40 8.10

4.142

0.008

(one-way anova analysis; *post hoc tukey test shows the significant). Table 5 Regression analysis of contributing factors on M-FIM gain Variable Age Gender Duration of disease Previous CVA DM* HT CAD Cigarette smoking Admission M-FIM* Admission C-FIM LOS

B (unstandardised coefficient) SE (standart error) ␤ (standardised coefficient) −0.430 4.409 −6.026 4.655 14.269 −9.248 −4.947 −3.849 0.809 0.660 0.106

0.262 6.504 3.295 8.129 6.775 7.265 6.600 7.346 0.199 0.396 0.431

−0.135 0.058 −0.150 0.045 0.177 −0.110 −0.060 −0.044 −0.446 0.154 0.024

p 0.104 0.499 0.070 0.568 0.037* 0.205 0.455 0.601 0.000* 0.098 0.806

FIM: Functional Independence Measure; SE: standard error. Adjusted R2 = 0.173, p: 0.000. * p < 0.05, significant.

on both M-FIM and C-FIM gains (p > 0.05, Mann Whitney U). Cigarette smoking and comorbid diseases as DM, HT, CAD were considered as contributing factors on functional improvement and regression models were performed (Tables 5 and 6). Possessing previous CVA or TIA was also estimated as a determinator of functional gain. M-FIM and C-FIM gains assessed seperately. M-FIM was found to be 21% under the influence of these factors (adjusted R square: 0.173, p:

0.000). The factors with the highest impact on the MFIM gain were the admission M-FIM scores and DM (p < 0.05). Negative correlation of DM (r: −0.213 p: 0.011), besides positive correlation of longer LOS (p: 0.000 r: 0.413) was analysed. M-FIM discharge scores were positively and significantly correlated with higher admission M-FIM scores whereas FIM gain seems lower (r: 0.926, p: 0.000). Older age, HT, CAD, TIA, cigarette smoking and duration of disease had negative impact but was not significant (p > 0.05).

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395

Table 6 Regresion analyses of contributing factors on C-FIM gain Variable Age Gender Duration of disease TIA DM* HT CAD Cigarette smoking Admission M-FIM Admission C-FIM* LOS

B (unstandardised coefficient)

SE (standart error)

␤ (standardised coefficient)

p

−0.025 −19.170 −4.806 −38.473 36.226 5.112 14.602 30.465 0.324 −4.068 1.590

0.694 17.190 8.708 21.485 17.904 19.199 17.443 19.414 0.527 1.048 1.139

−0.003 −0.098 −0.046 −0.145 −0.175 0.024 0.068 0.136 0.069 −0.369 0.142

0.971 0.267 0.582 0.076 0.045 0.790 0.404 0.119 0.540 0.000 0.165

FIM: Functional Independence Measure; SE: standard error. Adjusted R2 = 0.146, p:0.001. * p < 0.05, significant.

As C-FIM gain regression analysis performed the impact was found to be 20% (adjusted R square: 0.146, p: 0.001). Age, gender, TIA and disease duration were the negative contributors but not significant. Admission C-FIM scores had positive correlation with discharge C-FIM scores (r: 0.917, p: 0.000). Although older age was the negative determinant of C-FIM gain (r: −0.202, p: 0.016).

4. Discussion This study provides data on functional outcomes after inpatient rehabilitation. Demographical and clinical properties of the subjects, duration of disease and length of stay in hospital of them are exhibited and the impact of these factors on functional outcomes rewieved. More importantly, these data confirm that inpatient rehabilitation programmes improve functional outcomes. Several factors might influence the specific outcome of an individual patient who is involved in a stroke rehabilitation program. Numerous studies have examined and reported many various predictors of favorable or unfavorable recovery of physical or psychosocial functioning. A large number of factors have been found to be statistically associated with the outcome of stroke rehabilitation (Harvey, 2001). Age is one of the main determinant of outcome. Incidence of stroke is increasing as population gets older such found as ten times higher in ages between 75– 84 years than the ages between 55– 64 years (Karatepe, 2007; Kane, 2003; Sacco, 1997). Knoflach et al. presented age emerging as a highly significant inverse predictor of good functional outcome after ischemic stroke independent of stroke severity, characteristics, and complications with the age-outcome

association exhibiting a nonlinear scale and extending to young stroke patients according to the regressionadjusted probability results of highest good outcome in the age group 18–35 years and gradually declining by 3.1%–4.2% per decade until age 75 with a steep drop thereafter (Knoflach, 2012). The mean of age is 64.30 ± 11.9 years in our study population similar to results of Karatepe et al. (66.2 ± 10.6 years). Made of database belonging to Aegean Study Group among 2000 patients in Turkish population, it was 62.3 ± 12 years. Karatepe et al. found negative correlation between age and FIM scores, but not significant (Karatepe, 2007; Kumral, 1998). Dulgeroglu et al. described most of the cases were hemiplegic patients depending on CVA, all having various chronic diseases, having used pharmaceutics for long time, and benefited from rehabilitation program at a medium level among geriatric cases mean age of 70.31 years (Dulgeroglu, 2002). We had the result of significant negative correlation of age and C-FIM gain scores supporting the literature given by Ay et al. and Lin et al. also met negative impact of older age on functional scores (Ay, 2009; Lin, 2003). Whether the hemorrhagic type stroke has better outcomes than the ischemic stroke is still under investigation. Paoluccia reported better functional recovery in intracerebral hemorrhagia (ICH) patients compared with cerebral infarction (CI) patients evaluated by Barthel index. It is probably due to a better neurological recovery suggesting as the hematoma causing brain compression resolves, neurological functions recover and functional status improves (Paolucci, 2003). In annother study similarly patients who had ICH achieved a greater functional improvement with rehabilitation compared with patients who had CI however they were more severely disabled on admission. On general linear model analyses, stroke type remained a significant

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explanatory factor for FIM gain, after adjusting for admission FIM, length of stay, age, and days from stroke onset to rehabilitation admission (Katrak, 2009). Besides Franke et al. observed no difference on functional independence after 1 year of follow-up between ICH and CI patients (Franke, 1992). Our study population, not a large group unfortunately, exhibited better outcome in ICH patients than the CI ones. Studies have shown differences in the ratios of females to males and functional outcomes. Some study groups did not determine any difference in either the admittance or discharge functional outcomes of female and male patients (Dogan, 2004; Bardak, 2008). However Carod-Artal et al. reported that they determined advanced age at stroke onset and more severe impairment at discharge so worser functional status and quality of life 1 year after stroke in women than men (Carod-Artal 2000). Stroke incidence rates are 1.25 times greater in men, but because women tend to live longer than men, more women than men die of stroke each year (Sacco, 1997).We presented indifferent FIM gains of male and female groups. A period of 30 days before starting rehabilitation is among the probable bad prognosis indicators that negatively affect functional level. Only 11.3% of our patients had reached to rehabilitation unit before 30 days. We had significantly better results of FIM gain in patients who had delay in rehabilitation process less than 3 months. Most patients of Dogan et al. and our study population similarly applied for rehabilitation more than 30 days after the onset of CVA. But they found no difference in functional outcomes of the patient in terms of disease duration. The defect and delay in the orientation of hemiplegic patients towards rehabilitation and inadequate number of rehabilitation centers make patients have to wait (Dogan, 2004). Bardak and friends pointed out the importance of first 3 months in better outcomes (Bardak, 2008). Paolucci described the waiting duration as onset-arrival interval (OAI) and the short OAI subgroup had significantly higher effectiveness of treatment than did the medium and the long OAI groups (Paolucci, 2000). Beginning treatment within the first 20 days was associated with a significantly high probability of excellent therapeutic response and beginning later was associated with a similar risk of poor response (Paolucci, 2000; Balci, 2011). Ancheta et al. found FIM scores of the patients had rehabilitation process earlier higher than the patients had long interval. Also their LOS was increasing as interval gets longer. They defensed that interval from stroke to rehabilitation can be used to set FIM outcome goals, predict length

of rehabilitation hospitalization needed to meet those goals (Ancheta, 2000). In the other hand according to Balaban and friends length of time after stroke onset is not correlated with BI or FIM scores at admission. Also they presented LOS was not correlated with improvement in BI or FIM scores. They had no difference in BI and FIM scores of patients that had inpatient rehabilitation time of shorter than one month or longer (Balaban, 2011). Negative correlation between OAI and functional gains, in addition to significantly better results of rehabilitation within first 3 months was shown by Yildiz et al. Admission functional scores was a determinant of LOS in hospital with a negative correlation, besides positive correlation of LOS and discharge scores (Yildiz, 2009). It seems when arrival time is shorter admission scores are low but they have more gain at the end. It provides patients to apply a rehabilitation unit before they have any complication caused by stroke fortunately. Also they need more hospitalisation time to reach better results as LOS is positively correlated with outcomes. Some other medical problems/complications are common among patients undergoing stroke rehabilitation also consequence of older age. Hence remarkable effects on functional outcomes could seen in those with comorbidities, existing literature revealing the incidence and impact on outcomes in terms of stroke. Also there is risk for recurrence depending on the type of infarct, history of HT, blood glucose levels, cardiac disease and heavy alcohol use. It is apparent that being aware of risk factors either changable or unknown yet, will help in the design of acute stroke trials and in prevention programs (Brandstater, 2005; Yildiz, 2009; Sacco, 1999). In our results ratios for comorbidities as HT, DM, CAD, TIA and cigarette smoking were respectively 71.8%, 33%, 29.6%, 16.2%, 25.4%. We found negative impact of all but significant negative correlation with DM and FIM gains. HT is the most important and frequent risk factor for CVA with the highest ratio in our study similarly (Kannel, 1983). In a study among Turkish population 62% diagnosed as HT, 42% had CAD, 22% had DM. But they presented that their patients’ functional outcomes were not significantly influenced by the occurrence of medical problems (G¨okkaya, 2006). Karatepe et al. determined HT at 75%, DM at 23% of their patients and in Aegean database it is 63% of HT and 35%of DM (Karatepe, 2007; Kumral, 1998). Ratio of HT was between 58% and 83%, ratio of DM was between 13% and 35% among other studies in our country (Eskiyurt, 2005; Tur, 2003; Yildiz, 2009). It is reccommended to lower CVA incidence by life style modifications and

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control of HT (20). DM is an independent risk factor and also duration of diabetes is independently associated with ischemic stroke risk adjusting for risk factors. The risk increases 3% each year, and triples with diabetes ≥10 years (Banerjee, 2012; Kannel, 1983). Smoking ratios presented as 20–49%, 30.7%, 54.9% and 17% among stroke patients (Karatepe, 2007; Kumral, 1998; Sacco, 2006; Yildiz, 2009). Smoking is an independent major risk factor in all age, gender and race groups (Sacco, 2006). CAD has an effect of doubling the stroke risk. Among Turkish stroke patients CAD has a ratio between 16%–29% (Eskiyurt, 1992; Karatepe, 2007; Tur, 2003). After adjustment by major cardiovascular factors, TIA sustains as a risk factor by presenting CVA mostly within first month and 15%–20% in the first year (Sacco, 1997). Karatepe found TIA in 29%, Yildiz found TIA in 6%, as a lower ratio, of stroke patients (Karatepe, 2007; Yildiz, 2009). Dietary modifications and medical approaches are recommended for patients have TIA (Sacco, 2007). In our study we found the similar ratios presenting unfavorable unprevented risk factors yet. Besides quesstionning the known risk factors we haven’t assessed any unknowns as a limitation process. It is important to note that outcomes after stroke can be assessed in a number of ways, including medical morbidity, mortality, level of impairment, length of hospital stay, cost of care, functional limitations, placement at the time of discharge and follow-up, amount of handicap or social functioning, quality of life, and life satisfaction. Functional outcomes can be measured either as absolute functional level at the time of discharge or else as the amount of change or improvement in functional abilities between admission/onset and discharge/follow-up (Harvey, 2011). World Health Organisation (WHO) has provided a classification at 2001 needed for functional outcome assessment named International Classification of Functioning, Disability and Health (ICF). Body functions, body structures, activity and participation constitute one part of the classification and the other part is made up by contextual factors, both environmental factors and personal factors (Dahl, 2002). According to the rewievs made about stroke scales within the framework of ICF, FIM has a place among them (Sakalli, 2009). The FIM was considered to be valid and reliable in the assessment of disability. If the patient is more independent, the FIM is more likely to detect further improvements. Also admission FIM score can be used to set FIM outcome goals, predict length of rehabilitation hospitalization needed to meet those goals, and compare quality of care across

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institutions with different referral patterns (Ancheta, 2000; Kidd, 1995; Siv Svensson, 2012). We used the FIM at admission and discharge of the patients. Assessment of recovery done by calculating FIM gains both for motor-FIM and cognitive-FIM. After rehabilitation process significantly improvement has determined in discharge FIM scores among all patients. The most effective determinant on discharge FIM scores (motor and cognitive) was the admission scores. However gain seems lower but the discharge scores were higher cause of the ceiling effect also experienced by other studies (Oz, 2008; Ring, 1997). Poststroke functional outcomes demonstrate improvement by rehabilitation. It is now evident both clinically and scientifically that improvement in motor control after stroke is training dependent and continuous training programme recquired (Harvey, 2011; Ottenbacher, 2004). Insights in admission criteria, patients’ therapy time, content of therapy, and task characteristics of physiotherapists and occupational therapists were in line with the differences in recovery. Heterogenous patient groups are complicating the determination of effectiveness results. While several known prognostic factors such as age, sex, urinary incontinence, stroke location, etiology are balanced results will be more clearly pointing out the benefits of rehabilitation. Some data indicate that more intensive rehabilitation results in better recovery and efficient use of the therapeutic resources makes a difference in daily practice: “more is better” (Oz, 2008; Putman, 2009; Ring, 1997). 4.1. Study Limitations Heterogenity of patient groups in terms of disease duration and admissin functional levels masked the effect of rehabilitation and lowered the number of patients although provides comparement between different groups. Studies with more number of patients in homogeneous groups should be performed.

5. Conclusion This study presented effectiveness of stroke rehabilitation therapy evidenced by functional independence measurement. Neverthless by the limitations such as heterogenous patient group, small size of population, shortness of follow-up duration, etc. this retrospective screening provided a data for stroke rehabilitation, ongoing risk factors and application of FIM scale.

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N.S. Caglar et al. / Where are we in terms of poststroke functional outcomes

Admission FIM scores, age and inpatient duration were the determinants of functional gain. Unfortunately risk factors such as HT, DM, CAD, smoking were similar to the previous studies even though preventive reccommendations are pointed out. Declaration of interest Each and every author does not have any personal or financial relationships that have any potential to inappropriately influence (bias) his or her actions or manuscript, and no financial or other potential conflicts of interest exist (includes involvement with any organization with a direct financial, intellectual, or other interest in the subject of the manuscript) regarding the manuscript. In addition, there are no any grants and sources of financial support related to the topic or topics of the manuscript. We certify that no party having a direct interest in the results of the research supporting this article has or will confer a benefit on us or on any organization with which we are associated AND, if applicable, we certify that all financial and material support for this research (eg, NIH or NHS grants) and work are clearly identified in the title page of the manuscript. All authors also state that, This paper is not under consideration elsewhere. Any part of this paper has been previously published. All authors have read and approved the manuscript. There is no potential for conflict of interest. References Ancheta, J., Husband, M., Law, D., & Reding, M. (2000). Initial functional independence measure score and interval post stroke help assess outcome, length of hospitalization and quality of care. Neurorehabil Neural Repair, 14, 127-134. Ay, S., Dogan, K.S., & Evcik, D. (2009). Risk factors in patients with stroke and effects on functional recovery. Yeni Tip Dergisi, 26, 37-41. Balaban, B., Tok, F., Yavuz, F., Yas¸ar, E., & Alaca, R. (2011). Early rehabilitation outcome in patients with middle cerebral artery stroke. Neurosci Lett, 498(3), 204-207. Balci, B., Ertekin, O., Kara, B., & Yaka, E. (2011). The effects of inpatient rehabilitation program in acute stroke patients. Journal of Neurological Sciences [Turkish], 28, 142-154. Banerjee, C., Moon, Y.P., Paik, M.C., Rundek, T., Mora-McLaughlin, C., Vieira, J.R., et al. (2012) Duration of diabetes and risk of ischemic stroke: The Northern Manhattan Study. Stroke 43(5), 1212-1217. Bardak, A.N., Ersoy, S., Akcan, Z., Kaya, B., Dere, C., Uysal, E., et al. (2008). Functional outcome of inpatient stroke rehabilitation. Turk J Phys Med Rehab, 54, 17-21.

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