Ween J E, Mernoff S T, Alexander M P
Loma Linda University, California 92354, USA.
Neurorehabil Neural Repair. 2000;14(3):229-35. doi: 10.1177/154596830001400309.
Current assessments do not provide reliable factors predictive of outcome from stroke for stroke survivors of intermediate age and severity of deficit. We sought to investigate whether early rate of functional improvement can facilitate prediction of functional outcome, length of stay, and disposition beyond that afforded by age and initial severity of deficit. Prospective study of consecutive admissions to acute rehabilitation (N = 244) with diagnosis of ischemic or hemorrhagic stroke. Independent measures were age, marital status, living situation, social situation, lag from symptom onset to rehabilitation, stroke type, admission score on the Functional Independence Measure (FIM), rate of FIM change (ROFC) as assessed by the best weekly FIM change in the first 3 weeks of rehabilitation. Dependent measures were functional status on discharge as assessed by a modification of Steinman's method, length of stay, and discharge disposition. Logistic regression analyses on each of the dependent measures identified significant factors, and interactions of significant factors were assessed by analysis of variance on continuous dependent variables. Cross-tabulations using significant factors from the logistic regression analyses were performed to identify groups with homogeneous outcomes. Groups with >80% homogeneity were considered likely to have predictive value. Discharge functional status: Admission FIM (AFIM) again fractionated the population into groups with poor outcome (AFIM <50 remained dependent), good outcome (AFIM >70 achieved nondependence), and an intermediate group with unpredictable outcome. In this intermediate group, ROFC had significant effect only for a small number of patients (n = 9) with rapid improvement (ROFC >25) who achieved nondependence. LOS: AFIM >70 had less than average LOS, ROFC = 10-15 FIM/week had longer than average LOS. LOS was significantly prolonged in patients with poor outcomes. Disposition: AFIM >70 and age <60 were strongly associated with home discharge. Patients not living at home before admission were not discharged home. Married patients had a greater tendency to home discharge than did those not married. ROFC had no bearing on disposition. ROFC has an independent influence on outcome but was sufficiently powerful in our sample to identify reliably only a very small subset of patients with otherwise indeterminate prognosis. LOS seems inordinately prolonged in patients with poor outcomes. Both of these results can guide efficient rehabilitation management.
目前的评估未能为中年及有中度残疾的中风幸存者提供可靠的、可预测中风预后的因素。我们试图研究早期功能改善率是否有助于预测功能预后、住院时间及出院去向，而不仅仅依靠年龄和初始残疾严重程度。对连续收治的244例急性康复期缺血性或出血性中风患者进行前瞻性研究。独立变量包括年龄、婚姻状况、生活环境、社会状况、症状发作至康复的间隔时间、中风类型、功能独立性测量量表（FIM）入院评分、康复前3周内每周最佳FIM变化评估的FIM变化率（ROFC）。因变量包括出院时的功能状态（采用Steinman方法的改良版进行评估）、住院时间及出院去向。对每个因变量进行逻辑回归分析以确定显著因素，并通过对连续因变量的方差分析评估显著因素之间的相互作用。利用逻辑回归分析中的显著因素进行交叉制表，以确定预后同质的组。同质性>80%的组被认为可能具有预测价值。出院功能状态：入院FIM（AFIM）再次将人群分为预后差的组（AFIM<50仍为依赖状态）、预后好的组（AFIM>70实现非依赖状态）以及预后不可预测的中间组。在这个中间组中，ROFC仅对少数快速改善（ROFC>25）并实现非依赖状态的患者（n=9）有显著影响。住院时间：AFIM>70的患者住院时间低于平均水平，ROFC=10-15 FIM/周的患者住院时间长于平均水平。预后差的患者住院时间显著延长。出院去向：AFIM>70且年龄<60岁与出院回家密切相关。入院前不住在家中的患者未出院回家。已婚患者比未婚患者更倾向于出院回家。ROFC与出院去向无关。ROFC对预后有独立影响，但在我们的样本中其效力仅足以可靠地识别出一小部分预后原本不确定的患者。预后差的患者住院时间似乎过长。这两个结果均可指导高效的康复管理。
