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To determine the influence of initially lowered orientation on rehabilitation outcome in stroke patients, and how decreased orientation 6 months after stroke influences ADL and social activities.Prospective, consecutive, and community based.A stroke unit receiving all acute stroke patients from a well-defined catchment area. All stages of rehabilitation were completed within the unit.524 patients with acute stroke.Basic ADL assessed by the Barthel Index (BI) at discharge; discharge placement; higher level ADL and social functions assessed by the Frenchay Activity Index(FAI) at a 6-month follow-up.The independent influence of orientation in acute stroke on rehabilitation outcome was analyzed with multiple linear and logistic regression models, using initial stroke severity (Scandinavian Neurologic Stroke Scale), initial BI, age, sex, comorbidity, prior stroke, and marital status as covariates. A one-point decrease in orientation decreased BI with 9 points (coefficient b=8.66, SE(b)=1.02,p.0001) and reduced the likelihood (1.49, 95% CI: 1.05 to 2.11) of discharge to independent living (b=.40, SE(b)=.18,p=.026). Follow-up examinations 6 month poststroke showed that decreased orientation at this point still exerted a marked, negative influence on ADL and social functions (BI: coefficient b=12.06, SE(b)=1.95,p.0001; FAI: coefficient b=6.28, SE(b)=1.42,p.0001).The level of orientation influences basic ADL and higher level ADL and social activities in acute as well as chronic stroke. This finding suggests that rehabilitation of memory and attention might be relevant in stroke patients with impaired orientation.

Objectives: A "pusher syndrome" encompassing postural imbalance and hemineglect is believed to aggravate the prognosis of stroke patients. Our aim was to determine the incidence, associated neuropsychological symptoms, and the consequences for rehabilitation of ipsilateral pushing. Design: Consecutive and community-based. Setting: A stroke unit receiving all acute stroke patients from a well-defined catchment area. All stages of rehabilitation were completed within the unit. Patients: 647 acute stroke patients admitted during a 1-year period. Excluded were 320 patients who did not receive physiotherapy because they did not have pareses of the leg, had a fast remission, or died. Main Outcome Measures: Gain in activities of daily living (ADL) function (Barthel Index), time course of functional remission, and discharge rate to nursing home. The independent impact of ipsilateral pushing was analyzed with multiple linear and logistic regression analyses. Results: Ipsilateral pushing was found in 10% of the included patients. No significant differences were found in the incidence of hemineglect and anosognosia between patients with and without ipsilateral pushing. No association with side of stroke lesion was found. Ipsilateral pushing had no independent influence on gain in ADL function or discharge rate to nursing home, but patients with ipsilateral pushing used 3.6 weeks ( P Conclusions: The existence of a "pusher syndrome" was not confirmed. Ipsilateral pushing did not affect functional outcome, but showed the process of recovery considerably.

Objective: To determine the time course of both neurological and functional recovery from stroke. Design: Prospective, consecutive, and community based. Setting: The stroke unit of a hospital in Copenhagen, Denmark. This setting receives all acute stroke patients admitted from a well-defined catchment area of 239,886 inhabitants within the city of Copenhagen. Acute treatment as well as all stages of rehabilitation are cared for within the stroke unit regardless of age, stroke severity, and premorbid condition. Patients: 1,197 patients with acute stroke. Main Outcome Measures: Weekly examinations of neurological deficits (using the Scandinavian Neurological Stroke Scale) and functional disabilities (Activity of Daily Living (ADL) measured by the Barthel Index) were performed from the time of acute admission to the end of rehabilitation. These evaluations were repeated 6 months poststroke. Time course of recovery was stratified according to initial stroke severity and disability. Results: Functional recovery was completed within 12.5 weeks (95% confidence interval (CI) 11.6 to 13.4) from stroke onset in 95% of the patients. However, 80% of the patients had reached their best ADL function within 6 weeks (CI 5.3 to 6.7) from onset. The time course of functional recovery was strongly related to initial stroke severity. Best ADL function was reached within 8.5 weeks (CI 8 to 9) in patients with initially mild strokes, within 13 weeks (CI 12 to 14) in patients with moderate strokes, within 17 weeks (CI 15 to 19) in patients with severe strokes, and within 20 weeks (CI 16 to 24) in patients with very severe strokes. After these time-points, no significant changes occurred. However, a valid prognosis of functional outcome can be made much earlier. Best ADL function was reached by 80% of the patients with initially mild strokes within 3 weeks (CI 2.6 to 3.4), within 7 weeks (CI 6 to 8) of the patients with moderate strokes, and within 11.5 weeks (CI 10 to 13) of the patients with severe and very severe strokes. The time course of neurological recovery followed a pattern similar to that of functional recovery, but preceeded functional recovery by 2 weeks on average. Conclusions: A reliable prognosis can in all stroke patients be made within 12 weeks from stroke onset. Even in patients with severe and very severe strokes, neurological and functional recovery should not be expected after the first 5 months.

Time course and degree of the recovery of walking function after stroke and the influence of initial lower extremity (LE) paresis were studied prospectively in a community-based population of 804 consecutive acute stroke patients. Walking function and degree of LE paresis were assessed weekly using the Barthel index and the Scandinavian Neurological Stroke scale, respectively. Initially, 51% had no walking function, 12% could walk with assistance, and 37% had independent walking function. At the end of rehabilitation, 21% had died, 18% had no walking function, 11% could walk with assistance, and 50% had independent walking function. Recovery of walking function occurs in 95% of the patients within the first 11 weeks after stroke. The time and the degree of recovery are related to both the degree of initial impairment of walking function and to the severity of LE paresis, p < .0001. A valid prognosis of walking function in patients with initially no/mild/moderate leg paresis can be made in 3 weeks, and further recovery should not be expected after 9 weeks. A valid prognosis of walking function in patients with initially severe leg paresis or paralysis can be made in 6 weeks, and further improvement of walking function should not be expected later than 11 weeks after stroke.

Wandel A, Jorgensen HS, Nakayama H, Raaschou HO, Olsen TS. Prediction of walking function in stroke patients with initial lower extremity paralysis: the Copenhagen Stroke Study. Arch Phys Med Rehabil 2000;81:736-8. Objectives: The majority of stroke patients with initial leg paralysis do not regain independent walking. We characterize the minority who, despite initial leg paralysis, regained independent walking. Design: Consecutive and community based. Setting: A stroke unit receiving all stroke patients from a well-defined community. Patients: A total of 859 acute stroke patients; 157 (15%) initially had leg paralysis. Main Outcome Measures: Scandinavian Stroke Scale (SSS) and Barthel index (BI) on admission and weekly during rehabilitation. Univariate and multivariate statistics were considered. Results: Of the 157 patients with initial leg paralysis, 84 (60%) died; 73 (40%) survived. Fifteen (21%) survivors regained walking function (the walking group), and 58 (79%) did not (the nonwalking group). The BI on admission was the only factor of significant predictive value ( p p p Conclusion: Only 10% of stroke patients with initial leg paralysis regained independent walking. In these patients, BI on admission was high and leg strength improved quickly in the first week. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Objective: To assess activities of daily living (ADL) in stroke in a comprehensive way. The Barthel Index (BI) is widely used in stroke research, but is limited because it measures basic ADL functions only. This study sought to determine whether the Frenchay Activities Index (FAI) is a good choice for supplementary assessment of higher order ADL functions. Design: Prospective and consecutive. Setting: Follow-up investigation 6 months after stroke of patients who were admitted to, and completed rehabilitation at, a stroke unit. Patients: 437 patients with strokes. Main Outcome Measures: Factor analysis of the BI, FAI, and the Scandinavian Neurological Stroke Scale (SSS); distribution characteristics of a comprehensive, combined ADL scale. Results: Five factors were found. One factor comprised all items from the BI and all the motor items from the SSS, but no items from the FAI. The FAI loaded on three other factors. Finally, orientation and speech from the SSS loaded on a separate factor. A combined score consisting of the BI total score and a simple transformation of the FAI total score had a much improved distribution without strong ceiling or floor effects. Conclusions: The FAI supplements the BI with minimal overlap in content. A combined total score has a distribution that makes it very usable for research in stroke outcome and stroke rehabilitation effect.

Compensation by the unaffected upper extremity (UE) was studied in stroke patients who were unable to use the affected UE. The main aim was to evaluate the need of teaching compensatory techniques to stroke patients during rehabilitation of UE function. The study was prospective and community based and included 636 consecutive acute stroke patients. UE function and UE paresis were assessed weekly using the Barthel Index subscores for feeding and grooming and the Scandinavian Stroke Scale (SSS) subscores for arm and hand. Rehabilitation was performed according to the Bobath technique. Initially, 214 had severe UE paresis according to SSS; the arm could not move against gravity and the fingertips could not reach palm. In 64 of the 115 patients discharged alive, the affected UE definitely remained useless despite intensive and longstanding rehabilitation. Improvement of UE function was seen in 25 of these patients (39%) and was possible only through compensation by the unaffected UE. Patients who gained UE function by compensation were younger (p < 0.01), had less severe stroke (p < 0.01), smaller (p < 0.01), and subcortically located (p = 0.02) lesions and less affection of higher cortical function (p = 0.01). Recovery of UE function in more than half of the stroke patients with initial severe UE paresis can be achieved only by compensation by the unaffected UE.

Time course and degree of recovery of upper extremity (UE) function after stroke and the influence of initial UE paresis were studied prospectively in a community-based population of 421 consecutive stroke patients admitted acutely during a 1-year period. UE function was assessed weekly, using the Barthel Index subscores for feeding and grooming. UE paresis was assessed by the Scandinavian Stroke Scale subscores for hand and arm. The best possible UE function was achieved by 80% of the patients within 3 weeks after stroke onset and by 95% within 9 weeks; in patients with mild UE paresis, function was achieved within 3 and 6 weeks, respectively, and in patients with severe UE paresis within 6 and 11 weeks, respectively. Full UE function was achieved by 79% of patients with mild UE paresis and only by 18% of patients with severe UE paresis. A valid prognosis of UE function can be made within 3 and 6 weeks in patients with mild and severe UE paresis, respectively. Further recovery of UE function should not be expected after 6 and 11 weeks respectively, in these groups of patients.