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Introduction:The modified Rankin Scale (mRS) of clinician-rated global disability is commonly used to measure functional outcome after stroke but has limitations such as low granularity and ceiling effects. Measures of functional outcomes with higher resolution could provide improved insights into outcomes and therapeutic efficacy. Here we evaluated the performance of the mRS in relation to the Stroke Impact Scale v2.0 Activities of Daily Living score (SIS-ADL), a valid, reliable, patient-reported measure of post-stroke function.Methods:Patients in the STRONG Study were examined 90 d post-stroke. In addition to the mRS, exam included the SIS-ADL, which asks patients to rate the difficulty of performing 10 ADLs using a 5-level Likert Scale. SIS-ADL scores range from 0-40; higher scores indicate better function.Results:For 499 patients, age = 61.5±14.8 (mean±SD), acute NIHSS = 4 [2-9] (median [IQR], day 90 mRS median = 2 [1-3], and day 90 SIS-ADL median = 35 [26-39]. The d90 SIS-ADL correlated with d90 mRS (r = -0.74, p<.0001). The mean SIS-ADL value decreased with increasing mRS scores, as expected, but there was substantial overlap in SIS-ADL scores across mRS levels (Figure) to a degree beyond the minimal clinically important difference (5.9 points). The SIS-ADL was sensitive to mild deficits, identifying persistent ADL problems in 30/66 (45.5%) patients with a perfect mRS score of 0.Conclusions:In a population of mild-moderate stroke, the SIS-ADL identified a wide range of patient-reported functional deficits within each mRS level and was sensitive to functional deficits not identified by the mRS. The SIS-ADL complements the mRS for measuring functional outcome after stroke and may be useful for study design and sample size estimates for acute stroke and stroke recovery trials.

Background:Stroke is a sudden-onset, unexpected life event over which individuals have little control. These features can make the experience of having a stroke extremely stressful, which may potentiate its debilitating effects. Yet the role of lifetime stress/trauma exposure (LSE) and post-stroke acute stress (AS) have received limited attention in research seeking to identify factors influencing stroke-related disability.Hypothesis:Higher lifetime trauma and AS symptoms are associated with poorer post-stroke modified Rankin (mRS) and Fugl-Meyer scores.Method:Multi-site national study of patients admitted for a new stroke. Interviews were conducted at 2-10 days (N=763) & 3 months (N=513) post-stroke. Assessments included admission Acute Stress Disorder Interview, day-90 mRS, day-90 upper extremity motor Fugl-Meyer scale (affected side), and LSE. Structural Equation Modeling examined relationships among LSE, AS, and outcomes, controlling for admission NIHSS score, IV TPA treatment, and demographics.Results:After controlling for key covariates, AS immediately post-stroke and LSE were both associated with poorer day-90 mRS scores (p<.001; p=.02 respectively), and higher AS was associated with poorer day-90 Fugl-Meyer scores (p=.001). Higher LSE was indirectly associated with poorer day-90 Fugl-Meyer scores (p=.009) through its association with high AS (p<.001) upon admission.Conclusion:Lifetime stress and stress symptoms in the acute stroke setting are both associated with level of disability 3 months post-stroke; their assessment may be useful to facilitate early identification of high-risk patients and development of interventions that help improve functional outcomes after stroke.

Background:Much of human behavior revolves around use of the hand, yet distal arm motor deficits are not part of the NIH Stroke Scale (NIHSS), and so their measurement is omitted from many guidelines and care pathways. We examined the frequency of distal arm motor deficits and their functional implications.Methods:Patients in the STRONG Study were examined 1-10d and again 90 d post-stroke. Grip force, expressed as the ratio of paretic/nonparetic hands, and the NIHSS were measured serially. The modified Rankin (mRS) and Fugl-Meyer arm motor (FM) scales were measured at d90.Results:There were 763 patients, with age = 62.5±15.0 (mean±SD), acute NIHSS = 4 [2-9] (median [IQR]), and day 90 mRS median = 2 [1-3]. Grip force was available in 748 acutely and in 439 at d90. Weakness in grip strength was present in 60.2% acutely and 52.2% at d90. Acutely, grip force was not related to NIHSS total score (r=.04, p=.3) after accounting for proximal motor deficits (NIHSS Q5); at d90, there was a weak relationship (r= -0.15, p<.0001). Proximal weakness was only partially related to distal motor deficits at both timepoints (r = -0.48 to -0.53, p<.0001). At d90, grip force explained 24.6% of the variance in mRS score (p<.0001). D90 grip force showed convergent validity, correlating strongly with the distal arm motor FM score (r=.64, p<.0001).Conclusions:In this mild-moderate stroke population, distal arm motor deficits were common, were poorly captured by the NIHSS total score, and did not simply echo proximal arm motor deficits. Distal arm motor deficits were strongly related to level of global disability at d90. These findings argue that measurement of distal arm motor deficits should be included in guidelines and care pathways after stroke.