Stroke Disability - Physical Therapy Journal

Stroke Disability
Pamela W Duncan
PHYS THER. 1994; 74:399-407.
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Stroke Disability
Stroke is the third leading cause of death in the United States and a major cause
of disability in the elderly. Although the incidence of stroke is decreasing, its prevalence in the population is increasing because of enhanced survival and a growing elderly population. Estimating and understanding disability following stroke
should be a high priority in health care. To better characterize stroke-related disability, pbysical therapists should use a conceptual model of disablement and
measurefunctions across all domains of disablement (impaimtents,functional
limitations, disability, and quality of life). Therapists need to use the measurements
obtained and knowledge of stroke recovery and of the variables that influence
this recovery to stage patients for prediction of outcomes. Using predicted outcomes to stage patients may result in efictive treatment plans and more accurate
targeting of intensive rehabilitation to those patients most likely to benefit. [Duncan PW. Stroke disability. Pbys Thm 1994;74:399407.]
Key Words: Cerebrovascular accident, Disability, Measurement, Outcomes, Stroke.
Incidence and Prevalence
of Stroke
Stroke is the third leading cause of
death in the United States and a major
cause of disability. Each year approximately 500,000 Americans suffer a
new or recurrent stroke. Of this number, 350,000 will survive.' Although
the incidence of stroke is decreasing,
its prevalence in the population appears to be increasing because of
enhanced stroke survival and a growing elderly population. The prevalence of stroke survivors is currently
over 2,000,000.l
Within the first 30 days following
stroke, the mortality rate is high
(30%)).*It is more severe for hemorrhagic stroke than for ischemic
stroke.3 However, more than 50% of
stroke survivors are alive in 5 years.*
Given this good survival rate and the
continuing high incidence of stroke,
estimating and understanding disability following stroke becomes a high
priority in health care.
Dlsablllty Estlmates
Exact estimates of disability following
stroke are difficult to obtain because
patients selected for study may be
population based o r referral based
(acute hospitals or rehabilitation facilities), outcome measures may be inconsistent, and assessments may have
been taken at different times during
the recovery period. Patient-level
variables such as severity and type of
stroke, age, and comorbid conditions
will also affect stroke disability and
vary in different disability studies. The
best estimates of disability following
stroke are provided by populationbased studies. Stroke registries of all
patients referred to hospitals are the
PW Duncan, PhD, PT,is Associate Director for Research, Center for Health Policy Research and
Education, Duke University, and Associate Professor, Graduate Program in Physical Therapy, Duke
University. Address all correspondence to Dr Duncan at Center for Health Policy Research and
Education, Duke University, Erwin Sq, Ste 230, 2200 W Main St, Durham, NC 27705 (USA).
next best source, whereas studies of
patients referred to rehabilitation
facilities tend to be the most biased.
Patients who are selected for rehabilitation are usually moderately to severely impaired.
The incidence of dependence in activities of daily living (ADL) is highest
immediately after a stroke and decreases significantly thereafter, according to various auth01-s.~~
A retrospective analysis of data from 292 persons
in Rochester, Minn, following their
first stroke indicated that 75% were
dependent in ADL at onset of stroke.
Only 57% of the survivors, however,
were dependent at the time they were
discharged from the hospital.* In a
prospective, population-based registry
of 976 patients with stroke in the
Frenchay Health District in England,
Wade and Langton-Hewer7 found that
the incidence of total dependence in
ADL decreased from 58% at 1 week
poststroke to 9% at 6 months poststroke. In a Japanese study, Kojima et
a18 found similar results, with only
25% of 5-year survivors totally dependent in ADL. Christie' reported
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Physical
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6-month disability levels for 296
persons who participated in a
population-based study of stroke in
Melbourne, Australia. Twenty-five
percent of the subjects in that study
were independent in ADL, and 17%
could drive a car or use public transportation. Of those subjects under age
75 years who did not lose consciousness immediately after the stroke,
54% were independent in ADL and
36% could drive a car or use public
transportation.
Several other factors may influence
these results. Selective survival of the
least seriously disabled individuals
may bias these findings. Also, dependencies in ADL may vary by function,
making a summated ADL score less
representative of limitations in individual activities. For example, the
dependence in more complex functions such as bathing is much greater
than that in less complex activities
such as g r ~ o m i n g . ~
Population-based studies that assess
neurological function following stroke
support an optimistic view of the
patient's prospects for recovery. Bonita and Beaglehole,lowho assessed
the natural history of motor recovery
for patients with stroke in Auckland,
New Zealand, reported that 88% of
the subjects had motor deficits. The
proportion of survivors who had
persistent motor deficits at 6 months
poststroke, however, had declined to
62%, and the majority of these motor
deficits were mild. Similarly, in a
Finnish population-based study,673%
of all patients with stroke had hemiparesis, but only 37% demonstrated
hemiparesis at a 12-month follow-up.
An assessment of 148 long-term
stroke survivors in the Framingham
(Mass) community-based population
studyn revealed that 67 had residual
hemiparesis, 4 had bilateral motor
weakness, and 77 had no motor
deficit.
Although the inability to walk is one
of the no st common problems in
acute stroke, most survivors achieve
independence in ambulation. In the
population-based Frenchay Health
District: study, only 27% of patients
could functionally ambulate within 1
week of stroke, but at 6 months 85%
were independent, although only 25%
had regained normal speed of ambul a t i ~ n . Gresham
~J~
et all1 reported
that 78% of the stroke survivors in the
Framingham study were ambulatory.
A few studies have examined instrumental ADL and quality of life in
stroke survivors. In the Framingham
cohort, Gresham et all1 compared
stroke survivors with age-matched
controls and found that 90% of the
stroke survivors demonstrated one o r
more disabilities, compared with 58%
of the matched controls. Stroke survivors were more limited in several
areas, including household activities,
recreational activities, social interaction, and public transportation usage.
In a matched control study using the
Sickness Impact Profile, Schuling et
all3 found that stroke affected household management, leisure activities,
and mobility. Christie9 reported an
"imperfect correlation" between residual physical impairment and disability. For example, of the stroke
survivors who were employed prior
to stroke and who had no residual
physical impairments, only 60% returned to work and only 80% continued their prior leisure activities. Of
patients who had residual physical
impairments, 40% continued to work
and 60% engaged in leisure activities.9
been limited to early acute care management, rehabilitation units, o r longterm care facilities. In any given patient, the process of disablement may
be profound and complex. A broader
perspective is needed to understand
the nature of stroke-related disablement in the population.
Conceptual Models of
Disability
Several conceptual models of disability are available to facilitate the understanding, assessment, measurement,
and treatment of stroke-related disabilities. The World Health Organization's (WHO) International Classification of Impairments, Disabilities, and
Handicaps (ICIDH)16 and the Nagi
"functional limitation" model17 are
the most frequently presented models
of the disablement process. The WHO
model classifies disablement in terms
of "disease, impairment, disability,
and handicap." Nagi's model refers to
pathology, impairment, functional
limitation, and disability (Fig. 1).
In Nagi's model, pathology or diseuse
refers to the underlying pathologic
state that interferes with normal bodily
functions or structure.18In stroke, the
pathology may be due to thrombosis,
emboli, or hemorrhage in a particular
cerebrovascular distribution.
Other conditions in addition to physical disability undermine the quality of
life for persons following stroke.
These conditions include depression,
dependency on others, and the inability to return to work.14 Many patients
with stroke also have other major
comorbid disease, which contributes
to their disability. Based on the results
of the Framingham disability study of
stroke survivors,Jette et all5 concluded that a history of stroke explained only 12% of the variance in
physical disability among men living
in the community and only 3% of the
variance among women.
Impairments are the physiological or
psychological consequences, or the
signs and symptoms, of the pathology
of the disease. Some common impairments after stroke are impaired motor
function, sensory deficits, abnormal
tone, perceptual deficits, cognitive
limitations, aphasia, and depression.
Although some impairments are the
direct effects of stroke, others may be
indirect. For example, shoulder pain
may not be a direct effect of a stroke
but may instead result from the composite effects of loss of shoulder motor function, loss of range of motion,
and altered biomechanics of the
shoulder complex.
The overall prevalence of severe
disability among stroke survivors may
be overestimated by clinicians whose
contact with patients with stroke has
Functional limitations reflect the
functional consequences of the pathology or the abilities lost. Examples
of physical functional limitations fol-
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Number
Physical Therapy /Volume 74,
extremities. Neurological and functional recovery are often parallel,22-25
but distinctions should be made be.
tween neurological recovery and
functional recovery.
Pathology
Functional
+ Impairment 4 Limitation
+
Disability
Flgure 1. The Nagi model of the disablij29 process.
lowing stroke are restriction in activities such as transfers and walking.
Disability represents the social and
societal consequences of functional
limitations. It is defined by a patient's
inability to perform ADL and maintain
social and family relationships, to
continue in a vocation, or to pursue
leisure activities.
Assessment of the disablement of
stroke should capture not only the
patient's ability to perform basic or
instrurnental ADL, but also the patient's perceptions of his or her emotional, social, and physical functions
and the ease with which these activities are performed. This more complex and multidimensional concept of
well-being and perception of health is
called quality of life. Quality-of-life
assessments try to capture how limitations in function affect emotional,
social, and physical roles as well as
perceptions of health. Interest in
these assessments is growing rapidly.
Many measures have been developed,l9,20and one measure has been
used specifically with patients with
stroke.21
The pathways from pathology to disability are not necessarily unidirectional. For example, limitations in
functional activities can produce impairments such as increased weakness, restricted range of motion, and
deconditioning of the cardiovascular
system. Moreover, the disablement
process may be modified by many
32 / 401
other factors (eg, social support, physical environment, motivation, depression). Figure 2 is a graphical representation of a modified version of the
Nagi model. It illustrates the complexity of the physical disablement of
patients following a stroke and the
relationships among impairment,
functional limitation, disability, and
quality of life. This model of physical
disablement also makes a distinction
between functional performance that
is observed and functional performance that is self-reported. Under the
ideal circumstances often created in
rehabilitation settings, the patient may
be able to perform a task, but this
achievement does not reflect his or
her abilities in more variable environments or represent his or her usual
performance.
Recovery Patterns
Most patients experience some degree of recovery following a stroke. It
is difficult, however, to completely
distinguish between recovery from
impairments and recovery from disability. The recovery of motor function, sensation, and language are
representative of neurological recovery. Recovery of functional skills may
be attributable to neurological recovery or behavioral compensation, or
both. For example, in behavioral
compensation, the unaffected extremities may compensate for the reduced
function of the affected extremities or
the patient may learn to maximize
residual motor control in the affected
Although it is often thought that the
upper extremity does not recover as
well as the lower extremity following
stroke, the actual degree of neurological recovery of the upper and lower
extremities may be slmilar (Duncan
PW, unpublished observations from
the Durham County Stroke Study).
The lower extremity, however, can
function with less motor control than
the upper extremity. Thus, partial
motor recovery in the lower extremity may permit many patients with
stroke to ambulate independently,
although the pattern will not be "normal" in pattern or velocity. Partial
recovery of upper-extremity function
does not usually translate into functional use.
In general, neurological recovery
occurs within the first 1 to 3 months
following stroke. Further motor or
sensory recovery may continue to
occur 6 months to 1year later; however, these changes are generally
limited to individuals with some degree of volitional motor conand may not reach statistit1-oll0.22~~~~7
cal or clinical ~ignificance.4,5,~7
A
prospective study of recovery patterns
in 104 patients with anterior circulation ischemic stroke demonstrated
that 86% of the variance in 6-month
motor recovery can be predicted in 1
month. The more severely impaired
patients continued to experience
some measurable recovery of function
from 3 to 6 months poststroke, but
this recovery was not correlated with
clinically meaningful ADL scores (>60
on the Barthel Index).*5 In the
Framingham cohort, recovery of motor function and ADL occurred within
3 months of stroke, then subsequently
plateaued. Language and cognitive
function improved over longer periods of time."
The courses of recovery previously
described d o not reflect the natural
history of recovery because patients
who received rehabilitation were not
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Therapy/Volume
74, Number 5Nay 1994
,
Psychosocial
Environmental
Factors
Pathology
Factors
-Ischemic
-Hemorrhage
-Severity of
stroke
-Corn orbidities
-Soclel support
-Physical
envlronmant
age, history of prior stroke, incontinence, and visual-spatial deficits as
prognosticators of poor recovery.
Other studies have identified the
inability to sit unsupported30 and an
accumulation of motor, sensory, and
visual deficits31 as factors that contribute to more protracted recovery of
functional activities as well as poorer
functional outcomes. Depression and
lack of social support have also been
associated with longer and less extensive recovery of function following
stroke.32-3*
Staglng Patients
-Sensory
-Balance
-Percep tual
-Range o f motlon
-Tone
-Pain
-Cerdlovesculer
condltloning
\[
Functional Performance
Observed
(
Sdf-reported
(Quality of Life)
I/
I
Figure 2. Model of physical disablement in stroke.
excluded from the population studied. The profiles of recovery that are
reported represent measures of central tendency. Individual recovery
patterns may be more variable, and
some individuals may show more
protracted periods of recovery. In
spite of some variations in individuals,
the terriporal pattern of recovery has
now been well documented in several
independent cohorts. These studies
support the tenet that most neurological recovery occurs early. In addition,
the time course of recovery is similar
for different levels of stroke severity
(Duncan PW, unpublished observa-
tions from the Durham County Stroke
Study).
The prognosis for neurological and
functional recovery following stroke is
influenced by a number of factors. In
a review of the literature, Dombovy et
a128 identified the following factors as
predictors of poor functional outcc;me
after stroke: coma at onset, incontinence 2 weeks after stroke, poor
cognitive function, severe hemiparesis, no motor return within 1 month,
previous stroke, perceptual-spatial
disorders, and significant cardiovascular disease. In a similar review of 33
articles, Jongbloed2Vdentified older
Understanding the patterns of recovery
and the predictors of outcome are
critical for establishing realistic g d s
and planning appropriate intervention
strategies for each patient. Combined
with the results of clinical assessments,
this understanding can lead to more
accurate and realistic patient staging.
Staging of patients is useful as a means
cf dealing realistically with the patient's and his or her family's expectations of recovery and outcome. Staging
is also useful as a way of selecting the
most appropriate level of therapeutic
intervention. For example, staging
could be used to target limited resources for stroke rehabilitation so that
intensive rehabilitation would be provided only for those for whom it is
most appropriate.
Staging of patients following stroke by
degree of motor impairment was
introduced by Signe Brunnstrom over
23 years agd5 and has more recently
been expanded by G0wland.3~Staging
of patients following stroke by expected outcomes has not been a general practice, but it is currently being
attempted in some clinics. Table 1
outlines a classification system I use
in clinical management of patients
after stroke to stage them by expected
outcomes.
The results of standardized assessments of cognitive function, sensation,
motor control, perception, mobility
status, balance, continence, depression, and comorbid diseases guide my
classification of the expected outcomes. Patients classified as being at
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Table 1. Stages of Expected outcomes
&
Expected Outcome
Stage 1
lmpairment level
No major neurological recovery
Disability level
Patient will be dependent to semidependent in most
activities
Burden of care
Caregiver will provide majority of assistance
Stage 2
lmpairment level
Minimal neurological recovery
Disability level
Patient will function semiindependently in most
activities (eg, ambulate with assistance)
Burden of care
Caregiver will provide partial assistance
Stage 3
lmpairment level
Moderate neurological recovery, but patient has
residual impairments
Disability level
Patient will function independently in most activities, but
activities may be performed with assistive device or
at slower speed than before stroke; patient may need
assistance for complex tasks
Burden of care
Caregiver will need to provide minimal or no assistance
Stage 4
lmpairment level
Good to complete neurological recovery
Disability level
Patient will function entirely independently with little, if
any, deficit noted
Burden of care
None
stage 1 of expected outcomes exhibit
two or more of the following factors:
moderate to severe cognitive deficits,
hemiplegia (Brunnstrom stage 1 or
2), severe sensory deficits, severe
perceptual-motor deficits, impaired
sitting balance, incontinence of bowel
and bladder, major comorbidities, and
a Barthel ADL index of <60. At stage
2, patients may have moderate cognitive deficits, hemiplegia (Brunnstrom
stage 2 o r 3), mild sensory deficits,
impaired standing balance, major
comorbidities, bladder incontinence,
and a Barthel ADL index of at least 60.
At stage 3, patients exhibit mild o r no
cognitive deficits, hemiplegia
(Brunnstrom stage 4 or 5), mild or no
sensory deficits, good standing balance, and a limited number of comorbidities; they are continent of bowel
and bladder and score >6O on the
Barthel Index. Patients at stage 4 will
have good cognition, slight hemiparesis (Brunnstrom stage 5 o r 6), no
sensory deficits, good balance, and a
limited number of comorbidities and
34 / 403
ing impairments but rather on compensatory training in functional tasks
and ADL. The Drogram for ~atientsat
stage 1 would emphasize family o r
caregiver instruction and assistance
with basic ADL. The patient's stage of
expected outcomes would be considered in conjunction with other influencing factors (time since stroke,
social support, medical status, and
patient preferences) to help guide
selection of the most appropriate site
for postacute care. The proposed
method of staging and the accuracy of
prediction are yet to be validated.
Previous work by Korner-Bitensky et
a137 suggests that physical therapists
demonstrate a reasonable degree of
accuracy in predicting rehabilitation
discharge outcomes in patients who
have had a stroke. When therapists
predicted dependency, they were
almost always correct (predictive
value of dependence=91.3%-100%).
The predictive value of independence
was not as great, but was good
(70.5%-79.7%).
will be continent of bowel and
bladder.
A study is in progress at Harmarville
Rehabilitation Center, Pittsburgh, Pa,
to test the validity and reliability of
this outcome staging scheme. Physicians, occupational therapists, and
physical therapists are participating in
this study. They are also investigating
the optimal timing of assessments;
that is, they are trying to ascertain
how soon after an event the outcomes
can be accurately predicted.
Staging, if demonstrated to be reliable
and valid in the clinical setting, could
guide treatment goals and family
education of patients following a
stroke. For example, for patients in
stages 3 and 4, the therapeutic intervention program would be planned to
remediate neurological impairments
and to improve physical conditioning,
as well as to promote independence
in ADL. The program for patients in
stage 2 would not focus on remediat-
-
Recently, Kalra and Creme'" demonstrated that the Orpington Prognostic
Score (Tab. 2) measured at 2 weeks
poststroke was very useful in predicting outcomes in patients over 75
years of age. The correlation (r2)
between the Orpington score and
functional outcome was 89. Patients
with an Orpington score of C3.2
were discharged within 3 weeks of
stroke, whereas those scoring >5.2
required long-term ~ a r e . 3 ~
The results of the previously mentioned studies suggest that clinicians
are able to accurately predict outcomes in most patients. Initially, there
may be some hesitation to "stage"
patients. This resistance, however, will
decrease with recognition that staging
can be accurate in predicting recovery
and response to specific rehabilitation
services. Early staging can serve as a
guiding principle but will remain
subject to modification if the patient's
potential changes.
Measurement
We will never be able to adequately
capture the process of disablement
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Physical Therapy / Volume 74, Number 5May 1994
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Table 2. Orpington Prognostic Scord8
Cllnlcal Feature
Score
Motor deficit in arm
MRCa grade 5
MRC grade 4
MRC grade 3
MRC grade 1-2
MRC grade 0
Proprioception (eyes closed)
Locates affected thumb:
Accurately
Slight difficulty
Finds thumb via arm
Unable to find thumb
Balance
Walks 3.05 m (10 ft) without help
Maintains standing position
Maintains sitting position
No sittir~gbalance
Cognition
Mental 'rest score 10
Mental 'rest score E-9
Mental 'rest score !%7
Mental 'Test score 0 - 4
+
Total score= 1.6+motor+proprioception+balance cognition
"MRC=Medical Research Council
following stroke, define the recovery
process, o r develop predictive models
of outcome unless we use wellcharacterized measures of impairment, functional performance, and
disability. The selected measures must
be valid, reliable, and sensitive to
change. We should also use measures
that do not have ceiling effects. One
measure that has been used in most
assessments of stroke-related disability
is the Barthel Index. Although this
instrument may be an adequate measure of basic ADL, it may not measure
more complex functional loss and
disablement, such as a decline in the
performance of more advanced ADL
or in the patient's self-assessment of
quality of life.
Several factors appear to contribute to
the current reluctance to utilize standardized assessments in evaluating
patients who have had a stroke.
Stroke differs widely in its clinical
manifestations, and no single assessment instrument can measure the full
range of potential impairments, functional limitations, and disability. Adequate evaluation must rely on a battery of instruments. These measures
are available, but only a few have
demonstrated clinimetric priorities of
reliability, validity, and sensitivity to
change. Probably the most important
barrier, however, has been the reluctance of clinicians to adopt standardized instruments. Recent reports that
some formal assessments may be
more reliable than clinical impressions may help to overcome this
resistance.39
Table 3 represents a battery of measures that I recommend for assessment of stroke.40-50 The list is not
comprehensive of all assessments
available, but the measures included
are practical and have been assessed
for reliability and validity in studies of
patients who have sustained a stroke.
The assessments span the domains of
impairments, functional limitations,
and disability. Most of these measures
can be performed in the acute o r
postacute care setting o r following
discharge. Quality-of-life assessment,
however, is most relevant in the person's home setting and should preferably be done there. Quality-of-life
measures have the specific advantage
of capturing more complex functions,
which may be compromised poststroke even in the presence of good
recovery of basic ADL.
The cognitive and sensorimotor measures of impairment listed in Table 3
may need to be supplemented by
assessments of depression, language
deficits, and perceptual deficits because these factors can also affect the
level of disability. These assessments
can be performed by our colleagues
in psychology, speech and language
pathology, and occupational therapy.
For more comprehensive reviews of
the measures available for characterizing impairments, functional limitations, and disability following stroke,
the reader is referred to Wade.40
Modlfylng the Dlsablement
Process
The goals of physical therapy in
stroke rehabilitation should be to
maximize function and minimize
impairments within the constraints of
the patient's pathology, comorbidities,
and available resources. The ultimate
goal is to reduce the physical contributions to disability.
A primary step in reducing disability
is to examine the relationships between impairment and disability.
Exact measurements of both are obviously preliminary to this process. A
physical therapy evaluation should
involve more than just compiling a
list of patient impairments o r functional deficits. The challenge to the
physical therapist is to evaluate findings and to analyze critically the interrelationships among impairments,
functional limitations, and disability.
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Table 3. Recommended Battery of Measures of Stroke Disablement
Characterlstlcs of Measure
Thal Have Been Assessed
Tlme to Administer
Screens for memory, attention, language,
orientation, calculation
Validity
c10 rnin
Measures range of motion, pain, sensation, motor
function, balance
Validity
Impairment measuresa
Folstein Mini-Mental examination4'
Reliability
Sensitivity to change
Fugl-Meyer Sensorimotor AssessmenP2
3 0 4 0 min
Reliability
Sensitivity to change
Functional measures
Berg Balance Scale43.44
Measures 14 items of static and dynamic balance
c10 rnin
Validity
Reliability
Sensitivity to change
Record time to walk 10 m
c l min
Validity
Reliability
Sensitivity to change
Patient walks as far as he or she can at usual
self-paced rate
Measure distance walked in 6 min
Validity
6 rnin
Reliability
Sensitivity to change
Disability measuresb
Basic activities of daily living
Barthel Index46
Functional Independence Measure7
Ordinal score of 10 items: feeding, bathing,
grooming, dressing, bladder and bowel control,
chairlbed transfer, ambulation, and stair
climbing
Validity
Ordinal scale with seven levels including self-care,
sphincter control, mobility, locomotion,
communication, and social cognition
Validity
c20 rnin
Reliability
Sensitivity to change
c40 min
Reliability
Sensitivity to change
Instrumental activities of daily living
Frenchay Activities Index48
Ordinal score of 15 items: preparing meals,
washing up, washing clothes, light housework,
heavy housework, local shopping, social
outings, walking outside, pursuit of hobby,
drivinglpublic transportation, outings, gardening,
home maintenance, reading, gainful work
Validity
Reliability
c10 min
136 items with summated scores or 12 subscales
including ambulation, mobility, body care,
emotional, social, communication, alertness,
sleep, eating, home management, recreation,
employment
Validity
2&30 min
36 items including physical functioning, role
limitations due to physical or emotional
problems, social functioning, bodily pain, mental
health, vitality, general health perception
Validity
Reliability
Quality of life
Sickness Impact Profile49
Medical Outcomes Study 36-Item Short
Form=
Reliability
Sensitivity to change
10 min
Sensitivity to change
"Other impairments such as perceptual and language dysfunction and depression should b e screened and measured by other team members (psychologists, speech pathologists, occupational therapists).
h~nstrumental-activities-of-daily-living
and quality-of-life measures are performed following hospital discharge in long-term follow-up.
In addition, the variables that moderate these relationships need to be
carefully considered.
The movement deficits following
stroke are extremely complex and
reflect the complexity of normal motor control. One of the tasks for the
physical therapist is to observe the
patient's functional limitations and to
carefully assess the patient to determine which impairments are contributing to the functional limitations. The
physical therapist needs to adequately
diagnose the cause of the functional
limitations and to decide whether the
impairments can be remediated. If the
impairments cannot be remediated,
then the patient should be taught to
compensate for the impairments.
A primary question in all rehabilita-
tion programs is: What constitutes a
clinically significant change in impair-
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ment? Many impairments may be
modified to some degree with aggressive programs, but are these changes
in impairments clinically meaningful?
Clinically meaningful changes in impairmen.ts are those associated with
changes in function. Therefore, the
ultimate goal in the rehabilitation
process is to modify function. Any
evaluation of the effectiveness of the
rehabilitation program should assess
functional limitations and level of
disability.
We all know patients who have similar levels of impairment and similar
functional abilities but quite different
levels of disability. The quality of life
of a pelson following a stroke is not
determined solely by his or her physical function but may be modified by
many other factors (eg, age, general
health state, psychosocial, personal
motivation, social support, and physical envi.ronment). It is beyond the
scope of physical therapy to alter o r
control all of these moderating variables; however, we must consider
them in our plans to reduce the disablement of stroke.
In order to better characterize strokerelated disability, we should use
population-based studies to assess the
extent of impairment, functional limitation, and disability in patients following a stroke. Population-based
assessments of disability do not support the typically fatalistic attitude that
most stroke survivors are profoundly
disabled and need long-term care.
Many stroke survivors experience
some degree of neurological recovery; they are ambulatoly and not
totally dependent or in need of longterm care.
Disability following stroke can be
adequately characterized only if we
use measures across all the domains
of disa.blement (impairment, functional limitations, disability, and quality of life). Impairment-level measures
are important to define the factors
that are contributing to functional
limitations and to guide treatment.
Yet, the ultimate stroke outcome mea-
sures are not at the impairment level
but rather are at the functional and
disability level. We need to select our
measures of these domains carefully.
Finally, we need to use the measures
obtained to reasonably predict outcomes, making allowance in our predictions for the patient's own perceptions and the many variables outside
the clinical sphere that may affect the
patient's recovery. Using predicted
outcomes to stage patients may result
in more effective treatment plans and
a hopefully enhanced quality of life
for the ever-increasing numbers of
stroke survivors in the population we
serve.
Acknowledgments
I thank Annette Jurgelski, MAT, for
editorial assistance and Fikri Yucel for
assistance in preparing graphics.
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Stroke Disability
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