Neurological Sciences Volume 27 Issue 1 2006 [Doi 10.1007_s10072-006-0563-5] I. Aprile; D. B....

8/13/2019 Neurological Sciences Volume 27 Issue 1 2006 [Doi 10.1007_s10072-006-0563-5] I. Aprile; D. B. Piazzini; C. Bertoli

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Abstract The purposes of this study were: (1) to evaluate

the relationship between disability and Quality of Life

(QoL) in stroke outpatients undergoing rehabilitation and

(2) to determine whether and how demographic and social

features of the patient, duration of disease and concomitant

diseases influence the disability and QoL of the stroke out-

patients. We performed a prospective study using several

conventional disability measurements (Barthel Index,

Functional Independence Measure, Modified Rankin Scale

and Deambulation Index) and a validated patient-oriented

measurement of QoL (SF-36). Sixty-eight outpatients were

evaluated consecutively. As expected, all disability mea-

surements were related to Physical Function: patients with

higher disability, according to the physicians perspective,complained of higher deterioration of physical perfor-

mance. Unexpectedly, patients with higher disability from

the physicians point of view perceive that they were not

able to do some daily activities not only because of physi-

cal problems but also because of emotional problems, and

complained of higher deterioration of mental health.

Multivariate analysis showed that higher disability is asso-

ciated with higher age, depression and lower educational

level. Physical Composite Score appeared to be deteriorat-

ed in patients with lower educational level who lived with

family; on the contrary, Mental Composite Score appeared

deteriorated in patients with higher educational level who

lived alone. The current study provides interesting data

about the relationship, not always expected, between dis-

ability and QoL for stroke patients and about the influence

of patients characteristics on disability and QoL. Our

results showed that in a rehabilitation programme we should

consider not only disability assessment but also QoL, whichis more relevant for the patient.

Key words Outcome assessment Quality of Life

Rehabilitation Disability Stroke

Introduction

Disability is the most evident and measurable effect of stroke.

Many studies have assessed disability after stroke [1, 2].

From the patients point of view, deterioration of health-related quality of life (QoL) is the most relevant effect of

stroke. Usually physicians hypothesise the existence of a

strict relationship between patients QoL and their disabili-

ty: the higher the disability, the more impaired the QoL.

Nevertheless, some studies on spina bifida and multiple

sclerosis have shown that there is not an easy and linear

inverse correlation between disability and QoL [35].

Few published studies have assessed the relationship

between conventional disability measurements and QoL

measurements in stroke survivor patients [6, 7]. The aims

of the study were: (1) to evaluate the relationship between

disability and health-related QoL and (2) to determine

Neurol Sci (2006) 27:4046

DOI 10.1007/s10072-006-0563-5

I. Aprile D.B. Piazzini C. Bertolini P. Caliandro C. Pazzaglia P. Tonali L. Padua

Predictive variables on disability and quality of life in stroke outpatients

undergoing rehabilitation

O R I G I N A L

Received: 28 July 2005 / Accepted in revised form: 16 January 2006

I. Aprile ()Department of Physical Therapy and Rehabilitation

L.go F. Vito 1, I-00168 Rome, Italy

e-mail: [email protected]

I. Aprile L. Padua

Fondazione Don C. Gnocchi

Centro Santa Maria della Pace

Rome, Italy

I. Aprile P. Caliandro C. Pazzaglia P. Tonali L. Padua

Department of Neuroscience

Universit Cattolica

Rome, Italy

I. Aprile D.B. Piazzini C. Bertolini

Department of Physical Therapy and Rehabilitation

Universit Cattolica

Rome, Italy


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I. Aprile et al.: Disability and QoL in stroke patients 41

whether and how demographic and social features of the

patient, duration of disease and concomitant diseases influ-

ence the disability and QoL of stroke outpatients.

We performed this study using several conventional

disability measurements as well as a validated patient-ori-

ented measurement of QoL. During the period fromJanuary 2002 to December 2003, 68 consecutive outpa-

tients were evaluated.

Materials and methods

This was a prospective study on consecutive stroke survivors,

outpatients admitted to the Don Gnocchi Centre for rehabilitation

from January 2002 to December 2003.

As self-administered questionnaires require normal cognitive

function, we performed a screening of the patients through the

Mini Mental State Examination (MMSE) [8] in order to excludethose patients who were unable to fill in the questionnaire appro-

priately. An MMSE score of 24 was the only exclusion criterionfor enrolment in the study.

All patients were thoroughly informed about the study, and

gave their permission.

Personal data and patients history

Before examination, we acquired personal data for each patient:

name of patient (immediately replaced with an identification

code), age, sex, educational level, job, if the patient lived alone or

with family, duration of disease and concomitant diseases (dia-betes, cardiovascular disease).

Moreover in each patient the depression picture was evaluat-

ed using the Beck Depression Scale [9].

Health-related quality of life evaluation

To assess QoL in our patients we used the Medical Outcome

Study 36-item Short Form (SF-36), the most widely used gener-

ic health tool [10]. The Official SF-36 Italian version [11] was

administered to the patients in agreement with standardised

methodologies [12].

SF-36 consists of 36 questions that inquire about the general

health status of patients. This questionnaire provides eight spe-

cific categories of physical and emotional scores (Physical

Function PF, Role Physical RP, Bodily Pain BP, General

Health GH, Vitality VT, Social Functioning SF, Role

Emotional RE, Mental Health MH), which are summed up in

two main scores: Physical Composite Score (PCS) and Mental

Composite Score (MCS). A very low PCS indicates severe phys-

ical dysfunction, distressful bodily pain, frequent tiredness and

unfavourable evaluation of health status. Very low MCS indicates

frequent psychological distress, and severe social and role dis-

ability due to emotional problems [10].

Disability evaluation

To assess disability we used the Barthel Index (BI), Functional

Independence Measure (FIM), Modified Rankin Scale (MRS)

and Deambulation Index (DI).

The BI was developed to assess the change in functional sta-

tus in individuals with neurologic or musculoskeletal disorderswho undergo rehabilitation. The BI measures what an individual

can do, providing a measure of ability. The BI assesses 10

activities of daily life, 8 of which can be described as self-care

activities (feeding, transfer from chair to bed and back, groom-

ing, toileting, bathing, dressing, bowel continence and bladder

continence), and 2 as mobility-related activities (walking or pro-

pelling a wheelchair on a level surface 50 yards with or without

devices or prostheses, ascending and descending stairs). We

used the BI classical form; it is scored on a 3- or 4-point scale,

from totally dependent in a given activity to totally independent.

An intermediate score is assigned when some help is needed to

perform the activity. Items are given arbitrary weightings and

item scores are totalled to give a range of scores from 0 (total

dependence) to 100 (total independence) [13]. The BI is among

the most widely used measurements of functional status, pro-

viding great validity, reliability and sensitivity. Because it was

the first measurement developed to assess the rehabilitation

process, it has been a benchmark with which to judge other mea-

surements.

The FIM is the most widely accepted functional assessment

measurement in the rehabilitation community. It is a functional

assessment scale that evaluates the patients abilities in self-care,

sphincter control, mobility, locomotion, communication and

social cognition [14]. FIM consists of 18 scales scored from 1 to

7; higher numbers mean greater ability. We used the total score

(sum of all the scales) [15].

The MRS is primarily used in patients with stroke [16]; itdescribes the severity level of stroke according to the degree of

resulting disability (observed after symptoms stabilised in the

weeks following stroke occurrence). The five Rankin categories

are: (1) no significant disability: able to carry out all usual

activities of daily living; (2) slight disability: unable to carry

out some previous activities but able to look after own affairs

without assistance; (3) moderate disability: requiring some help

but able to walk without assistance; (4) moderately severe dis-

ability: unable to walk or attend to own bodily needs without

assistance; (5) severe disability: bedridden, incontinent and

requiring constant nursing care and attention.

The DI is an adapted form (8-point scale) of the physical

therapy portion of the Patient Evaluation Conference System.

The 8-point scale is: 0, not assessed; 1, needs maximal assis-

tance from 2 people or an assistive device + 1 person; 2,

requires minimal assistance from another person with or with-

out an assistive device; 3, requires supervision and an assistive

device; 4, requires supervision for safety, no assistive device

needed; 5, independent but cannot walk at a reasonable rate

and/or has poor endurance (i.e., 10 m or less with or without an

assistive device), difficulty ambulating outdoors; 6, independent

with assistive device, no supervision required, person can

ambulate indoors and outdoors under different conditions (i.e.,

ramp, carpet, curb, uneven surface, any season); 7, within nor-

mal limits, functionally independent [17].


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42 I. Aprile et al.: Disability and QoL in stroke patients

Statistical analysis

Statistical analysis was performed using the STAT-SOFT (OK,

USA) package. Because ordinal measurement (such as SF-36)

was used, non-parametric analysis of the correlation was assessed

by Spearmans rank correlation coefficient.

Multivariate analysis was used in order to find which variables have

a significant influence on the following dependent variables: DI,

FIM, BI, Rankin Scale, SF36 scores (PF, RP, BP, GH, VT, SF,

RE, MH, PCS, MCS). Age, sex, educational level, duration of

disease, if the patient lived alone or with family, concomitant dis-

eases (diabetes or cardiovascular disease) and Beck score were

considered independent variables. In this analysis, age of the

patient, Beck score and duration of the disease were considered

as continuous independent variables. Statistical significance was

set atp


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Influence of patient features on QoL and disability

Statistical multiple regression analysis was performed to

identify the variables that cause deterioration of QoL and

disability. All variables were associated with at least one

outcome measure in a statistically significant manner.

With regard to the disability (Table 2), age, sex, educa-tional level and the Beck score were associated with almost

all disability measures (older patients with lower education-

al level and higher depression are associated with higher dis-

ability, the women are associated with higher disability than

men). Moreover, diabetes was associated with higher dis-

ability (measured using BI and Rankin Scale) while a longer

duration disease was associated with lower disability (mea-

sured using DI). As expected, the patients living alone wereassociated with a lower disability (measured using FIM).

Fig. 1 Correlationship between

Barthel Index and Physical

Functioning

Table 2 Relationships between disability measurements and analysed factors (statistical results of multiple linear regression)

Disability measurements Predictive factors p(dependent variable) (independent variable)

Deambulation Index Age 0.68


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With regard to the QoL (Table 3), the main measure of

physical aspect of QoL (PCS) appeared to be deterioratedin patients with lower educational level living with family;

moreover men usually had better physical QoL.

On the contrary, the main measure of the mental aspect

of QoL (MCS) appeared to be deteriorated in patients with

higher educational level living alone.

With regard to the QoL domains, women presented a

higher deterioration of physical function, role physical,

vitality and mental health but referred less bodily pain than

men. The patients living with family showed a higher social

function and mental health but lower physical function and

pain tolerance. As expected, patients with higher depres-

sion referred lower physical function and mental health but

higher pain tolerance. Diabetes was associated with higher

QoL in almost all mental domains but with lower QoL inphysical function. Finally, patients with cardiovascular dis-

ease presented lower vitality.

Discussion

We performed a prospective study on stroke survivor out-

patients in which several disability measurements were

related to the commonly used generic health tool, SF-36.

It is very interesting to note that all general disability

measurements used were closely related to some domains of

Table 3 Relationships between QoL measurements and analysed factors (statistical results of multiple linear regression)

QoL measurements Predictive factors p(dependent variable) (independent variable)

Physical Composite Score Sex (ref. men) 0.38 0.002

Educational level 0.40 0.001

Living alone 0.60


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QoL. As expected, the disability measurements were related

to PF; in fact, this specific SF-36 domain is mainly a dis-

ability measurement as perceived by the patient: patients

with higher disability according to the physicians perspec-

tive (FIM, BI, Modified Rankin Scale and DI) complained of

higher deterioration of physical performance (PF).Unexpectedly, another QoL domain, Role Emotional,

which measures difficulty in daily activity due to emotion-

al problems, was always related to general disability scores.

This particular relationship may mean that patients with

higher disability from the physicians point of view per-

ceive themselves as unable to carry out various daily activ-

ities not only because of physical problems but also

because of emotional problems.

Moreover, another mental domain, Mental Health,

was always related to general disability measurements,

although less significantly than for PF and RE: patients

with higher disability according to the physicians perspec-

tive complained of higher deterioration of mental health.

The constancy of these correlations underlines the

important role of the Physical Function, Role Emotional

and Mental Health SF-36 domains in assessing QoL in

patients after stroke. With regard to Physical Function, a

low score on this item indicates limitations in performing

all physical activities, including bathing and dressing; a low

Role Emotional subscore indicates problems with work or

other daily activities as a result of emotional problems; and

a low Mental Health subscore indicates continuous feelings

of nervousness and depression.

Although the results of the different disability measure-

ments appeared to be uniformly related to QoL domains, itmust be noted that FIM was the only measurement related

to a thorough QoL measurement; in fact, FIM was the only

general disability measurement related to the main QoL

scores, i.e., PCS and MCS.

DI was closely related, like the general disability mea-

surements used, to PF and RE; however, it was not related

to MH. This last result may suggest that deambulation is not

so important for the mental aspect of the QoL. The relation-

ship observed between deambulation and QoL is interesting,

but the current results must be assessed more extensively in

focused studies. It must be noted that we observed a similar

finding in spina bifida patients where walking ability wasnot strictly related to the mental aspect of QoL [5].

As expected, all disability measurements gave very sim-

ilar results, which again prove their high reliability.

With regard to the role of patient features on disability,

the study showed that older patients with lower education-

al level, higher depression and living with family presented

higher disability.

With regard to the influence of variables on QoL, phys-

ical aspects appeared to be deteriorated in patients with

lower educational level living with family while the mental

aspects appeared to be deteriorated in patients with higher

educational level living alone. One hypothesis is that the


patients living alone adapt and better exploit their remain-

ing physical ability out of necessity, but they have a deteri-

oration of social function and perceive themselves to have

low mental health. More likely, the other hypothesis, is that

patients with lower disability are able to live alone although

they do not have possibilities for social activity.An association between depression and QoL has been

reported [1820]. Our data confirm this observations and

show that depression is a negative predictive factor on dis-

ability and QoL many years after stroke.

Women presented a higher disability and deterioration

of physical function, role physical, vitality and mental

health but lower bodily pain than men.

Diabetes was associated with higher disability but the

QoL evaluation showed that the diabetic patients even if

they have a lower QoL in the physical aspects, presented

higher QoL in almost all mental domains. Finally, patients

with a long duration of disease are better at walking and

tolerating bodily pain. The explanation of this result could

be that patients with a long duration of disease are the ones

who had a better evolution of disease.

In conclusion, the current study provides interesting data

about the relationship, not always expected, between disabil-

ity and QoL in stroke patients. In particular, some domains

of the most used QoL measurement, SF-36, which assesses

physical and mental limitation in daily activities, were close-

ly related to all of the disability measurements used.

Moreover, the current study provides useful information

about the significance of disability measurements as the

primary outcome in stroke trials and the influence of

patient features on disability and QoL. Considering thenegative and stronger influence of depression on disability

and QoL, our data suggest the need for follow-up pro-

grammes to include assessment and interventions to treat

depression.

Further multidimensional studies including a complete

screening for depression should be performed in order to

assess the role of deambulation in the QoL, the usefulness

of depression assessment and treatment on disability and

QoL. Results from these studies may be relevant for the

rehabilitation approach and, particularly, for targeting the

main goals of rehabilitation, which should take into

account not only disability assessment, but also QoL,which is more relevant for the patient.

Sommario Questo studio si propone di valutare la correlazio-ne tra disabilit e qualit della vita (QoL) e linfluenza dellecaratteristiche del paziente sulla disabilit e sulla QoL inpazienti affetti da stroke afferenti al Centro di Riabilitazionedella Fondazione Don Gnocchi. Si tratta di uno studio pro-spettico in cui abbiamo utilizzato misure validate di disabilit(Barthel Index, Functional Independence Measure, ModifiedRankin Scale and Deambulation Index) e di QoL (SF-36).


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Sessantotto pazienti ambulatoriali sono stati valutati consecu-tivamente. Come ci aspettavamo, tutte le misura di disabilitsono risultate correlate alla funzione fisica (physical function PF): in altre parole i pazienti con grave disabilit presenta-no, anche per quanto riguarda la prospettiva del paziente, una

maggiore compromissione degli aspetti fisici della loro qualitdella vita. I nostri dati mostrano anche che i pazienti congrave disabilit lamentano anche una incapacit nellesegui-re le attivit di tutti i giorni a causa non solo di problemi fisi-ci ma anche emotivi ed emozionali e lamentano un deteriora-mento della loro salute mentale. Inoltre lanalisi multivariataha mostrato che pazienti pi anziani, con pi bassa scolarit,con maggiore depressione e che vivono con i familiari presen-tano una maggiore disabilit. interessante notare riguardoalla valutazione della Qol che pazienti con pi elevata scola-rit e che vivono da soli mostrano un minore coinvolgimentodegli aspetti fisici della QoL ma una maggiore compromissio-

ne degli aspetti emotivi della QoL. Questo studio mostra inte-ressanti risultati circa la relazione tra disabilit e qualit dellavita e linfluenza delle caratteristiche del paziente sulla disa-bilit e sulla QoL nei pazienti affetti da stroke, risultati chedovrebbero essere considerati nel programma riabilitativo incui attenzione deve essere posta al riduzione del grado di disa-bilit ma anche, a ci che ancora pi importante per ilpaziente, al miglioramento della qualit della vita.

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