Features and predictors of activity limitations and participation restriction 2 years after intensive rehabilitation following first-ever stroke.

BACKGROUND: Although stroke-related disability has been extensively studied, only few studies have investigated Participation restriction in chronic stroke survivors. AIMS: To identify features and predictors of Activity limitation and Participation restriction in the chronic phase of a first-ever stroke. DESIGN: Cross-sectional observational study. SETTING: Comprehensive stroke unit with outpatient rehabilitation facility. POPULATION: Subjects submitted to intensive rehabilitation after first-ever stroke, from 1st January 2009 to 31st December 2010. METHODS: Participation was investigated through the Frenchay Activity Index (FAI) and the Functional Status Questionnaire (FSQ) at 2.4 ± 0.5 years after the event. Basic activities of daily living (ADL) and mood were also assessed through the Modified Barthel Index (MBI) and the Beck Depression Inventory (BDI). A retrospective search of the medical records looked for: type/side of brain lesion, stroke clinical syndromes, comorbidities and functional condition at discharge from intensive rehabilitation (upper limb motricity index-ULMI-,Functional Ambulation Category-FAC, MBI, cognitive deficits). RESULTS: Forty-five subjects (17 female, age 70.1±11.5 years) were enrolled. They showed a striking restriction in their Participation, mainly for FAI-outdoor activities (median FAI score was< 50% of the theoretical maximum). A poor gait function (FAC) and an impaired mood (BDI) were the only independent predictors of FAI indoor (F=6.1; p=,005; R^2= 64%) and outdoor activities (F=4.1; p=.01; R^2= 48%), respectively. The univariate analysis showed a strong dependence of all FSQ scores from global disability (MBI), motor function impairment (ULMI and FAC) and cognitive deficits. Depression influenced "psychological function" score, whereas gait capacity was the only factor significantly associated with the "work performance" score. The gait function level, achieved after intensive rehabilitation, was extrapolated by the multivariate analysis, as the most powerful independent predictor of the chronic activity limitations, as measured by MBI (F=33.8, p<,0001,R2=,539). CONCLUSION: Gait dysfunction is the main factor of Activities limitation and Participation restriction in chronic stroke. Participation is restricted by global disability, depression, older age and dementia. More than 50% variance of Participation measures cannot be explained by the quoted factors. CLINICAL REHABILITATION IMPACT: The study results support the need to integrate the standard rehabilitation approach with vocational rehabilitation in order to reduce Participation restriction.