Effect of a weekly functional independence measure scale on the recovery of patient with acute stroke

Abstract

Excessive assistance may decrease stroke patients’ physical activity and make them more dependent on assistance. We have structured a system that provides an ADL (activities of daily living) educational program that focuses on stroke patients’ toileting in our daily clinical practice. Here, we investigated the effect of a functional independence measure (FIM) scale on the recovery of patients with acute stroke.

We retrospectively collected the data of 407 stroke patients from the medical record system of our emergency hospital in Tsukuba, Japan. The enrolled stroke patients (n = 373) were divided into FIM and control groups. Both groups received the standard treatment, but for the FIM group, ward and rehabilitation staff calculated the toilet FIM score for patients 1 ×/wk. The FIM scale measures the amount of assistance a patient needs to perform activities of daily living and is often used in rehabilitation settings. The rehabilitation staff then instructed the ward staff about better assistance methods based on each patient’s physical function and executive dysfunction. We evaluated the usefulness of the FIM scale was based on the patients’ FIM scores at discharge and improvements in their scores.

The recoveries of the total, motor, and cognitive FIM scores recovery at discharge were significantly greater in the FIM group compared with the control group (68.0 vs 45.0, P = .004; 41.0 vs 24.0, P = .005; and 24.0 vs 20.0, P = .007, respectively). The use of the FIM scale contributes to the patients’ recovery of physical function and cognitive function.

The FIM scale can contribute to stroke patients’ recovery of activities of daily living.

1. Introduction

In older populations, stroke is a major cause of diminished ability to perform activities of daily living (ADLs) in the older population.^[1] Stroke patients’ ability to perform ADLs can be reduced due to brain damage due to reduced activity; the latter is thought to be partly due to the patients’ dependence on and excessive assistance from health care providers.^[2] Most individuals who have experienced an acute stroke have a low level of physical activity during hospitalization,^[3] and an association between low physical activity and poor functional outcomes has been reported.^[4] Even if a patient can perform some ADLs alone or with minimal assistance during rehabilitation, stroke patients are often assisted in all ADLs on the ward. Excessive assistance may decrease stroke patients’ physical activity and make them more dependent on assistance. We speculated that addressing the difference between ADLs in rehabilitation and the ward may prevent a decline in ADLs decline and promote the recovery of stroke patients.

Among the most important outcomes for stroke patients, ADLs related to toileting independence are important because being unable to use the toilet influences an individual’s quality of life^[5] and risk of depression.^[6,7] Toileting poses a high risk of falls,^[8,9] as 39% of falls occur during toileting.^[8] There are several aspects of toileting assistance, including a patient’s transfer to and from the toilet and putting on and removing pants. This need for assistance may impose a large burden of care and can result in excessive assistance and bed rest, which may delay a stroke patient’s recovery. To prevent excessive assistance and unnecessary bed rest, close cooperation is required between the rehabilitation staff and ward staff in a hospital. The rehabilitation staff should communicate to the ward staff about a stroke patient’s actual toileting function and the best way in which they can assist the patient.

The ADLs, physical functions, and higher brain functions of acute stroke patients change significantly; and health care providers can find it challenging to match assistance methods to each patient’s situation. Team education and training programs designed to meet this challenge have been reported, and the programs resulted in improvements in patients’ functional independence measure (FIM) scores^[10] and modified Rankin scale score.^[11] However, these improvements were achieved through the healthcare staffs’ participation in intensive educational programs and workshops, and staff members may find it difficult to allot some time in participating in educational programs during daily clinical work. We speculated that an educational program that would be were accessible to staff members as part of their clinical work would be helpful.

We thus devised a system in which an ADL educational program focusing on stroke patients’ toileting is implemented in our daily clinical practice. We hypothesized that this program could eliminate the difference in the perception of ADLs between the rehabilitation staff’s and ward staff’s, and if excessive assistance to patients was reduced, their recovery of ADLs would be improved. We conducted the present study to evaluate the effect of an FIM scale on the ADLs of stroke patients as part of the ADL educational program.

2. Methods

2.1. Study design and participants

In this descriptive, retrospective, observational study, the participants were patients who were hospitalized at Tsukuba Medical Center Hospital (Tsukuba, Japan), an emergency hospital, between September 2017 and April 2019. We included patients who were diagnosed with stroke, undergoing rehabilitation therapy, admitted to the general ward, and whose FIM was scored at admission and at discharge. Patients who died during hospitalization and whose main clinical condition was not stroke were excluded.

To determine the effect of implementing the FIM scale, we divided the stroke patients into 2 groups: the patients for whom the FIM scale was used (the FIM group) and the patients for whom the FIM scale was not used (the control group). The FIM and control groups received the standard medical treatment, care, and rehabilitation. Only the FIM group was involved in the weekly FIM scale program, in addition to receiving the standard medical treatment.

The study was approved by the ethics committee of Tsukuba Medical Center Hospital, Tsukuba, Japan (approval no. 2019-021) and was conducted in accord with the principles of the Declaration of Helsinki. Informed consent was obtained as a comprehensive agreement from all patients or from key people before the patients’ enrollment in the study. The data were analyzed anonymously. Patients were thus able to opt out by accessing our hospital’s homepage.

2.2. Measures

The profile and clinical data of the patients were collected from the hospital’s electronic medical record (EMR) system. The patients’ age, sex, body mass index, and self-care dependence before admission were recorded. The clinical data included the stroke type, medical history, and length of stay. Stroke severity was assessed based on paralysis of motor function, paraesthesia, and executive dysfunctions; there were assessed in all patients on admission and at discharge.

The severity of paralysis of motor function and sensory dysfunction was categorized into 3 levels: “severe,” “partial,” and “none.” Motor function was categorized by referencing the Brunnstrom recovery stage^[12]: stages 1-2 as “severe,” stages 3-5 as “partial,” and stage ≥6 as “none.” Executive dysfunction was recorded in terms of 4 items: aphasia, agnosia, attention disorder, and memory disorder. At the initial rehabilitation intervention and at discharge, the primary rehabilitation staff assessed the ADL data of the patients in the hospital by using the FIM score (ver. 3).^[13,14] The FIM score is an evaluation scale that is designed to measure the amount of assistance a patient needs in ADLs, and it is often used in rehabilitation settings.

Most of the patients received occupational therapy, physical therapy, and speech therapy at their physician’s request. The patients received daily rehabilitation 5 ×/wk in 20- to 40-minutes sessions. Rehabilitation was administered at the patient’s physician’s request based on the patient’s clinical condition; however, no established rehabilitation protocol existed. The content of the daily program was thus decided by each rehabilitation staff member. The rehabilitation program was comprised of mobilization, strength training, ADL training, aerobic exercise, range of motion exercise, swallowing training, and speech training.

2.3. Instructions to the ward staff on toileting assistance and FIM scoring

The FIM scale is administered by the ward staff with the goal of reducing excessive assistance by providing a weekly evaluation of the ADL of toileting. The use of the FIM scale also informs the staff about better ways to assist the patients. The stroke unit’s ward staff at our hospital consists of nursing staff and care workers; these individuals assist assisted patients with toileting in daily care. First, 1 ×/wk, 1 or 2 patients whose toileting assistance is particularly challenging were selected by the ward staff and the rehabilitation staff on each ward. No clear patient selection criteria were followed, and the selections were subjective; however, the patients whose self-toileting was difficult due to paralysis and/or higher brain dysfunction were more commonly selected. The rehabilitation staff members were experienced occupational therapists.

Second, the ward and rehabilitation staff together scored the patients’ FIM score 1 ×/wk. The FIM score was obtained after having the patient actually go to the ward’s bathroom. When the rehabilitation staff calculated the patient’s FIM score, they instructed the ward staff about the toileting assistance methods, based on the patient’s physical function and executive dysfunction. They also shared points of improvement and, compared the patient’s status with the previous week’s status, and set a toileting goal for the following week. Every week, the FIM score was obtained and recorded by the attending daily ward staff and the primary rehabilitation staff. Finally, the ward staff recorded the discussion of the patient’s status, improvement, and further goals in the EMR system. If needed, the ward staff shared the information with other staff members in a daily meeting. The program continued every week up to the point of discharge for each patient.

2.4. Statistical analysis

Missing data were imputed by a multiple imputation method. To account for differences in baseline characteristics, we used propensity score methods to match patients between the FIM group and the control group.^[15] A propensity score was calculated by a logistic regression model using the following 14 clinically relevant variables: age, sex, body mass index, paralysis of motor function, paraesthesia, aphasia, agnosia, attention disorder, memory disorder, stroke history, diabetes status, dementia history, and FIM scores for toileting and transfer to the toilet. These items were selected in reference to other studies of the prognoses of stroke patients.^[16-19] Toileting-related items were also added in order to exclude the influence of differences in toileting-related ADLs on admission. The predicted probability was calculated and set as the propensity score.

Propensity scores were matched using a caliper width of onequarter of a standard deviation,^[19] with a 1:1 matching ratio. The balance of covariates was assessed using receiver operating characteristic curves and the area under the curve. In this study, the area under the receiver operating characteristic curve was 78.7% (73.3-84.1%). In the propensity score-matched sample, continuous variables were compared using Student t test and the Mann-Whitney U test, and categorical variables were compared using the chi-squared test.

Statistical analyses were conducted using EZR software ver. 1.40 (Saitama Medical Centre, Jichi Medical University, Saitama, Japan),^[20] which is a graphical user interface for R (ver. 3.6.3; R Foundation for Statistical Computing, Vienna, Austria). All tests were 2-tailed. Probability (P)-values of <.05 were considered significant.

3. Results

3.1. Study population

During the study period, 407 stroke patients were admitted to the hospital’s general stroke ward. Patients who died during hospitalization (n = 20) and those whose primary clinical condition was not a stroke (n = 14) were excluded. Of the 373 included patients, 62 were allocated to the FIM group and 311 to the control group (Fig. 1). The propensity score matching resulted in 53 pairs who were matched 1:1.

Figure 1. Flow chart of the study participants.

The profile and clinical data of the patients before and after matching are summarized in Table 1. Before the matching, most of the patients in the FIM group were older (FIM group vs control group: 80.0 years vs 73.0 years), were mostly men (64.5% vs 64.3%), and lived independently (83.9% vs 86.8%) at home (91.9% vs 92.9%). In the FIM group and control group, ≥70% of the patients had an infarction (71.0% vs 71.1%), and ≥60% of the patients had hypertension (67.7% vs 64.3%). The patients’ age, limb paralysis, limb paraesthesia, memory disorder, attention deficit, and FIM score at admission were significantly different between the FIM and control groups. After the matching, the differences in the baseline characteristics were not significant between the 2 groups. All patients received occupational therapy and physical therapy, and a few patients did not receive speech-language pathology, but there were no significant differences between the groups after matching. The toileting ADL program was initiated 15.0 days after admission, with interventions taking place over a period of 2 weeks.

Table 1 .

Baseline characteristics of the stroke patients.

			Before matching			After matching
			FIM group	Control	P	FIM group	Control	P
Total no. of patients, n (%)			62 (16.6)	311 (83.4)		53 (50.0)	53 (50.0)
Men, n (%)			40 (64.5)	200 (64.3)	1	34 (64.2)	39 (73.6)	.402
Age (yrs), median (IQR)			80.0 (68.5, 85.0)	73.0 (66.0, 82.5)	.039*	80.0 (70.0, 85.0)	77.0 (72.0, 85.0)	.904
BMI (kg/m2), median (IQR)			22.1 (20.4, 25.5)	22.5 (20.3, 24.7)	.98	22.5 (20.5, 25.7)	22.2 (20.6, 24.5)	.94
ADL before admission, n (%)					.696			1
	Independent (all ADLs)		52 (83.9)	270 (86.8)		45 (84.9)	44 (83.0)
	Dependent (some ADLs)		9 (14.5)	34 (10.9)		7 (13.2)	8 (15.1)
	Dependent (all ADLs)		1 (1.6)	7 (2.3)		1 (1.9)	1 (1.9)
Place of residence before admission, n (%)					.897			.716
	Home		57 (91.9)	289 (92.9)		49 (92.5)	48 (90.6)
	Nursing home		4 (6.5)	19 (6.1)		3 (5.7)	5 (9.4)
	Other		1 (1.6)	3 (1.0)		1 (1.9)	0 (0)
Stroke type, n (%)					1			.305
		Infarction		44 (71.0)	221 (71.1)		38 (71.7)	32 (60.4)
	Hemorrhage		18 (29.0)	90 (28.9)		15 (28.3)	21 (39.6)
Medical history, n (%)
	Stroke		16 (25.8)	64 (20.6)	.455	13 (24.5)	14 (26.4)	1
	Diabetes		14 (22.6)	86 (27.7)	.505	12 (22.6)	15 (28.3)	.656
	Hypertension		42 (67.7)	200 (64.3)	.71	36 (67.9)	36 (67.9)	1
		Hyperlipidemia	16 (25.8)	68 (21.9)	.609	15 (28.3)	11 (20.8)	.499
	Chronic heart failure		3 (4.8)	9 (2.9)	.69	3 (5.7)	2 (3.8)	1
	Myocardial infarction		2 (3.2)	16 (5.1)	.75	2 (3.8)	2 (3.8)	1
	Atrial fibrillation		8 (12.9)	53 (17.0)	.538	8 (15.1)	10 (18.9)	.797
	Dementia		3 (4.8)	18 (5.8)	1	3 (5.7)	4 (7.5)	1
Stroke impairment at admission, n (%)
	Limb paralysis				< .001*			.87
		Severe	29 (46.8)	76 (24.5)		23 (43.4)	23 (43.4)
		Partial	30 (48.4)	132 (42.6)		27 (50.9)	25 (47.2)
		None	3 (4.8)	102 (32.9)		3 (5.7)	5 (9.4)
	Limb paraesthesia		46 (74.2)	164 (52.7)	< .001*	39 (73.6)	38 (71.7)	1
	Memory disorders		49 (80.3)	155 (50.2)	< .001*	41 (77.4)	45 (84.9)	.457
	Aphasia		18 (29.5)	92 (29.7)	1	16 (30.2)	19 (35.8)	0.68
	Attention deficit		58 (95.1)	223 (72.2)	< .001*	50 (94.3)	53 (100.0)	.243
	Apraxia		8 (13.1)	44 (14.3)	.969	7 (13.2)	7 (13.2)	1
	FIM score on admission		30.0 (23.0, 37.5)	43.0 (24.0, 84.0)	< .001*	27.0 (23.0, 38.0)	28.0 (20.0, 35.0)	.635
The interquartile range (IQR) is (25%, 75%). ADL = activities of daily living, FIM = functional independence measure.

^* P < .05.

3.2. Outcome data

The outcome data of the FIM scale program are shown in Table 2. At admission, the ADL score was not significantly different between the FIM and control groups. The total, motor, and cognitive FIM scores at discharge were significantly greater in the FIM group compared with the control group (total FIM score, 68.0 points vs 45.0 points, P = .004; motor FIM score, 41.0 points vs 24.0 points, P = .005; and cognitive FIM score, 24.0 points vs 20.0 points, P = .007).

Table 2 .

Data regarding FIM scores and stroke impairment at discharge.

			FIM group	Control	P
FIM score at admission, median (IQR)
	Total FIM score		27.0 (23.0, 38.0)	28.0 (20.0, 35.0)	.635
	Motor FIM score		13.0 (13.0, 19.0)	13.0 (13.0, 17.0)	.306
	Cognitive FIM score		12.0 (7.0, 20.0)	13.0 (7.0, 19.0)	.982
FIM score at discharge, median (IQR)
	Total FIM score		68.0 (47.0, 84.0)	45.0 (26.0, 76.0)	.004*
	Motor FIM score		41.0 (29.0, 58.0)	24.0 (14.0, 51.0)	.005*
	Cognitive FIM score		24.0 (19.0, 30.0)	20.0 (10.0, 27.0)	.007*
Stroke impairment at discharge, n (%)
	Limb paralysis				.703
		Severe	14 (26.4)	17 (32.1)
		Partial	30 (56.6)	25 (47.2)
		None	9 (17.0)	11 (20.8)
	Limb paraesthesia		36 (67.9)	39 (73.6)	.67
	Disorders of memory		40 (75.5)	44 (83.0)	.473
	Aphasia		14 (26.4)	23 (43.4)	.102
	Attention deficit		52 (98.1)	50 (94.3)	.618
	Apraxia		6 (11.3)	7 (13.2)	1
	Cognitive dysfunction		25 (47.2)	37 (69.8)	.03*
LOS (d), mean (IQR)			29.0 (22.0, 40.00)	31.0 (22.0, 43.0)	.929
The interquartile range (IQR) is 25%, 75%. FIM = functional independence measure, LOS = length of stay.

^* P < .05.

Details of the comparisons for each FIM score item at discharge are shown in Table 3. The motor FIM scores for the following 5 items were significantly higher in the FIM group compared with the control group: eating (6.0 points vs 1.0 points, P = .013), grooming (4.0 points vs 3.0 points, P = .017), bladder control (5.0 points vs 1.0 points, P = .001), bowel control (5.0 points vs 1.0 points, P = .001), and transfer to toilet (4.0 points vs 3.0 points, P = .047). The cognitive FIM scores of the following 4 items were significantly higher in the FIM group compared with the control group: expression (5.0 points vs 4.0 points, P = .02), social interaction (5.0 points vs 4.0 points, P = .017), problem solving (4.0 points vs 3.0 points, P = .027), and memory (4.0 points vs 3.0 points, P = .038). The ADL score for toileting was also higher greater in the FIM group than in the control group (3.0 points vs 2.0 points), although the difference was not significant (P = .066).

Table 3 .

Details of FIM score at discharge.

		FIM group	Control	P
FIM score recovery, median (IQR)
Self-care
	Eating	6.0 (4.0, 6.0)	1.0 (1.0, 6.0)	.013*
	Grooming	4.0 (3.0, 6.0)	3.0 (1.0, 4.0)	.017*
	Bathing	2.0 (1.0, 4.0)	1.0 (1.0, 3.0)	.358
	Dressing—upper body	3.0 (1.0, 4.0)	1.0 (1.0, 5.0)	.179
	Dressing—lower body	2.0 (1.0, 4.0)	1.0 (1.0, 4.0)	.122
	Toileting	3.0 (2.0, 5.0)	2.0 (1.0, 5.0)	.066
Sphincter control
	Bladder	5.0 (2.0, 7.0)	1.0 (1.0, 5.0)	.001*
	Bowel	5.0 (2.0, 7.0)	1.0 (1.0, 5.0)	.001*
Transfer
	Bed, chair, wheelchair	4.0 (3.0, 5.0)	3.0 (1.0, 5.0)	.055
	Toilet	4.0 (3.0, 5.0)	3.0 (1.0, 5.0)	.047*
	Tub, shower	1.5 (1.0, 4.0)	1.0 (1.0, 3.0)	.21
Locomotion
	Walking, wheelchair	2.0 (1.0, 4.8)	1.0 (1.0, 4.3)	.316
	Stairs	1.0 (1.0, 1.0)	1.0 (1.0, 4.0)	.386
Communication
	Comprehension	5.0 (4.0, 6.0)	5.0 (3.0, 6.0)	.095
	Expression	5.0 (4.0, 6.0)	4.0 (3.0, 6.0)	.02*
Social cognition
	Social interaction	5.0 (4.0, 6.3)	4.0 (2.0, 6.0)	.017*
	Problem solving	4.0 (3.0, 5.0)	3.0 (1.0, 5.0)	.027*
	Memory	4.0 (3.0, 5.0)	3.0 (1.0, 5.0)	.038*
The interquartile range (IQR) is (25%, 75%). FIM = functional independence measure, FIMs = FIM scale group.

^* P < .05.

4. Discussion

Using an FIM scale provides a daily clinical task that may improve patients’ FIM scores. In this study, the use of the FIM scale resulted in an enhanced recovery of stroke patients based on both motor and cognitive items. It is not clear whether the use of the FIM scale directly contributed to the patients’ recovery, but the FIM scale may increase opportunities for toileting and the physical activity of patients as the staff understood the patient’s abilities and devised more appropriate ways to assist them based on the FIM scale. In studies that have reported increased physical activity and rehabilitation of stroke patients, patients demonstrated recovery in both motor^[4,21-24] and cognitive functions.^[25,26] In the present study, the FIM scores showed a large difference between the FIM and control groups in terms of sphincter control items. A regular induction of urination has been reported to improve dysuria.^[27,28] In the present stroke patients, the frequency of toilet induction was increased, which may have improved their sphincter control. Although the FIM scale demonstrated recovery in many items, the scores reflecting bathing, dressing, toileting, transfer bed/chair/wheelchair, transfer to tub/shower, and locomotion did not recover. It was unexpected that the toilet scores did not show a significant improvement.

Kawanabe et al^[29] noted that toileting behavior has various components that vary in difficulty, including transfer to the toilet, wiping the buttocks, and removing and restoring clothing. Taking off pants and pulling them back up were categorized as relatively high difficulty items; and we suspect that the toileting score in the FIM scale may not have been able to sensitively assess the change. Additionally, with regard to mobility, many fall events occur during walking^[30]; thus, even if there was no medical restriction on resting, the staff may have restricted the mobility of patients who were not able to walk around safely. Although the FIM score at discharge differed between the present FIM and control groups, there was no significant difference in their physical function and higher brain function at discharge. Greater independence in ADLs among chronic stroke patients with higher self-care self-efficacy was described by Frost et al.^[31] Besides improving functional aspects, the FIM scale may have helped individuals learn how to perform ADLs and build their self-confidence. Moreover, the number of patients with higher brain dysfunction items was larger at discharge than at admission. A thorough detailed higher brain dysfunction examination cannot be performed at admission for stroke patients, and some patients who were considered to have no dysfunction during their screening at admission were confirmed to have disability by the detailed examination at discharge.

Team training has been reported to improve patients’ FIM score^[10] and modified Rankin scale score.^[11] Our study differed from these previous investigations in 2 aspects: focused on ADLs, particularly toileting, in stroke patients, and we used a participatory approach for the ward staff. The FIM scale might have been tackled more actively by the ward staff compared with previous educational programs because actual patients were scored in a practice-like manner, intervention was provided, and regular feedback was given. In addition, since this program was conducted in a clinical setting, the time involved in education could be minimized. A one-time educational program is affected by the transfer or retirement of trained staff, but it is possible to continue this program if staff members take turns and participate weekly. Although it cannot be compared with other methods, this program appears to be an effective method of clinical education.

This study had some limitations. The sample size was somewhat small. In the FIM group, the recruitment was limited to 1-2 stroke patients per week and further recruitment was difficult. Additional research with a larger sample size is warranted. It is also possible that more patients with potential for recovery were selected in the FIM group. We attempted to reduce the influence of selection bias as much as possible by using propensity score matching, but we may not have sufficiently eliminated bias due to unanticipated factors. In particular, factors such as motivation can influence the recovery of FIM scores. Satisfactory validation of the FIM scale will require randomized controlled trials to exclude the effects of confounding factors.

5. Conclusion

We investigated the effect of a weekly FIM scale in which both the rehabilitation and ward staff evaluated the ADL function of acute stroke patients. The FIM group achieved higher total, motor, and cognitive FIM scores than the control group. The use of the FIM scale resulted in the recovery of physical and cognitive functions. These findings suggest that using that the FIM scale can prevent excessive assistance and unnecessary bed rest for patients and support improvement in their ADLs.

Acknowledgments

The authors thank the ward staff and rehabilitation staff at Tsukuba Medical Center Hospital (Tsukuba, Japan).

Author contributions

Conceptualization: Kenta Kawamura, Kumi Murayama.

Data curation: Kenta Kawamura, Kumi Murayama.

Formal analysis: Kenta Kawamura, Kumi Murayama.

Investigation: Kenta Kawamura, Kumi Murayama, Jumpei Takamura.

Methodology: Kenta Kawamura, Kumi Murayama.

Project administration: Shinobu Minegishi.

Resources: Shinobu Minegishi.

Supervision: Shinobu Minegishi.

Validation: Kenta Kawamura.

Visualization: Kenta Kawamura.

Writing - original draft: Kenta Kawamura.

Writing - review & editing: Kenta Kawamura, Kumi Murayama, Jumpei Takamura, Shinobu Minegishi.