Original article
To What Extent Can Multimorbidity Be Viewed as a Determinant of Postural Control in Stroke Patients?

https://doi.org/10.1016/j.apmr.2012.01.004Get rights and content

Abstract

Spruit-van Eijk M, Zuidema SU, Buijck BI, Koopmans RT, Geurts AC. To what extent can multimorbidity be viewed as a determinant of postural control in stroke patients?

Objective

To investigate the determinants of postural imbalance after stroke in geriatric patients admitted for low-intensity rehabilitation in skilled nursing facilities (SNFs), particularly the role of multimorbidity.

Design

Cross-sectional study design.

Setting

Fifteen SNFs.

Participants

All patients who were admitted for rehabilitation after stroke in one of the participating SNFs (N=378) were eligible.

Interventions

Not applicable.

Main Outcome Measures

The Berg Balance Scale (BBS) was selected as a measure of standing balance and the Functional Ambulation Categories (FAC) as a measure of walking balance.

Results

Multimorbidity was present in 34% of the patients. The patients with multimorbidity differed from the patients without multimorbidity with respect to age, proprioception, and vibration sense, but not for any of the cognitive tests, muscle strength, or sitting balance. Patients with multimorbidity had, on average, lower scores on both outcome measures. In linear regression analyses, both the BBS and FAC were best explained by multimorbidity, muscle strength, and the interaction between muscle strength and static sitting balance (overall explained variance 66% and 67%, respectively), while proprioception added only to the variance of the FAC.

Conclusions

Multimorbidity was independently related to postural imbalance after stroke in patients admitted for rehabilitation in SNFs. Muscle strength and the interaction of muscle strength with static sitting balance were important determinants of both standing and walking balance, indicating these factors as essential targets for rehabilitation.

Section snippets

Methods

This cross-sectional study is part of the Nijmegen GRAMPS study (Geriatric Rehabilitation in AMPutation and Stroke). All patients admitted to 1 of 15 participating SNFs in the southern part of the Netherlands were eligible. No additional inclusion criteria were applied. Patients were excluded if they refused participation, were unable to give informed consent, were critically ill on admission, or were expected to have a short stay (<2wk). An extensive description of the study protocol has

Results

Of 378 eligible patients, 186 were included in this study. Reasons for exclusion were no informed consent (n=73), inability to give informed consent (n=64), expected short stay (n=7), critical illness (n=13), and other reasons (n=35). “Other reasons” for exclusion were mainly logistic. For instance, during holidays, merely every second patient was included to prevent too great a burden to the personnel. The patients who were eventually included did not differ from those who were excluded in

Discussion

To our knowledge, this is the first study to investigate the determinants of postural imbalance after stroke in geriatric patients admitted for low-intensity rehabilitation in SNFs, particularly the role of multimorbidity. In line with our hypothesis, multimorbidity was independently associated with standing (BBS) and walking balance (FAC), as was muscle strength of the affected body side. Interestingly, the latter relationship was modified by SSB. This interaction indicates that the influence

Study Strengths and Limitations

Strengths of this study are that the sample size was relatively large and that multimorbidity was carefully assessed using the adjusted Charlson Index. A limitation is that trunk control was assessed only with the SSB item of the Trunk Control Test. As a result, only a crude assessment of trunk impairments was possible. Another limitation is the relatively long poststroke interval (on average, 19d), which occurred because patients were included on admission to the nursing home and not during

Conclusions

We found that multimorbidity independently contributes to postural imbalance after stroke in geriatric patients admitted for rehabilitation in SNFs of nursing homes. Both standing and walking balance were best explained by a combination of multimorbidity, muscle strength of the affected body side, and the interaction between trunk control and limb muscle strength. Hence, to improve postural control in geriatric patients with stroke, it seems important to treat comorbidity whenever possible and

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    • Supported by the Dutch care organizations De Zorgboog and SVRZ. They employed the primary investigators (Buijck and Spruit-van Eijk, respectively) during the study period. A grant was received from the science promotion foundation for nursing homes (SWBV).

    No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

    In-press corrected proof published online on Apr 1, 2012, at www.archives-pmr.org.

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    Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.