Abstract
Objective
To develop a simple and effective risk score for predicting which stroke patients
will have persistent impairment of upper extremity motor function at 90 days.
Design
Post hoc analysis of clinical trial patients hospitalized with acute ischemic stroke
who were followed for 90 days to determine functional outcome.
Setting
Patient were hospitalized at facilities across the United States.
Participants
We created a harmonized cohort of individual patients (N=1653) from the NINDS tPA,
ALIAS part 2, IMS-III, DEFUSE 3, and FAST-MAG trials. We split the cohort into balanced
derivation and validation samples.
Interventions
Not applicable.
Main Outcome Measures
The primary outcome was persistent arm impairment, defined as a National Institutes
of Health Stroke Scale (NIHSS) arm domain score of 2 to 4 at 90 days in patients who
had a 24-hour NIHSS arm score of 1 or more. We used least absolute shrinkage and selection
operator regression to determine the elements of the persistent upper extremity impairment
(PUPPI) index, which we validated as a predictive tool.
Results
We included 1653 patients (827 derivation, 826 validation), of whom 803 (48.6%) had
persistent arm impairment. The PUPPI index gives 1 point each for age 55 years or
older and NIHSS values of worse arm (4), worse leg (>2), facial palsy (3), and total
NIHSS (≥10). The optimal cutpoint for the PUPPI index was 3 or greater, at which the
area under the curve was greater than 0.75 for the derivation and validation cohorts
and when using NIHSS values from either 24 hours or in a subacute or discharge time
window. Results were similar across different levels of stroke severity.
Conclusion
The PUPPI index uses readily available information to accurately predict persistent
upper extremity motor impairment at 90 days poststroke. The PUPPI index can be administered
in minutes and could be used as inclusion criterion in recovery-related clinical trials
or, with additional development, as a prognostic tool for patients, caregivers, and
clinicians.
Keywords
List of abbreviations:
AIS (acute ischemic stroke), AUC (area under the receiver operating characteristic curve), LASSO (least absolute shrinkage and selection operator), NIHSS (National Institutes of Health Stroke Scale), NPV (negative predicative value), PPV (positive predictive value), PUPPI (persistent upper extremity impairment), UE (upper extremity)To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Archives of Physical Medicine and RehabilitationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Does upper limb strength play a prominent role in health-related quality of life in stroke patients discharged from inpatient rehabilitation?.Top. Stroke Rehabil. 2020; 27: 525-533
- Predicting recovery potential for individual stroke patients increases rehabilitation efficiency.Stroke. 2017; 48: 1011-1019
- Biomarkers of stroke recovery: consensus-based core recommendations from the Stroke Recovery and Rehabilitation Roundtable.Int J Stroke. 2017; 12: 480-493
- Presence of finger extension and shoulder abduction within 72 hours after stroke predicts functional recovery.Stroke. 2010; 41: 745-750
- Arm subscore of motricity index to predict recovery of upper limb dexterity in patients with acute ischemic stroke.Am J Phys Med Rehabil. 2020; 99: 300-304
- Corticospinal tract injury estimated from acute stroke imaging predicts upper extremity motor recovery after stroke.Stroke. 2019; 50: 3569-3577
- A standardized approach to the Fugl-Meyer assessment and its implications for clinical trials.Neurorehabil Neural Repair. 2013; 27: 732-741
- Archived clinical research datasets.2020 (Available at:) (Accessed December 21)
- Tissue plasminogen activator for acute ichemic stroke.N Engl J Med. 1995; 333: 1581-1588
- High-dose albumin treatment for acute ischaemic stroke (ALIAS) part 2: a randomised, double-blind, phase 3, placebo-controlled trial.Lancet Neurol. 2013; 12: 1049-1058
- Endovascular therapy after intravenous t-PA versus t-PA alone for stroke.N Engl J Med. 2013; 368: 893-903
- Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging.N Engl J Med. 2018; 378: 708-718
- Prehospital use of magnesium sulfate as neuroprotection in acute stroke.N Engl J Med. 2015; 372: 528-536
- Covariate selection with group LASSO and doubly robust estimation of causal effects.Biometrics. 2018; 74: 8-17
- A review on variable selection in regression analysis.Econometrics. 2018; 6: 1-27
- Stochastic restricted LASSO-type estimator in the linear regression model.J Probab Stat. 2020; 2020e7352097
- Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach.Biometrics. 1988; 44: 837-845
- Models containing age and NIHSS predict recovery of ambulation and upper limb function six months after stroke: an observational study.J Physiother. 2013; 59: 189-197
- Minimal clinically important difference for the Fugl-Meyer assessment of the upper extremity in convalescent stroke patients with moderate to severe hemiparesis.J Phys Ther Sci. 2019; 31: 917-921
- Poststroke rehabilitation.Stroke. 2006; 37: 1477-1482
- Inter-individual variability in the capacity for motor recovery after ischemic stroke.Neurorehabil Neural Repair. 2008; 22: 64-71
Article info
Publication history
Published online: November 20, 2021
Accepted:
October 11,
2021
Received in revised form:
September 24,
2021
Received:
April 29,
2021
Footnotes
Presented as an oral abstract at the International Stroke Conference in 2021 (virtual).
Sources of Funding: NIH-NINDS K23NS105924. Swedish Research Council (2019-01757), Swedish Government, Swedish Heart and Lung Foundation, Region Skåne, Lund University, Skåne University Hospital, Sparbanksstiftelsen Färs och Frosta, Fremasons Lodge of Instruction Eos Lund. Australian-American Fulbright Commission. NIH/NICHD (K12HD093427). American Heart Association (AHA)-Bayer Discovery Grant (grant no. 17IBDG33700328), the AHA Cardiovascular Genome-Phenome Study (grant no. 15GPSPG23770000), NIH (grant no. R01-NS114045, R01-NS100178, and R01-NS105150), and the US Department of Veterans Affairs.
Dislcosures: Arne Lindgren receives personal fees from Bayer, Astra Zeneca, BMS Pfizer, and Portola outside this work. Steven C. Cramer serves as a consultant for AbbVie, Constant Therapeutics, MicroTransponder, Neurolutions, Regenera, SanBio, Stemedica, Fujifilm Toyama Chemical Co, Biogen, and TRCare. Bradford B. Worrall is the deputy editor for Neurology. Adam de Havenon receives research funding from AMAG and Regeneron. The other authors have nothing to disclose.
Identification
Copyright
© 2021 by the American Congress of Rehabilitation Medicine.
