“Good Outcome” Isn’t Good Enough

Background and Purpose— Functional outcome after stroke is often only evaluated using the modified Rankin Scale, which primarily assesses activities of daily living. Stroke patients may experience difficulties with social reintegration and mental functions, feel isolated, and experience poor quality of life, even after physical recovery is complete. Functional assessments based solely on activity limitations may not be able to capture the full range of problems experienced by stroke survivors. Methods— Telephone interviews were conducted 2 to 3 years poststroke to assess outcome on multiple levels of functioning as stated in the WHO International Classification of Functioning: body function (Montreal Cognitive Assessment and Patient Health Questionnaire-2), activity (modified Rankin Scale), and participation (Reintegration to Normal Living Index). Results— Ninety-six (68%) patients had a favorable functional outcome (modified Rankin Scale <2). Of these, 79, 91, and 93 patients completed the Montreal Cognitive Assessment, Reintegration to Normal Living Index, and Patient Health Questionnaire-2, respectively. Forty-three (54%) patients were cognitively impaired, 47 (52%) had restrictions in reintegration, and 30 (32%) endorsed symptoms of depression. There was no difference in Montreal Cognitive Assessment or Patient Health Questionnaire-2 scores between those who had activity limitations and those who had not. Conclusions— More than half of stroke patients with excellent functional recovery measured by the modified Rankin Scale continue to have cognitive impairment and participation restrictions, and one third of patients continue to have depression 2 to 3 years later. Current definitions of good functional outcome used in the majority of stroke acute trials focus on activity limitations, but greater attention to multiple levels of recovery is required.