What is the probability of patients who are nonambulatory after stroke regaining independent...

Systematic reviews

What is the probability of patients who arenonambulatory after stroke regaining independentwalking? A systematic review

Elisabeth Preston�1, Louise Ada1, Catherine M. Dean1, Rosalyn Stanton1, and

Gordon Waddington2

Patients after stroke who are nonambulatory require resources,

and independent walking becomes a major determinant of the

ability to participate in activities of daily living. Our objective

was to determine the probability of walking for patients who

are nonambulatory in the first month after stroke. We per-

formed a systematic review and meta-analysis of consecutive,

prospective studies of nonambulatory patients within the first

month after stroke in rehabilitation and acute units. The out-

comes were the probability of achieving independent walking

at three-, six- and 12 months after stroke. Twenty-six studies

were included in the review. Seventeen studies comprising

2856 participants were entered into meta-analyses. For initially

nonambulatory stroke patients managed in a rehabilitation

unit, the probability of independent walking was 0.60 (95% CI

0.47–0.74, 1373 participants) at three-months, 0.65 (95% CI

0.53–0.77, 444 participants) at six-months and 0.91 (95% CI

0.81–1.00, 24 participants) at 12 months. For patients managed

in an acute unit, the probability of independent walking was

0.39 (95% CI 0.27–0.52, 634 participants) at three-months, 0.69

(95% CI 0.46–0.92, 405 participants) at six-months and 0.74

(95% CI 0.59–0.88, 34 participants) at 12 months. 60% of

patients managed in a rehabilitation unit who are nonambula-

tory in the first month after stroke will regain independent

walking comparedwith39%of thosemanaged inanacute unit.

This information can be used clinically to make decisions about

allocation of rehabilitation resources,education of patients and

carers, and for discharge planning.

Key words: gait, locomotion, meta-analysis, outcome, prog-

nosis, rehabilitation, stroke, systematic review, walking

Introduction

The ability to regain independent walking after stroke is of

great importance to patients and health care providers alike.

People fear losing independence more than anything else and

the ability to walk promotes independence (1). Often after

stroke, the probability of walking again is the first question that

patients ask of health care providers. Regaining the ability to

walk is a major determinant of a person’s ability to participate

in activities of daily living and therefore of discharge destina-

tion (2, 3).

There are two systematic reviews evaluating prognostic

factors relating to walking after stroke (4, 5). Kwakkel and

colleagues’ review suggested that the predictors for outcome of

walking after stroke were age; previous stroke; urinary con-

tinence; consciousness at onset; disorientation in time and

place; severity of paralysis; sitting balance; admission ADL

score and level of social support and metabolic rate of glucose

outside the infarct area in hypertensive patients (4). More

recently, Meijer and colleagues’ review suggested that there was

insufficient quality of data to provide predictions, although

there was some evidence that low initial ADL functioning, high

age, cognitive disturbance, paresis of the limbs, reduced initial

level of consciousness, previous hemiplegia, homonymous

hemianopia, visual extinction, constructional apraxia, no

admission to a stroke unit, nonlacunar stroke, visuospatial

construction problems, urinary incontinence and female gen-

der were related to poorer outcome after stroke (5). Both these

reviews included patients who were initially ambulatory and

nonambulatory. What is still not clear is the probability of

independent walking for people who are nonambulatory

initially after stroke. Patients who are nonambulatory have

generally had a devastating stroke, and patients with severe

strokes require substantial physical and economic resources for

rehabilitation or future care (6, 7). Thus, the objective of this

systematic review was to determine the probability of walkingDOI: 10.1111/j.1747-4949.2011.00668.x

Conflicts of interest: None declared.

Funding: This research received no specific funding from any funding

agency in the public, commercial or not-for-profit sectors.

Correspondence: Elisabeth Preston�, Discipline of Physiotherapy, Faculty

of Health Sciences, The University of Sydney, Sydney, NSW, Australia.

E-mail: [email protected] of Physiotherapy, The University of Sydney, Sydney, NSW,

Australia2Discipline of Physiotherapy, The University of Canberra, Canberra, ACT,

Australia

& 2011 The Authors.International Journal of Stroke & 2011 World Stroke Organization Vol 6, December 2011, 531–540 531

mailto:[email protected]

for patients who are nonambulatory in the first month after

stroke.

This systematic review examined patients managed in

rehabilitation and acute units separately, because it is possible

that there will be different outcomes in terms of walking

between these settings. For example, acute units provide care

for a full range of patients after stroke, with varying degrees of

disability, including patients who are likely to walk quickly and

go directly home without requiring inpatient rehabilitation.

Therapeutic input may be more extensive in some rehabilita-

tion units, thus also contributing to a different walking out-

come. We were interested in examining the probability of

regaining independent walking because it is important in

enabling patients to participate in the community (8). Given

that the majority of functional recovery after stroke occurs

within the first 12 months (9) we examined the recovery of

walking across this time frame, which encompasses inpatient

rehabilitation (average discharge about three-months) and

outpatient rehabilitation (average discharge about six-

months).

The specific research questions for this study were:

� In patients, who are managed in a rehabilitation unit and are

nonambulatory within one-month of stroke, what is the

probability of regaining independent walking within 12

months?

� Is the probability any different for patients who are managed

in an acute unit?

Knowing the probability of regaining walking of patients

who are initially nonambulatory will provide a benchmark for

walking outcomes. This information may also contribute to

the process of triaging patients in acute units to home,

rehabilitation or a care facility and would also allow education

of family and carers regarding general expectations of walking

outcome in patients who are nonambulatory in the first month

after stroke.

Method

Identification and selection of studies

Searches were conducted of the following databases:

MEDLINE (1966 to September 2010), CINAHL (1982 to

September 2010), EMBASE (1980 to September 2010), Web

of Science (1982 to September 2010) and Scopus (1960 to

September 2010), without language restrictions, for relevant

articles. Search terms included words relating to stroke (e.g.

cerebrovascular disorder, CVA, infarct, bleed, brain, hemiple-

gia, etc.), prognosis (e.g. risk, outcome assessment, predict,

follow-up, etc.), and locomotion (e.g. walking, gait, ambula-

tion, mobility, etc.). Title and abstracts were displayed and

screened by one reviewer to identify relevant studies. Full paper

copies of relevant studies were retrieved and their reference lists

were screened. The methods of retrieved papers were examined

against predetermined inclusion criteria (Fig. 1) by two

independent reviewers. Conflict of opinion was resolved by

consensus after discussion with a third reviewer.

Assessment of characteristics of studies

QualityThe quality of included studies was determined using the

screening tool of prognostic studies developed by Hayden et al.

(10). Studies were evaluated using the four categories relevant

to this systematic review: study participation (criteria included

that the sample represented the population of interest in key

characteristics), study attrition (criteria included that the loss

to follow-up was not associated with key characteristics),

measurement of outcomes (criteria included that the measure-

ment was clearly defined as well as valid and reliable) and

measurement of confounders (criteria included that the im-

portant potential confounders were appropriately accounted

for by valid and reliable measurement). Studies were rated as

either meeting the criteria, partly meeting the criteria or not

meeting the criteria for each of these categories. A study was

defined as good quality if it either

(i) met the criteria for three categories or

(ii) met the criteria for two categories and partly met the

criteria for the other two categories.

Studies were evaluated by two reviewers independently with

disagreements resolved by a third reviewer.

ParticipantsParticipants had to be patients within one-month after a

stroke, who were nonambulatory. Age, gender, the number

of participants in the sample, inclusion criteria into the study

and the time between stroke onset and initial walking measure

were recorded and compared to examine similarity between

the studies.

SettingsStudies where participants were admitted to hospital were

included. The setting where the initial measurement of walking

ability was completed was recorded and compared to examine

similarity between the studies. Acute units included acute

Fig. 1 Inclusion criteria.

& 2011 The Authors.International Journal of Stroke & 2011 World Stroke Organization Vol 6, December 2011, 531–540532

Systematic reviews E. Preston et al.

stroke units or general medical units, thereby comprising a

nonselected population of patients after stroke. Rehabilitation

units included any inpatient rehabilitation unit, where patients

were selected and transferred after an acute episode of care.

Outcome measuresMeasures of walking, time of measurement since stroke and

definition of nonambulatory, as well as definition of ambula-

tory, were recorded and compared to examine similarity

between the studies. Where multiple measures of walking

were presented, independent walking was defined as being

able to walk with/without aids, but without human assistance.

Data analysis

Data were extracted from the included studies by one reviewer

and cross-checked by a second reviewer. Information about the

method (i.e. design, participants, measures) and outcome data

(i.e. number of participants that could walk independently)

was extracted. Authors were contacted where there was diffi-

culty extracting the data.

Walking outcome was examined over a 12-month time

frame, three categories were then developed: three-, six- and

12-months after stroke. Meta-analyses were performed to

calculate the pooled estimate of the proportion of patients

that could walk independently and reported with 95% CI. A

fixed effects model was used. In the case of significant statistical

heterogeneity, I2450% (11), a random effects model was

applied to check the robustness of the results. The meta-

analyses were performed using The MIX–Meta-Analysis Made

Easy program version 1.7 (12, 13).

Results

Flow of studies through the review

The search returned 1010 studies. After screening the titles and

abstracts, 66 papers were retrieved for evaluation of full text.

Forty studies failed to meet the inclusion criteria and therefore

26 papers were included in the review. Of these 26 papers, after

contacting authors, 17 had data available to be entered into

meta-analyses (Fig. 2).

Description of studies

The quality of the included studies is outlined in Table 1 and a

summary of the studies is presented in Table 2.

QualityOf the 26 studies included in this review, 21 were of good

methodological quality, and of the 17 entered into the meta-

analyses, 13 were of good methodological quality. The sample

was representative of the population in 62% of studies and

partly representative in 35%, loss to follow-up was not

associated with key characteristics in 88% of studies, outcome

measurement was adequate in 96% of studies and important

potential confounders were at least partly accounted for in

80% of studies.

ParticipantsThe mean ages of participants across the studies ranged from

58 to 80 years old and the mean time of initial measures of

walking ranged from two- to 31 days. Patients were managed

either in a rehabilitation unit (n 5 15) or an acute unit

(n 5 11).

Outcome measuresAlthough many different measurement tools were used to

report walking, independent walking was reported in 96% of

studies as the ability to walk alone or with an aid, but without

human assistance. Nonambulatory was defined as FIM mobi-

lity and locomotion subscale score o6 (n 5 5), Barthel index

mobility subscale score of 0, 5 or 10 (n 5 6), Barthel index

mobility subscale score of 0–2 (n 5 3), MAS item 5 score 0–2

(n 5 2), COVs mobility scale item 5 score 0–4 (n 5 1),

modified Rankin scale43 (n 5 1), Hemiplegic Stroke Severity

Scale 43 (n 5 1) and walking speed o0�15 m/s (n 5 1). The

remaining studies (n 5 6) used scales developed by the authors

to define nonambulatory. Independent walking data were

available to be used in a meta-analysis from patients managed

in a rehabilitation unit at three-months (n 5 9) and at six-

months (n 5 3) and from those managed in an acute unit at

three-months (n 5 6) and at six-months (n 5 3).

Fig. 2 Flow of studies through the review. �Papers may not have been

included for failing to meet more than one inclusion criteria.


E. Preston et al. Systematic reviews

Probability of regaining independent walking

Rehabilitation unitAt three-months, the probability of initially nonambulatory

stroke survivors regaining independent walking was examined

by pooling data from nine studies (14, 18, 21, 25, 26, 28, 29, 32,

35) comprising 1373 participants (Fig. 3). The probability of

independent walking in initially nonambulatory stroke pa-

tients was 0�60 (95% CI 0�47–0�72). Data were unavailable

from three studies.

At six-months, the probability of initially nonambulatory


by pooling data from three studies (18, 29, 30) comprising 444

participants (Fig. 4). The probability of independent walking

had increased to 0�65 (95% CI 0�53–0�77).

At 12 months, the probability of initially nonambulatory


by using data from one study (35) comprising 24 participants.

The probability of independent walking had increased to 0�91

(95% CI 0�81–1�00). Data were unavailable from one study.

Acute unitAt three-months, the probability of initially nonambulatory


by pooling data from five studies (2, 19, 20, 36, 38) comprising

634 participants (Fig. 5). The probability of independent

walking in initially nonambulatory stroke patients was 0�39

(95% CI 0�27–0�52). Data were unavailable from four studies.

At six-months, the probability of initially nonambulatory


by pooling data from two studies (19, 31) comprising 405

participants (Fig. 6). The probability of independent walking

had increased to 0�69 (95% CI 0�46–0�92). Data were unavail-

able from two studies.

At 12 months, the probability of initially nonambulatory


by using data from one study (24), comprising 34 participants.

The probability of independent walking had increased to 0�74

(95% CI 0�59–0�88).

Discussion

This is the first systematic review to pool data from prospec-

tive, consecutive studies of patients who are nonambulatory in

the first month after stroke to determine the probability of

regaining independent walking. A meta-analysis of available

data found that 60% of initially nonambulatory stroke patients

managed in a rehabilitation unit regained independent walk-

ing at three-months and this increased to 65% by six-months

after stroke. This differed from the findings for patients

managed in an acute unit – at three-months only 39% of

Table 1 Quality of included studies (n 5 26)

Study

Study participation – sample

represents the population of

interest in key characteristics

Study attrition – loss to

follow-up is not associated

with key characteristics

Outcome

measurement

if adequate

Important potential

confounders are

appropriately accounted for

Bacciglieri et al. (14) Y Y Y P

Baer and Smith (15) Y Y Y N

Bagg et al. (16) Y Y Y P

Daviet et al. (17) N N Y P

De Wit et al. (18) Y Y Y P

Ekstrand et al. (38) P Y Y P

Friedman (19) Y Y Y P

Jorgensen et al. (20) Y Y Y P

Kuys et al. (21) Y Y Y P

Loewen and Anderson (22) Y Y Y P

Macciocchi et al. (23) P Y Y P

Minelli et al. (24) Y Y Y N

Olsen (25) P Y Y N

Paolucci et al. (26) Y Y Y P

Patel et al. (27) Y Y Y P

Petrilli et al. (28) P Y Y P

Piron et al. (29) P Y Y P

Prevo et al. (30) P Y Y P

Reid et al. (31) P Y P P

Singh et al. (32) Y Y Y N

Sommerfeld and von Arbin (2) P Y Y P

Thommessen et al. (33) P Y Y P

Van Bennekom et al. (34) Y Y Y Y

Viosca et al. (35) Y N Y P

Wade et al. (36) Y N Y N

Ween et al. (37) Y Y Y P

Y, yes; N, no; P, partly.



Tab

le2

Sum

mar

yof

incl

uded

studie

s(n

526)

Study

Part

icip

ants

Sett

ing

Mea

sure

men

tof

wal

king

Char

acte

rist

ics

Incl

usi

on

Initia

lFo

llow

-up

Mea

sure

men

t

Def

initio

nof

nonam

bula

tory

Tim

e

(day

s)M

easu

rem

ent

Def

initio

nof

ambula

tory

Tim

e

Bac

ciglie

ri

etal

.(1

4)

n5

33/3

3

Age

(yea

rs)5

64

(SD

7)

Stro

keReh

abTh

ree-

poin

tcu

stom

mad

esc

ale

With

assi

stan

ce(h

um

an)

Cust

om

scal

esc

ore

1,2

14

Thre

e-poin

tcu

stom

mad

esc

ale

Without

assi

stan

ce

(hum

an)

Cust

om

scal

esc

ore

3

D/C

Bae

ran

d

Smith

(15)

n5

unkn

ow

n/2

38

Age

(yea

rs)5

72

(SD

11)

Gen

der

592

M,93

F

Stro

keReh

ab10

mw

alk

test

With

assi

stan

ce(h

um

an)

310

mw

alk

test

Without

assi

stan

ce

(hum

an)

D/C

Bag

get

al.(1

6)

n5

561

Age

(yea

rs)5

71

(SD

12)

Gen

der

5302

M,259

F

1st

stro

ke,ac

ute

ly

stab

le,no

seve

re

cognitiv

eim

pai

rmen

t

Reh

abFI

M–

mobili

ty

subsc

ale

With

assi

stan

ce(h

um

an)

FIM

1–5

31

FIM

–m

obili

ty

subsc

ale

Without

assi

stan

ce

(hum

an)

FIM

6,7

D/C

(thre

e-m

onth

s)

Dav

iet

(17)

n5

unkn

ow

n/1

56

1st

stro

ke,no

SAH

Reh

abBI

With

assi

stan

ce(h

um

an)

BIm

obili

tysc

ore

0,5,10

2BI

Without

assi

stan

ce

(hum

an)

BIm

obili

tysc

ore

15

12

month

s

De

Wit

etal

.(1

8)

n5

388/5

32

Age

(yea

rs)5

69

Gen

der

5283

M,249

F

1st

stro

ke,sc

ore

on

RM

Agro

ssfu

nct

ion

o11;le

g/t

runko

8;

arm

o12

Reh

abBI

With

assi

stan

ce(h

um

an)

BIm

obili

tysc

ore

0,5,10

19

BI

Without

assi

stan

ce

(hum

an)

BIm

obili

tysc

ore

15

Two-,

four-

,

six-

month

s

Ekst

rand

etal

.(38)

n5

46/6

0

Age

(yea

rs)5

66

Gen

der

534

M,26

F

1st

stro

ke,m

oto

rdef

icits

atfo

ur-

day

post

stro

ke,

no

aphas

ia

Acu

teC

OV

SW

ith

assi

stan

ce(h

um

an)

2C

OV

SW

ithout

assi

stan

ce

(hum

an)

Thre

e-m

onth

s

Frie

dm

an(1

9)

n5

113/1

13

Age

(yea

rs)5

74

(SD

6)

Gen

der

62

M,51

F

Stro

ke,4

60

year

sA

cute

Wal

king

spee

dW

ith

assi

stan

ce(h

um

an)

7W

alki

ng

spee

dW

alki

ng

spee

d

40�1

50

m/s

Thre

e-,fo

ur-

month

s

Jorg

ense

n

etal

.(2

0)

n5

510/8

04

Age

(yea

rs)5

74

(SD

11)

Stro

ke,no

aphas

ia,no

dis

orien

tation

Acu

teBI

Imm

obile

or

wal

kso

50

yd7

BI

Wal

ks4

50

ydw

ithout

assi

stan

ce(h

um

an)

D/C

(one-

month

),

thre

e–m

onth

s

Kuys

etal

.(2

1)

n5

58/1

05

Age

(yea

rs)5

70

(SD

13)

Gen

der

564

M,41F

Stro

keReh

abM

AS

Item

5W

ith

assi

stan

ce(h

um

an)

MA

SItem

5sc

ore

0–2

16

MA

SItem

5W

ithout

assi

stan

ce

(hum

an)

MA

SItem

5sc

ore

3–6

D/C

(tw

o-,�

four-

month

s)

Loew

enan

d

Ander

son

(22)

n5

unkn

ow

n/5

0

Age

(yea

rs)5

68

(SD

10)

Gen

der

528

M,22

F

Stro

ke,no

alte

red

consc

iousn

ess

Acu

teM

AS

Item

5W

ith

assi

stan

ce(h

um

an)

MA

SItem

5sc

ore

0–2

7M

AS

Item

5W

ithout

assi

stan

ce

(hum

an)

MA

SItem

5sc

ore

3–6

D/C

(tw

o-m

onth

s)

Mac

ciocc

hi

etal

.(2

3)

n5

unkn

ow

n/3

28

Age

(yea

rs)5

70

(SD

10)

Gen

der

5179

M,149

F

MC

Ais

chem

icst

roke

Acu

teBI

With

assi

stan

ce(h

um

an)

BIm

obili

tysc

ore

0,5,10

10

BI

Without

assi

stan

ce

(hum

an)

BIm

obili

tysc

ore

15

Thre

e-m

onth

s

Min

elli

etal

.(2

4)

n5

34/8

1

Age

(yea

rs)5

65

(SD

12)

Gen

der

551

M,30

F

Stro

keA

cute

BI

With

assi

stan

ce(h

um

an)

BIm

obili

tysc

ore

0,5,10

2BI

Without

assi

stan

ce

(hum

an)

BIm

obili

tysc

ore

15

12

month

s

Ols

en(2

5)

n5

72/7

2

Age

(yea

rs)5

68

(SD

10)

Gen

der

539

M,33

F

Stro

ke,nonam

bula

tory

Reh

abFi

ve-p

oin

tcu

stom

mad

esc

ale

With

assi

stan

ce(h

um

an)

Cust

om

scal

esc

ore

1–4

28

Five

-poin

tcu

stom

mad

esc

ale

Without

assi

stan

ce

(hum

an)

Cust

om

scal

esc

ore

5

Thre

e-m

onth

s



Tab

le2

(Continued

)

Study

Part

icip

ants

Sett

ing

Mea

sure

men

tof

wal

king

Char

acte

rist

ics

Incl

usi

on

Initia

lFo

llow

-up

Mea

sure

men

t

Def

initio

nof

nonam

bula

tory

Tim

e

(day

s)M

easu

rem

ent

Def

initio

nof

ambula

tory

Tim

e

Paolu

ccie

tal

.

(26)

n5

437/4

37

Age

(yea

rs)5

68

(SD

13)

Gen

der

5260

M,240

F

Isch

emic

stro

keReh

abC

ust

om

mad

esc

ale

Notw

alki

ng

orin

whee

lchai

r21

Cust

om

mad

esc

ale

Without

assi

stan

ce

(hum

an)

D/C

(tw

o-,�

five

-month

s)

Pate

let

al.(2

7)

n5

322/4

59

Age

(yea

rs)5

70

(SD

11)

Gen

der

5260

M,240

F

Stro

keA

cute

FIM

mobili

ty

subsc

ale

With

stan

dby

assi

stan

ce

(hum

an)FI

M1–5

2FI

Mm

obili

ty

subsc

ale

Without

assi

stan

ce

(hum

an)

FIM

6,7

Thre

e-,si

x-m

onth

s

Petr

illie

tal

.(2

8)

n5

93/9

3

Age

(yea

rs)5

65

Gen

der

46

M,47

F

1st

stro

keReh

abC

ust

om

mad

esc

ale

10

mw

ith

assi

stan

ce

(hum

an)

18

Cust

om

mad

esc

ale

10

mw

ithout

assi

stan

ce(h

um

an)

D/C

(tw

o-m

onth

s)

Piro

net

al.(2

9)

n5

13/2

0

Age

(yea

rs)5

68

(SD

6)

Gen

der

58

M,12

F

1st

stro

ke,

nonam

bula

-

tory

,dep

for

AD

Ls

Reh

abH

emip

legic

stro

ke

scal

e(H

SS)

With

assi

stan

ce(h

um

an)

HSS

score

43

30

HSS

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initially nonambulatory stroke patients in an acute unit regain

independent walking. However, at six-months after stroke, a

similar proportion of patients managed in an acute unit (69%)

regained independent walking to those managed in a rehabi-

litation unit (Fig. 7).

The overall quality of the included studies was good. The age

and gender of participants was similar across the studies, as

were the inclusion criteria to enter the studies. There were 15

studies that included participants managed in a rehabilitation

setting, and 11 that included participants managed in an acute

setting, which included both general acute units and desig-

nated stroke units. Initial measures of walking occurred earlier

on average in acute units (six-days) than in rehabilitation units

(19 days). Avariety of measures of walking were used across the

included studies, and not all studies defined independent

walking. However, of the studies that did, all but one study

defined independent walking as the ability to walk without

human assistance. There were sufficient data for a meta-

analysis to be included at three- and six-months for rehabilita-

tion units and acute units. The number of participants

included was 1373 in the rehabilitation unit meta-analysis

and 634 in the acute unit meta-analysis at three-months. The

good quality and similarity of the studies, as well as the number

of participants available for the three-month meta-analyses,

suggests that the results for the probability of regaining

independent walking at three-months after stroke in patients

who are initially nonambulatory are credible. Although there

were data available for analysis at six- and 12 months in both

settings, the number of participants is too small to draw valid

conclusions.

A substantially greater proportion of patients managed in a

rehabilitation unit regained independent walking at three-

months compared with those managed in an acute unit. There

are several possible explanations for this outcome. Patients

admitted to a rehabilitation unit have generally been selected as

being likely to benefit from a prolonged period of rehabilita-

tion, thus increasing the probability of this population regain-

ing independent walking, compared with an unselected

population of patients managed in an acute unit after stroke.

Patients admitted to an acute unit after stroke can include

those with severe stroke, including those with significant

physical and cognitive impairment. The severity of impair-

ments in these patients would also contribute to a reduced

probability of regaining independent walking for patients

managed in an acute unit. Moreover, the outcome of stroke

is associated with intensity of therapy (39) and rehabilitation

units are designed and resourced to provide a greater intensity

of therapy than acute units, thus increasing the probability of

improved walking outcomes in these patients.

There was variability in the number of days after stroke that

the initial measure of walking was completed across studies.

The correlation between the average day the participants were

measured as nonambulatory and the probability of walking

independently at three-months was high in both a rehabilita-

tion unit (r 5 0�88; P 5 0�002) and an acute unit (r 5 0�70;

P 5 0�19). This is not surprising given there is the potential for

substantial recovery in walking ability in the first month after

stroke (40), and a patient who is still nonambulatory 30 days

after stroke is likely to have had a devastating stroke, which is

not necessarily the case in patients who are nonambulatory at

only three-days after stroke. Therefore, we carried out a post

hoc regression analysis taking into account the number of days

after stroke that measurement of nonambulatory status oc-

curred. The prediction equation for determining the prob-

ability of independent walking at three-months in patients

who are nonambulatory in the first month after stroke in a

rehabilitation unit is:

� probability of walking 5 1�24–(0�034� day after stroke

measured as nonambulatory)

For an acute unit the prediction equation is:

� probability of walking 5 0�66–(0�04� day after stroke mea-

sured as nonambulatory)

For example, in a rehabilitation unit a patient who is

measured as nonambulatory 14 days after stroke has

a 76% chance of walking independently at three-months

[0�76 5 1�24–(0�034� 14)], compared with a patient in an

acute unit who is measured as nonambulatory 14 days after

stroke who has a 10% chance of walking independently at

three-months [0�1 5 0�66–(0�04� 14)]. These equations can

be used to refine the prediction of probability of individual

patients regaining independent walking at three-months after

stroke. This more accurate information could be utilized to

allocate resources amongst individual patients, as well as to

facilitate decisions about discharge destination. It also pro-

vides clinical services with a benchmark for evaluating the

effectiveness of service provision for patients who are initially

nonambulatory after stroke and can also be used as a guide to

educate patients and carers of the probability of regaining

independent walking. Moreover, these equations can be uti-

lized in clinical research as a benchmark for the performance of

control groups in trials examining walking outcome after

stroke. For instance in two recent randomized trials examining

the effectiveness of treadmill training in nonambulatory

participants (41, 42), the outcome of the control group in

both studies was consistent with the proportion of indepen-

dent walkers predicted by the equation, suggesting that the

control groups in both studies achieved a reasonable outcome

in terms of walking independence.

There are several limitations of this review. Firstly, data were

unable to be extracted from nine studies, thus reducing the

power of the results. There were substantially more data

available for the meta-analyses of walking outcome at three-

months than at any other time point, and only two studies had

data available for analysis at 12 months after stroke, suggesting

that the findings at six- and 12 months in both settings are

less robust than the findings at three-months after stroke.

Secondly, in line with best practice (43), inclusion in this

systematic review required studies to be consecutive with

inception cohorts, consequently randomized trials were not

screened. However, it has been suggested that the control



groups in randomized trials may provide ‘hidden’ information

about probability of outcomes (43). As a result, some poten-

tially relevant data may have been excluded from the analysis.

In conclusion, this systematic review found that in a

rehabilitation unit, the probability of regaining independent

walking for patients who are nonambulatory in the first month

after stroke is 60% at three-months. The probability of

regaining walking is lower for patients managed in an acute

unit at only 39% by three-months. The prediction may

be refined by using the time in the first month after stroke

that the patient remains nonambulatory, to predict walking

outcome at three-months for individual patients in both

rehabilitation and acute settings. This information may be

used clinically to make decisions about allocation of rehabili-

tation resources, education of patients and carers, and for

discharge planning.

Fig. 3 Probability (95% CI) of patients after stroke who are initially nonambulatory regaining independent walking at three-months when managed in a

rehabilitation unit by pooling data from nine studies (n 5 1373).

Fig. 4 Probability (95% CI) of patients after stroke who are initially nonambulatory regaining independent walking at six-months when managed in a

rehabilitation unit by pooling data from three studies (n 5 444).

Fig. 5 Probability (95% CI) of patients after stroke who are initially nonambulatory regaining independent walking at three-months when managed in an

acute unit by pooling data from five studies (n 5 634).

Fig. 6 Probability (95% CI) of patients after stroke who are initially nonambulatory regaining independent walking at six-months when managed in an acute

unit by pooling data from two studies (n 5 405).



Acknowledgements

We would like to thank Dr Liesbet De Wit, Ms Elisabeth

Ekstrand, Dr Cesar Minelli, Dr John Reid, Dr Disa Sommerfeld

and Dr Jon Ween for providing additional information for the

meta-analyses. We would also like to thank Ms Irmina Nahon,

Mrs Helen Preston and Mr Nicholas Stanton for their time and

skill in translating papers into English.

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