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and patient’s post-acute care disposition (5, 8–10).
Although the NIHSS has been used as a tool for goal-
setting and rehabilitative clinical decision-making, it
is not directly associated with an individual’s ability
to compensate for a neurological deficit, and therefore
it is not an ideal measure of functional outcome after
stroke (5). Hence, measures of dependence, such as
modified Rankin Scale (mRS), Barthel Index (BI)
and Functional Independence Measure (FIM) are
widely used in stroke trials and rehabilitation (6, 8,
11, 12). However, measures of participation are not
included in these traditional outcome measures (13,
14), although participation would appear to be the
most meaningful measure for the patient (6). So far,
there is no agreement about which critical measures
should be routinely captured (4, 15, 16). Instead of a
single instrument, a standard set of patient-centred and
patient-reported outcome measures after stroke have
been suggested to quantify outcomes accurately with
validated instruments (16, 17).
To unify the assessment of functioning globally,
regardless of health condition, the World Health Orga-
nization (WHO) has developed a generic patient- and
proxy-reported instrument to measure both activities
and participation, the WHO Disability Assessment
Schedule (WHODAS 2.0), which has been validated
in various conditions, including stroke (18). The short
12-item form of WHODAS 2.0 has been found to be
practical for use in various clinical settings (19–24).
Another short ICF-based instrument, the 7-item WHO
Minimal Generic Set of domains of functioning and
health, has been suggested for use as a starting point
to address comparability of data across studies (25).
As far as we know, there are no studies investigating
the utility of these 2 short ICF-based instruments in
subacute stroke. It is essential to assess patient and
proxy experiences of difficulties in activities and par-
ticipation early in post-stroke rehabilitation in order
to plan rehabilitation goals, discharge dispositions
and future community services. To find suitable tools
for this planning, we decided to compare these short
ICF-based tools (the 12-item WHODAS 2.0 and the
7-item WHO Minimal Generic Set) at discharge from
the stroke rehabilitation ward with 2 commonly used
outcome measures of dependence, FIM and mRS, in
different severity groups of stroke based on NIHSS
score.
PATIENTS AND METHODS
In this observational cross-sectional study, 195 consecutive
patients in intensive subacute inpatient stroke rehabilitation
were recruited between August 2015 and August 2018. Ques-
tionnaires, including the 12-item WHODAS 2.0 (18), and
personal background information (age, sex, accommodation,
www.medicaljournals.se/jrm
marital status, educational level, and working status), along with
informed consent, were completed by 167 (of 195) patients and
195 significant others at discharge from rehabilitation. Based on
clinical judgement, 28 patients were not capable of completing
the WHODAS scale because of the cognitive impairment caused
by a severe stroke and aphasia (Table I). The patients and their
significant others were blinded to each other’s evaluations.
Clinical information (date of diagnosis and comorbidities)
was gathered from the hospital records and by interviewing
the patients and their significant others, and the total number
of comorbidities was counted (26, 27). The stroke survivors
(diagnosis according to the International Classification of Di-
seases, 10 th revision (ICD-10) criteria) were mostly referred to
the neurological rehabilitation unit from the acute stroke unit of
the same university hospital. Sometimes the patient had to wait
on a general ward for stabilization of the medical condition after
acute stroke unit care before intensive rehabilitation or because
of lack of capacity of the rehabilitation ward. For admission to
intensive rehabilitation, the patients had to be able to sit for a
minimum of 30 min. Exclusion criteria were age under 16 years
at time of stroke onset, previous stroke, a current major medi-
cal or psychotic condition, or another neurological diagnosis
with functional impairment, brain injury without radiological
findings, and medical reasons for interrupted rehabilitation.
The severity of stroke was classified by a neurologist into
mild, moderate or severe according to NIHSS (5) firstly in the
acute phase (initial and 24-h NIHSS), and secondly on admis-
sion to rehabilitation unit. The participants were divided into 3
severity groups according to the 24-h NIHSS sum score (28);
0–5 was considered mild, 6–14 moderate, and 15–42 severe
stroke.
At discharge from inpatient rehabilitation, a neurologist as-
sessed the dependence of patients with the mRS, ranging from
0: no dependence to 6: death (5), and their disability with the
7-item WHO Minimal Generic Set (25). A rehabilitation nurse,
trained as a FIM rater, assessed the level of dependence of each
patient at admission and discharge using an electronic FIM tool
(FIM™ version 5.2, Uniform Data System for Medical reha-
bilitation, Amherst, NY, USA) rating all items on a scale 1–7
(“total dependence” to “complete independence”) to sum score
(18–126) and motor and cognitive sub-scores (29).
The 12-item WHODAS 2.0 includes 12 items assessing 6
disability domains in 2 components. The component “activi-
ties” includes cognition (learning and concentration), mobility
(standing and walking) and self-care (washing and dressing
oneself), and the component “participation” includes getting
along (dealing with strangers and maintaining friendships), life
activities (doing housework and working ability), and social
participation (emotional functions and engaging in community).
Each of the 12 items is rated according to a 5-point Likert-type
scale, which grades the difficulty experienced by the participant
in performing a given activity. The scoring is from 0 to 4, where
0 means no (0–4%), 1 means mild (5–24%), 2 means moderate
(25–49%), 3 means severe (50–95%), and 4 means extreme
or complete (96–100%) difficulty in this specific activity. The
total score of WHODAS is the sum of all these 12 sub-scores
and ranges from 0 to 48, with lower scores indicating better
functioning. Total scores of 1–4 belong to mild disability, 5–9 to
moderate disability, and 10–48 to severe disability (18, 19, 30,
31) (http//www.who.int/classifications/ICF/who/whodasii/en/).
The WHO Minimal Generic Set consists of 7 ICF domains:
energy and drive functions, emotional functions, sensation of
pain, carrying out daily routine, walking, moving around, and
remunerative employment. Generic means that this assessment
scale is applicable to all people despite of their health conditions.