680
S. Tarvonen-Schröder et al.
outcome measures. The slight differences across used
scales in the current study reflect the differing emphasis
on various outcome components (i.e. stroke severity,
dependence or functioning including physical, cogni-
tive and emotional difficulties, activity limitations and
restrictions in participation) of the instruments used. In
addition, the conventional instruments do not measure
the way (quality) performance in activities of daily living
is accomplished. All these scales may also be partly
influenced by the new phase of life for the patients and
their significant others, with the consequences of the
cerebrovascular accident and recent big changes, loss
and recovery of functioning. In this phase of rehabili-
tation before discharge, the patients had made home
visits (minimum one weekend) with the aid of their
significant others, but they had not yet fully resumed
their usual roles and activities, while residing mostly
in hospital since stroke onset (5). However, a clear
relationship between initial physician-rated disability
and self-rated functioning at discharge from subacute
inpatient rehabilitation was found. The results are also
in line with previous findings, that many patients even
with mild strokes have significant disability at discharge
from rehabilitation or 3 months post-stroke (33–35).
Previous studies of WHODAS 2.0 in stroke patients
have usually been based on a longer version of this
scale (36). The aim of the current study was to identify
as simple validated functioning scales as possible,
and the 12-item WHODAS 2.0 was found suitable,
especially as, in previous studies among patients with
amyotrophic lateral sclerosis, traumatic brain injury,
spinal cord injury and spinal pain (20–24), this mea-
sure was easy to apply for both patients and significant
others. As WHODAS includes not only activities, but
also items of participation, it provides a wider per-
spective for goal-setting and service-planning than the
conventional instruments. As a self-report instrument it
enhances individual patient- and family-centred proce-
dures in rehabilitation processes. The WHO Minimal
Generic Set is very brief, but it captures 7 items in
body functions, activities and participation. As these
2 ICF-based tools are short and concise, the burden to
the respondents is minimized. Also, other ICF-based
disease-specific functioning tools can be used in stroke
patients, but other measures are usually more time-
consuming (ICF checklist, ICF Comprehensive and
Brief Core Sets for Stroke). In the current study, the
12-item WHODAS had a strong inverse relationship
with the dependence measure FIM in the same way as
in a previous stroke study comparing ICF Brief Core
Set for stroke with FIM scores (37). In previous studies
with different diagnostic patient populations a similar
positive correlation has been found between WHODAS
2.0 and other measures of dependence (19).
www.medicaljournals.se/jrm
Interestingly, in the current study, even if relationships
between WHODAS ratings and other generic measures
were strong to very strong, they were even stronger in
proxy ratings compared with patient ratings. This result
is also in line with a previous study of subacute stroke
survivors (38). Significant others rated many activity
items more impaired than did the patients. As stroke
survivors in intensive rehabilitation are constantly en-
couraged to perform in activities of daily living, they
may think more of the capabilities they still have left
and perhaps the tasks they still can perform with assis-
tance than the activities they have lost. Proxies, on the
other hand, may think more of the capabilities lost, the
changed role, the dependence and need for help of the
patient at the time of discharge. In addition, patients with
more severe stroke may lack insight into the situation
at this early stage, especially in more complex items,
such as work. Also, cognitive and emotional functions
and, especially, relationships may be more difficult and
subjective items to rate before discharge. Clearly, abso-
lute comparisons between assessments by patients and
proxies are not possible, as appropriate weight cannot
be given to how a person will perceive his or her own,
or someone else’s, severity. However, as the correlations
between the patient and proxy WHODAS scores on the
whole, and also in single items were mostly moderate
to very strong, it seems possible, that, when assessing
functioning 2–3 months post-stroke, most of the patients
are able to make assessments reliably. The results of this
study are in line with a previous study of subacute stroke
survivors with moderate-to-strong correlations between
patient and proxy ratings in many functional items (38).
Although a physician who rated functioning using
the WHO Minimal Generic Set and dependence with
mRS was not blinded to background information, his
or her ratings sounded reasonable and could be even
more reliable through his or her insight into the clinical
history of the participants. Physician-rated functioning,
on the whole and in single items, correlated well with
stroke severity. The fact that working ability was rated
more impaired by a physician than by patients themsel-
ves is interesting. Only one-third of the patients were
employed at the time of the stroke, and at the time of
discharge all rehabilitants were on sick-leave trying to
readjust to community life, which could influence the
physician’s ratings. Many patients, as retirees, may have
a more subjective view of their employment capabilities
and the functioning ability they still have in diverse
voluntary and domestic work possibilities, whereas a
physician may think more of the requirements in the
open labour market reflected by the activity restrictions
and participation limitations the patients may have.
This study has some limitations. The cross-sectional
study design does not allow confirmation of causal re-