The TWIST Tool Predicts When Patients Will Recover Independent Walking After Stroke: An Observational Study

Abstract

Background The likelihood of regaining independent walking after stroke influences rehabilitation and hospital discharge planning. Objective This study aimed to develop and internally validate a tool to predict whether and when a patient will walk independently in the first 6 months post-stroke. Methods Adults with stroke were recruited if they had new lower limb weakness and were unable to walk independently. Clinical assessments were completed one week post-stroke. The primary outcome was time post-stroke by which independent walking (Functional Ambulation Category score ≥ 4) was achieved. Cox hazard regression identified predictors for achieving independent walking by 4, 6, 9, 16, or 26 weeks post-stroke. The cut-off and weighting for each predictor was determined using β-coefficients. Predictors were assigned a score and summed for a final TWIST score. The probability of achieving independent walking at each time point for each TWIST score was calculated. Results We included 93 participants (36 women, median age 71 years). Age < 80 years, knee extension strength Medical Research Council grade ≥ 3/5, and Berg Balance Test < 6, 6 to 15, or ≥ 16/56, predicted independent walking and were combined to form the TWIST prediction tool. The TWIST prediction tool was at least 83% accurate for all time points. Conclusions The TWIST tool combines routine bedside tests at one week post-stroke to accurately predict the probability of an individual patient achieving independent walking by 4, 6, 9, 16, or 26 weeks post-stroke. If externally validated, the TWIST prediction tool may benefit patients and clinicians by informing rehabilitation decisions and discharge planning.

Recovery of Quiet Standing Balance and Lower Limb Motor Impairment Early Poststroke: How Are They Related?

“…Regaining steady-state balance during quiet standing is mainly achieved within the first 3 months poststroke 1,2 and is a prerequisite for accomplishing independent gait and most activities of daily life. [2][3][4] Despite its clinical importance, a limited number of observational studies have investigated how lower limb motor recovery associates longitudinally with steady-state balance improvements within this time window.…”

Association between balance recovery during inpatient rehabilitation and gait without physical assistance in severe subacute post‐stroke patients

“…The discrimination as accurately as possible regarding the patients' chance of walking again is essential to determine realistic goals during the post‐stroke rehabilitation programs. The degree of motor impairments at the beginning of the rehabilitation is related to gait recovery and has been reported in previous studies (Bland et al., 2012; Duarte et al., 2010; Gianella et al., 2019; Jenkin et al., 2021; Kwah et al., 2013; Lee et al., 2021; Liao et al., 2021; Louie & Eng, 2018; Makizako et al., 2015; Masiero et al., 2007; Smith et al., 2017, 2022; Veerbeek et al., 2011). However, if we focus on patients with initial severe impairments, the balance at inpatient discharge is weakly related to the balance at admission (Gath et al., 2021).…”

“…These patients are those in whom admission balance is weakly related to balance at discharge (Gath et al., 2021). Moreover, in the TWIST Study (Smith et al., 2022), a BBS score below 6 was a predictor chance of achieving independent gait. In our study, only 6% of the patients achieved independent gait during inpatient rehabilitation (FAC ≥4).…”

“…Balance is widely accepted as a factor associated with gait recovery post‐stroke (Bland et al., 2012; Duarte et al., 2010; Gianella et al., 2019; Jenkin et al., 2021; Kollen et al., 2005; Kwah et al., 2013; Lee et al., 2021; Liao et al., 2021; Louie & Eng, 2018; Makizako et al., 2015; Masiero et al., 2007; Smith et al., 2017, 2022; Veerbeek et al., 2011). Most of the studies that analyze this relationship are based on evaluations carried out at a certain time, mainly in the first days or weeks after a stroke.…”

“…Louie & Eng, 2018;Makizako et al, 2015;Masiero et al, 2007;Smith et al, 2017Smith et al, , 2022Veerbeek et al, 2011). However, if we focus on patients with initial severe impairments, the balance at inpatientF I G U R E 1 Flowchart of participants for inclusion.4 of 8 -CF ET AL.…”