The Influence of Multimorbidity on Rehabilitation Outcomes in Stroke and Amputation

Monday, 31 July 2017: 10:20 PM

Bianca Ivonne Buijck, PhD, MScN
P/A Laurens, Rotterdam Stroke Service, Rotterdam, Netherlands


Multimorbidity is highly prevalent in older patients who rehabilitate in skilled nursing facilities (SNFs). In these SNFs, nurses have an important role in the rehabilitation process of patients. Although the high prevalence of multimorbidity, studies aimed at identifying determinants of outcome in elderly patients with multimorbidity that rehabilitate after stroke or lower limb amputation (LLA) in SNFs, are scarce. Therefore, this study aimed to investigate the influence of multimorbidity on rehabilitation outcomes in stroke and LLA.




The Geriatric Rehabilitation in AMPutation and Stroke (GRAMPS) study is a prospective, multicentre, cross sectional study in 15 SNFs. Univariate, and multivariate logistic and linear regression analyses were used to identify multimorbidity as independently related determinant of rehabilitation outcomes, such as postural imbalance (for stroke), and prosthetic use and timed-up-and-go test (for LLA).



186 patients with stroke and 46 patients with LLA were included in the study. Multimorbidity was present in 34% of the stroke patients and 53% of the patients with LLA. The stroke patients with multimorbidity differed from the patients without multimorbidity with respect to age, proprioception, and vibration sense, but not for any of the cognitive tests, muscle strength, or sitting balance. Patients with multimorbidity had, on average, lower scores on outcome measures. In linear regression analyses, both balance and walking abilities were best explained by multimorbidity, muscle strength, and the interaction between muscle strength and static sitting balance (overall explained variance 66% and 67%, respectively). In LLA patients multimorbidity was not independently related to prosthetic use.

Being able to ambulate independently, and having a transtibial amputation (rather than a higher level of amputation), without phantom pain, determined prosthetic use (R2=56%), while cognitive abilities, low amputation level, and pre-operative functional abilities were independently associ­ated with the timed-up-and-go test test (R2=82%).




Multimorbidity was independently related to postural imbalance after stroke in patients admitted for rehabilitation in SNFs, but surprisingly multimorbidity had no significant role on rehabilitation outcomes of patients with LLA, even though other authors found an associa­tion between multimorbidity and prosthetic use. However, multimorbidity was evenly distributed between patients with, and patients without, a prosthesis. Therefore, it could not give an independent contribution to prosthetic use. Because the presence of multiple chronic diseases influences the performance of stroke and LLA patients during rehabilitation in het SNF, it is important that nurses have insight in rehabilitation outcome.