Relationship between rehabilitation duration, functional independence measure performance index, and health-related quality of life in stroke survivors in Japan:  A cross-sectional study

Relationship between rehabilitation duration, functional independence measure performance index, and health-related quality of life in stroke survivors in Japan: A cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Relationship between rehabilitation duration, functional independence measure performance index, and health-related quality of life in stroke survivors in Japan: A cross-sectional study Junichiro Muranaka, Satoshi Sasada, Kohei Ikeda This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4225287/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose This study aimed to explore the relationship between the duration of rehabilitation of stroke survivors and the functional independence measure (FIM) performance index and health-related quality of life (HRQOL). Methods The study included stroke patients from 66 medical institutions in Kanagawa Prefecture, Japan who were admitted to and discharged from convalescent rehabilitation wards. Data on the FIM and HRQOL scores and duration of rehabilitation at discharge were collected for analysis, which included correlation analysis and statistical tests for differences. Results The study analysed data from 160 participants (103 men and 57 women), with the results showing that an extended rehabilitation duration had a negative effect on the FIM performance index and HRQOL (correlation between rehabilitation duration and FIM performance index :r= -0.43, P < 0.01; correlation between rehabilitation duration and HRQOL:r= -0.26, P < 0.01). Conversely, a small but significant positive correlation was observed between the FIM gain and the EQ-5D-5L HRQOL measure (r = 0.34, P < 0.01). Conclusion The study findings suggest that excessively prolonged rehabilitation may adversely affect FIM performance index and HRQOL in stroke survivors, highlighting the importance of optimizing rehabilitation duration to improve outcomes in stroke rehabilitation. stroke health-related quality of life rehabilitation functional independence measure hospital stay Figures Figure 1 Figure 2 Figure 3 Introduction In the Japanese healthcare system, a rehabilitation facility that specializes in rehabilitation is known as a Kaifukuki Rehabilitation Ward. The Kaifukuki Rehabilitation Ward system was introduced into the Japanese healthcare system in 2000; it provides intensive rehabilitation to improve activities of daily living (ADL) and discharge for patients with central nervous system disorders and orthopaedic conditions such as stroke and femur fractures. There is a maximum length of hospital stay of 150 days for patients with stroke (180 days for severe higher brain dysfunction) and 90 days for those with orthopaedic conditions such as femoral neck fractures [ 1 ]. The Kaifukuki Rehabilitation Ward system allows a maximum of 180 min of rehabilitation per day, which is rare, even globally [ 2 ]. According to the World Health Organization (WHO), approximately 5 million people suffer a stroke every year. A stroke is defined as a cerebral blood vessel disorder resulting from insufficient blood flow to the brain due to a thrombus, embolus, or haemorrhage, leading to neurological problems [ 3 , 4 ]. In 2016, the functional independence measure (FIM) performance index was introduced as a clinical outcome in recovery centres; it is calculated based on the proportion of discharged patients returning home, increase in FIM motor items and length of hospital stay. The FIM was developed by Granger in the 1980s and later translated into Japanese [ 5 ]. The FIM database is used as one of the indicators for determining reimbursement in countries like Australia and the UK [ 6 , 7 ]. The number of rehabilitation hours has a positive effect on the FIM in stroke survivors, as found in a study by Ottenbacher [ 8 ] and in a meta-analysis by Kwakkel [ 9 ]. These studies demonstrated that the number of hours of rehabilitation is related to improvement in FIM scores. However, the FIM has a floor effect in patients with severe disabilities and a ceiling effect in patients with mild disabilities [ 10 ]. Furthermore, as the FIM is directly related to reimbursement, it has been suggested that there may be changes in the scores of FIM motor items at admission and discharge; moreover, the need to re-examine the validity of the FIM assessment after the introduction of the system has been recognized [ 11 ]. Accordingly, the FIM performance index using FIM motor items presents a challenge in rehabilitating stroke patients in Japan. Improving health-related quality of life (HRQOL) is an important goal in modern rehabilitation medicine. HRQOL is widely accepted as one of the most important indicators of stroke outcomes [ 12 ]. Previous studies on stroke and HRQOL have shown that functional status, depression, social support, age, gender, and race are important determinants of HRQOL, with functional status and depression being the most important determinants [ 13 ]. A Dutch study monitored changes in HRQOL in the first 12 months after stroke and identified physical and psychosocial factors. The study showed that psychological factors (personality, coping style, understanding of the illness, and self-efficacy) were the most important factors in identifying people at risk of poor HRQOL after stroke [ 14 ]. Other studies have identified three additional psychosocial factors that influence health-related HRQOL: sense of coherence, understanding of stroke, and self-efficacy [ 15 ]. According to a literature study of 704 papers by Chen et al., stroke, rehabilitation, and HRQOL were the top three most frequently occurring terms [ 16 ]. This suggests that the QOL of stroke survivors requires special attention in the field of rehabilitation. Although previous studies have shown an association between the duration of rehabilitation and FIM score [ 8 , 9 ], no study has investigated the association between rehabilitation duration and the FIM performance index. Furthermore, the relationship between the number of rehabilitation hours and HRQOL, a critical indicator of rehabilitation effectiveness, has not been discussed. It is important to investigate the FIM performance index and other variables that measure the efficiency of rehabilitation medicine. Therefore, this study aimed to investigate the relationship between the hours of rehabilitation provided by physical therapists, occupational therapists, and speech therapists, and the FIM performance index and HRQOL in stroke patients. The results of the study will allow us to demonstrate how the duration of rehabilitation is related to efficient changes in the FIM and HRQOL and provide insights for optimizing outcomes in future stroke rehabilitation. Materials and Methods Stroke patients admitted to and discharged from recovery-phase rehabilitation wards were enrolled in this study. The inclusion criteria were (1) stroke patients admitted to recovery-phase rehabilitation wards of 66 medical institutions in Kanagawa prefecture, Japan; (2) patients who were to be discharged from recovery-phase rehabilitation wards; (3) patients with adequate levels of cognitive function to understand the study description and contents of the face sheet and HRQOL assessment; and (4) patients with communication skills to answer the questionnaires. The study was conducted in accordance with the principles of the Declaration of Helsinki. Additionally, this study was conducted in accordance with the STROBE Statement, which is a guideline for reporting observational studies. Data collection The study was approved by the Research Ethics Committee of the Kanagawa University of Human Services, Japan (No. 7-20-66). The principal investigator provided comprehensive written information to all research collaborators and study participants, outlining the study's objectives, methods, potential risks, benefits, and more. Data collection commenced only after securing written consent from each participant. Furthermore, the potential presentation of research findings at conferences and their publication in academic journals was discussed, and consent was obtained from all research facilities, collaborators, and study participants. Data were collected by a research associate at a healthcare facility where informed consent for the study had been obtained up to 10 days before the patient's scheduled discharge. Each item was collected from the study participants and recorded on a face sheet by the research assistant. The formula for calculating the FIM performance index is shown in Fig. 1 . The sample size for this study was calculated based on a priori power analysis using the G*Power 3.1 statistical software. The effect size was estimated to be moderate (d = 0.5) based on similar studies in the literature. The alpha error was set at 0.05 and the power (1-β error) was set at 90%. These conditions revealed that a minimum of 70 participants per group were required to satisfy the study requirements. Furthermore, to account for potential data loss or dropout, the sample size for each group was increased by 10% to 80 participants, aiming for a total sample of 160 participants. Data analysis The EQ-5D-5L was used to assess patients’ HRQOL; data on the FIM performance index, age, sex, length of hospital stay, return-to-home status, and number of units (hours) of each patient were collected using a research questionnaire. The unit of measurement for medical reimbursement in Japan is based on hours, with 20 min constituting one unit and a daily limit of nine units (equivalent to 180 min). Subsequently, we computed correlation coefficients among various variables, including length of hospital stay, performance index, hours of occupational therapy, hours of physiotherapy, hours of speech and language therapy, total hours, EQ-5D-5L HRQOL scores, visual analogue scale (VAS) scores, and FIM gain. Patients were divided into two groups based on length of hospital stay: those whose length of stay was longer than the mean (95.01 days) and those whose length of stay was shorter than the mean; the difference between their FIM gain and HRQOL scores was tested statistically. Differences were tested using the Student's t-test and the Mann–Whitney U test, with a 5% significance level for each statistic. Results Overview of the participants A total of 12 recovery units were recruited according to the selection criteria. Data were collected from 174 patients, of whom 160 were included in the study (103 men and 57 women); 14 patients were excluded due to errors or omissions. Missing values were handled by listwise case deletion, where all missing data were excluded. After discharge from the rehabilitation units, 147 patients were discharged to their homes and five to an institution. The mean age of the patients was 73.26 ± 11.09 years, and the mean length of hospital stay was 95.01 ± 43.52 days. The mean performance index was 63.06 ± 39.19, and the mean total number of therapy hours was 723.44 ± 444.97. The mean EQ-5D-5L HRQOL utility score was 0.74 ± 0.21, the mean EQ-5D-5L VAS score was 72.32 ± 20.02, and the mean FIM gain was 33.76 ± 16.47 (Table 1 ). Table 1 Summary table of study participants Data (item) Mean (standard deviation) Age (years) 73.26 (11.09) Length of hospital stay (days) 95.01 (43.52) Performance index 63.06 (39.19) Number of occupational therapy practices 267.6 (137.66) Number of physical therapy practices 331.36 (196.29) Number of speech therapy practices 124.5 (102.96) Total number of units implemented 723.44 (444.96) EQ-5D-5L (index) 0.74 (0.21) EQ-5D-5L (visual analogue scale) 72.36 (20.02) FIM gain 33.76 (16.47) Sex Female: 57 Male: 103 Post-discharge Returning home: 147 Others: 13 EQ-5D-5L, EuroHRQOL-5 Dimensions-5 Levels ; FIM, Functional Independence Measure Correlation coefficient for each variable Table 2 shows the correlation coefficients for nine variables. The “number of units (hours)” represents a unit of Japanese medical reimbursement, where each unit comprises 20 min, and there is a daily limit of 9 units (180 min) per day. In the correlation coefficients, P < 0.01 is indicated by **. The number of Occupational Therapy (OT) practices, number of Physical Therapy (PT) practices, number of Speech Therapy (ST) practices, and total number of practices all showed a strong positive correlation with length of hospital stay (P < 0.01). In addition, there was an inverse association between the length of hospital stay and total number of practices and EQ-5D-5L (index) [P < 0.01]. However, the correlation coefficient between length of hospital stay and FIM gain was r = 0.34 (P < 0.01). Table 2 Correlation coefficients for each variable **=P < 0.01 Length of hospital stay Performance index Number of OT practices Number of PT practices Number of ST practices Total number of practices EQ-5D-5L (Index) EQ-5D (VAS) FIM gain Length of hospital stay 1 Performance index -0.46** 1 Number of OT practices 0.79** -0.43** 1 Number of PT practices 0.79** -0.38** 0.72** 1 Number of ST practices 0.5** -0.18 0.3** 0.29** 1 Total number of practices 0.88** -0.43** 0.86** 0.9** 0.58** 1 EQ-5D-5L (Index) -0.34** 0.31** -0.21** -0.26** -0.12** -0.26** 1 EQ-5D (VAS) -0.15 0.21** -0.06 -0.08 -0.05 -0.08 0.62** 1 FIM gain 0.34** 0.46** 0.23** 0.24** 0.24** 0.29** 0.1 0.1 1 PT, Physical Therapy; OT, Occupational Therapy; ST, Speech Therapy; VAS, Visual analogue scale; FIM, Functional Independence Measure Inverse correlations between the performance index and PT, OT, ST, and the total number of units implemented (total number of hours) were found for all variables (P < 0.01). Meanwhile, positive correlations were found between EQ-5D-5L (index), EQ-5D (VAS scores), and FIM gain. For variables correlating with the total number of practice, an inverse correlation was found with the EQ-5D-5L (index) with r = -0.26 (P < 0.01), whereas a positive correlation was found with FIM gain (r = 0.29, P < 0.01). Difference in HRQOL and FIM gains There were 83 patients in the shorter hospital stay group, with a mean FIM gain of 29.74 ± 16.40. The longer stay group had 77 patients, with a mean FIM gain of 38.12 ± 16.49 A Student t-test was performed, yielding a t-value of -3.12 (upper bound of 1.975), and FIM gain was significantly higher in the longer hospital stay group than in the shorter hospital stay group (P < 0.01) (Fig. 2 ). The Mann–Whitney U test for difference in EQ-5D-5L (HRQOL) showed that the mean rank of the shorter stay group was 91.81 and that of the longer-stay group was 68.31. The shorter stay group had a significantly higher HRQOL (EQ-5D-5L) than did the longer stay group (P < 0.01), with an equal rank corrected Z score of 3.22 (upper bound 1.96) (Fig. 3 ). Discussion In the test for differences in FIM gain during hospital stay, FIM gain was significantly higher in the longer hospital stay group than in the shorter hospital stay group, with a t-value of -3.12 (upper bound of 1.975). According to stroke treatment guidelines, an increase in the number of rehabilitation hours is associated with better recovery of ADLs [ 17 , 18 ]; in addition, an increase in the number of rehabilitation hours relative to the length of hospital stay improves FIM gain in stroke patients. However, the correlation coefficient in this study indicated a significant negative correlation between the total number of rehabilitation hours and the FIM performance index, with r = -0.43 (P < 0.01). This result suggests that rehabilitation hours may be increase in cases where efficient gains in FIM scores are not expected. Kwakkel et al. showed that a continuous, intensive approach is more effective than a sporadic, prolonged approach [ 19 ]. Sonoda et al. reported that the cost required to increase the FIM score by one point was reduced by training 24 h a day, seven days a week, at a higher intensity than conventional rehabilitation [ 2 ]. In other words, it is predicted that in recovery centres, short-term intensive rehabilitation input would be more conducive to improving the FIM than a long-term approach. The results of this study suggest that the number of rehabilitation hours may contribute to some improvement in ADLs for stroke survivors; however, it may lead to unnecessarily long hospital stays and inefficient rehabilitation hours when a ceiling effect occurs in patients with no further improvement in FIM expected or for stroke survivors who have difficulty being discharged. Furthermore, the correlation coefficient between the number of rehabilitation hours and HRQOL was r = -0.26 (P < 0.01), with a significant negative correlation between length of hospital stay and QOL (r = -0.34; P < 0.01). This suggests that the number of rehabilitation hours may have a negative impact on HRQOL in stroke patients. Furthermore, the statistical test of difference in this study showed that HRQOL was higher in the shorter hospital stay group than in the longer hospital stay group (Z score = 3.22; P < 0.01). Ramos-Lima et al. showed that HRQOL was significantly negatively correlated with the Modified Rankin and National Institutes of Health Stroke Scale (NIHSS) scores, which could be due to the patients’ higher clinical severity or lower functional status, suggesting a lower QOL [ 20 ]. In addition, a Brazilian study reported that patients who had more complications on admission and consequently had a longer hospital stay had lower functionality and QOL after discharge [ 21 ]. Therefore, it is possible that in the present study, the shorter hospital stay group had more patients with a higher functional level and ADL capacity. Stroke and lower QOL are largely related to mental and psychological decline. Depressive symptoms and apathy are reported to be approximately 33% [ 22 ] and 36% [ 23 ], respectively, more common following a stroke. These post-stroke mental and psychological problems may worsen rehabilitation and HRQOL and increase mortality [ 13 , 24 ]. In addition, studies in Africa have shown that disability and depression reduce HRQOL [ 21 ]. Accordingly, prolonged hospital stays can lead to negative psychological and economic consequences, such as increased depression and social isolation in patients and increased financial burden. These findings suggest that a longer hospital stay is likely to significantly affect HRQOL, especially in patients with low functional levels and mental and psychological decline. It is generally accepted that rehabilitation is positively related to HRQOL [ 25 – 28 ]. However, existing studies focused on the quality and methods of rehabilitation but did not clarify the relationship between the number of rehabilitation hours and HRQOL. Therefore, the novelty of this study is that it focused on the number of rehabilitation hours of stroke survivors in Japan and examined the relationship with the FIM performance index and HRQOL. In the present study, the correlation coefficient between the number of days in hospital and total number of rehabilitation units was r = 0.88 (P < 0.01), suggesting that the number of days of hospitalization and number of hours of rehabilitation are strongly associated variables. This association exists because, from the perspective of ward management, rehabilitation needs to be provided for stroke survivors as long as they remain in recovery rehabilitation units of hospitals. However, as demonstrated by the results of this study, unsystematically increasing the number of rehabilitation hours during the hospitalization period is likely to be negatively associated with the FIM performance index and HRQOL. Regarding the required length of hospital stay for stroke survivors, Jorgensen et al. reported that it takes 12.5 weeks for maximum ADL improvement to be achieved in more than 95% of stroke patients [ 29 ]. Therefore, in the rehabilitation of stroke survivors, specific lengths of hospital stay need to be considered; however, caution may need to be exercised in increasing the number of rehabilitation hours. The correlation coefficient between the FIM performance index and HRQOL (EQ-5D-5L) was r = 0.31 (P < 0.01) and the correlation coefficient with EQ-5D (VAS) was r = 0.21 (P < 0.01), indicating a small but significant positive correlation between improved FIM performance index and HRQOL. Therefore, optimizing the length of hospital stay may be one of the most important considerations in improving the FIM performance index and HRQOL. Limitations The present study has several limitations. First, it was conducted within a specific region of Japan, and therefore, the findings may not be readily applicable to other regions or countries. Consequently, further research encompassing diverse geographical locations is warranted for broader generalization. Second, the study focused on the relationship between length of hospital stay, number of rehabilitation hours, and HRQOL and clinical outcomes without considering other potential factors and variables. Third, the study did not account for the impact of the number of rehabilitation hours on FIM performance index and HRQOL, which represents a notable gap in our research. Fourth, the study did not stratify patients according to the quality and content of rehabilitation or the severity of their illness; therefore, other factors that may affect HRQOL and outcomes need to be included. Finally, this study focused on identifying associations; therefore, to determine the causal relationship between rehabilitation and FIM performance index and HRQOL, experimental studies, such as long-term prospective cohort studies or randomised controlled trials, are needed. Declarations Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript． Competing Interests The authors have no relevant financial or non-financial interests to disclose. Data Availability Data availability statement The dataset utilized in this study is not publicly accessible to ensure the confidentiality of sample collection and to adhere to the terms regarding the protection of personal information provided by participants. Access to the data in Microsoft Excel format may be granted upon a reasonable and ethically approved request. Researchers interested in accessing the data should contact the corresponding author, Junichiro Muranaka, at [email protected] , to discuss the terms under which access may be provided, including any necessary ethical approvals and data use agreements. Author Contributions All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by [Junichiro Muranaka], [Satoshi Sasada], and [Kohei Ikeda]. The first draft of the manuscript was written by [Junichiro Muranaka], and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Ethics approval This study was performed in line with the principles of the Declaration of Helsinki. The study was approved by the Research Ethics Committee of the Kanagawa University of Human Services, Japan (No. 7-20-66). Consent to participate Informed consent was obtained from all individual participants included in the study. Consent to publish The potential presentation of research findings at conferences and their publication in academic journals were discussed, and consent was obtained from all research facilities, collaborators, and study participants. References Kinoshita S, Abo M, Okamoto T, Miyamura K. 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Int J Stroke. 2104;9:341–8. https://doi.org/10.1111/ijs.12149 Wang R, Langhammer B. Predictors of quality of life for chronic stroke survivors in relation to cultural differences: A literature review. Scand J Caring Sci. 2018;32:502–14. https://doi.org/10.1111/scs.12533 Jørgensen HS, Nakayama H, Raaschou HO, Vive-Larsen J, Støier M, Olsen TS. Outcome and time course of recovery in stroke. Part II: Time course of recovery. The Copenhagen stroke study. Arch Phys Med Rehabil. 1995;76:406–12. https://doi.org/10.1016/S0003-9993(95)80568-0 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4225287","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":290338202,"identity":"2f41fd9b-a648-46da-b38f-104eb8a99386","order_by":0,"name":"Junichiro Muranaka","email":"data:image/png;base64,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","orcid":"","institution":"Chigasaki Rehabilitation College","correspondingAuthor":true,"prefix":"","firstName":"Junichiro","middleName":"","lastName":"Muranaka","suffix":""},{"id":290338204,"identity":"f31950c0-8d7b-4899-ac75-50e75da35142","order_by":1,"name":"Satoshi Sasada","email":"","orcid":"","institution":"Kanagawa University of Human Services Graduate School","correspondingAuthor":false,"prefix":"","firstName":"Satoshi","middleName":"","lastName":"Sasada","suffix":""},{"id":290338206,"identity":"fea5abf9-f928-4e6e-ac9b-e56e97878326","order_by":2,"name":"Kohei Ikeda","email":"","orcid":"","institution":"Kanagawa University of Human Services","correspondingAuthor":false,"prefix":"","firstName":"Kohei","middleName":"","lastName":"Ikeda","suffix":""}],"badges":[],"createdAt":"2024-04-06 01:59:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4225287/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4225287/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54997411,"identity":"26d65d11-33da-47a4-8ff3-2ce3e51eac86","added_by":"auto","created_at":"2024-04-19 18:11:39","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":78495,"visible":true,"origin":"","legend":"\u003cp\u003eFormula for calculating the performance index. If a stroke patient (maximum hospital stay of 150 days) is discharged with a functional independence measure (FIM) gain of 30 and 60 days from admission to discharge, the formula is 30 (FIM gain)/60 (Number of days in hospital)/150 (Maximum number of days in hospital), and the performance index is calculated as 12\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4225287/v1/e4faaee9c04f10b3ad7c8f98.jpg"},{"id":54997409,"identity":"676c3d65-7714-4388-a767-84fe7c828eb8","added_by":"auto","created_at":"2024-04-19 18:11:39","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":49627,"visible":true,"origin":"","legend":"\u003cp\u003eDifferences in functional independence measure gains. Functional independence measure (FIM) gain is the change in FIM (TM) motor items. It is calculated as FIM at discharge - FIM at admission\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4225287/v1/98a0c96b27f713abb62b62e3.jpg"},{"id":54997410,"identity":"e899efb6-922d-4afe-b44b-c12472a80c3d","added_by":"auto","created_at":"2024-04-19 18:11:39","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":118085,"visible":true,"origin":"","legend":"\u003cp\u003eDifferences in quality of life (EQ-5D-5L)\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4225287/v1/ab6b40dbe0d0636e0bdfc335.jpg"},{"id":56508566,"identity":"d4a34102-a3cf-4727-915e-28516c25a8ca","added_by":"auto","created_at":"2024-05-15 06:03:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":715498,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4225287/v1/802bb72e-ed47-4fc1-83a6-f226d7091f6c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Relationship between rehabilitation duration, functional independence measure performance index, and health-related quality of life in stroke survivors in Japan: A cross-sectional study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn the Japanese healthcare system, a rehabilitation facility that specializes in rehabilitation is known as a Kaifukuki Rehabilitation Ward. The Kaifukuki Rehabilitation Ward system was introduced into the Japanese healthcare system in 2000; it provides intensive rehabilitation to improve activities of daily living (ADL) and discharge for patients with central nervous system disorders and orthopaedic conditions such as stroke and femur fractures. There is a maximum length of hospital stay of 150 days for patients with stroke (180 days for severe higher brain dysfunction) and 90 days for those with orthopaedic conditions such as femoral neck fractures [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The Kaifukuki Rehabilitation Ward system allows a maximum of 180 min of rehabilitation per day, which is rare, even globally [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. According to the World Health Organization (WHO), approximately 5\u0026nbsp;million people suffer a stroke every year. A stroke is defined as a cerebral blood vessel disorder resulting from insufficient blood flow to the brain due to a thrombus, embolus, or haemorrhage, leading to neurological problems [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 2016, the functional independence measure (FIM) performance index was introduced as a clinical outcome in recovery centres; it is calculated based on the proportion of discharged patients returning home, increase in FIM motor items and length of hospital stay. The FIM was developed by Granger in the 1980s and later translated into Japanese [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The FIM database is used as one of the indicators for determining reimbursement in countries like Australia and the UK [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The number of rehabilitation hours has a positive effect on the FIM in stroke survivors, as found in a study by Ottenbacher [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and in a meta-analysis by Kwakkel [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. These studies demonstrated that the number of hours of rehabilitation is related to improvement in FIM scores. However, the FIM has a floor effect in patients with severe disabilities and a ceiling effect in patients with mild disabilities [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Furthermore, as the FIM is directly related to reimbursement, it has been suggested that there may be changes in the scores of FIM motor items at admission and discharge; moreover, the need to re-examine the validity of the FIM assessment after the introduction of the system has been recognized [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Accordingly, the FIM performance index using FIM motor items presents a challenge in rehabilitating stroke patients in Japan.\u003c/p\u003e \u003cp\u003eImproving health-related quality of life (HRQOL) is an important goal in modern rehabilitation medicine. HRQOL is widely accepted as one of the most important indicators of stroke outcomes [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Previous studies on stroke and HRQOL have shown that functional status, depression, social support, age, gender, and race are important determinants of HRQOL, with functional status and depression being the most important determinants [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. A Dutch study monitored changes in HRQOL in the first 12 months after stroke and identified physical and psychosocial factors. The study showed that psychological factors (personality, coping style, understanding of the illness, and self-efficacy) were the most important factors in identifying people at risk of poor HRQOL after stroke [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Other studies have identified three additional psychosocial factors that influence health-related HRQOL: sense of coherence, understanding of stroke, and self-efficacy [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. According to a literature study of 704 papers by Chen et al., stroke, rehabilitation, and HRQOL were the top three most frequently occurring terms [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This suggests that the QOL of stroke survivors requires special attention in the field of rehabilitation.\u003c/p\u003e \u003cp\u003eAlthough previous studies have shown an association between the duration of rehabilitation and FIM score [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], no study has investigated the association between rehabilitation duration and the FIM performance index. Furthermore, the relationship between the number of rehabilitation hours and HRQOL, a critical indicator of rehabilitation effectiveness, has not been discussed. It is important to investigate the FIM performance index and other variables that measure the efficiency of rehabilitation medicine. Therefore, this study aimed to investigate the relationship between the hours of rehabilitation provided by physical therapists, occupational therapists, and speech therapists, and the FIM performance index and HRQOL in stroke patients. The results of the study will allow us to demonstrate how the duration of rehabilitation is related to efficient changes in the FIM and HRQOL and provide insights for optimizing outcomes in future stroke rehabilitation.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eStroke patients admitted to and discharged from recovery-phase rehabilitation wards were enrolled in this study. The inclusion criteria were (1) stroke patients admitted to recovery-phase rehabilitation wards of 66 medical institutions in Kanagawa prefecture, Japan; (2) patients who were to be discharged from recovery-phase rehabilitation wards; (3) patients with adequate levels of cognitive function to understand the study description and contents of the face sheet and HRQOL assessment; and (4) patients with communication skills to answer the questionnaires. The study was conducted in accordance with the principles of the Declaration of Helsinki. Additionally, this study was conducted in accordance with the STROBE Statement, which is a guideline for reporting observational studies.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003e The study was approved by the Research Ethics Committee of the Kanagawa University of Human Services, Japan (No. 7-20-66). The principal investigator provided comprehensive written information to all research collaborators and study participants, outlining the study's objectives, methods, potential risks, benefits, and more. Data collection commenced only after securing written consent from each participant. Furthermore, the potential presentation of research findings at conferences and their publication in academic journals was discussed, and consent was obtained from all research facilities, collaborators, and study participants. Data were collected by a research associate at a healthcare facility where informed consent for the study had been obtained up to 10 days before the patient's scheduled discharge. Each item was collected from the study participants and recorded on a face sheet by the research assistant. The formula for calculating the FIM performance index is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The sample size for this study was calculated based on a priori power analysis using the G*Power 3.1 statistical software. The effect size was estimated to be moderate (d\u0026thinsp;=\u0026thinsp;0.5) based on similar studies in the literature. The alpha error was set at 0.05 and the power (1-β error) was set at 90%. These conditions revealed that a minimum of 70 participants per group were required to satisfy the study requirements. Furthermore, to account for potential data loss or dropout, the sample size for each group was increased by 10% to 80 participants, aiming for a total sample of 160 participants.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe EQ-5D-5L was used to assess patients\u0026rsquo; HRQOL; data on the FIM performance index, age, sex, length of hospital stay, return-to-home status, and number of units (hours) of each patient were collected using a research questionnaire. The unit of measurement for medical reimbursement in Japan is based on hours, with 20 min constituting one unit and a daily limit of nine units (equivalent to 180 min). Subsequently, we computed correlation coefficients among various variables, including length of hospital stay, performance index, hours of occupational therapy, hours of physiotherapy, hours of speech and language therapy, total hours, EQ-5D-5L HRQOL scores, visual analogue scale (VAS) scores, and FIM gain. Patients were divided into two groups based on length of hospital stay: those whose length of stay was longer than the mean (95.01 days) and those whose length of stay was shorter than the mean; the difference between their FIM gain and HRQOL scores was tested statistically. Differences were tested using the Student's t-test and the Mann\u0026ndash;Whitney U test, with a 5% significance level for each statistic.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eOverview of the participants\u003c/h2\u003e \u003cp\u003eA total of 12 recovery units were recruited according to the selection criteria. Data were collected from 174 patients, of whom 160 were included in the study (103 men and 57 women); 14 patients were excluded due to errors or omissions. Missing values were handled by listwise case deletion, where all missing data were excluded. After discharge from the rehabilitation units, 147 patients were discharged to their homes and five to an institution. The mean age of the patients was 73.26\u0026thinsp;\u0026plusmn;\u0026thinsp;11.09 years, and the mean length of hospital stay was 95.01\u0026thinsp;\u0026plusmn;\u0026thinsp;43.52 days. The mean performance index was 63.06\u0026thinsp;\u0026plusmn;\u0026thinsp;39.19, and the mean total number of therapy hours was 723.44\u0026thinsp;\u0026plusmn;\u0026thinsp;444.97. The mean EQ-5D-5L HRQOL utility score was 0.74\u0026thinsp;\u0026plusmn;\u0026thinsp;0.21, the mean EQ-5D-5L VAS score was 72.32\u0026thinsp;\u0026plusmn;\u0026thinsp;20.02, and the mean FIM gain was 33.76\u0026thinsp;\u0026plusmn;\u0026thinsp;16.47 (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary table of study participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eData (item)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (standard deviation)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73.26 (11.09)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of hospital stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.01 (43.52)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerformance index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.06 (39.19)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of occupational therapy practices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e267.6 (137.66)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of physical therapy practices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e331.36 (196.29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of speech therapy practices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e124.5 (102.96)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal number of units implemented\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e723.44 (444.96)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEQ-5D-5L (index)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.74 (0.21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEQ-5D-5L (visual analogue scale)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72.36 (20.02)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFIM gain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.76 (16.47)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale: 57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale: 103\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePost-discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReturning home: 147\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers: 13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eEQ-5D-5L, EuroHRQOL-5 Dimensions-5 Levels ; FIM, Functional Independence Measure\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eCorrelation coefficient for each variable\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the correlation coefficients for nine variables. The \u0026ldquo;number of units (hours)\u0026rdquo; represents a unit of Japanese medical reimbursement, where each unit comprises 20 min, and there is a daily limit of 9 units (180 min) per day. In the correlation coefficients, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01 is indicated by **. The number of Occupational Therapy (OT) practices, number of Physical Therapy (PT) practices, number of Speech Therapy (ST) practices, and total number of practices all showed a strong positive correlation with length of hospital stay (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). In addition, there was an inverse association between the length of hospital stay and total number of practices and EQ-5D-5L (index) [P\u0026thinsp;\u0026lt;\u0026thinsp;0.01]. However, the correlation coefficient between length of hospital stay and FIM gain was r\u0026thinsp;=\u0026thinsp;0.34 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation coefficients for each variable **=P\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLength of hospital stay\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePerformance index\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNumber of OT practices\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNumber of PT practices\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNumber of ST practices\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTotal number of practices\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEQ-5D-5L \u003c/p\u003e \u003cp\u003e(Index)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eEQ-5D (VAS)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eFIM gain\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of hospital stay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerformance index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.46**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of OT practices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.79**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.43**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of PT practices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.79**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.38**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.72**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of ST practices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.5**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.3**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.29**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal number of practices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.88**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.43**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.86**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.9**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.58**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEQ-5D-5L (Index)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.34**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.31**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.21**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.26**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.12**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.26**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEQ-5D (VAS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.21**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.62**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFIM gain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.34**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.46**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.23**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.24**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.24**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.29**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003ePT, Physical Therapy; OT, Occupational Therapy; ST, Speech Therapy; VAS, Visual analogue scale; FIM, Functional Independence Measure\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eInverse correlations between the performance index and PT, OT, ST, and the total number of units implemented (total number of hours) were found for all variables (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Meanwhile, positive correlations were found between EQ-5D-5L (index), EQ-5D (VAS scores), and FIM gain. For variables correlating with the total number of practice, an inverse correlation was found with the EQ-5D-5L (index) with r = -0.26 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), whereas a positive correlation was found with FIM gain (r\u0026thinsp;=\u0026thinsp;0.29, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDifference in HRQOL and FIM gains\u003c/h2\u003e \u003cp\u003eThere were 83 patients in the shorter hospital stay group, with a mean FIM gain of 29.74\u0026thinsp;\u0026plusmn;\u0026thinsp;16.40. The longer stay group had 77 patients, with a mean FIM gain of 38.12\u0026thinsp;\u0026plusmn;\u0026thinsp;16.49 A Student t-test was performed, yielding a t-value of -3.12 (upper bound of 1.975), and FIM gain was significantly higher in the longer hospital stay group than in the shorter hospital stay group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The Mann\u0026ndash;Whitney U test for difference in EQ-5D-5L (HRQOL) showed that the mean rank of the shorter stay group was 91.81 and that of the longer-stay group was 68.31. The shorter stay group had a significantly higher HRQOL (EQ-5D-5L) than did the longer stay group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), with an equal rank corrected Z score of 3.22 (upper bound 1.96) (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the test for differences in FIM gain during hospital stay, FIM gain was significantly higher in the longer hospital stay group than in the shorter hospital stay group, with a t-value of -3.12 (upper bound of 1.975). According to stroke treatment guidelines, an increase in the number of rehabilitation hours is associated with better recovery of ADLs [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]; in addition, an increase in the number of rehabilitation hours relative to the length of hospital stay improves FIM gain in stroke patients. However, the correlation coefficient in this study indicated a significant negative correlation between the total number of rehabilitation hours and the FIM performance index, with r = -0.43 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). This result suggests that rehabilitation hours may be increase in cases where efficient gains in FIM scores are not expected. Kwakkel et al. showed that a continuous, intensive approach is more effective than a sporadic, prolonged approach [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Sonoda et al. reported that the cost required to increase the FIM score by one point was reduced by training 24 h a day, seven days a week, at a higher intensity than conventional rehabilitation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In other words, it is predicted that in recovery centres, short-term intensive rehabilitation input would be more conducive to improving the FIM than a long-term approach. The results of this study suggest that the number of rehabilitation hours may contribute to some improvement in ADLs for stroke survivors; however, it may lead to unnecessarily long hospital stays and inefficient rehabilitation hours when a ceiling effect occurs in patients with no further improvement in FIM expected or for stroke survivors who have difficulty being discharged.\u003c/p\u003e \u003cp\u003eFurthermore, the correlation coefficient between the number of rehabilitation hours and HRQOL was r = -0.26 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), with a significant negative correlation between length of hospital stay and QOL (r = -0.34; P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). This suggests that the number of rehabilitation hours may have a negative impact on HRQOL in stroke patients. Furthermore, the statistical test of difference in this study showed that HRQOL was higher in the shorter hospital stay group than in the longer hospital stay group (Z score\u0026thinsp;=\u0026thinsp;3.22; P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Ramos-Lima et al. showed that HRQOL was significantly negatively correlated with the Modified Rankin and National Institutes of Health Stroke Scale (NIHSS) scores, which could be due to the patients\u0026rsquo; higher clinical severity or lower functional status, suggesting a lower QOL [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In addition, a Brazilian study reported that patients who had more complications on admission and consequently had a longer hospital stay had lower functionality and QOL after discharge [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Therefore, it is possible that in the present study, the shorter hospital stay group had more patients with a higher functional level and ADL capacity. Stroke and lower QOL are largely related to mental and psychological decline. Depressive symptoms and apathy are reported to be approximately 33% [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and 36% [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], respectively, more common following a stroke. These post-stroke mental and psychological problems may worsen rehabilitation and HRQOL and increase mortality [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In addition, studies in Africa have shown that disability and depression reduce HRQOL [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccordingly, prolonged hospital stays can lead to negative psychological and economic consequences, such as increased depression and social isolation in patients and increased financial burden. These findings suggest that a longer hospital stay is likely to significantly affect HRQOL, especially in patients with low functional levels and mental and psychological decline.\u003c/p\u003e \u003cp\u003eIt is generally accepted that rehabilitation is positively related to HRQOL [\u003cspan additionalcitationids=\"CR26 CR27\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. However, existing studies focused on the quality and methods of rehabilitation but did not clarify the relationship between the number of rehabilitation hours and HRQOL. Therefore, the novelty of this study is that it focused on the number of rehabilitation hours of stroke survivors in Japan and examined the relationship with the FIM performance index and HRQOL.\u003c/p\u003e \u003cp\u003eIn the present study, the correlation coefficient between the number of days in hospital and total number of rehabilitation units was r\u0026thinsp;=\u0026thinsp;0.88 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), suggesting that the number of days of hospitalization and number of hours of rehabilitation are strongly associated variables. This association exists because, from the perspective of ward management, rehabilitation needs to be provided for stroke survivors as long as they remain in recovery rehabilitation units of hospitals. However, as demonstrated by the results of this study, unsystematically increasing the number of rehabilitation hours during the hospitalization period is likely to be negatively associated with the FIM performance index and HRQOL.\u003c/p\u003e \u003cp\u003eRegarding the required length of hospital stay for stroke survivors, Jorgensen et al. reported that it takes 12.5 weeks for maximum ADL improvement to be achieved in more than 95% of stroke patients [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Therefore, in the rehabilitation of stroke survivors, specific lengths of hospital stay need to be considered; however, caution may need to be exercised in increasing the number of rehabilitation hours.\u003c/p\u003e \u003cp\u003eThe correlation coefficient between the FIM performance index and HRQOL (EQ-5D-5L) was r\u0026thinsp;=\u0026thinsp;0.31 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and the correlation coefficient with EQ-5D (VAS) was r\u0026thinsp;=\u0026thinsp;0.21 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), indicating a small but significant positive correlation between improved FIM performance index and HRQOL. Therefore, optimizing the length of hospital stay may be one of the most important considerations in improving the FIM performance index and HRQOL.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThe present study has several limitations. First, it was conducted within a specific region of Japan, and therefore, the findings may not be readily applicable to other regions or countries. Consequently, further research encompassing diverse geographical locations is warranted for broader generalization. Second, the study focused on the relationship between length of hospital stay, number of rehabilitation hours, and HRQOL and clinical outcomes without considering other potential factors and variables. Third, the study did not account for the impact of the number of rehabilitation hours on FIM performance index and HRQOL, which represents a notable gap in our research. Fourth, the study did not stratify patients according to the quality and content of rehabilitation or the severity of their illness; therefore, other factors that may affect HRQOL and outcomes need to be included. Finally, this study focused on identifying associations; therefore, to determine the causal relationship between rehabilitation and FIM performance index and HRQOL, experimental studies, such as long-term prospective cohort studies or randomised controlled trials, are needed.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the\u0026nbsp;\u003c/p\u003e\n\u003cp\u003epreparation of this manuscript．\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset utilized in this study is not publicly accessible to ensure the confidentiality of sample collection and to adhere to the terms regarding the protection of personal information provided by participants. Access to the data in Microsoft Excel format may be granted upon a reasonable and ethically approved request. Researchers interested in accessing the data should contact the corresponding author, Junichiro Muranaka, at [email protected], to discuss the terms under which access may be provided, including any necessary ethical approvals and data use agreements.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ecollection, and analysis were performed by [Junichiro Muranaka], [Satoshi Sasada], and\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[Kohei Ikeda]. The first draft of the manuscript was written by [Junichiro Muranaka],\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eand all authors commented on previous versions of the manuscript. All authors read and\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eapproved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Research Ethics Committee of the Kanagawa University\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eof Human Services, Japan (No. 7-20-66).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe potential presentation of research findings at conferences and their publication in\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eacademic journals were discussed, and consent was obtained from all research facilities,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ecollaborators, and study participants.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKinoshita S, Abo M, Okamoto T, Miyamura K. 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Arch Phys Med Rehabil. 1995;76:406\u0026ndash;12.\u003c/span\u003e \u003cspan\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0003-9993(95)80568-0\u003c/span\u003e\u003cspan address=\"10.1016/S0003-9993(95)80568-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"stroke, health-related quality of life, rehabilitation, functional independence measure, hospital stay","lastPublishedDoi":"10.21203/rs.3.rs-4225287/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4225287/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThis study aimed to explore the relationship between the duration of rehabilitation of stroke survivors and the functional independence measure (FIM) performance index and health-related quality of life (HRQOL).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe study included stroke patients from 66 medical institutions in Kanagawa Prefecture, Japan who were admitted to and discharged from convalescent rehabilitation wards. Data on the FIM and HRQOL scores and duration of rehabilitation at discharge were collected for analysis, which included correlation analysis and statistical tests for differences.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study analysed data from 160 participants (103 men and 57 women), with the results showing that an extended rehabilitation duration had a negative effect on the FIM performance index and HRQOL (correlation between rehabilitation duration and FIM performance index :r= -0.43, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01; correlation between rehabilitation duration and HRQOL:r= -0.26, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Conversely, a small but significant positive correlation was observed between the FIM gain and the EQ-5D-5L HRQOL measure (r\u0026thinsp;=\u0026thinsp;0.34, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe study findings suggest that excessively prolonged rehabilitation may adversely affect FIM performance index and HRQOL in stroke survivors, highlighting the importance of optimizing rehabilitation duration to improve outcomes in stroke rehabilitation.\u003c/p\u003e","manuscriptTitle":"Relationship between rehabilitation duration, functional independence measure performance index, and health-related quality of life in stroke survivors in Japan: A cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-19 18:11:34","doi":"10.21203/rs.3.rs-4225287/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bd829a31-1da6-46d4-8a1f-313e8434cf29","owner":[],"postedDate":"April 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-15T05:55:45+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-19 18:11:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4225287","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4225287","identity":"rs-4225287","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}