post - stroke depression ( psd ) is one of the symptoms observed in stroke patients .
the 
 prevalence of psd is high , as it is diagnosed in 53% of patients at 3 months and in 42% of 
 patients at 12 months after stroke1 . 

additionally , psd has been reported to have a high incidence even 1 month from the onset of 
 stroke2,3,4 .
psd is the most 
 important reason for impaired quality of life in stroke patients15,16,17 .
furthermore , several studies have shown that psd is 
 associated with decreased activities of daily living ( adl)1,18,19,20,21,22,23,24 and impaired recovery of 
 adl25,26,27,28,29 .
bhogal et al.4 and hackett et al.30 suggested that depressive symptoms differ 
 depending on the stage of stroke recovery ( e.g. , acute , subacute , or chronic ) and the living 
 environment ( e.g. , in a hospital or in the community ) .
however , little is known about the 
 association between psd and the improvement in adl among patients in a rehabilitation ward 
 setting .
sinyor et al.18 reported that 
 adl were worse in depressed patients than in non - depressed patients on admission and at 
 discharge ; however , both groups showed similar improvement over the course of rehabilitation 
 in a subacute hospital setting , suggesting that the effect of psd on improvement in adl may 
 be minimal .
patients in that previous study , however , did not show an equal level of adl 
 between groups on admission , and the study did not distinguish between patients with and 
 without psd on admission .
the level of adl on admission has been reported to be related to 
 improvement in adl during the hospital stay31 , 32 .
therefore , to clarify the effect of psd 
 on improvement in adl , there needs to be an equivalent level independence in adl on 
 admission in the psd group and the non - psd group . in another study ,
chemerinski et al.27 reported that psd patients showed 
 significantly greater recovery in adl than non - psd patients in the subacute hospital 
 setting . in that study , the level of independence in adl on admission for the psd and 
 non - psd groups was equal ; however , the study had a small sample size . finally , there are no 
 reports on the effects of psd on improvement in various adl domains ( i.e. , the motor domain 
 and the cognitive domain ) .
therefore , the purpose of this study was to investigate improvement of adl between 
 admission to and discharge from a convalescent rehabilitation ward in patients with or 
 without psd who had equal levels of adl on admission .
there were 396 stroke patients who were admitted to and discharged from a convalescent 
 rehabilitation hospital ward from april 4 , 2011 to december 26 , 2012 .
on the basis of 
 clinical evaluations , 206 patients with dysphasia , low cognitive function ( < 21 points on 
 the hasegawa dementia rating scale or < 24 points on the mini mental state examination ) , 
 impaired consciousness ( > 1 point on the japanese coma scale ) , or a history of depression 
 were excluded .
another 82 patients were missing data on one or more of following items : the 
 brunnstrom recovery stage ( brs ) , geriatric depression scale , short version ( gds ) , and 
 functional independence measure ( fim ) . therefore , 108 patients fulfilled the inclusion 
 criteria for enrollment into the study ( fig .
this study was approved by the institutional research board of aida memorial 
 rehabilitation hospital ( approval no . , 014 ) .
because of the study s design , there were no risks , disadvantages , 
 or infringements to individual and/or family rights .
flow chart of participant selection information obtained from the medical records included sociodemographic variables ( i.e. , 
 age and gender ) , laterality of the lesion , primary disease , whether discharge was to home or 
 to a geriatric facility , medication information , illness duration , length of stay , total 
 units of therapy , units of therapy per day , and brs .
the brs was assessed for upper limbs , 
 fingers , and lower limbs at the time of admission and at discharge .
brs is classified in 6 stages , as follows : ( 1 ) 
 flaccidity , ( 2 ) synergy development , ( 3 ) voluntary synergistic movement , ( 4 ) some movements 
 deviating from synergy , ( 5 ) independence from basic synergies , and ( 6 ) isolated joint 
 movements .
the gds has scores ranging 
 from 0 to 15 , with a score of > 6 points indicating a likelihood of depression .
the short 
 version of the test used in this study is more convenient and less of a burden on the 
 patient .
the gds does not examine stroke symptoms ( e.g. , fatigability , constipation , and 
 decreased appetite)33 , 34 . as a screening test , the gds is predictive for psd35 and has a high sensitivity for psd as 
 diagnosed by a psychiatrist36 .
the fim contains 18 items composed of 13 motor tasks and 5 cognitive 
 tasks .
the dimensions assessed by the fim include eating , grooming , bathing , upper body 
 dressing , lower body dressing , toileting , bladder management , bowel management , bed - to - chair 
 transfer , toilet transfer , shower transfer , locomotion ( ambulatory or wheelchair - bound ) , 
 stairs , comprehension , expression , social interaction , problem solving , and memory .
tasks 
 are rated on a 7-point ordinal scale that ranges from total assistance to complete 
 independence .
scores range from 18 ( lowest ) to 126 ( highest ) , indicating the level of 
 function .
scores were rated on admission and at discharge . the reliability and validity of 
 the fim have already been confirmed in stroke patients37 . based on standard a cut - off score of 6 for the gds at the time of admission
, patients were 
 divided into the non - psd group or the psd group , and the two groups were compared .
the 
 degree of improvement in the fim ( fim gain ) was defined as the difference between the fim 
 score on admission and at discharge .
fim scores were compared in total ( fim total ) , by the 
 subscale of motor activities ( fim motor ) , and by the subscale of cognition ( fim cognition ) . 

 
 tests were used to compare differences between groups for gender , laterality of the lesion , 
 primary disease , whether discharge was to home or to a geriatric facility , and medication . 

an independent t - test was used to compare age , illness duration , length of stay , total units 
 of therapy , and units of therapy per day between groups .
the mann - whitney u - test was used to 
 compare fim total , fim motor , fim cognition , fim gain scores , and brs between groups . 

analysis of variance ( anova ) was used to examine the effect of the time period on psd .
fim 
 total , fim motor , and fim cognition scores were analyzed with a repeated - measures two - way 
 anova , with psd ( non - psd / psd ) and the time period ( admission / discharge ) being within - subject 
 variables .
factors that affected fim scores at the time of discharge were examined using 
 multiple regression analysis .
explanatory variables were gds , age , length of stay , illness duration , units of 
 therapy per day , and brs of the lower limbs on admission .
explanatory variables ( length of 
 stay , total units of therapy , brs of upper limbs and fingers on admission and at discharge , 
 and brs of lower limbs at discharge ) that caused multicollinearity were eliminated .
data 
 were analyzed using the japanese version of spss statistics for windows version 20.0 ( ibm 
 corporation , new york , ny , usa ) .
at the time of admission , 45 patients ( 42% ) were classified into the non - psd group , and 63 
 patients ( 58% ) were classified into the psd group .
with respect to the sociodemographic 
 variables , none ( age , gender , laterality of the lesion , primary disease , discharge to home 
 or to a geriatric facility , medication information , illness duration , length of stay , total 
 units of therapy , units of therapy per day , and brs ) was significantly different between the 
 two groups ( table 1table 1.demographic datanon - psd group ( n=45)psd group ( n=63)age , years66.3  15.267.2  14.7gender , nmale : 31 female : 14male : 39 female : 24laterality of lesion , nright : 17right : 20left : 24left : 39bilateral : 4bilateral : 4primary disease , nch : 14ch : 23ci : 28ci : 39sah : 3sah : 1discharge destination , nfacility : 2facility : 10home : 43home : 53medication information(antidepressant / ataractic ) , nnothing : 41nothing : 55antidepressant : 1antidepressant : 4ataractic : 3ataractic : 4illness duration , day39.8  39.843.9  13.7length of stay ,
day94.6  44.299.6  43.4total units of therapy , units*608.4  259.9616.8  235.7units of therapy per day , units*6.6  1.26.4  1.0gds , score3 ( 05)9 ( 615)brs ( admission)upper limb , score5 ( 16)5 ( 16)hand , score4 ( 16)5 ( 16)lower limb , score5 ( 26)5 ( 16)brs ( discharge)upper limb , score5 ( 16)5 ( 16)hand , score5 ( 16)5 ( 16)lower limb , score6 ( 26)5 ( 26)scores are presented as mean  sd , median ( minimum to maximum ) . * one unit is defined as 20 minutes of rehabilitation .
 tests were used to compare differences between groups for gender , 
 laterality of the lesion , primary disease , discharge destination , and medication 
 information .
independent t - tests were used to compare differences between groups for age , illness 
 duration , length of stay , total units of therapy , and units of therapy per day .
brs : brunnstrom recovery stage ; ch : cerebral hemorrhage ; ci : cerebral infarction ; 
 gds : geriatric depression scale short version ; psd : post - stroke depression ; sah : 
 subarachnoid hemorrhage ; sd : standard deviation ) .
 tests were used to compare differences between groups for gender , 
 laterality of the lesion , primary disease , discharge destination , and medication 
 information .
independent t - tests were used to compare differences between groups for age , illness 
 duration , length of stay , total units of therapy , and units of therapy per day .
brs : brunnstrom recovery stage ; ch : cerebral hemorrhage ; ci : cerebral infarction ; 
 gds : geriatric depression scale short version ; psd : post - stroke depression ; sah : 
 subarachnoid hemorrhage ; sd : standard deviation when the fim scores on admission were compared , there was no significant difference between 
 the two groups .
when the scores for fim total ( p=0.003 ) , fim motor ( p=0.002 ) , and fim 
 cognition ( p=0.011 ) at the time of discharge were compared , there were significant 
 differences between the two groups .
the psd group had worse scores than the non - psd group 
 did . when the fim gain score was compared between groups ,
there were significant differences 
 in fim total ( p=0.022 ) and fim motor ( p=0.035 ) between the two groups .
however , there was no significant difference 
 between the two groups in the fim gain score for cognition ( p=0.317 ) ( table 2table 2.comparison of fim scores in the psd group and the non - psd groupnon - psd group(n=45)psd group(n=63)admissionfim total , score76.7  16.772.4  21.7fim motor , score50.6  14.047.5  18.4fim cognition , score26.1  6.324.9  5.8dischargefim total , score110.1  6.791.2  25.2**fim motor , score80.3  5.465.4  22.1**fim cognition , score29.7  3.827.5  4.7*gainfim total , score33.3  12.926.8  16.1*fim motor , score29.7  11.024.5  13.4*fim cognition , score3.6  4.72.3  5.5*p<0.05 , * * p<0.01scores are presented as means 
sd.fim scores were analyzed between groups with the mann - whitney u test.fim : functional independence measure ; psd : post - stroke depression ) .
fim : functional independence measure ; psd : post - stroke depression the anova revealed significant interactions between the time period and psd factors for fim 
 total ( f [ 1 , 106]=5.07 , p=0.030 ) and fim motor ( f [ 1 , 106]=4.61 , p=0.030 ) ( table 3table 3.results of a two - way anova in the psd group ( n=63 ) and the non - psd group 
 ( n=45)time periodinteractionadmissiondischargemean  sdmean  sdfim total , scorenon - psd76.7  16.6110.1  14.7*psd72.3  21.799.1  22.2fim cognition , scorenon - psd26.1  6.229.7  5.1psd24.9  5.827.2  5.6fim motor , scorenon - psd50.6  13.980.3  11.7*psd47.4  18.371.9  18.5*p<0.05 .
anova : analysis of variance ; fim : functional independence measure ; psd : 
 post - stroke depression ; sd : standard deviation ) . * p<0.05 .
anova : analysis of variance ; fim : functional independence measure ; psd : 
 post - stroke depression ; sd : standard deviation the multiple regression analyses for fim total and fim motor were significant for gds , age , 
 and brs ( p<0.05 ) . the multiple regression analysis for fim cognition was significant for 
 gds , age , and illness duration ( p<0.05 ) .
the multiple regression analysis for gds was 
 significant for fim total ( r=0.28 , =0.22 , p=0.011 ) , fim motor 
 ( r=0.30 , =0.19 , p=0.025 ) , and fim cognition ( r=0.19 , =0.22 , 
 p=0.014 ) ( table 4table 4.results of a multivariate regression analysis to identify factors related to fim 
 score in the patients ( n=108)dependent variableexplanatory variablefim totalfim motorfim cognitiongds0.22*0.19*0.22*age0.40**0.37**0.34**illness duration0.130.100.19units of therapy of per day0.060.040.10brs ( lower limb , admission)0.29**0.38**0.08adjusted r0.28**0.300.19***p<0.05 , * * p<0.01 ,  : standardized coefficient ; brs : brunnstrom recovery stage ; 
 gds : geriatric depression scale , short version ; fim : functional independence 
 measure ) .
* p<0.05 , * * p<0.01 ,  : standardized coefficient ; brs : brunnstrom recovery stage ; 
 gds : geriatric depression scale , short version ; fim : functional independence 
 measure
adl improvement was investigated in patients who were categorized into the non - psd or psd 
 groups on admission in a convalescent rehabilitation ward setting . in general
, the results 
 indicated that psd decreased both the level of adl independence at discharge and adl 
 improvement in stroke patients . in this study
, there were no significant differences in adl between patients with and 
 without psd on admission , but there were significant differences in adl at discharge and in 
 the degree of improvement in adl .
these results indicate that there is less of a restorative 
 effect on adl in psd patients .
in addition , there was a statistically significant 
 interaction between the time period and psd in fim scores .
this finding supports the idea 
 that psd is related to adl recovery and that it adversely affects a patient s prognosis for 
 adl improvement in a convalescent rehabilitation ward setting . generally , the effects of the gain in adl score are associated with age and the intensity 
 of rehabilitation38 , 39 .
therefore , differences in age and intensity of rehabilitation were 
 controlled between psd patients and non - psd patients . however , there was a statistically 
 significant difference in the improvement of adl between the two groups , which also 
 indicated that psd affects the improvement in adl .
several studies have also shown that 
 there is impaired recovery of adl in psd patients compared with that in non - psd 
 patients25,26,27 , similar to the results 
 shown here in the setting of a convalescent rehabilitation ward .
on the other hand , in the multiple regression analysis , gds , age , and brs influenced the 
 adl at the time of discharge .
other studies have also reported that the adl of stroke 
 patients were influenced by age and the degree of paralysis of the lower limbs39,40,41 .
the results of the present study indicate 
 that the level of adl independence at discharge was related not only to these factors but 
 also to the severity of psd at admission .
feigin et al.42 investigated the course of stroke - related function and concluded 
 that depression was associated with adl independence at 5  years after stroke .
accordingly , 
 this study concluded that psd had a negative impact on recovery of adl and led to negative 
 outcomes with respect to rehabilitation in a convalescent rehabilitation ward .
in addition , the present results revealed that psd particularly inhibited fim motor adl , 
 which may be due to psychological rather than to physiological mechanisms .
for example , 
 depressed patients may be hopeless about the future and thus may be psychologically less 
 motivated to put any effort into rehabilitation or recovery27 .
in addition , because training may cause mental stress in psd 
 patients , it is important to train by avoiding mental load and to listen to the complaints 
 of patients43 . high - intensity training is 
 needed to promote recovery of adl44 , and 
 such training is often difficult for psd patients .
in addition , depression leads to reduced 
 attention and to an increased risk of falling45 , 
 46 .
therefore , the falling risk induced by psd may be associated with 
 low independence levels in adl . however ,
this study indicated a poor outcome with respect to rehabilitation in patients who had psd 
 on admission to a convalescent rehabilitation ward .
previous studies have shown that 
 alleviation of depressive symptoms is associated with better functional recovery27 , 49 . therefore
, early detection of psd by screening and early treatment 
 may lead to better functional recovery in patients in convalescent rehabilitation wards .
the study 
 sample was only from one convalescent ward , and it excluded patients with aphasia and mild 
 paralysis .
furthermore , this study did not assess the effects of higher brain dysfunction 
 and balance , which are related to adl and gait ability50,51,52,53,54,55,56,57,58,59,60,61 .
 [ purpose ] there have been no investigations into the improvement of activities of daily 
 living among patients suffering from post - stroke depression on admission to convalescent 
 rehabilitation wards in japan . 
 this study aimed to assess the improvement of activities in 
 daily living in patients with or without post - stroke depression at the time of admission 
 to a convalescent rehabilitation ward . 
 [ subjects and methods ] this retrospective study 
 included 108 stroke patients divided into two groups according to their geriatric 
 depression scale 15-item short form scores . activities of daily living were assessed using 
 the functional independence measure . 
 the degree of improvement on the functional 
 independence measure was defined as the difference between scores on admission and at 
 discharge . 
 [ results ] the functional independence measure gain score was significantly 
 different from the functional independence measure total score . 
 there was a significant 
 interaction between time period and post - stroke depression factors for the functional 
 independence measure total score . 
 a multiple regression analysis revealed a significant 
 association between geriatric depression scale score and functional independence measure 
 total score . 
 [ conclusion ] the present study suggests that post - stroke depression has a 
 negative impact on recovery of activities of daily living and on rehabilitation outcomes 
 in a convalescent rehabilitation ward setting . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION