Stair walking is associated with returning home after inpatient stroke rehabilitation in Belgium and Switzerland: a multicentric retrospective study

Authors

  • Odile Chevalley School of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland (HES-SO), Lausanne – Switzerland and Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp - Belgium https://orcid.org/0000-0003-0341-5212
  • Emmanuelle Opsommer School of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland (HES-SO), Lausanne - Switzerland https://orcid.org/0000-0002-3049-2283
  • Steven Truijen Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp - Belgium
  • Grégoire Eberlé Vaud University Hospital Center (CHUV), Lausanne - Switzerland https://orcid.org/0000-0002-3396-547X
  • Isabelle Lehmann Department of Physiotherapy, Bern University Hospital, Inselspital, Bern - Switzerland https://orcid.org/0000-0003-4674-848X
  • Katrien Van-Den-Keybus Deglon Vaud University Hospital Center (CHUV), Lausanne - Switzerland https://orcid.org/0009-0001-6614-9444
  • Wim Saeys Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp - Belgium https://orcid.org/0000-0001-8193-5016

DOI:

https://doi.org/10.33393/aop.2026.3588

Keywords:

Patient discharge, Stair climbing, Stroke, Stroke rehabilitation

Abstract

Introduction: Identifying factors associated with discharge destination after inpatient stroke rehabilitation is important for patients and healthcare professionals. It supports discharge planning and prevents delayed discharge.
Objective: To identify key variables from socio-demographic and clinical data associated with returning home after inpatient stroke rehabilitation, focusing on patients from three rehabilitation centers in Belgium and Switzerland.
Methods: This multicenter retrospective study, conducted in three centers, included 1475 adult patients with stroke admitted to an inpatient rehabilitation unit between December 2012 and June 2021. A logistic regression with backward selection was used to define the model for discharge destination. The dependent variable was the discharge destination (home vs other). The independent variables were selected from the socio-demographic, medical, neurological, care pathway, and functional data and included age, gender, living arrangement, type of stroke, previous stroke, cognitive impairments, independence in grooming, eating, and stair walking.
Results: The final model included three variables (independence in stair walking, living arrangement, and cognitive impairment). Stair walking had the strongest association with returning home. Patients who were partially (OR 5.83, 95% CI 3.67-9.26) or fully independent (OR 14.31, 95% CI 9.34-21.93) were more likely to return home than patients who were unable to walk the stairs. The results were similar for subgroups and for discharge and admission data.
Conclusion: The study showed that independence in walking stairs is strongly associated with discharge destination. Aligned with another study, these results should be confirmed in further research.

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Introduction

Stroke is a major health problem with a high burden on patients and their families, as well as on healthcare and economic systems (1). Every year, approximately 12.2 million people suffer a stroke in the world (2), including approximately 25,000 people in Belgium (3) and 19,000 in Switzerland (4). The absolute number of stroke cases worldwide is expected to increase in the coming decades (5), mainly due to ageing and population growth (6). Advances in acute treatment have led to improved survival and recovery. However, more than half of all patients require subacute inpatient rehabilitation (7), and many patients still experience long-term disability. Therefore, it is essential to identify the factors associated with discharge destinations to support the rehabilitation process and to enhance patient flow (8,9).

Stroke rehabilitation aims to improve patients’ health and independence in activities of daily living. It also seeks to enable the patient to return home and to regain their premorbid level of activity. After rehabilitation, patients may be discharged either to home or to a long-term care facility. This transition is managed through discharge planning, a process initiated at admission that involves healthcare professionals, patients, and their families (10,11). This process aims to identify the most appropriate discharge destination to improve patient flow.

Several associative variables for discharge destination have been investigated. In systematic reviews and meta-analyses of socio-environmental (12) and physical functioning factors (13) for discharge after inpatient rehabilitation, the most associative variables for returning home were living together, having support at home, being married, and achieving higher independence scores on the motor and total scores of the Functional Independence Measure. In addition, some individual motor activities have been associated with returning home, such as the ability to roll (14,15), to maintain minimal balance (16) or to sit (17), and to transfer independently (18). However, there is no consensus about the individual motor activity that is associated with returning home in this population. The aim of this study was to identify key socio-demographic and clinical variables associated with returning home after inpatient stroke rehabilitation, focusing on patients from three rehabilitation centers in Belgium and Switzerland.

Methods

Design and setting

This was a multicenter retrospective study including patients from three inpatient rehabilitation centers: Revarte, a specialized rehabilitation hospital in the vicinity of Antwerp, Flanders, Belgium; the neurorehabilitation unit of the University Hospital in Lausanne, Vaud, Switzerland; and the University Neurorehabilitation of the University Hospital Inselspital in Bern, Switzerland. Ethical approval was obtained from the Ethics Committee GasthuisZusters Antwerpen for the Belgian center (BVDE/AVG/2014/12.95), and from the Cantonal Commission for Ethics in Human Research (CER-VD) for the Swiss centers (2021-01159).

Participants

Patients discharged from the rehabilitation centers between December 2012 and June 2021 were eligible for the study. As this study aimed to identify factors consistently associated with discharge destination across all populations undergoing stroke rehabilitation, no specific inclusion criteria were defined, except that patients had a primary medical diagnosis of stroke (ischemic and hemorrhagic) confirmed on admission to rehabilitation, be admitted to inpatient stroke rehabilitation in the subacute phase (19), be an adult (18 years old and older), and have signed the general informed consent upon hospital admission. Patients were excluded if they were admitted to rehabilitation units for reasons other than stroke (e.g., traumatic brain injury, brain tumor).

In the three rehabilitation centers, therapy is tailored to the individual’s needs. Patients usually receive one hour of occupational therapy and one hour of physiotherapy a day during the working days (Monday to Friday). They also receive up to two hours of speech therapy and neuropsychology, depending on the severity of their impairments. In addition to their individual treatment, patients may participate in group therapy. The three rehabilitation centers admit patients from a stroke unit within a university hospital. Rehabilitation costs are covered by mandatory health insurance. Patients are typically discharged once they achieve their rehabilitation goal. Variability across rehabilitation centers was observed in the assessment tools used to evaluate functional status. For example, two centers used the Functional Independence Measure (20), while the other employed the Extended Barthel Index (21,22) to assess independence in activities of daily living. Similarly, cognitive function was assessed with the Mini-Mental State Examination (23) in two centers and with the Montreal Cognitive Assessment (24) in the other.

Data collection

Data were extracted from medical records in Belgium first and then in a similar way from the electronic medical records in Switzerland. Data of interest included personal and health-related data. Only data collected routinely in daily practice were included. Socio-demographic data, neurological and medical status were collected based on admission assessment, and functional data were collected based on discharge assessment in the three centers and based on admission assessment in the Swiss centers. Data was extracted according to the following five categories (definitions and codes are available in Supplementary material 1):

  • Socio-demographic data: age, gender, children, living arrangement, type of housing before stroke, presence of stairs at home, working partner, social support, formal care, non-medical help, and hospital insurance.
  • Neurological status: side of lesion, type of stroke, location of the lesion, the Mini-Mental State Examination score (23), and based on clinical reports, we categorized cognitive function, the presence of dysarthria, anosognosia, neglect, spasticity, phasic disorders, dysphagia, and aphasia, as well as the severity of aphasia.
  • Medical status: list of comorbidities (including the number of cardiac comorbidities, neurological comorbidities, orthopedic comorbidities, respiratory comorbidities, and the presence of depression), smoking habits, and previous stroke.
  • Care pathway: length of stay (time in days from admission in inpatient rehabilitation to discharge), onset-to-admission interval (time in days from admission to acute care to admission to inpatient rehabilitation), and discharge destination.
  • Functional status: stroke severity with the National Institutes of Health Stroke Scale (25), assessments of activities of daily living with the Extended Barthel Index score (21,22), or the Functional Independence Measure score (20), as well as expert assessment of independence in hygiene, dressing, feeding, transferring, walking and stair walking with categories based on the Functional Independence Measure, and assessments of upper and lower limb function, mobility, strength, pain, sensation, cognition, and communication based on appropriate assessment from clinical expert.

Data analysis

For all statistical analyses, significance was set at p < 0.05. Statistical analyses were conducted using SPSS (26). The analysis was conducted using a complete case approach under the assumption that the data were missing completely at random. Functional status was analyzed with categories based on the Functional Independence Measure and expert opinion for homogeneity across the three centers. Equivalence between the Extended Barthel Index and Functional Independence Measure scores was determined using the transformation table from the Swiss National Association for Quality Development in Clinics and Hospitals – ANQ (27). Missing data analysis was performed to evaluate the amount of missing data and to assess the pattern of missingness. Variables with missing data above 50% were not considered in the analyses (working partner, formal care, non-medical help, hospitalization insurance, Mini-Mental State Examination, anosognosia, spasticity, smoking habits, severity of aphasia and specific assessments for stroke rehabilitation (such as the Motor Assessment Scale or the Chedoke-McMaster Stroke Assessment).

For descriptive statistics, continuous data was reported as the median with the first and third quartiles (Q1; Q3), due to a non-normal distribution. Categorical data were reported as frequencies and percentages. The Mann–Whitney U test was used to analyze continuous or ordinal data, and the Chi2 test was used for categorical data to compare groups based on discharge destinations (home versus other).

For the logistic regression, variables associated with discharge destination (12,13) and independence in activities of daily living (28,29) were selected for the initial model. A backward elimination (30) was performed to identify significant variables associated with discharge destination in the final model. The initial model included nine variables: age, gender, living arrangement, previous stroke, type of stroke, cognitive impairment, independence in eating, grooming, and stair walking. Variables with high risk of multicollinearity were not included in the initial model (independence in dressing, transferring and walking). As a rule of thumb, a minimum sample size of 10 participants per event was required for logistic regression (31). We reported the adjusted odds ratio from the multivariable model and the corresponding 95% confidence intervals (CI). Analyses were performed for the entire cohort and separately for the Belgian and Swiss cohorts. For the Swiss cohort, functional data were also collected at admission. The model was rerun using these admission data to examine the association between admission variables and discharge destination in this subgroup. Bootstrapping was used to assess the internal validity of the model (32).

Results

The study included 1475 patients (931 in the Belgian and 544 in the Swiss cohorts) with a median age of 65.0 years (54.0; 76.0) and 45% of women. They had ischemic and hemorrhagic strokes in 72% and 28% of cases. Most patients (87%) had their first stroke. The median onset-to-admission interval was 16.0 days (10.0; 26.0), and the median length of stay in rehabilitation was 61.5 days (36.0; 93.0). Approximately two-thirds of patients were discharged home (62%), and 38% patients were discharged to other destinations, including nursing homes (13%), further rehabilitation (14%), and other hospitals (9%). Table 1 displays additional patient characteristics and corresponding missing data by discharge destination. Regarding the pattern of missingness, Little’s test was non-significant (p=.141), suggesting that the missingness can be considered as missing completely at random.

The logistic regression with backward selection included 648 patients (43.9% complete cases) and identified independence in stair walking, living arrangement, and cognitive impairments in the final model, showing their association with discharge destination. The results from the final model are presented in Table 2 for the full cohort, the Belgian and the Swiss cohorts on discharge and in Table 3 for the Swiss cohort on admission. Independence in stair walking was the most significant variable. When adjusted for living arrangement and cognitive functions, partially independent and independent patients in stair walking were more likely to return home (respectively OR 5.83, 95% CI 3.67-9.26 and OR 14.31, 95% CI 9.34-21.93) than patients who were not able to walk stairs. These results were similar on discharge in the subgroups (Belgian and Swiss cohorts, Table 2) and on admission in the Swiss cohort (Table 3).

Discussion

This study identified that stair walking had the strongest association with returning home after inpatient stroke rehabilitation, when adjusted for living arrangement and cognitive impairments, across the three sites in Belgium and Switzerland. Patients who were partially or fully independent in stair walking at discharge were 3.9 and 9.9 times more likely to return home, respectively, than those who were unable to climb stairs, regardless of the presence of stairs at home. These results identify stair walking as an important ability not reported in a previous systematic review on physical functioning factors associated with returning home after stroke (12).

Independence in stair walking is important but challenging for community living (33) as it requires both sensorimotor and cognitive functions (34). For sensorimotor abilities, balance (35-37), muscle strength (34,35,37), proprioception (37) and cardiovascular fitness (35) are strongly associated with stair walking. Cognitive functions also contribute to stair walking independence, especially unilateral spatial neglect (34) and fear of falling (37), impairing this skill in people after stroke, while vision deficits and pain affect stair walking in older adults (37). Moreover, stair-walking cadence, measured in stairs per second, is associated with the frequency and duration (38) of physical activity in the community after stroke.

Variable Full cohort (n = 1475)   Belgian cohort (n = 931)   Swiss cohort (n = 544)
Home (n = 908) Other (n = 567) P   Home (n = 632) Other (n = 299) P   Home (n = 276) Other (n = 268) P
Age, median (Q1; Q3) 65.5 (54.0; 76.0) 65.0 (55.0; 77.0) 0.450   70.0 (58.0; 78.0) 76.0 (66.0; 83.0) <.001   57.0 (48.0; 66.5) 58.0 (49.5; 64.0) 0.392
Gender (women), n (%) 400 (44) 267 (47) 0.254   282 (45) 153 (51) 0.061   118 (43) 114 (43) 0.959
Have children, n (%) 567 (84) 326 (77) 0.001   411 (86) 187 (78) 0.005   156 (80) 139 (75) 0.258
   Missing 235 (26) 141 (25)     155 (25) 59 (20)     80 (29) 82 (31)  
Living arrangement (together), n (%) 471 (69) 262 (60) 0.004   332 (69) 111 (46) <0.001   139 (69) 151 (78) 0.051
   Missing 222 (24) 132 (23)     147 (23) 58 (19)     75 (27) 74 (28)  
Social support, n (%)     0.002       <0.001       0.015
   Missing 263 (29) 155 (27)     154 (24) 61 (20)     109 (39) 94 (35)  
   Live alone and has no children 53 (8) 48 (12)     34 (7) 34 (14)     19 (11) 14 (8)  
   Live alone and has children 155 (24) 115 (28)     120 (25) 95 (40)     35 (21) 20 (12)  
   Live together and has no children 49 (8) 48 (12)     34 (7) 18 (8)     15 (9) 30 (17)  
   Live together and has children 388 (60) 201 (49)     290 (61) 91 (38)     98 (59) 110 (63)  
Type of home, n (%)     0.169       0.012       0.082
   Missing 267 (29) 163 (29)     163 (26) 61 (20)     104 (38) 102 (38)  
   Apartment with stairs 95 (15) 66 (16)     45 (10) 27 (11)     50 (29) 39 (24)  
   Apartment without stairs 163 (25) 111 (28)     104 (22) 70 (29)     59 (34) 41 (25)  
   House with stairs 312 (49) 183 (45)     254 (54) 105 (44)     58 (34) 78 (47)  
   House without stairs 56 (9) 27 (7)     53 (11) 21 (9)     3 (2) 6 (4)  
   Nursing home or service flat 10 (2) 15 (4)     10 (2) 14 (6)     0 (0) 1 (1)  
   House with a stairlift 5 (1) 2 (1)     3 (1) 1 (0)     2 (1) 1 (1)  
Presence of stairs, n (%) 432 (68) 261 (66) 0.437   303 (66) 135 (58) 0.061   129 (75) 126 (76) 0.771
   Missing 275 (30) 171 (30)     171 (28) 68 (23)     104 (38) 103 (38)  
Type of stroke, n (%)     0.003       0.250       0.004
   Missing 173 (19) 63 (11)     166 (26) 50 (17)     7 (3) 13 (5)  
   Ischemic 553 (75) 341 (68)     348 (75) 176 (71)     205 (76) 165 (65)  
   Haemorrhagic 182 (25) 163 (33)     118 (25) 73 (29)     64 (24) 90 (35)  
Side of lesion, n (%)     0.530       0.855       0.763
   Missing 197 (22) 92 (16)     176 (28) 58 (19)     21 (8) 34 (13)  
   Left 346 (49) 223 (47)     221 (49) 116 (48)     125 (49) 107 (46)  
   Right 305 (43) 203 (43)     206 (45) 107 (44)     99 (39) 96 (41)  
   Bilateral 60 (8) 49 (10)     29 (6) 18 (8)     31 (12) 31 (13)  
Previous stroke, n (%) 92 (14) 52 (11) 0.310   68 (14) 31 (12) 0.405   24 (12) 21 (11) 0.701
   Missing 225 (25) 112 (20)     148 (23) 38 (13)     77 (28) 74 (28)  
Presence of aphasia, n (%) 221 (45) 212 (64) <0.001   142 (42) 106 (65) <.001   79 (53) 106 (63) 0.069
   Missing 417 (46) 235 (41)     290 (46) 135 (45)     127 (46) 100 (37)  
Presence of dysphagia, n (%) 177 (31) 198 (51) <0.001   122 (28) 142 (59) <.001   55 (42) 56 (37) 0.426
   Missing 339 (19) 177 (31)     194 (19) 59 (20)     145 (53) 118 (44)  
Presence of neglect, n (%) 171/423 (40) 205 (60) <0.001   100 (35) 81 (49) 0.004   71 (51) 124 (71) 0.004
   Missing 485 (53) 226 (40)     349 (55) 134 (45)     136 (49) 92 (34)  
Cognitive impairment, n (%)     <0.001       <.001       <.001
   Missing 232 (26) 129 (23)     230 (36) 112 (37)     2 (1) 17 (6)  
   Age-associated to mild 504 (75) 208 (48)     276 (69) 82 (44)     228 (83) 126 (50)  
   Moderate to severe 172 (25) 230 (53)     126 (31) 105 (56)     46 (17) 125 (50)  
Cardiac comorbidities, n (%)     0.155       0.116       0.521
   Missing 365 (40) 188 (33)     295 (47) 119 (40)     70 (25) 69 (26)  
   None 110 (20) 67 (18)     59 (18) 27 (15)     51 (25) 40 (20)  
   Single 221 (41) 140 (37)     147 (44) 66 (37)     74 (36) 74 (37)  
   Multiple 212 (40) 172 (45)     131 (39) 87 (48)     81 (39) 85 (43)  
Neurological comorbidities, n (%)     <0.001       0.016       0.010
   Missing 450 (50) 221 (39)     377 (60) 152 (51)     73 (26) 69 (26)  
   None 292 (64) 171 (49)     166 (65) 76 (52)     126 (62) 95 (48)  
   Single 123 (27) 118 (34)     65 (25) 46 (31)     58 (29) 72 (36)  
   Multiple 43 (9) 57 (17)     24 (9) 25 (17)     19 (9) 32 (16)  
Orthopaedic comorbidities, n (%)     0.582       0.397       0.781
   Missing 368 (41) 193 (34)     297 (47) 119 (40)     71 (26) 74 (28)  
   None 247 (46) 183 (49)     114 (34) 51 (28)     133 (65) 132 (68)  
   Single 176 (33) 111 (30)     134 (40) 76 (42)     42 (21) 35 (18)  
   Multiple 117 (22) 80 (21)     87 (26) 53 (29)     30 (15) 27 (14)  
Respiratory comorbidities, n (%)     0.009       0.010       0.309
   Missing 421 (46) 192 (34)     347 (55) 126 (42)     74 (27) 66 (25)  
   None 304 (62) 199 (53)     188 (66) 98 (57)     116 (57) 101 (50)  
   Single 139 (29) 123 (33)     77 (27) 48 (28)     62 (31) 75 (37)  
   Multiple 44 (9) 53 (14)     20 (7) 27 (16)     24 (12) 26 (13)  
Presence of depression, n (%) 107 (24) 91 (26) 0.462   183 (27) 64 (40) 0.008   38 (19) 27 (14) 0.197
   Missing 456 (50) 216 (38)     380 (60) 139 (46)     76 (28) 77 (29)  
Onset to admission interval, median (Q1; Q3) 15.0 (10.0; 22.0) 18.0 (11.0; 32.0) <0.001   14.0 (10.0; 23.0) 18.0 (12.0; 31.5) <.001   15.0 (9.0; 20.0) 17.0 (10.0; 35.0) <.001
Length of stay in rehabilitation, median (Q1; Q3) 60.0 (36.0; 97.0) 64.0 (36.0; 89.0) 0.753   72.0 (48.0; 105.0) 76.0 (42.0; 106.0) 0.955   35.0 (20.0; 58.5) 53.0 (33.0; 78.5) <.001
Independence in grooming, n (%)     <0.001       <.001       <.001
   Missing 152 (17) 70 (12)     151 (24) 53 (18)     1 (0) 17 (6)  
   Independent 520 (69) 145 (29)     290 (60) 50 (20)     230 (84) 95 (38)  
   Under supervision 101 (13) 105 (21)     82 (17) 50 (20)     19 (7) 55 (22)  
   Partially independent 105 (14) 168 (34)     81 (17) 78 (32)     24 (9) 90 (36)  
   Dependent 30 (4) 79 (16)     28 (6) 68 (28)     2 (1) 11 (4)  
Independence in dressing, n (%)     <0.001       <.001       <.001
   Missing 154 (17) 73 (13)     153 (24) 56 (19)     1 (0) 17 (6)  
   Independent 542 (72) 149 (30)     314 (66) 56 (23)     228 (83) 93 (37)  
   Partially independent 158 (21) 230 (47)     114 (24) 76 (31)     44 (16) 154 (61)  
   Dependent 54 (7) 115 (23)     51 (11) 111 (46)     3 (1) 4 (2)  
Independence in eating, n (%)     <0.001       <.001       <.001
   Missing 184 (20) 91 (16)     183 (29) 74 (25)     1 (0) 17 (6)  
   Independent 583 (81) 226 (48)     344 (77) 85 (38)     239 (87) 141 (56)  
   Dependent on preparations 130 (18) 203 (43)     96 (21) 101 (45)     34 (12) 102 (41)  
   Dependent 11 (2) 47 (10)     9 (2) 39 (17)     2 (1) 8 (3)  
Independence in transfer, n (%)     <0.001       <.001       <.001
   Missing 186 (20) 82 (14)     185 (29) 65 (22)     1 (0) 17 (6)  
   Independent 597 (83) 220 (45)     339 (76) 82 (35)     258 (94) 138 (55)  
   Under supervision 45 (6) 71 (15)     36 (8) 27 (12)     9 (3) 44 (18)  
   Dependent 80 (11) 194 (30)     72 (16) 125 (53)     8 (3) 69 (28)  
Independence in walking, n (%)     <0.001       <.001       <.001
   Missing 158 (17) 79 (14)     155 (25) 57 (19)     3 (1) 22 (8)  
   Independent 361 (48) 137 (28)     195 (41) 49 (20)     166 (61) 88 (36)  
   With a walking device 240 (32) 77 (16)     168 (35) 57 (24)     72 (26) 20 (8)  
   With a wheelchair for long distances 106 (14) 79 (16)     86 (18) 46 (19)     20 (7) 33 (13)  
   Wheelchair independent 19 (3) 81 (17)     8 (2) 18 (7)     11 (4) 63 (26)  
   Dependent (wheelchair) 24 (3) 114 (23)     20 (4) 72 (30)     4 (2) 42 (17)  
Independence in stair walking, n (%)     <0.001       <.001       <.001
   Missing 293 (32) 152 (27)     292 (46) 135 (45)     1 (0) 17 (6)  
   Independent 425 (69) 101 (24)     237 (70) 46 (28)     188 (68) 55 (22)  
   Partially independent 127 (21) 74 (18)     74 (22) 29 (18)     53 (19) 45 (18)  
   Dependent 63 (10) 240 (58)     29 (9) 89 (54)     34 (12) 151 (60)  
TABLE 1 -. Socio-demographic and clinical data of participants by country and discharge destination
Cohort Variables Sig aOR 95% CI R2 Nagelkerke Overall percentage Home percentage Other percentage
Full cohort (n=785)         0.371 77.2 88.1 60.1
     Living arrangement              
     Alone   Reference          
     Together 0.016 1.568 1.086-2.265        
  Independence in stair walking              
     Dependent   Reference          
     Partially independent <0.001 5.832 3.673-9.260        
     Independent <0.001 14.313 9.342-21.930        
  Cognitive impairments              
     Moderate to severe   Reference          
     None to mild <0.001 2.453 1.720-3.500        
  Constant <0.001 0.125          
Belgian cohort (n=399)           0.369 79.9 90.0 56.3
  Living arrangement              
     Alone   Reference          
     Together <0.001 3.895 2.253-6.736        
  Independence in stair walking              
     Dependent   Reference          
     Partially independent <0.001 6.481 3.138-13.385        
     Independent <0.001 15.804 8.018-31.154        
  Cognitive impairments              
     Moderate to severe   Reference          
     None to mild 0.003 2.184 1.297-3.678        
  Constant <0.001 0.107          
Swiss cohort (n=386)           0.402 75.9 81.9 69.5
  Living arrangement              
     Alone   Reference          
     Together 0.223 0.709 0.408-1.232        
  Independence in stair walking              
     Dependent   Reference          
     Partially independent <0.001 5.139 2.714-9.727        
     Independent <0.001 12.356 6.897-22.134        
  Cognitive impairments              
     Moderate to severe   Reference          
     None to mild <0.001 3.395 1.995-5.776        
  Constant <0.001 0.140          
TABLE 2 -. Final model including living arrangement, independence in stair walking and cognitive impairments for discharge destination (home vs other) in the full cohort and in the Belgian and Swiss cohorts on discharge
Variables Sig aOR 95% CI R2 Nagelkerke Overall percentage Home percentage Other percentage
Living arrangement       0.399 72.1 61.9 83.0
   Alone   Reference          
   Together 0.157 0.665 0.378-1.170        
Independence in stair walking              
   Dependent   Reference          
   Partially independent <0.001 8.648 4.082-18.321        
   Independent <0.001 23.887 7.135-79.975        
Cognitive impairments              
   Moderate to severe   Reference          
   None to mild <0.001 3.784 2.222-6.444        
Constant <0.001 0.310          
Table 3 -. Final model including living arrangement, independence in stair walking, and cognitive impairments for discharge destination (home vs other) in the Swiss cohort on admission

The present study contributes to the growing literature on factors associated with returning home and highlights the central role of stair walking in stroke rehabilitation. Although stair walking has been studied with patients after stroke, it is not systematically reported in national guidelines. It is mentioned as part of mobility rehabilitation (41-44), circuit training (41), or aerobic endurance exercises (41), but many guidelines omit it or report the need for further research (41). The present results from two European cohorts suggest that stair walking should be an integral part of stroke rehabilitation and a goal for community living.

Although stair walking showed the strongest association in this study, other variables, such as living together, independence in dressing and walking and absence of cognitive impairment, were also significantly associated with returning home. Previous studies have identified additional variables significantly associated with returning home after inpatient stroke rehabilitation, such as transferring (18), walking (14,17), rolling (14), cognitive impairments assessed with the Mini Mental State Examination (45), and the presence of caregiver or family members (13) or social support assessed with Gijon scale (46). Transferring, walking and stair walking may be considered as part of a broader functional mobility that enables patients to be independent and safe at home. In contrast, activities such as dressing, bathing and eating can often be supported by formal or informal caregivers, which may explain why they were not significant in the model. These results suggest that returning home requires a combination of functional abilities, some of which may be supported by an informal caregiver. Stair walking is a complex activity that involves both physical and cognitive components. Given its strong association with returning home, it should be specifically addressed and practiced during inpatient stroke rehabilitation.

This study has several limitations. The retrospective multicenter design resulted in missing data and variable data quality, as standardized assessments were not systematically used across centers. We therefore focused on motor activities of daily living and reported different levels of independence, while other variables (cognitive impairment, comorbidities, social support, neurological symptoms) were reported more generally. Both admission and discharge data were included, although admission data were less complete. The extent of missing data led us to perform complete-case logistic regression without cluster adjustment (although principal component analysis showed similarities across centers), reducing sample size and potentially introducing selection bias while limiting generalizability due to residual inter-center heterogeneity. Finally, data collection during 2020 and 2021 coincided with the COVID-19 pandemic, which affected stroke presentation rates (47) and rehabilitation access (48), even though the impact on the quality of care in acute (49) and inpatient rehabilitation units appeared limited.

Conclusion

This study shows that stair walking is highly correlated with discharge destination and should be a key focus of physical rehabilitation after stroke. Although stair walking is already routinely practiced in clinical settings, it remains an essential and complex activity of daily living. During rehabilitation and after discharge, clinicians should incorporate stair walking into training and discharge planning discussions, and encourage patients to practice it safely and regularly, especially as they may be exposed to challenges such as functional decline (50) and the “bouncing-back” effect (i.e., increasing care needs, including hospital readmission) (51). Further studies should explore the relationship between stair walking and the risk of functional decline and bouncing back. In addition, the association between stair walking and discharge destination after inpatient stroke rehabilitation should be confirmed in future research using a detailed assessment of other relevant variables, such as cognitive impairments, social support, and neurological and medical status.

Other information

This article includes supplementary material

Corresponding author:

Odile Chevalley

email: odile.chevalley@hesav.ch

Disclosures

Conflict of interest: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Financial support: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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