AMJ Vol 7 No 1 2020Edit2.indd

Althea Medical Journal. 2020;7(1)

40 AMJ March 2020

Profile of Upper Extremities Function among Stroke Outpatients
in Dr. Hasan Sadikin General Hospital, Bandung

Putri Pamulani,1 Novitri,2 Sofiati Dian3
1Faculty of Medicine Universitas Padjadjaran, Indonesia, 2Department of Physical Medicine and
Rehabilitation Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital
Bandung, Indonesia, 3Department of Neurology Faculty of Medicine Universitas Padjadjaran/

Dr. Hasan Sadikin General Hospital Bandung, Indonesia

Correspondence: Putri Pamulani, Faculty of Medicine, Universitas Padjadjaran Jalan Raya Bandung-Sumedang KM 21,
Jatinangor, Sumedang, Jawa Barat, Indonesia, Email: pamulaniputri@gmail.com.

Introduction

Stroke is one of the leading causes of disability
in the older population, involving many
aspects of life such as physical, emotional, and
social life. As stroke mortality rates decline,
these older people are more likely to have
residual impairments that affect their activity
of daily living (ADL).1 The prevalence of stroke
in Indonesia is about 7 per 1000 population
and mostly aged 45 years old and older are
affected. Dr. Hasan Sadikin General Hospital in
Bandung as a referral hospital has more than
500 stroke patients admitted every year.2,3

Stroke affects not only patients, but their
family members are also involved and have to deal
with the sequeles of its residual impairments.
Consequently, post-stroke related-disability
continues to be another point of concern.4 This

is shown by several stroke impact measures that
have been developed, such as Health-Related
Quality of life (HRQoL) and Stroke Impact Scale
(SIS). The World Health Organization (WHO)
has published the International Classification
of Impairments, Disabilities, and Handicaps in
1980, which is frequently used in classifying
stroke after its effect.5

It has been reported previously that
there is 2,490 billion disability-adjusted
life years (DALYs) or 361 DALYs per 1000
population. Among all the diseases mentioned,
cardiovascular and circulatory diseases are
accounted for 11.8% of global DALYs; the major
diseases within this group are ischemic heart
disease (5.2%), hemorrhagic stroke (2.5%),
ischemic stroke (1.6%), and hypertensive
heart disease (0.6%).6 Approximately, 75% of
stroke survivors have upper extremities (UE)

AMJ. 2020;7(1):40–4

Abstract

Background: Stroke is one of the leading causes of death and disabilities worldwide. Among all types
of disabilities, disturbance in upper extremities functions is at the highest percentage. This study aimed
to determine the profile of upper extremities function among stroke outpatients in Dr. Hasan Sadikin
General Hospital Bandung as an initial step to provide a better follow up and management.
Methods: The design of this study was a descriptive study, conducted from April to October 2014
among stroke outpatients in the Department of Physical Medicine and Rehabilitation Dr Hasan Sadikin
General Hospital, Bandung based on a consecutive sampling method. The function of upper extremities
was tested by Chedoke Arm and Hand Integrated version 9 (CAHAI-9).
Result: In total, 42 patients were included, consisting of a male (n=25) and a female (n=17). Nine tasks
were performed with dependently by the patients such as open the coffee jar (n22; 52%), call 118
(n24;57%), draw a line with a ruler (n22;52%), pour a glass of water (n33;79%), wring out washed
cloth (n26;62%) do up five-button (n31;74%), dry back with the towel (n25;60%), put toothpaste on a
toothbrush (n25;60%), and cut medium resistance putty(n32;76%).
Conclusions: The majority of stroke outpatients in the sub-acute phase still have a dependent function
of upper extremities. Better patient management and interventions focusing on this function need to be
enhanced for a better outcome.

Keywords: CAHAI-9, disability, impairment, stroke, upper extremities

https://doi.org/10.15850/amj.v7n1.1762

Althea Medical Journal. 2020;7(1)

impairment and half of them have to learn to
compensate by using less-involved hand.7 The
UE makes a significant contribution to most
ADL and UE impairment can compromise
participation in many essential and meaningful
tasks.1

Regarding the evidence of high post-stroke
UE disturbance, data of the post-stroke UE
function’s profile is necessary for further
management.1 Various UE measurements are
available to examine the UE function. One of
them is the Chedoke Arm and Hand Activity
Inventory (CAHAI), a new validated upper-
limb measurement using a 7-point quantitative
scale to assess functional recovery of the arm
and hand after a stroke attack. There are 4
versions of CAHAI, including CAHAI-7, CAHAI-8,
CAHAI-9, and CAHAI-13. The number shows the
total tasks that must be performed by patients.
The examiners have options to choose any
version without risking a significant finding
that may influence the validity of the test. The
internal consistency among CAHAI tests is 0.98,
suggesting that there is an item’s redundancy
that by doing only 6 items the result can achieve
0.95 consistency. The objective of this study
was to explore the profile of UE function among
stroke outpatients in Dr. Hasan Sadikin General
Hospital, Bandung.

Methods

The design of this study was a descriptive
study, conducted from April to October 2014
among stroke outpatients in the Department

of Physical Medicine and Rehabilitation, Dr.
Hasan Sadikin General Hospital based on the
consecutive sampling method. Patients were
first signed informed consent to participate in
this research. Data on age, the onset of stroke,
and paretic side of the UE were collected before
the test. The onset of stroke was grouped as
the sub-acute onset of 2 weeks to 6 months
and chronic onset > 6 months.

The tasks of CAHAI-9 consisted of nine
activities, described followed; 1) open the
coffee jar, 2) call the local emergency number
118, adapted from 911 the USA emergency
number, with personal communication with
Susan Barecca, founder of CAHAI, 3) draw
line with a ruler, 4) pour a glass of water, 5)
wring out the washcloth, 6) do up five buttons,
7) dry back with a towel, 8) put toothpaste on
the toothbrush, and 9) cut medium resistance
putty. The examiner observed how the patients
carried out the tasks and interpreted the score.
Subsequently, the UE function was measured
with Chedoke Arm and Hand Inventory
version 9 (CAHAI-9) followed by the 7-points
scale of interpretation.8 The score of 1–5
was interpreted as ‘need for assistance and
supervision’, and a score of 6–7 was interpreted
as ‘modified and total independence’.
Each task was further categorized into an
‘independent’ and ‘dependent’ group, meaning
that in performing daily activities, whether
patients still at least needed some assistance
in the period of their post-stroke recovery.
The number of respondents performing
the tasks was summed up and described in

Table 1 Basic Characteristic of Stroke patients in Dr. Hasan Sadikin General Hospital,
Bandung

Variables Frequency Percentage (%)
Age (years old)
≤44 5 12
45–54 11 26
55–64 21 50
65–74 5 12
Onset of Stroke
sub-acute 27 64
chronic 15 36
Paretic Side
Right 24 57
Left 18 43

Note: Sub-acute onset 2 weeks to 6 months. Chronic onset > 6 month.

Putri Pamulani et al.: Profile of Upper Extremities Function among Stroke Outpatients in Dr. Hasan Sadikin General
Hospital, Bandung

Althea Medical Journal. 2020;7(1)

42 AMJ March 2020

percentage. The study was approved by the
Health Research Ethics Committee Faculty of
Medicine, Universitas Padjadjaran.

Results

In total, 42 post-stroke patients were included,
with the age ranging from 44 to 74 years old
of whom most patients (n=21;50%) were in
the group of 55 to 64 years old followed by
younger age group of 45–54 years old (n=11;
26%) as shown in Table 1. Based on the onset
of stroke, the sub-acute onset was higher than
the chronic onset (n=27;64%). All subjects
had their right side as their dominant upper
extremity (UE)of whom most of the patients
had right UE paresis (n=24;57%).

Of the tasks performed according to CAHAI-9
tasks, most patients were dependently in doing
the 9 tasks as the following result; open the
coffee jar (n=22;52%), dial 118 (n=24;57%),
draw a line with a ruler (n=22;52%), pour
a glass of water, (n=33;79%), wring out
the washed cloth (n=26;62%), do up five
button (n=31;74%), dry back with a towel
(n=25;50%), put toothpaste on a toothbrush
(n=25;60%), cut a medium putty (n=32;76%).

Discussion

After the interpretation of the CAHAI-9 score,
the result of this study shows that most of the
post-stroke patients are still dependent on
performing the daily activities and still at least
need some assistance in the period of their

post-stroke recovery.
The recovery of UE becomes very important

regarding its significant role in ADL. A profile
of UE function in performing basic daily
tasks is required before therapy, treatment,
and further management. CAHAI-9 as the
measurement tool has been used considering
its good clinical utility and representative
outcome of daily UE function that correlates
with impairment.9

Our study has shown that age group 55–
64 years old reached the highest percentage
among all groups (51%), which is different
from a preceding study conducted by
Construction of National Surveillance System
for Cardiovascular and Cerebrovascular
Disease of Korean Neurological Association
with their highest percentage (88.8%) of DALY
lost due to stroke in the age group 65–74
years old.10 Interestingly, there is an increasing
incidence of ischemic stroke in the young (age
20–54) for both black and white patients over
time. National data of Canada shows that the
risk factors of stroke are increasing in young
ages, especially in people with obesity and
diabetes. Lifestyle changes are assumed to be
the leading cause of this phenomenon of the
dropping age of stroke onset in society.11

All subjects in this study have their right
UE as the dominant side. Right, and left
paretic sides occurred in 57% and 43%,
respectively. The involvement of UE in stroke
can be explained by the evidence of the
middle cerebral artery (MCA) infarct as the
most common type of stroke.12,13 The relation

Table 2 The 7-point Scale for CAHAI-9 and the Interpretation among Post-stroke Patients
(n=42) in Dr. Hasan Sadikin General Hospital.

CAHAI-9 Tasks

Scale* Interpretation

1 2 3 4 5 6 7
Dependent Independent

n % n %
1. Open the coffee jar 12 2 2 3 3 10 10 22 52% 20 48%

2. Call 118 13 4 2 1 4 11 7 24 57% 18 43%

3. Draw a line 5 11 - 1 5 12 8 22 52% 20 48%
4. Pour a glass 10 5 1 5 12 5 4 33 79% 9 21%
5. Wring out the washed cloth 11 4 2 5 4 6 10 26 62% 16 38%
6. Do up five buttons 12 2 5 4 8 8 3 31 74% 11 26%
7. Dry back with a towel 11 3 5 1 5 8 9 25 60% 17 40%
8. Put toothpaste on a toothbrush 11 3 2 3 6 8 9 25 60% 17 40%
9. Cut a medium putty 12 3 3 3 11 6 4 32 76% 10 24%

Note: *CAHAI; Chedoke Arm and Hand Activity Inventory. The 7-points scale to CAHAI-9 tasks was given to the patients; score 1 to 5 as
a need for assistance and supervision and interpreted as a dependent; score 6-7 as modified and total independence and interpreted
as an independent.

Althea Medical Journal. 2020;7(1)

43Putri Pamulani et al.: Profile of Upper Extremities Function among Stroke Outpatients in Dr. Hasan Sadikin General
Hospital, Bandung

between UE impairment and its functional
“use” and “non-use” phenomenon shows
the compensation of the non-paretic side to
learn to do more tasks. Consequently, the
paretic side will not be used to its full capacity.
Considerable non-use of the paretic side, both
in duration and in intensity, and both during
unimanual and bimanual activities in patients
with chronic stroke have been reported as
such the patients compensate for this with the
increased use of the non-paretic side.14 This
may lead to the poor outcome of the paretic
side. However, several training programs can
improve the outcome of the paretic side by
using non-paretic UE as a “teaching hand”
to the paretic side. Bilateral transfer (BT)
occurs in the stroke patients with the same
phenomenon features as noted in the healthy
individuals, with a higher incidence among
men and a bigger effect when the trained
healthy hand is the dominant one, to the
paretic non-dominant hand.15

Most subjects in this study are sub-acute
patients (64%). Early after the stroke onset
or in an acute setting, the patients need to be
properly managed considering the emergency
condition of admission to limit morbidity
and mortality.16 The onset of stroke is a
very important aspect to note regarding the
outcome of stroke-related impairment. There
is a critical-time window during the first 3
months after stroke when most plasticity
can be expected. However, the improvement
of activities after stroke, such as dexterity
is mainly driven by learning compensation
strategies rather than by neural repair. The
strategies can be performed by learning to re-
use the same body segments in the same way
as subjects did before the stroke.17

The objectivity of the examiner is of
important to measure UE daily function based
on the CAHAI test. The profile of UE function
after stroke shows the relation of impairment
degree and functional use. Although there is no
interpretation of total scoring, CAHAI proves
that there is a strong relation between UE
impairment and its function. As the severity
of UE impairments increases, the CAHAI score
will decrease. The CAHAI-9 has been used in
this study according to its affordability and
performance effectiveness.

The outcome in this study is categorized
into the dependent and independent
groups. Most tasks have been measured as a
dependent. The dependent group contributes
to more than half of the total subjects in each
task of the measurement. The interpretation is
explained based on each task since there is no

total score interpretation. The absence of total
score interpretation would not be a problem
since the total score itself already show the
correlation between impairment severity
with UE function (personal communication
with Barecca, et al.). The more severe the
impairment is, the lower the CAHAI total score
will be.

In order not to put aside other aspects,
the recovery of motor impairment should
be considered since this motor impairment
is determined by several factors such as the
salvation of penumbral tissue in the first
days to weeks after stroke, the alleviation
of diaschisis, the homeostatic and learning-
dependent (Hebbian) neuroplasticity, and the
behavioral compensation strategies. These
mechanisms underlying recovery are very
interactive and operate in different and limited
time-windows after stroke onset.14

There are some limitations in this study;
first, the absence of total score interpretation
of CAHAI makes the categorization of the
outcome less clear. However, the 7-point scales
represent the direct and clear correlation
between impairment and functional loss of
the impaired UE. Second, the variables in this
study are limited. Further research should
consider including demography data and
other basic characteristics of the respondents,
depending on the study intention.

The profile of UE function after stroke
can be beneficial to the proper management
including therapy, medication, and education.
A point to concern is the education part;
patients should independently practice the
CAHAI tasks and keep doing other safe daily
tasks to train their impaired UE at home to
maximally regain its function.

To conclude, our study shows that the
upper extremities function of more than half
stroke outpatients is dependent. This result
may serve as information for better patient
management and intervention to obtain better
outcomes of post-stroke patients.

Acknowledgment

Researchers would like to acknowledge Susan
Barecca and the CAHAI team as the founder of
the CAHAI measurement tool that has provided
a very useful tool, especially for this study.

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