FUNCTIONAL OUTCOME OF THE UPPER LIMB AFTER STROKE ■ Blake P F, M Sc P hysiotherapy, University o f W itw atersrand m Fritz V U, M B B C H FCP(SA ), PhD (Med) S U M M A R Y Is m ovem ent regained in the hem iplegic arm after stroke trans­ lated into useful function in daily activity? As no answ ers could be found in the literature it w as decided to investigate an effective m ethod o f assessing and m easuring spontaneous use o f the arm, the extent to w h ich volu ntary m ovem ent correlated w ith sponta­ neous and observed use, and aspects o f neurological deficit w hich could adversely affect upper extrem ity function. A test battery w as draw n up and adm inistered to seven stroke patients, all o f w h om had som e recovery o f the hem iplegic upper limb. R esults o f the tests indicated a generally positive correlation betw een m otor function and spontaneous and observed use, respectively, thus fulfilling the second aim o f the study. The correlation also suggests that the first aim w as m et and that the tests w ere effective in w h at they w ere designed to evaluate. Sm all sam ple size lim ited the conclu sions w hich could be drawn from the results o f other sub-tests. Indications w ere that the outcom e for spontaneous use o f the hem iplegic arm is poorer in patients w ith non -d om inant hem isp here lesions. H andedness in association w ith dom inance also appears to play a p art in better outcom e for d om inant hem isp here lesions. In spite o f the positive correlation betw een m otor function and spontaneous use, it w as felt that com prehensive evaluation of upper extrem ity function should be extended to include autom at­ ic use. IN T R O D U C T IO N Im pairm ent o f upper limb function greatly contributes to func­ tional disability after stroke. W hile 50-80% o f survivors w ill w alk 1 2 3 independently ' ' , only 14% are likely to m ake good recovery of the upper lim b4. It is possible for stroke sufferers to m anage their ow n self care, live independently and even return to certain types o f w ork w hen no useful function o f the hem iplegic limb has been regained. N evertheless op portu nities for reintegration into an active life style will b e limited. M u ch o f the literature on the functional ou tcom e o f the upper limb after stroke concerns itself w ith studies w hich investigate recovery rates and indicators o f prognosis. There is general agreem ent that the earlier the return o f motor function the higher^ the level o f recovery, the first m onth being the o ptimal period ' ' . Thereafter three m onths is considered an im portant recovery m ilestone7'8. Further recovery occurs more slow ly and to a lesser extent. It may continue for as long as six to 12 m onths after strok e6'7'8. A variety o f tests and test batteries designed to m easure upper limb function have also been described. H ow ever, there is no indication that functional activities perform ed in a test situation w ill be carried over into daily life. Several authors voice this concern, for exam ple D e Souza w ho claim s that the m otor ability o f the arm m ay not be converted into functional ability^*. A ccording to L angton-H ew er, a p atient may have a considerable am ount o f m ovem ent in the a rm b u t no useful function , w h ile Bard and H irschberg state that volu ntary m o­ tion is not identical to upper extrem ity fu nction'’ . N evertheless there appear to be no studies in w h ich researchers have investi­ gated the extent to w hich m ovem ent is translated into useful function in daily activity. The present study w as carried ou t at the Johannesburg H ospital w ith the follow ing aims: • To develop an effective m ethod o f assessing and m easuring spontaneous use o f the arm. • To investigate the extent to w h ich volu ntary m ovem ent corre­ lates w ith autom atic use. • To identify aspects o f neurological d eficit w h ich cou ld ad­ versely affect upper extrem ity function. M E T H O D A battery o f tests designed to evaluate u p p er extrem ity func­ tion w as adm inistered to seven persons w ith resid ual hem iplegia follow ing stroke. All had reached a plateau in term s o f recovery and w ere independently am bulant. W hile five w ere independent in self care, two required m inim al assistance w ith clothes fasten­ ings. Their general level o f ability w as felt to indicate a good overall level o f outcom e. The follow ing biographical data w as recorded on each patient: Age, Sex, H andedness, Side of involvem ent, D ates o f onset and assessm ent, O ccupational Status before and after stroke. The tests com prising the battery w ere aimed at inclu ding all aspects o f neurological function w hich, if im paired , m ight lim it upper extrem ity use. They evaluated M o tor function, M uscle tone, Praxis, A u tom atic use, Spontaneous use, O bserved use, Sensation and N europsychological functions. MOTOR FUNCTION The upper extrem ity section o f the R iverm ead M otor Function assessm en t fo rm w as used sep arate ly as it h ad b ee n ind e­ pendently evaluated for validity and re lia b ility ^ . The fifteen test item s are hierarchically arranged according to known patterns o f upper limb recovery. W hen a task cou ld not be successfully com pleted after three attem pts, the test w as discon­ tinued. T est item s ranged from active p ro traction o f the shoulder in supine at the sim plest level to tvine a piece o f string b ehind the neck at the m ost com plex. MUSCLE TONE Bobath describes the characteristic p osture o f the hem iplegic arm produced by spasticity and how spasticity interferes w ith m ovem ent12. Severe spasticity can p revent m ovem ent, m oderate spastici ty causes m ovem ent to be perform ed abnorm ally and w ith excessive effort, w h ile mild spasticity allow s m ovem ent in norm al pattern b u t it is slow er and requires m ore effo rt than norm al. To establish the presence o f increased tone p atients w ere tested for the presence o f ^risk tendon reflexes. H offm an 's sign and associated reactions . The above m ethods o f testing for increased tone do not give an indication o f its distribution and intensity w h ich is relevant to the rehabilitation therapist. Tone w as therefore also assessed as the degree o f resistance to passive m ovem ent at should er, elbow , w rist and fingers and w as rated on a five point scale ranging from B la d s y 4 0 M e i 1996 SA T y d s k rif F is io te r a p ie , D e e l 5 2 N o 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 14 flaccidity to severe spasticity. D ifferent m ethods o f rating have been previously evaluated and a scale o f five fixed categories w as found to be the m ost reliable PRAXIS G eschw ind defines ap raxia as a _ learned m ovem ent not accounted for b y w eak ness, incoordina---------- ------ Hnn sensory loss, incom prehension or inattention . It w as there­ fore deem ed necessary to include assessm ent o f apraxia in the test battery. Five tasks com m only used in the assessm ent o f apraxia w ere chosen and hierarchically graded according to the p atient's ability to m im e, im itate or apply an object relevant to the task, appropri­ ately. T he activities included b rushing teeth, com bing hair, using a ham m er, turning a key in a lock and perform ing a s a lu te .. AUTOMATIC USE The term autom atic use w as chosen to indicate self-activated use o f the hem iplegic upper limb at a subconscious level in everyday activities. A utom atic use w as further subdivided into spontaneous and observed use. Spontaneous use w as evaluated in ten bim anu al activities. These w ere devised to involve the use o f both hands. No instruc­ tions w ere given regarding use o f the affected arm , it being hoped that residual function w ould spontaneously b e incorporated into the activity. The extent to w hich the affected arm and hand participated w as graded on a four point scale. The tasks included activities such as tying shoe laces, taking toy barrels apart, transferring polystyrene chips from one box to another and throw ing and ca tching a large b all. Observed use w as evaluated b y questionnaire. Keith states that behaviour executed on request in a structured treatm ent environm ent may n ot be the sam e as at hom e w here action m ust b e initiated by the individ- 16ual . The extent to w hich the affected arm w as used in six daily, rontine self care activities such as dressing, w ashing and groom ­ ing w as noted by the p atient's spou se or live-in com panion over a period o f time. Use w as scored on a three point scale and scores w ere given an added w eighting according to frequency o f use. SENSATION M uch is w ritten about the influence o f sensory deficits on function b u t how m uch do they really restrict function after stroke? G arland and W aters com m ent on a sm all group of stroke patients w ho regain good volu ntary control o f the hand but fail to use it . In such cases they found sensation to be impaired. Sensation w as clinically tested as follows: Exteroception as pain and light touch Proprioception as joint position and vibration sense. These w ere com pared with the unaffected side and rated as equal, slightly or very dim inished, or absent. The com bined sensations w ere evaluated b y testing two point discrim ination and stereog- nosis. NEU R O PSYC H O LO G ICA L TESTS In order to identify neglect, constructional dyspraxia, distur­ b ances o f body im age and bod y schem e, each participant w as asked to d o draw ings b oth copied and from m em ory. In addition recognised tests o f b od y part identification w ere carried out. R E S U L T S The average age o f the seven patients w as 59 years, six w ere m ale and one w as fem ale. A ll w ere right handed b efore the stroke while four w ere right and three w ere left hem iplegics. Pre stroke occupations varied from a tiler o f w alls and floors, to an accountant, to a Professor of languages. O nly one person continued to w ork at his previou s jo b since h is stroke. O ne had taken a different jo b and two had w orked post stroke b u t w ere not presently w orking; tw o others had since retired and one had not w orked at all. The m ain object o f the study w as to establish w heth er m otor function o f the affected upper limb after stroke w as translated into autom atic use in daily activity. R esults do show a generally positive correlation betw een scores o f m otor function and sp on- a positive correlation betw een spontaneous and observed use. H ow ever, a m uch larger sam ple w ould be required b efore these results could be generally applied. To dem onstrate the extent of the correlation b etw een the re­ sults, the scores o f the tests of m o tor function and au tom atic use w ere graphically plotted against each other as show n in Figures 1, 2 and 3. o Q.w 3 0 -i 2 5 - 2 0 - 15 - 10 - \ 0 ,c .c . • R.F. . C.C. • J.M. • E . L . • M.vdW. • F.L. T 6 8 10 M o to r F u n c tio n T - 12 —r - 14 I 16 Figure 1: Correlation b e tw e en m otor function and ________________spontaneous use________________ 80 i 7 0 - 6 0- ® 5 0 -w3 ■a 4 0 - <5