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Hand function in hemiplegia
J. chron. Dis. 1965, Vol. 18, pp. 493-500.
Pergamon Press Ltd. Printed in Great Britain
HAND FUNCTION IN HEMIPLEGIA I~OUGLAS CARROLL, Department
of Physical
Medicine
and Rehabilitation, (Received
M.D.
Baltimore
City Hospital,
Baltimore,
Md.
1 July 1964)
THE
development of an upper extremity functional evaluation test, described in the preceding paper, has made possible a more detailed description of the functional impairments found and the pattern of recovery after a cerebral infarction. MATERIALS
AND
METHODS
Fifty hospitalized patients with hemiplegia secondary to cerebral infarction were studied, using the upper extremity functional test (U.E.F.T.). The population of the Baltimore City Hospitals is made up largely of elderly welfare patients with multiple diseases and the selected patients had severe impairments and disabilities. Because of the selection of the patients, no conclusions as to the relative frequencies of different degrees of functional impairment can be drawn. RESULTS
An analysis of the patients’ performance of the upper extremity evaluation test demonstrated two points. First, it was possible to arrange the stable impairments found into three functional groups. Second, only a small proportion of the patients achieved unequivocal increase in significant usable function in the hemiplegic upper extremity while under observation. Static changes in prolonged hemiplegia
The static functional impairments (Table 1) seen in patients with hemiplegia secondary to cerebral infarction can be placed into three well defined groups. Group I. The normal hand. These patients show complete recovery with no abnormality. They are rarely seen in a physical therapy department or as inpatients because the duration of paralysis is invariably short, measured usually in hours, occasionally in days. Group II. The partially functional hmd.-‘functional’ (Scores 90-98), ‘partial (76-89), and ‘poor’ (51-75). The mildest impairment seen in this group is loss of ability to perform fine movements with the small finger (Case 1, Table 1). Along with this loss, there is invariable loss of strength in hand grip as measured by the Smedley Dynamometer. A slightly more severe impairment is loss of flexion and fine movement in both the ring and small finger (Cases 2 and 3, Table 1). More severe impairments include in addition the middle and index fingers (Cases 4 to about 20, Table 1). It is unusual to find a weak finger present without the fingers ulnar to it being more severely involved. The loss of function caused by finger 493
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Hand Function
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495
496
DOUGLAS CARROLL
weakness might not be so severe if thumb function remained intact. Unfortunately, rotation of the thumb into a position opposite the balls of the fingers is found to be lost increasingly in proportion to the number of fingers involved. The most severe impairment seen in this group is a common one. Only slight flexion is possible in three joints of the index finger. The thumb has a small range of motion in plantar adduction and abduction so that the medial distal surface of the ball of the thumb can just reach the lateral proximal ball of the index finger when both are brought together as far as possible. This motion does give a very weak pinch, but is quite ineffective in picking up small or heavy objects. When the hemiplegic hand is as severely impaired as this, it is generally found to have been abandoned for use in ordinary daily activities. Ability to write with the hemiplegic hand may be well maintained if only the small finger is involved, but as with all other functions, deterioration in writing occurs as more fingers are involved. Grasp of large square blocks, grip of pipes, lifting of a heavy clothes iron and ability to pronate and supinate the upper extremity are all less effectively performed as more fingers are involved. Group III. The z~~ekss hmd-‘very poor’ (Scores 26-50) and ‘trace’ (O-25). Hands with loss of pinch between the thumb and index finger are almost useless (Cases 21-50, Table 1). The upper extremity can be used to push large objects and sometimes the spastic fingers can be hooked over objects for pulling or carrying purposes, but if the other hand is near normal, generally the patient does not use the hemiplegic upper extremity at all. If the other hand is disabled by some other process or trauma, the patient may find some uses for the hemiplegic hand. In general, the more significant function present in the hand, the less the incidence of severe contractures, shoulder-hand syndrome and shoulder dislocation. Changes in upper extremity function following the onset of hemiplegia
The return of function of the upper extremity in hemiplegia secondary to cerebral infarction, if it occurs at all, generally starts soon after the onset of weakness and continues rapidly. If there has been no return of function within a week, it is unlikely that the patient will regain full function of the hemiplegic arm. The patient, his family or other observers will often mistake increase in spontaneous movement of the shoulder or elbow as significant return of function. More careful evaluation will generally show that what movement has returned does not allow more independence. Table 2 shows unusual improvement in upper extremity function in a man aged 43 who, on 11 February 1963, one week after having his mitral valve replaced by a Starr valve for‘ mitral insufficiency, suffered a complete flaccid right hemiplegia. Over the next few days there was rapid improvement in upper and lower extremity function. The first U.E.F.T. showed that there was difficulty in performing nearly all parts of the test. There was increasing difficulty in picking up small spheres, most marked in the small finger, but present in all fingers as the sphere decreased in size. There was gradual improvement in ambulation and in upper extremity function. An U.E.F.T. performed on 11 April 1963 showed that there had been general improvement in nearly all movements. The ability to pick up small objects had returned to normal in all fingers except the smallest. Within a week this activity
Hand Function TABLET.
491
in Hemiplegia
UNUSUALIMPROVEMBNTINUPPERFXTREMITY FUNCTIONIN APATIENTWITH PLEGIASECONDARYTOA CEREBROVASCULAREMBOLUS
1963 Patient No. 355561
...
Hand
...
.
21 Feb.
11 April
18 April
R
R
R
GRASP
2 2 2 0
3 3 3 3
3 3 3 3
2 2
3 3
3 3
2
3
3
.
3
3
3
..
2 2 2 2
3 3 3 3
3 3 3 3
2 2 2 0
3 3 3 3
3 3 3 3
2 0 0 0
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.._ . .
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.. .. .
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Hand behind head . . . Handtop head . .. Hand-mouth .. .
. ...
2 2 3
3 3 3
3 3 3
...
...
...
0
0
0
TOTAL
..
..
.. .
46
90
93
Dynamometer A.D.L. score
(kg) ...
. .. . ..
.. . .. .
3 65
5 100
5 100
1. 2. 3. 4.
Block4in. Block3in. Block2in. Block 1 in.
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PLACING
25. 26.
Washer Iron . ..
SUPINATION-PRONATION
27. 28. 29.
Pitcher Glass . . . Glass . .
SHOULDER
WRITE
NAME
A RIGHT HEMI-
498
DOUGLAS
TABLE 3.
C~ROLL
IMPROVEMENT IN UPPER EXTREMITY FUNCTION IN A PATIENT wrr~
A RIGHT HEMIPLEGIA
SECONDARY TO OBSTRUCTION OF THE LEFT CAROTID ARTERY 1963
Patient No. 36 15 86
20 May
Hand
R
6 June R
18 June R
3 Sept.
17 Sept.
8 Oct.
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SUPINATION-PRONATION 27. Pitcher . .. 28. Glass . 29. Glass . SHOULDER Hand behind head Hand top head . . Hand-mouth . .. WRllX NAME TOTAL Dynamometer A.D.L. score
(kg)
Hand Function in Hemiplegia
499
had improved, but still remained abnormal. The patient was illiterate and so was unable to write his name. Despite good improvement in upper extremity function, strength in the hand as measured by the dynamometer was poor. Table 3 records the U.E.F.T. scores on a 4%year-old man who suffered a right hemiplegia early in April 1963. On 25 April, after appropriate diagnostic studies, a clot was removed from the proximal portion of the left subclavian and the left carotid. There was slow recovery of function in the right upper extremity as recorded by the tests in Table 3. Early treatment of the hemiplegic upper extremity
The study of upper extremity function in hemiplegia is helpful in identifying the major areas of functional impairment, the usual pattern of return of function and the prognosis. From these observations it is possible to select the goals of treatment in the individual patient more accurately. There are three principal goals of treatment in hemiplegia. They are : (1) return of function; (2) prevention of complications; and (3) cosmetic considerations. These three purposes are complementary and should be sought in all patients. Bed positioning is important in the arm as well as the leg. A pillow should be placed in the axilla to prevent adduction, the elbow should be nearly extended and a wrist extension splint should be provided. While the patient is in bed the physical therapist should put the arm through full range of motion several times daily and edema should be prevented by elevating the hand above the elbow and shoulder. Once the patient is in a wheel chair, the upper extremity should be supported by a sling to prevent shoulder dislocation and edema. The shoulder-hand syndrome and severe contractures commonly follow hand edema. If no finger function at all has returned within a week, it is unlikely that the patient will recover any significant function, so that activities of daily living with the intact arm should be started. Along with this, the patient should be started on a daily program of movement of the hemiplegic shoulder, arm, wrist, and fingers through all ranges of motion using the intact arm. A splint designed to keep the wrist and fingers in extension should be used at night indefinitely if increased tone appears. The arm sling and wrist extension splint can be designed in a number of ways. Splints should be cheap and easy to fabricate and sufficiently simple so that the patient will be able to put them on by himself. One of the most useful exercises is performed with an overhead pulley. The hemiplegic hand grasps or is attached to one handle and the good arm pulls the hemiplegic arm out as straight as possible overhead. DISCUSSION
It was Sir CHARLES BELL who pointed out the inseparability of upper extremity function from that of the body as a whole and particularly of the brain [I]. The development of skill depends on coordination of eye, brain and sensation as well as muscular activity. It is possible, however, to differentiate peripheral, fine, precise, small, variable, special movements needing conscious effort to perform and generally located in the wrist, hand and fingers, from the more stereotyped general automatic movements of the shoulder and elbow [2].
500
DOUGLASCARROLL
In hemiplegia from almost any cause, it is the loss of the fine, precise movements of the fingers which constitutes the major functional impairment. The loss of this particular type of function renders the upper extremity practically useless even when the grosser movements of the shoulder and elbow are preserved. Some of the problems in selection of patients with hemiplegia have been previously discussed [3,4]. The patients herein reported tend to be those with the most severe impairments and disabilities. Patients who show rapid recovery to normal do not appear in hospitals. SUMMARY 1. Static upper extremity impairments. Following a hemiplegia owing to cerebral infarction, the upper extremity may regain normal function, partial function, or no significant function. Study of the group with partial hand function showed that they could be arranged in a spectrum of increasing usefulness of the hand depending roughly on the number of fingers involved. This group was characterized by general weakness as measured by the Smedley Dynamometer, and variable degrees of loss of finger function best indicated by ability to pick up small spheres (pinch). If a finger was impaired, the ones ulnar to it were almost always involved more severely, while the fingers radial to it were less involved. The greater the number of fingers involved, the greater the disability of the thumb, supinators and pronators. 2. Improving upper extremity function. In patients showing improvement under serial observation, there was greatest improvement in the index finger and thumb and decreasing improvement in the middle, ring and small fingers respectively. The prediction of how much functional improvement will occur in an upper extremity depends on the severity and duration of the paralysis and the temporal profile of return of function. If complete paralysis of the upper extremity lasts for longer than several hours, return of significant function is unlikely. There is generally little return of significant upper extremity function if grasp, pinch or lateral prehension of slight degree has not developed within the first few days. Exceptions occur, however, and treatment should be directed toward taking advantage of any function which may occur. Prevention of painful shoulder may be accomplished by adequate support of the upper extremity and passage of the joints through full range of motion several times daily. REFERENCES 1. 2. 3. 4.
BELL,C. : The Hand, Its Mechanics and Vital Endowments. 1835. MERCIER,C. : The phenomena of convulsion, Brain 4,325, 1881-82. CARROLL,D.: The disability in hemiplegia caused by cerebrovascular disease, J. chron. Dis. 15,179, 1962. CARROLL,D. : Comprehensive Evaluation and Management of Inpatients with Chronic Impairments. Paul Harrod, Baltimore, 1962.
Pergamon Press Ltd. Printed in Great Britain
HAND FUNCTION IN HEMIPLEGIA I~OUGLAS CARROLL, Department
of Physical
Medicine
and Rehabilitation, (Received
M.D.
Baltimore
City Hospital,
Baltimore,
Md.
1 July 1964)
THE
development of an upper extremity functional evaluation test, described in the preceding paper, has made possible a more detailed description of the functional impairments found and the pattern of recovery after a cerebral infarction. MATERIALS
AND
METHODS
Fifty hospitalized patients with hemiplegia secondary to cerebral infarction were studied, using the upper extremity functional test (U.E.F.T.). The population of the Baltimore City Hospitals is made up largely of elderly welfare patients with multiple diseases and the selected patients had severe impairments and disabilities. Because of the selection of the patients, no conclusions as to the relative frequencies of different degrees of functional impairment can be drawn. RESULTS
An analysis of the patients’ performance of the upper extremity evaluation test demonstrated two points. First, it was possible to arrange the stable impairments found into three functional groups. Second, only a small proportion of the patients achieved unequivocal increase in significant usable function in the hemiplegic upper extremity while under observation. Static changes in prolonged hemiplegia
The static functional impairments (Table 1) seen in patients with hemiplegia secondary to cerebral infarction can be placed into three well defined groups. Group I. The normal hand. These patients show complete recovery with no abnormality. They are rarely seen in a physical therapy department or as inpatients because the duration of paralysis is invariably short, measured usually in hours, occasionally in days. Group II. The partially functional hmd.-‘functional’ (Scores 90-98), ‘partial (76-89), and ‘poor’ (51-75). The mildest impairment seen in this group is loss of ability to perform fine movements with the small finger (Case 1, Table 1). Along with this loss, there is invariable loss of strength in hand grip as measured by the Smedley Dynamometer. A slightly more severe impairment is loss of flexion and fine movement in both the ring and small finger (Cases 2 and 3, Table 1). More severe impairments include in addition the middle and index fingers (Cases 4 to about 20, Table 1). It is unusual to find a weak finger present without the fingers ulnar to it being more severely involved. The loss of function caused by finger 493
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Hand Function
in Hemiplegia
495
496
DOUGLAS CARROLL
weakness might not be so severe if thumb function remained intact. Unfortunately, rotation of the thumb into a position opposite the balls of the fingers is found to be lost increasingly in proportion to the number of fingers involved. The most severe impairment seen in this group is a common one. Only slight flexion is possible in three joints of the index finger. The thumb has a small range of motion in plantar adduction and abduction so that the medial distal surface of the ball of the thumb can just reach the lateral proximal ball of the index finger when both are brought together as far as possible. This motion does give a very weak pinch, but is quite ineffective in picking up small or heavy objects. When the hemiplegic hand is as severely impaired as this, it is generally found to have been abandoned for use in ordinary daily activities. Ability to write with the hemiplegic hand may be well maintained if only the small finger is involved, but as with all other functions, deterioration in writing occurs as more fingers are involved. Grasp of large square blocks, grip of pipes, lifting of a heavy clothes iron and ability to pronate and supinate the upper extremity are all less effectively performed as more fingers are involved. Group III. The z~~ekss hmd-‘very poor’ (Scores 26-50) and ‘trace’ (O-25). Hands with loss of pinch between the thumb and index finger are almost useless (Cases 21-50, Table 1). The upper extremity can be used to push large objects and sometimes the spastic fingers can be hooked over objects for pulling or carrying purposes, but if the other hand is near normal, generally the patient does not use the hemiplegic upper extremity at all. If the other hand is disabled by some other process or trauma, the patient may find some uses for the hemiplegic hand. In general, the more significant function present in the hand, the less the incidence of severe contractures, shoulder-hand syndrome and shoulder dislocation. Changes in upper extremity function following the onset of hemiplegia
The return of function of the upper extremity in hemiplegia secondary to cerebral infarction, if it occurs at all, generally starts soon after the onset of weakness and continues rapidly. If there has been no return of function within a week, it is unlikely that the patient will regain full function of the hemiplegic arm. The patient, his family or other observers will often mistake increase in spontaneous movement of the shoulder or elbow as significant return of function. More careful evaluation will generally show that what movement has returned does not allow more independence. Table 2 shows unusual improvement in upper extremity function in a man aged 43 who, on 11 February 1963, one week after having his mitral valve replaced by a Starr valve for‘ mitral insufficiency, suffered a complete flaccid right hemiplegia. Over the next few days there was rapid improvement in upper and lower extremity function. The first U.E.F.T. showed that there was difficulty in performing nearly all parts of the test. There was increasing difficulty in picking up small spheres, most marked in the small finger, but present in all fingers as the sphere decreased in size. There was gradual improvement in ambulation and in upper extremity function. An U.E.F.T. performed on 11 April 1963 showed that there had been general improvement in nearly all movements. The ability to pick up small objects had returned to normal in all fingers except the smallest. Within a week this activity
Hand Function TABLET.
491
in Hemiplegia
UNUSUALIMPROVEMBNTINUPPERFXTREMITY FUNCTIONIN APATIENTWITH PLEGIASECONDARYTOA CEREBROVASCULAREMBOLUS
1963 Patient No. 355561
...
Hand
...
.
21 Feb.
11 April
18 April
R
R
R
GRASP
2 2 2 0
3 3 3 3
3 3 3 3
2 2
3 3
3 3
2
3
3
.
3
3
3
..
2 2 2 2
3 3 3 3
3 3 3 3
2 2 2 0
3 3 3 3
3 3 3 3
2 0 0 0
3 3 3 3
3 3 3 3
.._ . .
0 0 0 0
3 3 3 0
3 3 3 2
.. .. .
...
3 0
3 2
3 2
1::
1::
. ..
..
1 2 2
2 3 2
2 3 3
Hand behind head . . . Handtop head . .. Hand-mouth .. .
. ...
2 2 3
3 3 3
3 3 3
...
...
...
0
0
0
TOTAL
..
..
.. .
46
90
93
Dynamometer A.D.L. score
(kg) ...
. .. . ..
.. . .. .
3 65
5 100
5 100
1. 2. 3. 4.
Block4in. Block3in. Block2in. Block 1 in.
GRIP 5.
.,. . .. ... . ..
Pipelain. PipePin.
6.
PREHENSION I. Slate
.
. . . ..
..
PINCH
8.
Ball3in.
Marble 9. Index 10. Middle 11. Ring 12. Small
8 in.
...
. .
. .. . .
. .. .
.
Ball-bearzg & in. 13. Index . . . 14. Middle .. 15. Ring .. 16. Small . . 17. 18. 19. 20.
Ball-bearing 4 in. . Index .. Middle Ring .. . 1:: .. Small . . .
21. 22. 23. 24.
Ball-bearing & in. Index .. . .. .. . Middle . . .. Ring Small . . ..
. ...
. __.
. 1::
PLACING
25. 26.
Washer Iron . ..
SUPINATION-PRONATION
27. 28. 29.
Pitcher Glass . . . Glass . .
SHOULDER
WRITE
NAME
A RIGHT HEMI-
498
DOUGLAS
TABLE 3.
C~ROLL
IMPROVEMENT IN UPPER EXTREMITY FUNCTION IN A PATIENT wrr~
A RIGHT HEMIPLEGIA
SECONDARY TO OBSTRUCTION OF THE LEFT CAROTID ARTERY 1963
Patient No. 36 15 86
20 May
Hand
R
6 June R
18 June R
3 Sept.
17 Sept.
8 Oct.
R
R
R
GRASP 1. 2.
Block4in. Block3in.
3. 4.
Block2in. Block 1 in.
.
I
_., ._,
0 0
2
2 2
2 3
2 2
.,.
2 0
2
2
3
2
2 3 3
2
2
3
2
3
2 2
2 2
2 2
3 3
2 2
3 3
0
2
2
2
2
2
2
2
2
3
2
3
0 0 0 0
0 0 0 0
0 0 0 0
3 0 0 0
3 2 2 0
3 2 2 0
0 0 0 0
0 0 0 0
0 0 0 0
3 0 0 0
3 0 0 0
2 2 2 0
0 0 0 0
0 0 0 0
0 0 0 0
2 0 0 0
2 0 0 0
2 2 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
.
0
0
1
0
. ..
0
2
1
3
2 3
2 3
.
2 0
. .
0
2 2 2
2 2 2
3 2 2
3 2 2
2 2 2
. . ..
0 0 0
3 3 3
3 3 3
3 3 3
3 3 3
3 3 3
. .. :::
0 10
0 32
33
49
1 50
1 60
...... ......
0 95
4 95
95
95
14 95
12 95
.
GRIP 5. Pipe 12 in. . . 6. Pipe$in. .. . PREHENSION 7.
Slate
.
Ball 3 in.
.
PINCH 8.
...
Marble $ in. 9. 10. II. 12.
Index Middle Ring Small
13. 14. 15. 16.
lndex Middle Ring Small
17. 18. 19. 20.
. ..
Ball-bearing L in. .‘.” . .. ... ..
. . .. .
Ball-bearing -$ in.
.
Index Middle Ring Small
..
.
Ball-bearing & in. 21. 22. 23. 24.
Index Middle Ring Small
. .. .
PLACING 25. Washer 26. Iron
. .._
SUPINATION-PRONATION 27. Pitcher . .. 28. Glass . 29. Glass . SHOULDER Hand behind head Hand top head . . Hand-mouth . .. WRllX NAME TOTAL Dynamometer A.D.L. score
(kg)
Hand Function in Hemiplegia
499
had improved, but still remained abnormal. The patient was illiterate and so was unable to write his name. Despite good improvement in upper extremity function, strength in the hand as measured by the dynamometer was poor. Table 3 records the U.E.F.T. scores on a 4%year-old man who suffered a right hemiplegia early in April 1963. On 25 April, after appropriate diagnostic studies, a clot was removed from the proximal portion of the left subclavian and the left carotid. There was slow recovery of function in the right upper extremity as recorded by the tests in Table 3. Early treatment of the hemiplegic upper extremity
The study of upper extremity function in hemiplegia is helpful in identifying the major areas of functional impairment, the usual pattern of return of function and the prognosis. From these observations it is possible to select the goals of treatment in the individual patient more accurately. There are three principal goals of treatment in hemiplegia. They are : (1) return of function; (2) prevention of complications; and (3) cosmetic considerations. These three purposes are complementary and should be sought in all patients. Bed positioning is important in the arm as well as the leg. A pillow should be placed in the axilla to prevent adduction, the elbow should be nearly extended and a wrist extension splint should be provided. While the patient is in bed the physical therapist should put the arm through full range of motion several times daily and edema should be prevented by elevating the hand above the elbow and shoulder. Once the patient is in a wheel chair, the upper extremity should be supported by a sling to prevent shoulder dislocation and edema. The shoulder-hand syndrome and severe contractures commonly follow hand edema. If no finger function at all has returned within a week, it is unlikely that the patient will recover any significant function, so that activities of daily living with the intact arm should be started. Along with this, the patient should be started on a daily program of movement of the hemiplegic shoulder, arm, wrist, and fingers through all ranges of motion using the intact arm. A splint designed to keep the wrist and fingers in extension should be used at night indefinitely if increased tone appears. The arm sling and wrist extension splint can be designed in a number of ways. Splints should be cheap and easy to fabricate and sufficiently simple so that the patient will be able to put them on by himself. One of the most useful exercises is performed with an overhead pulley. The hemiplegic hand grasps or is attached to one handle and the good arm pulls the hemiplegic arm out as straight as possible overhead. DISCUSSION
It was Sir CHARLES BELL who pointed out the inseparability of upper extremity function from that of the body as a whole and particularly of the brain [I]. The development of skill depends on coordination of eye, brain and sensation as well as muscular activity. It is possible, however, to differentiate peripheral, fine, precise, small, variable, special movements needing conscious effort to perform and generally located in the wrist, hand and fingers, from the more stereotyped general automatic movements of the shoulder and elbow [2].
500
DOUGLASCARROLL
In hemiplegia from almost any cause, it is the loss of the fine, precise movements of the fingers which constitutes the major functional impairment. The loss of this particular type of function renders the upper extremity practically useless even when the grosser movements of the shoulder and elbow are preserved. Some of the problems in selection of patients with hemiplegia have been previously discussed [3,4]. The patients herein reported tend to be those with the most severe impairments and disabilities. Patients who show rapid recovery to normal do not appear in hospitals. SUMMARY 1. Static upper extremity impairments. Following a hemiplegia owing to cerebral infarction, the upper extremity may regain normal function, partial function, or no significant function. Study of the group with partial hand function showed that they could be arranged in a spectrum of increasing usefulness of the hand depending roughly on the number of fingers involved. This group was characterized by general weakness as measured by the Smedley Dynamometer, and variable degrees of loss of finger function best indicated by ability to pick up small spheres (pinch). If a finger was impaired, the ones ulnar to it were almost always involved more severely, while the fingers radial to it were less involved. The greater the number of fingers involved, the greater the disability of the thumb, supinators and pronators. 2. Improving upper extremity function. In patients showing improvement under serial observation, there was greatest improvement in the index finger and thumb and decreasing improvement in the middle, ring and small fingers respectively. The prediction of how much functional improvement will occur in an upper extremity depends on the severity and duration of the paralysis and the temporal profile of return of function. If complete paralysis of the upper extremity lasts for longer than several hours, return of significant function is unlikely. There is generally little return of significant upper extremity function if grasp, pinch or lateral prehension of slight degree has not developed within the first few days. Exceptions occur, however, and treatment should be directed toward taking advantage of any function which may occur. Prevention of painful shoulder may be accomplished by adequate support of the upper extremity and passage of the joints through full range of motion several times daily. REFERENCES 1. 2. 3. 4.
BELL,C. : The Hand, Its Mechanics and Vital Endowments. 1835. MERCIER,C. : The phenomena of convulsion, Brain 4,325, 1881-82. CARROLL,D.: The disability in hemiplegia caused by cerebrovascular disease, J. chron. Dis. 15,179, 1962. CARROLL,D. : Comprehensive Evaluation and Management of Inpatients with Chronic Impairments. Paul Harrod, Baltimore, 1962.