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Recovery of upper extremity function in stroke patients: The Copenhagen stroke study
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Recovery of Upper Extremity Function in Stroke Patients: The Copenhagen Stroke Study Hirofumi Nakayama, MB, He&k
Stig Jgtgensen, MD, Hans Otto Raaschou, MD, Tom Skyhuj Olsen, MD, PhD
ABSTRACT. Nakayama II, Jorgensen HS, Raaschou HO, Olsen TS. Recovery of upper extremity function in stroke patients: the Copenhagen Stroke Study. Arch Phys Med Rehabil 1994;75:394-8. a Time course and degree of recovery of upper extremity (UE) function after stroke and the inihtence of initial UE paresis were studied prospectively in a community-based population of 421 consecutive stroke patients admitted acutely during a l-year period. UE function was assessed weekly, using the Barthel Index subscores for feeding and grooming. UE paresis was assessed by the Scandinavian Stroke Scale subscores for hand and arm. The best possible UE function was achieved by 80% of the patients within 3 weeks after stroke onset and by 95% within 9 weeks; in patients with mild UE paresis, function was achieved within 3 and 6 weeks, respectively, and in patients with severe UE paresis within 6 and 11 weeks, respectively. Full UE function was achieved by 79% of patients with mild UE paresis and only by 18% of patients with severe UE paresis. A valid prognosis of UE function can he made within 3 and 6 weeks in patients with mild and severe UE paresis, respectively. Further recovery of UE function should not be expected after 6 and 11 weeks respectively, in these groups of patients. 0 1994 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehubilit&on Impairment of upper extremity (UE) function contributes greatly to functional disability after stroke. The remission of UE function takes place mainly in the first 3 months.‘” However, little is known about the time at which functional recovery is completed within these 3 months and such information is based entirely on selected patients referred to stroke rehabilitation clinics.2,4 Detailed knowledge of the time course of recovery is indispensable to rational planning of rehabilitation, discharge time, discharge placement, and to informing patient and family about the prognosis and the possibility of further recovery. This investigation describes UE function and its recovery in all hospitalized stroke patients from a well-defined community where approximately 90% of the stroke patients are hospitalized.5 Recovery of UE function was studied through weekly examinations from the time patients were admitted to the hospital until they were discharged or died during the hospital stay.
SUBJECTS AND METHODS All patients with stroke admitted to our hospital between March 1, 1992 and February 28, 1993 were included in the study (The Copenhagen Stroke Study). The study population is community-based, as our hospital serves a well-defined area with 239,886 inhabitants in Copenhagen. All persons from the community who have an acute cerebrovascular disease that requires admission to hospital are referred to and From the Department of Neurology (Drs. Nakayama, Jorgensen, Olsen) and Radiology (Dr. Raaschou), Bispebjerg Hospital, Copenhagen, Denmark. Submitted for publication June 28, 1993. Accepted in revised form October 4, 1993. This research supported by grants from The Danish Health Foundation, The Danish Heart Foundation, Ebba Celinders Foundation. and the Gangsted Foundation. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Hirofumi Nakayama, MD, Department of Neurology, Bispebjerg Hospital, Bispebjerg Bakke 23, DK-2400 Copenhagen NV, Denmark. 0 1994 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/94/7504-0120$3.CO/O
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treated at the neurological department, regardless of the age of the patient, the severity of the stroke, and the condition of the patient prior to the stroke. The patients receive acute treatment as well as rehabilitation. All stages of rehabilitation take place within the neurological department. Referral to other departments or hospitals for further rehabilitation is therefore not required. Hospital care is free, and 88% of stroke patients in the community are admitted to this hospita1.5The neurological department has 74 beds, approximately 80% of which are occupied by stroke patients.
Inclusion and Exclusion Criteria There were 515 stroke patients admitted to the hospital in the study period. Their mean age was 74.8 years (SD 11.1); 226 were men and 289 were women. Excluded from the study were 50 patients who were admitted later than 1 week after onset and 44 patients who were not well measured (4 could not cooperate because of aphasia, 9 could not because of disturbed consciousness/ disorientation, and 31 could not for other reasons). There was no significant difference in age (p = 0.99) and sex (x2 0.95; df 1; p = 0.33) between included and excluded patients. Thus, 421 patients comprise the study population.
Diagnosis of Stroke Stroke was diagnosed by a neurologist according to the WHO criteria: rapidly developed clinical signs of focal disturbance of cerebral function lasting more than 24 hours or leading to death, with no apparent cause other than vascular origin6 Subarachnoidal bleeding was not included. Computed tomography (CT) scan was performed with a Siemens Somatom DR” and CT description was used to divide patients into subgroups; infarction or hemorrhage (table).
Evaluation of UE Motor Strength UE motor strength was assessed using the Scandinavian Stroke Scale (SSS) subscores’.* for arm and hand on admission and weekly until discharge. Arm subscore was graded
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Number of Patients, Sex, Age, Type of Stroke, Interval Between Onset and Admission in Hours (median), Length of Hospital Stay in Days (mean) No. Sex (M/F) Age (SD) Infarction Hemorrhage CT not performed Onset-admission interval Hospital stay (SD)
421 1891232 74.8 (11.2) 314 17 90 13 hours 31.9 (37.7)
in 5 (0: paralysis, 2: can move but not against gravity, 4: raises arm with flexion in elbow, 5: raises arm with reduced strength, 6: raises arm with normal strength, score 1 and 3 do not exist in the SSS). Hand subscore was graded in 4 (0: paralysis, 2: some movement, fingertips do not reach palm, 4: reduced strength in full range, 6: normal strength, score 1, 3 and 5 do not exist in the SSS). UE paresis was classified into three categories: Severe (SSS subscores for hand as well as for arm were less than or equal to two), mild (SSS subscores for hand or arm were more than two but not full scores) and no paresis (full subscores both for hand and arm). Patients in the severe-paresis group could not use their affected UE because they could not move their arm against gravity and their fingertips could not reach the palm. Patients in the no-paresis group could lift their arm and use their fingers without motor problems. Patients in the mild-paresis group were in between these two groups.
Evaluation of UE Function UE function was assessed weekly during hospital stay, using the Barthel Index’ subscores for feeding and personal toilet because these two subscores involve primarily UE function. Patients were allowed to use both the nonaffected UE and, when possible, the affected UE when function was evaluated. Theoretically, full score can be achieved using only one UE. Feeding subscore was graded in 3 (0: much help is necessary: 5: some help is necessary; 10: independent in feeding self a meal from a tray or table, cutting up food, using salt and pepper, spreading butter, etc, in a reasonable time) and personal toilet subscore was graded in 2 (0: help is necessary, 5: independent in washing face, combing hair, shaving, cleaning teeth). These two subscores were added to obtain the UE function score. UE function was classified as totally unfunctional (UE function score = 0), partially functional (UE function score = 5, 10) and fully functional (UE function score = 15). The time of stationary UE function was defined as the time when a patient’s UE function score stopped changing.
Rehabilitation Rehabilitation based on the Bobath technique was offered daily to all patients by nursing staff, physiotherapists and occupational therapists.
Statistics For a comparison of included and excluded patients, Student’s t test was used to compare the mean age, and x2 test was used to compare sex ratio.
AFTER STROKE,
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To describe UE function and time course of recovery in the included subjects, the percentage of patients with full/ partial/no UE function was calculated every week after onset and at discharge. Numbers of patients in these functional categories at every week after onset were compared to the numbers at discharge using the x2 test to learn when these rates stop changing significantly. For a comparison of recovery between patients with severe, mild and no UE paresis, x2 test was used for comparing mortality rate, rate of patients with full UE function at week 12 and at discharge and rate of patients who improved to an upper category of UE function from admission to week 12 and to discharge. Significance level was set at p < 0.05.
Ethics The study was approved penhagen.
by the Ethics Committee
of Co-
RESULTS The table shows sex, age, type of stroke, interval between onset and admission, and length of stay of the 421 patients eligible for the study. On admission, 137 patients (32%) had severe UE paresis, 154 patients (37%) had mild UE paresis, and 130 patients (3 1%) did not have any UE paresis. In total, 297 patients (71%) received rehabilitation by a physiotherapist and/or occupational therapist. One hundred twenty-four patients did not receive physio-/occupational therapy; 69 were too well, 16 were too ill, 39 died too early (median time to death: 4 days after admission).
Discharge Status In patients discharged alive 253 (78.8%) were discharged with full UE function. The remaining 68 patients (21.2%) were discharged without attaining full UE function. Of these, 32 (10.0%) had been stationary for z-4 weeks and another 17 (5.3%) had been stationary for 2 to 3 weeks. Therefore, 94% and 89% of the patients were discharged either with full UE function or with UE function observed to be stationary for r2 and 24 weeks, respectively.
UE Function and Time Course of Recovery One week after stroke onset 19% of the patients had totally unfunctional UEs, 24% had partially functional UEs, 45% had UEs with full function, and 12% had died within the first week (fig 1A). At week four 9% had totally unfunctional UEs, 14% had partially functional UEs, 58% had UEs with full function, and 20% had died within the first 4 weeks. Thereafter, there was no statistically significant change in these rates (week 3 vs discharge: x1 17.33; df 3; p < 0.01, week 4 vs discharge: x2 6.62; df 3;p = 0.08). Of 229 patients who had no or partial UE function at week 1, 90 (39% of all, 67% of survivors) improved to an upper category, 42 ( 18% of all. 3 1% of survivors) did not improve, 2 (1% of all, 2% of survivors) deteriorated, and 95 (42%) had died by discharge. Figure 2 shows the rate of patients with stationary UE function including dead patients. After week 1, 63% did not change in UE function either because of full score (43%),
Arch Phys Med Rehabil Vol75,
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no improvement (8%) or death within the first week (12%). Eighty percent and 95% of all the patients had become stationary 3 and 9 weeks from stroke onset, respectively.
Initial UE Paresis and Functional Recovery Patients with severe UE paresis on admission (N = 137). Figure 1B shows UE function of patients with severe UE paresis on admission. At week 1, 46% had totally unfunctional UEs, 22% had partially functional UEs, 5% had UEs with full function and 27% had died within the first week. At week 4, 20% had totally unfunctional UEs, 24% had %
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Fig 2-Rate of patients with stationary UE function. n , all stroke patients; A, patients with severe UE paresis on admission; *, patients with mild UE paresis on admission; +, patients without UE paresis on admission.
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Fig l-Percentage of patients with full UE function (B), partial UE function no UE function (O), patients who had died (A) in all stroke patients; (B) in patients with severe UE paresis on admission; (C) in patients with mild UE paresis on admission; (D) in patients without UE paresis on admission. *DIS = at discharge from hospital.
partially functional UEs, 11% had UEs with full function, and 45% had died. Thereafter, there was no statistically significant change in these rates (week 3 vs discharge: x2 14.04; df 3; p < 0.01, week 4 vs discharge: x2 5.58; df 3; p = 0.13). Of 129 patients who had no or partial UE function at week 1, 35 (27% of all, 57% of survivors) improved to an upper category, 25 (19% of all, 41% of survivors) did not improve, 1 (1% of all, 2% of survivors) deteriorated and 68 (53%) had died by discharge. Figure 2 shows the percentage of patients with stationary UE function, including dead patients. After week 1, 44% did not change in UE function (full score 4%, no improvement l?%, death within the first week 27%). Eighty percent and 95% had become stationary in 6 and 11 weeks, respectively. Thirty-six (9% of total) patients changed in UE function after 4 weeks. Patients with mild UE paresis on admission (N = 154). Figure 1C shows UE function of patients with mild UE paresis on admission, including discharged patients. At week 1, 7% had totally unfunctional UEs, 3 1% had partially functional UEs, 56% had UEs with full function, and 6% had died within the first week. At week 4,5% had totally unfunctional UEs, 10% had partially functional UEs, 77% had UEs with full function, and 8% had died. Thereafter there was no statistically significant change in these rates (week 3 vs discharge: x2 8.58; df?; p = 0.04, week 4 vs discharge: x2 3.93; df 3; p = 0.27). Of 67 patients who had no or partial UE function at week 1, 39 (59% of all, 78% of survivors) improved to an upper category, 11 (16% of all, 22% of survivors) did not improve, none of them deteriorated, and 17 (25%) died. Figure 2 shows the rate of patients with stationary UE function including dead patients. After week 1, 67% did not
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change in UE function (full score 55%, no improvement 6%, death within the first week 6%). Eighty and ninety-five percent had become stationary in 3 and 6 weeks, respectively. Eleven patients (3%) changed in UE function after 4 weeks.
Patients without UE paresis on admission (N = 130). Figure 1D shows UE function of patients who did not have UE paresis on admission, including discharged patients. At week 1, 5% had totally unfunctional UEs, 19% had partially functional UEs, 74% had UEs with full function, and 2% had died within the first week. At week 2, 1% had totally unfunctional UEs, 14% had partially functional UEs, 80% had UEs with full function, and 5% had died. Thereafter, there was no statistically significant change in these rates (week 1 vs discharge: x’ 18.12; df 2; p < 0.01, week 2 vs discharge: x’ 5.53; df 2; p = 0.06, patients with partial and no UE function were put together into one category for x2 test because of too small expected frequencies). Of 33 patients who had no or partial UE function at week 1, 16 (49% of all. 70% of survivors) improved to an upper category, 6 (18% of all, 26% of survivors) did not improve, 1 (3% of all, 4% of survivors) deteriorated and 10 (30%) died. Figure 2 shows the rate of patients with stationary UE function, including patients who died. After week 1, 76% did not change in UE function (full score 7 1%, no improvement 3%, death within the first week 2%). Eighty percent and 95% had become stationary in 2 and 6 weeks, respectively. Twelve patients (3%) changed in UE function after 4 weeks.
Comparison of recovery between patients with severe, mild, and no UE paresis. Patients with severe UE paresis had higher mortality rate (x’ 79.41; df 1; p < O.Ol), poorer UE function at discharge (x’ 153.52; df 1; p < 0.01) and at week 12 (x’ 149.77; df 1; p < 0.01) and poorer improvement by discharge (x’ 18.34; df 1; p < 0.01) and by week 12 (x’ 14.85; df 1: p < 0.01) than patients with mild or no UE paresis. There was no significant difference between mildparesis and no-paresis groups regarding these rates (mortality rate: x2 0.2 1; df 1; p = 0.65, UE function at discharge: x2 0.92; df 1; p = 0.34. UE function at week 12: x2 0.79; df 1; p = 0.37. improvement by discharge: x’ 0.84; df 1; p = 0.36, and improvement by week 12: x’ 1.80; df 1; p = 0.18). For respective values see sections above. DISCUSSION
Evaluation of UE Function In this study UE function was evaluated using subscores of the Barthel Index for feeding and grooming. The independence in basic ADL function (including feeding and grooming) is the main goal of stroke rehabilitation. Even though the Barthel Index gives a simplified picture of UE function we chose it because it is widely used and results can be compared with other studies. The aim of rehabilitation is to recreate function by recovery of the affected side and/or by compensation using the nonaffected side. The compensation is especially important when the recovery of the affected side cannot be achieved. Therefore, the function, including both extremities, should be evaluated in the assessment of recovery. The Bar-the1 Index evaluates UE function using
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both the affected and the nonaffected UE and thereby reflects UE function in daily life. Other UE function tests, such as Frenchay Arm Test and Nine Hole Peg Test, measure arm function mainly in the affected side. UE motor strength was assessed using subscores of the Scandinavian Stroke Scale whose reliability has been documented.7,8.‘0 It is possible that a limited sensitivity of our measures of UE paresis and function could have contributed to our findings. Eighty-nine percent of patients discharged had either full UE function or were observed to be stationary in UE function for at least 4 weeks. We therefore assume that nearly all the patients reached their best possible UE function according to subscores of the Barthel Index and almost all of them were presumably discharged after having reached a plateau in UE function. The validity of this assumption is supported study of by Wade and colleagues ‘I in a community-based 531 stroke patients seen within 7 days after onset and reexamined 3 weeks and 6 months after stroke. Using the Barthel Index, they found that 77% of the survivors were independent in grooming and 87% were independent in feeding 6 months after stroke. These figures correspond to our figures. In our study, 83% of surviving patients were independent in grooming and 82% were independent in feeding at discharge.
Time Course of Recovery Remission of UE function takes place mainly in the first 3 months after stroke.‘-3 Wade and associates’ followed 92 stroke patients for 3 years and found no significant functional improvement after the first 3 months. Olsen2 studied the recovery of UE function in 75 stroke patients and found that the best UE function was on average achieved 9 weeks after stroke and 95% of the patients achieved their best possible function within 14 weeks after stroke. Parker and coworker? followed 118 patients for 6 months after stroke and found that only 13% changed significantly in UE function between 3 and 6 months. These studies showed that remission of UE function takes place mainly in the first 3 months but it is not known when within those 3 months that recovery IS completed. Our study shows, however, that in a community-based and unselected stroke population, whose UE function was evaluated weekly by the Barthel Index, the best possible UE function was achieved within 9 weeks after stroke. After that time UE function did not change significantly. In fact, 80% of the patients reached their best possible UE function within the first 3 weeks after stroke. The degree of UE paresis on admission strongly inlluenced the time course of functional recovery. Patients with mild and no paresis on admission recovered very quickly. Eighty percent reached their best possible UE function within 2 weeks and 95% within 6 weeks after admission. In patients with severe UE paresis on admission, the speed of recovery in UE function was slower. Eighty percent reached their best possible UE function within 6 weeks and 95% within I1 weeks after admission.
Recovery and the Degree of UE Paresis Recovery of UE function recorded by the Barthel Index subscores was closely related to the degree of UE paresis
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on admission. This agrees with findings in other studies.‘-3,‘2 In patients with severe UE paresis, only 27% improved in UE function whereas 59% of the patients with mild UE paresis on admission improved. In patients with severe UE paresis, only one out of five had reached full UE function by discharge whereas four out of five patients with mild UE paresis reached full UE function. Moreover, nearly half of the patients with severe UE paresis died during the hospital stay whereas only one tenth of patients with mild or no UE paresis died. CONCLUSION The present study shows that recovery of UE related ADL function mainly takes place within the first 2 months after stroke; the few patients (in this study 5%) who experience functional recovery after that are patients with severe paresis of the affected UE. Patients with mild UE paresis recover fast. A valid prognosis of UE function in this group of patients can be made in 3 weeks and further functional recovery should not be expected after 6 weeks. Recovery in patients with severe arm paresis is slower. A valid prognosis of UE function in this group of patients can be made in 6 weeks and further functional recovery should not be expected later than 11 weeks after stroke. References 1. Wade DT, Hewer RL, Wood VA, Skilbeck CE, Ismail HM. The hemiplegic arm after stroke: measurement and recovery. J Neurol Neurosurg Psvchiatrv _ 1983;46:521-4.
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2. Olsen TS. Arm and leg paresis as outcome predictors in stroke rehabilitation. Stroke 1990;21:247-51. 3. Parker VM, Wade DT, Hewer RL. Loss of arm function after stroke: measurement, frequency, and recovery. Int Rehabil Med 1986;8:6973. 4. Wade DT, Wood VA, Hewer RL. Recovery after stroke-the first 3 months. J Neurol Neurosurg and Psychiatry 1985;48:7-13. 5. Jorgensen HS, Plesner AM, Htibbe P, Larsen K. Marked increase of stroke incidence in men between 1972 and 1990 in Frederiksberg, Denmark. Stroke l992;23:1701-4. 6. WHO task force on stroke and other cerebrovascular diseases. Stroke1989 Recommendation on stroke prevention, diagnosis, and therapy. Stroke 1989;20:1407-31. 7. Scandinavian Stroke Study Group: Multicenter trial of hemodilution in ischemic stroke. Background and study protocol. Stroke 1985; l6:88590. 8. Scandinavian Stroke Study Group: Multicenter trial of hemodilution in ischemic stroke. Stroke 1987; 18:691-9. 9. Mahoney F, Barthel D. Functional evaluation: the Barthel Index. MD Med J 1965;2:61-5. 10. Lindenstrom E, Boysen G, Christiansen LW, Hansen BR, Nielsen PW. Reliability of Scandinavian Neurological Stroke Scale. Cerebrovasc Dis 1991;1:103-7. 11. Wade DT, Hewer RL. Functional abilities after stroke: measurement, natural history and prognosis. J Neurol Neurosurg and Psychiatry 1987;50:177-82. 12. Olsen TS. Improvement of function and motor impairment after stroke. J Neuro Rehab 1989;3:187-92.
a. Siemens
A/S, Borupvang
Supplier 3, DK-2750 Ballerup,
Denmark.
Recovery of Upper Extremity Function in Stroke Patients: The Copenhagen Stroke Study Hirofumi Nakayama, MB, He&k
Stig Jgtgensen, MD, Hans Otto Raaschou, MD, Tom Skyhuj Olsen, MD, PhD
ABSTRACT. Nakayama II, Jorgensen HS, Raaschou HO, Olsen TS. Recovery of upper extremity function in stroke patients: the Copenhagen Stroke Study. Arch Phys Med Rehabil 1994;75:394-8. a Time course and degree of recovery of upper extremity (UE) function after stroke and the inihtence of initial UE paresis were studied prospectively in a community-based population of 421 consecutive stroke patients admitted acutely during a l-year period. UE function was assessed weekly, using the Barthel Index subscores for feeding and grooming. UE paresis was assessed by the Scandinavian Stroke Scale subscores for hand and arm. The best possible UE function was achieved by 80% of the patients within 3 weeks after stroke onset and by 95% within 9 weeks; in patients with mild UE paresis, function was achieved within 3 and 6 weeks, respectively, and in patients with severe UE paresis within 6 and 11 weeks, respectively. Full UE function was achieved by 79% of patients with mild UE paresis and only by 18% of patients with severe UE paresis. A valid prognosis of UE function can he made within 3 and 6 weeks in patients with mild and severe UE paresis, respectively. Further recovery of UE function should not be expected after 6 and 11 weeks respectively, in these groups of patients. 0 1994 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehubilit&on Impairment of upper extremity (UE) function contributes greatly to functional disability after stroke. The remission of UE function takes place mainly in the first 3 months.‘” However, little is known about the time at which functional recovery is completed within these 3 months and such information is based entirely on selected patients referred to stroke rehabilitation clinics.2,4 Detailed knowledge of the time course of recovery is indispensable to rational planning of rehabilitation, discharge time, discharge placement, and to informing patient and family about the prognosis and the possibility of further recovery. This investigation describes UE function and its recovery in all hospitalized stroke patients from a well-defined community where approximately 90% of the stroke patients are hospitalized.5 Recovery of UE function was studied through weekly examinations from the time patients were admitted to the hospital until they were discharged or died during the hospital stay.
SUBJECTS AND METHODS All patients with stroke admitted to our hospital between March 1, 1992 and February 28, 1993 were included in the study (The Copenhagen Stroke Study). The study population is community-based, as our hospital serves a well-defined area with 239,886 inhabitants in Copenhagen. All persons from the community who have an acute cerebrovascular disease that requires admission to hospital are referred to and From the Department of Neurology (Drs. Nakayama, Jorgensen, Olsen) and Radiology (Dr. Raaschou), Bispebjerg Hospital, Copenhagen, Denmark. Submitted for publication June 28, 1993. Accepted in revised form October 4, 1993. This research supported by grants from The Danish Health Foundation, The Danish Heart Foundation, Ebba Celinders Foundation. and the Gangsted Foundation. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Hirofumi Nakayama, MD, Department of Neurology, Bispebjerg Hospital, Bispebjerg Bakke 23, DK-2400 Copenhagen NV, Denmark. 0 1994 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/94/7504-0120$3.CO/O
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April 1994
treated at the neurological department, regardless of the age of the patient, the severity of the stroke, and the condition of the patient prior to the stroke. The patients receive acute treatment as well as rehabilitation. All stages of rehabilitation take place within the neurological department. Referral to other departments or hospitals for further rehabilitation is therefore not required. Hospital care is free, and 88% of stroke patients in the community are admitted to this hospita1.5The neurological department has 74 beds, approximately 80% of which are occupied by stroke patients.
Inclusion and Exclusion Criteria There were 515 stroke patients admitted to the hospital in the study period. Their mean age was 74.8 years (SD 11.1); 226 were men and 289 were women. Excluded from the study were 50 patients who were admitted later than 1 week after onset and 44 patients who were not well measured (4 could not cooperate because of aphasia, 9 could not because of disturbed consciousness/ disorientation, and 31 could not for other reasons). There was no significant difference in age (p = 0.99) and sex (x2 0.95; df 1; p = 0.33) between included and excluded patients. Thus, 421 patients comprise the study population.
Diagnosis of Stroke Stroke was diagnosed by a neurologist according to the WHO criteria: rapidly developed clinical signs of focal disturbance of cerebral function lasting more than 24 hours or leading to death, with no apparent cause other than vascular origin6 Subarachnoidal bleeding was not included. Computed tomography (CT) scan was performed with a Siemens Somatom DR” and CT description was used to divide patients into subgroups; infarction or hemorrhage (table).
Evaluation of UE Motor Strength UE motor strength was assessed using the Scandinavian Stroke Scale (SSS) subscores’.* for arm and hand on admission and weekly until discharge. Arm subscore was graded
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FUNCTION
Number of Patients, Sex, Age, Type of Stroke, Interval Between Onset and Admission in Hours (median), Length of Hospital Stay in Days (mean) No. Sex (M/F) Age (SD) Infarction Hemorrhage CT not performed Onset-admission interval Hospital stay (SD)
421 1891232 74.8 (11.2) 314 17 90 13 hours 31.9 (37.7)
in 5 (0: paralysis, 2: can move but not against gravity, 4: raises arm with flexion in elbow, 5: raises arm with reduced strength, 6: raises arm with normal strength, score 1 and 3 do not exist in the SSS). Hand subscore was graded in 4 (0: paralysis, 2: some movement, fingertips do not reach palm, 4: reduced strength in full range, 6: normal strength, score 1, 3 and 5 do not exist in the SSS). UE paresis was classified into three categories: Severe (SSS subscores for hand as well as for arm were less than or equal to two), mild (SSS subscores for hand or arm were more than two but not full scores) and no paresis (full subscores both for hand and arm). Patients in the severe-paresis group could not use their affected UE because they could not move their arm against gravity and their fingertips could not reach the palm. Patients in the no-paresis group could lift their arm and use their fingers without motor problems. Patients in the mild-paresis group were in between these two groups.
Evaluation of UE Function UE function was assessed weekly during hospital stay, using the Barthel Index’ subscores for feeding and personal toilet because these two subscores involve primarily UE function. Patients were allowed to use both the nonaffected UE and, when possible, the affected UE when function was evaluated. Theoretically, full score can be achieved using only one UE. Feeding subscore was graded in 3 (0: much help is necessary: 5: some help is necessary; 10: independent in feeding self a meal from a tray or table, cutting up food, using salt and pepper, spreading butter, etc, in a reasonable time) and personal toilet subscore was graded in 2 (0: help is necessary, 5: independent in washing face, combing hair, shaving, cleaning teeth). These two subscores were added to obtain the UE function score. UE function was classified as totally unfunctional (UE function score = 0), partially functional (UE function score = 5, 10) and fully functional (UE function score = 15). The time of stationary UE function was defined as the time when a patient’s UE function score stopped changing.
Rehabilitation Rehabilitation based on the Bobath technique was offered daily to all patients by nursing staff, physiotherapists and occupational therapists.
Statistics For a comparison of included and excluded patients, Student’s t test was used to compare the mean age, and x2 test was used to compare sex ratio.
AFTER STROKE,
Nakayama
395
To describe UE function and time course of recovery in the included subjects, the percentage of patients with full/ partial/no UE function was calculated every week after onset and at discharge. Numbers of patients in these functional categories at every week after onset were compared to the numbers at discharge using the x2 test to learn when these rates stop changing significantly. For a comparison of recovery between patients with severe, mild and no UE paresis, x2 test was used for comparing mortality rate, rate of patients with full UE function at week 12 and at discharge and rate of patients who improved to an upper category of UE function from admission to week 12 and to discharge. Significance level was set at p < 0.05.
Ethics The study was approved penhagen.
by the Ethics Committee
of Co-
RESULTS The table shows sex, age, type of stroke, interval between onset and admission, and length of stay of the 421 patients eligible for the study. On admission, 137 patients (32%) had severe UE paresis, 154 patients (37%) had mild UE paresis, and 130 patients (3 1%) did not have any UE paresis. In total, 297 patients (71%) received rehabilitation by a physiotherapist and/or occupational therapist. One hundred twenty-four patients did not receive physio-/occupational therapy; 69 were too well, 16 were too ill, 39 died too early (median time to death: 4 days after admission).
Discharge Status In patients discharged alive 253 (78.8%) were discharged with full UE function. The remaining 68 patients (21.2%) were discharged without attaining full UE function. Of these, 32 (10.0%) had been stationary for z-4 weeks and another 17 (5.3%) had been stationary for 2 to 3 weeks. Therefore, 94% and 89% of the patients were discharged either with full UE function or with UE function observed to be stationary for r2 and 24 weeks, respectively.
UE Function and Time Course of Recovery One week after stroke onset 19% of the patients had totally unfunctional UEs, 24% had partially functional UEs, 45% had UEs with full function, and 12% had died within the first week (fig 1A). At week four 9% had totally unfunctional UEs, 14% had partially functional UEs, 58% had UEs with full function, and 20% had died within the first 4 weeks. Thereafter, there was no statistically significant change in these rates (week 3 vs discharge: x1 17.33; df 3; p < 0.01, week 4 vs discharge: x2 6.62; df 3;p = 0.08). Of 229 patients who had no or partial UE function at week 1, 90 (39% of all, 67% of survivors) improved to an upper category, 42 ( 18% of all. 3 1% of survivors) did not improve, 2 (1% of all, 2% of survivors) deteriorated, and 95 (42%) had died by discharge. Figure 2 shows the rate of patients with stationary UE function including dead patients. After week 1, 63% did not change in UE function either because of full score (43%),
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no improvement (8%) or death within the first week (12%). Eighty percent and 95% of all the patients had become stationary 3 and 9 weeks from stroke onset, respectively.
Initial UE Paresis and Functional Recovery Patients with severe UE paresis on admission (N = 137). Figure 1B shows UE function of patients with severe UE paresis on admission. At week 1, 46% had totally unfunctional UEs, 22% had partially functional UEs, 5% had UEs with full function and 27% had died within the first week. At week 4, 20% had totally unfunctional UEs, 24% had %
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Fig 2-Rate of patients with stationary UE function. n , all stroke patients; A, patients with severe UE paresis on admission; *, patients with mild UE paresis on admission; +, patients without UE paresis on admission.
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Fig l-Percentage of patients with full UE function (B), partial UE function no UE function (O), patients who had died (A) in all stroke patients; (B) in patients with severe UE paresis on admission; (C) in patients with mild UE paresis on admission; (D) in patients without UE paresis on admission. *DIS = at discharge from hospital.
partially functional UEs, 11% had UEs with full function, and 45% had died. Thereafter, there was no statistically significant change in these rates (week 3 vs discharge: x2 14.04; df 3; p < 0.01, week 4 vs discharge: x2 5.58; df 3; p = 0.13). Of 129 patients who had no or partial UE function at week 1, 35 (27% of all, 57% of survivors) improved to an upper category, 25 (19% of all, 41% of survivors) did not improve, 1 (1% of all, 2% of survivors) deteriorated and 68 (53%) had died by discharge. Figure 2 shows the percentage of patients with stationary UE function, including dead patients. After week 1, 44% did not change in UE function (full score 4%, no improvement l?%, death within the first week 27%). Eighty percent and 95% had become stationary in 6 and 11 weeks, respectively. Thirty-six (9% of total) patients changed in UE function after 4 weeks. Patients with mild UE paresis on admission (N = 154). Figure 1C shows UE function of patients with mild UE paresis on admission, including discharged patients. At week 1, 7% had totally unfunctional UEs, 3 1% had partially functional UEs, 56% had UEs with full function, and 6% had died within the first week. At week 4,5% had totally unfunctional UEs, 10% had partially functional UEs, 77% had UEs with full function, and 8% had died. Thereafter there was no statistically significant change in these rates (week 3 vs discharge: x2 8.58; df?; p = 0.04, week 4 vs discharge: x2 3.93; df 3; p = 0.27). Of 67 patients who had no or partial UE function at week 1, 39 (59% of all, 78% of survivors) improved to an upper category, 11 (16% of all, 22% of survivors) did not improve, none of them deteriorated, and 17 (25%) died. Figure 2 shows the rate of patients with stationary UE function including dead patients. After week 1, 67% did not
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change in UE function (full score 55%, no improvement 6%, death within the first week 6%). Eighty and ninety-five percent had become stationary in 3 and 6 weeks, respectively. Eleven patients (3%) changed in UE function after 4 weeks.
Patients without UE paresis on admission (N = 130). Figure 1D shows UE function of patients who did not have UE paresis on admission, including discharged patients. At week 1, 5% had totally unfunctional UEs, 19% had partially functional UEs, 74% had UEs with full function, and 2% had died within the first week. At week 2, 1% had totally unfunctional UEs, 14% had partially functional UEs, 80% had UEs with full function, and 5% had died. Thereafter, there was no statistically significant change in these rates (week 1 vs discharge: x’ 18.12; df 2; p < 0.01, week 2 vs discharge: x’ 5.53; df 2; p = 0.06, patients with partial and no UE function were put together into one category for x2 test because of too small expected frequencies). Of 33 patients who had no or partial UE function at week 1, 16 (49% of all. 70% of survivors) improved to an upper category, 6 (18% of all, 26% of survivors) did not improve, 1 (3% of all, 4% of survivors) deteriorated and 10 (30%) died. Figure 2 shows the rate of patients with stationary UE function, including patients who died. After week 1, 76% did not change in UE function (full score 7 1%, no improvement 3%, death within the first week 2%). Eighty percent and 95% had become stationary in 2 and 6 weeks, respectively. Twelve patients (3%) changed in UE function after 4 weeks.
Comparison of recovery between patients with severe, mild, and no UE paresis. Patients with severe UE paresis had higher mortality rate (x’ 79.41; df 1; p < O.Ol), poorer UE function at discharge (x’ 153.52; df 1; p < 0.01) and at week 12 (x’ 149.77; df 1; p < 0.01) and poorer improvement by discharge (x’ 18.34; df 1; p < 0.01) and by week 12 (x’ 14.85; df 1: p < 0.01) than patients with mild or no UE paresis. There was no significant difference between mildparesis and no-paresis groups regarding these rates (mortality rate: x2 0.2 1; df 1; p = 0.65, UE function at discharge: x2 0.92; df 1; p = 0.34. UE function at week 12: x2 0.79; df 1; p = 0.37. improvement by discharge: x’ 0.84; df 1; p = 0.36, and improvement by week 12: x’ 1.80; df 1; p = 0.18). For respective values see sections above. DISCUSSION
Evaluation of UE Function In this study UE function was evaluated using subscores of the Barthel Index for feeding and grooming. The independence in basic ADL function (including feeding and grooming) is the main goal of stroke rehabilitation. Even though the Barthel Index gives a simplified picture of UE function we chose it because it is widely used and results can be compared with other studies. The aim of rehabilitation is to recreate function by recovery of the affected side and/or by compensation using the nonaffected side. The compensation is especially important when the recovery of the affected side cannot be achieved. Therefore, the function, including both extremities, should be evaluated in the assessment of recovery. The Bar-the1 Index evaluates UE function using
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both the affected and the nonaffected UE and thereby reflects UE function in daily life. Other UE function tests, such as Frenchay Arm Test and Nine Hole Peg Test, measure arm function mainly in the affected side. UE motor strength was assessed using subscores of the Scandinavian Stroke Scale whose reliability has been documented.7,8.‘0 It is possible that a limited sensitivity of our measures of UE paresis and function could have contributed to our findings. Eighty-nine percent of patients discharged had either full UE function or were observed to be stationary in UE function for at least 4 weeks. We therefore assume that nearly all the patients reached their best possible UE function according to subscores of the Barthel Index and almost all of them were presumably discharged after having reached a plateau in UE function. The validity of this assumption is supported study of by Wade and colleagues ‘I in a community-based 531 stroke patients seen within 7 days after onset and reexamined 3 weeks and 6 months after stroke. Using the Barthel Index, they found that 77% of the survivors were independent in grooming and 87% were independent in feeding 6 months after stroke. These figures correspond to our figures. In our study, 83% of surviving patients were independent in grooming and 82% were independent in feeding at discharge.
Time Course of Recovery Remission of UE function takes place mainly in the first 3 months after stroke.‘-3 Wade and associates’ followed 92 stroke patients for 3 years and found no significant functional improvement after the first 3 months. Olsen2 studied the recovery of UE function in 75 stroke patients and found that the best UE function was on average achieved 9 weeks after stroke and 95% of the patients achieved their best possible function within 14 weeks after stroke. Parker and coworker? followed 118 patients for 6 months after stroke and found that only 13% changed significantly in UE function between 3 and 6 months. These studies showed that remission of UE function takes place mainly in the first 3 months but it is not known when within those 3 months that recovery IS completed. Our study shows, however, that in a community-based and unselected stroke population, whose UE function was evaluated weekly by the Barthel Index, the best possible UE function was achieved within 9 weeks after stroke. After that time UE function did not change significantly. In fact, 80% of the patients reached their best possible UE function within the first 3 weeks after stroke. The degree of UE paresis on admission strongly inlluenced the time course of functional recovery. Patients with mild and no paresis on admission recovered very quickly. Eighty percent reached their best possible UE function within 2 weeks and 95% within 6 weeks after admission. In patients with severe UE paresis on admission, the speed of recovery in UE function was slower. Eighty percent reached their best possible UE function within 6 weeks and 95% within I1 weeks after admission.
Recovery and the Degree of UE Paresis Recovery of UE function recorded by the Barthel Index subscores was closely related to the degree of UE paresis
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on admission. This agrees with findings in other studies.‘-3,‘2 In patients with severe UE paresis, only 27% improved in UE function whereas 59% of the patients with mild UE paresis on admission improved. In patients with severe UE paresis, only one out of five had reached full UE function by discharge whereas four out of five patients with mild UE paresis reached full UE function. Moreover, nearly half of the patients with severe UE paresis died during the hospital stay whereas only one tenth of patients with mild or no UE paresis died. CONCLUSION The present study shows that recovery of UE related ADL function mainly takes place within the first 2 months after stroke; the few patients (in this study 5%) who experience functional recovery after that are patients with severe paresis of the affected UE. Patients with mild UE paresis recover fast. A valid prognosis of UE function in this group of patients can be made in 3 weeks and further functional recovery should not be expected after 6 weeks. Recovery in patients with severe arm paresis is slower. A valid prognosis of UE function in this group of patients can be made in 6 weeks and further functional recovery should not be expected later than 11 weeks after stroke. References 1. Wade DT, Hewer RL, Wood VA, Skilbeck CE, Ismail HM. The hemiplegic arm after stroke: measurement and recovery. J Neurol Neurosurg Psvchiatrv _ 1983;46:521-4.
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2. Olsen TS. Arm and leg paresis as outcome predictors in stroke rehabilitation. Stroke 1990;21:247-51. 3. Parker VM, Wade DT, Hewer RL. Loss of arm function after stroke: measurement, frequency, and recovery. Int Rehabil Med 1986;8:6973. 4. Wade DT, Wood VA, Hewer RL. Recovery after stroke-the first 3 months. J Neurol Neurosurg and Psychiatry 1985;48:7-13. 5. Jorgensen HS, Plesner AM, Htibbe P, Larsen K. Marked increase of stroke incidence in men between 1972 and 1990 in Frederiksberg, Denmark. Stroke l992;23:1701-4. 6. WHO task force on stroke and other cerebrovascular diseases. Stroke1989 Recommendation on stroke prevention, diagnosis, and therapy. Stroke 1989;20:1407-31. 7. Scandinavian Stroke Study Group: Multicenter trial of hemodilution in ischemic stroke. Background and study protocol. Stroke 1985; l6:88590. 8. Scandinavian Stroke Study Group: Multicenter trial of hemodilution in ischemic stroke. Stroke 1987; 18:691-9. 9. Mahoney F, Barthel D. Functional evaluation: the Barthel Index. MD Med J 1965;2:61-5. 10. Lindenstrom E, Boysen G, Christiansen LW, Hansen BR, Nielsen PW. Reliability of Scandinavian Neurological Stroke Scale. Cerebrovasc Dis 1991;1:103-7. 11. Wade DT, Hewer RL. Functional abilities after stroke: measurement, natural history and prognosis. J Neurol Neurosurg and Psychiatry 1987;50:177-82. 12. Olsen TS. Improvement of function and motor impairment after stroke. J Neuro Rehab 1989;3:187-92.
a. Siemens
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