Upper Extremity Function in Stroke Subjects: Relationships between the International Classification of Functioning, Disability, and Health Domains

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CREDIT ARTICLE #197.

Upper Extremity Function in Stroke Subjects: Relationships between the International Classification of Functioning, Disability, and Health Domains Iza Faria-Fortini, OT, MSc

Department of Occupational Therapy, Fundac¸~ao Mineira de Educac¸~ao e Cultura (FUMEC), Belo Horizonte, Brazil

Stella Maris Michaelsen, PT, PhD Department of Physical Therapy, Universidade do Estado de Santa Catarina, Florianopolis, Brazil

Janine Gomes Cassiano, OT, PhD Department of Occupational Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil

Luci Fuscaldi Teixeira-Salmela, PT, PhD Department of Physical Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil

Deficits in body functions/structures of the upper limb (UL) after stroke are highly prevalent, and the impairments of the arm and hand are the major contributors to activity limitations and possibly to participation restrictions.1 More than 80% of individuals with stroke experience hemiparesis, as classified by the Scandinavian Stroke Care subscores for arm and hand recovery.2 Nakayama et al.3 reported Financial Support: Brazilian Government Funding Agencies: Conselho Nacional de Desenvolvimento a Pesquisa and Fundac¸~ ao de Amparo a Pesquisa de Minas Gerais. Correspondence and reprint requests to Luci Fuscaldi TeixeiraSalmela, PT, PhD, Department of Physical Therapy, Universidade Federal de Minas Gerais, Avenida Ant^ onio Carlos 6627, Campos Pampulha, 31270-901 Belo Horizonte, Minas Gerais, Brazil; e-mail: . 0894-1130/$ - see front matter Ó 2011 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. doi:10.1016/j.jht.2011.01.002

ABSTRACT: Upper limb (UL) impairments are the most common disabling deficits after stroke and have complex relationships with activity and participation domains. However, relatively few studies have applied the ICF model to identify the contributions of specific UL impairments, such as muscular weakness, pain, and sensory loss, as predictors of activity and participation. The purposes of this predictive study were to evaluate the relationships between UL variables related to body functions/structures, activity, and participation domains and to determine which would best explain activity and participation with 55 subjects with chronic stroke. Body functions/structures were assessed by measures of grip, pinch, and UL strength, finger tactile sensations, shoulder pain, and cognition (MMSE); activity domain by measures of observed performance (BBT, NHPT, and TEMPA); and participation by measures of quality of life (SSQOL). Upper-limb and grip strength were related to all activity measures (0.52 , r , 0.82, p , .0001). Shoulder pain (r ¼ .39,p , .001) was the variable which was mostly related to participation. Grip strength alone accounted for 62%, 54%, and 36% of the variance in the activity measures (respectively TEMPA, BBT and NHPT). Shoulder pain accounted for 30% of the participation measure. Strength deficits and shoulder pain of the paretic UL demonstrated to be important targets for clinical interventions to improve activity and participation with chronic stroke subjects. Level of Evidence: 2c. J HAND THER. 2011;24:257–65.

achievement of complete UL function, assessed by the subsections of the Barthel Index for feeding and grooming, only in 18% of the patients with severe hemiparesis, one year after stroke. Hunter and Crome4 reported a loss of function and disuse of the paretic UL in 50e70% of subjects two to four years after stroke, despite 25% having only mild impairments (.50 Fugl-Meyer Motor Assessment arm section). The presence of residual arm and hand impairments after stroke has potential impacts on UL performance of activities of daily living (ADLs).5 Activity limitations, assessed by the Test d’evaluation des membres superieurs des personnes ^agees (TEMPA), were significantly correlated to the degree of participation restrictions experienced by subjects six months after stroke,5 with negative consequences on personal, family, social relationships, and quality of life (QOL).5,6 Measures of body functions/structures, activity, and participation are key elements for the assessment JulyeSeptember 2011 257

of subjects with a stroke. The consequences of stroke can be understood in the context of the International Classification of Functioning, Disability, and Health (ICF).7e9 Upper limb impairments in people who have had a stroke are well documented and include spasticity, dystonia, muscle contracture, loss of strength and dexterity, decreased active joint range of motion, and lack of movement speed, precision, and bimanual coordination.10,11 The relationships between weakness and activity limitations of the paretic UL are well documented.12e17 Handgrip was shown to be correlated with UL performance, and the results of previous studies showed high correlations (r.0.70) between handgrip with the Frenchay arm test, ninehole peg test (NHPT),13 TEMPA,14 and box and block test (BBT)14,16 and moderate correlations (r.0.60) with the Chedoke Arm and Hand Activity Inventory and motor activity log (MAL) scores.17 These findings suggest that grip strength is a valuable marker for functional arm recovery in patients with acute stroke12,13 (#6 mo after stroke) and a valuable indicator of hand and arm functioning in subjects with chronic stroke14 (.6 mo after stroke). The strength of the wrist flexor/extensors was also recognized as an important indicator of UL function in subjects with chronic stroke.15 Mercier and Bourbonnais16 reported weakness of the shoulder flexors and handgrip, exceeding that of the shoulder and elbow extensors. Harris and Eng17 reported paretic UL strength (wrist and elbow flexors/extensors, shoulder flexors, and abductors) as the best predictors of UL performance in ADLs. Although the literature indicates reduced muscular strength as a major contributor to activity limitations,12e17 it has weak explanatory power for social participation.17e19 Therefore, further studies are needed to address, from the ICF perspective, the deficits in the UL body functions/structures, activity, and participation by focusing on highly prevalent impairments, such as finger and hand dexterity and pinch strength, activity limitations, and participation restrictions. Such knowledge may guide the selection of more effective intervention strategies. Therefore, the purposes of this study were to evaluate the relationships between UL variables related to body functions/structures, activity, and participation domains and determine which would best explain activity and participation with 55 subjects with chronic stroke.

following inclusion criteria: paresis of the UL, resulting from unilateral ischemic or hemorrhagic stroke, at least six months before the study, to ensure chronicity and to minimize any influences of spontaneous recovery; $stage 3 on the Chedoke McMaster Stroke Assessment-arm section to guarantee the ability to perform voluntary reaching movements;20 and mental competence, as assessed by the Mini-Mental State Examination (MMSE),21,22 with a cutoff point of 18/ 19 for the individuals with illiteracy and 24/25 for those with basic education, according to Lourenc¸o and Veras.21 Patients were excluded if they had aphasia, bilateral hemiparesis, or other musculoskeletal or neurological conditions, such as arthritis, Parkinson’s disease, and multiple sclerosis. Eligible subjects provided participation consent based on ethical approval, which was previously obtained from the University ethical review board. The sample size of minimum 50 participants was based on the formula proposed by Dohoo et al.23 For this calculation, four independent variables were used in the multiple regression model.

METHODS

Outcome Measures

Participants

The protocols for data collection were regrouped according to the ICF conceptual model and included measures of impairment (grip/lateral pinch and UL strength—wrist and elbow flexor/extensors and

Sixty-seven volunteers with chronic stroke were recruited from the general community based on the 258

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Procedures Initially, after verifying the inclusion criteria, the subjects received information regarding the objectives of the study and were invited to sign the consent form. After this, demographic and clinical data were collected for all subjects to document their age, gender, the time since the onset of stroke, and their paretic and dominant sides. Then, information on the percentage of recovery was assessed using the FuglMeyer (FM) scale—upper extremity.24 The FM is a valid and reliable25,26 impairment-based scale used to assess motor deficits and is one of the most widely used instruments for clinical assessments. The UL subscale consists of 33 items, and the scores for each item were summed to calculate the total score. An ordinal three-point scale was applied to each item: 0: cannot be performed, 1: partially done, and 2: normally performed. The total score of 66 points indicated normal motor function, scores between 50 and 65 reflected mild impairments, those between 30 and 49 indicated moderate impairments, and those below 30 reflected severe impairments.27 All testing was performed during a single session, with rest intervals, as requested by the participants, by an occupational therapist, who had clinical experience with stroke rehabilitation, and three trained research assistants, who were physical therapy students.

shoulder flexors, cognition, shoulder pain, and tactile sensations); activity limitations, assessed by the BBT, NHPT, and TEMPA; and participation restrictions, evaluated by the Stroke Specific Quality of Life (SSQOL) Scale scores. The selection of the measures of body functions/ structures was based on their evaluative prevalence in studies with UL function after stroke,5,12e17 whereas the measures of activity and participation were chosen due to their ability to reflect the activity performance of the UL in ADLs14,16 and the personperceived participation.7e9 Body Functions/Structures Grip and lateral pinch strength were respectively assessed with the Jamar hand-held dynamometerÒ (Enterprises Inc., Irvington, NY) and Preston pinch gaugeÒ (B & L Engineering, model PG 30, Tustin, CA). To perform the tests, the participants sat on a chair with their UL positioned at zero degrees of shoulder adduction at the side, 90 degrees of elbow flexion, and the wrist between zero and 30 degrees of extension.14 They were instructed to squeeze as hard as they could for 3 seconds and, then, relax for 20 seconds. The means of the three trials, whose values were similar, were recorded for analyses. High reliability has been found for hand-held dynamometry.14 The isometric strength of the wrist and elbow flexor/extensors and shoulder flexors was bilaterally evaluated using the manual microFET 2 digital handheld dynamometer (Hoggan Health Industries, Draper, UT), whose reliability has been previously established.28 These muscular groups were selected because they were recognized as most necessary to carry out the performance-based tasks.17 All measurements were performed in the standard positions proposed by Andrews et al.,28 and the non-paretic UL was always tested first. Each group was tested three times, and the mean values were recorded for analyses. To reduce the number of variables, a composite strength score for each UL was calculated by adding the strength values of the shoulder, elbow, and wrist flexor/extensors. The cognitive functions were assessed by the MMSE,21,22 a valid and realiable21 instrument, whose cutoff points were already established for the Brazilian population. The MMSE is divided into two sections, the first of which only requires verbal responses and covers orientation, memory, and attention. The second part assesses the subjects’ ability to name objects, follow verbal and written commands, write a sentence, and copy a complex polygon. The highest possible score is 30. To minimize the effects of school levels on the interpretation of the results, the cutoff points recommended by Lourenc¸o and Veras21 were used. For the illiterate individuals, the written commands were not administered.

The duration and severity of shoulder pain was evaluated by the Shoulder-Q questionnaire, which included both verbal and visual graphic rating scale questions and focused on pain severity at rest, during motion, and at night.29 Acceptable inter-rater reliability for poststroke shoulder pain intensity has been investigated.30 The tactile finger intensity estimations were evaluated by the Moving Touch Pressure (MTP).31 The MTP measured the individuals’ ability to discriminate between the sensations generated by moving brushes of different textures. A practice trial was given to the participants on the non-paretic UL to allow for familiarization with the expected sensations. The stimuli were applied proximal to the distal areas over the palmar surface of the distal phalanx of the index, and the brushes were positioned at an angle of 30 degrees with the skin surface. With their eyes closed, the participants were instructed to verbally indicate which brush was in contact with their skin. The final scores were determined by the percentages of correct answers over 12 attempts, four for each brush. The differences in sensations between the two sides were calculated by subtracting the percentages of correct responses of the non-paretic side from those of the paretic one. A score of zero indicated no differences, and higher scores demonstrated greater differences. Reliability, concurrent validity, and construct validity for MTP have been investigated with satisfactory results.31 Activity and Participation The activity domain was assessed by subjective and objective measures (hand and finger dexterity and observation of UL performance), whereas participation was measured only by subjective measures.32 Hand and finger dexterity were evaluated using the BBT33 and the NHPT,34 respectively. The BBT is a measure of manual dexterity, which requires moving blocks from one side of a box to another for 60 seconds.33 The reliability of this test has been demonstrated and its construct validity established.33 The NHPT is a timed measure of fine dexterity and involves placing and removing nine pegs on a pegboard. This test has also demonstrated adequate reliability and validity.34 The final scores for both tests were obtained by the mean number of blocks/minute and the average execution times in seconds for each hand for the calculation of the residual deficits (Rd). The Brazilian version of the TEMPA is a protocol for the observation of UL performance composed of eight tasks, four bilateral and four unilateral ones, which represented standardized daily activities.35 Each task was evaluated by three criteria: speed of execution, functional levels, and analyses of the performed tasks. The functional level refers to the individuals’ autonomy on each task measured on a JulyeSeptember 2011 259

four-level scale, in which the levels of the tasks are the following: (0) were successfully completed without hesitation or difficulty; (1) were completed, but with some difficulty; (2) were partially executed or some steps were performed with significant difficulty; and (3) failed to be completed, even if any degree of assistance was offered. The analyses of the performed tasks quantified the difficulties experienced by the subjects according to five dimensions related to upper extremity sensory motor skills: strength, range of motion, precision of gross movements, prehension, and precision of fine movements. The total scores were determined by adding the scores obtained for both the unilateral and bilateral tasks. The lower the score, the better was the performance, ranging from zero to 150.35 Adequate reliability has been reported for adults with hemiparesis.35 The Brazilian version of the SSQOL comprises 49 items over 12 subscales: energy, family roles, language, mobility, mood, personality, self-care, social rules, thinking, upper extremity function, vision, and work/productivity.36 A score between one (worst health state) and five (best health state) was obtained for each subscale. The SSQOL has been shown to be valid and reliable for stroke patients.36 In this study, the total scores and those related to the UL (SSQOL-UL) (self-care, upper extremity function, and work/productivity subscales) were used.

Data Analyses Descriptive statistics were used to describe the subjects’ characteristics, using the SPSS statistical software, version 15.0 for Windows (SPSS, Inc., Chicago, IL). The impairment (tactile sensations, grip, pinch, and UL strength) and activity measures (BBT and NHPT), which assessed the paretic and nonparetic UL, were expressed by the Rd, which quantified the UL performances normalized to the non-paretic UL.37 The calculations used the formula: Rd ¼ 100  (paretic/ non-paretic 3 100). For the finger dexterity, the formula Rd ¼ 100  (non-paretic/paretic 3 100) was used because a shorter time represented better

performance and the changes in the formula would cause higher values. Spearman’s correlation coefficients were calculated to examine the relationships (magnitude, direction, and significance) between body functions/ structures variables, activity, and participation measures. Correlation analyses were used as the initial steps required to determine the appropriate variables for their inclusion in the regression analyses. The strength of the relationships between the independent variables was described using the correlation coefficients (r) and was based on Munro’s correlation descriptors38 (very low ¼ 0.15e0.24, low ¼ 0.25e0.49, moderate ¼ 0.50e0.69, high ¼ 0.70e0.89, and very high ¼ 0.90e1.00). Those variables that were correlated with UL performance and participation were entered into their respective multiple regression models. Variable entry for the regression was set at 0.05, and removal was set at 0.10. Four forward regression models were created: three models of UL performance (activity) and two of participation (Table 1). The significance levels for all analyses were set at a # 0.05.

RESULTS Of the 67 recruited subjects, 12 individuals were excluded for not meeting the inclusion criteria. Therefore, 55 participants with a mean age of 54 6 13 years participated in the study. Of the 55, 12 were not able to complete the NHPT. Table 2 gives the description of the subjects’ characteristics, and Table 3 shows the descriptive data of the outcome measures. As shown in Table 4, grip and lateral pinch strength scores showed moderate-to-high relationships (r ¼ 0.50e0.82) with activity measures but had low correlations with participation (r ¼ 0.29e0.39), whereas shoulder pain scores showed low-to-moderate relationships with participation measures (r ¼ 0.39e0.54). Among the variables related to the activity domain (Table 5), only the TEMPA scores had relationships

TABLE 1. Regression Models for the Three Activity and the Two Participation Models Variable

Activity Model 1

Activity Model 2

Activity Model 3

Participation Model 4

Participation Model 5

Dependent

TEMPA

BBT

NHPT

SSQOL

SSQOL-UL

Independent

Grip strength Lateral pinch strength UL strength Finger tactile sensations Cognition

Grip strength Lateral pinch strength UL strength Finger tactile sensations

Grip strength UL strength

Grip strength Lateral pinch strength Shoulder pain

Grip strength Lateral pinch strength Shoulder pain TEMPA

TEMPA ¼ Test d’evaluation des membres superieurs des personnes ^agees; BBT ¼ box and block test; NHPT ¼ nine-hole peg test; SSQOL ¼ Stroke Specific Quality of Life; SSQOL-UL ¼ Stroke Specific Quality of Life-upper limb.

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TABLE 2. Participants’ Characteristics Variable

Data

Gender Male (n, %) Female (n, %)

30 (55) 25 (45)

Age, yr (mean, SD)

55 (13)

Lesion side Left (n, %) Right (n, %)

24 (44) 31 (56)

Hand dominance Left (n, %) Right (n, %)

3 (6) 52 (95)

Concordance (paretic arm ¼ dominant hand) Concordant (n, %) Discordant (n, %)

25 (46) 30 (55)

Time since stroke, mo (mean, SD)

64 (55)

Fugl-Meyer scale (0e66) Mild motor impairments (n, %) Moderate motor impairments (n, %) Severe motor impairments (n, %)

48 33 15 7

(16) (60) (27) (13)

Chedoke McMaster Assessment—Arm (1e7) Stage 3 (n, %) Stage 4 (n, %) Stage 5 (n, %) Stage 6 (n, %) Stage 7 (n, %)

14 8 18 10 5

(26) (15) (33) (18) (9)

SD ¼ standard deviation.

with the participation model (SSQOL-UL), although they were low (r ¼ 0.29). In Table 6, the variables related to grip and lateral pinch strength and finger tactile sensations were retained in the three activity regression models using the TEMPA, BBT, and NHPT scores. In the first step, grip strength accounted for 62% of the variance of the TEMPA, 54% of the BBT, and 36% of the NHPT

scores. In the second step, lateral pinch scores contributed to an additional 4% to the TEMPA, whereas finger tactile sensations contributed with an additional 3%. For the participation model, shoulder pain was the only impairment variable that was retained and accounted for 18% of the variance of the SSQOL total scores and 30% of the variance of the SSQOL-UL scores. Grip strength contributed to an additional 8% (Table 6).

DISCUSSION This study investigated the relationships between specific UL impairments, activity limitations, and participation restrictions, and the results indicated moderate-to-high relationships between the measures of grip, pinch, and UL strength with the activity measures and low correlations with participation measures. Paretic grip strength was the best contributor and strongly related to activity measures. These findings were supported by previous studies, which examined the relationships between strength and ADL performance. Boissy et al.14 found grip strength to be a significant contributor to activity, as measured by TEMPA and BBT scores. Mercier and Bourbonnais16 also found high correlations between grip strength and BBT scores; however, shoulder flexor strength was better correlated to the TEMPA. In contrast, the present results showed strong correlations between grip strength and total TEMPA scores. Despite strength measures being highly related to measures of activity, they were not able to explain the poor UL performances, as reported by Harris and Eng,17 who found that UL strength explained about 80% of the variance of the activity models. These differences may be due to the assessment protocols,

TABLE 3. Descriptive Statistics (Mean 6 SD and Ranges) of the Investigated Outcome Measures (n ¼ 55) Rd 6 SD

Mean 6 SD

Range (MinimumeMaximum)

ICF body functions/structures domain UL strength (kg) MicroFET-2 dynamometer Grip strength (kg) JamarÒ dynamometer Lateral pinch strength (kg) PinchÒ dynamometer Shoulder pain (0e10) Shoulder-Q Finger tactile sensations (%) Moving touch pressure Cognition (0e30) Mini-Mental State Examination

28.3 6 21.7 41.4 6 32.1 23.1 6 27.5 — 4.3 6 66.0 —

87.4 6 36.2 17.2 6 11.8 6.6 6 2.7 4.9 6 2.4 70.2 6 23.8 25.8 6 3.0

5.3e177.7 0e48.7 0e11.8 0e9.7 0e100 18e30

ICF activity domain Hand dexterity (blocks/min) Finger dexterity (sec) UL performance (0e150)

34.2 6 33.7 30.7 6 24.7 —

30.3 6 15.9 47.4 6 33.9 32.2 6 30.0

0e57 24.9e200.4 2e104

— —

3.8 6 0.7 4.3 6 0.7

2.0e4.9 2.2e5.0

Measure

ICF participation domain Quality of life (0e5)

Instrument

BBT NHPT TEMPA SSQOL SSQOL-UL

SD ¼ standard deviation; Rd ¼ residual deficits; ICF ¼ International Classification of Functioning, Disability, and Health; UL ¼ upper limb; BBT ¼ box and block test; NHPT ¼ nine-hole peg test; TEMPA ¼ Test d’evaluation des membres superieurs des personnes agees; SSQOL ¼ Stroke Specific Quality of Life; SSQOL-UL ¼ Stroke Specific Quality of Life-upper limb.

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TABLE 4. Spearman’s Correlation Coefficients between the Body Functions/Structures, Activity, and Participation Variables Activity

Participation

Body Functions/Structures Variable

TEMPA

BBT Rd

NHPT Rd

SSQOL

SSQOL-UL

Grip strength Rd Lateral pinch strength Rd UL strength Rd Cognition Shoulder pain Finger tactile sensory Rd

0.82*** 0.65*** 0.74*** 0.28* 0.12NS 0.34*

0.69*** 0.50*** 0.69*** 0.01NS 0.13NS 0.33*

0.54*** 0.15NS 0.52*** 0.07NS 0.02NS 0.11NS

0.30* 0.29* 0.22NS 0.26NS 0.39** 0.09NS

0.39** 0.35* 0.27NS 0.20NS 0.54*** 0.04NS

TEMPA ¼ Test d’evaluation des membres superieurs des personnes agees; BBT ¼ box and block test; Rd ¼ residual deficits; NHPT ¼ ninehole peg test; SSQOL ¼ Stroke Specific Quality of Life; SSQOL-UL ¼ Stroke Specific Quality of Life-upper limb; NS ¼ not significant; UL ¼ upper limb. ***p , 0.0001; **p , 0.001; *p , 0.05.

since Harris and Eng17 evaluated the quantity and the quality of use of the paretic UL using the MAL, and the levels of assistance required to complete bilateral tasks. In this study, activity was measured by observed performance during daily tasks and by manual and digital tasks. It should be noted that links to the ICF are not straightforward, and many existing measures included items which might fall into several ICF dimensions.7e9,32 The BBT and NHPT do not directly evaluate daily tasks, but they measure aspects related to UL activity during daily tasks as well as to the subcomponents of the body functions/structures domain.31 Thus, an overlap between the domains existed, and they were used to evaluate activity limitations31,39 because UL performance includes reaching, grasping, manipulation, transfer, and releasing of objects. These findings suggested that the grip and pinch strength appeared to be more relevant to UL performance than the strength of other muscular groups, probably due to the use of compensatory strategies, such as displacements of the trunk (flexion, lateral inclination, and rotation) to compensate for reduced UL (shoulder, elbow and wrist) strength.40 As supported by the strong correlations between grip/pinch strength and objective activity measures, adequate hand strength was required. Thus, efforts to optimize TABLE 5. Spearman’s Correlation Coefficients between the Activity and Participation Variables Participation Activity

SSQOL

SSQOL-UL

BBT Rd NHPT Rd TEMPA

0.09NS 0.22NS 0.15NS

0.23NS 0.13NS 0.29*

SSQOL ¼ Stroke Specific Quality of Life; SSQOL-UL ¼ Stroke Specific Quality of Life-upper limb; BBT ¼ box and block test; Rd ¼ residual deficits; NS ¼ not significant; NHPT ¼ nine-hole peg test; TEMPA ¼ Test d’evaluation des membres superieurs des personnes agees; UL ¼ upper limb. *p , 0.05.

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hand and finger strength may infer UL performance improvements. Moreover, grip/pinch strength and activity variables were not relevant for participation. In stroke, participation may be related to not only physical impairments but also behavioral factors, such as coping strategies and social support. The reported influences of shoulder pain on QOL41 might be related to greater perceptions of difficulties in carrying out daily activities and the impact of pain on aspects related to feelings of psychological wellbeing. The TEMPA scores showed weak correlations with the SSQOL-UL scores. In a previous study,42 whose sample included subjects only six months after stroke, only moderate correlations were found. Desrosiers et al.43 found weak correlations (r ¼ 0.35)

TABLE 6. Regression Models for the UL Activity and Participation using Impairment Variables R2*

R2 Changey

0.62 0.66

0.62 0.04

0.0001 0.015

0.69

0.03

0.049

Model 2—activity Grip strength

0.54

0.54

Model 3—activity Grip strength

0.36

0.36

Variable Model 1—activity Grip strength Lateral pinch strength Finger tactile sensation

Model 4—participation Shoulder pain Model 5—participation Shoulder pain Grip strength

p

TEMPA

BBT 0.0001 NHPT 0.0001 SSQOL 0.18

0.18

0.002

0.30 0.38

SSQOL-UL 0.30 0.08

0.0001 0.013

UL ¼ upper limb; TEMPA ¼ Test d’evaluation des membres superieurs des personnes agees; BBT ¼ box and block test; NHPT ¼ nine-hole peg test; SSQOL ¼ Stroke Specific Quality of Life; SSQOL-UL ¼ Stroke Specific Quality of Life-upper limb. *R2 ¼ the proportion of variability of the dependent variable that was explained by the independent variables. yR2 change ¼ how much additional variability was explained by each independent variable.

between the TEMPA and the assessment of life habits with subjects two to four years after stroke. These findings suggested that, over time, individuals overcame the limitations in activity performance and reduced their impact on participation restrictions. It should be pointed out that the TEMPA tasks were performed with or without partial weight bearing. The absence of relationships between shoulder pain and TEMPA scores may have been due to the utilization of compensatory strategies during vertical reaching tasks. However, during manipulation tasks, partial weight bearing with the elbow or part of the UL resting on the table might have occurred, as a strategy to avoid pain. It is possible that if the analyses included trunk and UL ranges of motion, this hypothesis could be confirmed. When QOL was considered as a dependent variable, shoulder pain was the variable that was most strongly related to the participation and activity domains and these results were consistent with those reported by Harris and Eng.17 The concept of QOL is broad and refers to multidimensional constructs. Thus, the evaluation of isolated UL aspects may be the cause of the low levels of the explained variance, and despite the specific UL deficits being relevant for activity completion, they may have not been relevant for participation. These findings, taken together, might indicate that subjects with chronic hemiparesis adopted compensations and adjustments to successfully live with their residual impairments. They also reinforced the hypotheses regarding the influences of other variables, such as environmental and personal factors. Finger sensory tactile deficits are commonly observed deficits after stroke. Accurate reaching and grasping relies on the integration of motor and sensory inputs and requires cutaneous tactile afferent inputs to coordinate the movement and adjust the output force balance.10 Impairments of sensory motor functions may be the contributors to reduced dexterity during common handling activities and disabilities to control the grasping of various objects, recognize their surfaces by their fingertips, and adapt their pressure forces.44 Because of its contribution to grip and pinch strength, the palmar surface of the distal phalanx of the index finger was evaluated to represent the sensory functions of the entire hand. Although this test is highly correlated to the SemmeseWeinstein Monofilament test,31 it may not reflect the global sensory functions of the UL. Stereognosis and two-point discrimination deficits are frequently observed; however, conventional sensory testing is often insufficient to precisely assess the amount of sensory dysfunctions. Vision may assist in the impairments of the sensory systems. However, hypertonia of the paretic UL may reduce supination and lead to difficulties in visualizing the palmar surfaces of the hand during

grasping and manipulation of objects, thus, preventing the use of this compensatory strategy. The present results should be analyzed with caution due to the relatively young sample with mild impairments, which might not represent the functional profiles of subjects with hemiparesis. In addition, the results related to participation were limited to individually perceived QOL, which might not fully reflect the ICF domain of participation. In conclusion, the impairment variables related to shoulder pain, lateral pinch and grip strength, and finger tactile sensations were related to deficits in UL activity. Despite recent advances in therapies for UL recovery, shoulder pain still remains a major problem, which may limit the participation of individuals with chronic stroke.

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15. Burridge JH, Turk R, Notley SV, Pickering RM, Simpson DM. The relationship between upper limb activity and impairment in post-stroke hemiplegia. Disabil Rehabil. 2009;31:109–17. 16. Mercier C, Bourbonnais D. Relative shoulder flexor and handgrip strength is related to upper limb function after stroke. Clin Rehabil. 2004;18:215–21. 17. Harris JE, Eng JJ. Paretic upper-limb strength best explains arm activity in people with stroke. Phys Ther. 2007;87:88–97. 18. Sturm JW, Geoffrey AD, Dewey HM, et al. Quality of life after stroke. Stroke. 2004;35:2340–5. 19. Paul SL, Sturm JW, Dewey HM, Donnan GA, Macdonell RAL, Thrift AG. Long-term outcome in the North East Melbourne Stroke Incidence Study. Stroke. 2005;36:2082–6. 20. Gowland C, Stratford P, Ward M, et al. Measuring physical impairment and disability with the Chedoke-McMaster Stroke Assessment. Stroke. 1993;24:58–63. 21. Lourenc¸o RA, Veras RP. Mini-Mental State Examination: Psychometric characteristics in elderly outpatients. Rev Public Health. 2006;22:712–9. 22. Folstein MF, Folstein SE, McHugh PR. Mini-mental state: a practical method of grading the cognitive state of patient for the clinician. J Phychiatr Res. 1975;12:189–98. 23. Dohoo IR, Martin SW, Stryhn H. Veterinary Epidemiology Research. Charlottetown: University of Prince Edward Island, 2003. 24. Fugl-Meyer AR, Jaasko L, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med. 1975;7:13–31. 25. Duncan PW, Propst M, Nelson SG. Reliability of the FuglMeyer assessment of sensorimotor recovery following cerebrovascular accident. Phys Ther. 1983;63:1606–10. 26. Platz T, Pinkowski C, van Wijck F, Kim IH, di Bella P, Johnson G. Reliability and validity of arm function assessment with standardized guidelines for the Fugl-Meyer Test, Action Research Arm Test and Box and Block Test: a multicentric study. Clin Rehabil. 2005;9:404–11. 27. Michaelsen SM, Dannenbaum R, Levin MF. Task-specific training with trunk restraint on arm recovery in stroke: randomized control trial. Stroke. 2006;37:186–92. 28. Andrews AW, Thomas MW, Bohannon RW. Normative values for isometric muscle force measurements obtained with handheld dynamometers. Phys Ther. 1996;76:248–59. 29. Turner-Stokes L, Jackson D. Assessment of shoulder pain in hemiplegia: sensitivity of the ShoulderQ. Disabil Rehabil. 2006;28:389–95. 30. Pomeroy VM, Frames C, Faragher EB, et al. Reliability of a measure of post-stroke shoulder pain in patients with and without aphasia and/or unilateral spatial neglect. Clin Rehabil. 2000;14:584–91.

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31. Dannenbaum RM, Michaelsen SM, Desrosiers J, Levin MF. Development and validation of two new sensory tests of the hand for patients with stroke. Clin Rehabil. 2002;16:630–9. 32. Metcalf C, Adams J, Burridge J, Yule V, Chappell P. A review of clinical upper limb assessment within the framework of the WHO ICF. Musculoskeletal Care. 2007;5:160–73. 33. Desrosiers J, Bravo G, Hebert R, Dutil E, Mercier L. Validation of the Box and Block Test as measures of dexterity of elderly people: reliability, validity, and norms studies. Arch Phys Med Rehabil. 1994;75:751–5. 34. Mathiowetz VG, Weber K, Kashman N, Volland G. Adult norms for the nine hole peg test of finger dexterity. Occup Ther J Res. 1985;5:24–38. 35. Michaelsen SM, Natalio MA, Silva AG, Pagnussat AS. Reliabil ity of the translation and adaptation of the Test d’Evaluation ^ ees (TEMPA) to des Membres Superieurs des Personnes Ag the Portuguese language and validation for adults with hemiparesis. Braz J Phys Ther. 2008;12:511–9. 36. Lima RCM, Teixeira-Salmela LF, Magalh~aes LC, Neto MG. Psychometric properties of the Brazilian version of the Stroke Specific Quality of Life Scale: application of the Rasch model. Braz J Phys Ther. 2008;12:149–56. 37. Alon G. Defining and measuring residual deficits of the upper extremity following stroke: a new perspective. Top Stroke Rehabil. 2009;16:167–76. 38. Munro BH. Correlations. In: Munro BH, Visintainer MA, Page EB (eds). Statistical Methods for Health Care Research. Philadelphia, PA: JB Lippincott, 1993. 39. Schoneveld K, Wittink H, Takken T. Clinimetric evaluation of measurement tools used in hand therapy to assess activity and participation. J Hand Ther. 2009;22:221–35. 40. Michaelsen SM, Jacobs S, Roby-Brami A, Levin MF. Compensation for distal impairments of grasping in adults with hemiparesis. Exp Brain Res. 2004;157:162–73. 41. Chae J, Mascarenhas D, Yu DT, et al. Poststroke shoulder pain: its relationship to motor impairment, activity limitation, and quality of life. Arch Phys Med Rehabil. 2007;88: 298–301. 42. Desrosiers J, Noreau L, Rochette A, Bravo G, Boutin C. Predictors of handicap situations following post-stroke rehabilitation. Disabil Rehabil. 2002;24:774–85. 43. Desrosiers J, Noreau L, Rochette A, Bourbonnais D, Bravo G, Bourget A. Predictors of long-term participation after stroke. Disabil Rehabil. 2006;28:221–30. 44. Machackova K, Vyskotova J, Opavsk y J, Sochorova H. The impairments of sensorimotor hand functions in stroke patients: the comparison of the results of a clinical assessment and the assessment utilizing the standard tests (a case study). Acta Univ Palacki Olomuc. 2007;37:57–67.

JHT Read for Credit Quiz: Article #197

Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue or to complete online and use a credit card, go to JHTReadforCredit.com. There is only one best answer for each question. #1. Concerning the relationships between upper limb activity and participation measures, it is correct to conclude that a. relatively simple time-related measures, such as BBT and NHPT, could explain how upper limb activity have impact upon participation. b. upper limb functional assessments which consider both tasks related to reaching and levels of difficulty in task completion could better explain participation than time-related measures. c. unlike the ICF framework, relationships between activity and participation domains were not found. d. upper limb activity and participation should be evaluated only by objective measures. #2. This study identified the impairment variables which were related to upper limb activity and the results showed that a. because grip strength had higher correlations with activity measures, its evaluation is sufficient to explain upper limb activity. b. the associations between finger tactile sensations and activity measures were too low, and thus, had no importance for upper limb activity. c. upper limb assessment after stroke should only focus on measures of muscular strength. d. in addition to upper limb and grip strength, pinch strength was also related to upper limb activity and, thus, their evaluations are important and could contribute to intervention planning.

#3. Which of the following statements regarding shoulder pain after stroke is correct? a. general measures of pain could better explain participation than those specifically related to common impairments observed after stroke. b. shoulder pain had high correlations with activity limitations and participation restrictions. c. despite shoulder pain accounting for only 30% of the participation measure, it was the variable which best explained participation. d. the relationships between shoulder pain and activity were low, and thus, demonstrated no relevance for rehabilitation after stroke. #4. In comparison to the measures of strength and upper limb activity after stroke, it is correct to conclude that a. only grip and lateral pinch strength measures were related to upper limb activities. b. both proximal and distal strength accounted for upper limb activity levels. c. reduced pinch strength significantly reduced finger dexterity. d. levels of dexterity assessed by BBT and NHPT could be completely explained by strength levels. #5. The study revealed that the impairment variables related to shoulder pain, grip and lateral pinch strength, and finger tactile sensations were relevant outcomes to examine activity limitations and participation restrictions with subjects with stroke a. true b. false When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of 3 or more to get full credit.

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