Motor and Proprioception Deficits in Post Rehab Stroke

Recovery of Patientswith a Combined Motorand Proprioception DeficitDuring the First Six Weeksof Post Stroke Rehabilitation

Debbie Rand, MSc, BOTDaniel Gottlieb, MD

Patrice L. (Tamar) Weiss, PhD, BSc(OT)

ABSTRACT. The objective of this study was to characterize (1) theseverity of the proprioception deficit in the affected upper extremity onadmission to rehabilitation and (2) the motor and functional recoveryduring the first six weeks of rehabilitation. Twenty patients who hadsustained a hemispheric cerebral vascular accident (CVA) and had aproprioception deficit in addition to a motor deficit of their upper ex-tremity participated in the study. Subjects were assessed for propriocep-tion loss and motor ability of the upper extremity four times (weeks 0,2, 4, and 6) and for functional ability of the upper extremity and BADL(Basic Activities of Daily Living) on admission and after six weeks. Onadmission, eight of the patients suffered from a severe deficit, eightpatients suffered from a moderate deficit, and four suffered from a milddeficit. By week 6, five patients had improved to the point where no

Debbie Rand is Occupational Therapist, Beit Rivka Geriatric Rehabilitation Hos-pital, Petach Tikva, Israel. She completed this study in partial fulfillment of therequirements for the Master of Science degree in Occupational Therapy, School ofOccupational Therapy, Faculty of Medicine, Hebrew University of Jerusalem. Hermailing address is 50 Heh B’Eyar Street, Apartment 5, Rosh Ha’Ayin, Israel, 48056.

Daniel Gottlieb is Director of the Stroke Rehabilitation Unit, The Beit RivkaGeriatric Rehabilitation Hospital, P.O. Box 270, Petach Tikva, Israel.

Patrice L. (Tamar) Weiss is Senior Lecturer at the School of Occupational Thera-py, Faculty of Medicine, Hebrew University of Jerusalem.

Address correspondence to Patrice L. (Tamar) Weiss, School of OccupationalTherapy, P.O.B. 24026, Mount Scopus, Jerusalem, Israel 91240 (E-mail: [email protected]).

Physical & Occupational Therapy in Geriatrics, Vol. 18(3) 2001E 2001 by The Haworth Press, Inc. All rights reserved. 69

PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS70

deficit was discerned. Only two patients retained a severe deficit,whereas the remaining 13 patients retained moderate or mild deficits. Inaddition a significant improvement in the motor and functional abilityof the upper extremity was found. Familiarity with these facts shouldhelp the clinician to establish more realistic therapeutic goals and toanticipate with greater accuracy the eventual treatment outcome. [Articlecopies available for a fee from The Haworth Document Delivery Service:1-800-342-9678. E-mail address: <[email protected]> Website:<http://www.HaworthPress.com> E 2001 by The Haworth Press, Inc. All rightsreserved.]

KEYWORDS. Proprioception, upper extremity, stroke rehabilitation

INTRODUCTION

Stroke is the third leading cause of death and the most commoncause of disability in the elderly (Bonita, 1992; Duncan, 1994). Themost dominant and common symptom following stroke is paralysis orweakness of the contralareral side to the brain lesion. This motorparalysis can be accompanied by a proprioception deficit, which isfound in a large percentage of the patients. Forty-four percent of thepatients in a study done by Smith, Akhar and Garraway (1983), 34%of the patients in Reding and Potes’s 1988 study, and 28% of thepatients in a study conducted by Sunderland, Tinson, Bradley, Flecher,Langton-Hewer and Wade (1992) were found to suffer from a pro-prioception deficit in addition to a motor deficit.A higher proportion of patients with a combined motor and pro-

prioception deficit, henceforth referred to as SM (sensory-motor) defi-cit, suffer from cognitive dysfunction as well as spatial and posturaldifficulties in comparison to patients with a pure motor deficit, hence-forth referred to as PM deficit (Smith et al., 1983). Moreover, pro-prioception deficit has been shown to predict poor functional outcomeafter stroke (Stern, MacDowell, Miller and Robinson, 1973; Prescott,Garraway and Akhtar, 1982; Wade, Wood & Langton-Hewer, 1985).Smith et al. (1983) found that a smaller percentage of patients withSM achieved independence in BADL (Basic Activities of Daily Liv-ing) (25% in comparison to 78% of those with PM deficit). Only 60%(in comparison to 92%) were discharged to their homes and they had alonger hospital stay. In addition, 15% of SM patients (in comparison to6% of PM patients) died. In studies carried out by Reding and Potes

Rand, Gottlieb, and Weiss 71

(1988), Reding (1990), and Gottlieb, Kipnis, Sister, Medvedev, Brill,and Vardi (1997) the SM patients had significantly longer hospitalstays and achieved significantly lower scores on BADL scales incomparison to the PM patients. In addition, the time between admis-sion to rehabilitation and achievement of functional goals such asdressing and walking was longer for the SM patients in comparison tothe PM patients (Reding & Potes, 1988).It should be noted that at least one study failed to find a correlation

between the proprioceptive deficit and functional outcome (Feigen-son, MacDowell, Meese, McCarthy, & Greenberg, 1977). It is possiblethat the long time between stroke onset and initial assessment (38days) distorted the results of this study.Although the relationship between proprioception deficit and func-

tional outcome has been demonstrated in numerous studies, the rela-tionship between the proprioception deficit and the motor and func-tional ability of the upper extremity is still unclear. Only a few studieshave addressed this issue, and the results are inconclusive. Leo andSoderberg (1981) evaluated 21 people at different recovery stagesafter stroke. They found a significant negative correlation betweenproprioception deficit and the ability to actively move the upper ex-tremity in complex movement patterns. Wade, Langton-Hewer, Wood,Skilbeck and Ismil (1983) examined the influence of different impair-ments on the functional recovery of the upper extremity. The onlythree factors found to correlate significantly were initial motor ability,proprioception deficit and the patient’s mental status. Shah, Harasy-miw and Stahl (1986) studied the correlation between proprioceptionand motor recovery of the upper extremity for 98 stroke patients whenadmitted to rehabilitation and when discharged. They concluded thatthe initial motor level seemed to influence motor recovery and not theproprioception deficit. Another study showed that the prevalence ofcomplications typical to the paralyzed upper extremity such as shoul-der pain and shoulder-hand syndrome is higher for SM patients (50%)than for PM patients (7%) (Chalsen, Fitzpatrick, Navia, Bean, & Red-ing, 1987).In contrast to the detailed examinations of the motor recovery pro-

cess after stroke (Twitchell, 1951; Brunnstrom, 1970; Fugl-Meyer,Jääsko, Leyman, Olsson, & Steglind, 1975), very few studies havemonitored the recovery process of the proprioception deficit. Smith etal. (1983) reported on the proprioception recovery of 95 patients (44%


of their study population) who suffered from a substantial propriocep-tion deficit on admission. By eight weeks post-stroke, 54 (69%) ofthese patients had recovered to a mild deficit or no deficit. Sunderlandet al. (1992) reported that 28% of 132 patients suffered from a sub-stantial proprioception loss when examined three weeks post-stroke;after three months only 12.3% still suffered from this deficit.In view of the scant and inconclusive data characterizing stroke

patients who have a combined proprioception and motor deficit wefelt it important to monitor the recovery period of these patients duringthe critical first six weeks of rehabilitation post-stroke. This was ac-complished by characterizing (1) the severity of the proprioceptiondeficit in the affected upper extremity on admission to rehabilitationand (2) the recovery during the first six weeks of rehabilitation interms of the proprioception and motor deficits as well as the return offunctional ability of the affected upper extremity. A comparison of themotor and functional recovery of this group of patients to a group ofpatients suffering from a pure motor deficit is published elsewhere(Rand, Weiss, & Gottlieb, 1999).

METHODS

Population

Twenty patients, seven male and 13 female, who had sustained ahemispheric cerebral vascular accident (CVA) (8 left CVA, 12 rightCVA) and who were admitted to a geriatric rehabilitation center duringthe eight month duration of the study, agreed to participate as subjects.All of the subjects had a proprioception deficit in addition to a motordeficit of their upper extremity. The stroke was diagnosed by a neurolo-gist in accordance with criteria defined by the World Health Organiza-tion (WHO, 1989), and the hemispheric localization of the stroke wasdetermined clinically and with the aid of computerized tomography.Inclusion criteria included:

1. A combined proprioception and motor deficit in the upper ex-tremity as determined by the Thumb Localization Test (score >0) and the Frenchay Arm Test (score < 3) (see following).

2. Independence in BADL and indoor mobility before the presentstroke.

3. Full use of the upper extremity before the present stroke.


4. Ability to understand and cooperate in all assessment proce-dures.

Admission to the rehabilitation center occurred between seven and40 days following the acute event (mean standard deviation (SD) =18 9 days). The average age was 72.5 years (SD = 8.2). Ninetypercent of subjects were right hand dominant and 10% were left handdominant. Sixty percent of the subjects had a right hemispheric strokeand 40% had a left hemispheric stroke. Forty percent of the subjectsdemonstrated unilateral neglect as determined by Albert’s (1973)screening test; 15% had mild neglect and 25% of the subjects demon-strated severe neglect. The remaining 60% did not demonstrate unilat-eral neglect. Fifteen percent of the subjects were aphasic, as diagnosedby a speech pathologist. By definition, upon admission, all the sub-jects suffered from a proprioception deficit; four patients (20%) suf-fered from a mild deficit, 8 patients (40%) from a moderate deficit,and 8 patients (40%) from a severe deficit.

Instruments

1. Assessment of Proprioception Deficit

The proprioception loss in the upper extremity in this study wasassessed using two tests, both of which are commonly used in thefield.

1.1 The Thumb Localization Test

Different variations of this test, also known as the Thumb FindingTest, are used in neurology and rehabilitation. The test is conducted byan examiner who holds the patient’s affected hand and moves it pas-sively to different positions in space. The patient, with vision masked,is asked to grasp the affected thumb with the healthy hand. This test iseasy to administer, even to aphasic patients or those with cognitivedeficit. Despite the wide use of this test, its validity and test-retestreliability has not been demonstrated. Leo and Soderberg (1981) didshow it to have modest inter-rater reliability (r = .54, p < .05) and it hasbeen shown to be predictive of function after stroke (Prescott et al.,1982; Smith et al., 1983). In the present study the scoring suggested byPrescott et al. (1982) was used. A score of ‘‘0,’’ indicating no loss ofproprioception, was given when the patient grasped his thumb quicklyand with no difficulty. A score of ‘‘1,’’ indicating a mild loss of


proprioception, was given when the patient reached close to the thumbbut missed by a small amount. A score of ‘‘2,’’ indicating a moderateloss of proprioception, was given when the patient located his arm andthen used this landmark to locate his thumb. A score of ‘‘3,’’ indicat-ing a severe loss of proprioception, was given when the patient did notsucceed in locating his thumb.

1.2 Finger Shift Test

The examiner passively moves the proximal joint of the finger ofthe patient’s affected hand to a flexed or extension position while thepatient’s vision is masked. The patient is instructed to say or point towhere his finger is (up or down) (Dannenbaum & Jones, 1993). This isthe traditional way to assess proprioception (Ziegler, 1975) but pa-tients with language difficulties or with motor planning problemsoften have difficulty in understanding or carrying out the test. Like theprevious proprioception test, neither its reliability nor validity havebeen established. In this study the test was repeated four times. Ascore of ‘‘4,’’ indicating no loss of proprioception, was given if thepatient correctly reported four movements of his finger. A score of‘‘3,’’ indicating a mild loss of proprioception, was given if the patientreported only three out of the four movements. A score of ‘‘2,’’ indi-cating a moderate loss, was given if the patient reported only two outof the four movements and a score of ‘‘1,’’ indicating a severe loss ofproprioception, was given if the patient reported only one or none ofthe movements.

2. Motor Ability of the Upper Extremity

The Fugl-Meyer Assessment (FMA) (Fugl-Meyer, Jääsko, Leyman,Olsson & Steglind, 1975). This test is based on previous work byTwitchell (1951), Reynolds, Archibald, Brunnstrom, and Tompson(1958) and Brunnstrom (1970), who described stages in the motorrecovery of patients after stroke. The FMA assesses the motor impair-ment in terms of the difficulty of producing an active movementwithin and out of basic movement synergies. The upper extremitysub-test of the FMA was used in the present study. Each movementwas graded on a 3-point scale such that ‘‘0’’ indicated that the patientcould not produce the movement, ‘‘1’’ indicated there is partial move-ment, and ‘‘2’’ indicated full movement. The minimal score was 0(fully paralyzed) and the maximal score was 60 (normal active move-


ment). It took about 10 to 15 minutes to administer this test. This testis one of the most commonly used instruments in rehabilitation (Mal-ouin, Pichard, Bonneau, Durand, & Corriveau, 1994) and its validityand reliability have been very well established (Fugl-Meyer et al.,1975; Berglund & Fugl-Meyer, 1986; Carr, Shepherd, Nordholm &Lynne, 1985; Chae, Johnston, Kim, & Zorowitz, 1995; Wood-Dauphi-nee, Williams, & Shapiro, 1990; Sanford, Moreland, Swanson, Strat-ford, & Gowland, 1993).

3. Assessment of the Functional Ability of the Upper Extremity

The Frenchay Arm Test (FAT) (Parker, Wade & Langton-Hewer,1986). This test assesses disability of the upper extremity with the aidof five functional tasks. This is a shortened version of the original 25and subsequently seven item battery (Wade et al., 1983). Four of thefive tasks are unilateral, which the patient does with the impaired armand hand (picking up and releasing a cylinder, drinking from a glass,combing hair, and unclipping a clothes peg); the fifth task is bilateral(drawing a line with the aid of a ruler). Scoring is binary with eachtask rated as 0 (unable to do the task) or 1 (able to do the task). Thetest’s validity and reliability have been established by the originalauthors (Parker et al., 1986; Heller, Wade, Wood, Sunderland, Lang-ton-Hewer & Ward, 1987).

4. Assessment of BADL

The Functional Independence Measure (FIM) (Hamilton, Granger,Sherwin, Zielenzy, & Tashman, 1987). The FIM instrument includes18 functional activities (such as eating, grooming, and dressing) re-quiring motor and cognitive ability, which are rated on a seven-pointscale. The rating scale describes increasing levels of assistance pro-vided to a patient to complete an activity and ranges from total assis-tance (1 point) to complete independence (7 points). The scores of all18 activities may be added up to generate a ‘‘Total’’ FIM score, whichestimates the extent of care required by the patient. The FIM appearsto be a reliable (Hamilton, Laughlin, Fiedler, & Grangar, 1994; Otten-bacher, Hsu, Granger, & Fiedler, 1996) and valid instrument whenused with stroke patients (Ring, Feder, Schwartz, & Samuels, 1997)and patients with other disorders such as degenerative neurologicaland orthopedic conditions (Stineman, Shea, Jette, Tassoni, Ottenbach-er, Feider, & Granger, 1996).


5. Assessment of Unilateral Neglect

Albert’s Test of Visual Neglect. This is a screening test for unilateralneglect. On a 200 260 mm piece of white paper are drawn 40 lines,each 25 mm in length, pointing in different directions and arranged insix columns (Albert, 1973). The patient, seated at a table upon whichhas been placed the test paper, is requested to locate and cross out allthe lines. It appears to be a reliable and valid test when used for strokepatients (Albert, 1973; Halligan, Cockburn, & Wilson, 1991; ChenSea & Henderson, 1994; Schenkenberg, Bradford, & Ajax, 1980).

Procedure

Each subject was assessed on admission to the rehabilitation center(designated week 0 for the purposes of this study) and at weeks two,four, and six following admission, by the same examiner, a staff occu-pational therapist with seven years of clinical experience treating thispopulation. All patient subjects received the same amount of occupa-tional, physical, and, if necessary, speech therapy normally providedduring this period (i.e., five one-half hour sessions per week). Thepatients were assessed for proprioception loss and motor ability of theupper extremity four times (weeks 0, 2, 4, and 6). Since the FAT isknown to be rather insensitive (Wade et al., 1983; Parker et al., 1986),functional ability of the upper extremity was assessed only on admis-sion (week 0) and after six weeks. BADL was also assessed on thesetwo occasions and unilateral neglect on admission only. All the tests ofthe upper extremity were assessed during the same session. First thetests of proprioception were administered, followed by the FMA andthen the FAT. The tests required from 10 minutes (for patients withminimal active ability) to 25 minutes (for those with greatest activeability) to administer. BADL was assessed separately in the patients’rooms, taking about 30 minutes to complete.

Data Analysis

The recovery process was first characterized with descriptive statis-tics. A repeated measures ANOVA was used to determine whetherthere were significant differences between the FMA scores (depictingmotor ability of the upper extremity) throughout the 6 week recoveryperiod. Differences in the functional ability of upper extremity (FAT


score) between weeks 0 and 6 were assessed with the Wilcoxon non-parametric test whereas a paired t-test was used to test differences inBADL function between weeks 0 and 6. Non-parametric Spearman’scorrelations of the two measures of proprioception (the Thumb testand the Finger shift test) and motor ability to functional ability wereperformed. The same measure was used to test whether the variableproprioception, FMA, FAT, and FIM at weeks 0 and 6 were correlated.

RESULTS

Proprioception Deficit

Proprioception was assessed at weeks 0, 2, 4, and 6 with the ThumbLocalization and the Finger Shift tests. Results from the former testwere available for all 20 patients but only 17 patients were able tounderstand and complete the latter test. The relationship between thesetwo tests was examined by means of Spearman’s correlation coeffi-cient. The two tests of proprioception were found to be significantlycorrelated on all four occasions with moderate r values ranging from.53 (p < .05) at week 0, to .71 (p < .01) at week 2, to .71 (p <

.01) at week 4, and to .61 (p < .01) at week 6. (Note that thecorrelations are negative since in the case of the Thumb Localizationtest the score increases with the severity of the proprioception losswhereas the reverse is true for the Finger Shift test.) In view of the factthat the two tests were correlated and given the incomplete data set forthe Finger Shift test, all subsequent analyses were carried out on resultsfrom the Thumb Localization Test only. (Note that the modest correla-tion between the two tests may be due to the fact that the Finger Shifttest focuses on manipulation of distal joints whereas the Thumb Local-ization test focuses on manipulation of the entire upper extremity.)Tables 1 and 2 illustrate the recovery of proprioception for the 20

patients over the six-week period of study. On admission, all 20patients had some degree of proprioception deficit; eight of the pa-tients suffered from a severe deficit, eight suffered from a moderatedeficit, and four suffered from a mild deficit. By week 2, three of thepatients in both the severe deficit and moderate deficit groups hadimproved so that only five patients remained in each of these catego-ries. By this time 10 patients suffered from a mild deficit. By week 4,only two patients had a severe deficit, seven patients had a moderatedeficit, and 11 patients had a mild deficit. By week 6, five patients,


representing 25% of the subjects, had improved to the point where nodeficit was discerned. Only two patients (10%) retained a severedeficit, whereas the remaining 13 patients (65%) retained moderateor mild deficits.

The Motor Recovery of the Upper Extremity

The subjects on average demonstrated a significant increase in thelevel of motor ability as assessed by the FMA scale. The progressionin mean FMA scores during the six-week follow-up period can beseen in Table 3. The mean score on admission was 9.2 5.0 and itincreased to 26.6 17.2 after six weeks. A repeated measures ANO-VA was performed to test whether the extent of the motor recovery

TABLE 1. Changes in severity of the proprioception deficit amongst the 20patient subjects during the six week recovery period. The results reported herewere obtained from the Thumb Localization test

Severity Frequency Distribution

of Proprioception Deficit of Proprioception Deficit

as assessed by Thumb

Localization test (score)

Week 0 Week 2 Week 4 Week 6

Severe 8 5 2 2

Moderate 8 5 7 6

Mild 4 10 11 7

None 0 0 0 5

TABLE 2. Recovery of the proprioception loss fromweek 0 toweek 6 accordingto the severity of the initial deficit

At Week 0 At Week 6

Of the 8 patients who had a severe proprioception S 2 patients retained a severe deficitdeficit S 4 patients improved to a moderate deficit

S 2 patients improved to a mild deficitS 0 patients improved to no deficit

Of the 8 patients who had a moderate S 2 patients retained a moderate deficitproprioception deficit S 4 patients improved to a mild deficit

S 2 patients improved to no deficit

Of the 4 patients who had a mild proprioception S 1 patient retained a mild deficitdeficit S 3 patients improved to no deficit


TABLE 3.Mean scores one standard deviation (SD) of the FMA (Fugl-MeyerMotor Assessment) at weeks 0, 2, 4 and 6 and the FAT (Frenchay Arm Test)at weeks 0 and 6 of the patient subjects (n = 20).

Week 0 Week 2 Week 4 Week 6

FMA 9.2 5.0 16.4 12.2 22.4 15.8 26.6 17.2

FAT 05 .22 * * 1.25 1.48

* test not performed

from the time of admission and throughout the following six weekswas significant. This test showed that the motor ability of the affectedupper extremity of the patients with proprioception deficit improvedsignificantly (F = 63.75, p = .000) during the six week study period toa recovery of 44% of the full motor ability of the upper extremity.

The Functional Recovery of the Upper Extremity

The subjects on average demonstrated a significant increase in thelevel of functional ability of the upper extremity as assessed by theFAT scale. The mean FAT scores increased from .05 .22 on admis-sion to 1.25 1.48 after six weeks (see Table 3), which was found tobe statistically significant (Wilcoxon test, z = 2.96, p = .003).Correlations between the motor ability (the ability to produce active

movement, tested by the FMA) and functional ability (the ability touse the affected upper extremity in a functional way, tested by theFAT) of the upper extremity were carried out on admission and aftersix weeks. On admission, no significant correlation was found. How-ever, after six weeks, a significant correlation was found between themotor ability and the functional ability of the upper extremity (Spear-man correlation r = .887, p < .01).

BADL Improvement

The mean FIM score on admission was 53.1 16.4 points andafter six weeks it increased significantly to 68.4 22.5 points (pairedt-test: t = 5.09, p = .000).

Additional Correlations Between the Variables

The correlation coefficients between the severity of the propriocep-tion deficit (both on admission and after 6 weeks) and motor ability,


functional ability and BADL function were low (r = .01 to .34) andnon-significant. In contrast, there was a moderately strong correlationbetween motor ability on admission to the function of the upper ex-tremity after six weeks (r = .59, p = .000) and a strong correlationbetween the motor ability to BADL after six weeks (r = .78, p = .000).The correlation between motor ability after six weeks to function ofthe upper extremity after six weeks was very strong (r = .88, p = .000)but the correlation between motor ability after six weeks to BADLfunction after six weeks was only moderate (r = .67, p = .000). Thefunction of the upper extremity on admission did not correlate with themotor ability of the upper extremity nor with BADL function onadmission. The function of the upper extremity at week 6 did correlatemoderately to BADL function at that time (r = .63, p < .01). Note thatit may be that the measurement scales were not sensitive enough tomeasure low level differences.

DISCUSSION

Previous studies of the motor recovery after stroke included patientswho were heterogeneous in terms of the presence of a proprioceptiondeficit (Twitchell, 1951; Brunnstrom, 1970; Fugl-Meyer et al., 1975).In contrast, all of the patients in this study suffered from a propriocep-tion deficit, and one of our major results was the demonstration of asignificant improvement in the motor and functional ability of theupper extremity of this relatively homogenous group (i.e., stroke pa-tients with a combined motor and proprioception deficit). Whereas, onadmission, all 20 patients suffered from a proprioception deficit intheir upper extremity (having, on average, only 15% of their motorability and 1% of the functional ability of the affected upper extremi-ty), six weeks after admission, 25% of the patients had completelyrecovered their proprioception deficit and had, on average, 44% oftheir motor ability and 25% of their functional ability of the affectedupper extremity.A second important result was the documentation of the pro-

prioception status of patients who suffered from this deficit on admis-sion to hospital. Prior to the present study, monitoring of patients ofthis type was published in only a few cases, and the results werelimited to a report of whether a deficit was present or not (Smith et al.,1983; Sunderland et al., 1992). In contrast, we made use of the ThumbLocalization Test to rank the proprioception deficit into three degrees


of severity--mild, moderate and severe. On admission 4 patients had amild deficit, 8 patients had a moderate deficit and 8 patients had a severeproprioception deficit. After six weeks 2 patients still had a severe defi-cit, 6 had a moderate deficit, 7 had a mild deficit and 5 patientsrecovered completely in terms of the proprioception deficit. Greaterfamiliarity with the pattern of recovery of the proprioception deficitcan help the clinician to establish more realistic therapeutic goals andto anticipate with greater accuracy the eventual treatment outcome.The Thumb Localization Test was a clinically feasible and apparentlyeffective instrument for assessing proprioception, and was easy toadminister to all the patients including those with aphasia. Pendingdemonstration of its reliability and validity, it should be considered forroutine use in the clinic.Although 75% of the patients still suffered from a mild to moderate

proprioception deficit six weeks after admission, this deficit did not ap-pear to interfere greatly with the motor or functional ability of the upperextremity. Indeed, there was no significant correlation between pro-prioception and the other motor or functional outcome measures at anytime during the six weeks of this study. It may be that the patients wereable to compensate for their loss of proprioception via increased relianceon visual cues or other sensory modalities such as light touch, particularlywhen tested with the FAT. Moberg (1983) concluded that cutaneousreceptors in the fingers play an important role in perception of positionand motion and Dannenbaum and Dykes (1988) added that feedbackfrom cutaneous receptors is needed to guide adjustment of muscle forceduring manipulation tasks such as drinking, dressing and eating.Various studies have shown that from about one quarter to close to

half of all stroke patients suffer from a combined motor and pro-prioception deficit (Smith et al., 1983; Reding & Potes, 1988; Sunder-land et al., 1992). There is evidence that these patients have difficultyachieving independence in BADL and mobility when compared topatients with a pure motor deficit (Smith et al., 1983; Wade et al.,1985; Reding & Potes, 1988; Reding, 1990; Gottlieb et al., 1997).They are, as a group, considered to be less amenable to treatment andto have a worse prognosis. The current results support this finding.The mean FIM scores on admission are lower than those reported byGranger, Hamilton, and Feider (1992) in their survey of 7090 strokepatients. The mean FIM score in this study was 51.7 as compared tothe mean FIM score 63 points reported by Granger et al. (1992). (Note


that admission to rehabilitation occurred after 33 22 days in theGranger et al. survey as compared to 18 9 days in the presentstudy). Although a significant improvement in the ability to functionin BADL was found, after six weeks these patients still required mod-erate assistance in BADL (mean Total FIM score after six weeks64.6/126, which is the maximum Total FIM score).Comparing the FIM scores of the patients in this study on admission

and after six weeks with other studies is difficult since the period oftime between admission and discharge varied greatly. However, it ispossible to compare the per day gain in the FIM. In this study the FIMgain per day was .35 .31 points, whereas in other studies done it washigher, as much as .55 .42 points per day (Gottlieb et al., 1997) and.54 .45 points per day (Adunsky, Levenkrohn, Fleissig, Chetrit, &Blumstein, 1998). The discrepancy may be due, in part, to differencesin the type of patients who participated. Both the Gottlieb et al. (1997)and Adunsky et al. (1998) studies included all stroke patients who weretreated in rehabilitation; their FIM scores were representative of thosefrom typical stroke patients. In this study, all of the patients sufferedfrom an additional impairment, a proprioception deficit; their deficitwas more severe than the average stroke patient and their FIM gain perday was also lower. This result supports other studies that concludedthat patients with a combined motor and proprioception deficit have apoorer functional outcome in terms of BADL and mobility (Reding &Potes, 1988; Reding, 1990; Gottlieb et al., 1997).On admission, the motor and functional ability of the upper extrem-

ity were not correlated. In contrast, after six weeks of rehabilitation, ahighly significant correlation was found between these two variables.The motor ability of the upper extremity on admission did correlatewell to the functional ability of the upper extremity after six weeks aswell as to the function in BADL at that time. It would appear thateither spontaneous recovery or therapy or a combination of the twohelped these patients learn how to better employ whatever activemovement they had regained for functional tasks.Independence in BADL is possible even with a completely para-

lyzed upper extremity. At least two studies (Nakayama et al., 1994;Olsen, 1989) assessed upper extremity disability using the BarthelIndex subscores for grooming/dressing and feeding. In both casesupper extremity function was achieved by using the unaffected upperextremity for compensation and not by recovery of the affected upper


extremity. Filiatrault, Arsenault, Dutil and Bourbonnais (1991) foundthe Barthel Index scores and the FMA scores of the upper extremity of18 stroke patients to be poorly correlated. They concluded that there isa weak relationship between independence in BADL and upper ex-tremity motor function and that independence is achieved by the learn-ing of compensatory techniques. Thus improvement in BADL func-tion does not necessarily provide information about the condition ofthe affected upper extremity. Nevertheless, it is worthwhile noting thata moderately strong correlation was found between the functionalability of the upper extremity and function in BADL six weeks afteradmission. Similar results were reported by Chae et al. (1995). In thatstudy a moderate correlation was found between the FMA scores forthe upper extremity on admission and the score of the self care sectionof the FIM on discharge (r = .56, p < .0025). This may indicate anassociation between the function of the upper extremity and BADLsince the patients used two hands to accomplish both tasks, or could berelated to other variables such as a general decrease in motor andcognitive impairment, or may simply be due to two concurrent, butunrelated occurrences.

Implications for Therapy

The patients who participated in this research were receiving occu-pational therapy at the time of the study. The therapy approach to treatthe affected upper extremity was remedial with emphasis on recoveryof active movement (i.e., to decrease the motor and sensory impair-ment) and to encourage use of the arm functionally, when possible.This was done using treatment methods based on Bobath (1990), Carrand Shepherd (1987), Brunnstrom (1970) and Dannenbaum andDykes (1988). Simultaneously, intervention of a compensatory char-acter was provided in order to increase independence in BADL; pa-tients were taught to use their unaffected upper extremity, when use ofthe affected one was not possible or effective. Since the recovery ofthe upper extremity in the stroke population as a whole is generallythought to be limited (Teasell & Gillen, 1993; Nakayama et al., 1994),the results of this study are encouraging. The population examined inthis study (patients with a combined motor and proprioception deficit)are usually more severely affected than patients with a pure motordeficit, since they tend to suffer from more extensive brain injury. Thus,the fact that these subjects demonstrated a significant improvement of


their affected upper extremity should serve to encourage therapists totreat the upper extremity of all patients scheduled for rehabilitation.In a study by Ferrucci, Bandinelli, Guralnik, Lamponi, Bertini,

Falchini, and Baroni (1993) patients were discharged from rehabilita-tion (length of hospitalization unknown) with an average of 27% oftheir motor ability of the upper extremity, as assessed by the FMA.The patients in the present study demonstrated an average of 44% oftheir upper extremity motor ability after six weeks. Wood-Dauphineeet al. (1990) reported the FMA scores of 119 patients on admission(30.4 23.6 points) and after five weeks (41.4 25.7 points). Thepatients in this study were admitted with lower FMA scores (9.25.0 points) and achieved lower scores after six weeks (26.6 17.2points). It is clear that our patients on admission were more severe interms of the impairment of the upper extremity but, even so, theaverage improvement was greater in this study in comparison to theimprovement reported by Wood-Dauphinee et al. (1990). Filiatrault etal. (1991) assessed 18 patients with the FMA on admission (meanFMA score = 17.7 20.3) and after one month (mean FMA score =22.1 24.6). Again, the initial FMA scores of our patients are some-what lower (9.2 5.0 in comparison to 17.7 20.3), but the scoresof the second assessment after one month are similar (the mean FMAscore of our patients after one month is 22.4 15.8 in comparison to22.1 24.6). Therefore, even though the patients suffered from acombined motor and proprioception deficit, the motor ability of theirupper extremity improved as much as or even more than the patientsreported by Filiatrault et al. (1991).In conclusion, when treating patients with a combined motor and

proprioception deficit therapists should take in to account that a signif-icant motor and functional improvement of the upper extremity can beexpected even though they will likely continue to have difficultiesachieving independence in BADL. These finding should guide thera-pists in planning treatment and setting goals for rehabilitation.

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Motor and Proprioception Deficits in Post Rehab Stroke