Recovery of Patients with a Combined Motor and Proprioception Deficit During the First Six Weeks of Post Stroke

Rehabilitation
Debbie Rand, MSc, BOT Daniel Gottlieb, MD Patrice L. (Tamar) Weiss, PhD, BSc(OT)
ABSTRACT. The objective of this study was to characterize (1) the severity of the proprioception deficit in the affected upper extremity on admission to rehabilitation and (2) the motor and functional recovery during the first six weeks of rehabilitation. Twenty patients who had sustained a hemispheric cerebral vascular accident (CVA) and had a proprioception deficit in addition to a motor deficit of their upper extremity participated in the study. Subjects were assessed for proprioception 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. On admission, eight of the patients suffered from a severe deficit, eight patients suffered from a moderate deficit, and four suffered from a mild deficit. By week 6, five patients had improved to the point where no
Debbie Rand is Occupational Therapist, Beit Rivka Geriatric Rehabilitation Hospital, Petach Tikva, Israel. She completed this study in partial fulfillment of the requirements for the Master of Science degree in Occupational Therapy, School of Occupational Therapy, Faculty of Medicine, Hebrew University of Jerusalem. Her mailing 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 Rivka Geriatric Rehabilitation Hospital, P.O. Box 270, Petach Tikva, Israel. Patrice L. (Tamar) Weiss is Senior Lecturer at the School of Occupational Therapy, Faculty of Medicine, Hebrew University of Jerusalem. Address correspondence to Patrice L. (Tamar) Weiss, School of Occupational Therapy, P.O.B. 24026, Mount Scopus, Jerusalem, Israel 91240 (E-mail: msweisst@ mscc.huji.ac.il). Physical & Occupational Therapy in Geriatrics, Vol. 18(3) 2001 E 2001 by The Haworth Press, Inc. All rights reserved. 69

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PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS

copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: <getinfo@haworthpressinc.com> Website: <http://www.HaworthPress.com> E 2001 by The Haworth Press, Inc. All rights reserved.]

deficit was discerned. Only two patients retained a severe deficit, whereas the remaining 13 patients retained moderate or mild deficits. In addition a significant improvement in the motor and functional ability of the upper extremity was found. Familiarity with these facts should help the clinician to establish more realistic therapeutic goals and to anticipate with greater accuracy the eventual treatment outcome. [Article

KEYWORDS. Proprioception, upper extremity, stroke rehabilitation

INTRODUCTION Stroke is the third leading cause of death and the most common cause of disability in the elderly (Bonita, 1992; Duncan, 1994). The most dominant and common symptom following stroke is paralysis or weakness of the contralareral side to the brain lesion. This motor paralysis can be accompanied by a proprioception deficit, which is found in a large percentage of the patients. Forty-four percent of the patients in a study done by Smith, Akhar and Garraway (1983), 34% of the patients in Reding and Potes’s 1988 study, and 28% of the patients in a study conducted by Sunderland, Tinson, Bradley, Flecher, Langton-Hewer and Wade (1992) were found to suffer from a proprioception deficit in addition to a motor deficit. A higher proportion of patients with a combined motor and proprioception deficit, henceforth referred to as SM (sensory-motor) deficit, suffer from cognitive dysfunction as well as spatial and postural difficulties in comparison to patients with a pure motor deficit, henceforth referred to as PM deficit (Smith et al., 1983). Moreover, proprioception deficit has been shown to predict poor functional outcome after 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 with SM achieved independence in BADL (Basic Activities of Daily Living) (25% in comparison to 78% of those with PM deficit). Only 60% (in comparison to 92%) were discharged to their homes and they had a longer hospital stay. In addition, 15% of SM patients (in comparison to 6% of PM patients) died. In studies carried out by Reding and Potes

Another study showed that the prevalence of complications typical to the paralyzed upper extremity such as shoulder pain and shoulder-hand syndrome is higher for SM patients (50%) than for PM patients (7%) (Chalsen. Reding (1990). MacDowell. Jääsko. They found a significant negative correlation between proprioception deficit and the ability to actively move the upper extremity in complex movement patterns.Rand. Sister. Brill. and Weiss 71 (1988). In addition. Wade. the relationship between the proprioception deficit and the motor and functional ability of the upper extremity is still unclear. 1977). Smith et al. Fitzpatrick. Leo and Soderberg (1981) evaluated 21 people at different recovery stages after stroke. and the results are inconclusive. Brunnstrom. It is possible that the long time between stroke onset and initial assessment (38 days) distorted the results of this study. and Gottlieb. McCarthy. & Reding. Shah. 1975). It should be noted that at least one study failed to find a correlation between the proprioceptive deficit and functional outcome (Feigenson. The only three factors found to correlate significantly were initial motor ability. In contrast to the detailed examinations of the motor recovery process after stroke (Twitchell. Medvedev. proprioception deficit and the patient’s mental status. and Vardi (1997) the SM patients had significantly longer hospital stays and achieved significantly lower scores on BADL scales in comparison to the PM patients. & Greenberg. Leyman. Fugl-Meyer. Wood. Langton-Hewer. Although the relationship between proprioception deficit and functional outcome has been demonstrated in numerous studies. Only a few studies have addressed this issue. very few studies have monitored the recovery process of the proprioception deficit. Harasymiw and Stahl (1986) studied the correlation between proprioception and motor recovery of the upper extremity for 98 stroke patients when admitted to rehabilitation and when discharged. Gottlieb. 1988). Meese. (1983) reported on the proprioception recovery of 95 patients (44% . 1970. Kipnis. Bean. the time between admission to rehabilitation and achievement of functional goals such as dressing and walking was longer for the SM patients in comparison to the PM patients (Reding & Potes. 1987). Skilbeck and Ismil (1983) examined the influence of different impairments on the functional recovery of the upper extremity. & Steglind. They concluded that the initial motor level seemed to influence motor recovery and not the proprioception deficit. 1951. Olsson. Navia.

3. Independence in BADL and indoor mobility before the present stroke. 12 right CVA) and who were admitted to a geriatric rehabilitation center during the eight month duration of the study. METHODS Population Twenty patients. 1999). Weiss. A combined proprioception and motor deficit in the upper extremity as determined by the Thumb Localization Test (score > 0) and the Frenchay Arm Test (score < 3) (see following). agreed to participate as subjects. Inclusion criteria included: 1. after three months only 12. 1989). Sunderland et al.3% still suffered from this deficit.72 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS of their study population) who suffered from a substantial proprioception deficit on admission. (1992) reported that 28% of 132 patients suffered from a substantial proprioception loss when examined three weeks post-stroke. 2. By eight weeks post-stroke. & Gottlieb. In view of the scant and inconclusive data characterizing stroke patients who have a combined proprioception and motor deficit we felt it important to monitor the recovery period of these patients during the critical first six weeks of rehabilitation post-stroke. All of the subjects had a proprioception deficit in addition to a motor deficit of their upper extremity. This was accomplished by characterizing (1) the severity of the proprioception deficit in the affected upper extremity on admission to rehabilitation and (2) the recovery during the first six weeks of rehabilitation in terms of the proprioception and motor deficits as well as the return of functional ability of the affected upper extremity. who had sustained a hemispheric cerebral vascular accident (CVA) (8 left CVA. . and the hemispheric localization of the stroke was determined clinically and with the aid of computerized tomography. The stroke was diagnosed by a neurologist in accordance with criteria defined by the World Health Organization (WHO. Full use of the upper extremity before the present stroke. 54 (69%) of these patients had recovered to a mild deficit or no deficit. seven male and 13 female. A comparison of the motor and functional recovery of this group of patients to a group of patients suffering from a pure motor deficit is published elsewhere (Rand.

Rand. Admission to the rehabilitation center occurred between seven and 40 days following the acute event (mean standard deviation (SD) = 18 9 days).05) and it has been shown to be predictive of function after stroke (Prescott et al. Gottlieb. A score of ‘‘0.. The average age was 72. upon admission.1 The Thumb Localization Test Different variations of this test. In the present study the scoring suggested by Prescott et al.’’ indicating no loss of proprioception. 15% had mild neglect and 25% of the subjects demonstrated severe neglect. p < . The test is conducted by an examiner who holds the patient’s affected hand and moves it passively to different positions in space. are used in neurology and rehabilitation. with vision masked. The remaining 60% did not demonstrate unilateral neglect. 1. Fifteen percent of the subjects were aphasic. Smith et al. even to aphasic patients or those with cognitive deficit. also known as the Thumb Finding Test. was given when the patient grasped his thumb quickly and with no difficulty. both of which are commonly used in the field. Sixty percent of the subjects had a right hemispheric stroke and 40% had a left hemispheric stroke.’’ indicating a mild loss of . The patient. four patients (20%) suffered from a mild deficit. Ability to understand and cooperate in all assessment procedures. Leo and Soderberg (1981) did show it to have modest inter-rater reliability (r = .. (1982) was used. 1983). as diagnosed by a speech pathologist.54. and Weiss 73 4. Instruments 1. is asked to grasp the affected thumb with the healthy hand. 8 patients (40%) from a moderate deficit. and 8 patients (40%) from a severe deficit. Despite the wide use of this test. Ninety percent of subjects were right hand dominant and 10% were left hand dominant. This test is easy to administer.5 years (SD = 8. Forty percent of the subjects demonstrated unilateral neglect as determined by Albert’s (1973) screening test. By definition. A score of ‘‘1. its validity and test-retest reliability has not been demonstrated. Assessment of Proprioception Deficit The proprioception loss in the upper extremity in this study was assessed using two tests. 1982. all the subjects suffered from a proprioception deficit.2).

A score of ‘‘3.’’ indicating a mild loss of proprioception. The minimal score was 0 (fully paralyzed) and the maximal score was 60 (normal active move- . The upper extremity sub-test of the FMA was used in the present study. Jääsko. who described stages in the motor recovery of patients after stroke. Reynolds. ‘‘1’’ indicated there is partial movement. was given if the patient reported only three out of the four movements.’’ indicating a severe loss of proprioception. Leyman. A score of ‘‘2. A score of ‘‘2.2 Finger Shift Test The examiner passively moves the proximal joint of the finger of the patient’s affected hand to a flexed or extension position while the patient’s vision is masked. Brunnstrom.’’ indicating no loss of proprioception. and ‘‘2’’ indicated full movement. The patient is instructed to say or point to where his finger is (up or down) (Dannenbaum & Jones. 1. 2.’’ indicating a severe loss of proprioception. was given if the patient reported only two out of the four movements and a score of ‘‘1. 1993). was given when the patient located his arm and then used this landmark to locate his thumb. was given when the patient reached close to the thumb but missed by a small amount. 1975). Archibald. was given when the patient did not succeed in locating his thumb. neither its reliability nor validity have been established. and Tompson (1958) and Brunnstrom (1970). This test is based on previous work by Twitchell (1951). was given if the patient correctly reported four movements of his finger.74 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS proprioception. A score of ‘‘4. In this study the test was repeated four times. Each movement was graded on a 3-point scale such that ‘‘0’’ indicated that the patient could not produce the movement. Motor Ability of the Upper Extremity The Fugl-Meyer Assessment (FMA) (Fugl-Meyer. Olsson & Steglind. This is the traditional way to assess proprioception (Ziegler. The FMA assesses the motor impairment in terms of the difficulty of producing an active movement within and out of basic movement synergies. A score of ‘‘3. Like the previous proprioception test. was given if the patient reported only one or none of the movements.’’ indicating a moderate loss.’’ indicating a moderate loss of proprioception. 1975) but patients with language difficulties or with motor planning problems often have difficulty in understanding or carrying out the test.

Sherwin. Granger. 4. & Grangar. Durand. & Zorowitz. Tassoni. 1983). Wood-Dauphinee. 1985. Feider. Pichard. Zielenzy. Scoring is binary with each task rated as 0 (unable to do the task) or 1 (able to do the task). grooming. Stratford. Carr. & Corriveau. The test’s validity and reliability have been established by the original authors (Parker et al. 1993). . 1994) and its validity and reliability have been very well established (Fugl-Meyer et al. and dressing) requiring motor and cognitive ability. Langton-Hewer & Ward. Schwartz. 1986. Williams. Bonneau. Wade & Langton-Hewer. 3. & Gowland. drinking from a glass. Kim. & Samuels. The rating scale describes increasing levels of assistance provided to a patient to complete an activity and ranges from total assistance (1 point) to complete independence (7 points). Moreland. Shea. Wood. Wade. 1975. the fifth task is bilateral (drawing a line with the aid of a ruler). 1996) and valid instrument when used with stroke patients (Ring. Heller. Berglund & Fugl-Meyer. which the patient does with the impaired arm and hand (picking up and releasing a cylinder. & Tashman.. The scores of all 18 activities may be added up to generate a ‘‘Total’’ FIM score. & Shapiro. 1996). Hsu. Assessment of the Functional Ability of the Upper Extremity The Frenchay Arm Test (FAT) (Parker. 1990. Chae. which estimates the extent of care required by the patient. 1986. The FIM appears to be a reliable (Hamilton. Ottenbacher. Granger. Johnston. and Weiss 75 ment).Rand. Fiedler. combing hair. Jette.. 1997) and patients with other disorders such as degenerative neurological and orthopedic conditions (Stineman. 1986). 1995. Nordholm & Lynne. 1987). Assessment of BADL The Functional Independence Measure (FIM) (Hamilton. Gottlieb. Four of the five tasks are unilateral. 1994. This test assesses disability of the upper extremity with the aid of five functional tasks.. It took about 10 to 15 minutes to administer this test. Sanford. Swanson. Feder. & Granger. & Fiedler. and unclipping a clothes peg). Ottenbacher. Sunderland. Shepherd. This test is one of the most commonly used instruments in rehabilitation (Malouin. Laughlin. This is a shortened version of the original 25 and subsequently seven item battery (Wade et al. which are rated on a seven-point scale. The FIM instrument includes 18 functional activities (such as eating. 1987).

if necessary. 1973). is requested to locate and cross out all the lines.. The patients were assessed for proprioception loss and motor ability of the upper extremity four times (weeks 0. speech therapy normally provided during this period (i. 1983.e. functional ability of the upper extremity was assessed only on admission (week 0) and after six weeks. Procedure Each subject was assessed on admission to the rehabilitation center (designated week 0 for the purposes of this study) and at weeks two. five one-half hour sessions per week). A repeated measures ANOVA was used to determine whether there were significant differences between the FMA scores (depicting motor ability of the upper extremity) throughout the 6 week recovery period. 2. physical. First the tests of proprioception were administered. BADL was also assessed on these two occasions and unilateral neglect on admission only.76 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 5. BADL was assessed separately in the patients’ rooms. 1973. a staff occupational therapist with seven years of clinical experience treating this population. Assessment of Unilateral Neglect Albert’s Test of Visual Neglect. Bradford. Since the FAT is known to be rather insensitive (Wade et al. Halligan.. four. followed by the FMA and then the FAT. It appears to be a reliable and valid test when used for stroke patients (Albert. and. by the same examiner. 1994. 1986). seated at a table upon which has been placed the test paper. and six following admission. 1991. 4. Chen Sea & Henderson. pointing in different directions and arranged in six columns (Albert. Schenkenberg. Parker et al. Differences in the functional ability of upper extremity (FAT . each 25 mm in length. & Wilson. The tests required from 10 minutes (for patients with minimal active ability) to 25 minutes (for those with greatest active ability) to administer. Data Analysis The recovery process was first characterized with descriptive statistics. & Ajax. All patient subjects received the same amount of occupational. The patient. All the tests of the upper extremity were assessed during the same session. taking about 30 minutes to complete. On a 200 260 mm piece of white paper are drawn 40 lines. and 6). This is a screening test for unilateral neglect. Cockburn. 1980)..

4. to . only two patients had a severe deficit. FAT. FMA. all subsequent analyses were carried out on results from the Thumb Localization Test only.61 (p < . By this time 10 patients suffered from a mild deficit. By week 4. and Weiss 77 score) between weeks 0 and 6 were assessed with the Wilcoxon nonparametric test whereas a paired t-test was used to test differences in BADL function between weeks 0 and 6. to . By week 6. The relationship between these two tests was examined by means of Spearman’s correlation coefficient.05) at week 0. and FIM at weeks 0 and 6 were correlated.Rand. eight suffered from a moderate deficit. and four suffered from a mild deficit. Gottlieb. RESULTS Proprioception Deficit Proprioception was assessed at weeks 0. eight of the patients suffered from a severe deficit. Non-parametric Spearman’s correlations of the two measures of proprioception (the Thumb test and the Finger shift test) and motor ability to functional ability were performed. On admission. The same measure was used to test whether the variable proprioception.) In view of the fact that the two tests were correlated and given the incomplete data set for the Finger Shift test.53 (p < . five patients. The two tests of proprioception were found to be significantly correlated on all four occasions with moderate r values ranging from . and 6 with the Thumb Localization and the Finger Shift tests. 2. . and to .01) at week 2. By week 2. (Note that the correlations are negative since in the case of the Thumb Localization test the score increases with the severity of the proprioception loss whereas the reverse is true for the Finger Shift test.71 (p < .71 (p < .) Tables 1 and 2 illustrate the recovery of proprioception for the 20 patients over the six-week period of study. (Note that the modest correlation between the two tests may be due to the fact that the Finger Shift test focuses on manipulation of distal joints whereas the Thumb Localization test focuses on manipulation of the entire upper extremity. three of the patients in both the severe deficit and moderate deficit groups had improved so that only five patients remained in each of these categories.01) at week 4. Results from the former test were available for all 20 patients but only 17 patients were able to understand and complete the latter test. and 11 patients had a mild deficit. seven patients had a moderate deficit.01) at week 6. all 20 patients had some degree of proprioception deficit.

The mean score on admission was 9. Recovery of the proprioception loss from week 0 to week 6 according to the severity of the initial deficit At Week 0 Of the 8 patients who had a severe proprioception deficit S S S S S S S S S At Week 6 2 patients retained a severe deficit 4 patients improved to a moderate deficit 2 patients improved to a mild deficit 0 patients improved to no deficit 2 patients retained a moderate deficit 4 patients improved to a mild deficit 2 patients improved to no deficit 1 patient retained a mild deficit 3 patients improved to no deficit Of the 8 patients who had a moderate proprioception deficit Of the 4 patients who had a mild proprioception deficit . The progression in mean FMA scores during the six-week follow-up period can be seen in Table 3.0 and it increased to 26. Only two patients (10%) retained a severe deficit.78 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS representing 25% of the subjects.6 17. Changes in severity of the proprioception deficit amongst the 20 patient subjects during the six week recovery period. whereas the remaining 13 patients (65%) retained moderate or mild deficits. had improved to the point where no deficit was discerned.2 5. The Motor Recovery of the Upper Extremity The subjects on average demonstrated a significant increase in the level of motor ability as assessed by the FMA scale.2 after six weeks. The results reported here were obtained from the Thumb Localization test Severity of Proprioception Deficit as assessed by Thumb Localization test (score) Week 0 Severe Moderate Mild None 8 8 4 0 Week 2 5 5 10 0 Week 4 2 7 11 0 Week 6 2 6 7 5 Frequency Distribution of Proprioception Deficit TABLE 2. A repeated measures ANOVA was performed to test whether the extent of the motor recovery TABLE 1.

2.4 * 15.22 on admission to 1. However.003). p = . Mean scores one standard deviation (SD) of the FMA (Fugl-Meyer Motor Assessment) at weeks 0. . z = 2.01). tested by the FMA) and functional ability (the ability to use the affected upper extremity in a functional way. and Weiss 79 TABLE 3.48 9.4 * 12.5 points (paired t-test: t = 5.1 16. p < .4 22.6 1.48 after six weeks (see Table 3). which was found to be statistically significant (Wilcoxon test. 4 and 6 and the FAT (Frenchay Arm Test) at weeks 0 and 6 of the patient subjects (n = 20).8 Week 6 26.887.25 17. Additional Correlations Between the Variables The correlation coefficients between the severity of the proprioception deficit (both on admission and after 6 weeks) and motor ability.09.25 1. a significant correlation was found between the motor ability and the functional ability of the upper extremity (Spearman correlation r = .Rand.2 05 5. p = . no significant correlation was found. BADL Improvement The mean FIM score on admission was 53. Week 0 FMA FAT * test not performed Week 2 16. The mean FAT scores increased from .0 .000). after six weeks. On admission. Gottlieb.2 1.22 from the time of admission and throughout the following six weeks was significant.96.4 points and after six weeks it increased significantly to 68. tested by the FAT) of the upper extremity were carried out on admission and after six weeks. The Functional Recovery of the Upper Extremity The subjects on average demonstrated a significant increase in the level of functional ability of the upper extremity as assessed by the FAT scale.2 Week 4 22.75. This test showed that the motor ability of the affected upper extremity of the patients with proprioception deficit improved significantly (F = 63. p = .000) during the six week study period to a recovery of 44% of the full motor ability of the upper extremity.05 . Correlations between the motor ability (the ability to produce active movement.

59.. 1975).80 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS functional ability and BADL function were low (r = . and one of our major results was the demonstration of a significant improvement in the motor and functional ability of the upper extremity of this relatively homogenous group (i.88. on average. Sunderland et al. The function of the upper extremity at week 6 did correlate moderately to BADL function at that time (r = . 1970.34) and non-significant. stroke patients with a combined motor and proprioception deficit).. six weeks after admission. monitoring of patients of this type was published in only a few cases. 44% of their motor ability and 25% of their functional ability of the affected upper extremity.000) and a strong correlation between the motor ability to BADL after six weeks (r = . 1951. we made use of the Thumb Localization Test to rank the proprioception deficit into three degrees .000). 1983. p = . Note that it may be that the measurement scales were not sensitive enough to measure low level differences.01). p = .. there was a moderately strong correlation between motor ability on admission to the function of the upper extremity after six weeks (r = . all 20 patients suffered from a proprioception deficit in their upper extremity (having. DISCUSSION Previous studies of the motor recovery after stroke included patients who were heterogeneous in terms of the presence of a proprioception deficit (Twitchell. The correlation between motor ability after six weeks to function of the upper extremity after six weeks was very strong (r = . on average. In contrast. p = . and the results were limited to a report of whether a deficit was present or not (Smith et al.000). on admission. p = . Fugl-Meyer et al. p < . Whereas. all of the patients in this study suffered from a proprioception deficit..67. 1992). In contrast. Prior to the present study. The function of the upper extremity on admission did not correlate with the motor ability of the upper extremity nor with BADL function on admission. Brunnstrom. A second important result was the documentation of the proprioception status of patients who suffered from this deficit on admission to hospital. only 15% of their motor ability and 1% of the functional ability of the affected upper extremity).78.000) but the correlation between motor ability after six weeks to BADL function after six weeks was only moderate (r = .e.01 to . In contrast.63. 25% of the patients had completely recovered their proprioception deficit and had.

Various studies have shown that from about one quarter to close to half of all stroke patients suffer from a combined motor and proprioception deficit (Smith et al. After six weeks 2 patients still had a severe deficit. 1997). 7 had a mild deficit and 5 patients recovered completely in terms of the proprioception deficit. considered to be less amenable to treatment and to have a worse prognosis.Rand. There is evidence that these patients have difficulty achieving independence in BADL and mobility when compared to patients with a pure motor deficit (Smith et al. Gottlieb et al. as a group. Greater familiarity with the pattern of recovery of the proprioception deficit can help the clinician to establish more realistic therapeutic goals and to anticipate with greater accuracy the eventual treatment outcome. 1985. Sunderland et al. Wade et al. it should be considered for routine use in the clinic... Moberg (1983) concluded that cutaneous receptors in the fingers play an important role in perception of position and motion and Dannenbaum and Dykes (1988) added that feedback from cutaneous receptors is needed to guide adjustment of muscle force during manipulation tasks such as drinking. The Thumb Localization Test was a clinically feasible and apparently effective instrument for assessing proprioception. 1988. On admission 4 patients had a mild deficit. and was easy to administer to all the patients including those with aphasia. Hamilton... Reding & Potes. 1992). The mean FIM score in this study was 51. 1990. 1988.. It may be that the patients were able to compensate for their loss of proprioception via increased reliance on visual cues or other sensory modalities such as light touch. The mean FIM scores on admission are lower than those reported by Granger. 8 patients had a moderate deficit and 8 patients had a severe proprioception deficit. there was no significant correlation between proprioception and the other motor or functional outcome measures at any time during the six weeks of this study. (Note . Indeed. this deficit did not appear to interfere greatly with the motor or functional ability of the upper extremity. Pending demonstration of its reliability and validity. The current results support this finding. They are. 1983. Although 75% of the patients still suffered from a mild to moderate proprioception deficit six weeks after admission. and Weiss 81 of severity-mild. dressing and eating. Gottlieb.7 as compared to the mean FIM score 63 points reported by Granger et al. 6 had a moderate deficit. Reding. (1992). moderate and severe. and Feider (1992) in their survey of 7090 stroke patients. particularly when tested with the FAT. Reding & Potes. 1983.

their deficit was more severe than the average stroke patient and their FIM gain per day was also lower. as much as .82 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS that admission to rehabilitation occurred after 33 22 days in the Granger et al. 1994.42 points per day (Gottlieb et al. This result supports other studies that concluded that patients with a combined motor and proprioception deficit have a poorer functional outcome in terms of BADL and mobility (Reding & Potes. 1990.. (1997) and Adunsky et al. Levenkrohn. In this study the FIM gain per day was . Reding.31 points. It would appear that either spontaneous recovery or therapy or a combination of the two helped these patients learn how to better employ whatever active movement they had regained for functional tasks. The discrepancy may be due. whereas in other studies done it was higher. 1989) assessed upper extremity disability using the Barthel Index subscores for grooming/dressing and feeding. the motor and functional ability of the upper extremity were not correlated. after six weeks of rehabilitation.. Fleissig. In contrast. Comparing the FIM scores of the patients in this study on admission and after six weeks with other studies is difficult since the period of time between admission and discharge varied greatly. a proprioception deficit.35 . The motor ability of the upper extremity on admission did correlate well to the functional ability of the upper extremity after six weeks as well as to the function in BADL at that time. In both cases upper extremity function was achieved by using the unaffected upper extremity for compensation and not by recovery of the affected upper . Chetrit. In this study. which is the maximum Total FIM score).6/126. in part. a highly significant correlation was found between these two variables. At least two studies (Nakayama et al.55 . 1997). 1997) and .. all of the patients suffered from an additional impairment. Gottlieb et al. However.54 . Olsen. 1998). after six weeks these patients still required moderate assistance in BADL (mean Total FIM score after six weeks 64. (1998) studies included all stroke patients who were treated in rehabilitation. to differences in the type of patients who participated. 1988.45 points per day (Adunsky. & Blumstein. survey as compared to 18 9 days in the present study). On admission. Although a significant improvement in the ability to function in BADL was found. their FIM scores were representative of those from typical stroke patients. Independence in BADL is possible even with a completely paralyzed upper extremity. Both the Gottlieb et al. it is possible to compare the per day gain in the FIM.

The population examined in this study (patients with a combined motor and proprioception deficit) are usually more severely affected than patients with a pure motor deficit. since they tend to suffer from more extensive brain injury. They concluded that there is a weak relationship between independence in BADL and upper extremity motor function and that independence is achieved by the learning of compensatory techniques.e. to decrease the motor and sensory impairment) and to encourage use of the arm functionally. 1993. Nakayama et al. Thus. Since the recovery of the upper extremity in the stroke population as a whole is generally thought to be limited (Teasell & Gillen. but unrelated occurrences. it is worthwhile noting that a moderately strong correlation was found between the functional ability of the upper extremity and function in BADL six weeks after admission. or could be related to other variables such as a general decrease in motor and cognitive impairment. Arsenault.. or may simply be due to two concurrent. Implications for Therapy The patients who participated in this research were receiving occupational therapy at the time of the study. Carr and Shepherd (1987).. p < . In that study a moderate correlation was found between the FMA scores for the upper extremity on admission and the score of the self care section of the FIM on discharge (r = . Filiatrault. the results of this study are encouraging. This was done using treatment methods based on Bobath (1990). patients were taught to use their unaffected upper extremity. 1994).0025). when possible. (1995). Brunnstrom (1970) and Dannenbaum and Dykes (1988). Simultaneously. and Weiss 83 extremity. when use of the affected one was not possible or effective. Similar results were reported by Chae et al. The therapy approach to treat the affected upper extremity was remedial with emphasis on recovery of active movement (i. the fact that these subjects demonstrated a significant improvement of .56. This may indicate an association between the function of the upper extremity and BADL since the patients used two hands to accomplish both tasks. intervention of a compensatory character was provided in order to increase independence in BADL. Nevertheless. Gottlieb. Thus improvement in BADL function does not necessarily provide information about the condition of the affected upper extremity.Rand. Dutil and Bourbonnais (1991) found the Barthel Index scores and the FMA scores of the upper extremity of 18 stroke patients to be poorly correlated.

(1998). 135. K. A.6 points) and after five weeks (41. REFERENCES Adunsky. Y. Bertini. (1991). Upper extremity function in hemiplegia: A . Albert.3) and after one month (mean FMA score = 22.L.4 23. M. Filiatrault et al.1 24.7 20. 658-664.84 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS their affected upper extremity should serve to encourage therapists to treat the upper extremity of all patients scheduled for rehabilitation. 23.0 in comparison to 17. Wood-Dauphinee et al. In conclusion. as assessed by the FMA. Therefore.6). These finding should guide therapists in planning treatment and setting goals for rehabilitation.4 25.7 20... In a study by Ferrucci. the average improvement was greater in this study in comparison to the improvement reported by Wood-Dauphinee et al..R.0 points) and achieved lower scores after six weeks (26. A.1 24. The patients in the present study demonstrated an average of 44% of their upper extremity motor ability after six weeks. Levenkrohn. Bandinelli. Falchini. The patients in this study were admitted with lower FMA scores (9. Chetrit. (1991) assessed 18 patients with the FMA on admission (mean FMA score = 17.4 15. (1986). (1990) reported the FMA scores of 119 patients on admission (30. Berglund.6). the initial FMA scores of our patients are somewhat lower (9.7 points). A. A simple test of visual neglect. Lamponi. It is clear that our patients on admission were more severe in terms of the impairment of the upper extremity but. Evaluation of predictive factors for stroke rehabilitation. Fleissig. & Blumstein. Guralnik.2 5. (1990). Neurology. even so.. & Fugl-Meyer.6 17. S.8 in comparison to 22. and Baroni (1993) patients were discharged from rehabilitation (length of hospitalization unknown) with an average of 27% of their motor ability of the upper extremity. when treating patients with a combined motor and proprioception deficit therapists should take in to account that a significant motor and functional improvement of the upper extremity can be expected even though they will likely continue to have difficulties achieving independence in BADL.2 5.2 points). the motor ability of their upper extremity improved as much as or even more than the patients reported by Filiatrault et al. 12. Again. Harefuah.3). but the scores of the second assessment after one month are similar (the mean FMA score of our patients after one month is 22. (1973). Z. even though the patients suffered from a combined motor and proprioception deficit.

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