Arm and leg paresis as outcome predictors in stroke rehabilitation.

T S Olsen

Stroke. 1990;21:247-251
doi: 10.1161/01.STR.21.2.247
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 247

Arm and Leg Paresis as Outcome Predictors

in Stroke Rehabilitation
Tom Skyh0j Olsen, MD

I used leg and arm paresis to predict outcome measured as extremity function in a prospective
study of 75 consecutive hemiplegic patients admitted to an inpatient stroke rehabilitation unit.
In each patient, extremity paresis was quantified according to the five-point scoring system
advised by the Medical Research Council, upper extremity function was quantified using the
Barthel Index subscore for feeding and dressing the upper body, and lower extremity function
was quantified according to a five-point scoring of the ability to walk. Improvement was
recorded for upper extremity function in 52% of the patients and for lower extremity function
in 89%. Best extremity function was reached a mean±SEM of 9±3 and 10±4 weeks after stroke
for the upper and lower extremities, respectively. In patients experiencing complete recovery,
this occurred a mean±SEM of 7±2 weeks (for both upper and lower extremities) after the
stroke. Only 8-11% of the patients with paresis scores of ^2 regained independent extremity
function after rehabilitation. Half of the patients with paresis scores of ^3 regained indepen-
dent extremity function after rehabilitation, while the other half were able to perform extremity
function with only minimal assistance. As predictors of extremity function, the Barthel Index
subscore was slightly better (r=0.64) than paresis score (r=0.58). However, because evaluation
of extremity paresis is easy, it appears to be useful as a preliminary predictor of outcome
following stroke. (Stroke 1990;21:247-251)

I mprovement of both upper and lower extremity

function is one of the major objectives of stroke
rehabilitation since extremity function greatly
affects the overall outcome. My investigation was
undertaken to study upper and lower extremity func-
tion after rehabilitation for stroke and the time to
reach maximum extremity function. Another purpose
of my study was to predict outcome measured as
extremity function on the basis of a simple bedside
evaluation on admission, that is, the degree of weak-
ness in the paretic arm and leg.
Subjects and Methods
This was a prospective study of consecutive
patients admitted to an inpatient stroke rehabilita-
tion unit. I excluded patients who were admitted >60
days after their stroke, those who did not have
paresis, and those who had strokes involving both
cerebral hemispheres. Seventy-five patients satisfied
these criteria. From this population, I established
two overlapping groups to test the effect of upper and
lower extremity paresis independently. One group
From the Burke Rehabilitation Center, White Plains, New York.
Supported by the Burke Foundation and the Burke Rehabilita-
tion Center.
Address for correspondence: Tom Skyhej Olsen, MD, Depart-
ment of Neurology, Gentofte Hospital, University of Copenhagen,
DK-2900 Hellerup, Denmark.
Received November 3, 1988; accepted August 21, 1989.
was made up of 66 patients with unilateral upper
extremity paresis who on admission were unable to
feed themselves and/or to dress their upper body
independently; seven patients with lower extremity
paresis but no upper extremity paresis and two
patients with unreliable scoring of upper extremity
function were excluded. The second group was made
up of 72 patients with unilateral lower extremity
paresis who on admission were unable to walk inde-
pendently; three patients who had upper extremity
paresis but no lower extremity paresis were excluded.
Computed tomography or magnetic resonance imag-
ing was performed in all patients before referral to
rehabilitation.
On admission to the rehabilitation unit, all patients
had a full neurologic examination including evalua-
tion of proximal (hip and shoulder flexion) and distal
(ankle and finger flexion) leg and arm paresis scored
according to the system advised by the Medical
Research Council (1: a trace of contraction, 2: active
movement with gravity eliminated, 3: active move-
ment against gravity, 4: active movement against
gravity and resistance, and 5: normal power).1
Upper extremity function was evaluated according
to the Barthel Index2 using subscores for the patients'
ability to prepare a tray and feed themselves (6: can
feed self a meal placed within reach, can put on an
assist device if used, can cut food, spread butter, and

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248 Stroke Vol 21, No 2, February 1990

TABLE 1. Characteristics of 75 Stroke Patients contact guarding, minimal assistance, etc. Use of a
Patients with upper Patients with lower brace and a cane did not constitute assistance.
extremity paresis extremity paresis Overall stroke severity was assessed by determin-
Characteristic (n=66) (" = 72) ing the Barthel Index score of each patient on
Age (years) 68±10 67±11 admission.
Sex Statistical analysis was performed using linear
Females 33 33
regression analysis and the Mann-Whitney test.
Males 33 39 Results
Side affected
Patient characteristics are listed in Table 1. Leg
Left 30 39
and arm paresis score on admission correlated signif-
Right 36 33 icantly with extremity function score on discharge
Stroke mechanism (proximal upper extremity: /-=0.58, proximal lower
Hematoma 3 4 extremity: r=0.53, distal upper extremity: r=0.55,
Infarct 63 68 distal lower extremity: r=0.54;/?<0.01). Proximal and
Admission after stroke distal paresis scores were found to be equally good in
(weeks) 4±2 4±2 predicting outcome measured as function score. Only
Length of stay (weeks) 9±3 9±3 the relations between proximal paresis scores and
Data are mean±SEM or number. outcome are given below.
On admission, 40 patients had upper extremity
paresis scores of 22 (Table 2). Three (8%) regained
use salt/pepper; 4: some help required, but can feed independence in both upper extremity functions
self once food is cut up; and 0: unable to feed self) (scored 11 on discharge), and nine (23%) regained
and to dress their upper body (5: able to put on, independence in at least one function (scored 9 or 11
fasten, and remove clothing; 3: needs help, but able on discharge). Eleven (42%) of the 26 patients with
to do at least half the work; and 0: performance upper extremity paresis scores of ^3 regained inde-
worse than described). The sum of the two Barthel pendence in both upper extremity functions, and 21
Index subscores was considered to be a measure of (81%) regained independence in at least one function.
upper extremity function. Patients who scored 11 On admission, 38 patients had lower extremity pare-
were independent in both upper extremity functions. sis scores of ^2 (Table 3). Four (11%) regained the
Those who scored 9 were independent in one func- ability to walk independently (scored 5 on discharge),
tion and needed only minimal assistance with the and 19 (50%) became able to walk >150 feet with
other. Patients who scored 7 and 3 or 4 needed assistance (scored 4 on discharge). Of the 34 patients
assistance in performing both functions. Patients who had paresis scores of ^ 3 , independent walking was
with the lowest possible function score, 0, needed regained by 19 (56%) and all 34 became able to walk
maximal help of another individual in performing > 150 feet with assistance or independently.
both upper extremity functions. Function thus refers The Barthel Index score on admission correlated
to both extremities, the paretic as well as the non- significantly with function score on discharge (upper
paretic one, while motor impairment refers to the extremity: r=0.64, lower extremity: r=0.65;/?<0.01).
paretic extremity only. Among the 28 patients with Barthel Index scores of
Lower extremity function was evaluated by scoring <40, only one (4%) regained independence in both
the patients' ability to walk (1: nonambulatory, 2: can upper extremity functions, and only six (21%)
walk <50 feet with assistance, 3: can walk 50-150 regained independence in at least one function
feet with assistance, 4: can walk >150 feet with (Table 4). Independence in both upper extremity
assistance, and 5: can walk independently). Patients functions was regained by 13 (34%) of the 38 patients
were said to require assistance when they needed the who had Barthel Index scores of £40, and 24 (63%)
presence of another individual for safety such as regained independence in at least one function.

TABLE 2. Proximal Upper Extremity Paresis on Admission and Upper Extremity Functional Outcome in 66 Stroke Patients

Paresis score Function score on discharge TotaJ

on admission 0 3,4 7 9 11 n %
0 5 8 10 4 2 29 44
1 0 3 2 2 0 7 10
2 0 1 2 0 1 4 6
3 0 1 3 3 4 11 17
4 0 1 0 7 7 15 23
Total 5 (8%) 14 (21%) 17 (26%) 16 (24%) 14 (21%) 66 100
Paresis scored by Medical Research Council system; function scored by Barthel Index subscores.

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 Olsen Outcome Predictors in Stroke Rehabilitation 249

TABLE 3. Proximal Lower Extremity Paresis on Admission and Lower Extremity Functional Outcome in 72 Stroke Patients
Function score on discharge Total
Paresis score
on admission 1 2 3 4 5 n %
0 1 1 2 4 1 9 12
1 2 1 1 6 2 12 16
2 0 1 6 9 1 17 24
3 0 0 0 10 7 17 24
4 0 0 0 5 12 17 24
Total 3 (4%) 3 (4%) 9 (13%) 34 (47%) 23 (32%) 72 100
Paresis scored by Medical Research Council system; function scored by ability to walk.

Table 5 shows that among 28 patients with Barthel Discussion

Index scores of <40, only one (4%) regained the
ability to walk independently, while 14 (50%) were
able to walk > 150 feet with assistance after rehabil-
itation. Of the 44 patients with Barthel Index scores
of ^40, 22 (50%) regained independent walking and
42 (95%) were able to walk >150 feet with assistance
or independently after rehabilitation. All four
patients with Barthel Index scores of ^80 were able
to walk independently after rehabilitation.
Table 6 shows the time to maximum extremity
function score in the patients who recovered. Upper
extremity function improved during rehabilitation in
34 patients (52%), while lower extremity function
improved in 60 patients (89%). The patients who
improved were discharged a mean±SEM of 2±1
weeks after they had reached their maximum extrem-
ity function score. Maximum score was reached 9±3
(for the upper extremity) and 10±4 (for the lower
extremity) weeks after the stroke; 95% of the patients
had achieved their best extremity function within 14
weeks after their stroke. Patients who recovered com-
pletely (achieved independent extremity function) did
so 7±2 weeks after the stroke, while patients who
recovered only incompletely reached best extremity
function 10±3 (for the upper extremity) and 10±4
(for the lower extremity) after the stroke. This differ-
ence in time to maximum score is significant (p>0.03
andp<0.002, respectively, by the Mann-Whitney test).
There was no significant difference between patients
with paresis scores of ^2 and those with scores of ^3
in the time to maximum extremity function score
(/?>0.05 by the Mann-Whitney test).
Functional outcome in this series was less favor-
able than that reported for the average stroke pop-
ulation since no more than 21% and 32% regained
independent upper and lower extremity function,
respectively. In unselected patients with stroke,
approximately 70% are able to feed and dress them-
selves independently and >80%3"5 are able to walk
independently 6 months after the event.5 Wade et al6
assessed lower extremity weakness 3-4 weeks after a
stroke in 196 unselected patients and found that 86%
had either no or only mild weakness. In my study, this
occurred in approximately 24% (paresis score of 4),
which indicates that these patients were recruited
from those with more severe strokes, usually 20% of
the stroke population.
Arm and leg paresis are easy to determine and
appear to be useful predictors of functional outcome.
Severe extremity paresis (Medical Research Council
scores of ^2 on admission) predicts a bad outcome.
Neither independent upper extremity function nor
independent walking should be expected by patients
with paresis of that degree. Only 8% and 11% of my
patients with paresis scores of £2 on admission per-
formed upper extremity functions and walked inde-
pendently after rehabilitation. Approximately 40%
were not able to walk 150 feet, even with assistance,
and upper extremity function outcome was even
worse; >75% of the patients with paresis scores of ^2
on admission still needed significant assistance with
upper extremity function after rehabilitation.
Mild extremity paresis (Medical Research Council
scores of ^3 on admission) predicts a relatively good
functional outcome. About half of these patients

TABLE 4. Overall Stroke Severity on Admission and Upper Extremity Functional Outcome in 66 Stroke Patients
Function score on discharge Total
Severity score
on admission 0 3,4 5-8 9 11 n %
0-19 3 2 2 0 0 7 11
20-39 2 9 4 5 1 21 32
40-59 0 3 7 7 4 21 32
60-79 0 0 4 4 8 16 24
80-100 0 0 0 0 1 1 1
Total 5 (8%) 14 (21%) 17 (26%) 16 (24%) 14 (21%) 66 100
Severity scored by Barthel Index; function scored by Barthel Index subscores.

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250 Stroke Vol 21, No 2, February 1990

TABLE 5. Overall Stroke Severity on Admission and Lower Extremity Functional Ontcome In 72 Stroke Patients
Function score on discharge Total
Severity score
on admission 1 2 3 4 5 n %
0-19 2 0 4 2 0 8 11
20-39 1 3 3 12 1 20 28
40-59 0 0 2 16 8 26 36
60-79 0 0 0 4 10 14 19
80-100 0 0 0 0 4 4 6
Total 3 (4%) 3 (4%) 9 (13%) 34 (47%) 23 (32%) 72 100
Severity scored by Barthel Index; function scored by ability to walk.

regained independent extremity function. After reha-
bilitation, all were able to walk >150 feet with
assistance or independently and 80% were either
independent or needed only minor assistance with
upper extremity functions.
Extensive work using the Barthel Index as a pre-
dictor of outcome has demonstrated a close relation
between the score on this index (i.e., overall func-
tion) at admission and outcome.3'5-14 The Barthel
Index cannot be established at the bedside on admis-
sion since it requires observation of the patient over
several days. The Barthel Index seems to be slightly
better than extremity paresis in delineating those
patients who will be unable to perform upper extrem-
ity functions or to walk independently after rehabil-
itation. In accordance with the findings of Granger et
a],9 in my study such functionally impaired patients
comprised only 4% of those with Barthel Index
scores of <40 compared with 8-11% of those with
Medical Research Council paresis scores of <2. The
Barthel Index is also better in predicting walking
outcome in "high-level" patients (those with a Bar-
thel Index score of >80).
Improvement may occur as long as 6-12 months
after a stroke,31'-18 but the majority of functional
recovery occurs within the first 3 months. Studying 39
stroke patients with hemiplegia, Newman19 found
that little recovery took place later than 14 weeks
after the stroke and that the average interval from
stroke onset to 80% of final recovery was 6 weeks.
Prescott et al20 studied 100 patients with moderate-
severe strokes from 4 weeks after the stroke until
discharge; 89% had reached their best functional
outcome ^16 weeks after their stroke. Wade et al17
studied arm function in 92 patients over 2 years
following their stroke; statistically significant improve-
ment was seen only during the first 3 months. In 135
stroke patients studied by Andrews et al,18 maximum
improvement for walking was reached within 8 weeks
after the stroke in 88% of the patients. These find-
ings are in accord with my findings. Best upper and
lower extremity function was obtained on average 9
and 10 weeks, respectively, after the stroke, and 95%
of the patients had reached their best upper and
lower extremity function within 13 and 14 weeks,
respectively.
Stroke severity affects the time required to obtain
maximal recovery. Length of stay in a rehabilitation
unit is directly related to the severity of paresis on
admission.21-22 Patients with a low Barthel Index
score on admission recover more slowly than patients
with a high score.3 In my study, complete recovery of

TABLE 6. Time to Obtain Best Extremity Function in Stroke Patients Who Improved During Rehabilitation

Time (weeks) Best function reached

by 95% of patients Stroke-discharge interval
n Mean±SEM Range (weeks) (mean±SEM weeks)
upper extremity (/v=66)
Best function 34 9±3 5-16 13 11+4
All patients
Paresis score <,2 17 9±3 5-16 13 13±4
Paresis score S3 17 8±2 5-11 10 10±3
Incomplete recovery 21 10±3 5-16 13 13±3
Complete recovery 13 7±2* 5-10 10 9±3
Lower extremity (N=12)
Best function 60 10±4 4-27 14 12±5
All patients
Paresis score s 2 33 10±4 4-27 14 13±5
Paresis score &3 27 9±3 5-20 13 12±4
Incomplete recovery 37 10±4 4-27 18 14±5
Complete recovery 23 7±2t 5-11 10 10±3
*tp<0.03, 0.002, respectively, different from incomplete recovery by Mann-Whitney test.

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 Olsen Outcome Predictors in Stroke Rehabilitation
extremity function was achieved on average 7 weeks
after the stroke, whereas recovery progressed for an
average of 10 weeks in patients who achieved only
incomplete recovery.
Andrews et al18 showed that approximately one
third of moderately or severely disabled stroke
patients had improvement of their walking between 3
and 6 months after their stroke. In my study, the
patients were discharged an average of 2 weeks after
maximum improvement was achieved. Although the
majority of the patients thus seemed to have reached
their best possible outcome on discharge, some
patients may continue to improve. However, the
process of recovery may be so slow in these patients
that recordable improvement of function requires >2
weeks of observation during inpatient rehabilitation.
Acknowledgments
Thanks to Dr. Fletcher H. McDowell and Dr.
Michael J. Reding for invaluable advice during prep-
aration of the manuscript.
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KEYWORDS • cerebrovasculardisorders • paresis • rehabilitation