Journal of Neurological Sciences [Turkish] 24:(3)# 12
Journal of Neurological Sciences [Turkish] 24:(3)# 12;226-233, 2007
The Impressive Factors On Functional Recovery Of The Upper Extremity In
Birgül DÖNMEZ1, Salih ANGIN1, Kürşat KUTLUK2
Dokuz Eylül Üniversitesi, Fizik Tedavi Ve Rehabilitasyon Yüksekokulu, İzmir, Türkiye2Dokuz
Eylül Üniversitesi, Nöroloji Anabilim Dalı, İzmir, Türkiye
The purpose of this study was to describe the association between motor and sensorial
impairment, to establish the relation to age, hemiplegic side, gender and emotion in ischemic
stroke and to determine the factors, influences the recovery of the upper extremity functions
in the hemiplegic patients. A total of 112 hemiplegic patients with the condition that at least 6
months were left from the onset of the stroke were assessed.
Sensorial and motor functions of the upper extremity were examined by using the Fugl-Meyer
(FM) Upper Extremity Performance Test, sensorial function test and the Motricity Index.
FM motor and sensorial scores were correlated significantly with Motricity index (p<0.05).
It was concluded that the age, hemiplegic side and emotional status are important factors that
effects the recovery of the upper extremity in hemiplegic patients.
Keywords: Hemiplegia, upper extremity, sensorimotor assessment, functional recovery
Hemiplejik Hastalarda Üst Ekstremite Fonksiyonel Geri Dönüşünü Etkileyen Faktörler
Bu çalışmanın amacı, iskemik inmede yaşa, hemiplejik tarafa ve emosyona göre sensorimotor
bozukluklar arasındaki ilişkiyi belirlemek ve hemiplejik hastalarda üst ekstremite
fonksiyonlarının geri dönşünü etkileyen faktörleri saptamaktır. Inmeden sonra en az 6 ay
zaman geçmiş toplam 112 hemiplejik hasta değerlendirilmiştir. Üst ekstremitenin duyu ve
motor fonksiyonları Fugl-Meyer (FM) Üst Ekstremite Performans Test, duyusal fonksiyon
testi ve Motricity Indeksi ile değerlendirilmiştir. FM motor ve duyusal skorları Motricity
indeksi ile anlamlı korelasyon göstermiştir (p<0.05). Motor ve duyusal bozukluklar yaş,
hemiplejik taraf ile ilişkili olmayıp FM (motor-duyusal), Motricity indeksi ve emosyonel
durum arasında anlamlı korelasyonlar saptanmıştır (p<0.05). Emosyonel durumu iyi olan
hastalar, sensorimotor fonksiyon testlerinden daha yüksek puanlar almış ve gruplar arasında
anlamlı fark görülmüştür (p<0.05). Çalışmanın sonucunda yaş, hemiplejik taraf ve emosyonel
durumun üst ekstremitede geri dönüşü etkileyen önemli faktörler olduğu tespit edilmiştir.
Anahtar Kelimeler: Hemipleji, üst ekstremite, sensorimotor değerlendirme, fonksiyonel geri
INTRODUCTION hemiplegia or hemiparesis, patient must be
Motor recovery after stroke may differ. conscious and willing to cooperate.
Degree of the motor recovery depends on Procedures:
severity of the initial neurological damage Sensorimotor Evaluation and emotional
and duration until the first voluntary status assessment were included:
1. Sensorial Evaluation: Regarding
Most patients experience some natural patient’s upper extremity, sense by touch,
recovery of neurologic functioning and sense of pain, position and movement
improvement in ability to perform sense, stereognosis, graphesthesia, ability
activities of daily living(10,14,25). to differenciate right-left side, finger and
Some authors have shown that increased body part recognition test were
age predicts poor outcome after stroke(1). examined(21,22).
In addition to age, the side of lesion also 2. Motor Evaluation: Performance of upper
appears strongly related to functional extremity was evaluated by means of Fugl-
outcomes. Patients with severe functional Meyer motor evaluation scale and
impairment on admission following right Motricity index(13,22,29). In Fugl-Meyer
hemisphere lesions appear to demonstrate upper extremity performance testing, the
less improvement than those with left movements that the patient able to perform
hemisphere lesions(11). Although these were scored as successful-able to perform
findings are not unique(20), some (2 points), partially successful-able to
researchers have not found a difference in perform (1 point), and unsuccessful-not
outcome related to lesion location(31) and able to perform (0 point)(26).
recent literature reviews suggest that
hemisphere of stroke does not predict 3. The highest grade that a patient could
outcome(11,26). The study was designed to get in terms of shoulder and elbow
describe the association between motor functions in Fugl-Meyer scale was 36
function and ability to perform activities of points while 19 points and higher meant
daily living, and secondly to describe the that the patient in question demonstrated
association between gender, emotional motor recovery in upper extremity(7).
status, age and lesion location (left vs Hence, based on the assumption that
right). recovery would develop after 4th phase,
patients were divided into two groups as
METHODS patients who recovered, and patients
Patients without recovery to observe and evaluate
Study population comprised a total of 112 the factors affecting recovery.
of those hemiplegic patients, who had a 4. Emotional Condition: At this stage
sudden vascular-originated cerebral lesion, patients asked to define how they perceive
hospitalized in Cerebrovascular Disorder their health condition. Patients were asked,
clinic at Neurology Department of Dokuz “How do you feel in regard to your health
Eylul University Hospital. Patients and condition nowadays?” and to choose the
patient’s close relatives were informed suitable option in a 5-grade scale. Options
about the study to be conducted and get were 5=very good, 4= good, 3= not very
their signed informed consent. good, 2= bad, 1= very bad(6).
Criteria applied for selection of the In order to determine the effect of age on
subjects for this study were as follows: At recovery patients were divided into three
least six months should have passed after groups; first one comprised patients, who
stoke, patients must have either unilateral were 54 and younger, second group with
patients between 55-64 of age, and third Fourty-nine (49) women (43.8 %) and 63
group was those, who were 65 and older. men (56.2 %) were enrolled consecutively.
Statistical Analyses: The mean age of patients was 65.52±10.32
(36-88) years. The patients were divided
All analyses were conducted using the into three groups according to the ages
SPSS 11.0 package. Pearson correlation and, who were 54 years and younger were
analysis was performed to determine the 14.3 %, between 55-64 of ages were 27.7
associations between FM motor-sensory %, and 65 years and older were 58 % of
function, and Motricity index, logistic the subjects.
regression analysis was used to determine
the effect of age, gender, hemiplegic side Logistic regression analysis were
and emotion on the recovery from stroke. performed in order to identify the factors
Statistical analyses were interpreted on the affecting recovery of upper extremity
basis of the significance less than 0.05 functions. As a result of these analysis it
(p<0.05). was ascertained that patient’s age
(p=0.012), affected upper extremity
RESULTS (p=0.033) and patient’s emotional
The results of sensorimotor and perceptual condition (p=0.000) significantly affected
evaluation scores were listed in Table 1. the motor recovery (Table 2).
Table 1: Overall Assessment Results of the Subjects
Mean ± SD Min. Max.
Sensorial Function 17.63 ± 5.69 0 22
Superficial Touch Sense 1.40 ± 0.60 0 2
Pain Sense 1.40 ± 0.60 0 2
Kinesthetic Sense 14.70 ± 5.30 0 18
Stereognosis 7.0 ± 3.50 0 9
Graphesthesia 0.80 ± 0.40 0 1
Finger Identification 2.70 ± 0.80 0 3
Right – Left differentiation 4.70 ± 1.0 0 5
Motor Function 41.50 ± 19.7 0 60
Shoulder-Elbow functions 27.21 ± 10.8 0 36
Wrist Function 6.2 ± 4.3 0 10
Grasp Function 8.7 ± 5.7 0 14
Motricity İndex 64.03 ± 26.22 0 100
Table 2: Influencing Factors that effect the Functional Recovery of Upper Extremity
β SE % 95 CI p Mean
54 years and below(R)
55-64 years -2.653 1.603 0.003 – 1.631 0.098 0.070
65 years and above -3.962 1.584 0.001 – 0.425 0.012* 0.019
Female -1.027 0.796 0.075 – 1.704 0.197 0.358
Left 1.609 0.753 1.142 – 21.881 0.033* 5.000
Bad 4.907 1.315 10.284 – 1779.255 0.000* 135.267
Recovery (constant) -3.383 2.769 0.222 0.358
* statistically significant at the 0.05 level
Regarding patients over 65 year age, It was determined a significant correlation
probability of having no recovery was between emotional and sensorimotor status
0.019 times greater than younger patients; (FMmotor p<0.01, r= -0.538) (FMsensorial
for patients with left hemiplegia it is 5 p<0.01, r= -0.369) (FMtotal p<0.01, r= -
times greater than right hemiplegia (Table 0.545) and (Motricity Index p<0.01, r= -
2). 0.475) (Table 3).
According to the self-perception of general Significant correlations were determined
health status, as emotional status, 56.3 % between sensorimotor scores and Motricity
patients mood were good and 43.8 % index (p=0.000) (Table 3).
patients mood were bad. For those patients Sixty-six patients (58.9 %) were right
whose emotional condition relatively worst hemiplegic and 46 patients (41.1 %) were
than others probability having no upper left hemiplegic. According to the mean
extremity motor recovery was 135 times score of Motricity index, the FM motor
greater than those with better emotional function test and the FM sensorial scores
conditions (Table 2). for right and left hemiplegic patients,
Nevertheless gender would not have a significant difference was found between
significant effect on recovery of functions two groups (p=0.013), (p=0.033),
(p>0.05) (Table 2). (p=0.024) (Table 4).
There was no significant correlation
between the functional scores and
hemiplegic side, age, gender (Table 3).
Table 3: Correlation Coefficients of the Sensorimotor Scores to the Patients Characteristics and Motricity Index
Fugl-Meyer Fugl-Meyer Fugl-Meyer Motricity Index
Motor score Sensorial score Total score
r r r r
Age 0.105 0.003 0.070 0.068
Hemiplegic side -0.111 -0.124 -0.120 -0.137
Gender 0.105 -0.016 0.072 0.033
Emotional status -0.538* -0.369* -0.545* -0.475*
Motricity İndex 0.878* 0.495* 0.878*
* correlation is significant at the 0.05 level (2-tailed)
Table 4: The Sensorimotor Scores According to The Hemiplegic Side of The Patients
Motricity İndex FMm** FMs** FMt**
R hemiplegic side 69.07±21.35 44.81±16.73 33.72±10.18 79.07±22.25
L hemiplegic side 56.63±30.70 36.78±22.71 31.45±9.87 68.19±30.21
p 0.013* 0.033* 0.024* 0.036*
* statistically significant at the 0.05 level
** FMm= Fugl-Meyer motor score, FMs= Fugl-Meyer sensorial score, FMt= Fugl-Meyer total score
DISCUSSION on discharge from hospital, adequate
Since the functional disorder caused by performance of ADL and return to
stroke depends on the affected cerebral work(18). Bagg and Macchiocchi have
artery only those functions on the related demonstrated that older age has caused
area will be affected. Depending on having weak functional outcomes and constituted
the lesion on either left or right hemisphere a risk factor for functional independence,
different clinical cases will occur and who were given a rehabilitation
recovery of affected functions will differ. programme in their acute phase(2,20).
Recovery after stroke is affected by such Lindmark and colleagues have mentioned
factors as patient’s age, density of the that males have stroke at relatively
lesion and location of the lesion. younger ages compared to females, and
males have little life expectancy than
Fugl-Meyer upper extremity performance females after stroke(19). In this study, it has
test evaluates voluntary motor functions been ascertained that younger patients
(degree of the synergy, ability to demonstrated better recovery compared to
coordinate voluntary functional older patients, and recovery potential
movements). The Brunnstrom-Fugl Meyer would lessen as the patient gets older. This
test is based on the observation that motor conclusion goes parallel with Bagg and
recovery occurs according to predictable Macchiocchi’s studies.
stages, each evaluated by a set of items.
Since results of Fugl-Meyer scale and Deshelton, Yavuzer and Katrak have
Activities of Daily Living (ADL) have ascertained that gender has no significant
strong correlation with performance impact on motor recovery and functional
capacity and somatosensorial-evoked level(7,16,33). Contrary to that, Wyller and
potentials, these tests are considered as colleagues have mentioned that gender
valid and reliable(9,11,12). Motricity index, factor is only significant in subacute phase.
which evaluates motor power of upper They argued that this was because of
extremity, is known as being very inflammatory reply occurred after cerebral
sensitive, simple and used in a wide range ischemia, which was observed in animal
of application to determine functional trials, was stronger in females compared to
recovery after stroke(29,30). males(32). In this study, we have concluded
that gender has no significant impact on
Somatosensorial measurements, which are recovery. As a result of our evaluations we
widely used to evaluate sensorial have found that whilst female subjects,
functions, include proprioceptive sense and 43.8 % of the study population, had greater
light touch while two-point discrimination grades compared to male subjects but this
test is the least used sensorial test(31). It was does not mean it is significant enough
choosen to use these functional tests (p>0.05). This also complies with the
because of they known as valid, reliable literature knowledge in regard to females
and sensitive to the functional progress. having more widespread hemispheric
Differences in association between age and organisation after stroke compared to
functional status across studies might be males, and males having more severe
due to the correlation of age with functional disorder after stroke compared
comorbidities such as medical, to females(23). It was determined that 81.6
psychosocial and psychiatric disorders % of females and 71.6 % males had
which may not emerge an independent experienced the recovery. Also, the reason
predictors of outcome and causes physical why there was no significant difference
intolerance and delay of functional between groups in terms of recovery
recovery in intensive rehabilitation(1,2,28). degree could be related that right
Similarly Kotila showed that patients over hemiplegic patients, consist of 60.6 % of
65 years had a significant negative impact male and 39.4 % females. And it was
determined those patients with right Emotional outcome is a critical factor
hemiplegia showing greater degree of influencing early evolution and late
recovery. prognosis after stroke. Mood changes,
Motor functions in patients with stroke modified judgment and emotional
may differ depending on which cerebral reactions may also dramatically alter
hemisphere is impacted. As for patients recruitment into clinical trials. Late
with right hemiplegia, obligatory depression is the most common mood
dominance, that is being obliged to use alteration during the first year after stroke
nondominant extremity, negatively affects and critical for the functional improvement
the functions. Therefore, patients with left of individual patients. There is a strong
hemiplegia have better functional link between depression and poor
performance compared to patients with functional outcome of the patients and
right hemiplegia(8). Zemke et al have been depression can lead to a worse functional
described that, stroke patients with right outcome.(4,5,27). Kauhanen and colleagues
arm involvement; smaller ipsilateral have mentioned that depressive patients are
(nonstroke) premotor and larger relatively older and more severe
contralateral (stroke-side) sensorimotor neurological disorders(17). Berg and
activation compared with left arm colleagues states that severity of stroke and
involvement. They also suggested that side functional disorder is related with
of stroke and final motor status are related depression yet development of depression
to motor system reorganization after has nothing to do with location of the
stroke(34). Macchiocchi has concluded that lesion(3). Our findings revealed that
patient with stroke whose left hemisphere patients with emotional distress had lower
is effected, have weaker functional points in sensorial, perceptual and motor
outcomes compared to those whose right tests compared to those patients with better
hemisphere is effected. This difference is emotional conditions. Hence it has been
because of the fact that lesion causes observed that emotional condition is an
disorder in perceptions, and such important factor affecting recovery in
behavioral problems as anosognosis and upper extremity functions similar with the
abulia(20). As a result of this study it was literature (p<0.05).
determined that right hemiplegic patient Similar to conclusion that nondominant
are more likely to recover compared to left hemisphere has a significant impact on
hemiplegic patients and hemiplegic side space perception, proprioception and
significantly affect recovery of upper orientation as well as emotonal
extremity functions. Findings revealed that condition(15). In this study it was found that
83.3 % of patients with right hemiplegia 63.5 % of right hemiplegic patient and 36.5
presented recovery while 65.2 % of % of left hemiplegic patients have better
patients with left hemiplegia recovered. emotional conditions (p>0.05).
These results were similar with results of CONCLUSION
Macchiocchi’s study, and the other
source(21), indicating that sensorial and It has been observed that the major factors
motor functional disorder would be more affecting recovery of upper extremity
severe in right hemisphere lesion for motor functions were age, hemiplegic side,
results of our study have revealed that and emotional conditions. These factors
whilst patients with right hemiplegia had have appeared to be a key role in planning
greater but not significant sensorial, rehabilitation programmes for hemiplegic
perceptual and motor grades compared to patients and success thereof.
patients with left hemiplegia.
Correspondence to a post rehabilitation follow-up study. Stroke 1993;
Birgül Dönmez 11. Feys H, Hetebrij J, Wilms G, Dom R. Predicting
E-mail: email@example.com Arm Recovery Following Stroke: Value of Site
Lesion. Acta Neurologica Scandinavica 2000 ; 102:
12. Feys H, De Weerdt WJ, Selz BE, Cox Steck GA,
Received by: 18 July 2007 Spichiger R, Vereeck LE, Putman KD, Van
Revised by: 06 September 2007 Hoydonck GA. Effect of a Therapeutic Intervention
for the Hemiplegic Upper Limb in the Acute Phase
Accepted : 10 September 2007 After Stroke. Stroke 1998; 29:785-792
13. Fugl-Meyer A, Jaasko L, Leyman I, Olsson S,
The Online Journal of Neurological Steglind S. The Post-stroke Hemiplegic Patient. A
Method for Evaluation of Physical Performance.
Sciences (Turkish) 1984-2007 Scandinavian Journal of Rehabilitation Medicine
This e-journal is run by Ege University 1975; 7: 13-31.
Faculty of Medicine, 14. Hamilton BB, Granger CV. Disability outcomes
following inpatient rehabilitation for stroke.
Dept. of Neurological Surgery, Bornova, Physical Therapy 1994; 74: 494-503
Izmir-35100TR 15. Henon H. Lebert F. Duriev J. Godefroy O, Lucas C,
as part of the Ege Neurological Surgery Pasquier F, Leys D. Confusional State in Stroke:
Relation to Preexisting Dementia, Patient
World Wide Web service. Characteristics and Outcome. Stroke 1999; 30: 773-
Comments and feedback: 779.
E-mail: firstname.lastname@example.org 16. Katrak P, Bowring G, Conroy P, Chilvers M, Poulos
R, Mcneil D. Predicting Upper Limb Recovery after
URL: http://www.jns.dergisi.org Stroke: The Place of Early Shoulder and Hand
Journal of Neurological Sciences (Turkish) Movement. Archives of Physical Medicine and
Abbr: J. Neurol. Sci.[Turk] Rehabilitation 1998; 79: 758-761
17. Kauhanen ML, Korpelainen JT, Hiltunen P, Brusin
ISSNe 1302-1664 E, Mononen H, Määttä R, Nieminen P, Sotaniemi
KA, Myllylä VV. Poststroke Depression Correlates
REFERENCES with Cognitive Impairment and Neurological
Deficits. Stroke 1999; 30: 1875-1880
18. Kotila M, Waltimo O, Niemi ML, Laaksonen R,
1. Alexander MP. Stroke rehabilitation outcome: a Lempinen M. The profile of recovery from stroke
potential use of predictive variables to establish and factors influencing outcome. Stroke 1984;
levels of care. Stroke 1994; 25: 128-134. 15:1039-1044
2. Bagg S, Pombo AP, Hopman W. Effect of Age on 19. Lindmark B, Hamrin E. A Five Year Foolow-Up of
Functional Outcomes After Stroke Rehabilitation. Stroke Survivors: Motor Function and Activities af
Stroke 2002; 33:179-185. Daily Living. Clinical Rehabilitation 1995; 9: 1-9.
3. Berg A, Psych L, Palomaki H, Lehtihalmes M, Phil 20. Macciocchi S, Diamond P, Mertz T. Ischemic
L, Lönnqvist J, Kaste M. Poststroke Depression; An Stroke: Relation of Age, Lesion Location, and Initial
18-Month Follow-Up. Stroke 2003; 34: 138-141. Neurologic Deficit to Functional Outcome. Archives
4. Bogousslavsky J. William Feinberg Lecture 2002: of Physical Medicine and Rehabilitation 1998; 79:
emotions, mood and behaviour after stroke. Stroke 1255-1257.
2003; 34:1046-1050 21. Otman S, Karaduman A, Livanelioğlu A. Hemipleji
5. Chemerinski E, Robinson RG, Kaiser JT. Improved Rehabilitasyonunda Nörofizyolojik Yaklaşımlar.
Recovery in Activities of Daily Living Associated H.Ü. Fizik Tedavi ve Rehabilitasyon Yüksekokulu
with Remission of Poststroke Depression. Stroke Yayınları. Ankara. 2001: 16-64.
2001; 32: 113-117. 22. Pedretti LW. Cerebrovascular Accident. In Pedretti:
6. Clarke P, Marshall V, Black SE, Colantonio A. LW (ed.) 1996, Occupational Therapy, Practice
Well-being after Stroke in Canadian Seniors: Skills For Physicial Dysfunction. pp 785-805. Mosby
Findings from the Canadian Study of Health and Company, Philadelphia.
Aging. Stroke 2002; 33: 1016-1021. 23. Robinson L, Fitts S, Kraft G. Laterality of
7. Deshelton F, Reding M. Effect of Lesion Location on Performance in Fingertapping Rate and Grip
Upper Limb Motor Recovery after Stroke. Stroke Strength by Hemisphere of Stroke and Gender.
2001; 32: 107-120. Archives of Physical Medicine and Rehabilitation
8. Desrosiers J, Bourbonnais D, Bravo G, Roy PM, 1990; 71: 695-698.
Guay M. Performance of the “Unaffected” Upper 24. Ryerson SD. Hemiplegia Resulting from Vascular
Extremity of Elderly Stroke Patients. Stroke 1996; Insult or Disease. In: Umphred DA (ed), 1990
27:1564-1570 Neurological Rehabilitation, pp 622-629. Mosby
9. Fabio R, Badke MB. Relationship of Sensory Company, Philadelphia.
Organization to Balance Function in Patients with 25. Roth EJ, Heinemann AW, Lovell LL. Impairment
Hemiplegia. Physical Therapy 1990; 70: 542-548. and disability: their relation during stroke
10. Ferrucci L, Bandinelli S, Guralnik JM, Lamponi M, rehabilitation. Archieves of Physical Medicine and
Bertini C. Recovery of functional status after stroke: Rehabilitation 1998; 79:329-335.
26. Sanford J, Moreland J, Swanson L, Stratford P. 31. Winward CE, Halligan PW, Wade DT. Current
Reliability of The Fugl Meyer Assessment for Practice and Clinical Relevance of Somatosensory
Testing Motor Performance in Patients Following Assessment after Stroke. Clinical Rehabilitation
Stroke. Physical Therapy 1993; 73: 447-454 1999 ; 13: 48-55.
27. Singh A, Black SE, Herrmann N, Leibovitch FS, 32. Wyller TB, Sedring KM, Sveev U, Ljunggren AE,
Ebert PL, Lawrence J, Szalai JP. Functional and Holter EB. Are there Gender Differences in
Neuroanatomic Correlations in Poststroke Functional Outcome After Stroke? Clinical
Depressions: The Sunnybrook Stroke Study. Stroke Rehabilitation 1997; 11: 171-179.
2000; 31: 637-644. 33. Yavuzer G, Küçükdeveci A, Arasil T, Elhan A.
28. Soyuer F, Özarslan M, Soyuer A. İskemik inme: Rehabilitation of Stroke Patients (Clinical Profile
Nörolojik kayıp ve özürlülük. Erciyes Medical and Functional Outcome). American Journal of
Journal 2004; 26:19-24 Physical Medicine and Rehabilitation 2001; 8: 250-
29. Sunderland A, Tınson DJ, Bradley EL, Fletcher D, 255.
Langton HR, Wade DT. Enhanced Physical Therapy 34. Zemke A, Heagerty P, Lee C, Cramer S. Motor
Improves Recovery of Arm Function after Stroke: a Cortex Organization after Stroke is Related to Side
Randomized Controlled Trial. Journal of Neurology of Stroke and Level of Recovery. Stroke 2003;
Neurosurgery and Psychiatry 1992; 55: 530-555. 34:E23-E28
30. Sunderland A, Tınson DJ. Arm Function after
Stroke: An Evaluation of Grip Strength as a
Measure of Recovery and a Prognostic Indicator.
Journal of Neurology Neurosurgery and Psychiatry
1989; 52: 1267-1272.