Journal of Neurological Sciences [Turkish] 24:(3)# 12


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Journal of Neurological Sciences [Turkish] 24:(3)# 12

  1. 1. J.Neurol.Sci.[Turk] Journal of Neurological Sciences [Turkish] 24:(3)# 12;226-233, 2007 Research Article The Impressive Factors On Functional Recovery Of The Upper Extremity In Hemiplegic Patients Birgül DÖNMEZ1, Salih ANGIN1, Kürşat KUTLUK2 1 Dokuz Eylül Üniversitesi, Fizik Tedavi Ve Rehabilitasyon Yüksekokulu, İzmir, Türkiye2Dokuz Eylül Üniversitesi, Nöroloji Anabilim Dalı, İzmir, Türkiye Abstract 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 Özet 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 dönüş 226
  2. 2. J.Neurol.Sci.[Turk] 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: movement(22,24). 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 227
  3. 3. J.Neurol.Sci.[Turk] 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 Age 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 Gender Male(R) Female -1.027 0.796 0.075 – 1.704 0.197 0.358 Hemiplegic Side Right(R) Left 1.609 0.753 1.142 – 21.881 0.033* 5.000 Emotional status Good(R) 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 228
  4. 4. J.Neurol.Sci.[Turk] 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 229
  5. 5. J.Neurol.Sci.[Turk] 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 230
  6. 6. J.Neurol.Sci.[Turk] 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. 231
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