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 BEyar Street, Apartment 5, Rosh HaAyin, 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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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 Potess 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

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(1988), Reding (1990), and Gottlieb, Kipnis, Sister, Medvedev, Brill, 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. In addition, 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, 1988). It should be noted that at least one study failed to find a correlation between the proprioceptive deficit and functional outcome (Feigenson, MacDowell, Meese, McCarthy, & Greenberg, 1977). It is possible that the long time between stroke onset and initial assessment (38 days) distorted the results of this study. Although the relationship between proprioception deficit and functional outcome has been demonstrated in numerous studies, the relationship between the proprioception deficit and the motor and functional ability of the upper extremity is still unclear. Only a few studies have addressed this issue, and the results are inconclusive. Leo and Soderberg (1981) evaluated 21 people at different recovery stages after stroke. They found a significant negative correlation between proprioception deficit and the ability to actively move the upper extremity in complex movement patterns. Wade, Langton-Hewer, Wood, Skilbeck and Ismil (1983) examined the influence of different impairments on the functional recovery of the upper extremity. The only three factors found to correlate significantly were initial motor ability, proprioception deficit and the patients mental status. Shah, 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. They concluded that the initial motor level seemed to influence motor recovery and not the proprioception deficit. 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, Fitzpatrick, Navia, Bean, & Reding, 1987). In contrast to the detailed examinations of the motor recovery process after stroke (Twitchell, 1951; Brunnstrom, 1970; Fugl-Meyer, Jsko, Leyman, Olsson, & Steglind, 1975), very few studies have monitored the recovery process of the proprioception deficit. Smith et al. (1983) reported on the proprioception recovery of 95 patients (44%

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of their study population) who suffered from a substantial proprioception deficit on admission. By eight weeks post-stroke, 54 (69%) of these patients had recovered to a mild deficit or no deficit. Sunderland et al. (1992) reported that 28% of 132 patients suffered from a substantial proprioception loss when examined three weeks post-stroke; after three months only 12.3% still suffered from this deficit. In view of the scant and inconclusive data characterizing stroke patients who have a combined proprioception and motor deficit we felt it important to monitor the recovery period of these patients during the critical first six weeks of rehabilitation post-stroke. 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. 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, Weiss, & Gottlieb, 1999). METHODS Population Twenty patients, seven male and 13 female, who had sustained a hemispheric cerebral vascular accident (CVA) (8 left CVA, 12 right CVA) and who were admitted to a geriatric rehabilitation center during the eight month duration of the study, agreed to participate as subjects. All of the subjects had a proprioception deficit in addition to a motor deficit of their upper extremity. The stroke was diagnosed by a neurologist in accordance with criteria defined by the World Health Organization (WHO, 1989), and the hemispheric localization of the stroke was determined clinically and with the aid of computerized tomography. Inclusion criteria included: 1. 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). 2. Independence in BADL and indoor mobility before the present stroke. 3. Full use of the upper extremity before the present stroke.

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4. Ability to understand and cooperate in all assessment procedures. Admission to the rehabilitation center occurred between seven and 40 days following the acute event (mean standard deviation (SD) = 18 9 days). The average age was 72.5 years (SD = 8.2). Ninety percent of subjects were right hand dominant and 10% were left hand dominant. Sixty percent of the subjects had a right hemispheric stroke and 40% had a left hemispheric stroke. Forty percent of the subjects demonstrated unilateral neglect as determined by Alberts (1973) screening test; 15% had mild neglect and 25% of the subjects demonstrated severe neglect. The remaining 60% did not demonstrate unilateral neglect. Fifteen percent of the subjects were aphasic, as diagnosed by a speech pathologist. By definition, upon admission, all the subjects suffered from a proprioception deficit; four patients (20%) suffered from a mild deficit, 8 patients (40%) from a moderate deficit, and 8 patients (40%) from a severe deficit. Instruments 1. Assessment of Proprioception Deficit The proprioception loss in the upper extremity in this study was assessed using two tests, both of which are commonly used in the field. 1.1 The Thumb Localization Test Different variations of this test, also known as the Thumb Finding Test, are used in neurology and rehabilitation. The test is conducted by an examiner who holds the patients affected hand and moves it passively to different positions in space. The patient, with vision masked, is asked to grasp the affected thumb with the healthy hand. This test is easy to administer, even to aphasic patients or those with cognitive deficit. Despite the wide use of this test, its validity and test-retest reliability has not been demonstrated. Leo and Soderberg (1981) did show it to have modest inter-rater reliability (r = .54, p < .05) and it has been shown to be predictive of function after stroke (Prescott et al., 1982; Smith et al., 1983). In the present study the scoring suggested by Prescott et al. (1982) was used. A score of 0, indicating no loss of proprioception, was given when the patient grasped his thumb quickly and with no difficulty. A score of 1, indicating a mild loss of

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proprioception, was given when the patient reached close to the thumb but missed by a small amount. A score of 2, indicating a moderate loss of proprioception, was given when the patient located his arm and then used this landmark to locate his thumb. A score of 3, indicating a severe loss of proprioception, was given when the patient did not succeed in locating his thumb. 1.2 Finger Shift Test The examiner passively moves the proximal joint of the finger of the patients affected hand to a flexed or extension position while the patients vision is masked. The patient is instructed to say or point to where his finger is (up or down) (Dannenbaum & Jones, 1993). This is the traditional way to assess proprioception (Ziegler, 1975) but patients with language difficulties or with motor planning problems often have difficulty in understanding or carrying out the test. Like the previous proprioception test, neither its reliability nor validity have been established. In this study the test was repeated four times. A score of 4, indicating no loss of proprioception, was given if the patient correctly reported four movements of his finger. A score of 3, indicating a mild loss of proprioception, was given if the patient reported only three out of the four movements. A score of 2, indicating a moderate loss, was given if the patient reported only two out of the four movements and a score of 1, indicating a severe loss of proprioception, was given if the patient reported only one or none of the movements. 2. Motor Ability of the Upper Extremity The Fugl-Meyer Assessment (FMA) (Fugl-Meyer, Jsko, Leyman, Olsson & Steglind, 1975). This test is based on previous work by Twitchell (1951), Reynolds, Archibald, Brunnstrom, and Tompson (1958) and Brunnstrom (1970), who described stages in the motor recovery of patients after stroke. The FMA assesses the motor impairment in terms of the difficulty of producing an active movement within and out of basic movement synergies. The upper extremity sub-test of the FMA was used in the present study. Each movement was graded on a 3-point scale such that 0 indicated that the patient could not produce the movement, 1 indicated there is partial movement, and 2 indicated full movement. The minimal score was 0 (fully paralyzed) and the maximal score was 60 (normal active move-

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

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

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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. Non-parametric Spearmans correlations of the two measures of proprioception (the Thumb test and the Finger shift test) and motor ability to functional ability were performed. The same measure was used to test whether the variable proprioception, FMA, FAT, and FIM at weeks 0 and 6 were correlated. RESULTS Proprioception Deficit Proprioception was assessed at weeks 0, 2, 4, and 6 with the Thumb Localization and the Finger Shift tests. Results from the former test were available for all 20 patients but only 17 patients were able to understand and complete the latter test. The relationship between these two tests was examined by means of Spearmans correlation coefficient. The two tests of proprioception were found to be significantly correlated on all four occasions with moderate r values ranging from .53 (p < .05) at week 0, to .71 (p < .01) at week 2, to .71 (p < .01) at week 4, and to .61 (p < .01) at week 6. (Note that 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.) In view of the fact that the two tests were correlated and given the incomplete data set for the Finger Shift test, all subsequent analyses were carried out on results from the Thumb Localization Test only. (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.) Tables 1 and 2 illustrate the recovery of proprioception for the 20 patients over the six-week period of study. On admission, all 20 patients had some degree of proprioception deficit; eight of the patients suffered from a severe deficit, eight suffered from a moderate deficit, and four suffered from a mild deficit. By week 2, 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. By this time 10 patients suffered from a mild deficit. By week 4, only two patients had a severe deficit, seven patients had a moderate deficit, and 11 patients had a mild deficit. By week 6, five patients,

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representing 25% of the subjects, had improved to the point where no deficit was discerned. Only two patients (10%) retained a severe deficit, whereas the remaining 13 patients (65%) retained moderate or mild deficits. 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. The progression in mean FMA scores during the six-week follow-up period can be seen in Table 3. The mean score on admission was 9.2 5.0 and it increased to 26.6 17.2 after six weeks. A repeated measures ANOVA was performed to test whether the extent of the motor recovery
TABLE 1. Changes in severity of the proprioception deficit amongst the 20 patient subjects during the six week recovery period. 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. 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

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TABLE 3. Mean scores one standard deviation (SD) of the FMA (Fugl-Meyer Motor Assessment) at weeks 0, 2, 4 and 6 and the FAT (Frenchay Arm Test) at weeks 0 and 6 of the patient subjects (n = 20).
Week 0 FMA FAT
* test not performed

Week 2 16.4 * 12.2

Week 4 22.4 * 15.8

Week 6 26.6 1.25 17.2 1.48

9.2 05

5.0 .22

from the time of admission and throughout the following six weeks was significant. This test showed that the motor ability of the affected upper extremity of the patients with proprioception deficit improved significantly (F = 63.75, p = .000) during the six week study period to a recovery of 44% of the full motor ability of the upper extremity. The Functional Recovery of the Upper Extremity The subjects on average demonstrated a significant increase in the level of functional ability of the upper extremity as assessed by the FAT scale. The mean FAT scores increased from .05 .22 on admission to 1.25 1.48 after six weeks (see Table 3), which was found to be statistically significant (Wilcoxon test, z = 2.96, p = .003). Correlations between the motor ability (the ability to produce active movement, tested by the FMA) and functional ability (the ability to use the affected upper extremity in a functional way, tested by the FAT) of the upper extremity were carried out on admission and after six weeks. On admission, no significant correlation was found. However, after six weeks, a significant correlation was found between the motor ability and the functional ability of the upper extremity (Spearman correlation r = .887, p < .01). BADL Improvement The mean FIM score on admission was 53.1 16.4 points and after six weeks it increased significantly to 68.4 22.5 points (paired t-test: t = 5.09, p = .000). 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,

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functional ability and BADL function were low (r = .01 to .34) and non-significant. In contrast, there was a moderately strong correlation between motor ability on admission to the function of the upper extremity after six weeks (r = .59, p = .000) and a strong correlation between the motor ability to BADL after six weeks (r = .78, p = .000). The correlation between motor ability after six weeks to function of the upper extremity after six weeks was very strong (r = .88, p = .000) but the correlation between motor ability after six weeks to BADL function after six weeks was only moderate (r = .67, p = .000). 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. The function of the upper extremity at week 6 did correlate moderately to BADL function at that time (r = .63, p < .01). Note that it may be that the measurement scales were not sensitive enough to measure low level differences. DISCUSSION Previous studies of the motor recovery after stroke included patients who were heterogeneous in terms of the presence of a proprioception deficit (Twitchell, 1951; Brunnstrom, 1970; Fugl-Meyer et al., 1975). In contrast, all of the patients in this study suffered from a proprioception deficit, 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.e., stroke patients with a combined motor and proprioception deficit). Whereas, on admission, all 20 patients suffered from a proprioception deficit in their upper extremity (having, on average, only 15% of their motor ability and 1% of the functional ability of the affected upper extremity), six weeks after admission, 25% of the patients had completely recovered their proprioception deficit and had, on average, 44% of their motor ability and 25% of their functional ability of the affected upper extremity. A second important result was the documentation of the proprioception status of patients who suffered from this deficit on admission to hospital. Prior to the present study, monitoring of patients of this type was published in only a few cases, and the results were limited to a report of whether a deficit was present or not (Smith et al., 1983; Sunderland et al., 1992). In contrast, we made use of the Thumb Localization Test to rank the proprioception deficit into three degrees

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of severity-mild, moderate and severe. On admission 4 patients had a mild deficit, 8 patients had a moderate deficit and 8 patients had a severe proprioception deficit. After six weeks 2 patients still had a severe deficit, 6 had a moderate deficit, 7 had a mild deficit and 5 patients recovered completely in terms of the proprioception deficit. 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. The Thumb Localization Test was a clinically feasible and apparently effective instrument for assessing proprioception, and was easy to administer to all the patients including those with aphasia. Pending demonstration of its reliability and validity, it should be considered for routine use in the clinic. Although 75% of the patients still suffered from a mild to moderate proprioception deficit six weeks after admission, this deficit did not appear to interfere greatly with the motor or functional ability of the upper extremity. Indeed, 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. 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, particularly when tested with the FAT. 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, dressing and eating. Various studies have shown that from about one quarter to close to half of all stroke patients suffer from a combined motor and proprioception deficit (Smith et al., 1983; Reding & Potes, 1988; Sunderland et al., 1992). 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., 1983; Wade et al., 1985; Reding & Potes, 1988; Reding, 1990; Gottlieb et al., 1997). They are, as a group, considered to be less amenable to treatment and to have a worse prognosis. The current results support this finding. The mean FIM scores on admission are lower than those reported by Granger, Hamilton, and Feider (1992) in their survey of 7090 stroke patients. The mean FIM score in this study was 51.7 as compared to the mean FIM score 63 points reported by Granger et al. (1992). (Note

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that admission to rehabilitation occurred after 33 22 days in the Granger et al. survey as compared to 18 9 days in the present study). Although a significant improvement in the ability to function in BADL was found, after six weeks these patients still required moderate assistance in BADL (mean Total FIM score after six weeks 64.6/126, which is the maximum Total FIM score). Comparing the FIM scores of the patients in this study on admission and after six weeks with other studies is difficult since the period of time between admission and discharge varied greatly. However, it is possible to compare the per day gain in the FIM. In this study the FIM gain per day was .35 .31 points, whereas in other studies done it was higher, as much as .55 .42 points per day (Gottlieb et al., 1997) and .54 .45 points per day (Adunsky, Levenkrohn, Fleissig, Chetrit, & Blumstein, 1998). The discrepancy may be due, in part, to differences in the type of patients who participated. Both the Gottlieb et al. (1997) and Adunsky et al. (1998) studies included all stroke patients who were treated in rehabilitation; their FIM scores were representative of those from typical stroke patients. In this study, all of the patients suffered from an additional impairment, a proprioception deficit; their deficit was more severe than the average stroke patient and their FIM gain per day was also lower. 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, 1988; Reding, 1990; Gottlieb et al., 1997). On admission, the motor and functional ability of the upper extremity were not correlated. In contrast, after six weeks of rehabilitation, a highly significant correlation was found between these two variables. 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. 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. Independence in BADL is possible even with a completely paralyzed upper extremity. At least two studies (Nakayama et al., 1994; Olsen, 1989) assessed upper extremity disability using the Barthel Index subscores for grooming/dressing and feeding. In both cases upper extremity function was achieved by using the unaffected upper extremity for compensation and not by recovery of the affected upper

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extremity. Filiatrault, Arsenault, 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. 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. Thus improvement in BADL function does not necessarily provide information about the condition of the affected upper extremity. Nevertheless, 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. Similar results were reported by Chae et al. (1995). 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 = .56, p < .0025). This may indicate an association between the function of the upper extremity and BADL since the patients used two hands to accomplish both tasks, or could be related to other variables such as a general decrease in motor and cognitive impairment, or may simply be due to two concurrent, but unrelated occurrences. Implications for Therapy The patients who participated in this research were receiving occupational therapy at the time of the study. The therapy approach to treat the affected upper extremity was remedial with emphasis on recovery of active movement (i.e., to decrease the motor and sensory impairment) and to encourage use of the arm functionally, when possible. This was done using treatment methods based on Bobath (1990), Carr and Shepherd (1987), Brunnstrom (1970) and Dannenbaum and Dykes (1988). Simultaneously, intervention of a compensatory character was provided in order to increase independence in BADL; patients were taught to use their unaffected upper extremity, when use of the affected one was not possible or effective. Since the recovery of the upper extremity in the stroke population as a whole is generally thought to be limited (Teasell & Gillen, 1993; Nakayama et al., 1994), the results of this study are encouraging. 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. Thus, the fact that these subjects demonstrated a significant improvement of

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their affected upper extremity should serve to encourage therapists to treat the upper extremity of all patients scheduled for rehabilitation. In a study by Ferrucci, Bandinelli, Guralnik, Lamponi, Bertini, Falchini, and Baroni (1993) patients were discharged from rehabilitation (length of hospitalization unknown) with an average of 27% of their motor ability of the upper extremity, as assessed by the FMA. The patients in the present study demonstrated an average of 44% of their upper extremity motor ability after six weeks. Wood-Dauphinee et al. (1990) reported the FMA scores of 119 patients on admission (30.4 23.6 points) and after five weeks (41.4 25.7 points). The patients in this study were admitted with lower FMA scores (9.2 5.0 points) and achieved lower scores after six weeks (26.6 17.2 points). It is clear that our patients on admission were more severe in terms of the impairment of the upper extremity but, even so, the average improvement was greater in this study in comparison to the improvement reported by Wood-Dauphinee et al. (1990). Filiatrault et al. (1991) assessed 18 patients with the FMA on admission (mean FMA score = 17.7 20.3) and after one month (mean FMA score = 22.1 24.6). Again, the initial FMA scores of our patients are somewhat lower (9.2 5.0 in comparison to 17.7 20.3), but the scores of the second assessment after one month are similar (the mean FMA score of our patients after one month is 22.4 15.8 in comparison to 22.1 24.6). Therefore, even though the patients suffered from a combined motor and proprioception deficit, the motor ability of their upper extremity improved as much as or even more than the patients reported by Filiatrault et al. (1991). In conclusion, when treating patients with a combined motor and proprioception deficit therapists should take in to account that a 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. These finding should guide therapists in planning treatment and setting goals for rehabilitation. REFERENCES
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RECEIVED: 11/24/99 REVISED: 03/18/00 ACCEPTED: 03/29/00