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(Stroke. 1996;27:1564-1570.)
© 1996 American Heart Association, Inc.
Articles |
Performance of the `Unaffected' Upper Extremity of Elderly Stroke Patients
the Centre de recherche en gerontologie et geriatrie (J.D., G.B., P.-M.R., M.G.), Sherbrooke, Quebec; Faculte de medecine (J.D., G.B.), Universite de Sherbrooke, Quebec; and Ecole de readaptation (D.B.), Universite de Montreal, Canada.
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Abstract |
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Background and Purpose The main objective of this study was to compare the sensorimotor performance of the unaffected upper extremity (UE) of elderly stroke patients with that of healthy elderly people.
Methods The group of stroke patients was composed of 43 hemiplegic/paretic subjects who had had a cerebrovascular accident at least 6 months earlier. They were 
60 years old, were right-handed before the stroke, had visual perception within normal limits, and showed no major cognitive impairments. A group of 43 healthy subjects matched for dominance, age, and sex was used for comparison. The main parameters of the performance of the unaffected UE of the stroke subjects and of the same side of the healthy subjects were measured with valid, reliable instruments. Some variables potentially related to the unaffected UE were also measured: affected UE motor function, functional independence, length of time since the stroke, self-perceived health status, activity level, and hand anthropometry.
Results Statistical analyses showed significant deficits in the unaffected UE of hemiplegic/paretic subjects compared with normal subjects with regard to the following parameters: gross manual dexterity, fine manual dexterity, motor coordination, global performance, and kinesthesia (P<.01 to P<.0001). No significant clinical or statistical difference was found for grip strength (P<.81), static and moving two-point discrimination (P=.21 and P=.12), or touch/pressure threshold (P<.91).
Conclusions Many factors (frequency of use of the unaffected hand, sensorimotor interaction tasks, severity of the deficits in corticifugal projections, and deficits in postural stabilization) could interact to provide the clinical picture obtained in the present study. (Stroke. 1996;27:1564-1570.)
Key Words: hemiplegia • motor activity • sensory testing, quantitative
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Introduction |
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Stroke is an important cause of death and one of the main causes of morbidity in the elderly population because
75% of stroke patients are 75 years old.1 Many of them will live with significant sensorimotor deficits that will considerably impede their level of functional independence.2 In fact, between 30% and 60% of people who survive a stroke will be dependent in certain aspects of their daily activities.3 During the active rehabilitation period after a stroke, rehabilitation interventions emphasize stimulation of the recovery of the sensorimotor function of the plegic/paretic side. The other side (the "unaffected" side) is often considered a reference point. It is therefore assumed that this side has no deficit. Nevertheless, previous research suggests or tends to show diminished strength in the unaffected lower extremity4 5 6 or the unaffected UE7 8 compared with healthy subjects, although two previous studies9 10 did not find any differences between the unaffected UE strength of stroke patients and the same UE side of healthy subjects. In addition, studies on UE sensorimotor function suggest a reduced or similar performance between the unaffected UE of stroke subjects and healthy subjects.10 11 12 13 14 15 16 17 18 19 20 Differences between studies may be explained in part by the side of the lesion, the length of time since the stroke, the types of tasks performed, and the level of independence of the subjects. Some researchers found a difference in UE performance between left and right hemiplegic/paretic patients compared with healthy subjects,11 12 13 14 15 16 whereas others observed a similar performance.8 9 17 18 Differences in the length of time since the onset of the stroke may explain these contradictory results. Some studies were performed with long-term patients (rehabilitation period finished),8 12 15 18 others with patients in the recovery process (short-term or rehabilitation phase),10 11 17 18 and some with short- and long-term patients6 7 9 ; a few studies did not even mention this variable.4 5 19 20 More differences between unaffected UE function and normal subjects would be found with tasks that require more sensorimotor interaction.9 10 Another potential explanation of the differences between studies concerns differences in the independence level of subjects, which often is not reported.
Some of the previous studies showed selection and information biases that could influence the results. Some uncontrolled variables, such as cognitive level, visual perception problems, and severe depression, could also have an impact on sensorimotor output. These variables could explain, at least in part, decreased performance of the unaffected side compared with normal subjects. Few of the previous studies considered all the parameters that are prerequisites for normal UE function (strength, gross dexterity, fine dexterity, motor coordination, kinesthesia, two-point discrimination, touch/pressure threshold, and global performance). In many cases, the metrical properties of the tests were not reported. Finally, in previous studies, all comparison groups were composed of volunteers who were not randomly selected and who may not be representative of the normal population.
The main objective of the present study was to compare the sensorimotor performance of the unaffected UE of poststroke hemiplegic/paretic subjects with that of a group of healthy subjects without UE deficits, who were randomly selected and matched for age and sex. Second, we wanted to study the influence of some variables on unaffected UE function. Finally, we also wanted to compare performance differences between right and left stroke subjects.
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Subjects and Methods |
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Stroke Group
The subjects in the stroke group had to meet the following eligibility criteria: unilateral hemiplegia/paresis subsequent to a stroke that had occurred at least 6 months earlier and not more than 4 years before, be right-handed before the stroke, live at home, be
60 years old, speak French or English, show no important visual perceptual deficits (minimum score of 24/36 on the Motor Free Visual Perceptual Test21 22 23 and a minimum score of 26/35 on the Bell Test24 to eliminate the presence of visual hemineglect), and show no important cognitive deficits (minimum result of 80/100 on the Modified Mini-Mental State Examination25 26 27 ). In addition, they could not have sensorimotor deficits, other than those related to the stroke, that could affect the UE ipsilateral to the cerebral lesion nor show any major depression (minimum score of 21/30 on the Geriatric Depression Scale28 29 ). After authorization from the ethics committees of the hospitals involved, the medical charts of individuals who had had a stroke diagnosis were consulted at the archives of four institutions. Subjects who appeared potentially eligible from this first screening were contacted by mail with a simple, brief letter explaining the research. A few days later, they were contacted by phone to verify their eligibility and agreement to participate in the study. Each subject was evaluated by an occupational therapist between December 12, 1994, and August 16, 1995. Each evaluation typically lasted between 1.5 and 2 hours.
Comparison Group
The comparison group was composed of men and women who were right-handed, 60 years old, lucid, independent in their activities of daily living, and without any UE deficit. The subjects were randomly chosen after being matched for exact age and sex with the stroke subjects from a database composed of 360 subjects who had been randomly selected from the electoral list of the city of Sherbrooke, Quebec, Canada, for a previous normative study30 that used the same sensorimotor tests given in the same order as those used in the present study.
Instruments
Unaffected UE sensorimotor parameters were evaluated in the following order: First, gross manual dexterity was measured by use of the Box and Block Test.31 32 33 This test consists of moving, one at a time in a 60-second time period, the maximum number of blocks from one side to the other of a box separated in the middle. Fine manual dexterity was then measured by use of the unilateral task of the Purdue pegboard.34 35 36 This test consists of manipulating small pins on a board as quickly as possible in a 30-second time period. The score is the number of pins handled. The four unilateral tasks of the TEMPA (pick up and move a coffee jar, pick up a pitcher and pour water into a glass, handle coins, and pick up and move small objects)37 38 were then used to evaluate UE global performance. Each task is timed and recorded in seconds. Next, motor coordination was estimated with the Finger-Nose Test.39 In this test, subjects move their UEs in a specific trajectory as quickly as possible.40 The Jamar dynamometer41 42 43 was used to measure grip strength.
Subsequent to these tests, static and moving two-point discriminations were measured on the palmar face of the distal phalanx of the index finger by use of the Mackinnon-Dellon Disk-Criminator.44 45 The examiner recorded the minimum distance in millimeters at which the subject felt the presence of two stimuli. Kinesthesia was estimated at the interphalangeal joint of the thumb. The subjects had to correctly identify the direction (up or down) of a 10° movement with an approximate speed of 5° per second. One point was scored for each correct answer, for a total of 10 points per hand. Finally, Semmes-Weinstein monofilaments46 47 48 were used to estimate the touch/pressure threshold at the distal phalanx of the index finger.
Other instruments were used to measure variables potentially related to UE function. Functional independence was estimated with the SMAF.49 50 A high score indicates an extreme dependence level. Motor function of the affected UE was measured with the Fugl-Meyer assessment.51 52 A high score (maximum of 66) implies better motor function. Finally, other information that may influence UE function was collected: time since the stroke (in months), rehabilitation duration after the stroke (in weeks), hand anthropometry (in centimeters), self-perceived health status (excellent, good, fair, or poor), and self-perceived current activity level (very active, active, slightly active, or sedentary).
Statistical Analyses
The characteristics of the study sample are described by mean and standard deviation for continuous variables and by frequency and percentage for categorical variables. Because the data were normally distributed, paired t tests were used for the comparison of the two groups (objective 1).
The influence of some variables potentially related to the unaffected UE was studied with Pearson correlation coefficients for two continuous variables or with the eta coefficient deduced from ANOVA for one continuous and one categorical variable (objective 2). Because age is correlated to some tests and variables, the correlations were adjusted for age. Finally, the comparison of LHS and RHS (objective 3) was performed with t tests for independent samples.
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Results |
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From the first screening based on the medical charts, 98 stroke patients were identified as potential subjects. Ten could not be located, 12 were excluded by the telephone screening because they did not meet the eligibility criteria, and 9 had died, leaving 67 eligible subjects. Eleven of them refused to participate in the study, which resulted in a participation rate of 84%. Of the 56 subjects evaluated, 13 were excluded after the fact because they did not meet eligibility criteria, mainly the criterion related to visual perception. The final sample consisted of 43 stroke subjects and 43 comparison subjects. Among the 43 stroke subjects, CT scan reports confirmed the presence of a unilateral lesion in 21 cases. In 11 cases, the CT scans performed at admission in acute-care hospitals were found to be normal despite the presence of evident signs of hemiplegia. Finally, CT scan reports were not available for 11 subjects who came from an acute-care hospital that did not have a CT scanner. For these subjects, clinical diagnoses made by a neurologist were used.
Table 1
presents the characteristics of the stroke and healthy subjects. Age varied between 60 and 87 years, with a mean of 72. The distribution of women and men was equivalent (21 versus 22) but not the distribution of right and left affected sides (29 versus 14, respectively). In addition to age, manual dominance, and sex, subjects in the two groups were comparable with regard to hand anthropometry. However, as expected, they were not comparable with regard to self-perceived health status (P=.02) and self-perceived current activity level (P=.04).
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Objective 1
Table 2 reports the results related to the main objective of comparing the sensorimotor performance of the unaffected UE of stroke subjects with that of the same side of a comparison group. A lower performance in the first group was found on tests measuring gross and fine manual dexterity, global performance (two of four tasks), motor coordination, and thumb kinesthesia. However, no difference was found for grip strength, static and moving two-point discrimination, or touch/pressure threshold.
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Objective 2
The second objective pertained to correlating unaffected UE test results with functional independence, affected UE motor function, time since stroke, rehabilitation duration, depression level, self-perceived health status, and activity level. Affected upper UE motor function was not related to unaffected UE tests (r=.02 to .19; P=.24 to .91) but was related to functional independence measured with the SMAF (r=.56; P=.0001). When correlations were adjusted for age, only fine manual dexterity, among all the unaffected UE tests, was related to functional independence (r=-.34; P=.03).
Activity level was positively related to gross dexterity (r=.53; P=.007) and kinesthesia (r=.50; P=.02). Those who perceived themselves as more active achieved better gross dexterity and kinesthesia scores. Depression level, self-perceived health, time since the onset of the stroke, and rehabilitation duration had no impact on the unaffected UE function test results.
Objective 3
The third objective was to establish a comparative profile of RHS and LHS. A relatively equal and minimum number of 22 subjects per group of RHS and LHS was required for this objective to detect an important effect size (
/
=0.8). This subsample size was exceeded for the RHS group (n=29) but was not reached for the LHS group (n=14). In spite of the lack of power to detect differences, t tests for independent samples were performed for the UE tests and other variables (Table 3). No difference was statistically significant except for affected UE motor function, for which LHS obtained higher scores that implied better performance. Age and time since the onset of the stroke were equivalent for LHS and RHS (age, 71.9 versus 71.8 years; time, 24.6 versus 26.0 months).
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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The present study was designed to compare UE performance of the unaffected side of stroke victims with that of the same side of healthy people. The comparison group was randomly selected from a database of subjects who were also randomly recruited for a prior normative study. The participation rate in the prior study was 78%, and those who accepted were comparable to those who refused to participate. The present study is the first study on this subject to use randomly recruited comparison subjects.
In addition to age and sex, the subjects in the two groups presented a similar profile for hand anthropometry, which was very important for the comparison of grip strength. Indeed, hand anthropometry is strongly related to grip strength.41 53 However, as expected because of medical conditions and the consequences of the stroke, the hemiplegic/paretic subjects perceived themselves to be in poorer health and less active than the healthy subjects. We must point out that current activity level was perceived by the subjects themselves, assisted by the evaluator. They may have tended to overestimate it (social desirability bias). Stroke subjects judge themselves to be active or very active when they are independent in their daily home activities, whereas healthy subjects perceive themselves as active when they do many activities outside the home. Consequently, the difference in activity level between the groups on this variable may be underestimated.
Objectives 1 and 2
Significant differences were observed between the two groups for fine and gross manual dexterity, motor coordination, global performance for two of four tasks, and thumb kinesthesia in favor of the healthy subjects. The observed statistically significant differences also appeared to be clinically significant, although less marked, for the TEMPA tasks.
The two groups of subjects demonstrated equivalent scores at statistical and clinical levels for grip strength, static and moving two-point discrimination, and touch/pressure threshold. Two previous studies9 10 are in agreement with the absence of a difference in grip strength, whereas two others are not.7 8 Colebatch and Gandevia7 explained the difference by the presence of bilateral projections of each cerebral hemisphere, whereas Haaland and Delaney9 and Jones et al10 discussed the comparability of grip strength in terms of the simplicity of this task, which requires little sensorimotor interaction. We may also try to explain the absence of a difference in grip strength by relating it to activities of daily living. Like the healthy subjects, all the stroke subjects were living at home and, in spite of their impairment, maintained a basic activity level requiring at least the minimal use of their unaffected UE. Even if the stroke subjects were less active than the healthy subjects, they must use their unaffected UE in their basic daily activities, which require a minimum strength level, implying the possibility that it is maintained by these subjects.
How can the lower performances of stroke subjects for dexterity, coordination, global performance, and kinesthesia be explained? It is known that UE dexterity, coordination, and global performance can be increased by practicing activities that require these abilities. Therefore, regular and repeated use of an extremity can improve or at least maintain its function. Without establishing the direction of the relationship because of the cross-sectional design of the study, it indeed was observed that the stroke subjects reported themselves as being less active than the healthy subjects. In addition, two unaffected UE tests (gross dexterity and kinesthesia) were statistically related to activity level. It is possible that the daily tasks of stroke subjects are mainly gross tasks, as required in self-care activities, resulting in maintaining grip strength and gross abilities, but with few fine tasks that would maintain or develop manual dexterity and coordination.
Sartor-Glittenberg and Powers19 found a reduction in kinesthesia in the unaffected elbow in stroke patients compared with control subjects. Kinesthesia is known to play a role in motor control; therefore, it is possible that a deficit in this sphere contributed to motor problems. Contrary to the touch/pressure threshold, which is an exteroceptive sensibility form, expressing the integrity of sensibility receptors,54 kinesthesia and static and moving two-point discrimination are two forms of functional sensibility55 that may be improved by more frequent use of the UE, especially the hand. Functional sensibility tests are considered integrative tests because of their high level of sensory processing.55 However, because we did not observe a difference between groups for the two-point discrimination, as observed by Vaughan and Costa,11 the strength of this potential explanation related to the activity level is reduced. These results partly support the hypothesis of a narrow relationship between unaffected UE performance and its use in daily activities. However, since we did not measure manual activities precisely, we cannot confirm this hypothesis.
Another possible explanation that may be relevant in the present study concerns the specific nature of the tests. It has been suggested that some tasks requiring more sensorimotor interaction imply more differences between the unaffected UEs of stroke patients and healthy subjects.9 10 Simple tasks minimize sensorimotor interaction, resulting in smaller deficits. Conversely, complex tasks, namely, those requiring more sensory feedback and greater nervous control, would be more easily disturbed by cerebral lesions. In these complex tasks, both hemispheres would be required or involved. However, because no relationship was observed between the performance of both UEs, the validity of this possible explanation could be reduced. In fact, according to this hypothesis, one might expect that a more severe deficit in the affected UE, related to greater stroke severity, would have more influence on the performance of the unaffected UE. This was not found to be true in the present study. Therefore, the hypothesis of the importance of the integrity of both hemispheres for performance of complex UE sensorimotor tasks may be called into question.
Other functions or mechanisms might have explained a loss of function in the unaffected UE but could not explain the absence of a difference in some parameters. Ipsilateral deficits in hemiparetic subjects might be due to the interruption of the ipsilateral projection of the corticospinal tract. Although most of the corticospinal fibers decussate in the medulla, a significant proportion remains uncrossed and forms the ventral corticospinal tract.56 57 In addition, it is possible that a lesion in one hemisphere resulting from a vascular cause interrupts corticobulbar and corticoreticular projections and consequently affects subcortical structures involved in motor control.58 Therefore, one cannot exclude the fact that the integrity of these descending pathways is necessary to achieve some motor performance on the unaffected side.
It is also possible that the weakness on the paretic side interferes with the performance of movement on the unaffected side. For example, it has been observed that the force production on the unaffected limb is reduced because of the difficulty in providing contralateral stabilization using the paretic side.59 This difficulty in providing a contralateral postural stabilization that is necessary to produce some movement60 might explain the deficits observed in functional tasks such as gross and fine manual dexterity, global performance, and motor coordination. Because grip involves a closed kinetic chain, there is no need to provide contralateral stabilization, and this would explain the absence of a deficit in this task.
All these factors (frequency of use of the unaffected hand, sensorimotor interaction tasks, severity of the deficits in corticifugal projections, and deficits in postural stabilization) are not mutually exclusive and could interact to produce the clinical picture obtained in the present study.
Objective 3
The last objective was to compare LHS and RHS. Because of a lack of statistical power, the results obtained and presented in Table 3
must be interpreted with caution. For selection and "control" variables, only the affected UE motor function is different between right and left lesions. Indeed, the LHS presented better motor function on the affected side, such as was also observed by other researchers,8 11 and although not statistically significant, they appeared to be less depressed than the RHS. The RHS were at a double disadvantage: in addition to higher affected UE deficits, they were obliged to change dominance or at least increase the use of their nondominant UE. In the present study, as in previous studies,8 61 the side of the cerebral damage appeared to have little influence on differences in functional independence. The SMAF difference between the RHS and LHS (2.4 points) was not statistically or clinically significant.
For unaffected UE tests, the scores of the LHS and RHS are comparable at statistical and clinical levels, except for gross manual dexterity, which appears clinically better for LHS (a difference of almost five blocks). Since all subjects in the present study were right-handed before the stroke, it would not have been surprising for the LHS, who used their dominant hand, to achieve better results in more tests, as was observed in previous studies.10 17 47 However, this was not the case in the present study, but because the sample size of this group was not large enough, no firm conclusions can be drawn from these results.
Conclusions
This research studied the unaffected UE function of elderly stroke victims by comparing them to healthy people of the same age and sex. The results showed that there were clinically and statistically significant differences between these two groups for fine and gross manual dexterity, motor coordination, global performance, and thumb kinesthesia, but not for grip strength, two-point discrimination, and touch/pressure threshold, for which the two groups were comparable. Certain factors such as activity level, the type of task performed, and neurophysiology could explain these results, at least in part.
This study implies that clinicians should take into account the performance of the unaffected UE in therapy, but never to the detriment of the affected UE reeducation.
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Selected Abbreviations and Acronyms |
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Acknowledgments |
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This study was funded by the National Health Research and Development Program, Health and Welfare Canada (No. 6605-4385-402). The authors would like to thank the following four institutions for allowing consultation of records for data collection purposes: Institut universitaire de geriatrie de Sherbrooke, Centre universitaire de sante de l'Estrie (pavillon Fleurimont), Institut de readaptation de Montreal, and Hopital La Providence de Magog. We also extend our deepest and most sincere thanks to those who participated in this study.
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Footnotes |
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Reprint requests to Johanne Desrosiers, Centre de recherche en gerontologie et geriatrie, 1036 Belvedere Sud, Sherbrooke (Quebec) J1H 4C4, Canada.
Received January 19, 1996; revision received June 12, 1996; accepted June 12, 1996.
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