247
Arm and Leg Paresis as Outcome Predictors
in Stroke Rehabilitation
Tom Skyh0j Olsen, MD
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I used leg and arm paresis to predict outcome measured as extremity function in a prospective
study of 75 consecutive hemiplegic patients admitted to an inpatient stroke rehabilitation unit.
In each patient, extremity paresis was quantified according to the five-point scoring system
advised by the Medical Research Council, upper extremity function was quantified using the
Barthel Index subscore for feeding and dressing the upper body, and lower extremity function
was quantified according to a five-point scoring of the ability to walk. Improvement was
recorded for upper extremity function in 52% of the patients and for lower extremity function
in 89%. Best extremity function was reached a mean±SEM of 9±3 and 10±4 weeks after stroke
for the upper and lower extremities, respectively. In patients experiencing complete recovery,
this occurred a mean±SEM of 7±2 weeks (for both upper and lower extremities) after the
stroke. Only 8-11% of the patients with paresis scores of ^2 regained independent extremity
function after rehabilitation. Half of the patients with paresis scores of ^3 regained independent extremity function after rehabilitation, while the other half were able to perform extremity
function with only minimal assistance. As predictors of extremity function, the Barthel Index
subscore was slightly better (r=0.64) than paresis score (r=0.58). However, because evaluation
of extremity paresis is easy, it appears to be useful as a preliminary predictor of outcome
following stroke. (Stroke 1990;21:247-251)
I
mprovement of both upper and lower extremity
function is one of the major objectives of stroke
rehabilitation since extremity function greatly
affects the overall outcome. My investigation was
undertaken to study upper and lower extremity function after rehabilitation for stroke and the time to
reach maximum extremity function. Another purpose
of my study was to predict outcome measured as
extremity function on the basis of a simple bedside
evaluation on admission, that is, the degree of weakness in the paretic arm and leg.
Subjects and Methods
This was a prospective study of consecutive
patients admitted to an inpatient stroke rehabilitation unit. I excluded patients who were admitted >60
days after their stroke, those who did not have
paresis, and those who had strokes involving both
cerebral hemispheres. Seventy-five patients satisfied
these criteria. From this population, I established
two overlapping groups to test the effect of upper and
lower extremity paresis independently. One group
From the Burke Rehabilitation Center, White Plains, New York.
Supported by the Burke Foundation and the Burke Rehabilitation Center.
Address for correspondence: Tom Skyhej Olsen, MD, Department of Neurology, Gentofte Hospital, University of Copenhagen,
DK-2900 Hellerup, Denmark.
Received November 3, 1988; accepted August 21, 1989.
was made up of 66 patients with unilateral upper
extremity paresis who on admission were unable to
feed themselves and/or to dress their upper body
independently; seven patients with lower extremity
paresis but no upper extremity paresis and two
patients with unreliable scoring of upper extremity
function were excluded. The second group was made
up of 72 patients with unilateral lower extremity
paresis who on admission were unable to walk independently; three patients who had upper extremity
paresis but no lower extremity paresis were excluded.
Computed tomography or magnetic resonance imaging was performed in all patients before referral to
rehabilitation.
On admission to the rehabilitation unit, all patients
had a full neurologic examination including evaluation of proximal (hip and shoulder flexion) and distal
(ankle and finger flexion) leg and arm paresis scored
according to the system advised by the Medical
Research Council (1: a trace of contraction, 2: active
movement with gravity eliminated, 3: active movement against gravity, 4: active movement against
gravity and resistance, and 5: normal power).1
Upper extremity function was evaluated according
to the Barthel Index2 using subscores for the patients'
ability to prepare a tray and feed themselves (6: can
feed self a meal placed within reach, can put on an
assist device if used, can cut food, spread butter, and
248
TABLE 1.
Stroke Vol 21, No 2, February 1990
contact guarding, minimal assistance, etc. Use of a
brace and a cane did not constitute assistance.
Overall stroke severity was assessed by determining the Barthel Index score of each patient on
admission.
Statistical analysis was performed using linear
regression analysis and the Mann-Whitney test.
Characteristics of 75 Stroke Patients
Patients with upper Patients with lower
extremity paresis
extremity paresis
(n=66)
(" = 72)
67±11
68±10
Characteristic
Age (years)
Sex
Females
Males
Side affected
Left
Right
Stroke mechanism
Hematoma
Infarct
Admission after stroke
(weeks)
Length of stay (weeks)
33
33
33
39
30
36
39
33
3
4
63
68
4±2
4±2
9±3
9±3
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Results
Patient characteristics are listed in Table 1. Leg
and arm paresis score on admission correlated significantly with extremity function score on discharge
(proximal upper extremity: /-=0.58, proximal lower
extremity: r=0.53, distal upper extremity: r=0.55,
distal lower extremity: r=0.54;/?<0.01). Proximal and
distal paresis scores were found to be equally good in
predicting outcome measured as function score. Only
the relations between proximal paresis scores and
outcome are given below.
On admission, 40 patients had upper extremity
paresis scores of 22 (Table 2). Three (8%) regained
independence in both upper extremity functions
(scored 11 on discharge), and nine (23%) regained
independence in at least one function (scored 9 or 11
on discharge). Eleven (42%) of the 26 patients with
upper extremity paresis scores of ^3 regained independence in both upper extremity functions, and 21
(81%) regained independence in at least one function.
On admission, 38 patients had lower extremity paresis scores of ^2 (Table 3). Four (11%) regained the
ability to walk independently (scored 5 on discharge),
and 19 (50%) became able to walk >150 feet with
assistance (scored 4 on discharge). Of the 34 patients
who had paresis scores of ^ 3 , independent walking was
regained by 19 (56%) and all 34 became able to walk
> 150 feet with assistance or independently.
The Barthel Index score on admission correlated
significantly with function score on discharge (upper
extremity: r=0.64, lower extremity: r=0.65;/?<0.01).
Among the 28 patients with Barthel Index scores of
<40, only one (4%) regained independence in both
upper extremity functions, and only six (21%)
regained independence in at least one function
(Table 4). Independence in both upper extremity
functions was regained by 13 (34%) of the 38 patients
who had Barthel Index scores of £40, and 24 (63%)
regained independence in at least one function.
Data are mean±SEM or number.
use salt/pepper; 4: some help required, but can feed
self once food is cut up; and 0: unable to feed self)
and to dress their upper body (5: able to put on,
fasten, and remove clothing; 3: needs help, but able
to do at least half the work; and 0: performance
worse than described). The sum of the two Barthel
Index subscores was considered to be a measure of
upper extremity function. Patients who scored 11
were independent in both upper extremity functions.
Those who scored 9 were independent in one function and needed only minimal assistance with the
other. Patients who scored 7 and 3 or 4 needed
assistance in performing both functions. Patients
with the lowest possible function score, 0, needed
maximal help of another individual in performing
both upper extremity functions. Function thus refers
to both extremities, the paretic as well as the nonparetic one, while motor impairment refers to the
paretic extremity only.
Lower extremity function was evaluated by scoring
the patients' ability to walk (1: nonambulatory, 2: can
walk <50 feet with assistance, 3: can walk 50-150
feet with assistance, 4: can walk >150 feet with
assistance, and 5: can walk independently). Patients
were said to require assistance when they needed the
presence of another individual for safety such as
TABLE 2.
Proximal Upper Extremity Paresis on Admission and Upper Extremity Functional Outcome in 66 Stroke Patients
Function score on discharge
TotaJ
Paresis score
on admission
0
3,4
7
9
11
n
%
0
1
5
0
2
3
4
0
0
0
8
3
1
1
1
10
2
2
2
0
1
3
0
4
2
0
3
7
29
7
4
11
44
10
6
17
23
5 (8%)
14 (21%)
17 (26%)
16 (24%)
14 (21%)
Total
4
7
Paresis scored by Medical Research Council system; function scored by Barthel Index subscores.
15
66
100
Olsen Outcome Predictors in Stroke Rehabilitation
249
TABLE 3. Proximal Lower Extremity Paresis on Admission and Lower Extremity Functional Outcome in 72 Stroke Patients
Paresis score
on admission
0
1
2
3
4
Total
Function score on discharge
Total
1
2
3
4
5
n
%
1
1
1
1
2
1
1
2
1
9
12
7
12
23 (32%)
12
16
24
24
24
100
2
0
0
0
0
0
6
0
0
4
6
9
10
5
3 (4%)
3 (4%)
9 (13%)
34 (47%)
17
17
17
72
Paresis scored by Medical Research Council system; function scored by ability to walk.
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Table 5 shows that among 28 patients with Barthel
Index scores of <40, only one (4%) regained the
ability to walk independently, while 14 (50%) were
able to walk > 150 feet with assistance after rehabilitation. Of the 44 patients with Barthel Index scores
of ^40, 22 (50%) regained independent walking and
42 (95%) were able to walk >150 feet with assistance
or independently after rehabilitation. All four
patients with Barthel Index scores of ^80 were able
to walk independently after rehabilitation.
Table 6 shows the time to maximum extremity
function score in the patients who recovered. Upper
extremity function improved during rehabilitation in
34 patients (52%), while lower extremity function
improved in 60 patients (89%). The patients who
improved were discharged a mean±SEM of 2±1
weeks after they had reached their maximum extremity function score. Maximum score was reached 9±3
(for the upper extremity) and 10±4 (for the lower
extremity) weeks after the stroke; 95% of the patients
had achieved their best extremity function within 14
weeks after their stroke. Patients who recovered completely (achieved independent extremity function) did
so 7±2 weeks after the stroke, while patients who
recovered only incompletely reached best extremity
function 10±3 (for the upper extremity) and 10±4
(for the lower extremity) after the stroke. This difference in time to maximum score is significant (p>0.03
andp<0.002, respectively, by the Mann-Whitney test).
There was no significant difference between patients
with paresis scores of ^2 and those with scores of ^3
in the time to maximum extremity function score
(/?>0.05 by the Mann-Whitney test).
TABLE 4.
Overall Stroke Severity on Admission and Upper Extremity Functional Outcome in 66 Stroke Patients
Severity score
on admission
0-19
20-39
40-59
60-79
80-100
Total
Discussion
Functional outcome in this series was less favorable than that reported for the average stroke population since no more than 21% and 32% regained
independent upper and lower extremity function,
respectively. In unselected patients with stroke,
approximately 70% are able to feed and dress themselves independently and >80%3"5 are able to walk
independently 6 months after the event.5 Wade et al6
assessed lower extremity weakness 3-4 weeks after a
stroke in 196 unselected patients and found that 86%
had either no or only mild weakness. In my study, this
occurred in approximately 24% (paresis score of 4),
which indicates that these patients were recruited
from those with more severe strokes, usually 20% of
the stroke population.
Arm and leg paresis are easy to determine and
appear to be useful predictors of functional outcome.
Severe extremity paresis (Medical Research Council
scores of ^2 on admission) predicts a bad outcome.
Neither independent upper extremity function nor
independent walking should be expected by patients
with paresis of that degree. Only 8% and 11% of my
patients with paresis scores of £2 on admission performed upper extremity functions and walked independently after rehabilitation. Approximately 40%
were not able to walk 150 feet, even with assistance,
and upper extremity function outcome was even
worse; >75% of the patients with paresis scores of ^2
on admission still needed significant assistance with
upper extremity function after rehabilitation.
Mild extremity paresis (Medical Research Council
scores of ^3 on admission) predicts a relatively good
functional outcome. About half of these patients
Function score on discharge
Total
0
3,4
5-8
9
11
n
3
2
0
0
0
2
9
3
0
5
7
4
0
1
4
0
0
2
4
7
4
5 (8%)
14 (21%)
7
21
21
16
1
66
0
0
8
1
17 (26%)
16 (24%)
14 (21%)
Severity scored by Barthel Index; function scored by Barthel Index subscores.
%
11
32
32
24
1
100
250
Stroke
TABLE 5.
Vol 21, No 2, February 1990
Overall Stroke Severity on Admission and Lower Extremity Functional Ontcome In 72 Stroke Patients
Severity score
on admission
0-19
20-39
40-59
60-79
80-100
Total
Function score on discharge
1
2
2
1
0
0
3
0
0
0
0
0
0
0
3 (4%)
3 (4%)
9 (13%)
Total
3
4
5
n
%
4
2
12
0
1
11
16
4
8
0
10
4
8
20
26
14
4
34 (47%)
23 (32%)
72
3
2
28
36
19
6
100
Severity scored by Barthel Index; function scored by ability to walk.
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regained independent extremity function. After rehabilitation, all were able to walk >150 feet with
assistance or independently and 80% were either
independent or needed only minor assistance with
upper extremity functions.
Extensive work using the Barthel Index as a predictor of outcome has demonstrated a close relation
between the score on this index (i.e., overall function) at admission and outcome.3'5-14 The Barthel
Index cannot be established at the bedside on admission since it requires observation of the patient over
several days. The Barthel Index seems to be slightly
better than extremity paresis in delineating those
patients who will be unable to perform upper extremity functions or to walk independently after rehabilitation. In accordance with the findings of Granger et
a],9 in my study such functionally impaired patients
comprised only 4% of those with Barthel Index
scores of <40 compared with 8-11% of those with
Medical Research Council paresis scores of <2. The
Barthel Index is also better in predicting walking
outcome in "high-level" patients (those with a Barthel Index score of >80).
Improvement may occur as long as 6-12 months
after a stroke,31'-18 but the majority of functional
recovery occurs within the first 3 months. Studying 39
TABLE 6.
stroke patients with hemiplegia, Newman19 found
that little recovery took place later than 14 weeks
after the stroke and that the average interval from
stroke onset to 80% of final recovery was 6 weeks.
Prescott et al20 studied 100 patients with moderatesevere strokes from 4 weeks after the stroke until
discharge; 89% had reached their best functional
outcome ^16 weeks after their stroke. Wade et al17
studied arm function in 92 patients over 2 years
following their stroke; statistically significant improvement was seen only during the first 3 months. In 135
stroke patients studied by Andrews et al,18 maximum
improvement for walking was reached within 8 weeks
after the stroke in 88% of the patients. These findings are in accord with my findings. Best upper and
lower extremity function was obtained on average 9
and 10 weeks, respectively, after the stroke, and 95%
of the patients had reached their best upper and
lower extremity function within 13 and 14 weeks,
respectively.
Stroke severity affects the time required to obtain
maximal recovery. Length of stay in a rehabilitation
unit is directly related to the severity of paresis on
admission.21-22 Patients with a low Barthel Index
score on admission recover more slowly than patients
with a high score.3 In my study, complete recovery of
Time to Obtain Best Extremity Function in Stroke Patients Who Improved During Rehabilitation
n
Mean±SEM
Range
Best function reached
by 95% of patients
(weeks)
34
9±3
5-16
13
11+4
17
17
21
13
9±3
8±2
10±3
7±2*
5-16
5-11
5-16
5-10
13
10
13
10
13±4
10±3
13±3
9±3
60
10±4
4-27
14
12±5
33
27
37
23
10±4
4-27
5-20
4-27
5-11
14
13
18
10
13±5
12±4
14±5
10±3
Time (weeks)
upper extremity (/v=66)
Best function
All patients
Paresis score <,2
Paresis score S3
Incomplete recovery
Complete recovery
Lower extremity (N=12)
Best function
All patients
Paresis score s 2
Paresis score &3
Incomplete recovery
Complete recovery
9±3
10±4
7±2t
*tp<0.03, 0.002, respectively, different from incomplete recovery by Mann-Whitney test.
Stroke-discharge interval
(mean±SEM weeks)
Olsen Outcome Predictors in Stroke Rehabilitation
extremity function was achieved on average 7 weeks
after the stroke, whereas recovery progressed for an
average of 10 weeks in patients who achieved only
incomplete recovery.
Andrews et al18 showed that approximately one
third of moderately or severely disabled stroke
patients had improvement of their walking between 3
and 6 months after their stroke. In my study, the
patients were discharged an average of 2 weeks after
maximum improvement was achieved. Although the
majority of the patients thus seemed to have reached
their best possible outcome on discharge, some
patients may continue to improve. However, the
process of recovery may be so slow in these patients
that recordable improvement of function requires >2
weeks of observation during inpatient rehabilitation.
Acknowledgments
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Thanks to Dr. Fletcher H. McDowell and Dr.
Michael J. Reding for invaluable advice during preparation of the manuscript.
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KEYWORDS • cerebrovasculardisorders • paresis • rehabilitation
Arm and leg paresis as outcome predictors in stroke rehabilitation.
T S Olsen
Stroke. 1990;21:247-251
doi: 10.1161/01.STR.21.2.247
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