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Research Article 

=y Relationship & Comparison between 
°” Post-Stroke Motor Recovery and 
swa FUNCtional Recovery — An Observational 

International Journal of Current Research and Review | 

Sci. Journal Impact 
Factor: 5.385 (2017) 
ICV: 71.54 (2015) 

Ashish Kakkad?, Priyanshu V. Rathod? 

'PhD Scholar, Assistant Professor, SPB College of Physiotherapy, Surat, Gujarat, India; *Guide & Dean, Faculty of Medicine, School of Physi- 
otherapy, RK University, Rajkot. 


Aims and Objectives: This study explored relationship between post-stroke motor recovery and functional recovery in Gujarat, 

Patients, Materials and Methods: This Study involved 67 (48 males and 19 females) individuals diagnosed of stroke by Neuro- 
physician or General Physician with less than 6 months of post stroke duration. Fugl Meyer Motor Assessment Score was (total 
of upper extremity and lower extremity sub score) was used to assess their post-stroke motor recovery. Their functional recovery 
was assessed using the Modified Barthel Index. They were assessed on the same day for Fugl-Meyer Motor Assessment as well 
as Modified Barthel Index. Data were analyzed using the Pearson’s Moment Correlation and Students’ paired t-test at p =0.05. 

Results: Patients’ mean age was 57.52+ 13.1 years ranging between 17 years and 80 years. Their motor recovery had direct 
positive relationship (r=0.791, p=0.00) with their functional recovery but there was significant difference (t=13.16, p=0.00) be- 
tween motor recovery and functional recovery. Mean score of motor recovery by total of Fugl-Meyer Upper extremity & Lower 
extremity subscore is 54.79 (54.79%) of total 100 score. Mean score of functional recovery by Modified Barthel Index was 14.06 
(70.3%) of total 20 score. 

Conclusion: Though Motor recovery has positive impact on the functional recovery in stroke survivors, motor recovery and 
functional recovery may differ significantly where functional recovery may exceed than motor recovery. 

Key Words: Stroke, Stroke rehabilitation, Recovery of function 


World Health Organization (WHO) defines stroke as a clini- 
cal syndrome characterized by rapidly developing clinical 
symptoms and/or signs of focal and at times global loss 
of cerebral function, with symptoms lasting more than 24 
hours or leading to death, with no apparent cause other 
than that of vascular origin. 

Stroke is classified into two types. Ischemic stroke is the 
most common fype affecting about 67-80% of individu- 
als with stroke and results when a clot or block impairs 
blood flow, depriving the brain of essential oxygen and nu- 
trients, leading to disruption of cellular metabolism, injury 

and death of tissues. Hemorrhagic stroke occurs when blood 
vessels rupture, causing leakage of blood in and around 
brain. It may occur due to increase in intracranial pressure 
or restriction of distal blood flow. Central Venous Sinus 
Thrombosis (CVST) is the presence of acute thrombosis (a 
blood clot) in the dural venous in sinuses, which drain blood 
from the brain. Symptoms may include headache, abnormal 
vision, any of the symptoms of stroke such as weaknegs of 
the face and limbs on the side of the body and seizures. 

Stroke is a global health problem. It is second commonest 
cause of death and fourth leading cause of disability world- 
wide. In developed countries, stroke is the firgt leading 
cause of disability, second leading cause of death. It makes 

Corresponding Author: 

ISSN: 2231-2196 (Print) 

Received: 10.12.2018 Revised: 20.12.2018 

Ashish Kakkad, PhD Scholar, Assistant Professor, SPB College of Physiotherapy, Surat, Gujarat, India; 

ISSN: 0975-5241 (Online) 

Accepted: 02.01.2019 

Oa ee | 
Int J Cur Res Rev | Vol 11 + Issue 01 + January 2019 a 

Kakkad Relationship & comparison between post-stroke motor recovery and functional recovery — an observational study 

an important concern not only for the physiotherapists but 
for the entire rehabilitation team. 

The incidence of stroke rises rapidly with increasing age. In 
India, the overall prevalence rate for stroke lies between 84 
— 262 per 100,000 in rural area and between 334 — 424 per 
100,000 in urban areas.® After the age of 55 years, the risk 
of stroke doubles every 10 years; two thirds of all strokes 
occurring in people older than the age of 65 years.’ The in- 
cidence of stroke is about 1.25 times greater for males than 

Katherine J. Sullivan et al did a study “Fugl-Meyer Assess- 
ment of Sensorimotor Function after Stroke Standardized 
Training Procedure for Clinical Practice and Clinical Trials” 
in 2011 to find out reliability of the same score and found 
that intra-rater reliability for the expert rater was high for 
the motor and sensory scores (range, 0.95—1.0). Inter-rater 
agreement (intraclass correlation coefficient, 2, 1) between 
expert and therapist raters was high for the motor scores (to- 
tal, 0.98; upper extremity, 0.99; lower extremity, 0.91) and 
sensory scores (total, 0.93; light touch, 0.87; proprioception, 

Ohura T et al in 2017, found validity and reliability for Modi- 
fied Barthel Index in study on stroke patients. ICC for inter- 
rater reliability for first session was 0.99. For intra rater reli- 
ability, mean value of ICC was 0.99 for individual task, inter 
rate kw coefficients for the first session ranged from 0.77 to 
0.94 with intra-rater kw coefficients from 0.85 to 0.96. They 
concluded with strong criterion related validity against the 
Barthel Index, with higher reliabilities. Scoring system is con- 
venient tool allowing anyone to assess activity of daily life.” 

Stroke- related physical disability diminishes quality of dai- 
ly living, place care burden on families, and increase need 
for long-term institutionalization ` 

Recovery after stroke occurs in two phases: neurological or 
functional. Neurological recovery occurs as a result of brain 
repair and reorganization while functional recovery depends 
on many factors including extent of motor affectation and the 
quality of rehabilitation". Although neurological recovery 
may peak within the first three months of stroke; functional 
recovery continues with improvement in the recoveries of 
specific functions like mobility and social participation." 
Neurological recovery includes motor recovery, sensory re- 
covery and also balance recovery. Functional recovery de- 
scribes dependency of individual in activity of daily life. An- 
other dimension to be taken into consideration is Quality of 
life which is individual perception of his/her position in life 
in the context of the culture and value system in which they 
live and in relation to their goals, expectations, standards, 
and concern.'* 

Recent studies have shown that Stroke has negative impact 
on both the functional recovery and quality of life of stroke 

survivors. Quality of life of stroke survivors increases with 
improvement in functional recovery.'* Stroke has impact on 
both the motor recovery and functional recovery in individu- 
als who have survived stroke episode but the relationship 
between motor recovery and functional recovery in stroke 
has not been clearly explained. However, the relationship 
between these differential shifts in neurological recovery 
and functional recovery among stroke survivors has not been 
well explored. Therefore, this study explored the relationship 
between post-stroke motor recovery and functional recovery 
in stroke survivors within first 6 months of post stroke dura- 


This study was ethically approved by a RK University, Gu- 
jarat. This study involved 67 consecutively recruited stroke 
survivors diagnosed of stroke by Neurophysician or General 
physician as per selection criteria as follows: 

Inclusion criteria: 
1. All stroke patients who are willing to participate 
2. Both male & female stroke patients 
3. Mini mental scale examination score >24!° 
4. Duration of stroke varies from discharge from hospital 
up to 6 months'® 

Exclusion criteria: 

1. Stroke patients who are not cooperative. 

2. Stroke patients who have auditory &/or visual deficits. 

3. Stroke patients who do not have proper medical re- 

4. Patients having another neurological deficit with 

Oral as well as written consent was taken by patient &/or 
relative from those who were willing to participate. All sub- 
jects were explained about the study and were assessed for 
different demographic data as well as for motor as well as 
functional recovery by Fugl-Meyer Motor Assessment Score 
and Modified Barthel Index Score respectively. Fugl-Meyer 
Motor Assessment scale was used to assess their post stroke 
motor recovery. And Modified Barthel Index was used to assess 
functional recovery of stroke patients. Both of these scales were 
assessed on the same day for particular patients. They were also 
interviewed for demographic characteristics (age, gender, 
body mass index, side of body affected), clinical variables 
(length of coma, length of hospitalization, hypertension, diabetes and 
other co-morbidities) and history (addiction history, transient ischemic 
attack history, family history). 

Data was summarized using mean and standard deviation, fre- 
quency. Data were analyzed using the Pearson’s correlation for 
relationship between motor recovery and functional recov- 
ery and paired t-test for comparison between motor recovery 
and functional recovery of participants. 

Int J Cur Res Rev | Vol 11 - Issue 01 + January 2019 

Kakkad Relationship & comparison between post-stroke motor recovery and functional recovery — an observational study 


Study included 67stroke patients. Mean age of the participants 
was 57.52+13.1 years with majority (92.53%) between 17 
and 80 years. Total 19 (28.36%) females and 48 (71.64%) 
males were included in study. The left side of the body 
was affected in 35 (52.23%) of the participants while right 
side of body was affected in 32 (47.76%) patients. Out of 
the participants who took part in the study, 57 had ischemic 
stroke (85.07%) while 10 (14.93%) had hemorrhagic stroke. 
Positive family history of stroke was found in 5 (7.46%) patients. 
13 (19.4%) patients themselves had history of transient ischemic at- 
tack or stroke in past and had stroke another time. Total 19 (28.36%) 
patients were diagnosed with hypertension as co-morbidity while 30 
(44.75%) patients were diagnosed with diabetes. 29 (43.28%) patients 
had at least one of the addictions of tobacco, alcohol or smoking. 

Table 1: Descriptive statistics 

Gender Males (71.64%) Females (28.36%) 

Side of body af- Right (47.76%) Left (52.23%) 


Type of stroke Ischemic (85.07%) | Hemorrhagic 

Family history Present (7.46%) Absent (92.54%) 

TIA/Stroke his- Present (19.4%) Absent (80.6%) 


Presence of co- Hypertension Diabetes (43.28%) 

morbidities (44.75%) 

Addiction history Present (43.28%) 

Data was checked for plausibility and cleaned. The kolmo- 
grov-smimov test was used to analyze normal distribution 
assumption of outcomes measures and was found normally 
distributed. Pearson correlation test was applied to find out 
relation between Fugl-Meyer Motor Assessment Score and 
Modified Barthel Index Score. By this test, r value found was 
0.791 (n=67, p=0.00). Paired student’s t-test was applied to 
compare Fugl-Meyer Motor Assessment Score and Modified 
Barthel Index Score. By this test, t value found was 13.161 
(n=67, df=66, p=0.00) 

Table 2: Pearson correlation test between Fugl-Meyer 
Motor Assessment Score and Modified Barthel Index 

0.791 67 o 

Table 3: Paired T test between Fugl-Meyer Motor As- 
sessment Score and Modified Barthel Index Score 

Mean Std. Std. 95% Confidence 
Devia- Error Interval of the 
tion Mean Difference 

Lower Upper 

40.73134 25.33328 3.09495 34.55207 46.91062 13.161 66 .000 

Fuunctional recovery 
(Modified Barthel Index) 

0 20 40 60 80 100 120 

Motor recovery 
(Fugl-Meyer Motor Assessment) 

Figure 1: Relationship between motor recovery and functional 
recovery after stroke. 

60:0000 54.7910 




30.0000 + = FMS 
m MBI 

20.0000 + 

10.0000 + 591065 
0.0000 — 
Mean Std. Deviation 

Figure 2: Comparison between motor recovery and functional 
recovery after stroke. 


From the results, it is observed that motor recovery has posi- 
tive impact on functional recovery which suggests that with 
motor recovery, functional performance also improves of 
stroke patient as the time passes. It is also found that there is 
significant difference between motor recovery and function- 
al recovery suggesting that motor recovery and functional 
recovery may happen at different rate. From mean value, it 
can be observed that functional recovery exceed than mo- 
tor recovery. Motor performance accounts recovery of af- 
fected side only which is limited to neurological recovery 
only. Functional performance may also include contribution 
from normal side also to compensate for completion of task 
along with affected side of body. By this reason, functional 

Int J Cur Res Rev | Vol 11 + Issue 01 « January 2019 

Kakkad Relationship & comparison between post-stroke motor recovery and functional recovery — an observational study 

recovery may exceed than motor recovery. Although, stroke 
had been shown to have negative impact on both the mo- 
tor recovery and functional recovery in stroke survivors, the 
relationship between motor recovery and functional recov- 
ery after stroke has not been clearly delineated. The result 
of this study shows that improved motor recovery results in 
improved functional recovery in individuals who have had 
an episode of stroke. This means that if effort is geared to- 
wards functional recovery rather than motor activity, there 
will be remarkable reduction in the dependency in activity of 
daily living. Even with less motor recovery, by efforts patient 
can be given advantage of more functional recovery which 
is more required for patient. This is a wake-up call for cli- 
nicians involved in stroke rehabilitation to plan goals that 
will improve various aspects of life of stroke survivors and 
tailored those activities that will improve societal integration 
and reduce activity limitation and participation restriction.'4 

Anthea Rhoda et al. (2014) conducted a similar type study. 
In this study, total of 73 patients from the two separate stud- 
ies were matched for age at stroke onset, gender, and initial 
motor functioning. Motor and functional recoveries were 
assessed at baseline, two and six months post stroke using 
the Rivermead Motor Assessment Scale and the Barthel In- 
dex (BI) respectively. Significant difference between motor 
and functional recovery was found." Lucca Nannetti et al. 
(2004) also conducted a study to compare motor and func- 
tional recovery on 170 post stroke depression patients. They 
found post stroke depression does not influence motor and 
functional recovery suggesting that depression is not affect- 
ing recovery.'® 

Limitations of this study include small size and only one 
time assessment was taken. Undiagnosed co-morbidities can 
also influence findings. Future studies can target on longitu- 
dinal follow-up for all stroke patients with more sample size. 


The findings of this study support the fact that motor re- 
covery had positive impact on functional outcome in stroke 
survivors. But functional recovery may exceed the motor re- 
covery. Therefore, rehabilitation of stroke patient should not 
be only focus on the motor recovery but also on functional 
recovery training equally or even more. 


Authors acknowledge the immense help received from the 
scholars whose articles are cited and included in references 
of this manuscript. The authors are also grateful to authors / 
editors / publishers of all those articles, journals and books 
from where the literature for this article has been reviewed 
and discussed. 


Conflict of interest 


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