Relationship & Comparison Between

Research Article
DOI: http://dx.doi.org/10.31782/IJCRR.2019.1112

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

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.

ABSTRACT

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

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

INTRODUCTION

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:

Email: kakkadashish@yahoo.co.in
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 |
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Kakkad et.al: 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
female.8

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,
0.96).

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-
tion.

METHODS

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-

cords.
4. Patients having another neurological deficit with
stroke.

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.

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

RESULTS

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%)

fected

Type of stroke Ischemic (85.07%) | Hemorrhagic
(14.93%)

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

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

tory

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
Score

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

50.0000

40.0000

29.74668

30.0000 + = FMS
m MBI

20.0000 +

14.0597
10.0000 + 591065
0.0000 —
Mean Std. Deviation

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

DISCUSSION

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

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Kakkad et.al: 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.

CONCLUSION

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.

ACKNOWLEDGEMENT

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.

Funding
Self

Conflict of interest
None

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