Associations between body functions, activities and health-related quality of life from onset until 18 months after stroke

Abstract

Introduction and aims: In planning rehabilitation services for patients with stroke, it is important to know the frequency of the impairments and activity limitations presented by the patients and also how each body function and activity is associated with other body functions and activities, as well as the patients health-related quality of life (HRQL) at different time-points after stroke. The overall aims of the thesis were to describe body functions, activities and HRQL in patients with stroke and to analyse the associations between those variables, in the first week and at three and 18 months after stroke onset.

Patients and methods: This thesis is based on two samples of consecutively recruited patients, presented in four papers. The patients presented in Paper I, II and IV were assessed in the first week (N=109) as well as at three (N=95) and 18 months (N=66) after stroke with reference to: occurrence of stereotyped mass patterns of movement (Brunnström s hemiplegic limb synergies); muscle tone (Modified Ashworth Scale); muscle stiffness (self-report); tendon reflexes (physical examination); motor performance (Lindmark Motor Assessment Scale); fine hand use (Nine Hole Peg Test); grip strength (Vigorimeter); somatosensory functions (light touch and Thumb Localizing Test); mobility (Rivermead Mobility Index); self-care, i.e. activities of daily living, ADL (Barthel Index); and HRQL (SF-36). For Paper III, 115 patients, ≥65 years, were assessed five days after stroke with reference to: somatosensory, perceptual (Line- and Letter Cancellation Tasks and Kohs Block Design Test); and cognitive functions (Mini Mental State Examination); depressive symptoms (Montgomery-Åsberg Depression Rating Scale); mobility; and self-care.

Results: Three months after stroke, the voluntary movements of 13% of hemiparetic stroke patients were restricted to the hemiplegic limb synergies, all of which displayed spasticity (Paper I). Eighteen months after stroke, 20% of all patients and 34% of the hemiparetic patients, displayed spasticity (Paper II). Both spasticity and the hemiplegic limb synergies were associated with impaired movements and activity limitations although severe disabilities were seen both in patients with and without these impairments (Papers I and II). Hemiparetic patients without spasticity had significantly better HRQL on one of the eight SF-36 health scales, than patients with spasticity (Paper II). Multivariate analyses showed that normal proprioceptive function was significantly associated with better mobility, five days after stroke onset. Normal perceptual and touch functions were significantly associated with better self-care (Paper III). Seventy percent of all patients had limited fine hand use in the first week, 41% at three months and 45% at 18 months after stroke. The strength of the associations between fine hand use and touch function, upper extremity movement function and self-care, respectively, was moderate to high but decreased over time. In general, fewer patients improved from limited fine hand use compared to other disabilities (Paper IV).

Conclusions: The assessment of hemiplegic limb synergies, as presented by Brunnström, may only be suitable for a small fraction of hemiparetic patients namely, those displaying spasticity. The current exaggerated focus on reflex-mediated spasticity in stroke care seems to overestimate its clinical importance, not for the single patient, but from a population-based perspective. It is of specific importance to consider somatosensory and perceptual functions, respectively, in the rehabilitation of older patients in the acute phase after stroke, since these functions significantly affect the patients mobility and self-care levels. Limited fine hand use is common after stroke. With time after onset, patients with stroke seem to become less dependent on fine hand use when performing upper extremity movements and self-care activities.