Motor Recovery Following Acute Stroke CHRISTOPHER S. GRAY, JOYCE M. FRENCH, DAVID BATES, NIALL E. F. CARTLIDGE, OLIVER F. W. JAMES, GRAHAM VENABLES
Introduction
stroke. Whilst such scales may be valid, sensitive, reliable and in some instances better than pre-existing scales their value is lost if, in routine clinical practice it is the older more established scales which are persistently used. The MRC motor scale [10] is a standard and well recognized measure of power which, in spite of its limitations, is in general clinical use. Maximal recovery occurs in the first month (6). We undertook a study to define the pattern and time course of recovery in different parts of the neuraxis in the first 28 days following acute stroke. This paper considers the recovery of motor function in the upper and lower limbs.
Clinical signs of prognostic value in stroke have been well defined. Marquarsden [1] demonstrated that fatality following stroke increases with progressive impairment of conscious level. Additional signs of extensive hemispheric lesions such as paresis of conjugate gaze and dense limb paresis are recognized as being associated with both increased fatality and impaired functional recovery [2-4]. The degree of motor paresis is of prognostic value not only for fatality but also subsequent placement; an estimated 75% of patients with a dense paresis go home compared with 90% of those with a mild paresis [5]. Functional recovery of the limbs closely follows neurological recovery and is associated Methods not only with measures such as limb tone [6] but All patients admitted to the Royal Victoria Infirmary also other factors such as memory loss, dys- and Freeman Hospital, Newcastle upon Tyne from February 1985 to September 1986 with a clinical praxia or loss of body awareness [7]. Recent attention has been directed towards diagnosis of acute stroke were recruited to the study. the recovery of function [8] which inevitably Stroke was denned as an episode of focal neurological includes the use of the unaffected side (adaptive dysfunction with symptoms lasting more than 24 h and thought to be due to infarction or haemorrhage recovery). There is, however, little information [11]. Patients with subarachnoid haemorrhage proavailable on the time course and pattern of ven by C T or CSF examination or with transient recovery of the affected side alone which has ischaemic attacks (TIAs) were excluded as was any been termed intrinsic recovery [9]. There are patient who was subsequently shown to have a deficit many scales which purport to measure different arising as a result of a non-vascular cause. All patients aspects of impairment and disability following admitted within 72 h of onset of their stroke were Age and Ageing 1990:19:179-184
Downloaded from http://ageing.oxfordjournals.org/ at University of California, San Diego on February 12, 2016
Summary There is little information available from which normal patterns of recovery from acute stroke can be ascertained. Most attention has been directed towards functional recovery in stroke patients but the neurological basis on which this occurs needs to be documented in a large cohort of patients. One hundred and fifty-seven patients admitted to hospital with a clinical diagnosis of acute stroke were examined daily for up to 28 days to determine the patterns of recovery of limb tone, power and reflexes. Changes in these variables during the first 28 days after stroke are described.
i8o
C. S GRAY ET AL. ery of the limb or limbs directly affected by the acute event.
Results
Altogether, 174 patients were recruited to the study: 157 with hemisphere, and 17 with brainstem lesions. This analysis concerns the 157 hemisphere events which involved 70 (45%) men and 87 (55%) women. Median age of the group was 73 years (mean 72 years) and range 39-96 years). All patients were examined and assessed within 72 h of onset of the stroke (92% of assessments were performed within 48 h). No patient totally recovered in under 7 days. In 14 patients (9%) there was a previous history of TI As and in 11 (7%) a previous history of major stroke on the contralateral side to the presenting Neurological Assessment event. Cumulative fatality at 7, 14 and 28 days Each patient underwent a full neurological examin- was 31 (20%), 42 (27%) and 49 (31 %), respectation at each assessment. This paper considers only ively. the recovery of limb tone, power and reflexes. Recovery of limb tone: Admission limb tone, Tone: Skeletal muscle tone was recorded for all changes in tone at 28 days and cumulative four limbs as normal, flexor, extensor or flaccid. fatality are shown in Table I. The predominant Tone was assessed for the limb as a whole and the abnormality of tone on admission in both upper predominant abnormality recorded [12]. Where tone was paratonic, the predominant abnormality (flexor and lower limb was flaccidity. Recovery to or extensor) on repeated examination was recorded. normal tone occurred mainly in the first 7 days Power: Limb power was recorded on a simple with 14 (16%) patients regaining normal hierarchical scale modified from the MRC scale [10] upper-limb tone and 14 (26%) patients normal to include an additional category (flexor/extensor) lower-limb tone. By 28 days, a total of 17 (20%) describing patients in whom no palpable contraction patients had normal upper-limb tone and 15 was observed but, in response to a noxious stimulus (28%) patients normal lower-limb tone. applied to the periphery of the limb, a flexor or Increased tone, i.e. flexor upper-limb and extensor motor response was observed [13]. Each extensor lower-limb tone, was present in a limb was assessed individually and power recorded for the limb as a whole as: 1. normal, 2. against similar number of patients (Table I). Recovery resistance, 3. against gravity, 4. without gravity/ to normal was again maximal in the first 7 days flicker, 5. flexor/extensor, or 6. nil. At each assess- when 2 1 % of patients regained normal upper ment interval, recovery was defined as any increase in limb tone and 24% normal lower-limb tone. A total of 10 (23%) patients had normal upperlimb power compared with that on admission. Reflexes: Tendon reflexes were recorded for each limb tone and 15 (33%) normal lower-limb tone limb as normal, increased or reduced. Where the at 28 days. Cumulative fatality at 28 days was reflex response was equivocal, even on repeated greatest in patients with flaccid limb tone at testing, a 'normal' response was recorded. admission. Recovery of power: Admission limb power, changes in power at 28 days and cumulative Statistics fatality are shown in Table II. The recovery of Data were collected on a standard pro forma and upper- and lower-limb power during this analysis performed using the SPSSX package on the period is shown in Figures 1 and 2, respectively. Newcastle University Multiple Access Computer The graphs show the patterns of recovery for (NUMAC). All data and graphs represent the recov- each group of patients presenting with a par-
Downloaded from http://ageing.oxfordjournals.org/ at University of California, San Diego on February 12, 2016
included. Each patient was seen by the main assessor (C.S.G.) and where the diagnosis was in doubt a second opinion sought. Patients were classified clinically into hemisphere or brainstem events. Each patient underwent an initial assessment comprising history, general medical and neurological examination. Serial neurological assessments were performed by C.S.G. until 28 days after onset. All assessments were performed between 08 h 00 and 11 h 00 with the patient rested. Discrete variables relating to the patients' history and examination were documented and simple hierarchical scales used to define abnormalities in limb tone, power and reflexes. For the purpose of the study the best neurological outcome was recorded at each assessment. Follow-up assessments were performed 24, 48 and 72 h, 4, 7, 10, 14 and 28 days after the admission assessment.
MOTOR RECOVERY FOLLOWING ACUTE STROKE
181
Table I. Recovery of limb tone at 28 davs Limb tone at 28 days Admission limb tone
No.
Normal
Flexor
Extensor
Flaccid
Dead
19 43
16 10 4 17
0 14 1 20
0 1 1 3
0 4 0
3 14 2 30
0 1 5 4
2 0 9 4
Upper limb 8 87
17
Lower limb
Normal Flexor Extensor Flaccid
47 11 45 54
38 4 15 15
ticular abnormality of power. The horizontal axis represents each assessment interval and the vertical axis the percentage of patients in each group who develop an increase in limb power when compared with that on admission. Patients with less severe motor deficits, i.e. power against resistance, are not shown in the graph.
0 1 3
7 5 13 24
7
In the upper limb 85% of patients presented with power 'against gravity' or less (Table II). As shown in Figure 1, recovery in all groups of patients occurred mainly in the first 48 h following which further recovery was limited to patients with less severe admission motor deficits, i.e. 'against gravity'. Recovery in these patients occurred up until 28 days in a total of
Table II. Recovery of limb power at 28 days Limb powei• at 28 days Without gravity/ Admission limb power
No.
Normal
Resistance
Gravity
flicker
5 19 34 15 43 41
5 10 3 2 1 0
0 6 24 5 2 4
0 0
0 0 2 2
9 35 29 22 49 13
9 12
0 16 14 7 6 0
0 2 1 0 1 1
Flexor/ extensor
Nil
Dead
0 0 0
0 2 3 2 27 15
Upper limb
Normal Against resistance Against gravity Without gravity/flicker Flexor/extensor Nil
1 1 0 3
1 4
0
1 1 2 5 2
1 7 13
Lower limb
Normal Against resistance Against gravity Without gravity/flicker Flexor/extensor Nil
9 1 1 1
0 1 1 4 7
0
0 0 0 4
8 0
0
0 0 0 1 1
0 4 4 6 25 10
Downloaded from http://ageing.oxfordjournals.org/ at University of California, San Diego on February 12, 2016
Normal Flexor Extensor Flaccid
C. S. GRAY ET AL.
182
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^GRAVITY WOUT GRAVITY/ / * FLICKER
S 60
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24h
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Figure 1. Recovery of upper-limb power in patients admitted with hemisphere stroke and reduced limb power.
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Introduction
stroke. Whilst such scales may be valid, sensitive, reliable and in some instances better than pre-existing scales their value is lost if, in routine clinical practice it is the older more established scales which are persistently used. The MRC motor scale [10] is a standard and well recognized measure of power which, in spite of its limitations, is in general clinical use. Maximal recovery occurs in the first month (6). We undertook a study to define the pattern and time course of recovery in different parts of the neuraxis in the first 28 days following acute stroke. This paper considers the recovery of motor function in the upper and lower limbs.
Clinical signs of prognostic value in stroke have been well defined. Marquarsden [1] demonstrated that fatality following stroke increases with progressive impairment of conscious level. Additional signs of extensive hemispheric lesions such as paresis of conjugate gaze and dense limb paresis are recognized as being associated with both increased fatality and impaired functional recovery [2-4]. The degree of motor paresis is of prognostic value not only for fatality but also subsequent placement; an estimated 75% of patients with a dense paresis go home compared with 90% of those with a mild paresis [5]. Functional recovery of the limbs closely follows neurological recovery and is associated Methods not only with measures such as limb tone [6] but All patients admitted to the Royal Victoria Infirmary also other factors such as memory loss, dys- and Freeman Hospital, Newcastle upon Tyne from February 1985 to September 1986 with a clinical praxia or loss of body awareness [7]. Recent attention has been directed towards diagnosis of acute stroke were recruited to the study. the recovery of function [8] which inevitably Stroke was denned as an episode of focal neurological includes the use of the unaffected side (adaptive dysfunction with symptoms lasting more than 24 h and thought to be due to infarction or haemorrhage recovery). There is, however, little information [11]. Patients with subarachnoid haemorrhage proavailable on the time course and pattern of ven by C T or CSF examination or with transient recovery of the affected side alone which has ischaemic attacks (TIAs) were excluded as was any been termed intrinsic recovery [9]. There are patient who was subsequently shown to have a deficit many scales which purport to measure different arising as a result of a non-vascular cause. All patients aspects of impairment and disability following admitted within 72 h of onset of their stroke were Age and Ageing 1990:19:179-184
Downloaded from http://ageing.oxfordjournals.org/ at University of California, San Diego on February 12, 2016
Summary There is little information available from which normal patterns of recovery from acute stroke can be ascertained. Most attention has been directed towards functional recovery in stroke patients but the neurological basis on which this occurs needs to be documented in a large cohort of patients. One hundred and fifty-seven patients admitted to hospital with a clinical diagnosis of acute stroke were examined daily for up to 28 days to determine the patterns of recovery of limb tone, power and reflexes. Changes in these variables during the first 28 days after stroke are described.
i8o
C. S GRAY ET AL. ery of the limb or limbs directly affected by the acute event.
Results
Altogether, 174 patients were recruited to the study: 157 with hemisphere, and 17 with brainstem lesions. This analysis concerns the 157 hemisphere events which involved 70 (45%) men and 87 (55%) women. Median age of the group was 73 years (mean 72 years) and range 39-96 years). All patients were examined and assessed within 72 h of onset of the stroke (92% of assessments were performed within 48 h). No patient totally recovered in under 7 days. In 14 patients (9%) there was a previous history of TI As and in 11 (7%) a previous history of major stroke on the contralateral side to the presenting Neurological Assessment event. Cumulative fatality at 7, 14 and 28 days Each patient underwent a full neurological examin- was 31 (20%), 42 (27%) and 49 (31 %), respectation at each assessment. This paper considers only ively. the recovery of limb tone, power and reflexes. Recovery of limb tone: Admission limb tone, Tone: Skeletal muscle tone was recorded for all changes in tone at 28 days and cumulative four limbs as normal, flexor, extensor or flaccid. fatality are shown in Table I. The predominant Tone was assessed for the limb as a whole and the abnormality of tone on admission in both upper predominant abnormality recorded [12]. Where tone was paratonic, the predominant abnormality (flexor and lower limb was flaccidity. Recovery to or extensor) on repeated examination was recorded. normal tone occurred mainly in the first 7 days Power: Limb power was recorded on a simple with 14 (16%) patients regaining normal hierarchical scale modified from the MRC scale [10] upper-limb tone and 14 (26%) patients normal to include an additional category (flexor/extensor) lower-limb tone. By 28 days, a total of 17 (20%) describing patients in whom no palpable contraction patients had normal upper-limb tone and 15 was observed but, in response to a noxious stimulus (28%) patients normal lower-limb tone. applied to the periphery of the limb, a flexor or Increased tone, i.e. flexor upper-limb and extensor motor response was observed [13]. Each extensor lower-limb tone, was present in a limb was assessed individually and power recorded for the limb as a whole as: 1. normal, 2. against similar number of patients (Table I). Recovery resistance, 3. against gravity, 4. without gravity/ to normal was again maximal in the first 7 days flicker, 5. flexor/extensor, or 6. nil. At each assess- when 2 1 % of patients regained normal upper ment interval, recovery was defined as any increase in limb tone and 24% normal lower-limb tone. A total of 10 (23%) patients had normal upperlimb power compared with that on admission. Reflexes: Tendon reflexes were recorded for each limb tone and 15 (33%) normal lower-limb tone limb as normal, increased or reduced. Where the at 28 days. Cumulative fatality at 28 days was reflex response was equivocal, even on repeated greatest in patients with flaccid limb tone at testing, a 'normal' response was recorded. admission. Recovery of power: Admission limb power, changes in power at 28 days and cumulative Statistics fatality are shown in Table II. The recovery of Data were collected on a standard pro forma and upper- and lower-limb power during this analysis performed using the SPSSX package on the period is shown in Figures 1 and 2, respectively. Newcastle University Multiple Access Computer The graphs show the patterns of recovery for (NUMAC). All data and graphs represent the recov- each group of patients presenting with a par-
Downloaded from http://ageing.oxfordjournals.org/ at University of California, San Diego on February 12, 2016
included. Each patient was seen by the main assessor (C.S.G.) and where the diagnosis was in doubt a second opinion sought. Patients were classified clinically into hemisphere or brainstem events. Each patient underwent an initial assessment comprising history, general medical and neurological examination. Serial neurological assessments were performed by C.S.G. until 28 days after onset. All assessments were performed between 08 h 00 and 11 h 00 with the patient rested. Discrete variables relating to the patients' history and examination were documented and simple hierarchical scales used to define abnormalities in limb tone, power and reflexes. For the purpose of the study the best neurological outcome was recorded at each assessment. Follow-up assessments were performed 24, 48 and 72 h, 4, 7, 10, 14 and 28 days after the admission assessment.
MOTOR RECOVERY FOLLOWING ACUTE STROKE
181
Table I. Recovery of limb tone at 28 davs Limb tone at 28 days Admission limb tone
No.
Normal
Flexor
Extensor
Flaccid
Dead
19 43
16 10 4 17
0 14 1 20
0 1 1 3
0 4 0
3 14 2 30
0 1 5 4
2 0 9 4
Upper limb 8 87
17
Lower limb
Normal Flexor Extensor Flaccid
47 11 45 54
38 4 15 15
ticular abnormality of power. The horizontal axis represents each assessment interval and the vertical axis the percentage of patients in each group who develop an increase in limb power when compared with that on admission. Patients with less severe motor deficits, i.e. power against resistance, are not shown in the graph.
0 1 3
7 5 13 24
7
In the upper limb 85% of patients presented with power 'against gravity' or less (Table II). As shown in Figure 1, recovery in all groups of patients occurred mainly in the first 48 h following which further recovery was limited to patients with less severe admission motor deficits, i.e. 'against gravity'. Recovery in these patients occurred up until 28 days in a total of
Table II. Recovery of limb power at 28 days Limb powei• at 28 days Without gravity/ Admission limb power
No.
Normal
Resistance
Gravity
flicker
5 19 34 15 43 41
5 10 3 2 1 0
0 6 24 5 2 4
0 0
0 0 2 2
9 35 29 22 49 13
9 12
0 16 14 7 6 0
0 2 1 0 1 1
Flexor/ extensor
Nil
Dead
0 0 0
0 2 3 2 27 15
Upper limb
Normal Against resistance Against gravity Without gravity/flicker Flexor/extensor Nil
1 1 0 3
1 4
0
1 1 2 5 2
1 7 13
Lower limb
Normal Against resistance Against gravity Without gravity/flicker Flexor/extensor Nil
9 1 1 1
0 1 1 4 7
0
0 0 0 4
8 0
0
0 0 0 1 1
0 4 4 6 25 10
Downloaded from http://ageing.oxfordjournals.org/ at University of California, San Diego on February 12, 2016
Normal Flexor Extensor Flaccid
C. S. GRAY ET AL.
182
£100 S
90
w
70
^GRAVITY WOUT GRAVITY/ / * FLICKER
S 60
I 50 f 40-
I 30£ 20-o 0
24h
0__-°---o
0FLEX/EXT
Figure 1. Recovery of upper-limb power in patients admitted with hemisphere stroke and reduced limb power.
£ too % a.
90
0 80
