Presence of Finger Extension and Shoulder Abduction Within 72 Hours After Stroke Predicts Functional Recovery: Early Prediction of Functional Outcome After Stroke: The EPOS Cohort Study
Abstract
Background and Purpose— The aim of the present study was to determine if outcome in terms of upper limb function at 6 months after stroke can be predicted in hospital stroke units using clinical parameters measured within 72 hours after stroke. In addition, the effect of the timing of assessment after stroke on the accuracy of prediction was investigated by measurements on days 5 and 9.
Methods— Candidate determinants were measured in 188 stroke patients within 72 hours and at 5 and 9 days after stroke. Logistic regression analysis was used for model development to predict upper limb function at 6 months measured with the action research arm test (ARAT).
Results— Patients with an upper limb motor deficit who exhibit some voluntary extension of the fingers and some abduction of the hemiplegic shoulder on day 2 have a probability of 0.98 to regain some dexterity at 6 months, whereas the probability was 0.25 for those without this voluntary motor activity. Sixty percent of patients with some early finger extension achieved full recovery at 6 months in terms of action research arm test score. Retesting the model on days 5 and 9 resulted in a gradual decline in probability from 0.25 to 0.14 for those without voluntary motor activity of shoulder abduction and finger extension, whereas the probability remained 0.98 for those with this motor activity.
Conclusions— Based on 2 simple bedside tests, finger extension and shoulder abduction, functional recovery of the hemiplegic arm at 6 months can be predicted early in a hospital stroke unit within 72 hours after stroke onset.
Although prospective epidemiological studies are lacking, findings of a number of prospective cohort studies suggest that 33% to 66%1,2 of stroke patients with a paretic upper limb do not show any recovery of upper limb function 6 months after stroke. Depending on the outcome measures used, 5% to 20% achieve full functional recovery of upper limb function at 6 months.3
Early prediction of final functional outcome for the paretic upper limb is paramount for stroke management, including discharge policies at hospital stroke units. Considering that most patients are discharged to rehabilitation centers or nursing homes within the first week after stroke to reduce health care costs, discharge planning should start within the first days after stroke.4 Moreover, guidelines for rehabilitation management recommend starting the treatment of stroke patients as early as possible.5 Prospective cohort studies have shown that early return of finger extension,6,7 shoulder shrug and abduction,8 and active range of motion9 are important prognostic determinants of the outcome for the paretic upper limb 6 months after stroke. Additionally, results from a recent cohort study with repeated measurements in time suggest that the outcome in terms of regaining dexterity at 6 months is largely defined within the first 4 weeks after stroke.10 Unfortunately, most previous studies did not investigate the time dependency of clinical determinants in relation to spontaneous neurological recovery in the very early stages of recovery.11,12
To improve early stroke management, an answer is required to the question whether accurate prediction of the final outcome in terms of upper limb function can be achieved within the first days after stroke at the hospital stroke unit. Therefore, the first aim of the present study was to determine if outcome in terms of upper limb function at 6 months can be predicted within 72 hours after stroke onset. The second aim was to explore the biological relationship of the proposed clinical predictors with spontaneous neurological recovery by means of investigating the effect of the moment of assessment on the accuracy of prediction by assessing on days 5 and 9 after stroke.
Materials and Methods
The Early Prediction of Functional Outcome after Stroke (EPOS) study is a prospective cohort study whose design involves intensive repeated measurements within the first 2 weeks after stroke onset. Over a period of 24 months, 188 stroke patients were recruited from 9 acute hospital stroke units in the Netherlands. All determinants were measured within 72 hours after stroke and were reassessed on days 5 and 9. Final outcome was defined at 6 months after stroke using the action research arm test (ARAT).13–15 Measurements were performed by trained assessors working as physical therapists or occupational therapists in the stroke units of the participating centers (including several affiliated nursing homes). All assessors were familiar with the test battery. In addition, a 1-day training course was given and the assessors were tested for interobserver reliability. All patients received treatment according to the Dutch rehabilitation guidelines, which are in agreement with current international rehabilitation guidelines.5,16 The research proposal was approved by ethics committees of all participating hospitals and all affiliated rehabilitation centers and nursing homes approved local feasibility.
Subjects
Stroke was defined according to the World Health Organization criteria.17 Type and localization of stroke were determined using CT or MRI scans and clinical features according to the Bamford classification.18 Patients meeting the following admission criteria were included: (1) a first-ever ischemic anterior circulation stroke; (2) a monoparesis or hemiparesis within the first 72 hours after stroke onset; (3) no disabling medical history (ie, a premorbid Barthel Index score ≥19); (4) at least 18 years of age; (5) no severe deficits in communication, memory, or understanding that impede proper measurement performance; and (6) signed informed consent.
Dependent Variable
The outcome in terms of hemiplegic arm function was assessed with the ARAT. This 1-dimensional hierarchical scale consists of 19 functional tasks that are divided into 4 domains, i.e, grasp, grip, pinch, and gross movement, with a maximum total score of 57 points. The clinimetric properties of the ARAT are excellent.13,14 All ARAT measurements were performed in a standardized manner according to van der Lee et al.14
For the purpose of logistic regression analysis, ARAT scores were dichotomized into “1” for those who regained some dexterity (≥10 points on ARAT) and “0” for those who did not regain any dexterity (<10 points on ARAT).10 A cut-off score of ≥10 points was chosen because a score of ≤9 points mainly reflects gross arm movements, whereas a score >9 points always represents some hand function.10,14,15
Independent Variables
On the basis of existing literature7–9 and a previous cohort study of predicting upper limb function early after stroke,10 the following candidate determinants were selected for the development of a prediction model: (1) gender; (2) age; (3) hemisphere of stroke; (4) type of stroke (Bamford classification)18; (5) days between stroke and first assessment; (6) recombinant tissue plasminogen activator; (7) comorbidity (Cumulative Illness Rating Scale19); (8) visual inattention (National Institutes of Health Stroke Scale20 item 11); (9) hemianopia (National Institutes of Health Stroke Scale item 3); (10) deviation conjugee (National Institutes of Health Stroke Scale item 2); (11) sensory loss (National Institutes of Health Stroke Scale item 8); (12) Activities of Daily Living score (Barthel Index total score21); (13) urinary incontinence (Barthel Index item 2); (14) severity and extent of paresis of the arm and leg according to the upper and lower extremity parts of the Motricity Index22 and the Fugl-Meyer assessment23; and (15) sitting balance (trunk control test,24 item 3).
Data Analysis
The possible association between the return of some dexterity on ARAT (ie, ≥10 points) at 6 months and the candidate determinants (independent variables) within 72 hours was investigated using bivariate logistic regression analysis and calculating odds ratios and their 95% confidence intervals (CI). Ordinal or ratio scaled determinants were preferably dichotomized on clinical grounds; in the other cases, the optimal cut-off point for each determinant was determined with the help of a receiver-operating characteristic curve. The optimal dichotomization was estimated separately for each candidate determinant on the basis of sensitivity/1 − specificity and maximum area under the curve for each cut-off score. Based on the bivariate logistic regression analysis, significant determinants (P≤0.10) were selected for the subsequent development of a multivariate logistic model predicting within 72 hours whether some (ie, ARAT ≥10 points) or no (ie, ARAT <10) dexterity will return after 6 months. Collinearity between the determinants included was defined if their correlation coefficient was ≥0.7. Subsequently, the determinant with the lowest odds ratio was excluded from multivariate modeling. Because of the large number of variables relative to the number of patients involved, the maximum likelihood estimation of parameters in the multivariate model was conditional on the basis of a forward stepwise approach. Entry and removal criteria with P=0.05 and P=0.10, respectively, were used. The multivariate logistic model thus derived was used to calculate probabilities for developing some dexterity at 6 months using the following equation: equation
A 2-way contingency table was used to calculate sensitivity, specificity, negative predictive value, and positive predictive value, including their 95% CI. The same analyses were repeated for assessments at 5 and 9 days after stroke. All analyses used 2-tailed tests and were conducted using SPSS version 15.
Results
One hundred eighty-eight stroke patients were recruited for the EPOS study in 24 months. Nineteen patients died during follow-up, 2 patients refused assessment at 6 months, 3 patients were excluded after admission because of recurrent stroke, 2 were unable to undergo the assessments, and 3 were lost to follow-up. Finally, 3 patients were excluded because of incomplete data on the baseline Fugl-Meyer assessments. Table 1 presents the main characteristics of the remaining 156 patients. The mean (SD) moments when the candidate determinants were measured were 2.26 (1.28), 5.48 (1.40), and 9.02 (1.81) days after stroke. The median ARAT score was 1.5 points on day 2. At 6 months, some dexterity (ARAT ≥10 points) in the paretic arm was found in 70.5% of the subjects, whereas 34% showed a maximum score of 57 points on the ARAT.Table 1. Patient Characteristics Within 72 Hours After Stroke
| Patient Characteristics | Total |
|---|---|
| BI indicates Barthel Index; BMI, body mass index; F, female; FAC, Functional Ambulation Categories Score; FM, Fugl-Meyer; L, left; LACI, lacunar anterior cerebral infarction; M, male; MI, Motricity Index; NIHSS, National Institutes of Health Stroke Scale; PACI, partial anterior cerebral infarction; R, right; rt-PA, recombinant tissue plasminogen activator; SD, standard deviation; TACI, total anterior cerebral infarction; TCT, trunk control test. | |
| *Median values (interquartile ranges). | |
| N | 156 |
| Gender, F/M | 87/69 |
| Mean age (SD), yr | 66.47 (14.43) |
| Hemisphere of stroke, L/R | 69/87 |
| rt-PA, no/yes | 117/39 |
| Mean BMI (SD) | 26 (4.62) |
| Mean time interval between stroke (SD) and | |
| First assessment, d, mean (SD) | 2.26 (1.28) |
| Second assessment, d | 5.48 (1.40) |
| Third assessment, d | 9.02 (1.81) |
| Type of stroke (Bamford) | |
| LACI | 79 |
| PACI | 50 |
| TACI | 27 |
| NIHSS* | 7 (4–14) |
| Cognitive disturbance | |
| Inattention, no/yes | 93/63 |
| Disorientation, no/yes | 119/37 |
| Impairments of vision | |
| Hemianopia, no/yes | 114/42 |
| Deviation conjugee, no/yes | 122/34 |
| Sensory loss, no/yes | 63/93 |
| TCT (0–100)* | 74 (37–100) |
| MI arm (0–100)* | 39 (0–76) |
| MI leg (0–100)* | 53 (23–83) |
| FM arm (0–66)* | 21 (4–56) |
| FM leg (0–34)* | 21 (9–29) |
| FAC (0–5)* | 1 (0–3) |
| ARAT total score (0–57)* | 1.5 (0–41) |
| BI total score (0–20)* | 8 (3–14) |
| BI urinary incontinence, no/yes (no=2; yes≤1) | 76/79 |
Bivariate Associations Between Dependent and Independent Variables
Table 2 shows odds ratios and their 95% CI as determined by bivariate logistic regression analysis within 72 hours after stroke. Eleven candidate determinants were significantly related to the return of some dexterity at 6 months after stroke. The highest odds ratios were found for finger extension according to the Fugl-Meyer hand score, using an optimal cut-off of 1 point, followed by shoulder abduction according to the Motricity Index arm score, with an optimal cut-off of 9 points. Collinearity diagnostics showed a significant correlation coefficient of 0.75 between “shoulder elevation” and “shoulder abduction.” As a consequence, shoulder abduction, which showed a higher association with ARAT, was included in the multivariate modeling.Table 2. Candidate Determinants Measured Within 72 Hours Associated With the Return of Some Dexterity at 6 Months After Stroke as Determined by Logistic Regression Coefficients
| Determinant | N=156 | ||
|---|---|---|---|
| OR | 95% CI | P | |
| The values between the brackets represent the cut-off scores. | |||
| BAMFORD: TACI, total anterior cerebral infarction; PACI, partial anterior cerebral infarction; LACI, lacunar anterior cerebral infarction; rt-PA, recombinant tissue plasminogen activator; CIRS, Cumulative Illness Rating Scale; MI, Motricity Index; FM, Fugl-Meyer. | |||
| Gender, M/F | 1.58 | 0.79–3.15 | 0.198 |
| Age (0<70; 1≥70) | 1.13 | 0.57–2.25 | 0.726 |
| Hemisphere of stroke, L/R | 0.44 | 0.21–0.91 | 0.027 |
| Bamford (0, TACI/PACI; 1, LACI) | 10.56 | 4.31–25.85 | <0.001 |
| Days between stroke and first assessment | 0.98 | 0.75–1.28 | 0.877 |
| rt-PA (no/yes) | 1.73 | 0.81–3.73 | 0.158 |
| CIRS total score (0≥1; 1=0) | 1.96 | 0.96–3.98 | 0.063 |
| Visual inattention (0≥1; 1=0) | 7.91 | 3.62–17.32 | <0.001 |
| Hemianopia (0≥1; 1=0) | 7.63 | 3.47–16.80 | <0.001 |
| Deviation conjugee (0≥1; 1=0) | 9.00 | 3.84–21.05 | <0.001 |
| Sensory loss (0≥1; 1=0) | 9.15 | 3.36–24.89 | <0.001 |
| Urinary incontinence (0<1; 1≥1) | 6.41 | 2.81–14.59 | <0.001 |
| MI shoulder abduction (0=0; 1≥9) | 32.57 | 12.64–83.92 | <0.001 |
| MI leg (0<25; 1≥5)16 | 15.35 | 6.47–36.49 | <0.001 |
| FM shoulder elevation (0<1; 1≥1) | 22.80 | 9.39–55.37 | <0.001 |
| FM finger extension (FM, 0<1; 1≥1) | 58.67 | 13.83–257.17 | <0.001 |
| Sitting balance (TCT item 3, 0<25; 1=25)16 | 20.67 | 8.44–50.62 | <0.001 |
Multivariate Modeling
Table 3 shows the multivariate logistic regression models for days 2, 5, and 9 after stroke. The probability to achieve some dexterity 6 months after the stroke for those patients who showed some voluntary finger extension and some shoulder abduction on day 2 was estimated at 0.98. The probability for those without voluntary motor activity of these determinants was estimated at 0.25. Two-way contingency table analysis showed a sensitivity of 0.89 (95% CI, 0.85–0.92), a specificity of 0.83 (95% CI, 0.72–0.90), a positive predictive value of 0.93 (95% CI, 0.88–0.96), and a negative predictive value of 0.76 (95% CI, 0.67–0.83). Sixty percent of the patients with some voluntary finger extension (N=82) reached the maximum ARAT score of 57 points, whereas 48% of the patients who were able to abduct the paretic shoulder (N=104) reached the maximum ARAT score. Thirty-four percent of all 156 patients reached a score of 57 points on the ARAT.Table 3. Probabilities of Achieving Some Dexterity at 6 Months After Stroke
| ARAT ≥10 at 6 Months | ||||||
|---|---|---|---|---|---|---|
| FE | SA | True Negatives, N | False Negatives, N | False Positives, N | True Positives, N | P |
| N=156. | ||||||
| FE indicates finger extension; SA, shoulder abduction; FM, Fugl-Meyer; MI, Motricity Index. | ||||||
| Model for day 2, P=1/(1+1*(EXP(−1.119+2.807*FE+2.149*SA))) | ||||||
| FM FE ≥1 | MI SA ≥9 | |||||
| + | + | 38 | 12 | 8 | 98 | 0.98 |
| + | − | 0.89 | ||||
| − | + | 0.71 | ||||
| − | − | 0.25 | ||||
| Model for day 5, P=1/(1+1*(EXP(−1.874+3.070*FE+3.075*SA))) | ||||||
| FM FE ≥1 | MI SA ≥9 | |||||
| + | + | 38 | 6 | 8 | 104 | 0.98 |
| + | − | 0.78 | ||||
| − | + | 0.78 | ||||
| − | − | 0.14 | ||||
| Model for day 9, P=1/(1+1*(EXP(−1.815+3.224*FE+2.449*SA))) | ||||||
| FM FE ≥1 | MI SA ≥9 | |||||
| + | + | 38 | 6 | 8 | 104 | 0.98 |
| + | − | 0.80 | ||||
| − | + | 0.65 | ||||
| − | − | 0.14 | ||||
Retesting the multivariate model for days 5 and 9 showed that the probability remained 0.98 for those patients able to extend their fingers and abduct their shoulders, and it declined to 0.14 for those who did not satisfy either of these criteria. Two-way contingency table analysis showed a sensitivity of 0.95 (95% CI, 0.91–0.97), specificity of 0.83 (95% CI, 0.74–0.89), positive predictive value of 0.93 (95% CI, 0.89–0.95), and negative predictive value 0.86 (95% CI, 0.77–0.93) for both days.
Discussion
The present study is the first prospective cohort study to our knowledge to show that accurate prediction of upper limb function is possible within 72 hours after stroke by using 2 simple clinical tests, ie, finger extension and shoulder abduction. Those patients with some finger extension and shoulder abduction on day 2 after stroke onset had a 98% probability of achieving some dexterity at 6 months. In contrast, patients who did not show this voluntary motor control had a probability of 25%. It is also remarkable that 60% of the patients with some finger extension within 72 hours had regained full recovery of upper limb function according to the ARAT at 6 months. This finding confirms the substantial predictive value of finger extension as a positive sign for a favorable outcome for the upper paretic limb in the acute phase after stroke. Retesting the model on days 5 and 9 showed that the probability of regaining dexterity remained 98% for those with some finger extension and shoulder abduction, whereas the probability decreased from 25% to 14% for those without this voluntary control.
Although the present study did focus on the early time window of stroke recovery, our findings build on results of previous prospective studies that started beyond the first week after stroke.7–10 For example, Smania et al7 showed in a sample of 48 stroke patients that active finger extension at day 7 after stroke is an early valid indicator of a favorable outcome in terms of upper limb function measured with the nine-hole peg test, the Fugl-Meyer arm, and the Motricity Index arm. Katrak et al8 reported that initial shoulder abduction, measured an average of 11 days after stroke, is an early predictor of good hand function at 1 and 2 months after stroke. Our results validate the value of assessing shoulder abduction and finger extension as early favorable indicators for some return of dexterity at 6 months after stroke.
The preservation of voluntary finger extension may reflect the need for some fibers of the corticospinal tract system in the affected hemisphere to remain intact to control distal arm and hand muscles,25,26 assuming that the hand lacks bilateral innervation from both hemispheres.27 To date, transcranial magnetic stimulation25,28 and diffusion tensor imaging25,29 studies further underpin this hypothesis. For example, van Kuijk et al28 showed that in patients with an initial paralysis of the upper limb, the presence or absence of a motor-evoked potential in the abductor digiti minimi measured with transcranial magnetic stimulation at the end of the first week after stroke is highly predictive for final outcome of dexterity at 6 months. However, the presence or absence of a motor-evoked potential in the abductor digiti minimi has similar predictive values when compared to clinical assessment alone.28 The present study suggests that transcranial magnetic stimulation measurements should investigate the predictive validity of motor-evoked potentials of finger extensors rather than finger flexors or the abductor digiti minimi alone.30
The presence of shoulder abduction as a determinant for upper limb function may reflect the intralimb neural coupling between proximal and distal segments in motor control. As early as 1916, Souques31 observed that elevation of the affected arm frequently caused the paralyzed finger to extend. A recent study has shown that distal elbow joint control is dependent on shoulder abduction.32 Obviously, the strength of shoulder abduction affects the elbow-flexion torque and, with that, the reaching range of motion (work area) in patients with stroke.32
With respect to the second aim of the present study, to explore the biological relationship of the proposed clinical determinants with spontaneous neurological recovery, the presented findings show that the probability of regaining some dexterity after 6 months decreased from 25% to 14% in the first 9 days for those without finger extension and shoulder abduction. This may reflect the gradual decline of uncertainty as a result of time-dependent spontaneous processes, such as decrease of cerebral shock or diaschisis.33,34 In contrast, for those patients with some finger extension and shoulder abduction, the probability of regaining dexterity remained 98%. This latter finding suggests that the viability of the corticospinal tract system is almost entirely defined within the first days after stroke in terms of achieving dexterity at 6 months. However, it is important to note that these findings do not suggest that no changes in upper limb function occur beyond 9 days, but rather that the final outcome of dexterity is almost fully defined within this critical time window in this cohort with mild to moderate impairments. To improve our understanding of mechanisms that may underlie recovery, future prospective studies should longitudinally combine clinical and noninvasive neurophysiologic assessments such as transcranial magnetic stimulation and functional MRI in an intensive, early, repeated-measurement design after stroke.30
For clinical practice, the findings of the present study might improve early stroke management decisions like discharge and multidisciplinary intervention planning at (sub)acute stroke units. As a consequence, subsequent multidisciplinary rehabilitation services may be optimized in line with the probability for regaining some dexterity, particularly acknowledging that many evidence-based therapies for the upper paretic limb, including Constrained Induced Movement Therapy and may require some return of voluntary wrist and finger extension.6,35 The findings of a recent study by Smania et al36 strengthen this suggestion by also showing the predictive validity of finger extension and shoulder abduction at day 7 for daily life autonomy.
In interpreting the findings of the present study, some limitations should be noted. In accordance with the stroke guidelines,5 we included only medically stable patients with first-ever ischemic strokes in 1 of the hemispheres. As a consequence, patients with a mild-to-moderate stroke who were able to communicate and understand were included in the present study. This might limit the generalization of the present findings to other patients with problems like dysphasia, confusion, or reduced consciousness. However, having an early prognosis is most relevant for an appropriate discharge treatment policy from a hospital stroke unit for the cohort we selected.
Acknowledgments
The authors thank all EPOS assessors in the stroke units of the participating university centers and local hospitals (AMC Amsterdam; Erasmus MC Rotterdam; LUMC Leiden; UMC Sint Radboud; UMC Utrecht; VUmc Amsterdam; Amphia Hospital Breda; Diaconessen Hospital Leiden; Franciscus Hospital Roosendaal) and in the affiliated nursing homes (ie, St. Jacob, Zonnehuis and Cordaan/Berkenstede in Amsterdam, Laurens Antonius Binnenweg and Reumaverpleeghuis in Rotterdam, Albert van Koningsbruggen in Utrecht and Wiekendaal in Roosendaal) for performing the measurements. The authors also thank the patients who participated in the study. Finally, the authors thank J. de Vries and A. Jansen, students at Hogeschool Amsterdam, for their contribution to the data management.
Sources of Funding
This study was part of the EPOS research project funded by the “Wetenschappelijk College Fysiotherapie” (WCF number 33368) of the Royal Dutch Society for Physical Therapy (KNGF), the Netherlands. This part of the EPOS project is co-financed by ZON-MW (grant 89000001) as a part of the EXPLICIT-stroke programme (www.explicit-stroke.nl).
Disclosure
None.
Footnote
EPOS Investigators: Executive committee: G. Kwakkel, PhD, principal investigator, Department of Rehabilitation Medicine, VU University Hospital Medical Center, Amsterdam, and co-principal investigator, B.C. Harmeling-van der Wel, Department of Rehabilitation Medicine and Physical Therapy, Erasmus MC University Medical Center, Rotterdam. Steering committee and data management: J.M. Veerbeek and R.H.M. Nijland, Department of Rehabilitation Medicine, VU University Hospital Medical Centre, Amsterdam. Revision of the manuscript: E.E.E. van Wegen, PhD, Department of Rehabilitation Medicine, VU University Hospital Medical Centre, Amsterdam. Monitoring board: M.A. van der Beek, UMC Utrecht; W.A.M. Cornelissen, AMC Amsterdam; A.A.G. Goos, Franciscus Hospital, Roosendaal; C.S. Steeg, UMC Sint Radboud, Nijmegen; J.M. Timmermans, LUMC, Leiden; R. Tichelaar, Amphia Hospital, Breda.
References
1.
Sunderland A, Fletcher D, Bradley L, Tinson D, Hewer RL, Wade DT. Enhanced physical therapy for arm function after stroke: a one year follow up study. J Neurol Neurosurg Psychiatry. 1994; 57: 856–858.
2.
Wade DT, Langton-Hewer R, Wood VA, Skilbeck CE, Ismail HM. The hemiplegic arm after stroke: measurement and recovery. J Neurol Neurosurg Psychiatry. 1983; 46: 521–524.
3.
Nakayama H, Jorgensen HS, Raaschou HO, Olsen TS. Recovery of upper extremity function in stroke patients: the Copenhagen Stroke Study. Arch Phys Med Rehabil. 1994; 75: 394–398.
4.
Summers D, Leonard A, Wentworth D, Saver JL, Simpson J, Spilker JA, Hock N, Miller E, Mitchell PH. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient. A scientific statement from the Amercian Heart Association. Stroke. 2009; 40: 2911–2944.
5.
Duncan PW, Zorowitz R, Bates B, Choi JY, Glasberg JJ, Graham GD, Katz RC, Lamberty K, Reker D. Management of Adult Stroke Rehabilitation Care: a clinical practice guideline. Stroke. 2005; 36: e100–e143.
6.
Fritz SL, Light KE, Patterson TS, Behrman AL, Davis SB. Active finger extension predicts outcomes after constraint-induced movement therapy for individuals with hemiparesis after stroke. Stroke. 2005; 36: 1172–1177.
7.
Smania N, Paolucci S, Tinazzi M, Borghero A, Manganotti P, Fiaschi A, Moretto G, Bovi P, Gambarin M. Active finger extension: a simple movement predicting recovery of arm function in patients with acute stroke. Stroke. 2007; 38: 1088–1090.
8.
Katrak P, Bowring G, Conroy P, Chilvers M, Poulos R, McNeil D. Predicting upper limb recovery after stroke: the place of early shoulder and hand movement. Arch Phys Med Rehabil. 1998; 79: 758–761.
9.
Beebe JA, Lang CE. Active range of motion predicts upper extremity function 3 months after stroke. Stroke. 2009; 40: 1772–1779.
10.
Kwakkel G, Kollen BJ, van der Grond J, Prevo AJH. Probability of regaining dexterity in the flaccid upper limb: impact of severity of paresis and time since onset in acute stroke. Stroke. 2003; 34: 2181–2186.
11.
Kwakkel G, Kollen B. Predicting improvement in the upper paretic limb after stroke: a longitudinal prospective study. Restor Neurol Neurosci. 2007; 25: 453–460.
12.
Kwakkel G, Kollen B, Twisk J. Impact of time on improvement of outcome after stroke. Stroke. 2006; 37: 2348–2353.
13.
Lyle RC. A performance test for assessment of upper limb function in physical rehabilitation treatment and research. Int J Rehabil Res. 1981; 4: 483–492.
14.
van der Lee JH, De Groot V, Beckerman H, Wagenaar RC, Lankhorst GJ, Bouter LM. The intra- and interrater reliability of the action research arm test: a practical test of upper extremity function in patients with stroke. Arch Phys Med Rehabil. 2001; 82: 14–19.
15.
Yozbatiran N, Der-Yeghiaian L, Cramer SC. A standardized approach to performing the action research arm test. Neurorehabil Neural Repair. 2008; 22: 78–90.
16.
Quinn TJ, Paolucci S, Sivenius J, Walker MF, Toni D, Lees KR. Evidence-based stroke rehabilitation: an expanded guidance document from the European stroke organisation (ESO) guidelines for management of ischaemic stroke and transient ischaemic attack 2008. J Rehabil Med. 2009; 41: 99–111.
17.
Hatano S. Experience from a multicentre stroke register: a preliminary report. Bull World Health Organ. 1976; 54: 541–553.
18.
Bamford J, Sandercock P, Dennis M, Burn J, Warlow C. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet. 1991; 337: 1521–1526.
19.
de Groot V, Beckerman H, Lankhorst GJ, Bouter LM. How to measure comorbidity. A critical review of available methods. J Clin Epidemiol. 2003; 56: 221–229.
20.
Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG, Biller J, Spilker J, Holleran R, Eberle R, Hertzberg V. Measurements of acute cerebral infarction: a clinical examination scale. Stroke. 1989; 20: 864–870.
21.
Collin C, Wade DT, Davies S, Horne V. The Barthel ADL Index: a reliability study. Int Disabil Stud. 1988; 10: 61–63.
22.
Collin C, Wade D. Assessing motor impairment after stroke: a pilot reliability study. J Neurol Neurosurg Psychiatry. 1990; 53: 576–579.
23.
Sanford J, Moreland J, Swanson LR, Stratford PW, Gowland C. Reliability of the Fugl-Meyer assessment for testing motor performance in patients following stroke. Phys Ther. 1993; 73: 447–454.
24.
Franchignoni FP, Tesio L, Ricupero C, Martino MT. Trunk control test as an early predictor of stroke rehabilitation outcome. Stroke. 1997; 28: 1382–1385.
25.
Stinear CM, Barber PA, Smale PR, Coxon JP, Fleming MK, Byblow WD. Functional potential in chronic stroke patients depends on corticospinal tract integrity. Brain. 2007; 130 (Pt 1): 170–180.
26.
Ward NS, Newton JM, Swayne OB, Lee L, Thompson AJ, Greenwood RJ, Rothwell JC, Frackowiak RS. Motor system activation after subcortical stroke depends on corticospinal system integrity. Brain. 2006; 129 (Pt 3): 809–819.
27.
Morecraft RJ, Herrick JL, Stilwell-Morecraft KS, Louie JL, Schroeder CM, Ottenbacher JG, Schoolfield MW. Localization of arm representation in the corona radiata and internal capsule in the non-human primate. Brain. 2002; 125 (Pt 1): 176–198.
28.
van Kuijk AA, Pasman JW, Hendricks HT, Zwarts MJ, Geurts AC. Predicting hand motor recovery in severe stroke: the role of motor evoked potentials in relation to early clinical assessment. Neurorehabil Neural Repair. 2009; 23: 45–51.
29.
Cho SH, Kim DG, Kim DS, Kim YH, Lee CH, Jang SH. Motor outcome according to the integrity of the corticospinal tract determined by diffusion tensor tractography in the early stage of corona radiata infarct. Neurosci Lett. 2007; 426: 123–127.
30.
Kwakkel G, Meskers CG, van Wegen EE, Lankhorst GJ, Geurts AC, van Kuijk AA, Lindeman E, Visser-Meily A, de VE, Arendzen JH. Impact of early applied upper limb stimulation: the EXPLICIT-stroke programme design. BMC Neurol. 2008; 8: 49.
31.
Brunnstrom S. Movement therapy in hemiplegia: a neurophysiological approach. New York, NY: Harper and Row; 1970.
32.
Ellis MD, Sukal-Moulton T, Dewald JP. Progressive shoulder abduction loading is a crucial element of arm rehabilitation in chronic stroke. Neurorehabil Neural Repair. 2009; 23: 862–869.
33.
Kwakkel G, Kollen B, Lindeman E. Understanding the pattern of functional recovery after stroke: facts and theories. Restor Neurol Neurosci. 2004; 22: 281–299.
34.
Feeney DM, Baron JC. Diaschisis. Stroke. 1986; 17: 817–830.
35.
Wolf SL, Winstein CJ, Miller JP, Taub E, Uswatte G, Morris D, Giuliani C, Light KE, Nichols-Larsen D. Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial. JAMA. 2006; 296: 2095–2104.
36.
Smania N, Gambarin M, Tinazzi M, Picelli A, Fiaschi A, Moretto G, Bovi P, Paolucci S. Are indexes of arm recovery related to daily life autonomy in patients with stroke? Eur J Phys Rehabil Med. 2009; 45: 349–354.
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Received: 6 November 2009
Revision received: 24 November 2009
Accepted: 25 November 2009
Published online: 18 February 2010
Published in print: 1 April 2010
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