Richard Langton Hewer

Functional abilities after stroke: measurement, natural history and prognosis.

Actual functional performance of 976 acute stroke patients was assessed using the Barthel index: the data were analysed to determine the frequency of disability after stroke, the validity of the Barthel index, and the recovery seen. At 6 months, over 45% of survivors were functionally independent. Validity of the Barthel index was confirmed: it related as expected with motor loss and factor analysis showed a single major factor. The items of the Barthel index form an hierarchical scale. There was some recovery between 3 weeks and 6 months in almost all patients: the major prognostic factors were urinary incontinence, functional ability, sitting balance and age.

Recovery after stroke

One hundred and sixty-two patients were referred to a rehabilitation unit after an acute stroke. The patterns of recovery of overall functional ability, arm function, walking and speech in 92 of 101 survivors have been analysed. In all modalities the majority of recovery occurs within 3 months; although improvement is seen thereafter it does not reach statistical significance. Possible reasons for the apparent lack of late recovery are discussed.

Arm function after stroke: measurement and recovery over the first three months.

Four short, simple measures of arm function, suitable for use with patients recovering from acute stroke, are described. These tests are: the Frenchay Arm Test, the Nine Hole Peg Test, finger tapping rate and grip strength. Good interobserver and test-retest reliability was demonstrated for all tests, and the Frenchay Arm Test was shown to be valid. Normal values for all tests were established on 63 controls. It was found that the limited sensitivity of the Frenchay Arm Test could be improved using the Nine Hole Peg Test and grip strength. Recovery of arm function has been studied in a sample of 56 patients seen regularly over the first 3 months after their stroke, using these standard measures. The results demonstrated a wide variation in recovery curves between patients. The use of the Nine Hole Peg Test enabled further recovery to be detected after patients achieved a top score on the Frenchay Arm Test. Failure to recover measureable grip strength before 24 days was associated with absence of useful arm function at three months. Measurement of finger tapping rate was not useful.

Social activities after stroke: Measurement and natural history using the Frenchay Activities Index

A method of assessing general (i.e. other than personal care) activities of stroke patients is described: the Frenchay Activities Index (FAI), a scale comprising 15 individual activities summed to give an overall score from 0 (low) to 45 (high). Data from 976 patients with acute stroke were analysed to establish the validity and reliability of the index, and to give information on the level of activities seen before stroke, at 6 months and 1 year post-stroke. Factors related to a lower overall score included loss of functional (ADL) ability, more depression, a lower IQ and, at 1 year, being female.

Arm function after stroke. An evaluation of grip strength as a measure of recovery and a prognostic indicator.

The value of strength of voluntary grip as an indicator of recovery of arm function was assessed by testing 38 recent stroke patients using a sensitive electronic dynamometer, and comparing the results with those from five other arm movement and function tests (Motricity Index, Motor Club Assessment, Nine Hole Peg Test, and Frenchay Arm Test). This procedure allowed measurement of grip in a large proportion of patients, and strength correlated highly with performance on the other tests. Measuring grip over a six month follow up period was a sensitive method of charting intrinsic neurological recovery. The presence of voluntary grip at one month indicates that there will be some functional recovery at six months.

Aphasia after stroke: natural history and associated deficits.

Data relating to 976 patients registered as suffering an acute stroke has been analysed to determine the natural history of speech disturbance: these patients came from a community survey of 215,000 people over a 28 month period. Of the 545 patients assessed within 7 days of stroke, 24% were aphasic and 28% unassessable. At 3 weeks, when over 90% of survivors were tested, 20% of those tested had aphasia. At 6 months only 12% of survivors had significant aphasia, but 44% of patients and 57% of carers thought speech was abnormal. Of those aphasic within 7 days, 40% remained so at 6 months; 60% of those aphasic at 3 weeks remained so. There was a high correlation between early and late aphasia scores. Aphasia was associated with more severe disability (degree of limb weakness, loss of function, loss of IQ), and with a less good recovery of social activities, but did not cause any measurable increase in stress upon carers. In a Health District of 250,000 people, about 60 patients each year may be referred for speech therapy after an acute stroke.

Recovery after stroke--the first 3 months.

Ninety-nine patients had their function recorded regularly over the first 13 weeks after their stroke. Five functional areas were studied: urinary continence, mobility, the ability to dress, feeding, and the ability to transfer from bed to chair. Thirty-two patients died before 13 weeks. Forty-five of the 67 survivors had assessments twice weekly from within 4 days of their stroke. Recovery in these 45 patients occurred fastest in the first 2 weeks, by which time at least 50% of recovery had occurred, but it was still continuing at 13 weeks. Urinary incontinence present between 7 and 10 days after stroke was the most important adverse prognostic factor both for survival and for recovery of function. Age was the second most important factor. Hospital discharge seemed to occur once recovery had stopped, although four of the 49 patients discharged had been fully independent for at least 12 days prior to discharge. It is suggested that rehabilitative therapy should concentrate less on physical function and more on cognitive ability.

The Frenchay Aphasia Screening Test: a short, simple test for aphasia appropriate for non-specialists.

This paper describes preliminary studies on a screening test for aphasia which takes 3-10 minutes to complete and which is suitable for use by general practitioners, junior medical staff and other non-specialists. Data are presented to show that it is a reliable, valid assessment. Using cut-off values derived from normal people, the test is sensitive, but its specificity is limited by such associated factors as hemianopia. Using cut-off values derived from patients known to have aphasia, its specificity is improved. An abnormal result needs to be interpreted in the light of all available clinical information. The test should help identify patients with linguistic disturbance.

Driving after a stroke.

Four hundred and thirty-eight stroke patients from a community register covering a period of 28 months were interviewed at one year post-stroke. Of 144 (34%) living at home who had been driving prior to their stroke, 82 (58%) did not resume post-stroke. Assessments of arm function, walking, functional ability and IQ showed ex-drivers to be significantly more disabled than drivers. Stopping driving was associated with a loss of social activities and with a higher frequency of depression amongst ex-drivers when compared with drivers. This was despite 79% of ex-drivers having easy access to alternative car transport. Extending mobility allowance to the 49 (60%) ex-drivers over 65 years old at the time of their stroke might ease their situation. More appropriate assessments would be needed to establish whether ex-drivers would benefit from retraining or car adaptations to enable them to return to driving.

Enhanced physical therapy for arm function after stroke: a one year follow up study.

Ninety seven patients with stroke who had participated in a randomised trial of conventional physical therapy nu an enhanced therapy for arm function were followed up at one year. Despite the emphasis of the enhanced therapy approach on continued use of the arm in everyday life, the advantage seen for some patients with enhanced therapy at six months after stroke had diminished to a non-significant trend by one year. This was due to some late improvement in the conventional therapy group whereas the enhanced therapy group remained static or fell back slightly. It is recommended that trials should be conducted comparing very intensive therapy for the arm with controls without treatment. This would provide a model of the effects of therapy on intrinsic neural recovery that would be relevant to all areas of neurological rehabilitation.