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Rehabilitation medicine
Original research
Predictors of upper limb motor recovery in stroke survivors: a pre–post test study design
  1. Hope Muwanei Sikuka1,
  2. Joseph Lupenga2,
  3. Loveness Nkhata1
  1. 1Department of Physiotherapy, University of Zambia, Lusaka, Zambia
  2. 2Department of Epidemiology and Biostatistics, University of Zambia School of Public Health, Lusaka, Zambia
  1. Correspondence to Ms Hope Muwanei Sikuka; hopemuwanei{at}gmail.com

Abstract

Objectives The study aimed to assess the predictors of upper limb motor recovery in stroke survivors.

Design Pre–post test study design.

Setting Conducted in two centres (First Level Hospital and University Teaching Hospital in Lusaka).

Participants Patients living with stroke accessing physiotherapy services at the two public hospitals. A total of 52 patients were recruited at the start of the study, 6 were lost to follow-up and 46 completed the study.

Intervention Conventional physiotherapy for 8 weeks (5 September 2022–28 October 2022).

Primary outcome Motor function measured using a Fugl-Meyer assessment of the upper extremity.

Results Analysis was conducted on 46 participants. A significant difference was observed between the level of motor function at baseline and after 8 weeks of treatment (p=0.0183). At baseline, 50% of participants had mild motor function, which improved after 8 weeks, with 69.6% having mild motor function. Stroke patients with severe motor function impairment at baseline were associated with 0.01 times likelihood of having mild motor function impairment after 8 weeks of physiotherapy treatment (AOR 0.01; 95 % CI 0.00 to 0.16; p=0.002).

Conclusion The motor function of stroke patients continues to improve over time. This study demonstrated that initial upper limb motor function impairment could be used as a predictor for upper limb motor function.

  • Stroke
  • REHABILITATION MEDICINE
  • STROKE MEDICINE
  • Risk Factors

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2023-081936

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • The pre–post study design allowed for the evaluation of changes in motor function over time, offering valuable insights into stroke recovery trajectory.

    • The use of the Fugl-Meyer assessment tool for upper extremity motor function improved the study’s validity and comparability with previous studies.

    • The study’s lack of a control group makes it challenging to determine if changes in upper limb motor recovery were solely due to the physiotherapy intervention or other factors.

    • The study’s generalisability and statistical power is limited by a small sample size.

    Introduction

    Global Burden of Disease released the most recent statistics on stroke in 2019. There were 12.2 million incident cases of stroke (95% uncertainty interval 11.0–13.6), 101 million (93.2–111) prevalent cases of stroke and 143 million (133–153) disability-adjusted life-years due to stroke in 2019. Stroke remained the third-leading cause of death and disability worldwide in 2019.1 In Africa, the annual incidence rate of stroke reaches as high as 316 per 100 000 individuals, placing it among the regions with the highest incidence rates globally.2 The pooled 1-month mortality rate for stroke in Africa is estimated to be approximately 24.1% (95% CI 21.5% to 27.0%) and 1-year mortality rate is estimated to be 33.2% (95% CI 23.6% to 44.5%).3

    A shift in movement early after stroke has been reported; bilateral use decreases and unilateral use of the non-paretic upper limb increases by 77%.4 Also, stroke survivors perform significantly worse on both their affected and unaffected sides.5 This is because the decreased activity in the affected upper limb is associated with increased severity of motor dysfunction.6–8 In addition, motor impairment in stroke patients limits their ability to do activities of daily living, lowers their quality of life and places a significant economic burden on them.9

    Previous studies have suggested that some stroke patients show a significant improvement in the early stages of the stroke, while it is in later stages for others.10–13 More so, some studies have revealed that a more significant improvement in the function of the upper limb occurs in the first 4–6 weeks after a stroke.11–13 However, people who have had a stroke continue to improve over a period of 6 months after the stroke and the improvements remain noticeable 12–18 months after the stroke.11 12 Furthermore, in the first 12 weeks following a stroke, most patients with an impaired upper limb show minimal improvement in their level of activity.10

    The field of stroke rehabilitation is faced with the challenge of tailoring evidence-based treatment strategies to meet the needs of the individual patients with stroke.14 In the case of sub-Saharan Africa, stroke rehabilitation services often lack essential components such as comprehensiveness, accessibility, quality, accountability, continuity and coordination, with common challenges including low service frequency, incomprehensible services, lack of trained staff and infrastructure limitations.15 Addressing these challenges is essential for improving stroke rehabilitation outcomes in sub-Saharan Africa. In addition, identifying and addressing predictors of stroke motor recovery within the context of limited rehabilitation services, and provision of patient-centred care is crucial to optimising outcomes for stroke patients in the region. The ability to predict who will recover from stroke and to what extent has been an ongoing priority in rehabilitation.16 Possible predictive factors that have been investigated in previous studies include age, sex, side affected, type of stroke, comorbidities, time since stroke and baseline motor function.17 18 These predictive factors of motor recovery in stroke survivors were selected based on theoretical models of neurorehabilitation and clinical research suggesting that stroke severity and functional recovery vary with these factors. For example, stroke types, such as ischaemic and haemorrhagic, have different aetiologies and clinical presentations,19 which can influence recovery and response to treatment. Age has been suggested to be an important predictor of motor recovery in stroke survivors, with older individuals having poorer outcomes due to reduced neuroplasticity, increased comorbidities and reduced functional reserve.20 Sex differences in stroke incidence, severity and recovery have been documented, with some studies suggesting that women may have better outcomes.19 Comorbidities such as hypertension, diabetes and cardiovascular disease have been linked to poor functional stroke recovery as they exacerbate vascular damage, and increase the risk of secondary complications.21 In addition, initiating stroke rehabilitation as soon as patients are medically stable is reported to be critical in capitalising on the window of recovery in the early stages of stroke rehabilitation.20 Therefore, it is important to consider the timing of commencing rehabilitation as a potential predictor for motor recovery. There is also evidence that the dominant hemisphere may cause more severe motor deficits, so the side affected by the stroke may influence motor recovery.22 For instance, one study showed that the side of hemiparesis after stroke may influence differences in functional recovery after stroke rehabilitation.23 Baseline motor function, which reflects the extent of neural damage and provides insight into the individual’s ability to relearn and rehabilitation success, can play an important role in predicting motor recovery.24 Recommendations have been made that the most important factors predicting recovery of the upper extremity (UE) were the initial assessment of impairment and function of the UE.17 18 Several studies have been conducted to identify predictors of motor recovery, but the identified predictors vary between studies, necessitating further studies to better understand predictors of upper limb motor recovery.17 18 23

    Currently, in Zambia, there is inadequate information on factors predicting motor recovery in people with a stroke. However, the capacity to predict motor recovery is crucial for rehabilitation planning because it allows treatment to be tailored to those features by choosing effective therapies that support upper-limb function and setting realistic and achievable treatment goals. Hence, the purpose of this study was to determine the predictors of upper limb motor recovery in stroke survivors.

    Materials and methods

    Study design

    This study was a pre–post test study design and participants were enrolled and followed up for a period of 8 weeks (from 5 September 2022 to 28 October 2022) which allowed them to have at least 10 sessions of physiotherapy. This study was conducted in the outpatient physiotherapy departments of two major public hospitals. These facilities were chosen because of the large number of patients visiting their departments.

    Study population and sample size

    The study population included all stroke patients accessing services at the two public hospitals. According to the District Health office, during normal seasons, nearly 100 stroke patients are attended to on a monthly basis at the 2 centres.25 However, since this study was conducted during the COVID-19 pandemic restrictions, the population size was approximately 75 per month. The study used G-Power V.3.1.9.7 software to estimate the sample size. Using 90% power and 5% type 1 error level, 41 participants were the minimum required sample size. The expected pretreatment Fugl-Meyer Assessment (FMA)-UE was 27.5, with an SD of 16.5, and post-treatment FMA-UE was 36.9, based on a previous study by Hiragami et al.26 The sample size was calculated using t-test family and statistical test for the difference between two dependent means (matched pairs). After accounting for a 20% dropout rate, the recommended sample size was 51 participants. Considering that the number of patients dropped during the COVID-19 pandemic, only a total of 52 participants who met the inclusion criteria which included; stroke patients between the ages of 18 and 80 years, who provided consent, had first incidence of stroke and were attending physiotherapy in the outpatient department for not more than 6 months.

    Data collection

    Data were collected at two points (baseline and exit) using a researcher-administered questionnaire that had two sections. Items on participant’s demographic characteristics and their clinical profile were collected in section A. It is important to note other items on baseline information were also obtained through assessment of the participant’s medical files where necessary. In section B, information about motor function and recovery was measured using the FMA, a tool commonly used in measuring upper limb function on items that comprise movements of the shoulder, elbow, wrist and hand movements.17 This tool is a stroke-specific performance-based impairment index with a maximum score of 66 and assesses also the motor functioning, balance, sensation and joint effectiveness in patients with stroke hemiplegia and has been shown to have excellent intrarater and inter-rater reliability.27 The FMA-UE was administered by two trained physiotherapists (one per healthcare facility) with more than 10 years of experience in the management and assessment of motor function in the upper limbs of stroke survivors. The assessment involved a structured examination of motor tasks related to upper limb movement, including coordination and reflex activity. The total score provided a quantitative measure of the participant’s upper limb motor recovery after stroke. To reduce bias, the physiotherapists who administered the FMA-UE were not involved in the treatment of the stroke patients. In addition, the assessors were blinded to the participants’ demographics, clinical characteristics and baseline assessment scores at follow-up assessments.

    Outcome measures and potential predictors

    The outcome variables in this study were motor function which was categorised as mild (43–66), moderate (29–42) or severe (0–28) and was measured using the FMA tool.28 Other potential predictors which were measured included age, sex, marital status, employment status, baseline motor impairment, type of stroke, side of stroke, presence of comorbidities, rehabilitation commencement and onset of stroke.

    Treatment programme

    The treatment programme was offered as part of the routine treatment for stroke patients in the outpatient physiotherapy departments during the 8-week study period. The principal investigator and four research assistants who are physiotherapists trained at BSc degree level conducted the treatment which comprised conventional upper limb physiotherapy, where exercise therapy and upper limb rehabilitation techniques such as functional tasks movements, coordination activities and proprioceptive stimulations. It is important to note that the treatment given to each participant was tailored to their needs, each session lasted for 1 hour with rest intervals (45 min of intervention and 15 min of rest) and was conducted three times a week for 8 weeks (online supplemental table 1).

    Data analysis

    Data were analysed by using Stata V.15.0 and normality for all continuous variables was patterned with the histograms and the Shapiro-Wilk test and presented using the first and third quartile values. To compare the pre and post data, the continuous motor function scores and Wilcoxon matched pairs signed rank test were used. The categorised motor function levels at preassessment and postassessment were compared using the Stuart-Maxwell test for marginal homogeneity. In addition, univariate and multivariate logistic regression analyses were performed to assess the association between potential predictors for upper limb motor impairment and reported using ORs with 95% CIs and the level of statistical significance was considered at <0.05 level. Further, we also used backward elimination logistic regression to build the final model and retain all explanatory variables with a p<0.05. This high level of significance had been chosen to avoid missing important variables which could have influenced the results and to avoid dropping less important variables in the model with practical and clinical significance.29 Bayesian information criterion and Akaike’s information criterion were used for model selection, with preference given to the model with the lowest value and the Hosmer-Lemeshow test was used to assess the goodness of fit of the final models.

    Results

    Figure 1 shows the recruitment and follow-up flow diagram of study participants. As can be seen in the diagram, we recruited 52 participants who met the inclusion criteria and were attending outpatient rehabilitation healthcare. However, six participants were lost to follow-up as 3 died and another 3 transferred to different towns, leaving a total number of 46 participants included in the analysis as shown in figure 1.

    Figure 1
    Figure 1

    Recruitment and follow-up flow diagram. FMA-UE, Fugl-Meyer Assessment-upper extremity,. OPD (Out patient department)

    Participant’s social demographic characteristics

    Table 1 shows that 50% of the participants were aged between 46 and 60 years and most of them (63%) were females. It can also be seen that 95.7% of the participants were hypertensive and 63% had right-sided stroke which lasted between 3 and 6 months for 65.2% before onset of this study.

    View this table:
    Table 1

    Participant’s social demographic characteristics (n=46)

    Participant’s pre and post Motor functional Impairment scores

    As shown in table 2, the results for FMA-UE motor recovery of Stroke indicate that there was a significant improvement in the UE motor function 8 weeks after treatment (p=0.0001). Precisely, there was significant improvement in the FMA-UE scores in the arm and forearm (0.0001), wrist (p=0.0051), coordination (p=0.0083) and hand motor function (p=0.0429).

    View this table:
    Table 2

    Participant’s pre and post Motor functional Impairment scores (n=46)

    Participant’s pre and post motor function impairment levels

    Significant differences were observed in motor function impairment levels preintervention and postintervention (p=0.0183). Furthermore, figure 2 shows that at 8 weeks, the proportion of participants with mild impairment increased significantly from 50% to 69.6%, while a decrease was observed in the proportion with moderate (23.9% to 15.2%) and severe (26.1% to 15.2%) impairment.

    Figure 2
    Figure 2

    Participant’s pre–post level of motor function impairment (n=46). FMA-UE, Fugl-Meyer Assessment-upper extremity.

    Predictors of upper limb motor function impairment among participants

    Table 4 highlights that stroke patients with severe motor function impairment at baseline were 0.01 times less likely to have mild motor function impairment after 8 weeks of physiotherapy treatment than stroke patients with mild motor function impairment at baseline (AOR (adjusted odds ratio) 0.01; 95 % CI 0.00 to 0.16; p=0.002).

    View this table:
    Table 3

    Predictors of Upper Limb Motor Function Impairment among participants (n=46)

    Discussion

    The study aimed to investigate predictors of upper limb motor recovery in stroke survivors, focusing on how motor function changes over time with physiotherapy treatment. It demonstrated a significant improvement in UE motor function 8 weeks after treatment. Specifically, there was a notable increase in the proportion of participants with mild impairment, and a decrease in the proportion of participants with moderate and severe impairment. Furthermore, the study found that stroke patients with severe motor function impairment at baseline were less likely to exhibit mild motor function impairment after 8 weeks of physiotherapy treatment.

    In this study, females made the majority of the study participants which is consistent with findings from a previous study that also reported that females were the majority.30 However, this finding contrasts with findings from previous studies that reported that the males were the majority of the participants.31 32 The study’s high proportion of female participants aligns with evidence from stroke epidemiology, which indicates gender-specific variations in stroke incidence. Women tend to experience higher stroke rates at younger ages and slightly elevated rates at older ages compared with men which could be the case in this study considering most participants were within 40–60 years.19 Various factors contribute to this difference, including pregnancy-related conditions like pre-eclampsia, the use of contraceptives and hormonal therapy, and the presence of migraines, all of which increase stroke risk in women. Additionally, atrial fibrillation raises the stroke risk by 20% in women aged over 75.19 However, understanding these variations between studies is crucial for gaining insights into the gender-specific aspects of stroke incidence, prevalence, risk factors and outcomes. Most of the participants were within the age range of 40–60 years old and similar findings were reported in previous studies.17 32 This age group is notable for being a period where individuals may be more susceptible to stroke due to various risk factors such as hypertension, diabetes and lifestyle factors like smoking and physical inactivity. The consistency of findings across multiple studies suggests that this age group is an important demographic for stroke research and intervention. On the contrary, a higher age group (mean age 69 years) than the one reported in this study has been reported in a similar study.31 The age distribution of stroke patients may vary between studies due to differences in populations, such as life expectancy and exposure to risk factors. Countries with higher life expectancy have a higher proportion of older adults with stroke. Exposure to these risk factors may also influence the age distribution of stroke patients, as seen in a study with a higher mean age of 69 years.

    Consistent with findings from literature, the study found that ischaemic stroke was the most common type of stroke.32 33 The consistency of the study results with the existing literature reinforces the established trends in stroke epidemiology that ischaemic stroke is the most common type of stroke globally, accounting for 80%–85% of all strokes.19 Risk factors such as high blood pressure, diabetes, high cholesterol and smoking exacerbate the predominance of ischaemic strokes, which are primarily caused by vascular pathology such as blood clots or atherosclerosis.19 In addition, hypertension was the most common comorbidity which is similar to what has been reported in earlier studies.34 Hypertension is the most common comorbidity among stroke patients possibly due to its high prevalence in the general population and being the predominant risk factors for stroke. Recognising this highlights the need for comprehensive public health strategies to prevent and manage hypertension, including promoting healthy lifestyle behaviours and improving access to healthcare services for blood pressure monitoring and management. Furthermore, the study found that stroke mainly affected the right side and this is consistent with the findings from earlier studies.33 34 However, this finding contradicts the findings from other previous studies that reported that the left side was the most affected.17 The reasons for the differences in the side affected between this study and other studies remain unknown.

    Following the 8-week intervention programme significant improvement was generally observed in all UE motor functions (table 2). Improvement was observed in motor function scores of the arm and forearm, wrist, hand and co-ordination. These findings raise the probability that stroke patients can regain their UE motor function with appropriate intervention, emphasising the potential for functional recovery even after stroke-related impairments. These outcomes are similar to Ingwersen et al32 who suggest that there is continuous improvement in motor function over time in stroke rehabilitation. In a similar study, Borschmann and Hayward12 specifically identified the greatest rate of improvement within the first 2–6 weeks poststroke but also noted that the trajectory of improvement varies among individuals, with some experiencing continued improvement in capacity and performance measures up to an average of 12–18 months poststroke, and others showing ongoing improvement even after 24 months. The improvements in stroke motor recovery observed in the study can be attributed to the principles of motor learning and the underlying neuroplasticity mechanisms that occur in the brain following a stroke. Through structural changes such as axonal or dendritic growth, new synapse formation, functional modulation and cortical reorganisation, stroke survivors can undergo significant improvements in motor function with appropriate rehabilitation interventions.35 36 This suggests that early intervention is crucial in order to maximise functional gains, however, improvements may continue to occur beyond the acute phase of the stroke. These variations emphasise the importance of personalised rehabilitation approaches that address patients’ individual needs and responses to treatment. The current study evaluated improvement over an 8-week period, which is relatively short compared with the longer-term trajectories of recovery observed in stroke rehabilitation. While significant improvement was observed within this time frame, it is crucial to recognise that stroke recovery is often a complex and ongoing process that may extend beyond the duration of the intervention. Therefore, longer-term follow-up assessments are necessary to fully understand the trajectory of recovery and the sustainability of improvements over time.

    The findings in this study suggest that the degree of initial motor impairment may be a useful factor to take into account when predicting the recovery of upper limb motor function. In addition to this, the outcomes demonstrate that severe motor function impairment is less likely to progress to mild motor function impairment compared with mild motor function impairment. This implies that patients with severe motor impairment following a stroke may require more time to regain functional use of upper limbs than patients with mild or moderate impairment. This is consistent with other reported findings by Wu et al37 and Snickars et al31 which suggest that the initial level of motor impairment is a strong predictor of upper limb recovery during stroke rehabilitation. These findings could be explained by the fact that patients with mild initial deficits often have less extensive damage to neural pathways involved in motor control compared with those with severe deficits. As a result, they may have greater potential for neuroplasticity and functional recovery.24

    We observed no differences in the levels of motor function impairment among the demographic factors, age, sex, lesion side, rehabilitation onset and comorbidities. These findings are consistent with findings from other studies, which have similarly failed to identify significant associations between these factors and motor function outcomes in stroke survivors.31 38 These findings contradict what has been suggested in the literature where these factors have been associated with motor recovery after stroke.23 39 40 The short follow-up period in the study may indeed contribute to the lack of observed differences in recovery among various factors compared with other studies. This could also be attributed to the small sample size as literature suggests that a small sample size is more likely to have inconclusive or contradictory results especially when there is a lot of variation.41 Thus, further research into the demographic and clinical factors related to motor function impairment with larger sample size is essential. The regression results also showed that type of stroke was not significantly associated with upper limb motor function recovery (table 3). This could suggest that the recovery of upper limb motor function between ischaemic and haemorrhagic stroke is similar. This finding is similar to Buyandelger et al33 and Persson et al40 who highlighted that upper limb motor function recovery in patients with ischaemic and haemorrhagic strokes has a similar recovery pattern as similar motor function and activity capacity were present in both types stroke after 3 months.25 While the current study did not find a significant association between stroke type and motor recovery, further research is needed to understand the mechanisms and moderators of recovery in ischaemic and haemorrhagic strokes.

    However, some study limitations should be acknowledged. The study assessed motor function outcomes before and after an intervention without a control group, making it difficult to determine if observed changes in upper limb motor recovery are solely due to the intervention or influenced by other factors like spontaneous recovery or natural progression. The study used a smaller sample size which would have weakened the power of the study, hence having insignificant results in the regression analysis. The small sample size affected the results of the study in that some factors that are rendered as significant predictors of upper limb motor recovery in literature were not significant in this study. A larger dataset might ensure adequate representation of the study population.

    Conclusion

    The findings on upper limb motor function recovery suggest that the motor function of stroke patients continues to improve over time. This study demonstrated that initial upper limb motor function impairment could be used as a predictor for mild upper limb motor function after a certain period of undergoing treatment. However, further research into the demographic and clinical factors related to mild upper limb motor function impairment with larger sample size is required.

    Data availability statement

    All data relevant to the study are included in the article or uploaded as online supplemental information.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and was approved by Research Ethics and Science Converge Institutional Review Board (ERES Converge IRB) (REF No. 2022-Jun-022). Participants gave informed consent to participate in the study before taking part.

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    Footnotes

    • X @NkhaYanila

    • Contributors HMS was involved in the conception, design of the study, data collection, analysis, interpretation of data and drafting of the manuscript. JL was involved in designing the study, analysing the data, interpreting the data and drafting the manuscript. LN was involved in the conception, design of the study, interpretation of data, drafting and critical revision of the manuscript. All authors approved the final manuscripts. HMS is responsible for the overall content as guarantor. HMS is responsible for the overall content as guarantor.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.