The contribution of motor function scales to rehabilitation in hemiplegic patients with stroke

Authors

Abstract

Aim Stroke is a disruption in the vascular structure of the brain. It causes mortality and morbidity. The most important symptom is hemiplegia. Rehabilitation is accepted as the primary treatment approach for reducing mortality and disability rates after stroke, and this study aims to evaluate the contribution of rehabilitation.
Materials and Methods This study included 85 patients who met the criteria and were undergoing inpatient rehabilitation. The patients were administered the Motricity Index (MI), Trunk Control Test (TCT), Rivermead Motor Assessment (RMA), Barthel Index (BI), and Functional Mobility Scale (FAS).
Results Statistical analyses revealed that motor and functional scores improved significantly at discharge (p<0.001). MI and GKT, which are scales with short application times and ease of use, showed high correlation with RMA. These results indicate that motor function assessment scales have predictive value in estimating the level of independence in activities of daily living. The average age of the patients participating in the study was 61, with a high proportion of women and illiterate individuals. The findings support the critical importance of objective motor function assessment in the early stages for rehabilitation and prognosis prediction.
Discussion Simple and short motor tests can be said to be comparable in effectiveness to detailed and lengthy tests, saving time and resources in the management of rehabilitation processes for hemiplegic patients.

Keywords

Introduction

Stroke or cerebrovascular accident (CVA) is a neurological disease with clinical, radiological, and pathological symptoms caused by bleeding or ischemia in the vascular system of the brain. The World Health Organization (WHO) defines stroke as a syndrome with a clinical presentation lasting longer than 24 hours, characterized by heterogeneity, and without any cause other than vascular dysfunction. According to researchers, the rates of disability and mortality are high worldwide [1, 2]. Approximately 80% of strokes globally are ischemic CVAs. It is generally a disease of aging with multiple risk factors. Individuals who have experienced a stroke may encounter issues such as motor control loss, hemiplegia, communication difficulties, and visual-spatial perception inconsistencies [3]. The most prominent losses include muscle weakness in the affected limbs, dyskinetic movements, spasticity, limited joint mobility, inability to transfer weight to the hemiplegic side, balance problems, loss of trunk control, dependence on bed activities, and difficulty walking [4].
The widespread use of science and technology in the field of health has facilitated access to healthcare, increased survival rates, and expanded the potential pool of patients eligible for rehabilitation. However, approximately 30% of these patients develop disabilities that require assistance with daily living activities, often accompanied by walking impairments. The most prominent neurological clinical presentation of CVA is hemiplegia with motor loss [5, 6, 7] advanced age, low physical activity level prior to the stroke, systemic diseases, prolonged coma, mental impairment, inadequate family support, low socioeconomic status, previous stroke, female gender, urinary and fecal incontinence, and late initiation of rehabilitation programs have been identified as factors that negatively affect the patient’s prognosis and medical rehabilitation potential [8]. Many predictive scales have been developed to analyze stroke patients’ motor, sensory, balance, and daily living activities, walking, informing patients, determining prognosis, preparing rehabilitation programs, and overcoming clinical changes that may occur. For this purpose, many scales have been developed to determine the patient’s physical capacity, neurological status, and motor skills, and programs suitable for the patient have been created based on these assessments [9].
In recent years, the use of scales has become widespread and accelerated for the purpose of obtaining approximate values to predict the patient’s condition during admission and discharge periods, both in terms of accurately determining treatment goals and efficiently utilizing rehabilitation services.

Materials and Methods

Type and Model of Research
This research was designed using a causal research model, which is a type of quantitative research conducted in a cross- sectional manner.
Research Population and Sample
The research population consists of 85 patients who were hospitalized for rehabilitation at the Ankara Physical Therapy and Rehabilitation Education and Research Hospital between June 2001 and January 2002. Since all patients who met the inclusion and exclusion criteria during the study period were included, no sampling method was applied. The study population consisted of patients who were hospitalized for rehabilitation at the Ankara Physical Therapy and Rehabilitation Education and Research Hospital between June 2001 and January 2002; had undergone CVA, were hospitalized for rehabilitation, and met the criteria for inclusion in the rehabilitation program, were able to answer questions appropriately, and agreed to participate in the study.
In the evaluation, patients’ demographic records, hemiplegic side, dominant side, time elapsed until hospitalization, length of hospital stay, and findings of physical and neurological examinations performed at admission were recorded. The Rivermead Motor Assessment (RMA), Trunk Control Test (TCT), and Motricity Index (MI) were used to evaluate motor function development before the start of the rehabilitation program and at discharge; the Barthel Index (BI) was used to evaluate activities of daily living; and the Functional Ambulation Scale (FAS) was used to determine ambulation levels.
SPSS was used for statistical evaluation. Spearman’s rank correlation coefficients were calculated to determine the relationship between the data. The Wilcoxon matched pairs signed test was used to determine the differences between the entry and exit values, and the chi-square test was used to examine the differences between the levels. The scales and measures used in the study are detailed below [10, 11].
• The Brunnstrom Scale was applied to assess synergy mismatch on the hemiplegic side; it was noted that it consists of six stages, ranging from poor to good. The assessment was performed manually.
• The Barthel (GYA) Scale was used to determine the physical abilities of hemiplegic patients in terms of feeding, transfer, dressing, toileting, and urinary and bowel control. The scale ranged from 0 points, indicating “completely dependent,” to 100 points, indicating “completely independent.”
• The Motricity Index was used to measure the maximum level of isometric muscle strength.
• The Rivermead Motor Assessment (RMA) is used to evaluate the patient’s motor performance. It includes test items consisting of three sections: whole body, arm, and leg. Due to the test’s length and exhausting nature, caution was exercised when administering it to acute and chronic patients.
• The Functional Ambulation Scale (FAS) is used to determine the walking level and support needs of hemiplegic individuals. It consists of six stages, ranging from Stage 0 (“not walking”) to Stage 5 (“walking independently on all surfaces, including ramps”).
Statistical Analysis
FAS indicates the extent to which a person needs assistance from others when walking, regardless of whether they use an assistive device. The Ml-GKT, RMA, and Bl values of patients at admission and discharge; the correlation between these three tests, and the FAS and Bl values at admission and discharge were statistically evaluated, and the correlations were investigated. The SPSS program was used for statistical evaluation. Spearman’s rank correlation coefficients were calculated to determine the relationship between the data, and the Wilcoxon matched-pairs signed test was performed to calculate the differences between the admission and discharge values. Additionally, the chi-square test was used to examine the differences between levels.
Ethical Approval
Since the present study was conducted prior to the date when ethical committee approval became mandatory, no ethical committee approval was obtained. The concurrence of the educational planning committee was sufficient. No ethical violations were committed during the conduct of the study or the reporting of its results.

Results

The study included 85 patients who were hospitalized due to hemiplegia caused by CVA. Forty (47.1%) of these patients were male, and 45 (52.9%) were female, with an average age of 61.01 (min. 28, max. 79). Of the 85 patients, 57 (67.1%)were married. The majority of patients, 42 (49.4%), were illiterate, and 3 patients (3.5%) had completed higher education.
Motor assessments of patients during hospitalization and discharge, as well as MI and GKT results, are presented in Table 1. Upon examination of the table, statistically significant increases were observed in all upper and lower extremities, total motor function, and Body Control Test scores at the time of discharge. As can be seen in Table 1, statistically significant increases were recorded in the RMA, another motor assessment scale used in the study, in all three aphasia groups at the discharge stage compared to the baseline values. When the difference between patients’ FAS entry-exit levels was examined, a significant improvement was found (X2=7.829, p<0.005). When the patients included in the study were evaluated using the FAS scale in terms of ambulation and divided into two groups, FAS 0-1-2-3 (dependent) and FAS 4-5 (independent), it was observed that 57 (67.1%) of the patients who were dependent at admission became independent at discharge. When we examined the statistical values of the FAS scale, which evaluates patients’ ambulation, and the level of independence in daily living activities, a statistically significant increase was observed at discharge compared to pre-rehabilitation values, as shown in Table 2 (Table 2). The average Barthel Index score at admission was 40.18±19.74, and the average score at discharge was 64.48±23.75. This increase was found to be statistically significant (z=2.7960, p<0.001). To investigate the predictive value of pre-rehabilitation motor assessment scores for independence levels in activities of daily living at discharge, the Ml, GKT, and RMA values at admission were correlated with the BI scores at discharge. Correlations were found between the total and subscores of all three tests and the BI (Table 3).

Discussion

This study aimed to evaluate the motor functions of 85 patients who developed hemiplegia after stroke and met the study criteria during hospitalization and discharge periods within the scope of the rehabilitation program, using predictive scales.
Conventional treatment is provided to rehabilitate the patient, primarily to correct motor impairment, as well as to support recovery from various impairments that may result from stroke, such as speech impairment, cognitive impairment, and swallowing difficulties, thereby improving quality of life and walking ability. However, there are no systematic scales that adequately convey the factors affecting the success of rehabilitation. A strong relationship between FAS and BI has been reported in post-stroke sitting-to-standing motor training [12, 13]. In a study involving 135 stroke patients, strong relationships were reported between BI and FAS scores and the Body Dysfunction Scale in terms of turning movements, extremity use, and walking skills [14].
According to the findings, 45 (52.9%) of the patients who met the treatment criteria were female, married (67.1%), literate (49.6%), with an average age of 61.01 (min. 28, max. 79). This situation confirmed that the study was conducted with a heterogeneous group and enabled the findings to be generalized to similar situations. The findings showed that the application of MI and GKT took less than 5 minutes, whereas the application of RMA took approximately 40 minutes [11, 15]. The study revealed a very high correlation between motor scales such as MI, GKT, and RMA, consistent with the literature. Additionally, since these three motor scales also have a high correlation with the Barthel Index (BI), the study demonstrated that the combined use of MI and GKT is appropriate and sufficient for pre-rehabilitation assessment.
Stroke is a life-threatening and common neurological disease. Significant mental and physical disabilities develop in hemiplegic patients who survive. Risk factors influence the recovery process and the selection of rehabilitation programs [16].
Early identification of the patient and initiation of the rehabilitation program increase the survival rate and have been proven to cause significant increases in the Functional Ambulation Scale (FAS) and Barthel Index. Although the mechanism of motor recovery in hemiplegia is not fully understood, it is thought that rehabilitation activates the neurons it affects, thereby promoting neuroplasticity.
While no significant correlation was found between motor and mental impairment progression and the Functional Independence Measure (FIM) in patients who had undergone CVA, it was determined that the Barthel Index is more effective than the FIM [17].
Musa et al. found a correlation between motor and balance changes and the Barthel Index three months after the event in their study of stroke patients. This is because, while the severity of movement deficits in daily living activities determines post- stroke recovery, the patient can become more independent even if there are no major changes in motor development [18]. Additionally, it was found that gross function and lower extremity values in the Rivermead Motor Assessment (RMA) test contribute more to daily living activities than upper extremity values [19].
Chen et al., when comparing BI scores 6 months after discharge, stated that BI was useful in predicting outcomes in these patients, reported that a BI exit score of 60 was a critical threshold, and that patients above this value achieved a better functional level [20].
A study was conducted to determine the predictive value of the Body Control Test (BCT) by comparing admission and discharge BCT and Functional Independence Scale (FIM) scores in patients with acute stroke. They found a high correlation between admission BCT and discharge FIM scores. Interestingly, the ability of the admission BCT score to predict the discharge motor FIM score was found to be even better than that of the admission motor FIM score [17]. The GKT enhances its predictive value by controlling not only sitting balance but also turning from the supine position to the affected and unaffected sides and transitioning from the supine position to the sitting position. It is found that patients with a GKT score of 50 or above at 6 weeks post-event were able to walk by 18 weeks. In this study, patients with scores of 40 or below were unable to walk after rehabilitation [11].
Motor function in hemiplegic patients was evaluated at regular intervals using the Motricity Index (MI) and the Body Control Test (GKT), and these two tests were compared with the Rivermead Motor Assessment (RMA), which is a time-consuming and highly detailed test [11, 21]. In stroke-induced hemiplegia, weakness in trunk muscles and impaired proprioception were reported, and positive developments were observed in patients when scales were used in a rehabilitation program involving strengthening exercises for trunk muscles. Researchers have noted that RMA, MI, and GKT are valid tests and equally sensitive to changes in motor function. The difference between MI and GKT is that they are short-term and simple when administered by observers. Therefore, it is recommended to use MI and GKT instead of RMA. However, the fact that MI and GKT are not sensitive to small changes in motor function and do not provide information about other phenomena such as functional quality, spasticity, sensory loss, and apraxia has been noted as a disadvantage of these tests [22, 23].
In a study aimed at evaluating physical recovery in stroke hemiplegia rehabilitation using RMA, it was reported that approximately 12% of patients had suffered or were at risk of suffering an accident during the completion of the RMA scale, taking into account age, gender, and body mass index [24]. Motor and functional assessment in hemiplegic patients is critical for determining rehabilitation goals and organizing treatment programs. Criteria with numerical values facilitate the comparison of patients’ conditions at different times, the determination of the effectiveness of rehabilitation programs, and statistical analysis in research.

Limitations

At the time of the study, patient information was recorded manually, the sample size could not be expanded, and access to information and references on the subject was limited; the results were not compared in detail.

Conclusion

At the start of the discharge rehabilitation program, RMA total, Motricity Index (MI) total, and Trunk Control Test (TCT) motor scales showed high correlations with the Barthel Index (BI), consistent with the literatüre. When the less time-consuming and less strenuous MI and GKT were used instead of the RMA, similar values were observed. It was concluded that the motor scales used in the rehabilitation program have the ability to predict the level of independence in activities of daily living (predictive value). In conclusion, the use of easy-to-apply predictive tools accelerates the achievement of goals, reduces treatment time and costs, enables healthcare professionals to master individualized rehabilitation, reduces the margin of error in outcomes, and simultaneously increases the confidence of patients and their families.

References

1. Walter K. What is acute ischemic stroke? JAMA. 2022;327(9):885.
   Article PubMed Google Scholar
2. Rotaru-Zăvăleanu AD, Dinescu VC, Aldea M, Gresita A. Hydrogel-based therapies for ischemic and hemorrhagic stroke: a comprehensive review. Gels. 2024;10(7):476.
   Article PubMed Google Scholar
3. Huang J, Ji JR, Liang C, et al. Effects of physical therapy-based rehabilitation on recovery of upper limb motor function after stroke in adults: a systematic review and meta-analysis of randomized controlled trials. Ann Palliat Med. 2022;11(2):521–31.
   Article PubMed Google Scholar
4. Johnston TE, Keller S, Denzer-Weiler C, Brown L. A clinical practice guideline for the use of ankle-foot orthoses and functional electrical stimulation post-stroke. J Neurol Phys Ther. 2021;45(2):112–96.
   Article PubMed Google Scholar
5. Chen PY, Chang WL, Hsiao CL, Lin SK. Seasonal variations in stroke and a comparison of the predictors of unfavorable outcomes among patients with acute ischemic stroke and cardioembolic stroke. Biomedicines. 2024;12(1):223.
   Article PubMed Google Scholar
6. Arabzadeh S, Kamali F, Bervis S, Razeghi M. The hip joint mobilization with movement technique improves muscle activity, postural stability, functional and dynamic balance in hemiplegia secondary to chronic stroke: a blinded randomized controlled trial. BMC Neurol. 2023;23(1):262.
   Article PubMed Google Scholar
7. Chen C, Yan B, He S, et al. Effects of lumbar joint mobilization on trunk control, balance, and gait in patients with stroke: study protocol for a randomized controlled trial. Trials. 2025;26(1):50.
   Article PubMed Google Scholar
8. Albitar MM, Maya S, Al Ashabia KK, Hamzeh G, Kakaje A. Modifiable risk factors for stroke in Syria: a nationwide multi-centre case-control study. Sci Rep. 2025;15(1):115.
   Article PubMed Google Scholar
9. Liu K, Yin M, Cai Z. Research and application advances in rehabilitation assessment of stroke. J Zhejiang Univ Sci B. 2022;23(8):625-41.
   Article PubMed Google Scholar
10. Sarikaya PM, Incel NA, Yilmaz A, Cimen OB, Sahin G. Effect of hand dominance on functional status and recovery of hand in stroke patients. SJCM. 2017;6(3):39.
    Article PubMed Google Scholar
11. Pollock A, Farmer SE, Brady MC, et al. Interventions for improving upper limb function after stroke. Cochrane Database Syst Rev. 2014;2014(11):CD010820.
    Article PubMed Google Scholar
12. In TS, Jung JH, Jung KS, Cho HY. Effect of sit-to-stand training combined with taping on spasticity, strength, gait speed and quality of life in patients with stroke: a randomized controlled trial. Life (Basel). 2021;11(6):511.
    Article PubMed Google Scholar
13. Yan Q, Wang X, Zhang Y, Zhang H, Zhao L. Analysis of influencing factors of rehabilitation treatment effect in patients with first-episode stroke. Am J Transl Res. 2021;13(12):14046–56.
    PubMed Google Scholar
14. Kim TJ, Seo KM, Kim DK, Kang SH. The relationship between initial trunk performances and functional prognosis in patients with stroke. Ann Rehabil Med. 2015;39(1):66–73.
    Article PubMed Google Scholar
15. Gor-García-Fogeda MD, Molina-Rueda F, Cuesta-Gómez A, Carratalá-Tejada M, Alguacil-Diego IM, Miangolarra-Page JC. Scales to assess gross motor function in stroke patients: a systematic review. Arch Phys Med Rehabil. 2014;95(6):1174– 83.
    Article PubMed Google Scholar
16. Pyöriä O, Talvitie U, Nyrkkö H, Kautiainen H, Pohjolainen T, Kasper V. The effect of two physiotherapy approaches on physical and cognitive functions and independent coping at home in stroke rehabilitation. A preliminary follow-up study. Disabil Rehabil. 2007;29(6):503–11.
    Article PubMed Google Scholar
17. Almasoudi AO, Seyam MK, Sanchez F. The effect of trunk exercises with hip strategy training to maximize independence level and balance for patient with stroke: randomized controlled study. Physiother Res Int. 2024;29(4):e2142.
    Article PubMed Google Scholar
18. Musa KI, Keegan TJ. The change of Barthel Index scores from the time of discharge until 3-month post-discharge among acute stroke patients in Malaysia: a random intercept model. PLoS One.2018;13(12):e0208594.
    Article PubMed Google Scholar
19. Wei X, Sun S, Zhang M, Zhao Z. A systematic review and meta-analysis of clinical efficacy of early and late rehabilitation interventions for ischemic stroke. BMC Neurol. 2024;24(1):91.
    Article PubMed Google Scholar
20. Chen G, Shen Z, Zhuang Y, Wang X, Song R. Intensity- and duration-adaptive functional electrical stimulation using fuzzy logic control and a linear model for dropfoot correction. Front Neurol. 2018;9:165.
    Article PubMed Google Scholar
21. Van Criekinge T, Truijen S, Schröder J, et al. The effectiveness of trunk training on trunk control, sitting and standing balance and mobility post-stroke: a systematic review and meta-analysis. Clin Rehabil. 2019;33(6):992–1002.
    Article PubMed Google Scholar
22. Kiper P, Przysiężna E, Cieślik, et al. Effects of immersive virtual therapy as a method supporting recovery of depressive symptoms in post-stroke rehabilitation: randomized controlled trial. Clin Interv Aging. 2022;17:1673–85.
    Article PubMed Google Scholar
23. Saeys W, Vereeck L, Lafosse C, Truijen S, Wuyts FL, Van De Heyning P. Transcranial direct current stimulation in the recovery of postural control after stroke: a pilot study. Disabil Rehabil. 2015;37(20):1857–63.
    Article PubMed Google Scholar
24. Scherbakov N, Barkhudaryan A, Ebner N, et al. Early rehabilitation after stroke: relationship between the heart rate variability and functional outcome. ESC Heart Fail. 2020;7(5):2983–91.
    Article PubMed Google Scholar

Declarations

Additional Information

Publisher’s Note
Bayrakol MP remains neutral with regard to jurisdictional and institutional claims.

Rights and Permissions

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0). To view a copy of the license, visit https://creativecommons.org/licenses/by-nc/4.0/

View full license details →

About This Article