Wade DT, Hewer RL, Wook VA. Stroke: influence of ... Ben-Yishay Y, Diller L, Gerstman L, Gordon W. Relation- ... Wade DT, Skilbeck DE, Hewer RL. Predicting ...
THE RELATIONSHIP BETWEEN NEU ROPSYCHOLOG ICAL MEASURES AND SELF-CARE SKILLS IN PATIENTS WITH CEREBROVASCULAR LESIONS A. Campbell, PhD, A. Brown, PhD, C. Schildroth, MEd, OTRIL, A. Hastings, MD, P. Ford-Booker, MS, 0. Lewis-Jack, MS, C. Adams, BS, OTR/L, A. Gadling, BS, OTRIL, R. Ellis, BA, LOTA, D. Wood, MD, G. Dennis, MD, A. Adeshoye, MD, R. Weir, MD, and G. Coffey, MD Washington, DC
The present investigation examined the relationship between performance on the Michigan Neuropsychological Battery (MNB) and selected self-care skills in a group of patients with unilateral cerebrovascular lesions. Among MNB measures, left-sided somatosensory and motor functions were the best predictors of self-care skills, showing that in these stroke patients lower level cerebral functions mediated by the right hemisphere are more strongly related to the self-care skills examined than higher cerebral functions. Also, evidence that patients with cerebrovascular lesions in the left hemisphere performed better than patients with right hemisphere lesions in several selfcare categories is further indication that right hemisphere processes have a special role to play in the mediation of these self-care activities. The research and clinical implications of these findings are noted. (J Nati Med Assoc. 1991 ;83:321-324.) * Key words * neuropsychological predictors * self-care skills * stroke
From the Howard University Psychology Department and College of Medicine and the Howard University Hospital, Department of Physical Medicine and Rehabilitation, Washington, DC. Requests for reprints should be addressed to Dr Alfonso Campbell, Jr, Psychology Department, Howard University, Washington, DC 20059. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 4
Historically, clinical neuropsychology has been preoccupied with issues that relate to the diagnosis and description of higher- and lower-level cortical impairments.1l2 Now, as the field continues to evolve, questions concerning the ecological validity of neuropsychological assessment procedures deserve greater attention. In this context, ecological validity expresses the extent to which neuropsychological test results can be used to predict behavior in a wide variety of settings, including the home, school, community, and workplace.3 While predictor/outcome research should be broadened to evaluate competencies in these domains, the present study was designed to examine self-care skills in a group of patients with acute unilateral cerebrovascular lesions and relate these measures to neuropsychological test results. This information will serve as preliminary data intended to establish the ecological validity of measures comprising the Michigan Neuropsychological Battery (MNB). As the objectives required by this validity procedure are realized, theoretical frameworks based on brain-behavior principles may emerge to guide the development of more effective rehabilitation strategies.
METHOD Subjects Thirty-four black patients, including 13 males and 21 females, participated in the present investigation. The patients (mean age: 55 years; mean years of education: 9 years) were admitted to the Neurology Service at Howard University Hospital with unilateral (left: 13 321
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TABLE 1. STEPWISE MULTIPLE REGRESSION ANALYSES OF NEUROPSYCHOLOGICAL PREDICTORS AND SELF-CARE OUTCOME MEASURES IN PATIENTS WITH RIGHT HEMISPHERE LESIONS
Self-Care Neuropsychological Skill Predictors FC Ravens BM SDSSR AA EE DA
GH OM OSC
Multiple R .56 .58
R2 .32 .34
.46 .75 .82 .58 .70 .65 .60
.21 .56 .68 .34 .50 .43 .36
No variables
BVRTMC(C) PPL60 BVRT(A) PPL60 Ravens BVRTMC(A) VOT
Abbreviations: FC = functional communication, BM = bed mobility, AA = ambulatory assistance, EE = eating efficiency, DA = dressing ability, GH = grooming and hygiene, OM = object manipulation, OSC = overall self-care score, Ravens = Ravens Coloured Progressive Matrices, SDSSR = Single and Double Simultaneous Stimulation Test (right side), BVRTMC(A) = Benton Visual Retention Test Multiple Choice (Administration A), BVRTMC(C) = Benton Visual Retention Test Multiple Choice (Administration C), PPL60 = Purdue Pegboard (left hand/60 seconds), BVRT(A) = Berton Visual Retention Test (Administration A), PPL60 = Purdue Pegboard (left hand/ 60 seconds), VOT= Visual Organization Test.
patients; right: 21 patients) cerebrovascular lesions. All of the patients were right-handed prior to their stroke, and none had a previous history of psychiatric disorder, brain insults, or alcohol or other drug abuse. Twenty-six of the participants in this study were subjects in Brown et al,4 while a subsample of eight patients was selected from another study (Campbell A. 1988. Unpublished data). There were no systematic differences in the cognitive and demographic characteristics of these two populations of stroke patients.
Procedure All patients participating in this study were given the Michigan Neuropsychological Battery (MNB), which is comprised of objective standardized measures of a broad range of language, verbal and nonverbal reasoning, and auditory and visual memory functions as well as selected somatosensory and manual motor skills.4 About the same time, these patients were also administered the self-care component of the Howard University Activities of Daily Living Scale (ADL) by an occupational therapist affiliated with the physical 322
TABLE 2. STEPWISE MULTIPLE REGRESSION ANALYSES INVOLVING NEUROPSYCHOLOGICAL PREDICTORS AND SELF-CARE OUTCOME MEASURES IN PATIENTS WITH LEFT HEMISPHERE LESIONS Self-Care Neuropsychological Multiple R2 Skill R Predictors FC SDSSL .63 .40 AA SDSSL .59 .34 EE SDSSL .77 .60 MURS .92 .85 DA PPL60 .82 .68 BVRT(A) .82 .68 GH SDSSL .75 .56 OM MURS .60 .36 OSC .72 SDSSL .55
Abbreviations: FC=functional communication, AA = ambulatory assistance, EE = eating efficiency, DA=dressing ability, GH=grooming and hygiene, OM = object manipulation, OSC = overall self-care score, SDSSL=Single and Double Simultaneous Stimulation Test (left side), PPL60= Purdue Pegboard (left hand/60 seconds), MURS= Memory for Unrelated Sentences, BVRT(A)=Benton Visual Retention Test (Administration A).
medicine and rehabilitation department. This self-care subscale is an adaptation of the Klein-Bell Activities of Daily Living Scale.5 The ADL is an objective rating instrument designed to assess degree of functional dependence in seven categories: * functional communication, * bed mobility, * ambulatory assistance, * eating efficiency, * dressing ability, * grooming and hygiene, and * object manipulation. A composite self-care score was obtained by totaling the scores earned by each patient in these self-care categories. This composite score served as an index of a patient's overall self-care stats.
RESULTS AND DISCUSSION While these findings are preliminary and should be cross-validated in a much larger population of patients with cerebrovascular and other types of lesions, they show that in this group of stroke patients MNB measures accounted for a moderate amount of the explained variance in the self-care skills that were evaluated (Tables 1 and 2). With regard to the composite self-care score, MNB measures also acJOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 4
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counted for a moderate share of the variance. These findings are consistent with other studies that show measures of higher cortical functions serve as significant predictors of self-care status among patients with acute and subacute cerebrovascular lesions.6-9 Primarily, left-sided tactile functions, as determined by performance on the Single and Double Simultaneous Stimulation (S&DSS) task, and the left hand Purdue Pegboard score emerged as the best predictors of self-care skills, showing that in this population of stroke patients lower-level cerebral functions mediated by the right hemisphere were more strongly related to the self-care skills examined than higher cerebral functions. Evidence that patients with lesions in the left hemisphere (Group LBD) performed better than patients with lesions in the right hemisphere (Group RBD) in such self-care skills as bed mobility, dressing, grooming and hygiene, and object manipulation is a further indication that right hemisphere processes have a special role to play in the mediation of these self-care activities (Table 3). This finding contrasts with other studies that report no relationship between lesion laterality and functional independence.10'12 On the other hand, it confirms evidence presented in two other studies that have noted patients with right hemisphere damage were more impaired on measures of self-care skills than patients with left hemisphere lesions.8'13"14 Differences in lesion parameters, the demographic characteristics of the various patient populations, and the use of different instruments to measure functional skills may have contributed to these conflicting outcomes. While some of the neuropsychological predictors of self-care skills in Groups LBD and RBD were the same, the magnitude of the relationship between these predictors and self-care skills, as well as the combination of predictors, were different. First, left-sided S&DSS functions served as the strongest predictor across self-care categories among patients in Group LBD, suggesting that the neural processes tapped by this task are basic to the operations underlying performance in these self-care domains (Table 1). Of course, an equally plausible explanation is that the cortical regions involved in the mediation of these self-care skills overlap anatomically with or lie adjacent to brain regions that subserve processes involved in the S&DSS task. Among patients in Group RBD, left-sided S&DSS functions in addition to left-sided motor functions (PPLGO), visual perceptual, visual spatial, visual memory, and visual analogous reasoning skills served as the JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 4
TABLE 3. MEAN SELF-CARE SKILL SCORES OF PATIENTS IN GROUP LBD AND GROUP RBD Self-Care Skill Group LBD Group RBD F NS 33.64 31.73 FC .04 24.81 33.69 BM NS 30.93 49.85 AA NS 105.43 110.50 EE .005 45.45 68.96 DA .006 54.88 87.85 GH .05 63.21 75.12 OM .003 358.35 457.69 OSC
Abbreviations: NS = not significant, FC = functional communication, BM=bed mobility, AA=ambulatory assistance, EE = eating efficiency, DA = dressing ability, GH = grooming and hygiene, OM = object manipulation, OSC = overall self-care score, LBD = group with left hemisphere brain damage, RBD = group with right hemisphere brain damage.
strongest predictor of different self-care skills (Table 2). These latter findings agree with another study that shows a strong relationship between visual, spatial, perceptual, and motor dysfunction and the ADL performance of stroke patients with right hemisphere damage.'4 Rehabilitation specialists generally agree that mobility, strength, somatosensory function, and coordination are crucial for efficient performance of behaviors required for everyday living.'5 Typically, services that these specialists provide in acute-care hospitals to brain-injured patients are designed to have an impact on impairments of these basic sensory and motor functions and associated functional skill deficits. In fact, a critical factor in the discharge disposition of many patients treated in acute-care facilities and comprehensive rehabilitation centers is the level of independence shown on self-care measures of ADL evaluations.16418 Typically, these measures include a group of motor dependent activities such as personal hygiene, bathing, feeding, toileting, stair climbing, dressing, bowel and bladder control, ambulation, and chair/bed transfers.19 However, it is unwarranted to assume that all brain-injured patients who reacquire competencies in these self-care skills through rehabilitation will be able to integrate these skills in problem-specific and contextspecific routines.20 Frequently, patients who display ADL competencies in structured clinical settings experience difficulties in maintaining these functional routines in their homes or other settings. Impairments in cognitive processes such as planning, initiating, and problemsolving may be important contributors to these difficulties. For example, patients classified as functionally 323
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independent in dressing may be able to put on and remove their clothes, yet experience great difficulty in selecting articles of clothing that are appropriate for the weather conditions and different social situations. Another dilemma that a person independent in dressing may encounter is knowing when to initiate the dressing routine. Some patients who know how to put their clothes on correctly dress in multiple layers of clothes because of impaired judgment. To overcome these types of cognitive disturbances, comprehensive rehabilitation centers and acute-care facilities, to a lesser extent, should not only focus on teaching patients to reacquire functional skills but also target for formal assessment and remediation those adaptive abilities (ie, planning, judgment, and problem-solving skills) that are major components of every functional routine.21'22
SUMMARY The data from this study confirm the relationship reported in other studies between neuropsychological variables and ADL categories during the acute and subacute stages of stroke. While most predictor/ outcome studies that have examined the relationship between ADL competencies and neuropsychological measures have focused on the early poststroke period of recovery, there is also a need to identify neuropsychological predictors of long-term functional outcome. At a time when health care institutions, insurance companies, and public agencies are carefully examining the cost:benefit ratio of rehabilitation services, this issue becomes an important consideration. The knowledge gained from neuropsychological studies designed to clarify and delineate the underlying nature of initial and long-term ADL deficits may help rehabilitation specialists develop intervention procedures that are more reliable, valid, and cost effective. Literature Cited 1. Lezak MD. Neuropsychological Assessment. Portland, Ore: Oxford University Press; 1983. 2. Smith A. Neuropsychological testing in neurological disorders. In: Friedlander WJ, ed. Advances in Neurology. New York, NY: Raven Press; 1975. 3. Acker MB. Relationships between test scores and everyday life functioning. In: Uzzell BP, Gross Y, eds. Clinical Neuropsychology of Intervention. Boston, Mass: Martinus Nijhoff Publishing; 1986. 4. Brown AP, Campbell A, Wood D, et al. Neuropsychological studies of blacks with cerebrovascular disorders: a preliminary investigation. J Natl Med Assoc. 1991;83:217-224.
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5. Klein R, Bell B. Self-care skills: behavioral measurement with Klein-Bell ADL scale. Arch Phys Med Rehabil. 1982;63:335-338. 6. Lehmann JF, DeLateur BJ, Fowler RS, et al. Stroke rehabilitation: outcome and prediction. Arch Phys Med Rehabil. 1975;56:383-389. 7. Novack TA, Haban G, Graham K, Satterfield WT. Prediction of stroke rehabilitation outcome from psychologic screening. Arch Phys Med Rehabil. 1987;68:729-734. 8. Bernspang B, Asplund J, Eriksson S, Fugl-Meyer AR. Motor and perceptual impairments in acute stroke patients: effects on self-care ability. Stroke. 1987;18:1081-1086. 9. Bourestom NC, Howard MT. Behavioral correlates of recovery of self-care in hemiplegic patients. Arch Phys Med Rehabil. 1968;49:449-454. 10. Wade DT, Hewer RL, Wook VA. Stroke: influence of patient's sex and side of weakness on outcome. Arch Phys Med Rehabil. 1984;65:513-516. 11. Boureston NC. Predictors of long-term recovery in cerebrovascular disease. Arch Phys Med Rehabil. 1967;48:415-419. 12. Kotila M, Waltimo 0, Niemi ML, Laaksonen R, Lempinen M. The profile of recovery from stroke and factors influencing outcome. Stroke. 1984;15:1939-1944. 13. Sundet K, Finset A, Reinvang I. Neuropsychological predictors in stroke rehabilitation. J Clin Exp Neuropsychol. 1988;10:363-379. 14. Kaplan J, Hier D. Visuospatial deficits after right hemisphere stroke. Am J Occup Ther. 1982;36:314-321. 15. Ben-Yishay Y, Diller L, Gerstman L, Gordon W. Relationship between initial competence and ability to profit from cues in brain-damaged individuals. J Abnorm Psychol. 1970;75:248259. 16. Shah E, Nouri F, Barer D. Measuring disability after a stroke. J Epidemiol Community Health. 1985;39:86-89. 17. Wade DT, Skilbeck DE, Hewer RL. Predicting Barthel ADL score at 6 months after an acute stroke. Arch Phys Med Rehabil. 1983;64:24-28. 18. Gresham GE, Phillips TF, Labi MLC. ADL status in stroke: relative merits of three standard indexes. Arch Phys Med Rehabil. 1980;71 :355-358. 19. Diller L. Neuropsychological rehabilitation. In: Meier MJ, Benton AL, Diller L, eds. Neuropsychological Rehabilitation. New York, NY: Churchill Livingstone; 1987. 20. Hart T, Hayden ME. The ecological validity of neuropsychological assessment and remediation. In: Uzzell BP, Gross Y, eds. Clinical Neuropsychology of Intenrention. Boston, Mass: Martinus Nijhoff Publishing; 1986. 21. Prigatano GP, Pepping M, Klonoff P. Cognitive, personality, and psychosocial factors in the neuropsychological assessment of brain-injured patients. In: Uzzell BP, Gross Y, eds. Clinical Neuropsychology of Intervention. Boston, Mass: Martinus Nijhoff Publishing; 1986. 22. Mayer HM, Keating DJ, Rapp D. Skills, routines, and activity patterns of daily living: a functional nested approach. In: Uzzell BP, Gross Y, eds. Clinical Neuropsychology of Intervention. Boston, Mass: Martinus Nijhoff Publishing; 1986.
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