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Neurorehabilitation and Neural
http://nnr.sagepub.com/content/22/2/173
The online version of this article can be found at:

DOI: 10.1177/1545968307305456
2008 22: 173 originally published online 17 September 2007 Neurorehabil Neural Repair
Stefanie Vanbeveren and Willy De Weerdt
Geert Verheyden, Alice Nieuwboer, Liesbet De Wit, Vincent Thijs, Jan Dobbelaere, Hannes Devos, Deborah Severijns,
Time Course of Trunk, Arm, Leg, and Functional Recovery After Ischemic Stroke

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Time Course of Trunk, Arm, Leg, and Functional
Recovery After Ischemic Stroke
Geert Verheyden, MSc, PhD, Alice Nieuwboer, MSc, PhD, Liesbet De Wit, MSc, PhD,
Vincent Thijs, MD, PhD, Jan Dobbelaere, MD, Hannes Devos, MSc, Deborah Severijns, MSc,
Stefanie Vanbeveren, MSc, and Willy De Weerdt, MSc, PhD
Copyright 2008 The American Society of Neurorehabilitation 173
Background. Patterns of recovery provide useful information
concerning the potential of physical recovery over time and
therefore the setting of realistic goals for rehabilitation
programs. Objective. To compare the time course of trunk
recovery with the patterns of recovery of arm, leg, and func-
tional ability. Methods. Consecutive stroke patients were
recruited in 2 acute neurology wards. Participants were evalu-
ated at 1 week, 1 month, and 3 and 6 months after stroke.
Patients were assessed with the Trunk Impairment Scale, Fugl-
Meyer arm and leg test, and Barthel Index. Results. Thirty-two
patients were included in the study. There were no dropouts.
Repeated measures analysis of the recovery patterns of motor
and functional performance revealed the most striking
improvement for all measures from 1 week to 1 month
(P value between .0021 and <.0001) and a significant
improvement from 1 month to 3 months after stroke (P value
ranges from .0008 to <.0001). No significant improvement
was found between 3 and 6 months after stroke for any of the
measures. Statistical analysis revealed no significant difference
between time course of trunk, arm, leg, and functional recov-
ery (P = .2565). No significant differences in level of motor
and functional recovery were found at the different time
points. Conclusions. Separate analyses of motor and functional
recovery patterns after stroke confirm the importance of the
first month for recovery. Contrary to common belief, the time
course of recovery of the trunk is similar to the recovery of
arm, leg, and functional ability.
Key Words: Cerebrovascular accidentRecovery of function
Rehabilitation.
K
nowledge of patterns of recovery after stroke is
helpful in determining when to expect recovery
and in targeting appropriate treatment and tim-
ing of rehabilitation.
1
Most recovery of motor and func-
tional performance is seen in the first month after
stroke.
2-10
However, motor and functional deficits remain
present in a large number of patients 1 month after stroke
onset. Six months after stroke, only 60% of people with
initial hemiparesis have achieved functional indepen-
dence in simple activities of daily living such as toileting
and walking short distances.
1,11
Further improvement
after 6 months can be expected but is mostly limited.
11-14
A recent study even reported a deterioration of long-term
mobility after stroke in 21% of its population.
15
Previous long-term studies on time course of motor
and functional performance after stroke showed com-
parable patterns of recovery based on visual inspec-
tion.
7,8,10
To the best of our knowledge, no statistical
analysis of the difference of the patterns of recovery for
trunk, arm, leg, and functional performance was
reported. Additionally, time course of trunk recovery
has only been demonstrated in 2 studies in relation to
restoration of arm, leg, or functional abilities after
stroke despite the importance of trunk performance as
a significant predictor of long-term functional out-
come.
16
Wade and Hewer found that 80% of patients
had a paresis in the arm or leg at 1 week after stroke, but
only 47% showed an impaired sitting balance.
5
Three
weeks after stroke, impairment of extremities and sit-
ting balance decreased to 60% and less than 2%, respec-
tively. The suggestion was made that sitting balance
after stroke is less impaired in comparison to the
extremities and that it recovers faster.
5
This was con-
firmed in a study by Partridge et al.
3
Furthermore, there
is evidence for bilateral innervation of central motoneu-
ron pools in humans, which innervate trunk muscula-
ture.
17
Therefore, it could be hypothesized that recovery
From the Katholieke Universiteit Leuven, Department of Rehabilitation
Sciences, Leuven, Belgium (GV, AN, LD, HD, DS, SV, WD); Katholieke
Universiteit Leuven, Department of Neurology, UZ Gasthuisberg,
Leuven, Belgium (VT); and Heilig Hart Ziekenhuis Leuven, Depart-
ment of Neurology, Leuven, Belgium (JD).
Address correspondence to Geert Verheyden, Southampton General
Hospital, Mailpoint 886, Tremona Road, Southampton, UK SO16
6YD. E-mail: gv@ soton.ac.uk.
Verheyden G, Nieuwboer A, De Wit L, Thijs V, Dobbelaere J, Devos H,
Severijns D, Vanbeveren S, De Weerdt W. Time course of trunk, arm,
leg, and functional recovery after ischemic stroke. Neurorehabil Neural
Repair. 2008;22:173179.
DOI: 10.1177/1545968307305456
at CHRISTIAN UNIV on May 8, 2014 nnr.sagepub.com Downloaded from
of trunk muscles after unilateral stroke is more favorable
compared to that of the affected extremities.
Studies examining the differential pattern of recovery of
trunk, arm, leg, and functional performance over time
might help the planning and timely introduction of reha-
bilitation strategies. It was therefore the aim of this study to
statistically compare the time course of trunk, arm, leg,
and functional recovery from 1 week over 1 month, 3
months, to 6 months after stroke. We expected a significant
improvement over time for all measures of motor and
functional performance. We further hypothesized that
trunk performance would be less impaired and recover
faster in comparison to arm, leg, and functional ability.
METHODS
Subjects
Over a 15-month period, all consecutive stroke
patients on the acute stroke ward of the university hos-
pital UZ Gasthuisberg (Leuven, Belgium) and the acute
neurological ward of Heilig Hart hospital (Leuven,
Belgium) were screened for inclusion. Stroke diagnosis
was based on the guidelines according to the World
Health Organization.
18
Patients were included in the study if they had an age
of under 90 years, a prestroke Barthel Index of 85 points
or more,
19
the permission of the supervising physician
to sit up, no other orthopedic or neurological impair-
ment that could influence sitting balance, no hip pros-
thesis on the nonaffected side, no terminal illness with a
life expectancy of less than 6 months, and gave informed
consent. Only patients with a motor deficit in the arm
or leg were accepted, established with the Fugl-Meyer
assessment for the upper and lower extremity.
20
Patients
had to score below 60 out of 66 points for the arm
section or under 30 points out of 34 points for the leg
section. Patients were not allowed to have severe com-
munication, memory, or language deficit that could
interfere with the testing protocol. Permission was asked
from the partner or closest relative if the patient was
unable to give consent personally. This study was
approved by the Ethical Commission of both hospitals
where patients were recruited.
Assessments
All participants were examined at 1 week, 1 month, 3
months, and 6 months after stroke. Demographic vari-
ables collected at 1-week poststroke were age, gender,
hemiplegic side, type of stroke, and site of lesion.
Assessments documenting time course of motor and
functional recovery at 1 week, 1 month, 3, and 6 months
after stroke were the Trunk Impairment Scale, the Fugl-
Meyer Motor Assessment for upper and lower extrem-
ity, and the Barthel Index. Assessments were conducted
at the acute ward, rehabilitation center, nursing home,
or at home, depending on where the patient stayed at
the time of assessment. All patients were evaluated by
the same assessor, on all measurement times.
The Trunk Impairment Scale assesses motor impair-
ment of the trunk after stroke. It assesses static and
dynamic sitting balance and trunk coordination.
21
The
scale ranges from 0 to 23 points. A higher score indicates
a better trunk performance. Adequate reliability and
validity of the Trunk Impairment Scale for stroke patients
has been reported.
21
The Fugl-Meyer Motor Assessment
consists of 2 subscales, 1 for the motor evaluation of the
upper extremity and 1 for the motor evaluation of the
lower extremity.
20
The scoring range for the arm section
is 0 to 66 points. For the lower extremity section, the
score ranges from 0 to 34 points. A higher score indicates
a better performance. Adequate psychometric properties
for the Fugl-Meyer Test have been presented.
22
The
Barthel Index is a measure of functional activity after
stroke. We used the 10 items version, which has a maxi-
mum score of 100. This means that the patient is com-
pletely independent for several activities of daily living.
19
Adequate psychometric characteristics for the 10-item
Barthel Index have been reported.
23
Statistical Analysis
Nonparametric statistics were used to describe the
recovery of motor and functional performance. The
time pattern of recovery of trunk, arm, leg, and func-
tional ability was first evaluated separately using an
analysis for repeated measures (PROC MIXED state-
ment). If the effect of time appeared to be significant
(P < .05), 3 pairwise consecutive comparisons were
carried out to detect between which 2 measurement
points a significant difference occurred (P < .05).
Estimates, standard errors, and 95% confidence inter-
vals for the estimates, as a result of the repeated mea-
sures analysis, were calculated for each of the
parameters, and residuals were inspected for normality
by means of a histogram plot. Raw scores were then
transformed into percentages of the maximum value of
each scale. This allowed us to examine if the time pat-
tern of recovery was significantly different between the
4 scales of motor and functional recovery. Therefore,
again, an analysis of repeated measures was used to
explore if there was a significant interaction between
time and the type of clinical scale. A significant interac-
tion (P < .05) indicated a different time pattern of
Verheyden et al
174 Neurorehabilitation and Neural Repair 22(2); 2008
at CHRISTIAN UNIV on May 8, 2014 nnr.sagepub.com Downloaded from
recovery for the clinical scales of motor and functional
performance. Finally, at each time point, scores on the
measures of motor and functional ability were also sta-
tistically compared by means of the statistical method
described previously. A Bonferroni correction was used
for multiple comparisons. The adjusted P value was P <
.0083. All statistical analyses were performed with the
statistical package SAS version 8.2.
RESULTS
A total of 32 consecutive patients were included in the
study. Patients had a mean (SD) age of 69 (9.46) years.
There were 13 women and 19 men. Sixteen patients had
a left and 16 a right hemiplegia. All patients suffered from
an ischemic stroke. Seventeen patients suffered from an
infarct in the middle cerebral artery, 5 in the pons, 3 in
the anterior choroidal artery, 2 in the posterior cerebral
artery, 1 in the anterior cerebral artery, and 1 in both the
middle and posterior cerebral artery. Site of lesion of 3
patients could not be detected. Consent was obtained
from the partner or closest relative for 3 participants.
There were no dropouts throughout the study.
The patterns of recovery for trunk, arm, leg, and
functional performance are presented in Figure 1.
Results of the analysis for the repeated measures proce-
dure are given in Table 1.
All measures of motor and functional ability showed a
significant improvement over time (P < .0001). Further
inspection of the recovery pattern for trunk, arm, leg, and
functional performance revealed that most recovery
occurred between 1 week and 1 month after stroke. A sig-
nificant improvement of motor and functional ability was
observed between 1 week and 1 month and again between
1 month and 3 months after stroke. Between 3 and 6
months after stroke, small changes were apparent but the
differences were no longer significant. In the plots pre-
sented in Figure 1, a large degree of variability can be
noted, especially for the recovery pattern of the arm.
Figure 2 gives an overview of the estimates stan-
dard errors of trunk, arm, leg, and functional recovery
expressed as percentage of the maximum score.
Statistical comparison by means of repeated measures
analysis revealed no significant interaction between
time points and measures of motor and functional
recovery (P = .2565), indicating no statistical difference
in the slopes of recovery for the different measures.
When observing Figure 2, leg and trunk performance
scored relatively higher compared to arm and func-
tional performance at 1 week after stroke. At 1 month, the
Fugl-Meyer leg, Barthel Index, and Trunk Impairment
Scale scores were comparatively higher than the Fugl-
Meyer arm score. At 3 and 6 months after stroke,
Time Course of Recovery After Ischemic Stroke
Neurorehabilitation and Neural Repair 22(2); 2008 175
Figure 1. Recovery pattern of median (interquartile range)
trunk, arm, leg, and functional performance for 32 ischemic
stroke patients.
Figure 2. Recovery pattern of estimates standard errors
(expressed in percentage of maximum score) for trunk (TIS), arm
(F-M arm), leg (F-M leg), and functional performance (BI) for 32
ischemic stroke patients. Repeated measures analysis revealed no
significant difference between recovery patterns (P = .2565).
at CHRISTIAN UNIV on May 8, 2014 nnr.sagepub.com Downloaded from
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at CHRISTIAN UNIV on May 8, 2014 nnr.sagepub.com Downloaded from
Barthel Index, Fugl-Meyer leg, and Trunk Impairment
Scale score were still relatively higher in comparison
to Fugl-Meyer arm score. Despite these relative
differences, the results of the repeated measures analysis
showed that there were no significant differences between
the measures of motor and functional ability at 1 week,
1 month, 3 months, and 6 months after stroke.
Table 2 gives an overview of the change of the mea-
sures of motor and functional performance between the
different time points, expressed as percentage of the max-
imum score. Between 1 week and 1 month after stroke,
the median improvement ranged from 16% (Fugl-Meyer
arm and leg section) to 30% (Barthel Index). Between 1
month and 3 months after stroke, median improvements
ranged from 6% (Fugl-Meyer leg test) to 10% (Barthel
Index). Between 3 and 6 months, only the Trunk
Impairment Scale score showed a median improvement
of 2%. All other measures had a median change of 0%,
indicating that 50% of the patients showed no further
improvement or even deterioration.
DISCUSSION
It was the aim of this study to examine the patterns
of recovery of trunk, arm, leg, and functional ability
from 1 week to 6 months after stroke and compare the
time course of trunk performance with that of arm, leg,
and overall functional performance.
When we consider the pattern of motor and func-
tional recovery separately, the results of this study con-
firm the results of several other studies.
2-10
Most
improvement for trunk, arm, leg, and functional recov-
ery was observed from 1 week to 1 month after stroke
and then to a lesser extent between 1 and 3 months after
stroke. In contradiction to our expectation, only small
changes in median scores could be seen between 3 and
6 months after stroke, and none of them was statistically
significant, indicating that a plateau phase was already
reached at 3 months after stroke. This was further
reflected in the fact that a large part of this cohort of
patients was in the postintensive rehabilitation phase.
One week after stroke, all patients were examined at the
acute medical ward of the 2 hospitals. One month after
stroke, most patients (88%) were in an in-patient reha-
bilitation hospital. Only 4 patients (12%) were at home,
following an outpatient rehabilitation program. Three
months after stroke, 18 patients (56%) were at home, of
which 5 (28%) received no further therapy. The lack of
continuous rehabilitation together with the less inten-
sive rehabilitation often delivered outside specialized
centers
24
might have contributed to the stagnation. The
relative ceiling effect demonstrated by the clinical mea-
sures in this study may also have contributed to the
plateau phase. However, 3 months after stroke, median
values for motor and functional performance ranged
still from 70% for Fugl-Meyer arm score to 85% for
Fugl-Meyer leg score.
An interesting result of this study is the fact that
between 3 and 6 months after stroke, 50% of our
patients showed no further improvement in the Fugl-
Meyer arm and leg and Barthel Index scores. Although
some patients fully recovered, the majority still pre-
sented mild to severe impairments. These will still affect
activities of daily living.
1,11
Furthermore, the stagnation
and relative deterioration observed in this study (see
Table 2) are in line with the results of van de Port et al.
15
Therefore, for a select group of patients, continuation of
therapy should be considered. Possibilities suggested in
the literature for effective and efficient postrehabilita-
tion treatment are alternating intensities of therapy
(periodization of training) as well as intensive task-ori-
ented exercise training early after stroke, which
appeared to be effective in high-quality clinical trials.
25,26
Most improvement occurred between 1 week and 1
month after stroke, and the rate of improvement in
motor and functional recovery clearly decreased between
1 and 3 months after stroke. Barthel Index scores showed
a relatively greater improvement in comparison to the
other measures in the first 2 periods, but this difference
Time Course of Recovery After Ischemic Stroke
Neurorehabilitation and Neural Repair 22(2); 2008 177
Table 2. Median (Interquartile Range) Change Between the Different Measurement Points for Measures of Motor and Functional
Performance, Expressed in Percentage of the Maximum Score
Measure (Score) Week 1Month 1 Month 1Month 3 Month 3Month 6
TIS (0-23) 21.74% 8.7% 2.17%
(11.96-34.78) (0-17.39) (1.09-8.7)
F-M arm (0-66) 15.91% 6.82% 0%
(2.65-21.21) (3.03-23.86) (2.65-3.79)
F-M leg (0-34) 16.18% 5.88% 0%
(2.21-38.97) (2.94-12.5) (2.94-8.82)
BI (0-100) 30% 10% 0%
(18.75-40) (5-25) (0-5)
TIS = Trunk Impairment Scale; F-M arm = Fugl-Meyer arm section; F-M leg = Fugl-Meyer leg section; BI = Barthel Index.
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Verheyden et al
178 Neurorehabilitation and Neural Repair 22(2); 2008
did not reach the level of significance. The Barthel Index
evaluates the degree of independence in activities of daily
living such as grooming, dressing, toileting, walking, as
well as bowel and bladder control. In comparison to the
Fugl-Meyer arm and leg test and the Trunk Impairment
Scale, it does not take quality of movement into account
and compensations are allowed. Compensations are
often an initial response in the recovery phase.
24
This
could explain the relatively better functional recovery in
comparison to motor recovery, although no statistical
differences were found in this study.
A surprising and novel finding was that no signifi-
cant differences in the rate of recovery for the different
measures of motor and functional performance were
present. Based on evidence suggesting bilateral innerva-
tion of central motoneuron pools in humans, which
innervate trunk musculature,
17
it was expected that
recovery of trunk muscles after unilateral stroke was
more favorable compared to that of the affected extrem-
ities. The results of this study do not support this
hypothesis. In an earlier study, impairment of extremi-
ties and sitting balance at 3 weeks after stroke were pre-
sent in 60% and 2% of the patients, respectively.
5
In our
study, patients obtained a median value for trunk per-
formance of 65% at 1 month after stroke, indicating
that there is still a clear impairment of trunk control.
Measures of sitting balance and trunk performance have
improved over the past decade. Earlier studies reported
single-item ordinal scales to assess sitting balance, often
without statistical analysis. Over the recent years, the
content of scales measuring trunk performance has
improved considerably and psychometric analysis of
these new clinical scales has been established. The cur-
rent study used the Trunk Impairment Scale, which
evaluates static sitting balance, dynamic sitting balance,
and trunk coordination. It measures selective trunk
movements and takes the quality of the movement into
account.
21
Comparison between studies using different
clinical measures to document recovery is difficult. The
adequacy of choice of measures in stroke research is a
current point of discussion.
27
Ability to generalize
results from other studies could improve decisions
made in stroke rehabilitation. For this to occur, agree-
ment, however, is required regarding the best measures
to use. A possible explanation for the reason why there
were no significant differences between the recovery of
the trunk and other measures of motor and functional
performance could be the fact that the Trunk Impairment
Scale measures sitting balance as well as selective trunk
movements. Therefore the Trunk Impairment Scale is
more comparable to the measures of motor and func-
tional performance than the earlier scales measuring
only sitting balance as such. It must be noted that the
limited number of participants and heterogeneity in
stroke lesions probably resulted in a lack of power.
Future studies with a larger number of participants who
are stratified by level of disability might give further
insight into this new finding.
One of the inclusion criteria was a score on the
Fugl-Meyer arm or leg test under 10% of the maximum
value. Therefore we excluded patients with a very mild or
no motor deficit of the limbs. Furthermore, patients were
not allowed to have severe communication, memory, or
language deficit that could interfere with the testing pro-
tocol. This way we excluded severely affected and uncon-
scious patients from this study. Even after leaving out
extremes on both sides of the scale, a large variability of
scores was observed. Furthermore, the results of this
study only apply for patients with ischemic stroke.
Generalization of the results should therefore be done
with caution. Still, to the best of our knowledge, this is the
first long-term follow-up study that includes a standard-
ized measure of motor performance of the trunk allow-
ing statistical comparison of the change of motor and
functional recovery after stroke.
This study documented and compared patterns of
recovery of motor and functional performance after
ischemic stroke from 1 week to 6 months after stroke. The
results showed a significant improvement for trunk, arm,
leg, and functional performance between 1 week and 1
month and from 1 month to 3 months after stroke.
However, between 3 and 6 months after stroke, a large
number of patients did not show further improvement or
even a decline in performance. Contrary to common belief,
the hypothesis that trunk recovery would have a different
time course compared to the recovery of arm, leg, and func-
tional ability could not be confirmed. Future studies on a
larger number of patients as well as studies including neu-
rophysiological and neuroimaging data could give more
insight in the change of and relation between motor and
functional recovery after ischemic stroke.
IMPLICATIONS
This study emphasizes the importance of the period
between 1 week and 1 month after stroke. Intensive treat-
ment early after stroke has been shown to be beneficial
for motor and functional recovery in previous studies,
and further research should be conducted into this field.
Furthermore, the lack of significant change between 3
and 6 months after stroke should be of interest to both
stroke research and clinical practice. Patients demon-
strating a stagnation or deterioration at this stage
should be detected early. The type and amount of ther-
apy needed for further motor and functional improve-
ment in this group of patients needs to be considered
and investigated. Because there was no significant dif-
ference in the time course of motor and functional
recovery after stroke, they may have one and the same
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Time Course of Recovery After Ischemic Stroke
Neurorehabilitation and Neural Repair 22(2); 2008 179
neurophysiological basis. Therapists working with
stroke patients are therefore encouraged to monitor the
level of impairment, activity, and participation rather
than focusing on one aspect only.
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