This article was downloaded by: [University of Victoria]On: 19 November 2014, At: 03:38Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Journal of Clinical andExperimental NeuropsychologyPublication details, including instructions for authorsand subscription information:http://www.tandfonline.com/loi/ncen19

Neuropsychological predictors instroke rehabilitationKjetil Sundet a , Arnstein Finset a & Ivar Reinvang aa Sunnaas Rehabilitation Hospital , Oslo, NorwayPublished online: 04 Jan 2008.

To cite this article: Kjetil Sundet , Arnstein Finset & Ivar Reinvang (1988)Neuropsychological predictors in stroke rehabilitation, Journal of Clinical andExperimental Neuropsychology, 10:4, 363-379, DOI: 10.1080/01688638808408245

To link to this article: http://dx.doi.org/10.1080/01688638808408245

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information(the “Content”) contained in the publications on our platform. However, Taylor& Francis, our agents, and our licensors make no representations or warrantieswhatsoever as to the accuracy, completeness, or suitability for any purposeof the Content. Any opinions and views expressed in this publication are theopinions and views of the authors, and are not the views of or endorsed byTaylor & Francis. The accuracy of the Content should not be relied upon andshould be independently verified with primary sources of information. Taylor andFrancis shall not be liable for any losses, actions, claims, proceedings, demands,costs, expenses, damages, and other liabilities whatsoever or howsoever causedarising directly or indirectly in connection with, in relation to or arising out ofthe use of the Content.

This article may be used for research, teaching, and private study purposes.Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expresslyforbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Journal of Clinical and Experimental Neuropsychology 1988, Vol. 10, NO, 4, pp. 363-379

0168-8634/88/1004-0363$3.00 Wwets & Zeitlinger

Neuropsychological Predictors in Stroke Rehabilitation*

Kjetil Sundet, Arnstein Finset, and Ivar Reinvang Sunnaas Rehabilitation Hospital, Oslo, Norway

A mailed questionnaire, sent routinely to discharged stroke patients, divided left- hemisphere (n=68) and right-hemisphere (n=77) patients into three groups of general help dependency in basic activities-of-daily-life skills. A subsample of 29 patients was visited at home and asked to reanswer the questionnaire under guidance of a trained occupational therapist. The reliability of the questionnaire was considered satisfactory. Both neurological deficits and neuropsychological syndromes correlated significantly with the level of help needed for managing alone at home. Multiple regression analysis revealed a major gain in explained variance in help dependency when neuropsychological test results were added to information on degree of hemiplegia and hemianopia. Keeping in mind the subject characteristics of the study sample, apraxia and pathological emotional reactions were the more important variables in the left-hemisphere and right- hemisphere groups respectively. The challenge from rehabilitation psychology is discussed and the need for developing more sophisticated methods for assessing rehabilitation potential is stressed.

The traditional domain of clinical neuropsychology faces a demand for expansion in two directions. On the one hand, new brain-imaging techniques require greater precision in functional diagnosing (Kertesz, 1983; Lezak, 1983). Cognitive deficits formerly labelled subclinical may be of utmost importance to measure reliably in order to furnish finer anatomical and physiological anomalities delimited by NMR and rCBF, with functional validity.

On the other hand, rehabilitation of brain-damaged patients is an expanding working field in need of both treatment methods and outcome evaluations (Goldstein & Ruthven, 1983; Miller, 1980; Newcombe, 1985; Powell, 1981; Trexler, 1982). The success of adding specific neuropsychological principles to traditional rehabilitation programs, however, is still in want of supportive evidence (Bieliauskas, 1986; Shore, 1984).

* An earlier version of this article was presented as a paper at the International Neuropsychological Society’s 8th European conference in Copenhagen, June 13th, 1985. We thank K. Pfaff for conducting the home visits and organizing the mailing of questionnaires, E. Bjerneby for using the questionnaire, and K. M. Adams and L. D. Costa for helpful comments on earlier drafts of the article. The work was supported by grants from the Norwegian Council for Coronary and Vascular Diseases and the Norwegian Council for Science and Humanities (12.68.96.013). Request for reprints should be sent to Kjetil Sundet, Sunnaas Rehabilitation Hospital, 1450 Nesoddtangen, Norway. Accepted for publication: March 4, 1987.

Dow

nloa

ded

by [

Uni

vers

ity o

f V

icto

ria]

at 0

3:38

19

Nov

embe

r 20

14

364 KJETIL SUNDET ET AL.

In order to evaluate the therapeutic potentials of neuropsychological theories and methods, it is necessary to specify the various levels ofhntervenlion and the actual patient group to be treated. Different p u p s of patients in different stages of rehabilitation will most likely demand Werent training regimens. Hence, successful rehabilitation must balance its program according to the specific needs for physical, cognitive, emotional, and social intervention.

The results from treating stroke patients in special stroke units are so far encouraging (Garraway, 1985). Stroke unit patients need shorter hospitalization and the process of rehabilitation is accelerated (Strand et al., 1986). However, patients still react to treatment in diffenrnt ways &pending primarily on the site and size of the brain lesion. Some patients recovc~ their function more or less spontaneously, some remain severely disabled regardless of the amount of rehabilitation offered, whereas paw@ ia the middle group are the ones believed to profit the most from training.

In order to separate patients into outcome groups at an w l y stage, the search for neuropsychological prognostic factors has become important both in stroke rehabilitation (Allen, 1984; Caplan, 1982; Hilton & @aetschmer, 1983; RoSinson, Bolduc, Kubos, Starr, & Price, 1985) as well as in other fields of medical rehabilitation (Baird, Adams, Ausman, Bt D k , 1985; Dull et al., 1982). Results show that the presence of particular neuropsycbbgid deficit patterns observed initially may predict degree of independence at alaterstage. However, no uniform criteria have so far been found to differentiate with sufficient accuracy for clinical use between patients who notd rehabilitation from those who will recover spontaneously or do poorly (Dombovy, Saadok, & Basford, 1986).

Allen (1984) demonstrated that hemiplegic patients without hemianopia or higher cerebral dysfunction were likely to return to functional iudependence. Clinical features such as aphasia, visuospatial neglect, drowsiness or loss of consciousness initially, and older age were evidence of poor prognosis. Neuropsychological syndromes such as visuo-perceptive and visuo-practic deficits were found to be of predictive value for rehabilitation outcome in several studies by Feigenson and associates (Feigenson, McCarthy, Greenberg, & Feigenson, 1977; Feigenson et al., 1977). Communicational deficits due to aphasia were reported by Kinsella and D a y (1979) to lead to major complaints among spouses of aphasic hemiplegics, thereby affecting the psychological adaptation for both patients and the family.

So called “nonadequate emotional reactions”, i.e., emotional lability, indifference, euphoria, and anosognosia, were added to the list of neuropsycho- logical predictors by Kotila, Waltimo, Niemi, Laaksonen, and Lempinen (1984). They found that depression was of less prognostic importance. However, depression was found by Feibel and Springer (1982) to be signifi- cantly correlated with failure to resume premorbid social activites. Raymond and Susset (1984) found that depressed mood was related to physical functional return for both left- and right-hemisphere stroke patients.

Dow

nloa

ded

by [

Uni

vers

ity o

f V

icto

ria]

at 0

3:38

19

Nov

embe

r 20

14

NEUROPSYCHOLQGICAL PREDICTORS 365

Bjnrrneby and Reinvang (1985) found a significant relationship between degree of apraxia in the acute phase and need for help in activites of daily life (ADL) following discharge. Fugl-Meyer and Jaasko (1980) investigated how stroke patients managed at home compared to their functioning at the hospital. They found a significant deterioration in ADLfunctioning after discharge. Bjnrrneby and Reinvang (1985) confirmed this trend suggesting that present rehabilitation programs do not guarantee a transfer of training from hospital to home demands. However, other studies have reported satisfactory retention of self-care skills (e.g., Anderson, Anderson, & Kottke, 1977).

Neither the sex of the patient nor the laterality of lesion have proved to be statistically valid subject characteristics for predicting rehabilitation outcome (Jongbloed, 1986; Wade, Hewen, & Wood, 1984). Left- and right-brain-injured patients do experience different patterns of initial deficits, but this alone does not seem to affect the level of daily-life functioning at large after discharge.

The abovementioned studies of rehabilitation outcome differ as of what time span the prediction is meant to cover and the criterion used to evaluate outcome. In the acute treatment phase, it is important to single out patients who will survive the stroke and remain intact concerning rehabilitation potential (Garraway, 1985). At a later stage, the focus of interest is both to decide which treatment regimes will offer best results as well as to distinguish between patients who will be able to manage at home with various kinds of help and patients who must remain in a nursing home. The validity of the many studies addressing the questions above is severely hampered by poor measurement instruments (Keith, 1984). Lack of consensus among researchers upon items and rating scales and the small consideration paid to what set of criteria should be used to define level of rehabilitation makes it difficult to compare results from one study to another.

The present study is designed to investigate how aphasia, apraxia, emotional disturbances and other neuropsychological syndromes present at the start of rehabilitation, may predict level of help dependency in ADLfunctioning after discharge. Patients studied are left- and right-hemisphere-damaged stroke patients. The study does not attempt to answer questions concerning success of rehabilitation per se. However, it is of interest to identify neuropsychological syndromes that may explain level of ADLfunctioning in order for future rehabilitation programs to focus specifically on these neuropsychological deficits.

The method chosen for assessing functional status in this study runs many of the risks mentioned by Keith (1984). There are no standardized measures of ADLfunctioning after stroke available in the Norwegian language. Instead of translating any of the internationally known rating scales, a questionnaire was developed specifically to meet the demands of the present study, i.e., a brief list of unambiguous items covering assumed important ADGskills and simple enough to be administered by mail (Bjerrneby & Reinvang, 1985)'). A parallel method was successfully carried out by Ebrahim, Nouri, and Barer (1985). In I ) Copies of the questionnaire may be obtained from the senior author.

Dow

nloa

ded

by [

Uni

vers

ity o

f V

icto

ria]

at 0

3:38

19

Nov

embe

r 20

14

366 KJETIL SUNDET ET AL.

the first part of the article, validity and reliability of the assessment measure are addressed. In the last part, multiple aspects of ADLfunationing dter discharge are discussed, and the predictive value of neuropsychulogicall test performances on help-dependency living at home are analyzed.

METHOD

Approximately 6 months following discharge, stroke patients treated at Sunnaas Rehabilitation Hospital (1978-1983) received by mail a questionnaire requesting information about ADLfunctioning in their home enviromncat. Ths questionnaire consisted of 13 items concerning skills in dressing, gr~amiw shoppiag, use of aids, dependency upon others, and ability to manage alone. The qu@ws w~tlp formulated as simply and directly as possible, demanding a yes/no answer (Bjerncby & Reinvang, 1985). Close to 70% of the patients answered the questionnaire and w t d it by mail.

In this article we present results from a sample of 145 stroke patients comprising all patients who had been tested neuropsychologically while receiving treatment at the hospital. The sample includes both left-hemisphere (LH) injured aphasic stroke patients ( ~ 6 8 ) as well as right-hemisphere (RH) injured nonaphasic stroke patients ( ~ ~ 7 7 ) .

In order to check the reliability of the answers received by mail, an experienced occupational therapist visited patients living in close vicinity td the hospital, i.e., in Oslo, soon after having received their answers. A subsample of 29 patients was visited for this followLup study during 1981 and the patients {or their spouses) were a s k 4 to fill out the questionnaire anew under her guidance. A phi-correlation was computed between the two sets of answers. This measure of stability was taken as an indication of the reliability of the questionnaire, i.e., whether or not the questions were perceived unambigously.

The internal validity of the questionnaire was studied by performing a principal component analysis (PA1 with VARIMAX rotation) on the questionnaire in an attempt to reveal separate clusters of ADLproblems (Nie, Hull, Jenkins, Steinbrenner, & Bent 1975). Our goal was to look for trends in the answer profiles by decomposing the over-all variance into separate indexes given the information obtained from the questionnaire, rather than looking for genuine factors of ADGfunctioning at large. Hence, the method of factor analysis (PA2 in SPSS logo) was not performed. The content validity for items comprising a cluster will give name to the constructs.

The neuropsychological tests used are described elsewhere (Bjsmeby & Reinvang, 1985; Reinvang, 1985; Reinvang & Sundet, 1985) and comprise subtests from the WAIS, the Wechsler Memory Scale, the Halstead-Reitan battery, Raven’s Coloured Progressive Matrices, the Knox Cube test, Frostig’s Spatial Relations task and tests of ideomotor and ideational apraxia. The aphasic LH patients were tested with the Norwegian Basic Aphasia Assessment (Reinvang & Engvik, 1980) whereas the nonaphasic RH group was scored on 5-point rating scales with respect to nature and degree of different emotional behaviours (Finset, Sundet, & Haakonsen, in press). Four emotional behaviours were rated: depressive affect, involuntary crying, emotional indifference, and denial of illness. The two former and the two latter variables correlated with each other, and one variable from each of the correlating pairs were chosen (Involuntary Crying and Denial of Illness).

The tests and rating scales attempt to evaluate functional entities such as aphasia,

Dow

nloa

ded

by [

Uni

vers

ity o

f V

icto

ria]

at 0

3:38

19

Nov

embe

r 20

14

NEIJROPSYCHOLOGICAL PREDICTORS 367

different aspects of apraxia, nonverbal intelligence, memory and learning capacity, visual neglect, and emotional reactions. Tests supposedly measuring each of these neuropsychological constructs were transformed to z-scores and added to a total sum- score representing the deficit syndrome. Since LH and RH patients are admitted to separate wards at the hospital in order to encourage team specialization and treatment proficiency, they go through a somewhat different test program, e.g., LH patients are tested for aphasia and RH for emotional disturbances. Hence, the z-score transformations on the test comprising each test battery were done separately for the two hemisphere groups.

Correlation analysis and multiple regression analysis were used in order to compare medical status and neuropsychological test performance with ADLfunctioning at home. Missing data were replaced by mean scores from the corresponding hemisphere group when performing the regression analyses.

SAMPLE

Subject characteristics for the LH and the RH group are presented in Table 1. Patients in the sample had infarcts mainly of thrombo-embolic origin (80%)

diagnosed by angiograms or CTs. Lesion descriptions were available for less than half the patient group, hence data on site and size of infarcts are not given. Mean age when taken ill was 56 years (range: 21 to 79 years) which indicates that the rehabilitation needs differ substantially, at least at the social-emotional and occupational level. Testing was done approximately 5 months after the stroke. The questionnaire was sent out 6 months after discharge and usually returned after 2-3 weeks.

RH patients received a somewhat longer period of rehabilitation than LH patients (3.6 months, 2.6 months, f (143)=2.18, p=.03) and were less mobile at discharge: 53% of the RH patients needed wheelchair for transportation in comparison to 10% of the LH patients, and none of the RH patients could walk without support or crutches whereas 52% LH patients managed to do so (x’ (2)=60.37, p<.Ol).

The groups differed with regard to the sex proportion in that the LH group counted 54% female patients compared to 35% in the RH group (x2(1)=4.73, p=.03). The social status in the two groups was not significantly different. 81% had a spouse or lived with another relative or a friend. Patients discharged to other hospitals or nursing homes were not included in the study thereby restricting the generalizability of the results to this group of patients.

The differences in subject characteristics between the two groups are believed in part to follow from the selection criteria used at intake of patients to the hospital. LH patients without hemiplegia may receive rehabilitation merely on grounds of aphasia, whereas RH patients seldom get hospitalized if not presenting a physical deficit in the form of hemiplegia. The uncommonly high proportion of females in the LH group is, however, difficult to explain. In other

Dow

nloa

ded

by [

Uni

vers

ity o

f V

icto

ria]

at 0

3:38

19

Nov

embe

r 20

14

368 KJETIL SUNDET ET AL.

Table 1 Subject Characteristics for LH (n=68) and RH ( ~ ~ 7 7 ) Patients

Age at illness (years) LH 55.5 (14.1) RH 57.6 (12.0) n.s.

CVA to testing (mos) LH 5.9 ( 6.6) RH 4.4 ( 5.31 n.s.

Duration of rehabilitation LH 2.6 ( 2.3) (mas) RH 3.6 2.8) , I .~

n.s. Time after discharge to LH 7.1 ( 2.2) questionnaire (mos) RH 6.7 ( 2.0)

Sex Male Female

LH 46% 54% RH 65% 35% x2=4.73, p=.03

Living arrangement

Alone With oth- ers

LH 24% 76% RH 15% 85% n.s.

Diagnosis

Throm- Haemor- SAB bosis rhage

LH 82% 5% 13% RH 78% 9% 13% ns .

Yes Support Wheelch. LH 52% 38% lo% x2=60.37, 6 . 0 1 RH - 47% 53% Mobility at discharge

l) Married or living with a friendhelathe

respects, the two groups of patients are regarded as representative of the Norwegian stroke population discharged to the home following a period of rehabilitation.

Patients belonging to the subsample (11 LH and 18 RH patients) were visited at home at the average of 2.8 months after their answering the questionnaire. The subsample was not found to differ significantly from the main sample on any of the variables described above, due to the fact that the greater part of the total 1981 sample was included. Hence, results derived from the subsample will be acknowledged as valid for the whole group of stroke patients.

Dow

nloa

ded

by [

Uni

vers

ity o

f V

icto

ria]

at 0

3:38

19

Nov

embe

r 20

14

NEUROPSYCHOLOGICAL PREDICTORS 369

RESULTS

Reliability Items from the questionnaire are reproduced in an abridged version in Table 2. The response rate for each question and percent yes-answers for the main sample are given in columns (1) and (2). The phi-correlations between the two sets of questionnaires for the subsample are presented in column (3). Due to the small number of patients in the subsample (n=29), minor disagreement will produce major reduction on the coefficient. In the further analysis, items with high response stability (phz>.68), were taken as having suficient reliability and were used.

Table 2 Questionnaire Characteristics (N= 145)

Questions

Fuctor loadings N Yes phi I I1 111 ( 1 ) (2) (3) (4) ( 5 ) (6)

I. Help to wash 143 38% .90 2. Help to dress 142 33% .78 3. Help to prepare food 140 55% 1.00 4. Help to do shopping 142 10% .49 5. Help to do housework 139 72% .78 6. Use of crutches 136 58% 1.00 7. Use of wheelchair 137 20% .75 8. Use of wheeltable 131 22% .92 9. Use of kitchen aids 17 34% .79

10. Use of washing aids 133 36% .68 1 1. Use of other aids 92 16% S 5 12. Independent of daily help 138 48% .68 13. Manage alone one day &night 139 60% .91

Eigenvuhes % of variance

.73

.80 1671 .68 1801

c591 .41

-.so .74 .72 .52 .47

m

3.2 2.5 1.7 24.6 18.9 12.9

Validity The questionnaire was intended to cover several different aspects of daily-life functioning. A principal component analysis confirmed that this goal had been reached in that the unrotated first factor explained less than 30% of the total variance among the 13 items. After rotation, three factors fulfilled both statistical and theoretical criteria for clarity. The rotated factor-loadings are presented in Table 2, column (4) to (6). Only loadings above .40 are given, and items chosen to represent the factors are boxed in. On factor I, item #5 (Housework) was preferred over #I (Washing) since it reflected a more general domain of ADLfunctioning, and #2 (Dressing) was preferred over #3

Dow

nloa

ded

by [

Uni

vers

ity o

f V

icto

ria]

at 0

3:38

19

Nov

embe

r 20

14

370 K J F TIL SUNDF r ET AL

(Cooking) because it measured a somewhat different aspect of functioning than the other three household items. On factor 11, item #9 (Kitchen Aids) was dropped because of the low answering rate and #10 (Washing Aid) because of low phi-value.

The factors are described more fully in Table 3. The first factor reflects use of personal help in daily-life functioning, the second factor represents the use of technical aids, and the third factor refers to the patient's ability to manage alone for a shorter period of time. By adding the scores (yes or no) on the reported two items for each factor, the resulting index divided patients into three groups. In an effort to create a reliable measure of global help-dependency, patients were assigned to one of the following groups: group 1: those who manage alone independently, group 2: those who use some help and/or aids but may be left alone for a shorter time, and group 3: those who are dependent upon others for most aspects of daily life functioning.

The group of RH patients scored significantly more dependent than the LH group on the Personal Help and the Technical Aids index, which is in accordance with the previous reported finding that RH patients were less mobile when leaving the hospital (see Table 1). However, there was no significant group difference in General Help-Dependency.

Table 3 Distribution of LH (n=68) and RH (n=77) Patients on Indexes of ADLFunctioning and General Dependency.

Factor

Number of patients Some

Indep. help Depend Significance

I Useof LH 15 38 15 personal HELP RH 20 23 34 (2 & 5 )

x2= 1 1.26, p<.O I

I1 Useof LH 40 I6 12 technical ~~'18.96, p<.O1 AIDS RH 20 23 34 (6 8)

111 Ability to LH 30 15 23 __

MANAGE ~ ~ ~ 4 . 9 2 , pz.09 alone RH 23 29 25 (ns.) (12 & 13)

GENERALHELP- LH 29 15 24 DEPENDENCY x2=4.44,p=.1 1

RH 21 17 39 (n.s.)

Dow

nloa

ded

by [

Uni

vers

ity o

f V

icto

ria]

at 0

3:38

19

Nov

embe

r 20

14

NEUROPSYCHOIDGICAL PRLDICTORS 37 1

The correlations between the three indexes of ADLfunctioning and the global measure of help-dependency are shown in Table 4 for both patient groups. The use of Technical Aids differ among patients quite independently of other measures of help-dependency, as indicated by correlations from .15 to .27 with these ADLmeasures. Use of crutches and wheeltable has little relation to the ability to manage alone.

Table 4 Spearman’s Rank correlation between Indexes of ADLFunctioning and General Help- Dependency (N=145).

ADLIndexes Aids Manage Dependency

Help Aids Manage

15 .54 .21

.69

.26

.93

(all correlations are significant at the .05 level)

Secondly, use of Personal Help correlates .54 with the ability to manage alone. Evidently, some patients are able to stay alone for a shorter period of time if they receive some help with dressing and cooking, whereas other patients demand constant attention.

Even though the different measures correlate substantially, the coefficients are far from perfect. The aim of this study was to find neuropsychological predictors of general ADLfunctioning, hence further analyses will be confined to the overall measure of General Help-Dependency, mentioned above.

Predictors of General Help-Dependency Since LH- and RH-injured patients were tested with somewhat different neuropsychological test-batteries, the two groups will be treated separately in the following analyses. Though the scores of two groups were significantly different from each other on tests measuring the language function and classical apraxia (favoring RH patients) and visuospatial memory (favoring LH patients), there was no significant differences between the groups on Raven’s Progressive Coloured Matrices (LH: 20.4 vs. RH: 21.3, t (136)=0.74, n.s.) (For further documentation on test scores, see Reinvang and Sundet (1985) and Finset et al., in press). Hence, although differently impaired physically and suffering from different neuropsychoiogical syndromes, the two groups are considered of comparable severity in global cognitive functioning.

Correlations between subject characteristics and neuropsychological test results, and the measure of General Help-Dependency are shown in Table 5 for both LH and RH patients.

Dow

nloa

ded

by [

Uni

vers

ity o

f V

icto

ria]

at 0

3:38

19

Nov

embe

r 20

14

372 KJETIL SUNDET ET AL.

Table 5 Correlations between Subject Characteristics and Neuropsychological Test Results at Intake, and General HelpDependency 7 Months Following Discharge.

General HelpDepcndency LH group (n=68) RH group (n=77)

N r N r - SEX 68 - 77

AGE 68 .29 77 HEMIANOPIA 68 - 77 .41 HEMIPLEGIA 68 .23 77 .39

KINETIC APRAXIA

CONSTRUCTIONAL APRAXIA

-

Grooved pegboard 58 .45 69 .25

Copy-a-cross 56 .41 57 .24 Block Design, WAIS 66 .29 71 .38

Total 52 .43 57 .33 Frostig’s Spat. Relat.task 54 .36 57 .22

IDEOMOTOR APRAXIA Imitative Finger Position 59 .47 57 - Imitative Hand Movements 58 .39 53 -

Total 58 .45 53 - IDEATIONAL APRAXIA

NONVERBAL MEMORY Manipulating real objects 57 -28 40 -

---”--, serial learning 60 - 47 - Total 60 .26 47 -

- Block-pointing span 63 .40 48

NONVERBAL INTELLIGENCE Ravens CPM 65 .39 71 -

APHASIA Communication 68 .40 Aphasia coefficient 68 .33

Total 68 .38 Missing

Knox blocks 72 .22 Visual reproduction, WMS 74 .23 Coding, WAIS 62 .29

Total Missing 57 .29

VISUALSPATIAL FUNCTIONING

VISUAL NEGLECT

EMOTIONAL REACTIONS Letter cancellation task Missing 71 .22

Denial of illness 77 .35 Involuntary crying 77 .28

Total Missing 77 .41 All printed correlations are significant at the .05-level

Dow

nloa

ded

by [

Uni

vers

ity o

f V

icto

ria]

at 0

3:38

19

Nov

embe

r 20

14

NEUROPSYCHOLOGICAL PREDICTORS 373

In the LH group all the measures of neuropsychological deficits correlated with Help-Dependency; measures of apraxia and aphasia were the most potent predictors. Age and hemiplegia correlated moderately.

In the RH group of patients, tests of visuo-spatial functioning such as Block Design and Coding from WAIS, measures of hemianopia and visual neglect, and pathological emotional reactions correlated significantly with Help- Dependency. The classical apraxia syndromes of ideomotor and ideational apraxia were of no importance among RH patients. The correlations were generally smaller than those from the LH group, only indicators of hemianopia and pathological emotional reactions stood out with correlations greater than .40

The results so far indicate that most of the neuropsychological test results have some predictive potential with regard to the defined measure of help- dependency. The clinician is, however, not limited to a one-by-one evaluation of test results when estimating the prognosis for ADLfunctioning. Rather, the prediction is based upon an overall impression of test performance by the patient, giving some results more weight than others.

In an attempt to operationalize the complexity of clinical evaluation, multiple regression analyses were performed for each group separately. The method estimates the amount of variance in Help-Dependency which may be explained by the selected variables. The four personal and medical characteristics, i.e. sex, age, hemiplegia, and hemianopia, were included in the analysis before any of the test variables were entered. All test variables were forced into the regression equation but the order was left open for the program to decide. The criterion for selecting a variable was magnitude of correlation after partialling out the variance explained by variables already selected. The validity of the entrance sequence is thus threatened by the fallacy of minor and chance-dependent differences in the partial correlations (Share, 1984). Secondly, the subjects per variable ratios are too low in both hemisphere groups (6.8 among LH and 5.9 among RH patients) to guarantee replicable results but sufficient as explorative solutions (Adams, 1979).

Among patients in the LH group, 22% of the variance was explained by the first four measures (R’z.22, see Figure 1). Ideomotor apraxia was the first test variable to be included after the four medical variables were entered, boosting the amount of explained variance to 34%. Nonverbal memory and constructional apraxia were included next. Aphasia came second to last. Ideational apraxia was excluded from the equation due to a decrease in the multiple correlation (R). Having entered the six neuropsychological test variables described in Figure 1, the amount of variance explained in Help- Dependency among LH patients was 42% (R=.65) This is almost twice as much as accounted for by the four personal/medical characteristics entered first and is considered a major gain.

A statistical argument for aphasia being of low predictor value in the analysis is the fact that all the LH patients suffered from aphasia whereas not all had

Dow

nloa

ded

by [

Uni

vers

ity o

f V

icto

ria]

at 0

3:38

19

Nov

embe

r 20

14

374 KJETIL SUNDET ET AL.

‘GEXEZAL HELP-REPENCEUCY ‘

.OU .05 .70 . I 5 .20 .25 .30 .35 .40 .45

Fig. 1: Left hemisphere group (n=68): Amount explained variance in General Help- Dependency (R2) by multiple regression analysis.

hemiplegia or apractic symptoms. A potentially high correlation between aphasia and Help-Dependency is thus reduced merely because of reduced variance in the measure of aphasia. More important, though, is probably the earlier mentioned fallacy of the entrance sequence. Neuropsychological tests intercorrelate. When apraxia was entered prior to aphasia in the analysis, the shared amount of variance was attributed to the apraxia variable.

Among RH patients the first four characteristics explained 30% of the variance (see Figure 2). Pathological emotional reactions, i.e., Involuntary Crying and Denial of Illness, were entered as the most important neuropsycho- logical measures. Kinetic apraxia followed next. Visuospatial deficits and visual neglect were included later in the analysis, probably due to reasons of the same kind as discussed above with regard to aphasia and the entrance sequence. A total of 52% (R=.72) explained variance in Help-Dependency among RH patients was reached when including measures of nine neuropsychological variables in addition to the basic four variables.

Dow

nloa

ded

by [

Uni

vers

ity o

f V

icto

ria]

at 0

3:38

19

Nov

embe

r 20

14

NEIJROPSYCHOLOGICAL PREDICTORS 375

SEX

l+RZ .OO .05 .10 .I5 .20 .25 .30 .35 .40 .45 .SO .55

Fig. 2: Right hemisphere group ( ~ 7 7 ) : Amount of explained variance in General Help- Dependency (R2) by multiple regression analysis.

DISCUSSION

A major dilemma when evaluating ADLfunctioning is to distinguish between what the patient says he or she can do and what the patient actually does at his/ her own initiative. The questionnaire used in this study contained items asking about particular acts performed at home on a regular basis. It was shown to reliably describe three aspects of actual ADLfunctioning: use of Personal Help, use of Technical Aids, and ability to Manage Alone at home for a shorter time regardless of help or aids. This reproduced essentially the findings by Jette (1980) who derived five functional categories as ADLindicators, subdividing the ones found here according to various domains of activity.

Although the LH and RH groups refer to somewhat different patient populations in terms of physical mobility and specific neuropsychological deficits, the groups were found to be equally impaired in general cognitive

Dow

nloa

ded

by [

Uni

vers

ity o

f V

icto

ria]

at 0

3:38

19

Nov

embe

r 20

14

376 KJETIL SUNDET ET AL.

capacity. RH patients indicated that they required more help than LH patients on items concerning particular actions of ADLfunctioning (#I to #1 I), documented as group differences on the two ADLindexes named use of Personal Help and use of Technical Aids. However, on the more general questions of ability to Manage Alone (#12 and #13), the reported level of help- dependency did not differ significantly between LH and RH patients. Whether this seeming contradiction is caused by the RH patient’s tendency to deny deficits in global terms (anosognosia) but forced to admit need for help when asked about specific actions, or by a real difference in the RH p u p between different levels of ADLfunctioning, is not known. In further research the formulation of questions about ability to manage alone should be of a most specific nature and behavioural precision.

The study was not aimed at finding a set of predictor variables to be used for all stroke patients. The results may thus validly be generalized to other stroke patients only if the subject characteristics are kept in mind, recognizing also that other predictors may be important for nonaphasic LH and nonhemiplegic RH patients.

The results showed that apraxia and pathological emotional reactions were the more important neuropsychological predictors in the LH and RH group respectively. Ths does not necessarily mean that emotional disturbances have more impact on rehabilitation outcome in RH than in LH patients, as emotional variables were not studied in the LH sample. LH stroke patients have been found to suffer from catastrophic reaction (Gainotti, 1972) and depression, which are most evident in patients with left frontal lesions (Robinson, Kubos, Starr, Rao, & Price, 1984; Sinyor et al., 1986). On the other hand, denial of illness has most often been linked to RH damage (Weinstein & Kahn, 1955). The finding that emotional disturbances contribute so clearly to the prediction of rehabilitation outcome should indicate an enhanced interest in the management of emotional problems after both LH and RH stroke.

A total of 42% of the variance in Help-Dependency among LH and 52% among RH patients was explained by the chosen predictor variables. Though this amount is a substantial increase from that offered by patient characteristics such as age, sex, hemianopia, and hemiplegia, it is still far from predicting actual outcome status for the single patient (Dombovy et al., 1986)

The measure of Help-Dependency reflects the actual use of aids and persons in order to manage alone, and does not assess the objective need for these forms for help. When studying the independent variables by means of tests and ratings, it is the patient’s capacity which is investigated, not the likelihoodof him or her using this capacity. This partly accounts for the imperfect predictive relationship. To improve the prediction of Help-Dependency, one needs more information about variables not covered in the present study, such as the patient’s feeling of insecurity and of patterns of interaction in the family.

It should be pointed out that awareness of deficits in the therapy team was high, and that efforts were made to stimulate the patients to compensate for

Dow

nloa

ded

by [

Uni

vers

ity o

f V

icto

ria]

at 0

3:38

19

Nov

embe

r 20

14

NEUROPSYCHOLOGICAL PREDICTORS 377

such deficits. This may have attenuated the relationship between deficits and outcome, as was actually found in the study by Feigenson, McDowell, Meese, McCarthy, Greenberg, and Feigenson (1977).

Further research may proceed in two different directions. One is to create tests and assessment procedures that reflect ADLfunctioning more directly. With regard to aphasia, Holland (1980) has designed a test of functional communication. The search for a method of describing natural communication has been impeded so far because of the wide variation of communicative needs showed by aphasics in real-life situations (Smith, 1985). The objective of this avenue of research is to construct neuropsychological tests with optimal relevance to functional status. To the extent that the predictor variables (neuropsychological tests) are defined more or less identical to the criterion variable (functional status), the problem of prediction becomes meaningless. The test may offer a reliable shorthand measure of the deficit but not its consequences, i.e., an aphasia test produces an impression of the nature of the language impairment, not the pragmatical and communicational difficulties.

The alternative avenue of research is to sharpen and develop the independent variables, while preserving their distinctness from functional outcome measures. Present neuropsychological tests give structural descriptions of relative sparing or deficits in abilities. In order to relate these functional profiles to actual psychological processes, new sets of variables and procedures should be introduced in neuropsychological test batteries. Measures relating to the speed and effort aspects of processing, as well as the ability to integrate different sources of information in working memory, are relevant and show promise (Butter & Cermak, 1980).

The value of neuropsychological theories and methods in rehabilitation depends on their ability to make general statements about human functioning based on observable behaviours. Cognitive and affective processes and strategies should be its prime field of interest. In working out the pragmatic aspect of such knowledge, its predictive power in relation to daily-life functioning is of central concern. In this regard, the two avenues of research described above, meet.

REFERENCES

Adams, K. M. (1979). Linear discriminant analysis in clinical neuropsychology research. Journal of Clinical Neuropsychology, I , 259-272.

Allen, C. M. C. (1984). Predicting the outcome of acute stroke: A prognostic score. Journal of Neurology, Neurosurgery, and Psychiatry, 47, 475-480.

Anderson, E., Anderson, T. P., & Kottke, F. (1977). Stroke rehabilitation: Maintenance of achieved gains. Archives of Physical Medicine and Rehabilitation, 58, 345-352.

Baird, A., Adams, K. M., Ausman, J. I., & Diaz, F. G. (1985). Medical, neuropsychologi- cal, and quality-of-life correlates of cerebrovascular disease. Rehabilitation Psycho- logy, 30, 145-155.

Dow

nloa

ded

by [

Uni

vers

ity o

f V

icto

ria]

at 0

3:38

19

Nov

embe

r 20

14

378 KJETIL SUNDET ET AL.

Bieliauskas, L. A. (1986). The void still exists. [Review of G. Goldstein & L. Ruthven (1983). Rehabilitation of the braindamagedudult]. Journal of Clinic01 andExperheural Neuropsycho logy, 8,465-467.

Bjnrrneby, E., & Reinvang, I. (1985). Acquiring and maintaining selfcare skills after stroke. The predictive value of apraxia. Scandinavian Journal of Rehabilitation Medicine, 17, 75-80.

Butters, N., & Cermak, L.S. (1980). Alcoholic Korsakoff s Syndrome. An information- processing approach to amnesia. New York: Academic Press.

Caplan, B. (1982). Neuropsychology in rehabilitation: Its role in evaluation and intervention. Archieves of PhysicalMedicine and Rehabilitation, 63, 362-366.

Dombovy, M. L., Sandok, B. A., & Basford, J R. (1986). Rehabilitatb&fcW s W e : A review. Stroke, 17,363-369.

Dull, R. A., Brown, G. G., Adams, K. M., Shatz, M. W., Diaz, F. G., & Ausman, J. I. (1982). Preoperative neurobehavioural impairment in cerebral revascularization candidates. Journal of Clinical Neuropsychology, 4, 15 1-165.

Ebrahim,, S., Nouri, F., & Barer, D. (1985). Measuring disability after stroke. Journal of Epidemiology and Community Health, 39.86-89.

Feibel, J. H., & Springer, C. J. (1982). Depression and failure to resume social activities after stroke. Archives of Physical Medicine and Rehabilitation, 63, 276-278.

Feigenson, J. S., McCarthy, M. L., Greenberg, S. D., & Feigenson, W. D. (1977). Factors influencing outcome and length of stay in a stroke rehabilitation unit - Part 2. Comparison of 318 screened and 248 uncreened patients. Stroke, 8,657-662.

Feigenson, J. S., McDowell, F. H., Meese, P. D., McCarthy, M. L., Greenberg, S. D., & Feigenson, W. D. (1977). Factors influencing length of stay in a stroke rehabilitation unit - Part 1: Analysis of 248 unscreencd patients - medical and functional prognostic indicators. Stroke, 8,65 1-656.

Finset, A,, Sundet, K., & Haakonsen, M. (in press). Neuropsychological syndromes in right hemisphere stroke patients. Scandinavian Journal of Psychology.

Fugl-Meyer, A., & Jaasko, E. (1980). Post stroke herniplegid and ADLperformance. Scandinavian Journal of Rehabilitation Medicine, Suppl. 7, 140-152.

Gainotti, G. (1972). Emotional behavior and hemispheric side of lesion. Cortex, 8,41-55. Garraway, M. (1955). Stroke rehabilitation units: Concepts, evaluation, and unresolved

Goldstein, G., & Ruthven, L. (1983). Rehabilitation of the brain-damaged adult. New

Hilton, L., & Kraetschmer, K. (1983). International trends in aphasia rehabilitation.

Holland, A. (1980) Communicative abilities in daily living. Baltimore: University Park

Jette, A. M. (1980). Functional capacity evaluation: Empirical approach. Archives of

Jongbloed, L. (1986). Prediction of function after stroke: A critical review. Stroke, 17,

Keith, R. A. (1984). Functional assessment measures in medical rehabilitation: Current

Kertesz, A. (1983). Localization in neuropsychology. New York: Academic Press. Kinsella, G. J., & Duffy, F. D. (1979). Psychosocial readjustment in the spouses of

aphasic patients. Scandinavian Journal of Rehabilitation Medicine, I I . 129-132.

issues. Stroke, 16, 178-181.

York: Plenum Press.

Archives of Physical Medicine and Rehabilitation, 64, 462-467.

Press.

PhysicalMedicine and Rehabilitation, 61, 85-89.

76 5 - 7 7 6.

status. Archives of Physical Medicine and Rehabilitation, 65, 74-78.

Dow

nloa

ded

by [

Uni

vers

ity o

f V

icto

ria]

at 0

3:38

19

Nov

embe

r 20

14

NEUROPSYCHOLOGICAL PREDICTORS 379

Kotila, M., Waltimo, O., Niemi, M.-L., Laaksonen, R., & Lempinen, M. (1984). The profile of recovery from stroke and factors influencing outcome. Stroke, 15, 1039-1044.

Lezak, M. D. (1983). Neuropsychological assessment (2nd ed.) New York: Oxford University Press.

Miller, E. (1980). Psychological intervention in the management and rehabilitation of neuropsychological impairments. Behavioural Research and Therapy, 18, 527-535.

Newcombe, F. (1985). Rehabilitation in clinical Neurology: Neuropsychological aspects. In J. A. M. Fredriks (Ed.), Handbook of Clinical Neurology, Vol. 2(46): Neurobehaviou- ral disorders (pp. 609-642). Amsterdam: Elsevier Science Publisher

Nie, N., Hull, C. H., Jenkins, J. G., Steinbrenner, K., & Bent, D. H. (1975). Statistical packagefor the social sciences. New York: McGraw-Hill.

Powell, G. E. (1981). Brain function therapy. Aldershot: Gower. Raymond, P. M., & Susset, V. (1984). Depression in stroke: Further evidence for an

organic etiology. Archives of Physical Medicine andliehabiliation, 65, 630 (Abstract). Reinvang, I. (1985). Aphasia and brain organization. New York: Plenum Press. Reinvang, I., & Engvik, H. (1980). HGndbok: Norsk Grunntest fo r Afasi [Handbook:

Norwegian Basic Aphasia Assessment]. Oslo: Universitetsforlaget. Reinvang, I., & Sundet, K. (1985). The validity of functional assessment with

neuropsychological tests in aphasic stroke patients. Scandinavian Journal of Psycho-

Robinson, R. G., Bolduc, P. L., Kubos, K. L., Starr, L. B., & Price, T. R. (1985). Social functioning assessment in stroke patients. Archives of Physical Medicine and Rehabili- tation, 66, 496-500.

Robinson, R. G., Kubos, K. L., Starr, L. B., Rao, K., & Price, T. R. (1984). Mood disorders in stroke patients: Importance of location of lesion. Brain, 107, 81-93.

Share, D. L. (1984). Interpreting the output of multivariate analyses: A discussion of current approaches. British Journal of Psychology, 75, 349-362.

Shore, D.L. (1984). The rush to fill the void. [Review of L. E. Trexler (Ed.) (1982). Cognitive rehabilitation: Conceptualization and intervention] Journal of Clinical Neuropsychology, 6, 345-349.

Sinyor, D., Jacques, P., Kaloupek, D. G., Becker, R., Goldenberg, M., & Coopersmith, H. (1986). Poststroke depression and lesion location. Brain, 109, 537-546.

Smith, L. (1985). Communicative activities of dysphasic adults: A survey. British Journal of Disorders of Communication, 20, 3 1-44.

Strand, T., Asplund, K. , Eriksson, S., Hagg, E., Lithner, F., & Wester, P. 0. (1986). Stroke unit care - who benefits? Comparisons with general medical care in relation to prognostic indicators on admission. Stroke, 17, 377-381.

Trexler, L. E. (Ed.) (1982). Cognitive rehabilitation. Conceptualization and intervention. New York: Plenum Press.

Wade, D. T., Hewen, R. L., & Wood, V. A. (1984). Stroke: Influence ofpatient’s sex and side of weakness on outcome. Archives of Physical Medicine and Rehabilitation, 65,

logy, 26, 208-218.

5 13-5 16. Weinstein, E. A., & Kahn, R. C. (1955). Denialof illness. Sprinfield, 11: Thomas.

Dow

nloa

ded

by [

Uni

vers

ity o

f V

icto

ria]

at 0

3:38

19

Nov

embe

r 20

14