Archives of Physical Medicine and Rehabilitation
Volume 87, Issue 11 , Pages 1496-1502, November 2006

Predicting Recovery of Upper-Body Dressing Ability After Stroke

  • Makoto Suzuki, MA, OT

      Affiliations

    • Department of Rehabilitation Medicine, Kawasaki Municipal Tama Hospital, Kawasaki, Japan
    • Corresponding Author InformationReprint requests to Makoto Suzuki, MA, OT, 1-30-37, Shukugawara, Tama-ku, Kawasaki-shi, Kanagawa, 214-0021 Japan
    • ,
  • Mikayo Omori, OT

      Affiliations

    • Department of Rehabilitation Medicine, St. Marianna University School of Medicine Hospital, Kawasaki, Japan
    • ,
  • Mayumi Hatakeyama, OT

      Affiliations

    • Department of Rehabilitation Medicine, St. Marianna University, Yokohama City Seibu Hospital, Yokohama, Japan
    • ,
  • Sumio Yamada, PhD, PT

      Affiliations

    • School of Health Science, Nagoya University, Nagoya, Japan
    • ,
  • Kazuhiko Matsushita, PhD, MD

      Affiliations

    • Department of Orthopedics, Kawasaki Municipal Tama Hospital, Kawasaki, Japan
    • ,
  • Setsu Iijima, PhD, MD

      Affiliations

    • Institute of Disability Sciences, University of Tsukuba, Bunkyo, Japan.

Article Outline

Abstract 

Suzuki M, Omori M, Hatakeyama M, Yamada S, Matsushita K, Iijima S. Predicting recovery of upper-body dressing ability after stroke.

Objective

To identify predictors of the recovery of independent dressing ability after stroke.

Design

Prospective cohort study.

Setting

Rehabilitation unit at a university hospital.

Participants

Sixty-three consecutive stroke patients were enrolled in the study. Twelve patients were not able to complete the study because they were discharged or transferred to another hospital before study completion.

Intervention

Fifty-one patients underwent and completed 15 days of dressing training based on the time-delay method, which included the 10 component actions of upper-body dressing and 4 cues given by therapists.

Main Outcome Measures

The dressing item of the FIM instrument, Brunnstrom motor recovery stages, presence or absence of deep and tactile sensation, Rey-Osterrieth complex figure test, Kohs block design test, body image test, Weintraub cancellation task, and presence or absence of the visual extinction phenomenon and the motor impersistence phenomenon.

Results

The FIM upper-body dressing item score and the cancellation task score at the start of training were significantly better in patients who achieved independence in dressing within 15 training days than in patients who did not (P<.05). The motor impersistence phenomenon was found less frequently among patients who achieved independence in upper-body dressing than among patients who did not (P<.05). However, logistic regression analysis showed that only the FIM score for upper-body dressing on the first day of training was a significant independent predictor of dressing ability at the end of training (odds ratio, 4.33; 95% confidence interval, 1.51–12.37). The receiver operating characteristic curve indicated that a cutoff score of 3 would provide the best balance between sensitivity and specificity for the FIM upper-body dressing item. The positive predictive value of this cutoff score was .90, and the negative predictive value was .70.

Conclusions

Our findings indicate that the FIM upper-body dressing score on the first day of dressing training is an independent predictor of recovery of upper-body dressing ability after stroke.

Key Words: Activities of daily living, Prognosis, Rehabilitation, Stroke

 

INDEPENDENCE IN DRESSING enables a person to maintain a sense of dignity, self-respect, and achievement.1 Therapists working with stroke patients spend a large proportion of the day teaching patients how to put on and take off items of clothing.2 Despite such instruction, however, many patients are still unable to dress themselves independently for several weeks after hospital admission.3, 4, 5, 6 Dressing is more difficult than undressing, and upper-body dressing requires more advanced recognition than lower-body dressing.1, 2

Many studies1, 2, 7, 8, 9, 10, 11, 12, 13 have shown a relation between difficulty in dressing and cognitive and physical impairments. Despite more than 50 years of research, it is still difficult to predict the extent or duration of loss of dressing ability.7, 8, 9, 10, 11, 12, 13, 14, 15 There is no clear understanding of the effect of early neurologic impairments and early dressing disorder on a stroke patient’s ultimate recovery from dressing disorder.1, 2, 7, 8, 9, 10, 11, 12, 13, 14, 15 In a single-blind randomized controlled trial, Kwakkel et al14 investigated the effects of different intensities of arm and leg rehabilitation on the functional recovery of activities of daily living (ADLs) including dressing. They found no differences in ADL scores between the arm-training and control groups, and they suggested that stroke patients compensate for the loss of function in the paretic arm by using the nonparetic arm during ADLs. They noted that impairment was not always associated with dressing disorder in their patients. Jongbloed15 performed a critical review of 33 studies and concluded that the admission ADL score is a strong predictor of discharge ADL status, but its relation to improvement in cognitive and physical impairment is unclear.

Which is a stronger predictor of recovery of dressing ability, early neurologic impairments or early dressing disorder? Because it is still difficult to identify predictors of dressing ability, success in training is largely due to the extent of a therapist’s experience rather than any scientific data. If we could identify predictors of recovery of dressing ability and predict the extent or duration of dressing ability loss, training in upper-body dressing skills would become more evidence based.

We conducted a prospective cohort study to identify predictors of the recovery of independent dressing ability after stroke.

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Methods 

Outcome Measures 

The study protocol is shown in figure 1. Each patient’s upper-body dressing ability was assessed according to the FIM instrument dressing item16 on the first day of dressing training. The ability to dress the upper body is precisely defined by the FIM, and scores range from 1 to 7, with 1 indicating complete dependence during an activity and 7 indicating complete independence.

Many studies1, 2, 7, 8, 9, 10, 11, 12 have shown a relation between difficulty in dressing and cognitive and physical function impairments including motor palsy, sensory disturbance, constructional disorder, body image disturbance, visual inattention, unilateral spatial neglect, and motor impersistence. Therefore, the presence or absence of these impairments was also determined. The severity of motor palsy was assessed according to the 6 motor recovery stages of Brunnstrom17 representing muscle conditions ranging from the initial flaccidity of palsy to normal coordination. Sensory disturbance was evaluated according to the presence or absence of deep and tactile sensation. Constructional disorder was assessed by the Rey-Osterrieth complex figure test18 and Kohs block design test19; these are 36-point and 131-point scales, respectively. Body image disturbance was assessed by an unpublished test of each patient’s ability to discriminate the head, nose, right shoulder, left shoulder, abdomen, and back of the neck (6-point scale). Visual inattention was evaluated by a cancellation task involving a sheet of paper containing 360 randomly arranged shapes, 60 of which were target stimuli.20 Unilateral spatial neglect was measured by the presence or absence of the visual extinction phenomenon.21 Motor impersistence was assessed by each patient’s ability to sustain tongue protrusion and eye closure simultaneously for 20 seconds.22 The reliability and validity of the 4 tests (FIM, Brunnstrom stages, Rey-Osterrieth complex figure test, Kohs block design test) have been established.21, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32 We assessed 2 tests for their test-retest reliability in 15 stroke patients with an interval of 5 days between measurements. The intraclass correlation coefficients were .78 for the target cancellation task (P<.01) and 1.00 for the body image test (P<.01).

Participants 

Sample size calculation was based on a desired 95% statistical power to detect a 1-point difference in the FIM dressing item score, with a 2-sided α of 5%. The average value and standard deviation (SD) of FIM dressing item scores in 20 stroke patients were assessed to determine the standard effect size. The average FIM dressing item score was 2.45±1.50 points, and the standard effect size was .66. A sample size of 53 was derived by insertion of 1-power (.05), α (.05), and standard effect size (.66) values in the Hulley matrix.33 We therefore planned to recruit about 50 stroke patients.

Between May 1, 2001, and May 1, 2004, 63 consecutive stroke patients from the Department of Rehabilitation Medicine, St. Marianna University School of Medicine Hospital, were enrolled in the study. Stroke was diagnosed according to the World Health Organization definition.34 Eligibility criteria included hemiplegia, dependence on spoken cues or physical assistance to accomplish upper-body dressing, ability to sit up with a backrest for more than 30 minutes, lucid consciousness, a period of less than 3 months since the stroke event, absence of severe cardiopulmonary or respiratory insufficiency, and a desire to participate in the study. Baseline characteristics of patients who satisfied the inclusion criteria are presented in table 1. The mean age of participants was 69.4±10.6 years. There were 25 women and 38 men, 45 patients with cerebral infarction and 18 with cerebral hemorrhage, and 27 patients with right hemiplegia and 36 with left hemiplegia. The average time since the stroke event was 23.0±17.2 days.

Table 1. Baseline Characteristics of Patients Who Satisfied the Inclusion Criteria
CharacteristicsValues
Age (y)69.4±10.9
Sex (n)
Male38
Female25
Diagnosis (n)
Infarction45
Hemorrhage18
Time poststroke at assessment (d)23.0±7.2
Paralysis side (n)
Right27
Left36
Sensory disturbance (n)
Tactile sense21
Deep sense17
Visual extinction phenomenon (n)28
Motor impersistence (n)23
FIM dressing item2.0(2.0–3.0)
Brunnstrom motor recovery stage3.0(2.0–4.0)
Kohs block design test score0.0(0.0–17.0)
Rey-Osterrieth complex figure test score4.0(0.0–21.4)
Target cancellation task21.0(0.0–49.0)
Disturbance of body image6.0(4.0–6.0)

NOTE. Values are mean ± SD, n, or median (interquartile range [IQR]).

Twelve patients (6 with right hemiplegia, 6 with left hemiplegia) withdrew from the study because they were discharged or transferred to another hospital before study completion.

The study was approved by the St. Marianna University School of Medicine Institutional Committee on Human Research. Informed consent was obtained from each patient before his/her participation in the study.

Intervention 

ADLs such as dressing are considered behavioral chains of component actions.35 Such chains have been learned and performed since childhood. A patient with hemiplegia cannot dress by means of the behavioral chains of component actions used by a healthy person and thus has to learn new behavioral chains of component actions to achieve independence in dressing. It is necessary to control the cue stimulations and rewards presented in training to support the organization of new behavioral chains.35, 36 For the purpose of the study, upper-body dressing was viewed in 10 separate stages: (1) the paralyzed upper extremity is inserted into the sleeve, (2) the sleeve is pulled up beyond the elbow joint, (3) the sleeve is pulled up beyond the shoulder joint, (4) the shirt is pulled across the back to the opposite shoulder joint, (5) the intact upper extremity is inserted into the other sleeve, (6) the collar is arranged, (7) the first button is fastened, (8) the second button is fastened, (9) the third button is fastened, and (10) the fourth button is fastened (fig 2). These 10 component actions describe the entire process of upper-body dressing. The list was developed after observation of the behavioral chains of upper-body dressing used by 33 stroke patients with hemiplegia. The 22 stroke patients (66.7%) who achieved the greatest independence in upper-body dressing used these 10 component actions as a behavioral chain. Thus, these actions were selected for use in our current study.

The study patients underwent 15 days of training based on the time-delay method,37 which is a recognized and effective training method.38 In the time-delay method, cues are given after a set interval of time has elapsed, in this case 10 seconds. The starting position for dressing training was the patient grasping the shirt collar. Dressing training began with the verbal instruction, “Please put on the shirt.” If the patient responded with inadequate component actions or if the patient did nothing for 10 seconds, the therapist offered cues at 4 levels in the following order: (1) verbal cue, (2) gesturing, (3) tapping, and (4) physical assistance. Verbal cues were instructions such as, “Can you pass your right hand into the sleeve?” or “Can you pull the sleeve up to your elbow?” Gesturing consisted of the therapist mimicking the component action of upper-body dressing. Tapping consisted of the therapist tapping the patient’s clothes and body. Physical assistance consisted of the therapist taking the patient’s hand and guiding it in the appropriate direction. When the patient performed each component action, the therapist praised him/her. After 15 days of training, each patient was assessed for his/her ability to dress the upper half of the body independently.

Statistical Analysis 

Patients were classified into 2 groups: those who could perform the upper-body dressing tasks independently after the 15 days of training and those who required assistance. Cognitive and physical function and upper-body dressing ability on the first day of dressing training were compared between the 2 groups. Differences in categoric variables were analyzed by the chi-square test or Fisher exact test. The Mann-Whitney U test was used to analyze ordinal variables. Logistic regression analysis was used to identify the best independent predictors of independent upper-body dressing ability after 15 days of training. All statistical procedures were performed with SPSS softwarea with a significance level set at P equal to .05. A receiver operating characteristic (ROC) curve was used to assess the clinical utility of the independent predictors.39 Constructing the ROC curve involved setting several cutoff points for significant variables and calculating sensitivity, specificity, positive predictive value, and negative predictive value at each point.

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Results 

Statistics related to subjects’ performances of each task are presented in table 2. Upper-body dressing ability and visual attention at the start of training were significantly better in patients who achieved independence in dressing within 15 training days than in patients who did not. The FIM upper-body dressing item score for independent patients was higher than that for dependent patients (median score, 3 points; interquartile range [IQR], 2–3 points vs median score, 2 points; IQR, 1–2 points; P<.001). The target cancellation task score for independent patients was higher than that for dependent patients (median score, 40 points; IQR, 10.5–57.5 points vs median score, 2 points; IQR, 0–21 points; P=.004). In addition, motor impersistence was found less frequently among patients who achieved independence in upper-body dressing than among patients who did not. There were 4 (14.3%) independent patients and 12 (54.2%) dependent patients (P=.014) with motor impersistence. Independence in dressing was not significantly associated with the severity of motor palsy or body image disturbance. Logistic regression analysis of the 14 variables showed only the FIM upper-body dressing score to be a significant predictor of the recovery of dressing ability (odds ratio, 4.33; 95% confidence interval, 1.51–12.37).

Table 2. Predictors of Upper-Body Dressing Ability After Stroke
CharacteristicsIndependent (n=28)Dependent (n=23)P⁎Odds Ratio (95% CI)
Age⁎ (y)69.8±10.070.3±10.0.837NS
Sex (% male)53.665.2.580NS
Diagnosis (% cerebral infarction)71.469.6.758NS
Paralysis side (% right hemiplegia)46.434.8.259NS
Tactile sense disturbance (% positive cases)25.034.8.543NS
Deep sense disturbance (% positive cases)17.926.1.732NS
Visual extinction phenomenon (% positive cases)28.660.9.079NS
Motor impersistence (% positive cases)14.354.2.014NS
FIM dressing item3.0(2.0–3.0)2.0(1.0–2.0)<.0014.33 (1.51–12.37)
Brunnstrom motor recovery stage3.0(3.0–4.3)3.0(2.0–3.5).163NS
Kohs block design test score7.0(0.0–18.8)0.0(0.0–1.0).063NS
Rey-Osterrieth complex figure test score13.5(1.3–24.5)2.5(0.0–6.5).088NS
Target cancellation task40.0(10.5–57.5)2.0(0.0–21.0).004NS
Disturbance of body image6.0(4.0–6.0)6.0(4.0–6.0).668NS

NOTE. Values are mean ± SD, median (IQR), or as otherwise indicated. Odds ratios show logistic regression analysis.

Abbreviations: CI, confidence interval; NS, not significant.

⁎χ2 test or Fisher exact test (categoric variables), Mann-Whitney U test (ordinal variables).

FIM upper-body dressing scores were plotted as an ROC curve (fig 3). Sensitivity, specificity, and predictive value at several cutoff points are presented in table 3. The curve indicated that a cutoff score of 3 being “moderate” would provide the best balance between sensitivity and specificity for the FIM upper-body dressing item (sensitivity, .68; 1 – specificity, .09). The positive predictive value of this cutoff score was .90, and the negative predictive value was .70. Characteristics of patients who withdrew from the study were similar to those of patients who completed the study (table 4).

Table 3. Sensitivity, Specificity, and Predictive Values at 3 Cutoff Points
Cutoff PointSensitivitySpecificityPositive Predictive ValueNegative Predictive Value
20.8930.3910.6410.750
30.6790.9130.9050.700
40.1431.0001.0000.489
Table 4. Characteristics of Subjects Who Completed the Study and Those Who Withdrew
CharacteristicsPatients Who Completed the StudyPatients Who Withdrew From the StudyP
Age (y)70.0±9.966.6±15.4.716
Sex (% male)60.858.3.383
Diagnosis (% cerebral infarction)70.675.0.563
Paralysis side (% right hemiplegia)41.250.0.290
Tactile sense disturbance (% positive cases)29.450.0.218
Deep sense disturbance (% positive cases)21.650.0.281
Visual extinction phenomenon (% positive cases)43.150.0.021
Motor impersistence (% positive cases)31.40.7.002
Period from crisis to measurement (d)23.0±16.522.8±21.8.620
FIM dressing item2.0(2.0–3.0)2.0(2.0–3.5).446
Brunnstrom motor recovery stage3.0(2.5–4.0)2.0(2.0–3.5).104
Kohs block design test score0.0(0.0–17.0)0.0(0.0–17.5).932
Rey-Osterrieth complex figure test score4.0(0.5–22.5)0.0(0.0–6.0).092
Target cancellation task21.0(0.0–50.5)15.0(0.5–23.0).453
Disturbance of body image6.0(4.0–6.0)6.0(2.5–6.0).617

NOTE. Values are mean ± SD, median (IQR), or as otherwise indicated.

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Discussion 

Our results indicate that the FIM upper-body dressing score on the first day of dressing training is an independent predictor of recovery of upper-body dressing ability after stroke. Williams8 correlated the constructional abilities of 136 hemiplegic patients with their abilities to relearn upper-extremity dressing skills. Patients with normal constructional ability were more likely to be independent in upper-extremity dressing or had a greater capacity to achieve this skill than patients with a constructional disorder. In an evaluation of 60 stroke patients by the Nottingham Stroke Dressing Assessment and other physical and cognitive assessments, Walker and Lincoln2 found that difficulty in lower-body dressing was associated with physical impairment and that difficulty in upper-body dressing was associated with visual inattention and sensory disturbance. Chen et al11 investigated the relation between patterns of visuospatial inattention and performance of ADLs by means of the Klein-Bell ADL Scale and the Random Chinese World Cancellation Test in 64 patients with a right brain lesion. They found that hemi-inattention was highly related to poor ADL performance and that independence in dressing appeared to be more adversely affected by hemi-inattention than was independence in bathing and hygiene, eating, or use of the telephone. Hier et al12 evaluated 41 patients with unilateral right hemisphere stroke for hemiparesis, hemianopia, constructional apraxia, spatial neglect, dressing disorder, and motor impersistence. Dressing disorder was associated with severe constructional apraxia, spatial neglect, motor impersistence, and hemianopia.

In marked contrast to the findings of earlier studies,1, 2, 7, 8, 9, 10, 11, 12 the final regression model in our study showed no significant relation between the recovery of upper-body dressing ability and any underlying cognitive or physical impairment assessed in this study. As noted above, patients with hemiplegia are unable to use the same behavioral chains that are used by healthy people to accomplish dressing tasks. However, if a new behavioral chain is learned, patients can achieve a degree of independence in dressing. The reason why early dressing disorder is a stronger predictor of the recovery of dressing ability than cognitive or physical impairment is related to the degree of change to the original behavioral chain.

According to univariate analysis, visual attention at the start of training was significantly better in patients who achieved independence in dressing within 15 training days than in patients who did not. Also, motor impersistence was found less frequently among patients who achieved independence in upper-body dressing than among patients who did not. These findings corroborate those reported by Walker and Lincoln2 and Hier et al.12 There is still no clear understanding of the effect of underlying neurologic impairments on a stroke patient’s ability to relearn to dress. Prior studies1, 2, 7, 8, 9, 10, 11, 12 have failed to answer this question for several reasons. In some cases, multivariate analysis was not performed, and in others, variables were not tested for independent prediction. In addition, no prospective cohort study to identify the predictors of recovery of independent dressing ability has been conducted. In the present study, the target cancellation task score and motor impersistence on the first day of dressing training were independent predictors of recovery of upper-body dressing ability after stroke. However, the recovery of independent dressing ability was more strongly related to the FIM upper-body dressing score than to the target cancellation task score and motor impersistence.

Our analysis indicated that the FIM upper-body dressing score can serve as a valuable predictor of the ability to dress the upper body independently after stroke. Ninety percent of patients with a FIM upper-body dressing score of 3 or more on the first training day recovered the ability to dress the upper body independently within 15 training days. However, 70% of patients with a score of 2 or less could not perform this task independently after 15 days of training. Such patients require other solutions, such as different types of training or changes in materials or types of clothes. In addition, therapists should be consulted about the appropriate method for assisting these patients. Therapists can predict the recovery of independent dressing ability after stroke scientifically by an initial assessment with the FIM dressing item. Our findings will contribute to an increasingly evidence-based approach to upper-body dressing training for stroke patients.

The FIM score was investigated in relation to the burden of care; a 1-point change in the total FIM score was equivalent to an average of 2 to 5 minutes of help from another person per day.25, 26, 27 Rogers et al38 examined the effectiveness of a behavioral rehabilitation intervention based on the time-delay method for improving the performance of morning care routines by nursing home residents with dementia. In their study,38 physical assistance were provided for significantly smaller proportions of a morning care session during the behavioral rehabilitation intervention. However, the intervention took considerably more time than was needed for the usual care. Our results indicated that the time spent in nonassisted dressing increased for patients who could perform upper-body dressing independently after the 15 days of training. However, a therapist may spend more time with a patient who requires only partial assistance after the 15 days of training than with patients who require full assistance. Therefore, therapists should devise a method in which assistance and promotion of independence are balanced.

Study Limitations 

Because this was a prospective cohort study, we did not randomize patients into groups before the training. Patients were classified into 2 groups after training: those who could perform the upper-body dressing tasks independently after the 15 days of training and those who required assistance. We also did not evaluate cognitive or physical function of patients after training. Therefore, the effect of dressing training based on the time-delay method is not clear in this study. If patients were allocated before or re-evaluated after the training, the effect of any natural recovery could be excluded. Further research in a randomized controlled trial is needed to verify the effect of dressing training based on the time-delay method.

The FIM upper-body dressing item used in this study is part of a standardized ADL test. However, this item does not distinguish the component actions of upper-body dressing, and it does not account for cues given by the therapist during evaluation of upper-body dressing ability. The difficulty of upper-body dressing varies according to the dressing components and is also affected by cues given during evaluation. Thus, the FIM upper-body dressing item cannot be used to evaluate details of upper-body dressing or the level of assistance required. Therefore, further research is needed to develop an upper-body dressing assessment scale that accounts for the individual components of dressing activities and controls for cue stimulation during any evaluation of dressing skills.

The number of participants in our study was determined on the basis of Hulley’s matrix for sample-size estimation.33 However, a larger number of participants will be needed in further studies to remove the influence of natural differences between people in recovery from cognitive and physical impairments. With the addition of a detailed examination classifying participants by types of lesion and by attributes and the inclusion of a large number of patients, the results of a study like ours would be more generalizable.

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Conclusions 

We conducted a prospective cohort study to investigate the influence of early neurologic impairments or early dressing disorder on the recovery of independent dressing ability after stroke. Our findings indicate that early dressing disorder (as measured by the FIM upper-body dressing score) on the first day of dressing training is an independent predictor of the upper-body dressing ability after stroke. We expect our findings will contribute to a more evidence-based method of training in upper-body dressing skills.

The most popular behavioral chain of component actions in dressing training based on the time-delay method was used in this study. However, the behavioral chain of component actions will vary according to the seriousness of impairments in cognitive and physical function. There was no significant relation between the recovery of upper-body dressing ability and any underlying cognitive or physical impairment assessed in this study, but this finding may be related to the fact that only 1 behavioral chain was targeted. Therefore, it is necessary to investigate the relation between cognitive and physical impairments and several different behavioral chains of component actions.

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Acknowledgments 

We thank Mihoko Nakadate, OT, Sachiko Izawa, OT, Yuko Matsumoto, OT, Ari Watanabe, OT, Akiko Kataoka, OT, Eriko Musha, OT, Seiko Sugano, OT, Junko Matsumoto, OT, Masuo Sasa, PhD, MD, and Yoshikatsu Tagawa, OT, for help and assistance in the study.

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  • a SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.

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PII: S0003-9993(06)00872-0

doi:10.1016/j.apmr.2006.07.267

Archives of Physical Medicine and Rehabilitation
Volume 87, Issue 11 , Pages 1496-1502, November 2006

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