Original article| Volume 93, ISSUE 11, P1957-1962, November 2012

Relationship Between Arm Usage and Instrumental Activities of Daily Living After Unilateral Stroke


      Haaland KY, Mutha PK, Rinehart JK, Daniels M, Cushnyr B, Adair JC. Relationship between arm usage and instrumental activities of daily living after unilateral stroke.


      To determine whether the preferred pattern of arm use after unilateral hemispheric damage was associated with better everyday functioning. Our previous work showed that right-handed stroke patients with right hemisphere damage (RHD) used their right, ipsilesional arm most frequently, while those with left hemisphere damage (LHD) used both arms together most frequently. This effect was explained by right-hand preference, but its relationship to functional performance is not known.


      Observational cohort.


      Research laboratory.


      Stroke patients (n=60; 30 RHD, 30 LHD) and healthy controls (n=52).


      Not applicable.

      Main Outcome Measures

      The Functional Impact Assessment was used to assess performance on instrumental activities of daily living (IADLs).


      The preferred patterns of arm use were similar to those in our previous report. However, it was the greater use of both arms together that was associated with better IADL performance in both stroke groups. Ipsilesional arm use alone was not significantly associated with IADL performance in the RHD group and was associated with poorer performance in the LHD group.


      The modal arm use pattern did not always optimize IADL functioning. Better IADL functioning in both stroke groups was associated with the use of both arms together, which is the most common arm use pattern of healthy individuals doing these same IADLs. An important practical question that arises from these findings is whether bilateral arm rehabilitation should be emphasized, because using both arms together is the best predictor of better performance on everyday tasks.

      Key Words

      List of Abbreviations:

      ADL (activity of daily living), FIA (Functional Impact Assessment), IADL (instrumental activity of daily living), LHD (left hemisphere damage), RHD (right hemisphere damage)
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        • Annett J.
        • Annett M.
        • Hudson P.T.W.
        • Turner A.
        The control of movement in the preferred and non-preferred hands.
        Q J Exp Psychol. 1979; 31: 641-652
        • Harris J.E.
        • Eng J.J.
        Individuals with the dominant hand affected following stroke demonstrate less impairment than those with the nondominant hand affected.
        Neurorehabil Neural Repair. 2006; 20: 380-389
        • McCombe W.S.
        • Whitall J.
        Hand dominance and side of stroke affect rehabilitation in chronic stroke.
        Clin Rehabil. 2005; 19: 544-551
        • Rinehart J.K.
        • Singleton R.D.
        • Adair J.C.
        • Sadek J.R.
        • Haaland K.Y.
        Arm use after left or right hemiparesis is influenced by hand preference.
        Stroke. 2009; 40: 545-550
        • Thrane G.
        • Emaus N.
        • Askim T.
        • Anke A.
        Arm use in patients with subacute stroke monitored by accelerometry: association with motor impairment and influence on self-dependence.
        J Rehabil Med. 2011; 43: 299-304
        • Bernspang B.
        • Fisher A.G.
        Differences between persons with right or left cerebral vascular accident on the Assessment of Motor and Process Skills.
        Arch Phys Med Rehabil. 1995; 76: 1144-1151
        • Wetter S.
        • Poole J.L.
        • Haaland K.Y.
        Functional implications of ipsilesional motor deficits after unilateral stroke.
        Arch Phys Med Rehabil. 2005; 86: 776-781
        • Rexroth P.
        • Fisher A.G.
        • Merritt B.K.
        • Gliner J.
        ADL differences in individuals with unilateral hemispheric stroke.
        Can J Occup Ther. 2005; 72: 212-221
        • Wolf S.L.
        • Winstein C.J.
        • Miller J.P.
        • et al.
        Retention of upper limb function in stroke survivors who have received constraint-induced movement therapy: the EXCITE randomised trial.
        Lancet Neurol. 2008; 7: 33-40
        • Oldfield R.C.
        The assessment and analysis of handedness: the Edinburgh inventory.
        Neuropsychologia. 1971; 9: 97-113
        • Fugl-Meyer A.R.
        • Jaasko L.
        • Leyman I.
        • Olsson S.
        • Steglind S.
        The post-stroke hemiplegic patient.
        Scand J Rehabil Med. 1975; 7: 13-31
        • Heaton R.K.
        • Marcotte T.D.
        • Mindt M.R.
        • et al.
        The impact of HIV-associated neuropsychological impairment on everyday functioning.
        J Int Neuropsychol Soc. 2004; 10: 317-331
        • Rorden C.
        • Brett M.
        Stereotaxic display of brain lesions.
        Behav Neurol. 2000; 12: 191-200
        • Loewenstein D.A.
        • Bates D.C.
        Manual for administration and scoring the Direct Assessment of Functional Status Scale for Older Adults (DAFS).
        Mount Sinai Medical Center, Miami Beach1992
        • Sadek J.R.
        • Stricker N.
        • Adair J.C.
        • Haaland K.Y.
        Performance-based everyday functioning after stroke: relationship with IADL questionnaire and neurocognitive performance.
        J Int Neuropsychol Soc. 2011; 17: 832-840
        • Karver C.
        • Teshiba T.M.
        • Haaland K.Y.
        • Adair J.C.
        • Sadek J.R.
        Performance-based assessment: correlation with neuropsychological functioning in a dementia sample.
        J Int Neuropsychol Soc. 2008; 14: 252-253
        • Uswatte G.
        • Miltner W.H.
        • Foo B.
        • Varma M.
        • Moran S.
        • Taub E.
        Objective measurement of functional upper-extremity movement using accelerometer recordings transformed with a threshold filter.
        Stroke. 2000; 31: 662-667
        • Kleinblum D.
        • Kupper L.
        • Nizam A.
        • Muller K.
        Applied regression analysis and multivariable methods.
        4th ed. Thomson Learning, Pacific Grove2007
        • Kim S.G.
        • Ashe J.
        • Hendrich K.
        • et al.
        Functional magnetic resonance imaging of motor cortex: hemispheric asymmetry and handedness.
        Science. 1993; 261: 615-617
        • Amunts K.
        • Schlaug G.
        • Schleicher A.
        • et al.
        Asymmetry in the human motor cortex and handedness.
        Neuroimage. 1996; 4: 216-222
        • Ochipa C.
        • Rothi L.J.G.
        Limb apraxia.
        Semin Neurol. 2000; 20: 471-478
        • Heilman K.M.
        • Watson R.T.
        • Valenstein E.
        Neglect and related disorders.
        in: Heilman K.M. Valenstein E. Clinical neuropsychology. 4th ed. Oxford University Pr, New York2003: 296-346
        • Foundas A.L.
        • Macauley B.L.
        • Raymer A.M.
        • Maher L.M.
        • Heilman K.M.
        • Gonzalez Rothi L.J.
        Ecological implications of limb apraxia: evidence from mealtime behavior.
        J Int Neuropsychol Soc. 1995; 1: 62-66
        • Hanna-Pladdy B.
        • Heilman K.M.
        • Foundas A.L.
        Ecological implications of ideomotor apraxia: evidence from physical activities of daily living.
        Neurology. 2003; 60: 487-490
        • Sunderland A.
        • Shinner C.
        Ideomotor apraxia and functional ability.
        Cortex. 2007; 43: 359-367
        • Haaland K.Y.
        • Harrington D.L.
        Neuropsychological assessment of motor skills.
        in: Goldstein G. Nussbaum P.D. Handbook of human brain function. Plenum Pr, New York1998: 421-437
        • Schaefer S.Y.
        • Mutha P.K.
        • Haaland K.Y.
        • Sainburg R.L.
        Hemispheric specialization for movement control produces dissociable differences in online corrections after stroke.
        Cereb Cortex. 2012; 22: 1407-1419
        • Winstein C.J.
        • Pohl P.S.
        Effects of unilateral brain damage on the control of goal-directed hand movements.
        Exp Brain Res. 1995; 105: 163-174
        • Desrosiers J.
        • Bourbonnais D.
        • Bravo G.
        • Roy P.M.
        • Guay M.
        Performance of the 'unaffected' upper extremity of elderly stroke patients.
        Stroke. 1996; 27: 1564-1570
        • Desrosiers J.
        • Bourbonnais D.
        • Corriveau H.
        • Gosselin S.
        • Bravo G.
        Effectiveness of unilateral and symmetrical bilateral task training for arm during the subacute phase after stroke: a randomized controlled trial.
        Clin Rehabil. 2005; 19: 581-593
        • Yarosh C.A.
        • Hoffman D.S.
        • Strick P.L.
        Deficits in movements of the wrist ipsilateral to a stroke in hemiparetic subjects.
        J Neurophysiol. 2004; 92: 3276-3285
        • Poole J.L.
        • Sadek J.
        • Haaland K.Y.
        Ipsilateral deficits in 1-handed shoe tying after left or right hemisphere stroke.
        Arch Phys Med Rehabil. 2009; 90: 1800-1805
        • Luft A.R.
        • McCombe-Waller S.
        • Whitall J.
        • et al.
        Repetitive bilateral arm training and motor cortex activation in chronic stroke.
        JAMA. 2004; 292: 1853-1861
        • Whitall J.
        • Waller S.M.
        • Silver K.H.C.
        • Macko R.F.
        Repetitive bilateral arm training with rhythmic auditory cueing improves motor function in chronic hemiparetic stroke.
        Stroke. 2000; 31: 2390-2395
        • Stewart K.C.
        • Cauraugh J.H.
        • Summers J.J.
        Bilateral movement training and stroke rehabilitation: a systematic review and meta-analysis.
        J Neurol Sci. 2006; 244: 89-95
        • Summers J.J.
        • Kagerer F.A.
        • Garry M.I.
        • Hiraga C.Y.
        • Loftus A.
        • Cauraugh J.H.
        Bilateral and unilateral movement training on upper limb function in chronic stroke patients: a TMS study.
        J Neurol Sci. 2007; 252: 76-82