Functional Differences in Patients with Left or Right

Cerebrovascular Accidents

VIRGINIA M. MILLS
and MONICA DiGENIO

The purpose of this study was to examine possible differences in functional

abilities of patients with cerebrovascular accidents on the right or left side.
Medical records of 102 right-handed patients with the same degree of motor
impairment were reviewed; 50 had cerebrovascular accidents on the right side,
and 52 on the left. Each patient was rated on five categories: mobility, percep-
tion/information processing, language, activities of daily living skills, and the
total length of hospital stay (acute care plus rehabilitation). There were no
statistically significant differences between the right-sided and left-sided groups
in any of the categories except language (p < .001). Long hospitalization
correlated negatively with low mobility scores for the right-sided group (r =
- . 3 8 , p < .003) and with low language scores for the left-sided group (r = - . 3 2 ,
p < .01). Results of this study indicate that patients with cerebrovascular
accidents seem to have the same prognosis for functional motor rehabilitation
regardless of the side of the lesion. The correlation of length of hospitalization
with mobility for the right-sided group and length of hospitalization with language
for the left-sided group may be a reflection of hemispheric specialization.

Key Words: Cerebrovascular accidents, laterality; Language; Motor skills; Percep-

tion; Rehabilitation.

Much has been written describing functional motor sphere's dominance for motor performance. Lesions
recovery following cerebrovascular accidents of the left hemisphere impair the bilateral upper-
(CVAs).1-3 However, the investigation of the influ- extremity performance of complex motor sequences
ence of laterality of cerebral lesion on functional regardless of whether the sequences are purposeful or
motor recovery in rehabilitation following CVAs has not. Lesions of the left hemisphere can result in
not been extensive or detailed.4, 5 differing types of apraxia, which are primarily disor-
Hemispheric specialization has been demonstrated ders of learned movement that cannot be accounted
for language, perception, and motor performance for by weakness, incoordination, sensory loss, incom-
abilities. Language is the function most commonly prehension, or inattention.14-16 The left hemisphere
associated with the left cerebral hemisphere.6 The has also been associated with bilateral control of the
right hemisphere usually plays a major role in spatial speed of a single movement and alternating move-
processing.7-9 Visual, tactile, and auditory stimuli are ments.17"19
associated with the right or left hemisphere depending Right hemisphere lesions are associated with motor
on the relative linguistic and spatial components.10"13 impersistence (an impairment in the ability to sustain
In the general population, the predominance of a posture). The right hemisphere integrates spatial
right-handed people is a reflection of the left hemi- sensory information required to sustain postures.20, 21
Movements of the left hand and arm are used for
spatial processing tasks and those of the right hand
Ms. Mills is Senior Staff Therapist, Braintree Hospital, Brain
Injury Unit, Braintree, MA 02184 (USA). are used for manipulation in the development of
Ms. DiGenio is Staff Therapist, Melrose Visiting Nurse Services, reaching and grasping in infants.22
Melrose, MA 02176.
This paper was presented as a poster board exhibition at the
The left hemisphere appears to exert control over
APTA National Conference, Washington, DC, 1981, and at the bilateral motor sequence tasks.16"18 This evidence sug-
Annual Conference of the Academy and Congress of Physical Med- gests that patients with left CVAs may have greater
icine and Rehabilitation, San Diego, CA, 1981.
This article was submitted March 3, 1982, and accepted August 10, motor deficits than patients with right CVAs. In our
1982. clinical experience, successful functional motor re-

Volume 63 I Number 4, April 1983 481

habilitation of patients with left CVAs seems longer summaries. The five categories rated were 1) mobility,
and more difficult than that of patients with right 2) activities of daily living (ADL), 3) perception/
CVAs. Identification of functional differences be- information processing, 4) language, and 5) total hos-
tween patients with left CVAs and those with right pital length of stay (LOS).
CVAs would allow therapists to develop specific eval- Mobility included transfers (the ability to stand and
uation procedures and therapeutic approaches to help pivot from one sitting surface to another), standing
maximize the rehabilitation potential for the patients balance, and ambulation. Transfers were rated ac-
in each of these diagnostic categories. Recognition cording to the amount of assistance required: maxi-
and specification of assets and deficits in these two mal assistance, moderate assistance, minimal assist-
groups will also assist therapists in making more ance, contact guarding, supervision, and independent.
realistic decisions about a patient's prognosis and Ambulation was rated according to both the amount
length of treatment. of assistance required and whether an assistive device
The purpose of this study was 1) to examine the was used: nonambulatory, maximal assistance and an
differences between the functional abilities of patients assistive device, moderate assistance and an assistive
with CVAs on the left and those with CVAs on the device, minimal assistance and an assistive device,
right side; 2) to determine the relationships among contact guarding and an assistive device, supervision
the various functional abilities of the patients in each and an assistive device, contact guarding, supervision,
of the two groups; and 3) to compare the relationships independent and an assistive device, and independ-
among the functional abilities of the two groups. ent. Standing balance was rated as poor (stands with
contact guarding to requiring minimal or moderate
METHOD assistance), fair (stands unsupported to withstanding
minimal displacement), or good (withstands moderate
Medical records of patients treated at Braintree to maximal displacement).
Hospital between 1977 and 1980 with the diagnosis Activities of daily living included dressing and upper
of CVA were reviewed. The patients selected for extremity function. Dressing was rated according to
participation had a CVA in the distribution of the
the amount of assistance required: maximal assist-
middle cerebral artery, had moderate motor involve-
ance, moderate assistance, minimal assistance, super-
ment at admission, and were right-handed. They had
vision, and independent. Upper extremity function
been admitted to the rehabilitation hospital two to
was rated as nonfunctional, grossly functional, or
four weeks after onset of the CVA. Patients with
functional.
previous CVAs or other major medical problems
including myocardial infarction, multiple sclerosis, Perception/information processing included short-
cancer, peripheral vascular disease, and chronic ob- term memory, judgment, and body schema and was
structive pulmonary disease were excluded. Patients rated as being impaired or intact.
who were discharged for medical problems or who Language measured verbal expression, auditory
did not complete their rehabilitation treatment pro- comprehension, reading, and writing. Each was rated
grams were also excluded. The sample size was 102 according to the degree of impairment in communi-
patients; 50 had right CVAs and 52 had left CVAs. cative ability: severe (no usable communicative abil-
The left CVA group (mean age = 67.7 years, s = 10.8) ity); moderately severe (great need of questioning and
consisted of 33 women and 19 men, and the right guessing by the listener); moderate (frequent failure
CVA group (mean age = 70.8 years, s = 8.8) consisted by the patient in communicative ability, but the pa-
of 30 women and 20 men. tient shares the burden of communication with the
Moderate motor involvement was defined as the listener); mild (patient shows some obvious loss of
presence of three or more of the following: 1) abnor- communicative ability without significant limitation);
mal muscle tone in the affected lower extremity, 2) and within normal limits (patient's ability to com-
active movement in synergy in the affected lower municate is within acceptable limits for his needs).
extremity, 3) isolated movement in the affected lower Length of stay included the total days spent in the
extremity, 4) diminished sensation in the affected acute and rehabilitation hospitals. (Total hospital
lower extremity, or 5) fair sitting balance (sitting LOS ranged from 37 to 141 days with the median =
unsupported to withstanding minimal displacement 80.1, the = 79.7, and the s = 24.5.)
by the therapist). Upper extremity criteria were not Transfers, standing balance, and ambulation are
used because documentation at the time of admission standard components of every physical therapy eval-
was inconsistent. uation at our rehabilitation hospital. The terminology
Each record was rated on five categories to deter- used to describe the amount of assistance needed has
mine the patient's status at the time of discharge. been defined as follows by departmental protocol and
Data were obtained from the physical therapy, occu- was used by physical and occupational therapists in
pational therapy, and speech pathology discharge their documentation of the patients' status.

482 PHYSICAL THERAPY

 RESEARCH

Maximal assistance—the patient requires complete TABLE 1

physical assistance of one therapist to perform an Spearman Correlations (r) for Left CVA Group (n = 52)
activity. Category Language ADL
Moderate assistance—the patient and the therapist
Length of stay -.32a -.32a
each perform half of an activity. Perception/information processing .40b .32 c
Minimal assistance—most (75%) of an activity is Mobility ... .43 d
completed by the patient with some physical assist- ADL .29 c ...
ance from the therapist. a
p< .01.
Contact guarding—an activity is performed by the b
p< .005.
c
patient with the therapist touching or holding the p< .02.
d
patient for guidance and safety. p< .001.
Supervision—an activity is performed by the patient
with the therapist at an arm's reach from the patient to no documentation (which very rarely occurred)
for safety. and a score of 1 was assigned to the highest functional
Independent—the patient can consistently perform rating. Despite the varying number of rating choices
an activity safely without the therapist present. for each subcategory, the >0 to 1 rating scale provided
The data for ADL and perception/information a relative measure of the patients' functional abilities
processing were obtained from the occupational ther- that could then be used for comparisons between and
apy discharge summary and were standard compo- among categories. For example, language function
nents of each patient's evaluation. The occupational was rated as follows: no documentation = 0, severe
therapy department has developed specific tests to = 0.2, moderately severe = 0.4, moderate = 0.6, mild
evaluate short-term memory, judgment, and body = 0.8, within normal limits = 1.0.
schema. These tests are administered in a format The statistical package for social sciences was used
established by the department. to analyze the data.24 Mann-Whitney U tests were
Language data were taken from the speech pathol- used to analyze differences between patients with
ogy discharge summary. The Boston Diagnostic right CVAs and those with left CVAs in each of the
Aphasia Exam or the Porch Index of Communicative five categories. Spearman correlation coefficients
Ability was used by the speech pathology department were used to determine the relationships among the
to evaluate language function.23 five categories for both patient groups.
The authors performed an interrater reliability test
to obtain an indication of how closely and reliably RESULTS
physical therapists and occupational therapists fol-
lowed established departmental protocols and rating There were no significant differences between the
systems when documenting patient status. Two phys- left and right groups in mobility, ADL, perception/
ical and two occupational therapists were each asked information processing, or LOS. There were signifi-
to evaluate five patients in the subcategories included cant differences, however, in the areas of language
in mobility, ADL, and perception/information proc- abilities (U = 613, z = -5.78, p < .001) as expected.
essing. Each patient was evaluated by each of the two Within the left CVA group, long LOSs were asso-
therapists in the same working day. The therapists ciated with low language (r = —.32, p < .01) and
were not allowed to discuss their findings. The ratings ADL (r = — .32, p < .01) scores. High perception/
assigned by the therapists were identical for transfers, information processing scores were associated with
standing balance, dressing, upper extremity function, high language (r = .40, p < .005) and ADL (r = .32,
short-term memory, judgment, and body schema. p < .02) scores. High ADL scores were associated
One discrepancy between the two physical therapy with high language (r = .29, p < .02) and mobility (r
raters was found for ambulation (minimal assistance = .43, p < .001) scores (Tab. 1).
vs contact guarding). This rating scale, therefore, Within the right CVA group, long LOSs were
appears to have good interrater reliability based upon associated with low mobility (r = —.38, p < .003) and
this limited number of subjects. ADL (r = —.31, p < .02) scores. High perception/
The rating score for each category was determined information processing scores were associated with
by adding the scores for each subcategory. Within the high mobility scores (r = .28, p < .02). High ADL
categories of mobility, ADL, perception/information scores were associated with high mobility scores (r =
processing, and language, the subcategories (as out- .65, p < .001) (Tab. 2).
lined) were assigned numerical values and progres- A comparison of the correlations found for the left
sively rated from least functional to most functional. and right CVA groups showed the following differ-
The numerical values (ranging from >0 to 1) were ences: 1) LOS correlated negatively with language (r
determined by dividing the number of rating choices = -.32, p < .01) for the left CVA group and with
for each subcategory into 1. A score of 0 was assigned mobility (r = —.38, p < .003) for the right CVA

Volume 63 / Number 4, April 1983 483

 TABLE 2 for standing and ambulation. The left hemisphere has
Spearman Correlations (r) for Right CVA Group (n = 50) been associated with motor sequencing, and language
Category Mobility ADL
skills are commonly considered highly sequenced
tasks.14-18 There was a low positive correlation be-
Length of stay -.38a -.31b tween improved communication skills and improved
Perception/information processing .28 b ...
Mobility ... .65 c ADL performance, both of which are sequencing
a
tasks. This further demonstrates the left hemisphere's
p < .003. role in motor sequencing. Clinicians may want to
b
p < .02.
c
p < .001. evaluate in more detail the functions of posturing and
mobility in the right CVA group and motor sequenc-
ing and language in the left CVA group to attain a
group, and 2) perception/information processing cor- better understanding on which to base the patient's
related positively with language (r = .40, p < .005) prognosis for rehabilitation.
and ADL skills (r = .29, p < .02) for the left CVA Better perception/information processing skills
group and with mobility (r = .28, p < .02) for the were associated with the patients' performance in
right CVA group. mobility for the right CVA group and associated with
It should be taken into consideration and noted language and ADL abilities in the left CVA group.
that the coefficient of determination (r2) or variance Again, hemispheric specialization may be reflected in
was low for all the r values obtained. the low positive correlation of perception/informa-
tion processing with the different categories for each
DISCUSSION of the left and the right CVA patient groups.
Clinically, we have observed that perceptual and
No significant right versus left hemispheric motor cognitive deficits are good prognostic indicators of
differences, as currently evaluated by our physical poor functional motor recovery. This observation re-
and occupational therapists, were found in the func- flects the rather interdependent relationship between
tional rehabilitation of patients with CVAs. motor, perceptual, and cognitive systems.3 When we
Our physical and occupational therapy evaluations examined the low positive correlations for the left and
assess gross and fine motor activity on the basis of right CVA patient groups, high scores in perception/
deficits and amount of assistance required. Although information processing were associated with high
patients with left CVAs may have greater motor scores for mobility, ADL skills, and language. These
deficits than patients with right CVAs, as discussed results and other studies seem to reinforce the impor-
in the literature, these motor differences may be too tance of perceptual and cognitive testing and retrain-
subtle to measure accurately using our current phys- ing.25 Detailed perceptual and cognitive testing and
ical and occupational therapy evaluation tech- retraining may give the clinician important data
niques.14-20, 22 Nonetheless, even though these motor needed when formulating the patient's prognosis and
differences may exist, functional motor performance would allow for a more comprehensive rehabilitation
at the time of discharge was not significantly different program.
between right and left CVA groups in this study. An important qualification of this study is that data
Therefore, patients with CVAs appear to have the were collected from a chart review and a compilation
same prognosis for functional rehabilitation regard- of different therapists' evaluations. Although the in-
less of the side of the lesion. terrater reliability among therapists cannot be as-
Comparing right and left CVA groups may not be sured, the small interrater test performed between the
an adequate method for evaluating hemispheric spe- two physical and two occupational therapists showed
cialization in functional rehabilitation. Researchers a perfect correlation in all but one of the subcatego-
may have to examine the patterns of deficits associ- ries.
ated with each hemisphere to better identify possible At present, chart review is the most available
prognostic indicators of functional rehabilitation. method for data collection in this type of study. Using
There was a low negative correlation between LOS established hospital protocols allows the researcher to
and language for the left CVA group and between compare different therapists' evaluations but does not
LOS and mobility for the right CVA group. Why guarantee reliability. The consistent use of standard-
wasn't there a low negative correlation between LOS ized tests would guarantee reliability.
and mobility for the left CVA group? Possibly, LOS An effort should be made to develop and incorpo-
correlated with the different categories in each of the rate standardized motor tests to assess neurologically
two patient groups as a reflection of hemispheric impaired patients. Standardized testing techniques
specialization. The right hemisphere appears more would greatly increase the objectivity of therapists'
involved with sustaining physical postures.20'21 The evaluation data and more accurately measure the
ability to sustain postures is a necessary prerequisite patients' clinical progress.

484 PHYSICAL THERAPY

 RESEARCH

This project is a preliminary study. Assuring relia- CVA patients. Patients with CVAs seem to have the
bility of data should be a primary concern of future same prognosis for functional motor rehabilitation
researchers in this area. Possibly, data could be col- regardless of the side of the lesion.
lected from standardized tests used by neuropsychol- The correlation of LOS with mobility for the right
ogists such as Grooved Peg Board, Finger Tapping CVA group and LOS with language and ADL for the
Speed, Static Steadiness, and Kinetic Steadiness.26 left CVA group may be a reflection of hemispheric
Data could also be collected from the CVA patients specialization. Hemispheric specialization may also
treated by a particular therapist or team of therapists. be reflected by the correlation of perception/infor-
In addition, therapists may want to evaluate more mation processing with mobility for the right CVA
specific types of motor ability such as quality and group and with language and ADL for the left CVA
speed of movement, and muscle tone. group.
The role of perceptual and cognitive testing and
CONCLUSIONS retraining merits further evaluation and study.

As measured by our physical therapists and occu- Acknowledgments. The authors gratefully ac-
pational therapists, there were no significant right knowledge Braintree Hospital and its staff for their
versus left hemispheric differences in the functional assistance and support during the development and
motor rehabilitation or time of hospitalization in execution of this study.

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