44

Japanese Journal of Comprehensive Rehabilitation Science (2017)

Original Article

The relationship between proximal function of the upper extremity
on the paralyzed side and upper extremity skills in daily life of
subacute stroke patients
Naoko Nakashima, OTR,1 Hiroyuki Miyasaka, OTR, PhD,1,2 Izumi Kondo, MD, PhD,3
Kasumi Iwata, OTR,4 Hitomi Uematsu, OTR,1 Chihiro Yamamura, OTR,1
Shigeru Sonoda, MD, PhD1,2,5
Fujita Health University Nanakuri Memorial Hospital, Tsu, Mie, Japan
Fujita Memorial Nanakuri Institute, Fujita Health University, Tsu, Mie, Japan
3
National Center for Geriatrics and Gerontology, Obu, Aichi, Japan
4
Fujita Health University Hospital, Toyoake, Aichi, Japan
5
Department of Rehabilitation Medicine II, School of Medicine, Fujita Health University, Tsu, Mie, Japan1
2

ABSTRACT
Nakashima N, Miyasaka H, Kondo I, Iwata K,
Uematsu H, Yamamura C, Sonoda S. The relationshipbetween proximal function of the upper extremity on
the paralyzed side and upper extremity skills in daily
life of subacute stroke patients. Jpn J Compr Rehabil
Sci 2017; 8: 44-50.
Objectives: The effects of proximal function of theupper extremity on the paralyzed side on daily life
skills were examined in stroke patients.
Methods: One hundred and forty-seven stroke patientswere evaluated using the Functional Skills Measure
After Paralysis (FSMAP), the Finger-Function test(FF), and the Knee-Mouth test (KM) of the Stroke
Impairment Assessment Set (SIAS). The FSMAP
score for each subgroup of the SIAS-KM level wascompared.
Results: The FSMAP score was significantly higher inpatients with a KM score of 2/3 compared to patientswith a KM score of 0/1 when SIAS-FF was 0/1A; inpatients with a KM score of 2/3 compared to patientswith a KM score of 0/1 and in patients with a KM
score of 4/5 compared to patients with a KM score of
2/3 when SIAS-FF was 1B, 1C, or 2; and in patientswith a KM score of 4/5 compared to patients with a
KM score of 2/3 when SIAS-FF was 3, 4, or 5.
Conclusion: The cross-sectional study indicated thatdifferences in the level of proximal function affect theCorrespondence: Naoko Nakashima, OTR
Takahama Branch Hospital, Kariya Toyota General
Hospital, 3-2-11 Hieda, Takahama, Aichi 444-1321, Japan.
E-mail: nksmnok_s0611@yahoo.co.jp
Accepted: March 10, 2017.
Conflict of Interest: The authors have no conflict of interest
directly relevant to the content of this article.
©Kaifukuki Rehabilitation Ward Association 2017
doi.org/10.11336/jjcrs.8.44

upper extremity skills when the level of distal function
is equivalent.
Key words: stroke, upper extremity function, activities
of daily life, evaluation
Introduction
It is generally believed that post-stroke function of
the upper extremity on the paralyzed side greatly
improves within 8 weeks after stroke onset [1], andthat the recovery of proximal and distal functions
follows a similar course [2]. On the other hand, thefunctional outcome varies between proximal dominantand distal dominant paralysis depending on thelocation and size of lesions [3]. Moreover, the degreeof functional recovery in stroke patients may vary,depending on several factors. Thus, upper extremity
skills on the paralyzed side should be comprehensively
assessed while providing training during rehabilitation.
Lang et al. investigated the relationship between
functional impairment and upper extremity skills on
the paralyzed side in stroke patients, and reported thatproximal and distal functions mutually affect upper
extremity functionality. The authors had found that theactive range of motion of each segment of the upper
extremity on the paralyzed side in stroke patients was
highly correlated with the results of upper extremity
functionality assessed using the Jebsen Test of Hand
Function and the Action Research Arm Test [4]. In
addition, Merians et al. provided robot-assisted
training to improve the proximal and distal functionsof post-stroke patients, and reported improvements inthe outcomes of upper extremity skills, including
improved proximal stability, smoothness, andefficiency of the movement path in concert with an
improvement in distal function [5]. Thus, there are
Jpn J Compr Rehabil Sci Vol 8, 2017

Nakashima N et al.: The relationship between proximal function of the upper extremity on the paralyzed side and upper extremity
skills45

several studies reporting that proximal and distalfunctions are mutually correlated with upper extremity
skills, such as grasping an object. However, the effectof proximal function alone on upper extremity skills
has not been clarified.
While robot-assisted training is effective for
improving proximal function of the upper extremity
on the paralyzed side, its effect is unlikely to bereflected in the improvement of activities of daily life(ADL) [6, 7]. According to a review by Kwakkel et al.,the effects of robot-assisted training on ADL havebeen studied using the Functional Independence
Measure (FIM) [7]. However, it may have failed toprecisely capture the effect because ADL and upper
extremity functionality are different aspects. Moreover,the lack of a rating scale with high affinity for bothproximal function of the upper extremity and ADL
may also be a factor for this failure.
In this study, we assessed whether upper extremity
skills are affected by the difference in proximal
function of the upper extremity on the paralyzed sidein stroke patients using the Functional Skills Measure
After Paralysis (FSMAP) [8-10].
Subjects
This study included 147 patients with first-everstroke who were admitted to the Fujita Health
University Nanakuri Memorial Hospital (Table 1).
The inclusion criteria were as follows: patients who
had supratentorial lesions with paralysis in theunilateral upper extremity; and those who fully

understood directions and were able to indicate theirintention (FIM [11] not less than 4 points incomprehension, not less than 2 points in expression).
The exclusion criteria were as follows: patients who
had a history of functional impairment, such as fractureof the upper extremity on the paralyzed side or
rheumatoid arthritis; and those with a serious
comorbidity, as indicated by a score of 4 or higher on
the Liu comorbidity index [12].
Methods
1. Evaluation items
Evaluation items included the FSMAP, Knee-Mouth
test (KM), and Finger-Function test (FF) of the Stroke
Impairment Assessment Set (SIAS) [13], grip force,pinch force, and FIM. These items were evaluated atadmission by an occupational therapist of the Fujita
Health University Nanakuri Memorial Hospital.
2. FSMAP
FSMAP is used to assess functional skills of theupper extremity on the paralyzed side. Functional
skills include those that support capability, forinstance, the motion of drinking water from a cup iscomposed of a series of functional skills: reaching forthe cup, holding the cup, carrying the cup to the mouth,and drinking the water. In the FSMAP, 15 items of
ADL were assessed, and each item consisted of 3-5
functional skills. Each item on the FSMAP was rated
as either possible (score 1) or impossible (score 0)
with the total score being 65. Miyasaka et al. [14]Table 1. Patient characteristics.
Age [years]
Paretic side [right / left]
Gender [male / female]Days from stroke onset [days]
Lesion type
IschemicHemorrhagic
Subarachnoid hemorrhage
SIAS
Knee-Mouth test (0 / 1 / 2 / 3 / 4 / 5)
Finger-Function test (0 / 1A / 1B / 1C / 2 / 3 / 4 / 5)
Grip force [kg]Paralyzed side
Non-paralyzed side
Pinch force [kg]Paralyzed side
Non-paralyzed side
FIM
Motor item
Cognitive item

64.4 ± 13.5 [66]73 / 74
81 / 66
35.4 ± 13.8 [35]7570
245 / 32 /19 / 21 / 21 /9
61 / 22 / 7 / 15 / 13 / 6 / 14 / 9
3.7 ± 6.7 [0]25.4 ± 11.4 [25.0]
1.4 ± 2.1 [0]7.2 ± 4.9 [7.0]49.8 ± 18.6 [50]26.2 ± 7.6 [28]Mean ± Standard deviation [Median]; SIAS, Stroke Impairment Assessment Set; FIM,
Functional Independence Measure.


Jpn J Compr Rehabil Sci Vol 8, 2017

46 Nakashima N et al.: The relationship between proximal function of the upper extremity on the paralyzed side and upper extremity skills
performed a Rasch analysis of the FSMAP, andconverted the raw score (65 points) to the corresponding
value (scaled score), which ranged from 0 to 100
points. Therefore, the scaled score can be treated as aninterval scale.
Evaluation items included in the FSMAP and an
example of the evaluation content are shown in Table
2 and Figure 1, respectively.
3. Methods
In this study, SIAS-FF scores of 0/1A, 1B/1C/2, and3/4/5 were defined as severe paralysis (individual
movement is difficult), intermediate paralysis (slightindividual movement is possible), and mild paralysis(individual movement is possible), respectively. To
study the functional skills at each level of proximal
function, the differences in functional skills at each
KM level were compared according to the severity ofparalysis in FF using the scaled score of the FSMAP.
Patient clinical characteristics were stratified by
SIAS-FF and SIAS-KM and are shown in Table 3.
4. Statistical procedure
In this study, patients were stratified by the severity
Table 2. Category and subitems of Functional Skills
Measure After Paralysis (FSMAP).
Category

Number of subitems
5
4
4
3
4
4
3
5
5
5
5
5
4
4
5

Use of a glass
Opening a PET bottle
Holding a PET bottle
Holding paper
Tearing newspaper
Folding paper
Turning over pages
Coin
Bowl
Spoon
Garment
Buttons
Pants
Washing face
Washing handsof paralysis. The Kolmogorov-Smirnov test was
performed to determine data normality. Data wasobserved to be normally distributed for an FF score of
0/1A and a KM score of 2/3; FF score of 1B/1C/2 andKM score of 2/3; FF score of 1B/1C/2 and KM scoreof 4/5, and FF score of 3/4/5 and KM score of 2/3,
while other combinations of scores did not exhibit datanormality. A nonparametric test was performed for all
combinations due to the small sample size of eachgroup in this study.
The scaled FSMAP score was used for comparison.
The Mann-Whitney U test was used for FF scores of
0/1A and 3/4/5, while the Kruskal-Wallis test was used
for an FF score of 1B/1C/2. The significance level was
set at 5%.
Results
The maximum value, minimum value, quartile
value, and median of the scaled score of the FSMAP
for the SIAS-FF and SIAS-KM subgroups are shownin Figure 2. When the FF score was 0 or 1A, the scaled
score was significantly higher in patients with a KM
score of 2/3 compared to patients with a KM score of
0/1, while it was significantly higher in patients with a
KM score of 2/3 and 4/5 compared to patients with a
KM score of 0/1 and 2/3, respectively, when the FF
score was 1B, 1C, or 2. When the FF score was 3, 4, or
5, the scaled score was significantly higher in patientswith a KM score of 4/5 compared to patients with a
KM score of 2/3. In this study, the scaled scores forfunctional skills were significantly higher in patientswith a higher KM level when the SIAS-FF was
equivalent.
Discussion
In this study, the effects of the difference in level ofproximal function of the paralyzed-side upper
extremity on functional skills were examined in stroke
patients. When the level of distal function iscomparable, functional skills are affected by thedifference in level of proximal function.
Stabilization of proximal function has been reported

Table 3. Background data for subgroups stratified by severity of paralysis according to evaluation results with
SIAS.
Finger-Function test
Knee-Mouth test
Number of patients
Age [years]
Paretic side [right / left]
Gender [male / female]Days from stroke onset [days]

0, 1A
0, 1

1B, 1C, 2
2, 3

12
71
65.0 ± 13.0 57.9 ± 17.7
7/5
39 / 32
6/6
40 / 3136.0 ± 15.3 38.2 ± 14.1

0, 1

4, 5

6
23
6
72.5 ± 9.9 62.4 ± 14.2 66.5 ± 4.8
1/5
9 / 14
3/3
3/3
9 / 14
3/3
39.7 ± 14.1 35.4 ± 14.0 31.5 ± 7.9

Mean ± Standard deviation; SIAS, Stroke Impairment Assessment Set.
Jpn J Compr Rehabil Sci Vol 8, 2017

2, 3

3, 4, 5
2, 3

4, 5

24
5
58.0 ± 15.2 67.2 ± 13.2
11 / 13
3/2
10 /14
1/4
26.8 ± 11.5 32.9 ± 9.8

Nakashima N et al.: The relationship between proximal function of the upper extremity on the paralyzed side and upper extremity
skills
47

Washing hands
Notes
Patient is allowed a maximum of three attempts or trials for each task.
Position: Standing (Assisted standing is acceptable).
Patients who are unable to stand are not acceptable for this item.
Subitems(1) Moves paralyzed hand towards the sink, and soaks it in water for longer than 5 s.
(2) Puts hand soap on paralyzed hand (Use of non-paralyzed hand is acceptable).
(3) Fixes paralyzed hand and rubs it with non-paralyzed hand. Fixation is longer than 5 s.
(4) Washes non-paralyzed hand with paralyzed hand.
(5) Washes and rubs hands including washing between fingers.

Rating (1 or 0)

Rating standard
Starting position and instrument arrangement.
The sink is positioned at a height between the mid-thigh and navel.
The patient may turn the tap with the non-paralyzed hand.
The paralyzed arm should not contact the sink.
(1) Moves paralyzed hand towards the sink, and soaks it in water.
For a score of 1, the patient must raise his/her paralyzed hand, reach the tap water, and wet his/her paralyzed
hand for longer than 5 s, regardless of the size of wet area; otherwise, the score is 0. The paralyzed upper arm
can contact the side of the trunk. The paralyzed arm should not contact the sink.
(2) Puts hand soap on the paralyzed hand.
For a score of 1, the patient must put hand soap on the paralyzed hand; otherwise, the score is 0.
The patient separates the paralyzed hand from the trunk and maintains the space, and operates the push pumpwith the non-paralyzed hand.
In addition, the push pump may be held either in the air or on the sink.
(3) Fixes paralyzed hand and rubs it with the non-paralyzed hand.
For a score of 1, the paralyzed hand must be fixed and the non-paralyzed hand rubs it under running water;otherwise, the score is 0.
If the paralyzed hand cannot be fixed for longer than 5 s and it moves with the movement of the non-paralyzed
hand, or it contacts the sink, the score is 0.
The paralyzed hand can contact the side of the trunk.
(4) Washes non-paralyzed hand with paralyzed hand.
For a score of 1, the paralyzed hand must wash the dorsal side and palm of the non-paralyzed hand; otherwise,
the score is 0.
If the paralyzed hand contacts the sink and/or there is compensatory movement of the non-paralyzed arm andhand, the score is 0.
The paralyzed upper arm may contact the side of the trunk.
When it is difficult to judge, the rater may hold the non-paralyzed arm.
(5) Washes and rubs hands including washing between fingers.
For a score of 1, the patient must wash the paralyzed hand including between the fingers with cooperative
movement of the non-paralyzed hand; otherwise, the score is 0.
When washing only partially between the fingers, the score is 0.
Holding the paralyzed arm against the trunk is not acceptable.
Instruments
Liquid hand soap (Push pump system 500 ml).
Figure 1. Evaluation manual in the FSMAP (Washing hands).
Washing hands consisted of 5 functional skills (subitems). The rater scores each subitem as either 1 (possible) or
0 (impossible) according to the rating criteria.
Precautions and goods to be used are specified; thus, evaluation can be done by anyone by using the manual.



Jpn J Compr Rehabil Sci Vol 8, 2017

48 Nakashima N et al.: The relationship between proximal function of the upper extremity on the paralyzed side and upper extremity skills

Figure 2. Scaled score of FSMAP grouped according to the severity of paralysis.
Scaled score of FSMAP for each subgroup of SIAS-FF and SIAS-KM. Scaled scoreof FSMAP is rated on a 100-point scale. The Mann-Whitney U test was used for FF
scores of 0/1A and 3/4/5, while the Kruskal-Wallis test was used for an FF score of
1B/1C/2.
Box plots present the minimum value, lower quartile, median, upper quartile, andmaximum value in ascending order.
**
p Represents significance level < 0.01; * p Represents significance level < 0.05.
to improve upper extremity function in some studies[4, 5]. However, subgroups were not stratified by theseverity of paralysis and differences in level ofproximal function were not examined in these studies.
The results of the present study demonstrated that the
FSMAP score varied depending on the level ofproximal function despite the equivalent level offinger-function on the paralyzed side. In particular,
patients with an SIAS-KM score of 2/3 were able toreach over and hold an object even though their SIASFF score was 0/1A and their ability to performvoluntary distal functions was poor. Generally,
rehabilitation of the upper extremity on the paralyzed
side is performed to facilitate movement of the upper
extremity on the paralyzed side. Stewart et al. indicatedthat patients with severe upper extremity paralysis
have difficulty using the upper extremity on theparalyzed side in daily life [15]. On the other hand,Thielman et al. reported that the improvement of
coordination of elbow-shoulder motion may affectupper extremity functionality in patients with low
motor function [16]. Patients with severe paralysis in
this study were able to perform more gross tasks using
proximal functions while they experienced difficulty
performing the gripping and pinching tasks using
distal functions.
It has been reported that the severity of upper
Jpn J Compr Rehabil Sci Vol 8, 2017

extremity motor paralysis is correlated with trunkcompensation during reaching movements in stroke
patients, and that a trunk compensatory strategy isused for more severe motor paralysis to compensate
for reaching movement [17, 18]. In the FSMAP usedin this study, trunk compensation was not limited. As aresult, the object reaching tasks and tasks that required
holding the upper extremities in space were performedby the effective use of trunk compensation, and thismay have contributed to the results of this study.
Several studies have reported a correlation between
proximal function and distal function, and that motor
activity in the upper extremity is controlled by thecomplementary action of both proximal and distalfunctions of the upper extremities [4, 19-22]. Finger
extension and individual movements are observed inpatients with an SIAS-FF score of 1B, 1C, or 2.
Patients at these levels are assumed to be capable ofperforming an object grasping task. Therefore, distal
dominant functional skills are acquired when proximal
function is poor, while difficult proximal functional
skills, including performing an object reaching task
and holding the upper extremity of the paralyzed sidein space, increase with proximal function improvement.
Therefore, greater stabilization of proximal function
may affect the ability to perform distal functions.
Montgomery et al. reported that the trunk andNakashima N et al.: The relationship between proximal function of the upper extremity on the paralyzed side and upper extremity
skills49

proximal upper extremity muscles are innervated by
the ipsilateral cerebral cortex [23]. Thus, proximal
function experiences greater improvement compared
to distal function due to bilateral innervation in stroke
patients. Hence, rehabilitation of proximal function
should be actively performed, and it may be useful for
improvement of upper extremity skills.
Study limitations
This study has some limitations.
First, the sample size was small. The SIAS was used
for classification of the severity of paralysis in thisstudy. While the SIAS is clinically easy to use, it islimited by a distribution bias as its categorical structure
does not allow for equal distribution. Therefore, since
only five patients were included in the smallest groupin the study, it is important to be cautious wheninterpreting our results.
Second, patients during the recovery phase wereenrolled in this study. As function following paralysis
begins to recover in stroke patients, patients may not
yet be able to perform tasks that require the upper
extremity on the paralyzed side as residual, but not yet
compensatory, function is available. Conversely, skills
requiring
coordinatedmovements
involvingcompensatory upper extremity on the non-paralyzed
side may be acquired in patients with chronic stroke
because spontaneous recovery of the upper extremity
on the paralyzed side is reduced. It is necessary toinvestigate functional skills in patients with chronic
stroke to study the differences in functional skill
recovery following stroke onset in the future.
Finally, patients included in this study were
inpatients at the same hospital, and sampling biases,
such as days from stroke onset and the paralysis side,
were eliminated when possible. Therefore, the resultsof this study are considered to be generally reliable.
However, we cannot determine a causal relationshipbetween changes and rehabilitation as the data wascollected in a cross-sectional manner. In the future, alongitudinal study is required to examine the effects ofimprovement of proximal function on upper extremity
functionality.
Acknowledgements
This study was partially supported by the Research
Grants (Research number: 2011-02) of the Japanese
Association of Occupational Therapists and the Japan
Society for the Promotion of Science KAKENHI(Grant number: 16K01524). We would like to thankthe following people for their contributions to thedevelopment of the Functional Skills Measure After
Paralysis and data collection: Ms. Yuko Sasaki (Ban
Buntane Hotokukai Hospital, Fujita Health
University), Ms. Chieko Usami and Ms. Mikiko
Nakane (Medical Corporation Meiwa SocietyTsujimura Surgery
experiments.

Hospital)for

helping

ourReferences

1.	Kwakkel G, Kollen B, Twisk J. Impact of time on
improvement of outcome after stroke. Stroke 2006; 37:2348-53.
2.	Beebe JA, Lang CE. Active range of motion predicts
upper extremity function 3 months after stroke. Stroke
2009; 40: 1772-9.
3.	Hatakenaka M, Miyai I, Sakoda S, Yanagihara T.
Proximal paresis of the upper extremity in patients withstroke. Neurology 2007; 69: 348-55.
4.	Lang CE, Beebe JA. Relating movement control at 9
upper extremity segments to loss of hand function inpeople with chronic hemiparesis. Neurorehabil Neural
Repair 2007; 21: 279-91.
5.	Merians AS, Fluet GG, Qiu Q, Saleh S, Lafond I,Davidow A, et al. Robotically facilitated virtual
rehabilitation of arm transport integrated with finger
movement in persons with hemiparesis. J Neuroeng
Rehabil 2011; 8: 27.
6.	Basteris A, Nijenhuis SM, Stienen AH, Buurke JH,
Prange GB, Amirabdollahian F. Training modalities inrobot-mediated upper limb rehabilitation in stroke: aframework for classification based on a systematic
review. J Neuroeng Rehabil 2014; 11: 111.
7.	Kwakkel G, Kollen BJ, Krebs HI. Effects of robotassisted therapy on upper limb recovery after stroke: asystematic review. Neurorehabil Neural Repair 2008; 22:111-21.
8.	Miyasaka H, Kondo I, Kato H, Takahashi C, Uematsu H,
Yasui C, et al. Assessment of the content validity offunctional skills measure after paralysis with nominalgroup discussion and revision of its content. Jpn J Compr
Rehabil Sci 2011; 2: 24-30.
9.	Kato H, Miyasaka H, Yasui C, Nakanishi C, Nakanishi
C, Kondo I, et al. Reliability and validity of the functional
skills measure after paralysis (FSMAP) in patients withstroke. Jpn J Occup Ther 2012; 46: 286-91.
10.	 Miyasaka H, Kondo I, Tomita Y, Yamamura C, Nakanishi
C, Sonoda S. Construct validity of evaluation scale forfunctional skills measure after paralysis in subacutestroke patients. Jpn J Occup Ther 2014; 48: 889-94.
11.	Granger CV. The emerging science of functional
assessment: our tool for outcomes analysis. Arch Phys
Med Rehabil 1998; 79: 235-40.
12.	Liu M, Domen K, Chino N. Comorbidity measures forstroke outcome research: a preliminary study. Arch Phys
Med Rehabil 1997; 78: 166–72.
13.	Chino N, Sonoda S, Domen K, Saitoh E, Kimura A.
Stroke impairment assessment set (SIAS). In: Chino N,
Melvin JL, editors. Functional Evaluation of Stroke
Patients. Tokyo: Springer-Verlag; 1996. p. 17-40.
14.	Miyasaka H, Kondo I, Tomita Y, Teranishi T, Kato H,
Yasui C, et al. Determination of items of functional skill
measure after paralysis with rasch analysis and nominalgroup discussion. 6th International Society of Physical &Jpn J Compr Rehabil Sci Vol 8, 2017

50 Nakashima N et al.: The relationship between proximal function of the upper extremity on the paralyzed side and upper extremity skills
Rehabilitation Medicine; San Juan, Puerto Rico. 2011.
15.	Stewart JC, Cramer SC. Patient-reported measuresprovide unique insights into motor function after stroke.
Stroke 2013; 44: 1111-6.
16.	Thielman GT, Dean CM, Gentile AM. Rehabilitation ofreaching after stroke: task-related training versus
progressive resistive exercise. Arch Phys Med Rehabil
2004; 85: 1613-8.
17.	Michaelsen SM, Jacobs S, Roby-Brami A, Levin MF.
Compensation for distal impairments of grasping in
adults with hemiparesis. Exp Brain Res 2004; 157: 16273.
18.	Cirstea MC, Levin MF. Compensatory strategies forreaching in stroke. Brain 2000; 123: 940-53.
19.	Mercier C, Bourbonnais D. Relative shoulder flexor andhandgrip strength is related to upper limb function after
stroke. Clin Rehabil 2004; 18: 215-21.
20.	Miller LC, Dewald JP. Involuntary paretic wrist/finger

Jpn J Compr Rehabil Sci Vol 8, 2017

flexion forces and EMG increase with shoulder abduction
load in individuals with chronic stroke. Clin Neurophysiol
2012; 123: 1216-25.
21.	Nijland RH, van Wegen EE, Harmeling-van der Wel BC,
Kwakkel G; EPOS Investigators. Presence of finger
extension and shoulder abduction within 72 hours after
stroke predicts functional recovery: early prediction offunctional outcome after stroke: the EPOS cohort study.
Stroke 2010; 41: 745-50.
22.	Katrak P, Bowring G, Conroy P, Chilvers M, Poulos R,
McNeil D. Predicting upper limb recovery after stroke:
the place of early shoulder and hand movement. Arch
Phys Med Rebabil 1998; 79: 758-61.
23.	Montgomery LR, Herbert WJ, Buford JA. Recruitmentof ipsilateral and contralateral upper limb muscles
following stimulation of the cortical motor areas in themonkey. Exp Brain Res 2013; 230: 153-64.