Volume 22, Issue 1 (Spring 2021)                   jrehab 2021, 22(1): 86-101 | Back to browse issues page

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Mazidi M H, Akbarfahimi N, Hosseini S A, Vahedi M, Amirzargar N. The Relationship Between Upper Limb Function and Participation and Independence in Daily Activities of Life in People With Stroke. jrehab 2021; 22 (1) :86-101
URL: http://rehabilitationj.uswr.ac.ir/article-1-2819-en.html
1- Department of Occupational Therapy, School of Rehabilitation Sciences, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
2- Department of Occupational Therapy, School of Rehabilitation Sciences, Rofeideh Rehabilitation Hospital, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. , na.akbarfahimi@uswr.ac.ir
3- Department of Biostatistics and Epidemiology, Iranian Research Center on Aging, Faculty of Rehabilitation Sciences, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
4- Neurologis Rofeideh Rehabilitation Hospital, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
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troke is one of the diseases affecting health worldwide and one of the main causes of long-term disabilities [1]. The prevalence of this disease in Iran is 372 people per 100,000 people [2].
Based on the conceptual framework of the International Classification Model of Function, Disability, and Health, health components and health-related areas are defined as body and individual social aspects along with two basic lists: 1. Functions and body structures; 2. Activities and participation [3]. According to this classification, participation is defined as dealing with different life situations, and participation limitations are problems that are experienced in dealing with different situations [4].
 In addition to the simple definition of participation above, participation is a complex and broad concept at the community level that many factors, such as cultural, social, and environmental issues are considered as a deterrent or facilitator that indicate the dependence of the concept of participation on social factors and its differences in different structures and cultures [5].
About 80% of people with a history of stroke have dysfunction of the upper and lower limbs on one side of the body [6]. Restricting upper extremity movement (arm, hand, and finger) is one of the most common consequences of a stroke, which is often permanent and is a debilitating factor and affects daily life activities [7].
In occupational therapy, there is a close relationship between health and participation in acupuncture, and also the focus of occupational therapy interventions is to improve the level of individual participation in various acupunctures, such as leisure and work [8]. It is believed that maintaining a person’s participation in acupuncture can help improve and maintain his health. Therefore, for occupational therapy interventions on stroke, studying participation can show the extent of the impact of stroke on a person’s life and also determine the interventional method [8].
About 25 to 74% of stroke patients worldwide need some help to become independent in their daily activities or are completely dependent on caregivers to carry out their daily activities after a stroke [4]. Returning to previous activities is important for well-being and is often seen as a goal of rehabilitation; thus, it is important to examine the relationship between upper limb function and independence in daily life activities with a history of stroke [7, 9].
Past studies have identified the factors affecting participation and independence in daily life activities, but because of participation and its diversity in different cultures and regions, the results of studies cannot be generalized to other regions. Therefore, this study was done to investigate the relationship between the level of independence in daily life activities and participation and upper limb function in people with stroke. 
Materials and Methods
This study was performed by the cross-sectional correlation method. The study sample was selected from the people referring to the treatment centers of the University of Social Welfare and Rehabilitation Sciences in 2019-20 20, according to the research criteria, by convenience sampling method. The sample size was calculated considering a probability of the first type error of 5%, a test power of 80%, using the sample volume formula for the correlation coefficient [14], concerning the correlation of 0.32 in the study of Hartman et al. [15], and 10% loss. Inclusion criteria included the diagnosis of stroke by a specialist, the age of between 18 and 70 years, passing less than 2 years after the stroke [10], following the verbal instructions (score greater than 22 on the MMSE test) [16], no other neurological diseases, such as epilepsy and Parkinson’s disease, no other orthopedic (musculoskeletal) disease, no swallowing, aphasia, and mental disorder. Exclusion criteria included no continued involvement of clients in the study and clinical instability, such as seizures and recurrent stroke. The study was approved by the Ethics Committee of Tehran University of Social Welfare and Rehabilitation Sciences (IR.USWR.REC.1398.129).
Tools and Methods
After obtaining a license from the university and occupational therapy centers and studying the medical records of stroke patients, consent was obtained from eligible individuals. Candidates were then evaluated for indicators in two sessions. In the first session, the demographic questionnaire and the functional independence measurement scale were completed, respectively, and then, in the second session, the Participation Questionnaire and Fugl-Meyer Scale were completed, respectively.
The demographic questionnaire was prepared by the researcher and included questions about the demographic characteristics of the samples and contextual variables (age, sex, marital status, type of stroke, side of the conflict, and the number of strokes).
The Iranian Participation Questionnaire was designed by Farzad et al. in 2014 to measure all aspects of participation [10]. The Fugl-Meyer scale is a tool designed by Fugl-Meyer based on the Branstrom and Twitchell approach to assess physical recovery after a stroke. In this study, the upper limb of this test was used [11]. The Functional Independence Scale is one of the most common tools in the rehabilitation sciences designed by Granger et al. to assess independence or dependence when performing functional daily living activities [12].
For each client, a total of 5 assessments, including demographic questionnaire, Iranian Participation Questionnaire, Fugl-Meyer Scale , Functional Independence Measurement Scale, and the Short form of Mental Status Test were completed by the researcher. 
Statistical analysis of the data was done using SPSS software version 23 by Spearman test. The value of ancient D was used to evaluate the effect; 0.1 to 0.2 indicates a weak correlation and 0.3 to 0.4 and 0.5 to 1 indicate a moderate and strong correlation, respectively [13].
The demographic characteristics of the study population are given in Table 1

Most of the study participants were male and 29.8% of them were female. Also, 73.8% were retired and unemployed, most of them had secondary school education, and 83.3% were married.
The mean values of functional independence, participation, and Fugl-Meyer Scale are given in Table 2

The average scores of total participation, Fugl-Meyer Scale, and the total score of functional independence were 135.79, 26.26, and 100.17, respectively, and their standard deviations were 40.914, 20.521, and 23.695, respectively.
Table 3 indicates the correlation between the variables. 

According to this table, the upper extremity function variables strongly correlated with the total score of independence in daily life activities (r = 0.625, P<0.001) and the upper extremity function with moderate motor independence functional correlation (r = 0.613, P<0.001). The function of the upper limb was moderately correlated with the cognitive part of functional independence (r=0.356 ,P=0.001) and participation (r = 0.315, P =0.003).
Discussion and Conclusion
The average mobility of the upper limb was 26.26. The mobility of the upper limb was assessed based on the Fugl-Meyer Scale for people with a history of stroke, which was obtained from 0 to 66. The classification of this scale is based on the study of Fugl-Meyer et al., as follows: for severe upper extremity mobility injury: < 33, the upper extremity mobility injury: 33 to 55, the moderate upper limb mobility injury: 56 to 62, and mild injury group of upper limb mobility: 62 to 65. According to this classification, the upper limb mobility injury of the participants was at a severe level.
The average degree of independence in daily life activities was 100.17. Because the items of the Functional Independence Scale are scored on a seven-point scale, the average score of the participants’ independence is approximately 5.5. Accordingly, on average, participants perform various activities under supervision.
The average participation rate was 135.79. Considering that the total score of the Iranian Participation Questionnaire was 300; thus, on average, the level of participation of the participants in the research was less than half of the total score of the Iranian Participation Questionnaire.
Banjai et al. showed that upper extremity sensory-motor impairment, measured by the Fugl-Meyer Scale, can determine the effect of the upper limb on self-participation in people with stroke. In contrast to the present study, they showed a strong and significant relationship between the Fugl-Meyer scale score and participation. This difference could be due to the use of the Stroke Impact Scale (SIS), hand function section, to evaluate participation. This tool is not as comprehensive as the Iranian Participation Questionnaire used in the present study [14]. Ezekel et al. showed that the relationship between hand and arm function and participation is weaker than the relationship between lower limb function or balance with participation [22]. Considering that participation is a comprehensive concept and includes the involvement of the individual in various activities and the extent of this involvement depends on various factors, motor function is only one of these factors [4]; thus, regarding the difficulty in motor function, the person can still maintain his participation with alternative solutions and the use of other factors. However, all motor functions cannot be easily replaced, including lower limb function and balance, which are necessary for movement, and the individual needs extensive changes in lifestyle and movement to compensate for the limitations in these functions. Therefore, these motor functions have a significant impact on participation [7]. However, there are other alternatives for limiting the function (mobility) of the upper limb, such as having a healthy limb on the opposite side and environmental changes and having supportive people who minimize the impact of limiting the function (mobility) of the upper limb on participation. Therefore, there is a moderate correlation between these variables. On the other hand, Andernley et al. showed that gait disorder was the most important factor in limiting participation. Participation was limited by general factors, depression, aging, dementia, which is in line with the present study [15]. Therefore, upper limb function is not the main and determining factor in the level of participation and participation of individuals in addition to motor functions (motor abilities) is limited by other factors, such as psychological and cultural factors and individual motivation.
Independence in the activities of daily life means doing them directly or indirectly without the need for the help of others [12]. Therefore, if one seeks help from others, he has reduced his independence, but participation in activities is not limited to the activities of daily living, and involvement in activities is based on the interest and desire of the individual and is not based on activities alone. Therefore, it is expected that the level of participation and independence of individuals in daily life activities is not the same. Given the non-uniformity of participation and independence in the activities of daily living and their nature, the existence of a high correlation between independence in the activities of daily living and the function of the upper limbs is justified. Akbar Fahimi et al. showed a moderate correlation between these two variables. In this study, the Bartel scale was used to evaluate the indepence of Activities Daily Living (ADL) Instrumental Activities daily Living (IADL) was also evaluated, which are more complex activities that require interaction with more factors. Thus, the effect of upper limb function on independence in these activities is reduced by other factors [7]. Jane et al. showed that the severity of incomplete upper limb paralysis is a strong component of the consequences of daily life activities, which is in line with the findings of the present study [9].
To improve future studies in this field, it is suggested to examine the effect of cultural factors on participation and independence in the daily activities of stroke clients, participation, and based on the injured side and the dominant hand.
In general, the present study showed that the average upper limb function injury of people with a history of stroke participating in the study is severe and on average, they need supervision to perform daily life activities. The relationship between upper limb function and independence in daily life activities is significantly strong; thus, as the upper limb improves and becomes more efficient, independence also increases in the patient’s daily life activities. The relationship between upper limb function and significant participation is moderate; therefore, to increase and improve the involvement of stroke patients, other factors should be considered along with upper limb function.

Ethical Considerations
Compliance with ethical guidelines

The ethical principles observed in the article, such as the informed consent of the participants, the confidentiality of information, the permission of the participants to cancel their participation in the research. Ethical approval was obtained from the Research Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (IR.USWR.REC.1398.129).

This study was extracted from the MSc. thesis of second author at Department Occupational Therapy of the University of Social Welfare and Rehabilitation Sciences. 

Authors' contributions
Conceptualization: Nazila Akbarfahimi, Seyed Ali Hosseini, Nasibeh Amir Zargar; Methodology: Mohammad Hassan Mazidi, Mohsen Vahedi; Investigation: Mohammad Hassan Mazidi, Nazila Akbarfahimi, Nasibeh Amir Zargar; Writing – original draft: Nazila Akbarfahimi, Mohammad Hassan Mazidi; Writing – review & editing: All author.

Conflict of interest
The authors declared no conflict of interest.

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Type of Study: Applicable | Subject: Occupational Therapy
Received: 1/08/2020 | Accepted: 12/10/2020 | Published: 1/04/2021

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