The Relationship Between Executive Function and Functional Mobility in Subacute Stroke Patients

PURPOSE: The purpose of this study was to explore the relationship between screenings of executive function (EF) and measures of functional mobility in subacute stroke rehabilitation. Cognitive status following neurological damage due to stroke has implications for one’s progress in regaining functional mobility (Kim, Han, & Lee, 2014). Although motor function was thought to be automatic in nature, recent findings have suggested it is more complex than once presumed (Arsic et al., 2015). Several studies have linked EF skills to motor function (Arsic et al., 2015; Holtzer, Verghese, Xue, & Lipton, 2006); however, there is little research on the relationship between commonly used cognitive assessment outcomes and mobility outcome measures during inpatient stroke rehabilitation. The inpatient rehabilitation process is short, and thus it is critical to assess the particular factors influencing patients’ ability to be functionally mobile upon discharge (Perry, Marchetti, Wagner, & Wilton, 2006). While the effects of EF on motor function are documented in the literature, there is a lack of consensus as to what assessments are best able to demonstrate these effects early on in the rehabilitation process.

DESIGN: This is a descriptive, nonexperimental, and retrospective study. Patients who had a confirmed primary diagnosis of cerebrovascular accident as per radiological assessment met the criteria to be admitted to the inpatient rehabilitation unit and provided consent to have routine assessment measures included within an interdisciplinary rehabilitation database. Only people with all targeted measures completed were included in the analysis.

METHOD: Initial assessments of cognition were completed within 72 hr of admission and included the Montreal Cognitive Assessment (MoCA), Symbol Digit Modalities Test (SDMT), and Trail Making Test Parts A and B (TMT–A and TMT–B). In addition, the TMT was repeated at discharge and used in the analysis. Measures of mobility were administered 48 hr before discharge and included the Timed Up & Go (TUG), gait speed (10-meter walk test), and the Berg Balance Scale. Descriptive statistics were used to examine patient characteristics. Spearman’s rho correlations were used to explore relationships between outcome measures.

RESULTS: A total of 86 participants were included in this study (M age = 67.67 yr ± 15.79; 58% male, 42% female). The TUG had significant moderate correlations with the MoCA (r _s = –.34, p < .01), SDMT (r _s = –.39, p < .01), TMT–A (r _s = .31, p < .01), and TMT–B (r _s = .34, p < .01); the strongest relationship was found between the TUG and the SDMT (r _s = –0.39, p < .01).

CONCLUSION: Findings suggest that the TUG may be more influenced by executive function than other measures of mobility. This is likely due to the complex sequence of motor tasks and type of instructions given within this test. Implications for occupational therapy practice include the importance of incorporating measures representative of the relationship between EF and functional mobility. By using assessments that evoke the necessary cognitive skills needed for motor function, therapists can develop a deeper understanding of factors influencing performance. This in turn influences clinical decision making, such as providing earlier and more specific cognitive intervention.

IMPACT STATEMENT: Our findings suggest that EF deficits can decrease the ability to perform multistep mobility tasks. This needs to be considered for optimal participation during the rehabilitation process. Occupational therapists can help promote awareness of the relationship between cognition and mobility performance among team members and provide recommendations to enhance EF performance within functional mobility tasks.

References

Arsic, S., Konstantinovic, L., Eminovic, F., Pavlovic, D., Popovic, M. B., & Arsic, V. (2015). Correlation between the quality of attention and cognitive competence with motor action in stroke patients. BioMed Research International, 2015 , 823136. https://doi.org/10.1155/2015/823136

Holtzer, R., Verghese, J., Xue, X., & Lipton, R. B. (2006). Cognitive processes related to gait velocity: Results from the Einstein aging study. Neuropsychology, 20, 215–223. https://doi.org/10.1037/0894-4105.20.2.215

Kim, G., Han, M., & Lee, H. (2014). Effect of dual-task rehabilitative training on cognitive and motor function of stroke patients. Journal of Physical Therapy Science, 26, 1–6. https://doi.org/10.1589/jpts.26.1

Perry, S. B., Marchetti, G. F., Wagner, S., & Wilton, W. (2006). Predicting caregiver assistance required for sit-to-stand following rehabilitation for acute stroke. Journal of Neurologic Physical Therapy, 30, 2–11. https://doi.org/10.1097/01.NPT.0000282144.72703.cb