Nursing effects of finger exercise on cognitive function and others for cerebral ischemic stroke patients

Abstract

Objective: To investigate the nursing effects of finger exercise training on cognitive function and others for patients with cerebral ischemic stroke (CIS). Methods: A total of 200 patients with CIS were selected in this prospective study. According to the random number table method, they were divided into control group (n=100, routine nursing) and research group (n=100, routine nursing combined with finger exercise training). Various scales were used to evaluate the cognitive function, hand function, upper limb motor function, wrist flexor muscle tone, degree of neurological impairment and ability of daily living (ADL) in the two groups before and after intervention. And the incidence of mild vascular cognitive impairment (VCI) after intervention was compared. Results: After intervention, Montreal Cognitive Assessment (MoCA), Mini Mental State Examination (MMSE), hand function, Fugl-meyer Assessment (FMA) and ADL scores in both groups were significantly increased, and those in the research group were significantly higher than those in the control group (all P<0.05). There were opposite trends in the Neurologic Functional Defect (NIHSS) and Modified Ashworth Scale (MAS) for wrist flexor scores (all P<0.05). The incidence of mild VCI in the research group was significantly lower than that in the control group (P<0.05). Conclusion: On the basis of early rehabilitation nursing, combined finger exercise training can improve cognitive function, hand function, upper limb function and ADL for patients with CIS.

Introduction

Cerebral stroke (CS) is one of the major diseases that lead to disability in China, among which cerebral ischemic stroke (CIS) is the most common one. And the number of CIS patients accounts for about 80% of all CS patients [1]. After CS, patients usually have a variety of physiological dysfunction, such as cognitive dysfunction, hand dysfunction, motor dysfunction, etc. [2]. Delavaran et al. reported that the incidence of cognitive dysfunction after CS was 20-80% worldwide, and Yeh et al. found that about 1/3 of the survivors would have significant cognitive dysfunction one month after stroke [3,4]. Finger exercise is a simple way of training, which is easy to learn and master. Previous studies have shown that finger exercise has a relatively obvious effect on the rehabilitation of CS patients and significantly improves their upper limb function, hand function and cognitive function [5]. However, some scholars believe that the effects of improvement, especially the improvement on cognitive function, is limited and difficult to observe [6]. Therefore, this study evaluated the intervention effect of finger exercise on cognitive function, hand function, upper limb motor, sensory function, and ability of daily living (ADL) for patients with CIS.

Materials and methods

General information

A total of 200 patients with CIS admitted to The First Affiliated Hospital of Xi’an Jiaotong University from November 2018 to November 2019 were selected in this prospective study. They were divided into control group (n=100, routine nursing) and research group (n=100, routine nursing combined with finger exercise training) by the random number table method. This study was approved by the Ethics Committee of The First Affiliated Hospital of Xi’an Jiaotong University and all patients or their families signed the informed consent.

Inclusion criteria: Patients aged 50-75 years old; patients who met the diagnostic criteria of CIS in Chinese Guidelines for Diagnosis and Treatment of Acute Cerebral Ischemic Stroke 2014 and were confirmed by relevant imaging examination [7]; patients with first CS and course of disease <6 months; patients who were conscious with stable vital signs and volunteered to this training; patients with muscle strength of both upper limbs ≥ level 4.

Exclusion criteria: Patients with cerebral trauma, cerebral tumor and other cerebral diseases; patients with a pacemaker or metal implant placed in the skull; patients with Alzheimer’s disease, depression, etc.; patients who couldn’t complete the cognitive examination due to physical dysfunction; patients who participated in other researches within the same period.

Methods

Both groups received routine treatment for CIS, such as improving cerebral circulation and nourishing brain nerve, etc. Details are as follows. Intravenous drips of edaravone injection (30 mg; China Resources Double-Crane Pharmaceutical Co., Ltd., China) and Xueshuantong Injection (350 mg; Harbin Shengtai Bio-Pharmaceutical Co., Ltd., China) were given twice a day, respectively. Deproteinized extract of calf blood (800-1,200 g; Harbin Shengtai Bio-Pharmaceutical Co., Ltd., China) was injected once a day. All the drugs were administered continuously for 2 weeks.

The control group received routine education and early rehabilitation nursing of CIS, including limb active movement, joint activity exercise, etc. On the basis of the above measures, the research group received finger exercise training. In addition to hands and fingers, this training also involves wrist, elbow and shoulder joints. Details are as follows. 1) Palm massage: One hand were made to draw circles in the palm of the other hand alternately. 2) Dorsum massage: One hand were made to draw circles in the dorsum of the other hand alternately. 3) Finger grasp: One hand were made to grasp the fingers of the other hand interactively. 4) Fingers opening and closing: Both hands were opened or closed to make fists at the same time. 5) Finger extension: Five fingers of both hands were outstretched successively. 6) Finger clicking: The five fingers were clicked in turn by the other hand interactively. 7) Palm and dorsum hitting: The palm and dorsum were hit by the other hand. 8) Wrist flipping: The palms were put together, and turned over in turn to the inside and outside. Each of the above movements was repeated for 20 times, with 3-5 cycles each time, twice a day. After discharge, the training was performed continually at home, and the medical staff supervised and instructed patients through WeChat, telephone or monthly face-to-face communication. The effects were observed after 3 months.

Outcome measures

The following scales were filled in by the patient himself or the nursing staff according to the patients’ wishes before and 3 months after intervention, and were retrieved on the spot.

Primary outcome measures: 1) Cognitive function: The Montreal Cognitive Assessment (MoCA) and Mini Mental State Examination (MMSE) scales were used to evaluate the cognitive function, with a total score of 30 points [8,9]. Cognitive function is improved as the score increases. 2) Hand function: The hand fine motor assessment scale was used to evaluate the hand function, including 6 items as finger adduction/abduction, finger flexion and extension, digital opposition, palmar opposition, wrist-joint rotation and wrist-joint flexion and extension [10]. Higher score suggest better functions in the above items.

Secondary outcome measures: 1) Upper limb motor function: Fugl-meyer Assessment (FMA) Scale includes 33 items such as coordination ability and stability of various joints of upper limb movement (shoulder, elbow, wrist and hand), with a total score of 66 points [11]. Higher score refers to better upper limb motor function. 2) Wrist flexor muscle tone: In the Modified Ashworth Scale (MAS), 6 points and 0 point represent rigid and normal state when passive flexion and extension occurs, respectively [12]. 3) Degree of neurological impairment: The total score of Neurologic Functional Defect (NIHSS) is 42 points and the increased score indicates more serious neurological impairment [13]. 4) ADL: The total score of ADL scale is 100 points [14]. Higher score suggests stronger ADL. 5) The incidence of mild vascular cognitive impairment (VCI) after intervention was compared between the two groups. And 22-26 points of MoCA or MMSE presages mild VCI [8,9]. The incidence of mild VCI = Number of case of mild VCI/total number of cases * 100%.

Statistical analysis

SPSS 20.0 was used for statistical analysis. The count data were expressed as case/percent (n, %) and comparison of count data was conducted by χ² test. The measurement data conforming to the normal distribution was expressed by the mean ± standard deviation (x̅ ± sd). Paired t test was used for intra-group comparison before and after intervention, and independent t test was used for inter-group comparison. P<0.05 is considered statistically significant.

Results

Comparison of general information

There was no difference in the general information between the two groups (all P>0.05, Table 1).

Table 1.

Comparison of general information (x̅ ± sd, n)

Index	Research group (n=100)	Control group (n=100)	χ2/t	P
Gender			0.720	0.396
Male	54	48
Female	46	52
Age (years)	63.3±5.7	64.2±5.0	1.187	0.237
BMI (kg/m2)	23.45±2.22	23.10±2.84	0.971	0.333
Brunnstrom stage [15]			2.321	0.313
I	36	29
II	30	40
III	34	31
Level of education			1.807	0.405
Junior high school education or below	50	58
Senior high school education or associate degree	26	25
Bachelor or above degree	24	17
Nursing knowledge			0.272	0.602
Yes	9	7
No	91	93

Note: BMI: body mass index.

Comparisons of cognitive function and hand function

After intervention, scores of cognitive function and hand function in both groups were significantly increased, and those in the research group were significantly higher than those in the control group (all P<0.05, Tables 2, 3).

Table 2.

Comparisons of cognitive function (x̅ ± sd, score)

Group	MoCA score	MMSE score
Research group (n=100)
Before intervention	20.04±2.20	21.40±3.22
After intervention	25.96±3.22*,#	25.40±3.50*,#
Study group (n=100)
Before intervention	20.48±2.40	21.03±4.39
After intervention	22.94±3.08*	23.98±4.05*

Note: Compared with before intervention;

^*P<0.05.

Compared with control group after intervention;

^#P<0.05.

MoCA: Montreal Cognitive Assessment; MMSE: Mini Mental State Examination.

Table 3.

Comparison of hand function (x̅± sd, score)

Group	Finger adduction/abduction	Finger flexion and extension	Digital opposition	Palmar opposition	Wrist-joint rotation	Wrist-joint flexion and extension
Research group (n=100)
Before intervention	5.50±1.04	13.30±2.04	4.09±1.01	5.10±1.10	2.01±0.92	2.33±0.95
After intervention	7.03±1.25*,#	16.80±2.10*,#	6.40±1.38*,#	6.98±1.02*,#	3.98±1.01*,#	4.03±0.80*,#
Study group (n=100)
Before intervention	5.20±1.19	12.95±3.29	4.25±1.24	5.03±1.05	1.97±0.95	2.18±0.96
After intervention	6.22±1.14*	14.50±2.88*	5.86±1.30*	6.06±1.29*	3.02±0.88*	3.04±0.89*

Note: Compared with before intervention;

^*P<0.05.

Compared with control group after intervention;

^#P<0.05.

Comparison of the incidence of mild VCI

The incidence of mild VCI in the research group was significantly lower than that in the control group (3.00% vs. 12.00%; χ²=5.838, P=0.016). See Figure 1.

Figure 1.

Comparison of the incidence of mild VCI. Compared with control group after intervention, #P<0.05. VCI: vascular cognitive impairment.

Comparisons of upper limb motor function, wrist flexor muscle tone, degree of neurological impairment and ADL

After intervention, FMA and ADL scores in both groups were significantly increased, and the changes in the research group were more obvious than those in the control group (all P<0.05). There were opposite trends in NIHSS and MAS for wrist flexor scores (all P<0.05). See Tables 4, 5.

Table 4.

Comparisons of upper limb motor function and wrist flexor muscle tone (x̅ ± sd, score)

Group	FMA score	MAS for wrist flexor score
Research group (n=100)
Before intervention	44.40±4.30	2.88±0.70
After intervention	55.30±4.93*,#	1.43±0.49*,#
Study group (n=100)
Before intervention	45.09±5.04	2.96±0.85
After intervention	51.40±5.69*	1.99±0.79*

Note: Compared with before intervention;

^*P<0.05.

Compared with control group after intervention;

^#P<0.05.

FMA: Fugl-meyer Assessment; MAS: Modified Ashworth Scale.

Table 5.

Comparisons of degree of neurological impairment and ADL (x̅ ± sd, score)

Group	NIHSS score	ADL score
Research group (n=100)
Before intervention	34.40±4.06	68.70±6.50
After intervention	26.49±5.30*,#	78.89±7.10*,#
Study group (n=100)
Before intervention	33.96±4.94	67.98±5.69
After intervention	28.80±5.44*	72.20±6.60*

Note: Compared with before intervention;

^*P<0.05.

Compared with control group after intervention;

^#P<0.05.

NIHSS: Neurologic Functional Defect; ADL: ability of daily living.

Discussion

Cerebral tissue ischemia in patients with CIS leads to neuronal necrosis and further neurological damage. In the development of the disease, most patients have multiple physiological dysfunctions, such as limb motor dysfunction, cognitive dysfunction, sensory dysfunction, etc. [16]. Among them, cognitive dysfunction after CS has been widely studied. However, since most of CS patients are middle-aged and elderly, and they are often combined with other basic diseases, drug therapy is inevitable. It brings a great impact on liver and kidney function and takes high cost and heavy economic burden to family. In contrast, finger exercise training is more practical for elderly CS patients.

Finger exercise training is an exercise form of hand motor. Plentiful researches have shown that finger exercise can activate the function of cerebral cortex in multiple brain regions, and delay the decline of cognitive function [17-19]. This study found that the MoCA and MMSE scores in the research group were higher than those in the control group after intervention, and the incidence of mild VCI in the research group was significantly lower than that in the control group (3.00% vs. 12.00%). Our study results confirmed that the combination of finger exercise training on the basis of early rehabilitation nursing had a more obvious improvement effect on the cognitive function of CIS patients. Sindi et al. also believed that finger exercise training was helpful to increase the brain excitability, thereby contributing to the recovery of cognitive dysfunction [20]. The increase of cerebral blood flow during finger activity is conducive to improving intelligence and sharpening mind. And regular finger exercise can improve brain circulation and form new exciting points in the brain, which is beneficial to the improvement of understanding, memory and thinking [21].

Hand function accounts for about 90% of upper limb function. It is innervated by complex nerves, and the distribution of hand nerves in the cerebral cortex is quite exquisite. If patients have hand dysfunction, almost all upper limb function will be lost [22]. However, the limitation of conventional rehabilitation therapy extremely blocks the improvement of hand function after stroke [23]. This study discovered that after intervention, the improvement of various hand functions, FMA score and MAS for wrist flexor score in the study group was better than those in the control group. It is suggested that for patients with CIS, on the basis of early rehabilitation nursing, combined finger exercise training can help to significantly improve various hand functions and also contribute to the recovery of upper limb function and wrist flexor muscle tone. Guidelines for CIS rehabilitation nursing intervention recommends repetitive task training as a routine training to improve the function of the upper limbs. Therefore, finger exercise through repeated movement of fingers and joints is designed, in order to improve the various motor functions of the patients’ upper limbs [24]. Lezkan et al. reported that the repeated practice of palm massage, dorsum massage, finger grasp, fingers opening and closing, finger extension, finger clicking, palm and dorsum hitting improved the flexibility of the fingers and joints, thus helping the gradual recovery of the hand function [25].

In this study, compared with the control group, the NIHSS and ADL scores of the research group were significantly decreased and increased after intervention, respectively. It suggests that combined finger exercise training based on early rehabilitation nursing is helpful to improve the degree of neurological impairment in patients with CIS and improve their self-care ADL. Eschmann et al. also believes that finger exercise involves the massage and repeated movement of fingers, hand acupoints and joints; repeated massage and hand-eye coordination movement are helpful to stimulate the activation of one side of cerebral hemisphere to the other side of cerebral tissue in CS patients, thus helping to improve the defect of nerve function [26]. The recovery of various physiological functions also depends on the recovery of neurological functions. It can be a long process with many effect factors for CS patients; therefore, persistence is critical in the finger exercise training [27].

This study also has some limitations. No follow-up was conducted in this study, and the effect of finger exercise training on long-term physiological function of CS patients still needs further investigation.

Based on early rehabilitation nursing, combined finger exercise training can improve cognitive function, hand function, upper limb function and ADL for CIS patients, which is worth promoting in clinic.

Disclosure of conflict of interest

None.