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mise à jour du 30 mai 2002
Scand J Rehab Med
 Assoctiated reactions in the hemiplegic arm
Graham Mulley
Department of Health Care of the Elderly, Sherwood Hospital, Nottingham, England
Associated movements are normal automatic postural adjustments which accompany voluntary movements (1). By contrast, associated reactions are abnormal reflex activities which may occur in the absence of voluntary movements. The incidence of these involuntary movements in hemiplegic stroke patients and patients interpretations of the phenomenon have not been documented.

Associated reactions have been said to occur when the uninvolved limbs are moved forcibly (for example flexion of the normal arm against resistance may produce a flexor response in the hemiplegic arm (3) and in response to artificial reflex stimulation. These two types of stimuli (5) have been extensively studied and form the basis of the Brunnstrom school of physiotherapy (2) which aims to capitalise on these movements in order to improve the mobility and function of the affected arm. However, little attention has been paid to the involuntary reactions occurring in association with quasi-automatic movements such as yawning, sneezing, coughing and stretching. As the hemiplepic patient begins to Yawn his paralysed arm may flex involuntarily at the elbow, the arm is drawn up in front of him and it returns to its resting position as the yawn ceases. During this movement the hand and fingers are said to be held in extension (6, 9,10). Many of our stroke patients had these movements. As they differed in pattern from previous descriptions and as many patients had false ideas about their nature and implications, I decided to investigate the phenomenon.

Patients and methods : Forly hemiplegic stroke patients who were attending the out-patient physiotherapy department at Nottingham General Hospital were studied. These patients had been previousiy admitted under the care of consultant physicians who had made a diagnosis of stroke on clinical grounds. They constituted all the stroke patients who were regularly attending the physiotherapy department. Each patient was questioned using a standard questionnaire. Those patients who had experienced associated reactions were asked to describe the pattern of movement and to identify activities which provoked the movement. They were also asked about their interpretation of the phenornenon. The patient's age and sex, handedness, the side of the stroke and the interval between stroke and onset of movements were noted. The degree of arm movement was gauged on a-3-point scale (no. minimal.. and considerable arm movement) and a similar scale was used for manipulative function (no. some and very useful function of the hand).

Results : The ages of the patients ranged between 40 and 82 vears. Four patients had a moderate or severe speech defect: 3 of these could answer 'Yes' or'No' appropriately, and the fourth could not. The remainder of the patients could give detailed answers to all questions. Thirty-two patients had experienced automatic movements of the hemiplegic arm. In 15 of them, the movements had begun within a month of the stroke but in 4 a yaer or more had elapsed between the stroke and the onset of movements. In most of the patients. the movement started within 6 months of the stroke.

Pattern of movement : In 28 of the 32 patients with associated reactions the elbow was flexed during the movement; in 4 the elbow became extended. Only 9 patients had the type of movement hitherto described in which flexion was accompanied by extension of the fingers. In 7 patients, the fist was clenched during each episode. Of the remainder, one bad a fixed flexion contracture of the hand: there was no hand movement in 5 and 6 were not sure about the presence or pattern of hand movement. ln 2 patients, the movement of the arm was so violent that the hand hit their face.

Movements of the affected leg accompanying automatic arm movements were mentioned spontaneously by 8 patients. In 7 of these, the leg only moved in concert with the arm when the patient was lying in bed. In the eighth, the knee flexed without any arm movement whenever the patient coughed; however, when he yawned only the elbow flexed. In 4 patients the knee extended, in 3 it flexed and in one it moved laterally.

Side of hemiplegia and associated reactions : Twenty-three of the patients studied had a leftsided hemiplegia, in 17 the right side was affected. There was no significant difference between the side of paralysis and prevalence of involuntary movements: of the 8 patients who did not have associated reactions, 3 had sustained a left hemiplegia, 5 a right hemiplegia. Of the 32 patients with associated reactions, 4 extended their elbows whilst yawning. All 4 had a left-sided hemiplegia. The other 28 flexed the elbow: 16 of these had paralysis of the left side of the body, 12 had right-sided paralysis. There were no significant correlations between finger flexion and extension and stroke laterality.

Activities producing associated reactions : In 31 patients, the arm moved involuntarily in association with yawning. The arm movement would begin at the onset of the yawn and subsided as the yawn ended. Fifteen patients had arm movements every time they yawned. Several piatients found that the degree of arm movement was proportional to the size of the yawn. Others noted that yawn-induced arm movements were more likely to occur when they were lying in bed. In some cases, the arm fell to the side quite abruptly at the end of the yawn. One patient had to hold his paralysed arm when he yawned to prevent wrenching of the shoulder by sudden downward arm movement. Other activities which triggered automatic movements were sneezing (10 patients), coughing (8), stretching (3), and laughing (1). In 4 patients (including the only person in whom these movements were not stimulated by yawning) the associated reactions occurred whilst the patient was lying in bed, in the apparent absence of truncal movement.

Patients' interpretations of association reactions : Twenty-three patients thought that these movements were a sign of recovery. In several patients the onset of associated reactions engendered false optimism, they felt that the arm was coming back to life and that useful function would soon return. Four patients thought that the involuntary arm movements were a direct result of physiotherapy. One patient, who was not referred to the physiotherapy department until 17 months after a dense left-sided hemiplegia had not had any abnormal movements prior to treatment. Shortly after starting therapy he began to have associated reactions whenever he couched or yawned. Not everyone greeted these movements with enthusiasm. One man thought that they heralded the onset of another stroke: another was concerned that they might lead to flexion contractures. Seven patients felt that the movements were of no significance. One of these had become weary of comments by therapists and family about incipient improvement whenever the arm moved automatically.

Patients with no associated reactions : Eight patients had never had automatic movements. ln all cases, at least 3 months had elapsed between the date of the stroke and the interview with the patient. A striking feature of this group was the good movement and function in the hemiplegic arm and hand: 7 had coniderable voluntary arm movement and one had minimal movement: 4 had very useful hand function, and 3 had some use in the arm. This contrasts with the arm movement and function in those patients with associated reactions. No other significant differences between the two groups were found.

DISCUSSION Involuntary movements of the affected arm are common in hemiplegia. occurring in 80% of the patients studied. This study does not cover an entirely representative group of stroke patients (35 out of the 40 were men, and all were weil enough to attend outpatient physiotherapy), but it appears that associated reactions are much more common than would be expected from the brief descriptions found in most contemporary neurological texis. We do not know why involuntary arm movements occur when hemiplegic patients yawn. One attractive hypothesis (8) suggests an evolutionary basis. Yawning may he considered as a lower type of respiration than ordinary respiration.Originally, respiratory movements in animals were associated with limb movements. As the limbs began to perform more specialized movements, and respiratory movements became increasingly automatic, limb and respiratory movements became dissociated with the development of inhibitory influences. After a stroke, these inhibitory influences are removed and the arm tends to resume its old association with respiration.

Stejskal (6, 7) has studied the influence of respiration on reflex neuromuscular activity. As a general rule. inspiration stimulates neuromuscular excitability, expiration promotes relaxation. In spastic patients, there is an increase in the activity of striated skeletal muscles during inspiration. This activity reaches a peak during the Valsalva manoeuvre, when the patient inhales deeply and holds his breath. When a hemiplegic patient performs the Valsalva manoeuvre, certain muscles contract in a stereotyped way: the arm becomes flexed, adducted and pronated, with fingers flexed; the leg assumes the extended posture with the foot in plantarflexion and equinovarus. This activation of antigravity muscle groups during inspiration is greater if the patient is in the supine rather than the prone position. Stejskai suggests that in forced expiration (Müller's manoeuvre) hemiplegic patients very often spontaneously extend the fingers and the elbow in the spastic upper limb. He states that yawning is the most natural form of this strong expiration and that the hemiplegic patients who yawn have associated extension of the affected arm.

De Jong (4) however states that yawning is a prolonged inspiration. It is probable that people yawn in different ways but a common pattern comprises a prolonged inspiratory phase; a phase when the breath is held. and an expiratory phase. The patients whom I studied noticed that the paretic arm began to move at the onset of yawning; during the expiratory phase the flexed arm would extend and return to its resting position. Yawning cannot therefore be considered to be simply prolonged inspiration or forced expiration. Although yawning has been considered to be of minor medical importance, it is clearly not without interest and merits much more detailed study.

There was no relationship between sidedness of the stroke and prevalence of associated reactions. However, all 4 patients who reported elbow extension during yawning had left-sided paralysis. No conclusion can be drawn from such small numbers and larger-scale studies are needed to determine whether there is indeed a relationship between pattern of associated reaction and the side of the stroke.

None of the patients with associated reactions had received a satisfactory explanation for these movements from their doctor or physiotherapist and most patients had mistaken notions about the movements. Many hemiplegic stroke patients fall to regain useful manipulative function in the paralysed arm and the development of involuntary arm movements frequently causes unwarranted optimism in the patient and his or her family. The doctor involved in the care of stroke patients must be aware of the prevalence and implications of these movements and must resist the temptation to attach prognostic importance to them, since this will lead to ultimate disappointment. It is suggested that doctors should routinely ask stroke patients about the presence of these movements so that simple explanation and reassurance can be given.

The commonest patterns of movement differed from those previously described. Walshe (9, 10) describes extension of the hands and digits during the movement. In Walshe's patients the extension was complete and was accompanied by fanning of the fingers. In the present study only 9 patients had extension of the fingers. The reason for these differing patterns is obscure but may be related to differences in physiotherapy technique or to individual variation in yawning patterns. This study shows that the presence of voluntary arm control does not exclude the appearance of typical associated reactions: involuntary arm movements occurred in many patients with useful hand function and considerable arm movement. However, of the 8 patients who denied having automatic movements, 7 had considerable arm movement and useful manipulative function. Fur ther work is necessary to establish whether the absence of these movements is a useful prognostic index in determining arm recovery in hemiplegia.


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