An accelerometry and observational study to quantify upper limb use after stroke during inpatient rehabilitation

Factors Influencing Real-World Use of the More-Affected Upper Limb After Stroke: A Scoping Review

IMPORTANCE

Current interventions are limited in improving use of the more-affected upper limb in real-world daily occupations and functional independence poststroke. A comprehensive understanding of the factors influencing real-world upper limb use is required to develop interventions to improve functional independence poststroke.

OBJECTIVE

To systematically review the factors that influence real-world use of the more-affected upper limb poststroke.

DATA SOURCES

We searched MEDLINE, Embase, PsycINFO, and the Physiotherapy Evidence Database for English-language articles from 2012 to 2023.

STUDY SELECTION AND DATA COLLECTION

Of 774 studies, we included 33 studies that had participants at least age 18 yr who exhibited upper limb impairments poststroke, objectively measured real-world upper limb use using a movement sensor, and measured factors affecting upper limb use. Two reviewers independently screened the abstracts.

FINDINGS

The results were categorized by International Classification of Functioning, Disability and Health domains. Prominent factors were upper limb impairment; motor ability; functional independence; task type; hand dominance; stroke-related factors, including time since stroke; and perception of use of the more-affected upper limb.

CONCLUSIONS AND RELEVANCE

Existing interventions primarily focus on upper limb impairments and motor ability. Our findings suggest that interventions should also incorporate other factors: task type (unilateral vs. bilateral), hand dominance, self-efficacy, and perception of more-affected limb use as active ingredients in improving real-world use of the more-affected upper limb poststroke. We also provide recommendations to use behavioral activation theory in designing an occupation-focused intervention to augment self-efficacy and confidence in use of the more-affected upper limb in daily occupations. Plain-Language Summary: In order to develop interventions to improve functional independence poststroke, occupational therapy practitioners must have a comprehensive understanding of the factors that influence real-world more-affected upper limb use. The study findings provide a set of distinct factors that practitioners can target separately or in combination to improve real-world use of the more-affected upper limb poststroke.

Grade-4/5 motor activity log-Brazil for post-stroke individuals with a severely impaired upper limb: a validity, reliability and measurement error study

PURPOSE

This study examined the clinimetrics of the Brazilian-Portuguese translation of the Grade-4/5 Motor Activity Log (MAL 4/5), which assesses everyday use of the more affected upper-limb (UL) in stroke survivors with moderate/severe or severe motor impairment.

MATERIALS AND METHODS

The translated MAL 4/5 was administered to 47 stroke survivors with moderate/severe or severe UL motor impairment. Accelerometers were worn on participants' wrists for five days on average prior to the first assessment. Test-retest and inter-rater reliabilities were assessed using the intraclass correlation coefficient (ICC), internal consistency using Cronbach's α, and construct validity was tested with correlations with the accelerometry. The measurement error (SEM) and the minimal detectable change (MDC) were calculated.

RESULTS

MAL4/5-Brazil's test-retest reliability (AOU: ICC = 0.84; QOU: ICC = 0.90), inter-rater reliability (AOU: ICC = 0.83; QOU: ICC = 0.91), internal consistency (Cronbach's α = 0.91 and 0.95 for AOU and QOU scales, respectively), the SEM and MDC were 0.3 and 0.8 points for the AOU subscale and 0.2 and 0.5 points for the QOU subscale, respectively. The construct validity (AOU scale: r = 0.67; QOU scale: r = 0.76) was high.

CONCLUSION

Grade-4/5 Motor Activity Log-Brazil is a reliable and valid instrument for assessing the more-affected UL use of stroke patients with moderate/severe or severe UL motor impairments.

Haptic Nudging Using a Wearable Device to Promote Upper Limb Activity during Stroke Rehabilitation: Exploring Diurnal Variation, Repetition, and Duration of Effect

Haptic nudging via wearable devices promotes physical activity and may increase upper limb movement in stroke rehabilitation. This study investigated the optimal approach to haptic nudging by examining diurnal variation, duration of effect, and repeated nudging. The study analysed data from a multiple-period randomised crossover study. A 12 h inpatient rehabilitation day was divided into 72 intervals in which participants with stroke (n = 20) randomly received either a 'nudge' or 'no nudge'. Upper limb movement was observed, classified, and analysed using longitudinal mixed models. The odds of affected upper limb movement following a nudge compared with no nudge were significantly higher during active periods such as breakfast, lunch, and morning and afternoon activities (odds ratios (ORs) 2.01-4.63, 95% CIs [1.27-2.67, 3.17-8.01]), but not dinner (OR 1.36, 95% CI [0.86, 2.16]). The effect of nudging was no longer statistically significant at 50-60 s post-nudge. Consecutive delays in nudging significantly decreased the odds of moving when a nudge was eventually delivered. Contrary to expectations, people with stroke appear more responsive to haptic nudging during active periods rather than periods of inactivity. By understanding the optimal timing and frequency of haptic nudging, the design of wearable devices can be optimised to maximise their therapeutic benefits.

Dose, Content, and Context of Usual Care in Stroke Upper Limb Motor Interventions: A Systematic Review

OBJECTIVE

The objectives of this systematic review were to describe the current dose and content of usual care upper limb motor intervention for inpatients following stroke and examine if context factors alter dose and content.

DATA SOURCES

A systematic search (EMBASE, MEDLINE) was completed from January 2015 to February 2023 (PROSPERO CRD42021281986).

METHODS

Studies were eligible if they reported non-protocolised usual care upper limb motor intervention dose data for stroke inpatients. Studies were rated using the Johanna Briggs Institute critical appraisal tool. Data were descriptively reported for dose dimensions of time (on task or, in therapy) and intensity (repetitions, repetition/minute), content (intervention type/mode), and context (e.g., severity strata).

RESULTS

Eight studies were included from four countries, largely reflecting inpatient rehabilitation. Time in therapy ranged from 23 to 121 min/day. Time on task ranged from 8 to 44 min/day. Repetitions ranged from 36 to 57/session, and 15 to 282/day. Time on task was lowest in the stratum of people with severe upper limb impairment (8 min/day), the upper limit for this stratum was 41.5 min/day. There was minimal reporting of usual care content across all studies.

CONCLUSION

Upper limb motor intervention dose appears to be increasing in usual care compared to prior reports (e.g., average 21 min/day and 23 to 32 repetitions/session). Context variability suggests that doses are lowest in the stratum of patients with a severely impaired upper limb. Consistent reporting of the multiple dimensions of dose and content is necessary to better understand usual care offered during inpatient rehabilitation.

Suitability of accelerometry as an objective measure for upper extremity use in stroke patients

Background

Upper limb (UL) paresis is one of the most common stroke consequences and significantly restricts patients in everyday life. Instruments objectively measuring direct arm use in stroke patients are lacking, but might be helpful to understand patients’ impairment. Aiming to examine whether accelerometry is a suitable objective measure for everyday UL use in stroke patients, we conducted a systematic review on the association between accelerometer-derived measurements and clinical scales.

Methods

Articles were systematically searched in PubMed, Scopus, Cochrane Library, PeDro and LIVIVO through December 12^th, 2021, screened for inclusion by AH, and subsequently independently screened by CK and MK. Disagreements were discussed until consensus. We included English and German peer-reviewed articles dealing with the validity of accelerometers as a measurement of UL use in stroke patients and eligible systematic reviews. Studies exclusively using accelerometry as an outcome parameter, book contributions, conference abstracts and case studies were excluded. Data extraction was conducted by AH and confirmed by CK focussing on study type, objective, accelerometer device, sample size, stroke status, assessments conducted, measurement method, wearing time and key results. We analysed all eligible articles regarding the correlation between accelerometry and other clinical assessments and the validity in accordance with the type of accelerometer.

Results

Excluding duplicates, the initial search yielded 477 records. In the 34 eligible studies accelerometers was used with a predominance of tri-axial accelerometery (n = 12) and only few with two-axial application (n = 4). Regarding measures to examine association to accelerometer data different clinical scales were applied depending on the setting, the degree of impairment and/or the status of stroke. Cut-off values to determine correlations varied largely; most significant correlations are reported for the MAL [Range 0.31- 0.84] and the ARAT [Range 0.15–0.79].

Conclusions

Accelerometers can provide reliable data about daily arm use frequency but do not supply information about the movements´ quality and restrictions on everyday activities of stroke patients. Depending on the context, it is advisable to use both, accelerometry and other clinical measures. According to the literature there is currently no accelerometer device most suitable to measure UL activity. High correlations indicate that multi-dimensional accelerometers should be preferred.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02743-w.

Daily Life Upper Limb Activity for Patients with Match and Mismatch between Observed Function and Perceived Activity in the Chronic Phase Post Stroke

We investigated actual daily life upper limb (UL) activity in relation to observed UL motor function and perceived UL activity in chronic stroke in order to better understand and improve UL activity in daily life. In 60 patients, we collected (1) observed UL motor function (Fugl-Meyer Assessment (FMA-UE)), (2) perceived UL activity (hand subscale of the Stroke Impact Scale (SIS-Hand)), and (3) daily life UL activity (bilateral wrist-worn accelerometers for 72 h) data. Data were compared between two groups of interest, namely (1) good observed (FMA-UE >50) function and good perceived (SIS-Hand >75) activity (good match, n = 16) and (2) good observed function but low perceived (SIS-Hand ≤75) activity (mismatch, n = 15) with Mann-Whitney U analysis. The mismatch group only differed from the good match group in perceived UL activity (median (Q1-Q3) = 50 (30-70) versus 93 (85-100); p < 0.001). Despite similar observed UL motor function and other clinical characteristics, the affected UL in the mismatch group was less active in daily life compared to the good match group (p = 0.013), and the contribution of the affected UL compared to the unaffected UL for each second of activity (magnitude ratio) was lower (p = 0.022). We conclude that people with chronic stroke with low perceived UL activity indeed tend to use their affected UL less in daily life despite good observed UL motor function.

Quantification of the relative arm use in patients with hemiparesis using inertial measurement units

Introduction

Accelerometry-based activity counting for measuring arm use is prone to overestimation due to non-functional movements. In this paper, we used an inertial measurement unit (IMU)-based gross movement (GM) score to quantify arm use.

Methods

In this two-part study, we first characterized the GM by comparing it to annotated video recordings of 5 hemiparetic patients and 10 control subjects performing a set of activities. In the second part, we tracked the arm use of 5 patients and 5 controls using two wrist-worn IMUs for 7 and 3 days, respectively. The IMU data was used to develop quantitative measures (total and relative arm use) and a visualization method for arm use.

Results

From the characterization study, we found that GM detects functional activities with 50–60% accuracy and eliminates non-functional activities with >90% accuracy. Continuous monitoring of arm use showed that the arm use was biased towards the dominant limb and less paretic limb for controls and patients, respectively.

Conclusions

The gross movement score has good specificity but low sensitivity in identifying functional activity. The at-home study showed that it is feasible to use two IMU-watches to monitor relative arm use and provided design considerations for improving the assessment method.

Clinical trial registry number: CTRI/2018/09/015648

Whole-Body Movements Increase Arm Use Outcomes of Wrist-Worn Accelerometers in Stroke Patients

Wrist-worn accelerometers are often applied to measure arm use after stroke. They measure arm movements during all activities, including whole-body movements, such as walking. Whole-body movements may influence clinimetric properties of arm use measurements—however, this has not yet been examined. This study investigates to what extent arm use measurements with wrist-worn accelerometers are affected by whole-body movements. Assuming that arm movements during whole-body movements are non-functional, we quantify the effect of whole-body movements by comparing two methods: Arm use measured with wrist-worn accelerometers during all whole-body postures and movements (P&M method), and during sitting/standing only (sit/stand method). We have performed a longitudinal observational cohort study with measurements in 33 stroke patients during weeks 3, 12, and 26 poststroke. The P&M method shows higher daily paretic arm use outcomes than the sit/stand method (p < 0.001), the mean difference increased from 31% at week three to 41% at week 26 (p < 0.001). Differences in daily paretic arm use between methods are strongly related to daily walking time (r = 0.83–0.92). Changes in the difference between methods are strongly related to changes in daily walking time (r = 0.89). We show that not correcting arm use measurements for whole-body movements substantially increases arm use outcomes, thereby threatening the validity of arm use outcomes and measured arm use changes.

Objectively measured arm use in daily life improves during the first 6 months poststroke: a longitudinal observational cohort study

Background

It is unclear how arm use in daily life changes after stroke since studies investigating the change in arm use poststroke are scarce. The aim of this study was to investigate the change in arm use during the first six months poststroke. Secondary aim was to compare arm use changes between arm recovery clusters.

Methods

Arm use was measured during week 3, 12, and 26 poststroke with accelerometers on the wrists and the nonaffected leg. Outcomes were the amount of affected and nonaffected arm use during sitting and standing per day and per sit/stand hour, and the daily ratio between arms. Arm function was measured with the Fugl-Meyer Upper Extremity Scale to identify recovery clusters (poor/moderate/excellent). Generalized estimating equations compared arm use outcomes between time points and between recovery clusters.

Results

Thirty-three stroke patients participated. Affected arm use per day increased between week 3 and 12 (30 %; p = 0.04) and it increased per sit/stand hour between week 3–12 (31 %; p < 0.001) and between week 3 and 26 (48 %; p = 0.02). Nonaffected arm use per day decreased between week 3 and 12 (13 %; p < 0.001) and between week 3 and 26 (22 %; p < 0.001) and it decreased per sit/stand hour between week 3 and 26 (18 %; p = 0.003). The daily ratio increased between week 3 and 12 (43 %; p < 0.001) and between week 3 and 26 (95 %; p < 0.001). Changes in arm use did not differ significantly between recovery clusters (p = 0.11–0.62). Affected arm use was higher in the excellent recovery cluster (p < 0.001).

Conclusions

Affected arm use and the ratio between arms increase during the first 26 weeks poststroke especially in patients with excellent arm recovery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12984-021-00847-x.

Haptic Nudges Increase Affected Upper Limb Movement During Inpatient Stroke Rehabilitation: Multiple-Period Randomized Crossover Study

BACKGROUND

As many as 80% of stroke survivors experience upper limb (UL) disability. The strong relationships between disability, lost productivity, and ongoing health care costs mean reducing disability after stroke is critical at both individual and society levels. Unfortunately, the amount of UL-focused rehabilitation received by people with stroke is extremely low. Activity monitoring and promotion using wearable devices offer a potential technology-based solution to address this gap. Commonly, wearable devices are used to deliver a haptic nudge to the wearer with the aim of promoting a particular behavior. However, little is known about the effectiveness of haptic nudging in promoting behaviors in patient populations.

OBJECTIVE

This study aimed to estimate the effect of haptic nudging delivered via a wrist-worn wearable device on UL movement in people with UL disability following stroke undertaking inpatient rehabilitation.

METHODS

A multiple-period randomized crossover design was used to measure the association of UL movement with the occurrence of haptic nudge reminders to move the affected UL in 20 people with stroke undertaking inpatient rehabilitation. UL movement was observed and classified using movement taxonomy across 72 one-minute observation periods from 7:00 AM to 7:00 PM on a single weekday. On 36 occasions, a haptic nudge to move the affected UL was provided just before the observation period. On the other 36 occasions, no haptic nudge was given. The timing of the haptic nudge was randomized across the observation period for each participant. Statistical analysis was performed using mixed logistic regression. The effect of a haptic nudge was evaluated from the intention-to-treat dataset as the ratio of the odds of affected UL movement during the observation period following a "Planned Nudge" to the odds of affected limb movement during the observation period following "No Nudge."

RESULTS

The primary intention-to-treat analysis showed the odds ratio (OR) of affected UL movement following a haptic nudge was 1.44 (95% CI 1.28-1.63, P<.001). The secondary analysis revealed an increased odds of affected UL movement following a Planned Nudge was predominantly due to increased odds of spontaneous affected UL movement (OR 2.03, 95% CI 1.65-2.51, P<.001) rather than affected UL movement in conjunction with unaffected UL movement (OR 1.13, 95% CI 0.99-1.29, P=.07).

CONCLUSIONS

Haptic nudging delivered via a wrist-worn wearable device increases affected UL movement in people with UL disability following stroke undertaking inpatient rehabilitation. The promoted movement appears to be specific to the instructions given.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry 12616000654459; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370687&isReview=true.