Belief, Confidence, and Motivation to Use the Paretic Upper Limb in Daily Life Over the First 24 Weeks After Stroke

ICF classification of therapeutic goals for outpatient episodes of neurorehabilitation in post-stroke and Parkinson disease

PURPOSE

To understand therapeutic priorities, a secondary data analysis on a retrospective cohort was conducted to classify rehabilitation goals according to the International Classification of Functioning, Disability, and Health (ICF).

MATERIALS AND METHODS

Therapeutic goals from an initial outpatient physical or occupational therapy evaluation for patients post-stroke or with Parkinson disease, were classified into Level 1 of the ICF. Goals in the Activity and Participation component were further sub-classified as activity capacity or activity performance (self-report or direct) in daily life.

RESULTS

776 goals across 104 participants were classified into Level 1 of the ICF. The majority, 73% (563/776) were classified as Activity and Participation, 20% (155/776) as Body Function and 2% (17/776) as Environmental Factors. Fifty-two percent (400/776) of all goals were classified as activity capacity and 21% (163/776) as activity performance in daily life, with 21% (160/776) of goals measuring self-report activity performance in daily life and less than 1% (3/776) of goals measuring direct activity performance in daily life.

CONCLUSIONS

While the majority of therapeutic goals were classified into the Activity and Participation component, less than 1% of goals measured direct activity performance in daily life. If people seek outpatient rehabilitation to improve functioning in their real-world environment, therapeutic goal setting should reflect this.

Predicting later categories of upper limb activity from earlier clinical assessments following stroke: an exploratory analysis

BACKGROUND

Accelerometers allow for direct measurement of upper limb (UL) activity. Recently, multi-dimensional categories of UL performance have been formed to provide a more complete measure of UL use in daily life. Prediction of motor outcomes after stroke have tremendous clinical utility and a next step is to explore what factors might predict someone's subsequent UL performance category.

PURPOSE

To explore how different machine learning techniques can be used to understand how clinical measures and participant demographics captured early after stroke are associated with the subsequent UL performance categories.

METHODS

This study analyzed data from two time points from a previous cohort (n = 54). Data used was participant characteristics and clinical measures from early after stroke and a previously established category of UL performance at a later post stroke time point. Different machine learning techniques (a single decision tree, bagged trees, and random forests) were used to build predictive models with different input variables. Model performance was quantified with the explanatory power (in-sample accuracy), predictive power (out-of-bag estimate of error), and variable importance.

RESULTS

A total of seven models were built, including one single decision tree, three bagged trees, and three random forests. Measures of UL impairment and capacity were the most important predictors of the subsequent UL performance category, regardless of the machine learning algorithm used. Other non-motor clinical measures emerged as key predictors, while participant demographics predictors (with the exception of age) were generally less important across the models. Models built with the bagging algorithms outperformed the single decision tree for in-sample accuracy (26-30% better classification) but had only modest cross-validation accuracy (48-55% out of bag classification).

CONCLUSIONS

UL clinical measures were the most important predictors of the subsequent UL performance category in this exploratory analysis regardless of the machine learning algorithm used. Interestingly, cognitive and affective measures emerged as important predictors when the number of input variables was expanded. These results reinforce that UL performance, in vivo, is not a simple product of body functions nor the capacity for movement, instead being a complex phenomenon dependent on many physiological and psychological factors. Utilizing machine learning, this exploratory analysis is a productive step toward the prediction of UL performance. Trial registration NA.

Mediating Effect of Upper Limb Use on the Relationship Between Upper Limb Performance and Activities of Daily Living: A Longitudinal Mediation Analysis

INTRODUCTION

Upper limb performance, frequency of upper limb use, and psychological factors are associated with activities of daily living (ADLs) after stroke. We performed a mediation analysis to investigate how the frequency of upper limb use and some psychological factors mediate the relationship between upper limb performance and ADLs.

METHODS

Twenty-two patients with stroke were included in this longitudinal study. We utilized the frequency of upper limb use outcome measures (amount of use and quality of motion of the motor activity log), psychological factors outcome measures (General Self-Efficacy Scale), upper limb performance outcome measures (Fugl-Meyer Assessment (FMA)), and ADLs outcome measure (Functional Independence Measure (FIM) motor subscale (M)). Mediation analysis with a bootstrap sampling procedure was used to assess the indirect effects.

RESULTS

Mediation analysis showed that the FMA, as measured by the FIM (M), had significant indirect effects on the amount of use (95% bootstrapped confidence interval (CI): 0.36-2.42) and quality of motion (95% bootstrapped CI: 0.06-1.88). The relationship between upper limb performance and ADLs was mediated by the frequency of upper limb use.

CONCLUSION

Our findings suggest that improving the frequency of upper limb use may accelerate post-stroke recovery.

Perceived Facilitators and Barriers for Actual Arm Use during Everyday Activities in Community Dwelling Individuals with Chronic Stroke

BACKGROUND

Our aim was to gain a deeper understanding of perceived predictors for actual arm use during daily functional activities.

METHODS

Qualitative study. Semi-structured interview data collected from individuals with chronic stroke living in the community. Codebook thematic analysis used for the data analysis.

RESULTS

Six participants 5-18 years post stroke with moderate to severe UE impairment. Three domains were identified: Person, Context, and Task. Themes for the Person domain included mental (cognitive effort, lack of acceptance), behavioral (routines/habits, self-evaluation), and physical (stiffness/fatigue). Themes for the Context domain included social environment (being in public, presence, and actions of others) and time constraints (being in a hurry). Themes for the task domain included necessity to complete bilateral and unilateral tasks, and safety (increased risk of accidents).

CONCLUSION

Actual arm use is a complex construct related to the characteristics of the person, contextual environment, and the nature of the task. Facilitators included cognitive effort, routines/habits, self-evaluation, and the perceived necessity. Barriers included in lack of acceptance, stiffness/fatigue, being in public, being in a hurry, and risk of ac-cidents. Social support was both a facilitator and a barrier. Our results support the growing call to adopt a broader biopsychosocial framework into rehabilitation delivery.

Upper extremity self-efficacy correlates with daily hand-use of individuals with high functional capacity post-stroke

PURPOSE

To understand the role of affected upper extremity (UE) self-efficacy for explaining daily-hand-use in individuals post-stroke. Specifically, to describe UE self-efficacy and to assess the associations between UE self-efficacy to UE motor and functional capacity and daily hand-use.

MATERIALS AND METHODS

This cross-sectional study included individuals post-stroke receiving rehabilitation with high UE functional capacity [Action Research Arm Test (ARAT) > 50]. The Rating of Everyday Arm-Use in the Community and Home (REACH) assessed perceived UE daily use and the Confidence in Arm and Hand Movement scale (CAHM) assessed UE self-efficacy. Functional capacity was assessed by the ARAT and the Fugl-Meyer-motor-assessment assessed motor impairment. Correlations between measures were assessed.

RESULTS

Twenty-two individuals, aged 19-80, with high UE functional capacity [median (IQR) ARAT-56.5 (54-57)] and varying UE self-efficacy [median (IQR) CAHM-76.7 (58-84.4)], were included. UE self-efficacy was significantly correlated with the ARAT (r_s = 0.53, p < 0.01) and REACH (r_s = 0.51, p < 0.01) but ARAT was not significantly correlated with REACH.

CONCLUSIONS

UE self-efficacy is correlated with perceived daily hand-use in individuals with high functional capacity. Further research and a deeper understanding of the clinical implications of UE self-efficacy are warranted. UE self-efficacy should perhaps be assessed during rehabilitation. IMPLICATIONS FOR REHABILITATIONIndividuals with stroke with high affected upper extremity functional capacity do not necessarily use this hand for daily living.Upper extremity self-efficacy is correlated with perceived daily hand-use in individuals with high functional capacity; participants with higher upper extremity self-efficacy also reported more daily hand-use.Upper extremity self-efficacy seems to be upper extremity task or situation-specific.Upper extremity self-efficacy should be assessed during rehabilitation and the clinical implications of (low) upper extremity self-efficacy should be further researched.

Changes in upper limb capacity and performance in the early and late subacute phase after stroke

BACKGROUND

The course of spontaneous biological recovery indicates that no essential improvements in upper limb (UL) capacity should be expected 3 months after stroke. Likewise, UL performance as assessed with accelerometers does not seem to increase. However, this plateau may not apply to all patients with stroke.

OBJECTIVES

This study aimed to investigate the changes in UL capacity and performance from 3 to 6 months post-stroke, and the association between patients' UL capacity and actual UL performance.

METHODS

This study was a secondary analysis of a prospective longitudinal cohort study. Patients with UL impairment and first or recurrent stroke were included. Their UL capacity was assessed at 3 and 6 months with the Action Research Arm Test (ARAT) and UL performance was examined with accelerometry and expressed as a use ratio. The association between ARAT and use ratio was examined with multiple regression analyses.

RESULTS

Data from 67 patients were analyzed. It was shown that UL capacity as assessed with ARAT still improved from 3 to 6 months. A clinically meaningful improvement (≥ 6 points on ARAT) was found in 16 (46%) of the 35 patients whose scores allowed for such an increase. Improvements were mainly observed for patients with ARAT scores in the range of 15-51 at 3 months. Conversely, UL performance did not change. Three and 6 months after stroke respectively 69% and 64% of the variation in use ratio was explained by ARAT.

CONCLUSION

While a substantial part of patients improved their UL capacity, UL performance did not change from 3 to 6 months post-stroke. Strategies to remind patients of including their affected UL may encourage the transfer from better capacity to increased performance.

Relationship Between Body-Specific Attention to a Paretic Limb and Real-World Arm Use in Stroke Patients: A Longitudinal Study

Learned nonuse is a major problem in upper limb (UL) rehabilitation after stroke. Among the various factors that contribute to learned nonuse, recent studies have focused on body representation of the paretic limb in the brain. We previously developed a method to measure body-specific attention, as a marker of body representation of the paretic limb and revealed a decline in body-specific attention to the paretic limb in chronic stroke patients by a cross-sectional study. However, longitudinal changes in body-specific attention and paretic arm use in daily life (real-world arm use) from the onset to the chronic phase, and their relationship, remain unknown. Here, in a longitudinal, prospective, observational study, we sought to elucidate the longitudinal changes in body-specific attention to the paretic limb and real-world arm use, and their relationship, by using accelerometers and psychophysical methods, respectively, in 25 patients with subacute stroke. Measurements were taken at baseline (TBL), 2 weeks (T2w), 1 month (T1M), 2 months (T2M), and 6 months (T6M) after enrollment. UL function was measured using the Fugl-Meyer Assessment (FMA) and Action Research Arm Test (ARAT). Real-world arm use was measured using accelerometers on both wrists. Body-specific attention was measured using a visual detection task. The UL function and real-world arm use improved up to T6M. Longitudinal changes in body-specific attention were most remarkable at T1M. Changes in body-specific attention up to T1M correlated positively with changes in real-world arm use up to T6M, and from T1M to T6M, and the latter more strongly correlated with changes in real-world arm use. Changes in real-world arm use up to T2M correlated positively with changes in FMA up to T2M and T6M. No correlation was found between body-specific attention and FMA scores. Thus, these results suggest that improved body-specific attention to the paretic limb during the early phase contributes to increasing long-term real-world arm use and that increased real-world use is associated with the recovery of UL function. Our results may contribute to the development of rehabilitation strategies to enhance adaptive changes in body representation in the brain and increase real-world arm use after stroke.

Role of Self-efficacy in the Predictive Relationship of Motor Ability to Functional Performance After Task-Related Training in Stroke: A Secondary Analysis of Longitudinal Data

OBJECTIVE

To determine whether self-efficacy (SE) mediates or moderates the relationship between motor ability at pretest and functional use of the affected arm at posttest in task-related training for stroke.

DESIGN

Retrospective, observational cohort study.

SETTING

Outpatient rehabilitation settings.

PARTICIPANTS

Eighty patients with chronic stroke (N=80).

INTERVENTIONS

The training was delivered to the participants for 60-90 min/session, 3-5 sessions/wk for 4-6 weeks. The training involved specific robot-assisted, mirror, or combined therapy, followed by functional task practice for approximately 30 minutes in each session.

MAIN OUTCOME MEASURES

The outcome measure was the perceived amount of functional arm use and quality of movement evaluated by the Motor Activity Log (MAL) at posttest. The predictor was scores on the Fugl-Meyer Assessment (FMA)-Upper Extremity subscale at pretest. The tested mediator and moderator were scores on the Stroke Self-Efficacy Questionnaire (SSEQ) at pretest and posttest.

RESULTS

The SSEQ scores at pretest and posttest moderated the predictive relationship of pretest FMA to posttest MAL. The interaction between pretest FMA and SSEQ accounted for an additional 3.14%-5.37% of the variance in the posttest MAL. The predictive relationship between FMA and MAL was its greatest when the SSEQ was high, with a less amplified positive relationship at low levels of SSEQ.

CONCLUSIONS

The results suggest the evaluation of SE at pretest for a better prediction of an individual patient's functional arm use after an intervention and recommend aiming at SE during training to make the most of motor ability transferred to functional use. Future research may compare the effectiveness of task-related training with and without SE building to verify the findings of this study.

Sensor-based categorization of upper limb performance in daily life of persons with and without neurological upper limb deficits

Background: The use of wearable sensor technology (e. g., accelerometers) for tracking human physical activity have allowed for measurement of actual activity performance of the upper limb (UL) in daily life. Data extracted from accelerometers can be used to quantify multiple variables measuring different aspects of UL performance in one or both limbs. A limitation is that several variables are needed to understand the complexity of UL performance in daily life.

Purpose: To identify categories of UL performance in daily life in adults with and without neurological UL deficits.

Methods: This study analyzed data extracted from bimanual, wrist-worn triaxial accelerometers from adults from three previous cohorts (N = 211), two samples of persons with stroke and one sample from neurologically intact adult controls. Data used in these analyses were UL performance variables calculated from accelerometer data, associated clinical measures, and participant characteristics. A total of twelve cluster solutions (3-, 4-, or 5-clusters based with 12, 9, 7, or 5 input variables) were calculated to systematically evaluate the most parsimonious solution. Quality metrics and principal component analysis of each solution were calculated to arrive at a locally-optimal solution with respect to number of input variables and number of clusters.

Results: Across different numbers of input variables, two principal components consistently explained the most variance. Across the models with differing numbers of UL input performance variables, a 5-cluster solution explained the most overall total variance (79%) and had the best model-fit.

Conclusion: The present study identified 5 categories of UL performance formed from 5 UL performance variables in cohorts with and without neurological UL deficits. Further validation of both the number of UL performance variables and categories will be required on a larger, more heterogeneous sample. Following validation, these categories may be used as outcomes in UL stroke research and implemented into rehabilitation clinical practice.

The Impact of Home-Based Exercise Rehabilitation on Functional Capacity in Patients With Acute Ischemic Stroke: A Randomized Controlled Trial

One of the major consequences of stroke impairments is hemiparesis, which affects activities of daily living and contributes sedentary lifestyle. The purpose of this study was evaluation of the effectiveness of home-based exercise rehabilitation incentive on daily living activities and functional capacity among acute ischemic patients. This randomized controlled trial was done from August 2017 to September 2018. Iranian subjects with unilateral ischemic stroke were recruited from inpatient wards at educational hospital. Patients were randomly assigned to the home-based rehabilitation program (intervention group) or usual care (control group). National Institute of Health Stroke Scale (NIHSS), Barthel Index Score (BI), Modified Rankin Scale (MRS), and Fugl-Meyer Upper and Lower Extremity Sensorimotor Score were evaluated in both groups at baseline and 3 months later. Intervention group received home-based rehabilitation exercise program for 3 months. Control group did not receive home-based rehabilitation program and incentive telephone call. All data were collected and analyzed by SPSS software (Version 20.0; SPSS Inc., Chicago, Illinois) using chi-square test to compare demographic variables, and independent and paired t-tests to between- and within-group assessment, respectively. Forty ischemic stroke patients (20 intervention group and 20 control group) were examined. Results showed BI, Fugl-Meyer Upper and Lower Extremity Score, and MRS score in the interventional group were significantly higher than the control group after 3-month home-based exercise rehabilitation ( p < .001). Providing a home rehabilitation program in this study resulted in a motor recovery on ischemic stroke survivors in the acute phase of recovery. This was assumed to be cost-effective intervention in low-income countries

Upper Limb Performance in Daily Life Improves Over the First 12 Weeks Poststroke

Background. Upper limb (UL) performance, or use, in daily life is complex and likely influenced by many factors. While the recovery trajectory of UL impairment poststroke is well documented, little is known about the recovery trajectory of sensor-measured UL performance in daily life early after stroke and the potential moderating role of psychosocial factors. Objective. To examine the recovery trajectory of UL performance within the first 12 weeks poststroke and characterize the potential moderating role of belief, confidence, and motivation on UL performance. Methods. This was a longitudinal, prospective cohort study quantifying UL performance and related psychosocial factors early after stroke. UL performance was quantified via bilateral, wrist-worn accelerometers over 5 assessment sessions for 24 hours. Belief, confidence, and motivation to use the paretic UL, and self-perceived barriers to UL recovery were quantified via survey. Change in 4 accelerometer variables and the moderating role of psychosocial factors was tested using hierarchical linear modeling. The relationship between self-perceived barriers and UL performance was tested via Spearman rank-order correlation analysis. Results. UL performance improved over the first 12 weeks after stroke. Belief, confidence, and motivation did not moderate UL performance over time. There was a negative relationship between UL performance and self-perceived barriers to UL recovery at week 2, which declined over time. Conclusions. Sensor-measured UL performance can improve early after stroke. Early after stroke, rehabilitation interventions may not need to directly target belief, confidence, and motivation but may instead focus on reducing self-perceived barriers to UL recovery.