Changes in actual arm-hand use in stroke patients during and after clinical rehabilitation involving a well-defined arm-hand rehabilitation program: A prospective cohort study

Clinician perceptions of a novel wearable robotic hand orthosis for post-stroke hemiparesis

PURPOSE

Wearable robotic devices are currently being developed to improve upper limb function for individuals with hemiparesis after stroke. Incorporating the views of clinicians during the development of new technologies can help ensure that end products meet clinical needs and can be adopted for patient care.

METHODS

In this cross-sectional mixed-methods study, an anonymous online survey was used to gather clinicians' perceptions of a wearable robotic hand orthosis for post-stroke hemiparesis. Participants were asked about their clinical experience and provided feedback on the prototype device after viewing a video.

RESULTS

154 participants completed the survey. Only 18.8% had previous experience with robotic technology. The majority of participants (64.9%) reported that they would use the device for both rehabilitative and assistive purposes. Participants perceived that the device could be used in supervised clinical settings with all phases of stroke. Participants also indicated a need for insurance coverage and quick setup time.

CONCLUSIONS

Engaging clinicians early in the design process can help guide the development of wearable robotic devices. Both rehabilitative and assistive functions are valued by clinicians and should be considered during device development. Future research is needed to understand a broader set of stakeholders' perspectives on utility and design.

Combining muscle-computer interface guided training with bihemispheric tDCS improves upper limb function in patients with chronic stroke

Transcranial direct current stimulation (tDCS) may facilitate neuroplasticity but with a limited effect when administered while patients with stroke are at rest. Muscle-computer interface (MCI) training is a promising approach for training patients with stroke even if they cannot produce overt movements. However, using tDCS to enhance MCI training has not been investigated. We combined bihemispheric tDCS with MCI training of the paretic wrist and examined the effect of this intervention in patients with chronic stroke. A crossover, double-blind, randomized trial was conducted. Twenty-six patients with chronic stroke performed MCI wrist training for three consecutive days at home while receiving either real tDCS or sham tDCS in counterbalanced order and separated by at least 8 mo. The primary outcome measure was the Fugl-Meyer Assessment Upper Extremity Scale (FMA-UE) that was measured 1 wk before training, on the first training day, on the last training day, and 1 wk after training. There was neither a significant difference in the baseline FMA-UE score between groups nor between intervention periods. Patients improved 3.9 ± 0.6 points in FMA-UE score when receiving real tDCS, and 1.0 ± 0.7 points when receiving sham tDCS (P = 0.003). In addition, patients also showed continuous improvement in their motor control of the MCI tasks over the training days. Our study showed that the training paradigm could lead to functional improvement in patients with chronic stroke. We argue that appropriate MCI training in combination with bihemispheric tDCS could be a useful adjuvant for neurorehabilitation in patients with stroke.NEW & NOTEWORTHY Bihemispheric tDCS combined with a novel MCI training for motor control of wrist extensor can improve upper limb function especially a training-specific effect on the wrist movement in patients with chronic stroke. The training regimen can be personalized with adjustments made daily to accommodate the functional change throughout the intervention. This demonstrates that bihemispheric tDCS with MCI training could complement conventional poststroke neurorehabilitation.

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.

The relationship between Rating of Everyday Arm-use in the Community and Home (REACH) scale affected arm-use assessment, activity and participation after stroke

BACKGROUND AND OBJECTIVES

While arm function has been traditionally used as a primary goal for upper extremity rehabilitation post-stroke, we propose a simple measure of arm use, which may translate into better activities and participation. The aim was to determine the relationship between arm use and measures of activity and participation.

METHODS

This was a cross-sectional study with evaluative components involving community-dwelling individuals with chronic stroke. The Rating of Everyday Arm-Use in the Community and Home (REACH) Scale was used to assess affected arm use, Barthel Index and activity domain of the Stroke Impact Scale (SIS) for activities, and participation domain of the SIS for participation. The participants were also asked if they resumed driving after the stroke.

RESULTS

Forty-nine individuals (mean age = 70.3 ± 11.5 years, male sex = 51%) living with the effects of a stroke for at least 3 months participated in this study. There was a positive relationship between affected arm use and activities (Barthel Index score - rs  = 0.464; SIS activities - rs  = 0.686), participation (rs  = 0.479), and driving (rs  = 0.581). The Barthel Index scores were higher for individuals with dominant arm hemiparesis (p = 0.003) or left hemisphere lesions (p = 0.005). There was also greater arm use in left hemisphere lesions (p = 0.018).

CONCLUSIONS

Affected arm use in individuals with chronic stroke is related to activities and participation. Given the importance of arm use in activities and participation after stroke, rehabilitation therapists may consider utilizing the REACH Scale, a simple and quick outcome measure, as a means to assess arm use and implement effective interventions for improving arm use.

Can specific virtual reality combined with conventional rehabilitation improve poststroke hand motor function? A randomized clinical trial

TRIAL OBJECTIVE

To verify whether conventional rehabilitation combined with specific virtual reality is more effective than conventional therapy alone in restoring hand motor function and muscle tone after stroke.

TRIAL DESIGN

This prospective single-blind randomized controlled trial compared conventional rehabilitation based on physiotherapy and occupational therapy (control group) with the combination of conventional rehabilitation and specific virtual reality technology (experimental group). Participants were allocated to these groups in a ratio of 1:1. The conventional rehabilitation therapists were blinded to the study, but neither the participants nor the therapist who applied the virtual reality-based therapy could be blinded to the intervention.

PARTICIPANTS

Forty-six patients (43 of whom completed the intervention period and follow-up evaluation) were recruited from the Neurology and Rehabilitation units of the Hospital General Universitario of Talavera de la Reina, Spain.

INTERVENTION

Each participant completed 15 treatment sessions lasting 150 min/session; the sessions took place five consecutive days/week over the course of three weeks. The experimental group received conventional upper-limb strength and motor training (100 min/session) combined with specific virtual reality technology devices (50 min/session); the control group received only conventional training (150 min/session).

RESULTS

As measured by the Ashworth Scale, a decrease in wrist muscle tone was observed in both groups (control and experimental), with a notably larger decrease in the experimental group (baseline mean/postintervention mean: 1.22/0.39; difference between baseline and follow-up: 0.78; 95% confidence interval: 0.38-1.18; effect size = 0.206). Fugl-Meyer Assessment scores were observed to increase in both groups, with a notably larger increase in the experimental group (total motor function: effect size = 0.300; mean: - 35.5; 95% confidence interval: - 38.9 to - 32.0; wrist: effect size = 0.290; mean: - 5.6; 95% confidence interval: - 6.4 to - 4.8; hand: effect size = 0.299; mean: - -8.9; 95% confidence interval: - 10.1 to - 7.6). On the Action Research Arm Test, the experimental group quadrupled its score after the combined intervention (effect size = 0.321; mean: - 32.8; 95% confidence interval: - 40.1 to - 25.5).

CONCLUSION

The outcomes of the study suggest that conventional rehabilitation combined with a specific virtual reality technology system can be more effective than conventional programs alone in improving hand motor function and voluntary movement and in normalizing muscle tone in subacute stroke patients. With combined treatment, hand and wrist functionality and motion increase; resistance to movement (spasticity) decreases and remains at a reduced level.

TRIALS REGISTRY

International Clinical Trials Registry Platform: ISRCTN27760662 (15/06/2020; retrospectively registered).

Effects of a remote-handling-concept-based task-oriented arm training (ReHab-TOAT) on arm-hand skill performance in chronic stroke: a study protocol for a two-armed randomized controlled trial

BACKGROUND

Improving arm-hand skill performance is a major therapeutic target in stroke rehabilitation and needs intensive and varied training. However, guided treatment time is limited. Technology can assist in the training of patients, offering a higher intensity and more variety in content. A new task-oriented arm training approach was developed, using a 'Remote Handling concept based' device to provide haptic feedback during the performance of daily living activities (ReHab-TOAT). This study aims to investigate the effects of ReHab-TOAT on patients' arm-hand function and arm-hand skill performance, quality of life of both patients in the chronic phase after stroke and their caregivers and the patients' perception regarding the usability of the intervention.

METHODS

A randomized clinical trial was designed. Adult chronic stroke patients suffering from hemiparesis and arm-hand problems, with an Utrechtse Arm-hand Test score of 1-3, will be invited to participate. Participants in the experimental group receive ReHab-TOAT additional to care as usual. ReHab-TOAT contains task-oriented arm training for stroke patients in combination with haptic feedback, generated by a remote handling device. They will train for 4 weeks, 3× per week, 1.5h per day. Participants in the control group will receive no additional therapy apart from care as usual. The Fugl-Meyer Assessment (FMA), measuring participants' motor performance of the affected arm, is used as the primary outcome measure. Secondary outcome measures are arm-hand capacity of the patient (ARAT), perceived arm-hand skill performance (MAL), actual arm-hand skill performance (accelerometry), patients' quality of life (EuoQol-5D) and caregivers' quality of life (CarerQoL). Participants' perception regarding the usability of the intervention, including both the developed approach and technology used, will be evaluated by the System Usability Scale and a questionnaire on the user experience of technology. Measurements will be performed at 1, 2, 3 and 4 weeks pre-intervention (baseline); immediately post-intervention; and 3, 6 and 9 months post-intervention. Statistical analysis includes linear mixed model analysis.

DISCUSSION

This study is designed to investigate the evidence regarding the effects of ReHab-TOAT on patients' performance at different levels of the International Classification of Functioning, disability and health (ICF) model, i.e. a framework measuring functioning and disability in relation to a health condition, and to provide insights on a successful development and research process regarding technology-assisted training in co-creation.

TRIAL REGISTRATION

Netherlands Trial Register NL9541. Registered on June 22, 2021.

Development and feasibility of first- and third-person motor imagery for people with stroke living in the community

BACKGROUND

Impairment of arm movement occurs in up to 85% of people post-stroke, affecting daily living activities, and quality of life. Mental imagery effectively enhances hand and daily function in people with stroke. Imagery can be performed when people imagine themselves completing the movement or imagine another person doing it. However, there is no report on the specific use of first-person and third-person imagery in stroke rehabilitation.

AIMS

To develop and assess the feasibility of the First-Person Mental Imagery (FPMI) and the Third-Person Mental Imagery (TPMI) programs to address the hand function of people with stroke living in the community.

METHODS

This study comprises phase 1-development of the FPMI and TPMI programs, and phase 2-pilot-testing of the intervention programs. The two programs were developed from existing literature and reviewed by an expert panel. Six participants with stroke, living in the community, participated in the pilot-testing of the FPMI and TPMI programs for 2 weeks. Feedback collected included the suitability of the eligibility criteria, therapist's and participant's adherence to intervention and instructions, appropriateness of the outcome measures, and completion of the intervention sessions within the specified time.

RESULTS

The FPMI and TPMI programs were developed based on previously established programs and included 12 hand tasks. The participants completed four 45-min sessions in 2 weeks. The treating therapist adhered to the program protocol and completed all the steps within the specified time frame. All hand tasks were suitable for adults with stroke. Participants followed the instructions given and engaged in imagery. The outcome measures selected were appropriate for the participants. Both programs showed a positive trend towards improvement in participants' upper extremity and hand function and self-perceived performance in activities of daily living.

CONCLUSIONS

The study provides preliminary evidence that these programs and outcome measures are feasible for implementation with adults with stroke living in the community. This study outlines a realistic plan for future trials in relation to participant recruitment, training of therapists on the intervention delivery, and the use of outcome measures.

TRIAL REGISTRATION

Title: Effectiveness of first-person and third-person motor imagery in relearning daily hand tasks for people with chronic stroke: a randomised controlled trial.

REGISTRATION NO

SLCTR/2017/031. Date registered: 22nd September 2017.

Essential Role of Social Context and Self-Efficacy in Daily Paretic Arm/Hand Use After Stroke: An Ecological Momentary Assessment Study With Accelerometry

OBJECTIVE

To determine the momentary effect of social-cognitive factors, in addition to motor capability, on post-stroke paretic arm/hand use in the natural environment.

DESIGN

A 5-day observational study in which participants were sent 6 Ecological Momentary Assessment (EMA) prompts/day.

SETTING

Participants' daily environment.

PARTICIPANTS

Community-dwelling, chronic stroke survivors with right-dominant, mild-moderate upper extremity paresis (N=30).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Time duration of bimanual and unimanual paretic arm/hand use indexed by accelerometry; social-cognitive factors (social context, self-efficacy, mood) captured by EMA; motor capability of the paretic limb measured by Fugl-Meyer Upper Extremity Motor Assessment (FM).

RESULTS

After accounting for participants' motor capability, we found that momentary social context (alone or not) and self-efficacy significantly predicted post-stroke paretic arm/hand use behavior in the natural environment. When participants were not alone, paretic arm/hand movement increased both with and without the less-paretic limb (bimanual and unimanual movements, P=.018 and P<.001, respectively). Importantly, participants were more likely to use their paretic arm/hand (unimanually) if they had greater self-efficacy for limb use (P=.042). EMA repeated-measures provide a real-time approach that captures the natural dynamic ebb and flow of social-cognitive factors and their effect on daily arm/hand use. We also observed that people with greater motor impairments (FM<50.6) increase unimanual paretic arm/hand movements when they are not alone, regardless of motor capability.

CONCLUSIONS

In addition to motor capability, stroke survivors' momentary social context and self-efficacy play a role in paretic arm/hand use behavior. Our findings suggest the development of personalized rehabilitative interventions which target these factors to promote daily paretic arm/hand use. This study highlights the benefits of EMA to provide real-time information to unravel the complexities of the biopsychosocial (ie, motor capability and social-cognitive factors) interface in post-stroke upper extremity recovery.

Task-oriented arm training for stroke patients based on remote handling technology concepts: A feasibility study

BACKGROUND

Improving arm-hand skill performance is a major therapeutic target in stroke rehabilitation. Arm-hand rehabilitation may be enriched in content and variation by using technology-assisted training. Especially for people with a severely affected arm, technology-assisted training offers more challenging training possibilities.

OBJECTIVE

The aim of this study was to explore the feasibility of ReHab-TOAT, a "Remote Handling Based Task-Oriented Arm Training" approach featuring enriched haptic feedback aimed at improving daily activities and participation.

METHODS

Five subacute or chronic stroke patients suffering moderate to severe arm-hand impairments and five rehabilitation therapists participated. All participants received 2 ReHab-TOAT sessions. Outcome measure was a bespoke feasibility questionnaire on user experiences and satisfaction regarding 'motivation', 'individualization of training', 'potential training effects', and 'implementation in rehabilitation' of patients and therapists.

RESULTS

Both patients and therapists experienced ReHab-TOAT as being feasible. They found ReHab-TOAT very motivating and challenging. All patients perceived an added value of ReHab-TOAT and would continue the training. Small improvements regarding exercise variability were suggested.

CONCLUSION

ReHab-TOAT seems to be a feasible and very promising training approach for arm-hand rehabilitation of stroke patients with a moderately or severely affected arm. Further research is necessary to investigate potential training effects of ReHab-TOAT.

[Modern view on upper limb physical rehabilitation after stroke. Literature review]

Stroke is the world's second leading cause of death and the first cause of disability among all diseases. The most common complication of a stroke is a violation of the motor function of the limbs, which significantly worsens the quality of life and the level of self-care and independence of patients. Restoring the function of the upper limb is one of the priority tasks of rehabilitation after a stroke. A large number of factors, such as the location and size of the primary brain lesion, the presence of complications in the form of spasticity, impaired skin and proprioceptive sensitivity, and comorbidities, determine the patient's rehabilitation potential and the prognosis of ongoing rehabilitation measures. Of particular note are the timing of the start of rehabilitation measures, the duration and regularity of the treatment methods. A number of authors propose scales for assessing the rehabilitation prognosis, as well as algorithms for compiling rehabilitation programs for restoring the function of the upper limb. A fairly large number of rehabilitation methods and their combinations have been proposed, including special methods of kinesitherapy, robotic mechanotherapy with biofeedback, the use of physiotherapeutic factors, manual and reflex effects, as well as ready-made programs that include sequential and combined use of various methods. Dozens of studies have been devoted to comparative analysis and evaluation of the effectiveness of these methods. The purpose of this work is to review current research on a given topic and draw up our own conclusion on the appropriateness of using and combining these methods at various stages of rehabilitation in stroke patients.

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.

Effectiveness of Intensively Applied Mirror Therapy in Older Patients with Post-Stroke Hemiplegia: A Preliminary Trial

INTRODUCTION

The present work was carried out to determine the effectiveness of neuromuscular stimulation triggered by mirror therapy (MT) in older patients with post-stroke hemiplegia by two different intervention protocols, either intensively or spaced.

METHODS

A preliminary trial conducted on Spanish rehabilitation centres was conducted. Forty older patients (>70 years) with diagnosed post-stroke hemiplegia were randomly distributed to intensive intervention group (5 times/week for 6 weeks) or to spaced intervention group (3 times/week for 10 weeks), which underwent a similar number of MT sessions (n = 30). Muscle strength and activity were measured at baseline and at the end of treatment. Functional ability was also evaluated.

RESULTS

Although both interventions improved muscle activity parameters, intensive MT showed a significantly and statistically higher intervention effect on electromyographic activity (p < 0.001) and muscle strength (p < 0.001) than the spaced over time protocol. Attending to the Barthel Index scores, the effect on functionality was also greater in the intensive therapy group (p < 0.001), although the functional improvement measured by the Fugl-Meyer test was similar (p = 0.235). The effect of the interventions was independent of age and clinical antecedents.

CONCLUSION

Intensive MT appears to be more effective than a more spaced over time therapy; therefore, at least in the older adults, this treatment protocol should be recommended in the post-stroke recovery of these patients. Further studies will confirm with certainty whether this treatment is the most suitable guideline for to treat these patients.

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.

Predictors of high dose of massed practice following stroke

Objective

The aim of this study is to determine the factors that affect patients' ability to carry out high dose of massed practice.

Methods

Patients with stroke were included in the study if they had no severe impairment in motor and cognitive functions. Dose of massed practice, motor function, perceived amount and quality of use of the arm in the real world, wrist and elbow flexors spasticity, dominant hand stroke, presence of shoulder pain, and central post-stroke pain were assessed on the first day. Dose of massed practice was assessed again on the second day. The data were analyzed using descriptive statistics and linear multiple regression.

Results

Only motor function (β = -0.310, r = 0.787, P < 0.001), perceived amount of use (β = 0.300, r = 0.823; 95% CI = 0.34-107.224, P = 0.049), severity of shoulder pain (β = -0.155, r = -0.472, P = 0.019), wrist flexors spasticity (β = -0.154, r = -0.421, P = 0.002), age (β = -0.129, r = -0.366, P = 0.018), dominant hand stroke (β = -0.091, r = -0.075, P = 0.041), and sex (β = -0.090, r = -0.161, P = 0.036) significantly influenced patients' ability to carry out high dose of massed practice.

Conclusion

Many factors affect patients' ability to carry out high dose of massed practice. Understanding these factors can help in designing appropriate rehabilitation.

Real-World Functional Grasping Activity in Individuals With Stroke and Healthy Controls Using a Novel Wearable Wrist Sensor

Background. While wrist-worn accelerometers have been used to measure upper extremity use in the past, they primarily measure arm motion and lack the ability to capture functional hand opening and grasping activities which are essential for activities of daily living. Objectives. To characterize real-world functional hand opening and grasping activities captured over multiple days in adults with stroke and in matched controls using a novel wrist-worn device. Methods. Twenty-eight individuals (fourteen individuals with stroke and 14 healthy controls) wore the devices on both wrists for 3 days. Functional hand activity was characterized by daily hand counts, hourly hand counts, and asymmetry between hands. The Mann-Whitney U test was used to evaluate differences in functional hand activities between the two groups. Results. The stroke group had 1480 and 4691 daily hand counts in their affected and nonaffected hands, respectively. The control group had 3559 and 5021 daily hand counts in their nondominant and dominant hands, respectively. Significantly fewer daily hand counts (P = .019), fewer hourly hand counts (P = .024), and a larger asymmetry index (P = .01) of the affected hand in the stroke group were found compared to that of the nondominant hand in the control group. Conclusions. Real-world functional upper extremity activity can be measured using this novel wrist-worn device. Unlike wrist-worn accelerometers, this wrist-worn device can provide a measurement of functional grasping activity. The findings have implications for clinicians and researchers to monitor and assess real-world hand activity, as well as to apply specific doses of repetitions to improve neural recovery after stroke.

Poststroke Grasp Ability Assessment using an Intelligent Data Glove based on Action Research Arm Test: Development, Algorithms, and Experiments

Growing impact of poststroke upper extremity (UE) functional limitations entails newer dimensions in assessment methodologies. This has compelled researchers to think way beyond traditional stroke assessment scales during the out-patient rehabilitation phase. In concurrence with this, sensor-driven quantitative evaluation of poststroke UE functional limitations has become a fertile field of research. Here, we have emphasized an instrumented wearable for systematic monitoring of stroke patients with right-hemiparesis for evaluating their grasp abilities deploying intelligent algorithms. An instrumented glove housing 6 flex sensors, 3 force sensors, and a motion processing unit was developed to administer 19 activities of Action Research Arm Test (ARAT) while experimenting on 20 voluntarily participating subjects. After necessary signal conditioning, meaningful features were extracted, and subsequently the most appropriate ones were selected using the ReliefF algorithm. An optimally tuned support vector classifier was employed to classify patients with different degrees of disability and an accuracy of 92% was achieved supported by a high area under the receiver operating characteristic score. Furthermore, selected features could provide additional information that revealed the causes of grasp limitations. This would assist physicians in planning more effective poststroke rehabilitation strategies. Results of the one-way ANOVA test conducted on actual and predicted ARAT scores of the subjects indicated remarkable prospects of the proposed glove-based method in poststroke grasp ability assessment and rehabilitation.

Prediction of Upper Limb use Three Months after Stroke: A Prospective Longitudinal Study

BACKGROUND

A major goal of upper limb (UL) rehabilitation after stroke is to facilitate the use of the paretic arm in daily life activities.

PURPOSE

To examine if UL impairment two weeks after stroke can predict real-life UL use at three months. Furthermore, to identify additional factors which contribute to future UL use, and characteristics of patients who do not achieve normal UL use.

METHODS

This study included patients with stroke ≥ 18 years. UL impairment was assessed by Fugl-Meyer upper extremity motor assessment (FM). Use ratio between affected and unaffected UL was assessed with accelerometers at three months after stroke. The association between FM score and UL use ratio was investigated with linear regression models and adjusted for secondary variables. Non-normal use was examined by a logistic regression.

RESULTS

Eighty-seven patients were included. FM score two weeks after stroke predicted 38% of the variance in UL use ratio three months after stroke. A multivariate regression model predicted 55%, and the significant predictors were FM, motor-evoked potential (MEP) status, and neglect. Non-normal use could be predicted with a high accuracy based on MEP and/or neglect. In a logistic regression sensitivity for prediction of non-normal use was 0.93 and specificity was 0.75.

CONCLUSION

Better baseline capacity of the paretic UL predicted increased use of the arm and hand in daily life. Non-normal UL use could be predicted reliably based on the absence of MEPs and/or presence of neglect.

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

Magnetically Counting Hand Movements: Validation of a Calibration-Free Algorithm and Application to Testing the Threshold Hypothesis of Real-World Hand Use after Stroke

There are few wearable sensors suitable for daily monitoring of wrist and finger movements for hand-related healthcare applications. Here, we describe the development and validation of a novel algorithm for magnetically counting hand movements. We implemented the algorithm on a wristband that senses magnetic field changes produced by movement of a magnetic ring worn on the finger (the “Manumeter”). The “HAND” (Hand Activity estimated by Nonlinear Detection) algorithm assigns a “HAND count” by thresholding the real-time change in magnetic field created by wrist and/or finger movement. We optimized thresholds to achieve a HAND count accuracy of ~85% without requiring subject-specific calibration. Then, we validated the algorithm in a dexterity-impaired population by showing that HAND counts strongly correlate with clinical assessments of upper extremity (UE) function after stroke. Finally, we used HAND counts to test a recent hypothesis in stroke rehabilitation that real-world UE hand use increases only for stroke survivors who achieve a threshold level of UE functional capability. For 29 stroke survivors, HAND counts measured at home did not increase until the participants’ Box and Blocks Test scores exceeded ~50% normal. These results show that a threshold-based magnetometry approach can non-obtrusively quantify hand movements without calibration and also verify a key concept of real-world hand use after stroke.

The probability of choosing both hands depends on an interaction between motor capacity and limb-specific control in chronic stroke

A goal of rehabilitation after stroke is to promote pre-stroke levels of arm use for every day, frequently bimanual, functional activities. We reasoned that, after a stroke, the choice to use one or both hands for bimanual tasks might depend not only on residual motor capacity, but also the specialized demands imposed by the task on the paretic hand. To capture spontaneous, task-specific choices, we covertly observed 50 pre-stroke right-handed chronic stroke survivors (25 each of left, LHD, and right-hemisphere damage, RHD) and 11 age-similar control adults and recorded their hand use strategies for two pairs of bimanual tasks with distinct demands: one with greater precision requirements (photo-album tasks), and another with greater stabilization requirements (letter-envelope tasks). The primary outcome was the choice to use one or both hands. Logistic regression was used to test the two hypotheses that the probability of choosing a bimanual strategy would be greater in those with less severe motor impairment and also in those with LHD. When collapsed across the four tasks, we found support for these hypotheses. Notably, however, the influence of these factors on bimanual choice varied based on task demands. For the photo-album pair, the probability of a bimanual strategy was greater for those with LHD compared to RHD, regardless of the degree of motor impairment. For the letter-envelope pair, we found a significant interaction between impairment and side of lesion in determining the likelihood of choosing both hands. Therefore, the manner in which side of lesion moderates the effect of impairment on hand use depends on the task.