Margit Alt Murphy

Kinematic Variables Quantifying Upper-Extremity Performance After Stroke During Reaching and Drinking From a Glass

Background. Three-dimensional kinematic analysis provides quantitative and qualitative assessment of upper-limb motion and is used as an outcome measure to evaluate impaired movement after stroke. The number of kinematic variables used, however, is diverse, and models for upper-extremity motion analysis vary. Objective. The authors aim to identify a set of clinically useful and sensitive kinematic variables to quantify upper-extremity motor control during a purposeful daily activity, that is, drinking from a glass. Methods. For this purpose, 19 participants with chronic stroke and 19 healthy controls reached for a glass of water, took a sip, and placed it back on a table in a standardized way. An optoelectronic system captured 3-dimensional kinematics. Kinematical parameters describing movement time, velocity, strategy and smoothness, interjoint coordination, and compensatory movements were analyzed between groups. Results. The majority of kinematic variables showed significant differences between study groups. The number of movement units, total movement time, and peak angular velocity of elbow discriminated best between healthy participants and those with stroke as well as between those with moderate (Fugl-Meyer scores of 39-57) versus mild (Fugl-Meyer scores of 58-64) arm impairment. In addition, the measures of compensatory trunk and arm movements discriminated between those with moderate and mild stroke impairment. Conclusion. Kinematic analysis in this study identified a set of movement variables during a functional task that may serve as an objective assessment of upper-extremity motor performance in persons who can complete a task, such as reaching and drinking, after stroke.

Movement Kinematics During a Drinking Task Are Associated With the Activity Capacity Level After Stroke

Background. Kinematic analysis is a powerful method for an objective assessment of movements and is increasingly used as an outcome measure after stroke. Little is known about how the actual movement performance measured with kinematics is related to the common traditional assessment scales. The aim of this study was to determine the relationships between movement kinematics from a drinking task and the impairment or activity limitation level after stroke. Methods. Kinematic analysis of movement performance in a drinking task was used to measure movement time, smoothness, and angular velocity of elbow and trunk displacement (TD) in 30 individuals with stroke. Sensorimotor impairment was assessed with the Fugl-Meyer Assessment (FMA), activity capacity limitation with the Action Research Arm Test (ARAT), and self-perceived activity difficulties with the ABILHAND questionnaire. Results. Backward multiple regression revealed that the movement smoothness (similarly to movement time) and TD together explain 67% of the total variance in ARAT. Both variables uniquely contributed 37% and 11%, respectively. The TD alone explained 20% of the variance in the FMA, and movement smoothness explained 6% of the variance in the ABILHAND. Conclusions. The kinematic movement performance measures obtained during a drinking task are more strongly associated with activity capacity than with impairment. The movement smoothness and time, possibly together with compensatory movement of the trunk, are valid measures of activity capacity and can be considered as key variables in the evaluation of upper-extremity function after stroke. This increased knowledge is of great value for better interpretation and application of kinematic data in clinical studies.

An overview of systematic reviews on upper extremity outcome measures after stroke

BackgroundAlthough use of standardized and scientifically sound outcome measures is highly encouraged in clinical practice and research, there is still no clear recommendation on which tools should be preferred for upper extremity assessment after stroke. As the aims, objectives and methodology of the existing reviews of the upper extremity outcome measures can vary, there is a need to bring together the evidence from existing multiple reviews. The purpose of this review was to provide an overview of evidence of the psychometric properties and clinical utility of upper extremity outcome measures for use in stroke, by systematically evaluating and summarizing findings from systematic reviews.MethodsA comprehensive systematic search was performed including systematic reviews from 2004 to February 2014. A methodological quality appraisal of the reviews was performed using the AMSTAR-tool.ResultsFrom 13 included systematic reviews, 53 measures were identified of which 13 met the standardized criteria set for the psychometric properties. The strongest level of measurement quality and clinical utility was demonstrated for Fugl-Meyer Assessment, Action Research Arm Test, Box and Block Test, Chedoke Arm and Hand Activity Inventory, Wolf Motor Function Test and ABILHAND.ConclusionsThis overview of systematic reviews provides a comprehensive systematic synthesis of evidence on which outcome measures demonstrate a high level of measurement quality and clinical utility and which can be considered as most suitable for upper extremity assessment after stroke. This overview can provide a valuable resource to assist clinicians, researchers and policy makers in selection of appropriate outcome measures.

Responsiveness of upper extremity kinematic measures and clinical improvement during the first three months after stroke.

Background. Kinematic movement analysis is increasingly used as an outcome measure in evaluation of upper extremity function after stroke. Little is known, however, about what observed longitudinal changes in kinematics mean in the context of an individual’s functioning. In this study, the responsiveness and expected change in kinematic measures associated with clinically meaningful improvement in the upper extremity were evaluated. Methods. Kinematic movement analysis of a drinking task and Action Research Arm Test (ARAT) were performed early (9 days poststroke) and at 3 months after stroke in 51 subjects. The receiver-operating characteristic curve and linear regression analyses were used to evaluate responsiveness of kinematic parameters. Results. Movement time, smoothness, and trunk displacement discriminated those subjects demonstrating clinically meaningful improvements. Significant associations of 31% to 36% were found between the change in ARAT and kinematic measures. A real clinical improvement in kinematics lies in the range of 2.5 to 5 seconds, 3 to 7 units, and 2 to 5 cm in movement time, smoothness, and trunk displacement, respectively. Conclusions. All kinematic measures reported in this study are responsive measures for capturing improvements in the upper extremity during the first 3 months after stroke. Approximate estimates for the expected change in kinematics associated with clinically meaningful improvement in upper extremity activity capacity illustrate the usefulness of the linear regression analysis for assessing responsiveness. This knowledge facilitates the selection of kinematic measures for clinical and movement analysis research as well as for technology-based devices.

SALGOT - Stroke Arm Longitudinal study at the University of Gothenburg, prospective cohort study protocol

BackgroundRecovery patterns of upper extremity motor function have been described in several longitudinal studies, but most of these studies have had selected samples, short follow up times or insufficient outcomes on motor function. The general understanding is that improvements in upper extremity occur mainly during the first month after the stroke incident and little if any, significant recovery can be gained after 3-6 months. The purpose of this study is to describe the recovery of upper extremity function longitudinally in a non-selected sample initially admitted to a stroke unit with first ever stroke, living in Gothenburg urban area.Methods/DesignA sample of 120 participants with a first-ever stroke and impaired upper extremity function will be consecutively included from an acute stroke unit and followed longitudinally for one year. Assessments are performed at eight occasions: at day 3 and 10, week 3, 4 and 6, month 3, 6 and 12 after onset of stroke. The primary clinical outcome measures are Action Research Arm Test and Fugl-Meyer Assessment for Upper Extremity. As additional measures, two new computer based objective methods with kinematic analysis of arm movements are used. The ABILHAND questionnaire of manual ability, Stroke Impact Scale, grip strength, spasticity, pain, passive range of motion and cognitive function will be assessed as well. At one year follow up, two patient reported outcomes, Impact on Participation and Autonomy and EuroQol Quality of Life Scale, will be added to cover the status of participation and aspects of health related quality of life.DiscussionThis study comprises a non-selected population with first ever stroke and impaired arm function. Measurements are performed both using traditional clinical assessments as well as computer based measurement systems providing objective kinematic data. The ICF classification of functioning, disability and health is used as framework for the selection of assessment measures. The study design with several repeated measurements on motor function will give us more confident information about the recovery patterns after stroke. This knowledge is essential both for optimizing rehabilitation planning as well as providing important information to the patient about the recovery perspectives.Trial registrationClinicalTrials.gov: NCT01115348

Kinematic analysis of the upper extremity after stroke – how far have we reached and what have we grasped?

Abstract Background: Consequences of stroke frequently comprise reduced movement ability of the upper extremity (UE) and subsequent long-term disability. Clinical scales are used to monitor and evaluate rehabilitation but are often insufficient, while technological advances in 3D motion capture provide detailed kinematics to more objectively quantify and interpret movement deficits. Objectives: To provide a comprehensive overview of research using kinematic movement analysis of the UE in individuals post-stroke with focus on objectives, methodology and findings while highlighting clinical implications and future directions. Major Findings: A literature search yielded 93 studies categorised into four groups: comparative (healthy, stroke, task condition), intervention (clinical trials), methodological and longitudinal. The majority of studies used optoelectronic systems, investigated discrete reaching and involved mainly individuals with moderate or mild stroke impairment in chronic stage. About 80% of the studies were published after year 2004. Speed-related variables were most frequently addressed followed by smoothness indicators, joint angles and trunk displacement. Movements in the hemiparetic side are generally slower, less smooth and show a compensatory movement pattern. Task specificity is crucial for kinematic outcomes. Tables summarising the main characteristics, objectives and results of all included studies are provided. Conclusions: There is still a lack of studies addressing reliability and responsiveness and involving more complex, everyday UE tasks with ecological validity. To facilitate the use of UE kinematic movement analysis in clinics, a research-based simpler data handling with pre-defined output for the results, as commonly used in gait analysis, is warranted.

Early prediction of long-term upper limb spasticity after stroke Part of the SALGOT study

Objective: To identify predictors and the optimal time point for the early prediction of the presence and severity of spasticity in the upper limb 12 months poststroke. Methods: In total, 117 patients in the Gothenburg area who had experienced a stroke for the first time and with documented arm paresis day 3 poststroke were consecutively included. Assessments were made at admission and at 3 and 10 days, 4 weeks, and 12 months poststroke. Upper limb spasticity in elbow flexion/extension and wrist flexion/extension was assessed with the modified Ashworth Scale (MAS). Any spasticity was regarded as MAS ≥1, and severe spasticity was regarded as MAS ≥2 in any of the muscles. Sensorimotor function, sensation, pain, and joint range of motion in the upper limb were assessed with the Fugl-Meyer assessment scale, and, together with demographic and diagnostic information, were included in both univariate and multivariate logistic regression analysis models. Seventy-six patients were included in the logistic regression analysis. Results: Sensorimotor function was the most important predictor both for any and severe spasticity 12 months poststroke. In addition, spasticity 4 weeks poststroke was a significant predictor for severe spasticity. The best prediction model for any spasticity was observed 10 days poststroke (85% sensitivity, 90% specificity). The best prediction model for severe spasticity was observed 4 weeks poststroke (91% sensitivity, 92% specificity). Conclusions: Reduced sensorimotor function was the most important predictor both for any and severe spasticity, and spasticity could be predicted with high sensitivity and specificity 10 days poststroke.

Movement Kinematics of the Ipsilesional Upper Extremity in Persons With Moderate or Mild Stroke

Background. An increasing number of studies have indicated that the ipsilesional arm may be impaired after stroke. There is, however, a lack of knowledge whether ipsilesional deficits influence movement performance during purposeful daily tasks. Objective. The aim of this study was to investigate whether, and to what extent, movement impairments are present while performing an ipsilesional upper extremity task during the first 3 months after stroke. Methods. Movement kinematics describing movement time, smoothness, velocity, strategy, and pattern were captured during a standardized drinking task in 40 persons with first-ever stroke and 20 controls. Kinematics were measured early and at 3 months poststroke, and sensorimotor impairment was assessed with Fugl-Meyer Assessment in stroke. Results. Half of the ipsilesional kinematics showed significant deficits early after stroke compared to controls, and the stroke severity had a significant impact on the kinematics. Movements of the ipsilesional arm were slower, less smooth, demonstrated prolonged relative time in deceleration, and increased arm abduction during drinking. Kinematics improved over time and reached a level comparable with controls at 3 months, except for angular velocity of the elbow and deceleration time in reaching for those with more severe motor impairment. Conclusions. This study demonstrates that movements of the ipsilesional arm, during a purposeful daily task, are impaired after stroke. These deficits are more prominent early after stroke and when the motor impairment is more severe. In clinical studies and praxis, the use of less-affected arm as a reference may underestimate the level of impairment and extent of recovery.

Wearable sensors for clinical applications in epilepsy, Parkinson’s disease, and stroke: a mixed-methods systematic review

ObjectivesWearable technology is increasingly used to monitor neurological disorders. The purpose of this systematic review was to synthesize knowledge from quantitative and qualitative clinical researches using wearable sensors in epilepsy, Parkinson’s disease (PD), and stroke.MethodsA systematic literature search was conducted in PubMed and Scopus spanning from 1995 to January 2017. A synthesis of the main findings, reported adherence to wearables and missing data from quantitative studies, is provided. Clinimetric properties of measures derived from wearables in laboratory, free activities in hospital, and free-living environment were also evaluated. Qualitative thematic synthesis was conducted to explore user experiences and acceptance of wearables.ResultsIn total, 56 studies (50 reporting quantitative and 6 reporting qualitative data) were included for data extraction and synthesis. Among studies reporting quantitative data, 5 were in epilepsy, 21 PD, and 24 studies in stroke. In epilepsy, wearables are used to detect and differentiate seizures in hospital settings. In PD, the focus is on quantification of cardinal motor symptoms and medication-evoked adverse symptoms in both laboratory and free-living environment. In stroke upper extremity activity, walking and physical activity have been studied in laboratory and during free activities. Three analytic themes emerged from thematic synthesis of studies reporting qualitative data: acceptable integration in daily life, lack of confidence in technology, and the need to consider individualization.ConclusionsWearables may provide information of clinical features of interest in epilepsy, PD and stroke, but knowledge regarding the clinical utility for supporting clinical decision making remains to be established.

Upper extremity recovery after ischaemic and haemorrhagic stroke: Part of the SALGOT study:

Introduction The purpose was to explore if there are differences in extent of change in upper extremity motor function and activity capacity, in persons with ischaemic versus haemorrhagic stroke, during the first year post stroke. Patients and methods One hundred seventeen persons with stroke (ischaemic n = 98, haemorrhagic n = 19) and reduced upper extremity function 3 days after onset were consecutively included to the Stroke Arm Longitudinal Study at the University of Gothenburg (SALGOT) from a stroke unit. Upper extremity motor function (Fugl-Meyer Assessment Scale for Upper Extremity (FMA-UE)) and activity capacity (Action Research Arm Test (ARAT)) were assessed at 6 assessments during the first year; age and initial stroke severity were recorded. Differences between groups in extent of change over time of upper extremity motor function and activity capacity were analysed with mixed models repeated measurements method. Results Significant improvements were found in function and activity in both groups within the first month (p = 0.001). Higher age and more severe stroke had a negative impact on recovery in both groups. Larger improvements of function and activity were seen in haemorrhagic stroke compared to ischaemic, both from 3 days to 3- and 12 months, and from 1 month to 3 months. Both groups reached similar levels of function and activity at 3 months post stroke. Conclusion Although persons with haemorrhagic stroke had initially lower scores than those with ischaemic stroke, they had a larger improvement within the first 3 months, and thereafter both groups had similar function and activity.