Ryan R. Bailey

Assessment of upper extremity impairment, function, and activity after stroke: Foundations for clinical decision making

The purpose of this review is to provide a comprehensive approach for assessing the upper extremity (UE) after stroke. First, common UE impairments and how to assess them are briefly discussed. Although multiple UE impairments are typically present after stroke, the severity of ones impairment, paresis, is the primary determinant of UE functional loss. Second, UE function is operationally defined and a number of clinical measures are discussed. It is important to consider how impairment and loss of function affect UE activity outside of the clinical environment. Thus, this review also identifies accelerometry as an objective method for assessing UE activity in daily life. Finally, the role that each of these levels of assessment should play in clinical decision making is discussed to optimize the provision of stroke rehabilitation services.

Effect of Upper Extremity Nerve Damage on Activity Participation, Pain, Depression, and Quality of Life

PURPOSE To explore the relationship between upper extremity nerve damage and activity participation, pain, depression, and perceived quality of life. METHODS A total of 49 patients with upper extremity nerve damage completed standardized measures of activity participation, pain, depression, and quality of life. We analyzed scores for all subjects and for 2 diagnostic groups: patients with compressive neuropathy and patients with nerve injury (laceration, tumor, and brachial plexus injury), and explored predictors of overall quality of life. RESULTS Participants had given up 21% of their previous daily activities; greater activity loss was reported in patients with nerve injury. Pain was moderate and 39% had signs of clinical depression. Physical and psychological quality of life ratings were below the norms. Activity loss was strongly associated with higher levels of depression and lower physical and psychological quality of life. Higher depression scores correlated strongly with lower overall quality of life. Greater pain correlated moderately with higher depression scores and weakly with quality of life; no statistical relationship was found between pain and physical quality of life. Activity participation and depression predicted 61% of the variance in overall quality of life in patients with nerve damage. CONCLUSIONS The results of this study suggest that hand surgeons and therapists caring for patients with nerve compression and nerve injury should discuss strategies to improve activity participation, and decrease pain and depression, to improve overall effect on quality of life throughout the recovery process. Depression screening and referral when indicated should be included in the overall treatment plan for patients with upper extremity nerve damage. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.

Quantifying Real-World Upper-Limb Activity in Nondisabled Adults and Adults With Chronic Stroke

Background. Motor capability is commonly assessed inside the clinic, but motor performance in real-world settings (ie, outside of the clinic) is seldom assessed because measurement tools are lacking. Objective. To quantify real-world bilateral upper-limb (UL) activity in nondisabled adults and adults with stroke using a recently developed accelerometry-based methodology. Methods. Nondisabled adults (n = 74) and adults with chronic stroke (n = 48) wore accelerometers on both wrists for 25 to 26 hours. Motor capability was assessed using the Action Research Arm Test (ARAT). Accelerometry-derived variables were calculated to quantify intensity of bilateral UL activity (ie, bilateral magnitude) and the contribution of both ULs to activity (magnitude ratio) for each second of activity. Density plots were used to examine each second of bilateral UL activity throughout the day. Results. Nondisabled adults demonstrated equivalent use of dominant and nondominant ULs, indicated by symmetrical density plots and a median magnitude ratio of −0.1 (interquartile range [IQR] = 0.3), where a value of 0 indicates equal activity between ULs. Bilateral UL activity intensity was lower (P < .001) and more lateralized in adults with stroke, as indicated by asymmetrical density plots and a lower median magnitude ratio (−2.2; IQR = 6.2, P < .001). Density plots were similar between many stroke participants who had different ARAT scores, indicating that real-world bilateral UL activity was similar despite different motor capabilities. Conclusions. Quantification and visualization of real-world bilateral UL activity can be accomplished using this novel accelerometry-based methodology and complements results obtained from clinical tests of function when assessing recovery of UL activity following neurological injury.

An accelerometry-based methodology for assessment of real-world bilateral upper extremity activity.

Background The use of both upper extremities (UE) is necessary for the completion of many everyday tasks. Few clinical assessments measure the abilities of the UEs to work together; rather, they assess unilateral function and compare it between affected and unaffected UEs. Furthermore, clinical assessments are unable to measure function that occurs in the real-world, outside the clinic. This study examines the validity of an innovative approach to assess real-world bilateral UE activity using accelerometry. Methods Seventy-four neurologically intact adults completed ten tasks (donning/doffing shoes, grooming, stacking boxes, cutting playdough, folding towels, writing, unilateral sorting, bilateral sorting, unilateral typing, and bilateral typing) while wearing accelerometers on both wrists. Two variables, the Bilateral Magnitude and Magnitude Ratio, were derived from accelerometry data to distinguish between high- and low-intensity tasks, and between bilateral and unilateral tasks. Estimated energy expenditure and time spent in simultaneous UE activity for each task were also calculated. Results The Bilateral Magnitude distinguished between high- and low-intensity tasks, and the Magnitude Ratio distinguished between unilateral and bilateral UE tasks. The Bilateral Magnitude was strongly correlated with estimated energy expenditure (ρ = 0.74, p<0.02), and the Magnitude Ratio was strongly correlated with time spent in simultaneous UE activity (ρ = 0.93, p<0.01) across tasks. Conclusions These results demonstrate face validity and construct validity of this methodology to quantify bilateral UE activity during the performance of everyday tasks performed in a laboratory setting, and can now be used to assess bilateral UE activity in real-world environments.

Upper-limb activity in adults: Referent values using accelerometry

The goal of physical rehabilitation following upper-limb (UL) impairment is functional restoration of the UL for use in daily activities. Because capacity for UL function may not translate into real-world activity, it is important that assessment of real-world UL activity be used in conjunction with clinical measures of capacity. Accelerometry can be used to quantify duration of UL activity outside of the clinic. The purpose of this study was to characterize hours of UL activity and potential modifying factors of UL activity (sedentary activity, cognitive impairment, depressive symptomatology, additive effects of comorbidities, cohabitation status, and age). Seventy-four community-dwelling adults wore accelerometers on bilateral wrists for 25 h and provided information on modifying factors. Mean time of dominant UL activity was 9.1 +/- 1.9 h, and the ratio of activity between the nondominant and dominant ULs was 0.95 +/- 0.06 h. Decreased hours of dominant UL activity was associated with increased time spent in sedentary activity. No other factors were associated with hours of dominant UL activity. These data can be used to help clinicians establish outcome goals for patients given preimpairment level of sedentary activity and to track progress during rehabilitation of the ULs.

Validity of body-worn sensor acceleration metrics to index upper extremity function in hemiparetic stroke.

Background and Purpose: Accelerometers have been used to capture real-world use of the paretic upper extremity in people with stroke. It may be possible to characterize different aspects of the recorded acceleration to gain insight about movement capabilities during task-specific behavior. These measures may be of value for guiding rehabilitation. We undertook a study to identify the acceleration characteristics that have a stable association with upper extremity function and sensitivity to within-participant fluctuations in function over multiple sessions of task-specific training. Methods: Twenty-seven adults 6 months or more poststroke with upper extremity paresis participated. Signals from wrist-worn accelerometers were sampled at 30 Hz during 7 sessions of task-specific training. Paretic upper extremity function was evaluated with the Action Research Arm Test. We used Spearman correlations to examine within-session associations between acceleration metrics and Action Research Arm Test performance. A mixed model was used to determine which metrics were sensitive to within-participant fluctuations in upper extremity function across the 7 training sessions. Results: Upper extremity function correlated with bilateral acceleration variability and use ratio during 5 and 6 sessions, respectively. Time accelerating between 76% and 100% of peak acceleration correlated with function in 6 sessions. Variability of the paretic upper extremity acceleration and the ratio of acceleration variability between upper extremities were associated with function during all 7 sessions. Variability in both the acceleration of the paretic upper extremity, and acceleration of the paretic and nonparetic extremities combined were sensitive to within-participant fluctuations in function across training sessions. Discussion and Conclusions: Multiple features of the acceleration profile track with upper extremity function within and across sessions of task-specific training. It may be possible to monitor these features with accelerometers to index upper extremity function outside of clinical settings. Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A91).

Real-world affected upper limb activity in chronic stroke: an examination of potential modifying factors

Abstract Background: Despite improvement in motor function after intervention, adults with chronic stroke experience disability in everyday activity. Factors other than motor function may influence affected upper limb (UL) activity. Objective: To characterize affected UL activity and examine potential modifying factors of affected UL activity in community-dwelling adults with chronic stroke. Methods: Forty-six adults with chronic stroke wore accelerometers on both ULs for 25 hours and provided information about potential modifying factors [time spent in sedentary activity, cognitive impairment, depressive symptomatology, number of comorbidities, motor dysfunction of the affected UL, age, activities of daily living (ADL) status, and living arrangement]. Accelerometry was used to quantify duration of affected and unaffected UL activity. The ratio of affected-to-unaffected UL activity was also calculated. Associations within and between accelerometry-derived variables and potential modifying factors were examined. Results: Mean hours of affected and unaffected UL activity were 5.0 ± 2.2 and 7.6 ± 2.1 hours respectively. The ratio of affected-to-unaffected UL activity was 0.64 ± 0.19, and hours of affected and unaffected UL activity were strongly correlated (r = 0.78). Increased severity of motor dysfunction and dependence in ADLs were associated with decreased affected UL activity. No other factors were associated with affected UL activity. Conclusions: Severity of motor dysfunction and ADL status should be taken into consideration when setting goals for UL activity in people with chronic stroke. Given the strong, positive correlation between affected and unaffected UL activity, encouragement to increase activity of the unaffected UL may increase affected UL activity.

Does Task-Specific Training Improve Upper Limb Performance in Daily Life Poststroke?

Background. A common assumption is that changes in upper limb (UL) capacity, or what an individual is capable of doing, translates to improved UL performance in daily life, or what an individual actually does. This assumption should be explicitly tested for individuals with UL paresis poststroke. Objective. To examine changes in UL performance after an intensive, individualized, progressive, task-specific UL intervention for individuals at least 6 months poststroke. Methods. Secondary analysis on 78 individuals with UL paresis who participated in a phase II, single-blind, randomized parallel dose-response trial. Participants were enrolled in a task-specific intervention for 8 weeks. Participants were randomized into 1 of 4 treatment groups with each group completing different amounts of UL movement practice. UL performance was assessed with bilateral, wrist-worn accelerometers once a week for 24 hours throughout the duration of the study. The 6 accelerometer variables were tested for change and the influence of potential modifiers using hierarchical linear modeling. Results. No changes in UL performance were found on any of the 6 accelerometer variables used to quantify UL performance. Neither changes in UL capacity nor the overall amount of movement practice influenced changes in UL performance. Stroke chronicity, baseline UL capacity, concordance, and ADL status significantly increased the baseline starting points but did not influence the rate of change (slopes) for participants. Conclusions. Improved motor capacity resulting from an intensive outpatient UL intervention does not appear to translate to increased UL performance outside the clinic.

Changes in Upper-Extremity Functional Capacity and Daily Performance During Outpatient Occupational Therapy for People With Stroke

OBJECTIVE This study explored how upper-extremity (UE) functional capacity and daily performance change during the course of outpatient rehabilitation in people with stroke. METHOD Fifteen participants receiving outpatient occupational therapy services for UE paresis poststroke were enrolled. UE motor capacity was measured with the Action Research Arm Test (ARAT), and UE performance was measured using bilateral, wrist-worn accelerometers. Measurements were taken at or near the start of therapy, at every 10th visit or every 30 days throughout the duration of services, and at discharge. RESULTS Three patterns were observed: (1) increase in ARAT scores and more normalized accelerometry profiles, (2) increase in ARAT scores but no change in accelerometry profiles, and (3) no change in ARAT scores or in accelerometry profiles. CONCLUSION UE performance in daily life was highly variable, with inconsistencies between change in UE capacity and change in UE performance. UE capacity and performance are important constructs to assess separately during rehabilitation.

The Association Between Handgrip Strength and Diabetes on Activities of Daily Living Disability in Older Mexican Americans

Objective: The aim of this study is to determine the independent and joint effects of muscle weakness and diabetes on incident activities of daily living (ADL) disability in older Mexican Americans. Method: A subsample of 2,270 Mexican Americans aged at least 65 years at baseline were followed for 19 years. Handgrip strength was normalized to body weight (normalized grip strength [NGS]). Weakness was defined as NGS ≤0.46 in males and ≤0.30 in females. Diabetes and ADL disability were self-reported. Results: Compared with participants that were not weak and did not have diabetes, those that had diabetes only, were weak only, and were both weak and had diabetes experienced a 1.94 (95% confidence interval [CI] = [1.89, 1.98]), 1.17 (CI = [1.16, 1.19]), and 2.12 (CI = [2.08, 2.16]) higher rate for ADL disability, respectively. Discussion: Muscle weakness and diabetes were independently and jointly associated with higher rates for ADL disability in older Mexican Americans.