Background Motor capability is commonly assessed inside the clinic, but motor performance in real-world settings (i.e. 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 25-26 hours. Motor capability was assessed using the Action Research Arm Test (ARAT). Accelerometry-derived variables were calculated to quantify intensity of bilateral UL activity (i.e. 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: 0.3) where a value of 0 indicates equal activity between ULs. Bilateral UL activity intensity was lower (p<0.001) and more lateralized in adults with stroke as indicated by asymmetrical density plots and a lower median Magnitude Ratio (-2.2, Interquartile Range: 6.2, p<0.001). 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 neurologic injury.

The purpose of this review is to provide a comprehensive approach for assessing the upper extremity (UE) after stroke. First, common upper extremity impairments and how to assess them are briefly discussed. While multiple UE impairments are typically present after stroke, the severity of one 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 in order to optimize the provision of stroke rehabilitation services.

BackgroundThe 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.MethodsSeventy-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.ResultsThe 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.ConclusionsThese 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.

The goal of physical rehabilitation following upper extremity (UE) impairment is functional restoration of the UE for use in daily activities. Because capacity for UE function may not translate into real-world activity, it is important that assessment of real-world UE activity be used in conjunction with clinical measures of capacity. Accelerometry can be used to quantify duration of UE activity outside of the clinic. The purpose of this study was to characterize hours of UE activity and potential modifying factors of UE 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 hours and provided information on modifying factors. Mean hours of dominant UE activity was 9.1 ± 1.9 hours and the ratio of activity between the non-dominant and dominant UEs was 0.95 ± 0.06. Decreased hours of dominant UE activity was associated with increased time spent in sedentary activity. No other factors were associated with hours of dominant UE activity. These data can be used to help clinicians establish outcome goals for patients, given pre-impairment level of sedentary activity, and to track progress during rehabilitation of the UEs.

Background A common assumption is that changes in upper limb (UL) capacity, or what an individual is capable of doing, translate to improved UL performance in daily life, or what an individual actually does. This assumption should be explicitly tested for individuals with UL paresis post-stroke. Objective To examine changes in UL performance after an intensive, individualized, progressive, task-specific UL intervention for individuals at least 6 months post-stroke. 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 six 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.

Health behavior change is challenging for most individuals, but there are many strategies that individuals can use to facilitate their behavior change efforts. Goal setting is one such strategy that assists individuals to identify specific behaviors to change and how to go about doing so. For many, however, simply setting a goal seldom leads to actual behavior change. For some, identifying an appropriate goal is difficult, while for others, putting goals into action is the roadblock. Two strategies may be of assistance for setting and achieving goals. First, consideration of key goal characteristics (eg, approach vs avoidance goals, performance vs mastery goals, level of difficulty) may result in selection of more appropriate and feasible goals. Second, action planning can help individuals put goals into action. Clinicians can help patients utilize these strategies to set and achieve goals for health behavior change.

Background and Purpose In people with stroke, real-world use of the paretic upper extremity influences function. Therefore, measures of real-world use are 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 post stroke with upper extremity paresis participated. Signals from wrist-worn accelerometers were sampled at 30 Hz during seven sessions of task-specific training. Paretic upper extremity function was evaluated with the Action Research Arm Test (ARAT). We used Spearman correlations to examine within-session associations between acceleration metrics and ARAT performance. A mixed model was used to determine which metrics were sensitive to within-participant fluctuations in upper extremity function across the seven training sessions. Results Upper extremity function correlated with bilateral acceleration variability and use ratio during five and six session, respectively. Time accelerating between 76-100% of peak acceleration correlated with function in six sessions. Variability of the paretic upper extremity acceleration and the ratio of acceleration variability between upper extremities were associated with function during all seven sessions. Variability in both the acceleration of the paretic upper extremity, and acceleration of the paretic and non-paretic extremities combined were sensitive to within-participant fluctuations in function across training sessions. Conclusion 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.

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