A Novel Combination of Accelerometry and Ecological Momentary Assessment for Post-Stroke Paretic Arm/Hand Use: Feasibility and Validity

Abstract

Use of the paretic arm and hand is a key indicator of recovery and reintegration after stroke. A sound methodology is essential to comprehensively identify the possible factors impacting daily arm/hand use behavior. We combined ecological momentary assessment (EMA), a prompt methodology capturing real-time psycho-contextual factors, with accelerometry to investigate arm/hand behavior in the natural environment. Our aims were to determine (1) feasibility and (2) measurement validity of the combined methodology. We monitored 30 right-dominant, mild-moderately motor impaired chronic stroke survivors over 5 days (6 EMA prompts/day with accelerometers on each wrist). We observed high adherence for accelerometer wearing time (80.3%), EMA prompt response (84.6%), and generally positive user feedback upon exit interview. The customized prompt schedule and the self-triggered prompt option may have improved adherence. There was no evidence of EMA response bias nor immediate measurement reactivity. An unexpected small but significant increase in paretic arm/hand use was observed over days (12–14 min), which may be the accumulated effect of prompting that provided a reminder to choose the paretic limb. Further research that uses this combined methodology is needed to develop targeted interventions that effectively change behavior and enable reintegration post-stroke.

Virtuous and Vicious Cycles of Arm Use and Function Post-stroke

“…Mean change in the activity of the paretic limb estimated by the wearable system across participants with respect to day 1 across days of intervention in which patients received haptic feedback and arm activity reports (days 2–4), and immediately after (day 5). (E) Small but statistically significant increase in paretic arm use over 5 days in our second study with an EMA / accelerometer combination ( 27 ). Solid color circles: daily average duration of unimanual right (paretic) arm/hand movements.…”

“…We found that the simple act of probing about arm use produced a small but significant increase (~10 min) in paretic arm use over 5 days ( Figure 2E ). In the same study, an analysis of EMA responses along with the quantitative accelerometer data revealed that social context (i.e., not alone) and self-efficacy for paretic arm/hand use complement an individual's motor capability (i.e., FM score) and play essential roles in paretic arm/hand use behavior in the natural environment ( 45 , 48 ). Previous work from one of us showed that including social interaction in stroke VR-based motor rehabilitation enhances performance ( 49 ).…”

“…As predicted, spontaneous paretic hand use measured at home did not increase until the participants reached a certain level of function captured by a standardized clinical scale of motor dexterity (i.e., Box and Blocks Test). Recently, Chen et al ( 27 ) monitored in the wild paretic limb use both alone (unimanual) and with the less affected limb (bimanual) over 5 days in a group of chronic stroke survivors with a wide range of FM motor scores (i.e., 20–66) and found in a subsequent analysis ( 45 ) that it was only in 16 out of 30 participants who had FM score > 50 that average unimanual paretic use time (% accelerometer wearing time) increased from 5 to ~15% as FM score increased to 66. In contrast, bimanual arm use linearly increased from 10 to 40% as FM score increased from 20 to 66.…”

“…The results showed a general increase in use of the more affected arm, and this increase was retained after feedback suppression ( Figure 2D ). Recently, we showed the feasibility of such EMA and sensor combination with thirty mild-severely motor-impaired stroke survivors ( 27 ). We found that the simple act of probing about arm use produced a small but significant increase (~10 min) in paretic arm use over 5 days ( Figure 2E ).…”

“…However, a difficulty is to monitor (via the sensors) and promote (via EMA) daily tasks that are at the “just right challenge” to maximize plastic processes involved in motor recovery. One solution is to use EMA + sensors ( 27 ) in conjunction with EMI (ecological momentary intervention) to design the optimal intervention strategy ( 48 ). As clearly shown by an early monkey study ( 50 ), not all repetitions yield plastic changes in the motor system: only the precision grasps, which had to be learned, and not the power grasps, were associated with motor cortical map plasticity.…”