[ARTICLE] 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 – Full Text

Abstract

Introduction

Improvement of arm-hand function and arm-hand skill performance in stroke patients is reported by many authors. However, therapy content often is poorly described, data on actual arm-hand use are scarce, and, as follow-up time often is very short, little information on patients’ mid- and long-term progression is available. Also, outcome data mainly stem from either a general patient group, unstratified for the severity of arm-hand impairment, or a very specific patient group.

Objectives

To investigate to what extent the rate of improvement or deterioration of actual arm-hand use differs between stroke patients with either a severely, moderately or mildly affected arm-hand, during and after rehabilitation involving a well-defined rehabilitation program.

Methods

Design: single–armed prospective cohort study. Outcome measure: affected arm-hand use during daily tasks (accelerometry), expressed as ‘Intensity-of arm-hand-use’ and ‘Duration-of-arm-hand-use’ during waking hours. Measurement dates: at admission, clinical discharge and 3, 6, 9, and 12 months post-discharge. Statistics: Two-way repeated measures ANOVAs.

Results

Seventy-six patients (63 males); mean age: 57.6 years (sd:10.6); post-stroke time: 29.8 days (sd:20.1) participated. Between baseline and 1-year follow-up, Intensity-of-arm-hand-use on the affected side increased by 51%, 114% and 14% (p < .000) in the mildly, moderately and severely affected patients, respectively. Similarly, Duration-of-arm-hand-use increased by 26%, 220% and 161% (p < .000). Regarding bimanual arm-hand use: Intensity-of-arm-hand-use increased by 44%, 74% and 30% (p < .000), whereas Duration-of-arm-hand-use increased by 10%, 22% and 16% (p < .000).

Conclusion

Stroke survivors with a severely, moderately or mildly affected arm-hand showed different, though (clinically) important, improvements in actual arm-hand use during the rehabilitation phase. Intensity-of-arm-hand-use and Duration-of-arm-hand-use significantly improved in both unimanual and bimanual tasks/skills. These improvements were maintained until at least 1 year post-discharge.

 

Introduction

After stroke, the majority of stroke survivors experiences significant arm-hand impairments [1, 2] and a decreased use of the paretic arm and hand in daily life [3]. The actual use of the affected hand in daily life performance depends on the severity of the arm-hand impairment [4–6] and is associated with perceived limitations in participation [7, 8]. Severity of arm-hand impairment is also associated with a decrease of health-related quality of life [9], restricted social participation [10], and subjective well-being [11, 12].

Numerous interventions and arm-hand rehabilitation programs have been developed in order to resolve arm-hand impairments in stroke patients [6, 13]. In the Netherlands, a number of stroke units in rehabilitation centres implemented a well-described ‘therapy-as-usual’ arm-hand rehabilitation program, called CARAS (acronym for: Concise Arm and hand Rehabilitation Approach in Stroke)[14], serving a broad spectrum of stroke patients across the full stroke severity range of arm-hand impairments. The arm-hand rehabilitation program has been developed to guide clinicians in systematically designing arm-hand rehabilitation, tailored towards the individual patient’s characteristics while keeping control over the overall heterogeneity of this population typically seen in stroke rehabilitation centres. A vast majority of stroke patients who participated in CARAS improved on arm-hand function (AHF), on arm-hand skilled performance (AHSP) capacity and on (self-) perceived performance, both during and after clinical rehabilitation [15]. The term ‘arm-hand function’ (AHF) refers to the International Classification of Functioning (ICF) [16] ‘body function and structures level’. The term ‘arm-hand skilled performance’ (AHSP) refers to the ICF ‘activity level’, covering capacity as well as both perceived performance and actual arm-hand use [17].

Improved AHF and/or AHSP capacity do not automatically lead to an increase in actual arm-hand use and do not guarantee an increase of performing functional activities in daily life [18–20]. Improvements at function level, i.e. regaining selectivity, (grip) strength and/or grip performance, do not automatically lead to improvements experienced in real life task performance of persons in the post-stroke phase who live at home [18, 21]. Next to outcome measures regarding AHF, AHSP capacity and (self-) perceived AHSP, which are typically measured in controlled conditions, objective assessment of functional activity and actual arm-hand use outside the testing situation is warranted [22, 23].

Accelerometry can be used to reliably and objectively assess actual arm-hand use during daily task performance [24–32]and has been used in several studies to detect arm-hand movements and evaluate arm-hand use in the post-stroke phase [20, 33–35]. Previous studies have demonstrated that, in stroke patients, movement counts, as measured with accelerometers, are associated with the use of the affected arm-hand (Motor Activity Log score) [36, 37] and, at function level, with the Fugl-Meyer Assessment [38]. Next to quantifying paretic arm-hand use, accelerometers have also been used to provide feedback to further enhance the use of the affected hand in home-based situations [39]. Most studies consist of relatively small [27, 30, 40–44] and highly selected study populations [45] with short time intervals between baseline and follow-up measurements. As to our knowledge, only a few studies monitored arm-hand use in stroke patients for a longer period, i.e. between time of discharge to a home situation or till 6 to 12 months after stroke [19, 44, 46]. However, they used a relatively small study sample and their intervention aimed at arm-hand rehabilitation was undefined. Both studies of Connell et al. and Uswatte et al. describe a well-defined arm hand intervention where accelerometry data were used as an outcome measure [27, 47]. However, the study population described by Connell et al. consisted of a relative small and a relative mildly impaired group of chronic stroke survivors. The study population described by Uswatte et al. consisted of a large group of sub-acute stroke patients within strict inclusion criteria ranges [37], who, due to significant spontaneous neurologic recovery within this sub-acute phase, had a mildly impaired arm and hand [48, 49]. This means that the group lacked persons with a moderately to severely affected arm-hand, who are commonly treated in the daily rehabilitation setting.

The course of AHF and AHSP of a broad range of sub-acute stroke patients during and after rehabilitation involving a well-defined arm-hand rehabilitation program (i.e. CARAS) [14] has been reported by Franck et al. [15]. The present paper provides data concerning actual arm-hand use in the same study population, and focuses on two objectives. The first aim is to investigate changes in actual arm-hand use across time, i.e. during and after clinical rehabilitation, within a stroke patient group typically seen in daily medical rehabilitation practice, i.e. covering a broad spectrum of arm-hand problem severity levels, who followed a well-described arm-hand treatment regime. The second aim is to investigate to what extent improvement (or deterioration) regarding the use of the affected arm-hand in daily life situations differs between patient categories, i.e. patients with either a severely, moderately or mildly impaired arm-hand, during and after their rehabilitation, involving a well-defined arm-hand rehabilitation program.[…]

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Fig 3. Mean values for Intensity-of-arm-hand-use during uptime for subgroups 1, 2 and 3.
T = time; bl = baseline; cd = clinical discharge; m = month; Solid line = subgroup 1; Dotted line = subgroup 2; Dashed line = subgroup 3.
https://doi.org/10.1371/journal.pone.0214651.g003