Advertisement

Predictors of Clinically Important Changes in Actual and Perceived Functional Arm Use of the Affected Upper Limb After Rehabilitative Therapy in Chronic Stroke

  • Yi-chun Li
    Affiliations
    School of Occupational Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
    Search for articles by this author
  • Wan-wen Liao
    Affiliations
    School of Occupational Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
    Search for articles by this author
  • Yu-wei Hsieh
    Affiliations
    Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan

    Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan

    Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkou, Taiwan
    Search for articles by this author
  • Keh-chung Lin
    Correspondence
    Corresponding author Keh-chung Lin, ScD, OTR, School of Occupational Therapy, College of Medicine, National Taiwan University, and Division of Occupational Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, 17, F4, Xu Zhou Rd, 10055, Taipei, Taiwan.
    Affiliations
    School of Occupational Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan

    Division of Occupational Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
    Search for articles by this author
  • Chia-ling Chen
    Affiliations
    Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkou, Taiwan

    Graduate Institute of Early Intervention, College of Medicine, Chang Gung University, Taoyuan, Taiwan
    Search for articles by this author
Published:September 26, 2019DOI:https://doi.org/10.1016/j.apmr.2019.08.483

      Abstract

      Objective

      To identify the predictors of minimal clinically important changes in actual and perceived functional arm use of the affected upper limb after rehabilitative therapy.

      Design

      Retrospective, observational cohort study.

      Setting

      Outpatient rehabilitation settings.

      Participants

      A cohort of 94 patients with chronic stroke.

      Interventions

      Patients received robot-assisted therapy, mirror therapy, or combined therapy for 4 weeks.

      Main Outcome Measures

      The primary outcome measures, assessed pre- and post intervention, included actual functional arm use measured by an accelerometer and perceived functional arm use measured by the Motor Activity Log (MAL). Candidate predictors included age, sex, time after stroke, side of stroke, and scores on the Fugl-Meyer Assessment, Modified Ashworth Scale, Medical Research Council scale, Wolf Motor Function Test, MAL (quality of movement), and Nottingham Extended Activities of Daily Living.

      Results

      Being male (odds ratio [OR], 3.17; 95% CI, 1.13-8.87) and having a higher than median Medical Research Council score (OR, 2.68; 95% CI, 1.12-6.41) significantly predicted minimal clinically important changes assessed by an accelerometer. Fugl-Meyer Assessment scores (odds ratio, 1.06; 95% CI, 1.02-1.11) were a significant predictor of achieving clinically important changes in MAL amount of use. Wolf Motor Function Test (quality) scores (OR, 3.05; 95% CI, 1.38-6.77) could predict clinically important improvements in MAL quality of movement.

      Conclusions

      Predictors of clinically important changes in the use of the affected upper limb after robot-assisted therapy, mirror therapy, or combined therapy in patients with chronic stroke for 4 weeks differ for actual vs perceived use. Further studies are recommended to validate these findings in a larger sample.

      Keywords

      List of abbreviations:

      AOU (amount of use), FMA (Fugl-Meyer Assessment), MAL (Motor Activity Log), MAS (Modified Ashworth Scale), MCID (minimal clinically important difference), MRC (Medical Research Council), MT (mirror therapy), NEADL (Nottingham Extended Activities of Daily Living), OR (odds ratio), QOM (quality of movement), RT (robot-assisted therapy), WMFT (Wolf Motor Function Test), VIF (variance inflation factor)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • World Health Organization
        International classification of functioning, disability and health: ICF.
        World Health Organization, Geneva2001
        • Uswatte G.
        • Taub E.
        • Morris D.
        • Light K.
        • Thompson P.
        The Motor Activity Log-28 assessing daily use of the hemiparetic arm after stroke.
        Neurology. 2006; 67: 1189-1194
        • Gadidi V.
        • Katz-Leurer M.
        • Carmeli E.
        • Bornstein N.M.
        Long-term outcome poststroke: predictors of activity limitation and participation restriction.
        Arch Phys Med Rehabil. 2011; 92: 1802-1808
        • Winstein C.J.
        • Stein J.
        • Arena R.
        • et al.
        Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2016; 47: e98-e169
        • Chuang I.C.
        • Lin K.C.
        • Wu C.Y.
        • Hsieh Y.W.
        • Liu C.T.
        • Chen C.L.
        Using Rasch analysis to validate the motor activity log and the lower functioning motor activity log in patients with stroke.
        Phys Ther. 2017; 97: 1030-1040
        • Taub E.
        • Miller N.E.
        • Novack T.A.
        • et al.
        Technique to improve chronic motor deficit after stroke.
        Arch Phys Med Rehabil. 1993; 74: 347-354
        • Petrillo J.
        • Cano S.J.
        • McLeod L.D.
        • Coon C.D.
        Using classical test theory, item response theory, and Rasch measurement theory to evaluate patient-reported outcome measures: a comparison of worked examples.
        Value Health. 2015; 18: 25-34
        • Dobkin B.H.
        • Martinez C.
        Wearable sensors to monitor, enable feedback, and measure outcomes of activity and practice.
        Curr Neurol Neurosci Rep. 2018; 18: 87
        • Lynch E.A.
        • Jones T.M.
        • Simpson D.B.
        • et al.
        Activity monitors for increasing physical activity in adult stroke survivors.
        Cochrane Database Syst Rev. 2018; 7CD012543
        • Dobkin B.H.
        • Dorsch A.K.
        The evolution of personalized behavioral intervention technology: will it change how we measure or deliver rehabilitation?.
        Stroke. 2017; 48: 2329-2334
        • Winstein C.
        • Varghese R.
        Been there, done that, so what’s next for arm and hand rehabilitation in stroke?.
        NeuroRehabilitation. 2018; 43: 3-18
        • Chen H.L.
        • Lin K.C.
        • Hsieh Y.W.
        • Wu C.Y.
        • Liing R.J.
        • Chen C.L.
        A study of predictive validity, responsiveness, and minimal clinically important difference of arm accelerometer in real-world activity of patients with chronic stroke.
        Clin Rehabil. 2018; 32: 75-83
        • Lin K.C.
        • Fu T.
        • Wu C.Y.
        • et al.
        Minimal detectable change and clinically important difference of the Stroke Impact Scale in stroke patients.
        Neurorehabil Neural Repair. 2010; 24: 486-492
        • Olsen TSj
        Arm and leg paresis as outcome predictors in stroke rehabilitation.
        Stroke. 1990; 21: 247-251
        • Coupar F.
        • Pollock A.
        • Rowe P.
        • Weir C.
        • Langhorne P.
        Predictors of upper limb recovery after stroke: a systematic review and meta-analysis.
        Clin Rehabil. 2012; 26: 291-313
        • Park S.W.
        • Wolf S.L.
        • Blanton S.
        • Winstein C.
        • Nichols-Larsen D.S.
        The EXCITE trial: predicting a clinically meaningful motor activity log outcome.
        Neurorehabil Neural Repair. 2008; 22: 486-493
        • Hsieh Y.W.
        • Lin K.C.
        • Wu C.Y.
        • et al.
        Predicting clinically significant changes in motor and functional outcomes after robot-assisted stroke rehabilitation.
        Arch Phys Med Rehabil. 2014; 95: 316-321
        • Ashburn A.
        • Hyndman D.
        • Pickering R.
        • Yardley L.
        • Harris S.
        Predicting people with stroke at risk of falls.
        Age Ageing. 2008; 37: 270-276
        • Austin P.C.
        • Steyerberg E.W.
        The number of subjects per variable required in linear regression analyses.
        J Clin Epidemiol. 2015; 68: 627-636
        • Liao W.W.
        • Wu C.Y.
        • Hsieh Y.W.
        • Lin K.C.
        • Chang W.Y.
        Effects of robot-assisted upper limb rehabilitation on daily function and real-world arm activity in patients with chronic stroke: a randomized controlled trial.
        Clin Rehabil. 2012; 26: 111-120
        • Hsieh Y.W.
        • Wu C.Y.
        • Wang W.E.
        • et al.
        Bilateral robotic priming before task-oriented approach in subacute stroke rehabilitation: a pilot randomized controlled trial.
        Clin Rehabil. 2017; 31: 225-233
        • Hung C.S.
        Unilateral vs. bilateral hybrid approaches for upper limb function in chronic stroke rehabilitation [doctoral dissertation]. School of Occupational Therapy.
        National Taiwan University, Taipei, Taiwan2018
        • Li Y.C.
        • Lo C.H.
        • Lin K.C.
        Comparison of robotic primed mirror therapy and bilateral arm training with transfer package in chronic stroke: A pilot study. Paper presented at: Taiwan Occupational Therapy Association Annual Meeting and International Conference.
        (November 2-3)2019 (Taipei, Taiwan)
        • Fini N.A.
        • Holland A.E.
        • Keating J.
        • Simek J.
        • Bernhardt J.
        How is physical activity monitored in people following stroke?.
        Disabil Rehabil. 2015; 37: 1717-1731
        • Van der Lee J.
        • Beckerman H.
        • Knol D.
        • De Vet H.
        • Bouter L.
        Clinimetric properties of the motor activity log for the assessment of arm use in hemiparetic patients.
        Stroke. 2004; 35: 1410-1414
        • See J.
        • Dodakian L.
        • Chou C.
        • et al.
        A standardized approach to the Fugl-Meyer assessment and its implications for clinical trials.
        Neurorehabil Neural Repair. 2013; 27: 732-741
        • Sullivan K.J.
        • Tilson J.K.
        • Cen S.Y.
        • et al.
        Fugl-Meyer assessment of sensorimotor function after stroke: standardized training procedure for clinical practice and clinical trials.
        Stroke. 2011; 42: 427-432
        • Bohannon R.W.
        • Smith M.B.
        Interrater reliability of a modified Ashworth scale of muscle spasticity.
        Phys Ther. 1987; 67: 206-207
        • Gregson J.M.
        • Leathley M.J.
        • Moore A.P.
        • Smith T.L.
        • Sharma A.K.
        • Watkins C.L.
        Reliability of measurements of muscle tone and muscle power in stroke patients.
        Age Ageing. 2000; 29: 223-228
        • Paternostro-Sluga T.
        • Grim-Stieger M.
        • Posch M.
        • et al.
        Reliability and validity of the Medical Research Council (MRC) scale and a modified scale for testing muscle strength in patients with radial palsy.
        J Rehabil Med. 2008; 40: 665-671
        • Whitall J.
        • Savin Jr., D.N.
        • Harris-Love M.
        • Waller S.M.
        Psychometric properties of a modified Wolf Motor Function test for people with mild and moderate upper-extremity hemiparesis.
        Arch Phys Med Rehabil. 2006; 87: 656-660
        • Wu C.Y.
        • Chuang L.L.
        • Lin K.C.
        • Horng Y.S.
        Responsiveness and validity of two outcome measures of instrumental activities of daily living in stroke survivors receiving rehabilitative therapies.
        Clin Rehabil. 2011; 25: 175-183
        • Hou F.
        • Yu Z.
        • Peng C.K.
        • Yang A.
        • Wu C.
        • Ma Y.
        Complexity of wake electroencephalography correlates with slow wave activity after sleep onset.
        Front Neurosci. 2018; 12: 809
        • Iacobucci D.
        • Posavac S.S.
        • Kardes F.R.
        • Schneider M.J.
        • Popovich D.L.
        Toward a more nuanced understanding of the statistical properties of a median split.
        J Consum Psychol. 2015; 25: 652-665
        • Wolf S.L.
        • Thompson P.A.
        • Morris D.M.
        • et al.
        The EXCITE trial: attributes of the Wolf Motor Function Test in patients with subacute stroke.
        Neurorehabil Neural Repair. 2005; 19: 194-205
      1. Rohafza M, Fluet GG, Qiu Q, Adamovich S. Correlation of reaching and grasping kinematics and clinical measures of upper extremity function in persons with stroke related hemiplegia. Paper presented at: 2014 36th Annual International Conference of the IEEE Engineering in Medicine and Biology Society August 26-30, 2014; Chicago, IL.

        • Edwards D.F.
        • Lang C.E.
        • Wagner J.M.
        • Birkenmeier R.
        • Dromerick A.W.
        An evaluation of the Wolf Motor Function Test in motor trials early after stroke.
        Arch Phys Med Rehabil. 2012; 93: 660-668
        • Morris D.M.
        • Uswatte G.
        • Crago J.E.
        • Cook III, E.W.
        • Taub E.
        The reliability of the wolf motor function test for assessing upper extremity function after stroke.
        Arch Phys Med Rehabil. 2001; 82: 750-755
        • Chong D.K.
        Measurement of instrumental activities of daily living in stroke.
        Stroke. 1995; 26: 1119-1122
        • Taylor R.
        Interpretation of the correlation coefficient: a basic review.
        J Diagn Med Sonogr. 1990; 6: 35-39
        • Chen H.L.
        • Lin K.C.
        • Liing R.J.
        • Wu C.Y.
        • Chen C.L.
        Kinematic measures of arm-trunk movements during unilateral and bilateral reaching predict clinically important change in perceived arm use in daily activities after intensive stroke rehabilitation.
        J Neuroeng Rehabil. 2015; 12: 84
        • Hosmer Jr., D.W.
        • Lemeshow S.
        • Sturdivant R.X.
        Applied logistic regression. 398. John Wiley & Sons, 2013
        • Lang C.E.
        • Wagner J.M.
        • Edwards D.F.
        • Dromerick A.W.
        Upper extremity use in people with hemiparesis in the first few weeks after stroke.
        J Neurol Phys Ther. 2007; 31: 56-63
        • Bohannon R.W.
        Muscle strength and muscle training after stroke.
        J Rehabil Med. 2007; 39: 14-20
        • Renner C.I.
        • Bungert-Kahl P.
        • Hummelsheim H.
        Change of strength and rate of rise of tension relate to functional arm recovery after stroke.
        Arch Phys Med Rehabil. 2009; 90: 1548-1556
        • Kim J.S.
        • Lee K.B.
        • Roh H.
        • Ahn M.Y.
        • Hwang H.W.
        Gender differences in the functional recovery after acute stroke.
        J Clin Neurol. 2010; 6: 183-188
        • Wang Z.
        • Li J.
        • Wang C.
        • et al.
        Gender differences in 1-year clinical characteristics and outcomes after stroke: results from the China National Stroke Registry.
        PLoS One. 2013; 8e56459
        • Hiraga A.
        Gender differences and stroke outcomes.
        Neuroepidemiology. 2017; 48: 61-62
        • Rasmussen C.L.
        • Palarea-Albaladejo J.
        • Korshøj M.
        • et al.
        Is high aerobic workload at work associated with leisure time physical activity and sedentary behaviour among blue-collar workers? A compositional data analysis based on accelerometer data.
        PLoS One. 2019; 14e0217024
        • Rand D.
        • Eng J.J.
        Predicting daily use of the affected upper extremity 1 year after stroke.
        J Stroke Cerebrovasc Dis. 2015; 24: 274-283
        • Huang P.C.
        • Hsieh Y.W.
        • Wang C.M.
        • Wu C.Y.
        • Huang S.C.
        • Lin K.C.
        Predictors of motor, daily function, and quality-of-life improvements after upper-extremity robot-assisted rehabilitation in stroke.
        Am J Occup Ther. 2014; 68: 325-333
        • Fleming M.K.
        • Newham D.J.
        • Roberts-Lewis S.F.
        • Sorinola I.O.
        Self-perceived utilization of the paretic arm in chronic stroke requires high upper limb functional ability.
        Arch Phys Med Rehabil. 2014; 95: 918-924
        • Lin K.C.
        • Huang Y.H.
        • Hsieh Y.W.
        • Wu C.Y.
        Potential predictors of motor and functional outcomes after distributed constraint-induced therapy for patients with stroke.
        Neurorehabil Neural Repair. 2009; 23: 336-342
        • Li K.Y.
        • Lin K.C.
        • Wang T.N.
        • Wu C.Y.
        • Huang Y.H.
        • Ouyang P.
        Ability of three motor measures to predict functional outcomes reported by stroke patients after rehabilitation.
        NeuroRehabilitation. 2012; 30: 267-275
        • Fritz S.L.
        • Light K.E.
        • Clifford S.N.
        • Patterson T.S.
        • Behrman A.L.
        • Davis S.B.
        Descriptive characteristics as potential predictors of outcomes following constraint-induced movement therapy for people after stroke.
        Phys Ther. 2006; 86: 825-832
        • Waddell K.J.
        • Lang C.E.
        Comparison of self-report versus sensor-based methods for measuring the amount of upper limb activity outside the clinic.
        Arch Phys Med Rehabil. 2018; 99: 1913-1916