ORIGINAL RESEARCH| Volume 103, ISSUE 7, P1327-1337, July 2022

Ecological Momentary Assessment of Real-World Functional Behaviors in Individuals With Stroke: A Longitudinal Observational Study

Published:March 08, 2022DOI:



      To validate and characterize real-world functional behaviors in individuals after stroke.


      Longitudinal observational study using ecological momentary assessment (EMA) as a real-time assessment of functional behaviors in natural contexts. Wilcoxon rank-sum tests, Fisher exact tests, and Spearman correlations were used to analyze data.




      Individuals with mild to moderate stroke (N=212).


      Not applicable.

      Main Outcome Measures

      Individuals were assessed 5 times daily for 14 days with EMA surveys to determine what, with whom, and where individuals were doing activities and appraise mental, somatic, and cognitive symptoms. Individuals also completed standardized assessments during laboratory visits, including Lawton Instrumental Activities of Daily Living Scale, Activity Card Sort, Patient-Reported Outcome Measurement Information System, and Quality of Life in Neurological Disorders.


      Most individuals (median age, 60 years; 55% male) were ischemic stroke (90%) and had mild stroke severity (median National Institutes of Health Stroke Scale, 2). A total of 14,140 EMA surveys were analyzed. Individuals were home 78% of the time; primarily participated in passive, unproductive activities (27%), especially watching television and resting; and participated least in physical activities (4%). EMA was sensitive to indicators of poststroke disability; unemployed individuals reported fewer vocational activities but more activities of daily living (ADL) and passive activities than employed counterparts. Users of mobility devices and individuals with cognitive problems spent significantly less time on vocational activities and more on ADL than nonusers and those without cognitive problems. Our data supported the validity of EMA methods in stroke, with small to moderate correlations of EMA with in-laboratory measures of daily functioning (r=−0.30 to 0.35, P<.05) and very large correlations between EMA and in-laboratory measures of symptoms, especially those measuring same constructs (r=−0.64 to 0.79, P<.0001).


      Our findings reveal that EMA tracked poststroke functioning precisely. EMA may be beneficial in examining poststroke functional recovery, in monitoring patients for home-based interventions, and for longitudinal research.


      List of abbreviations:

      ADL (Activities of Daily Living), EMA (Ecological Momentary Assessment), HIV+ (Human Immunodeficiency Virus Infection), IADL (Instrumental Activities of Daily Living), IQR (Interquartile Range), mRS (Modified Rankin Scale), NeuroQoL (Quality of Life in Neurological Disorders), NIHSS (National Institutes of Health Stroke Scale), PROMIS (Patient-Reported Outcome Measurement Information System), TBI (Traumatic Brain Injury)
      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 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


        • Gorelick PB.
        The global burden of stroke: persistent and disabling.
        Lancet Neurol. 2019; 18: 417-418
        • Virani SS
        • Alonso A
        • Aparicio HJ
        • et al.
        Heart disease and stroke statistics—2021 update: a report from the American Heart Association.
        Circulation. 2021; 143: e254-e743
        • White JH
        • Alston MK
        • Marquez JL
        • et al.
        Community-dwelling stroke survivors: function is not the whole story with quality of life.
        Arch Phys Med Rehabil. 2007; 88: 1140-1146
        • Stinear C.
        Prediction of recovery of motor function after stroke.
        Lancet Neurol. 2010; 9: 1228-1232
        • Kapoor A
        • Lanctôt KL
        • Bayley M
        • et al.
        Good outcome" isn't good enough: cognitive impairment, depressive symptoms, and social restrictions in physically recovered stroke patients.
        Stroke. 2017; 48: 1688-1690
        • Quinn TJ
        • Dawson J
        • Walters MR
        • Lees KR.
        Functional outcome measures in contemporary stroke trials.
        Int J Stroke. 2009; 4: 200-205
        • Beninato M
        • Gill-Body KM
        • Salles S
        • Stark PC
        • Black-Schaffer RM
        • Stein J.
        Determination of the minimal clinically important difference in the FIM instrument in patients with stroke.
        Arch Phys Med Rehabil. 2006; 87: 32-39
        • Wu CY
        • Chuang LL
        • Lin KC
        • Horng YS.
        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
        • Stone AA
        • Shiffman S.
        Capturing momentary, self-report data: a proposal for reporting guidelines.
        Ann Behav Med. 2002; 24: 236-243
        • Shiffman S
        • Stone AA
        • Hufford MR.
        Ecological momentary assessment.
        Annu Rev Clin Psychol. 2008; 4: 1-32
        • Strassnig MT
        • Miller ML
        • Moore R
        • Depp CA
        • Pinkham AE
        • Harvey PD.
        Evidence for avolition in bipolar disorder? A 30-day ecological momentary assessment comparison of daily activities in bipolar disorder and schizophrenia.
        Psychiatry Res. 2021; 300113924
        • Granholm E
        • Holden JL
        • Mikhael T
        • et al.
        What do people with schizophrenia do all day? Ecological momentary assessment of real-world functioning in schizophrenia.
        Schizophr Bull. 2020; 46: 242-251
        • Jones SE
        • Moore RC
        • Depp CA
        • Ackerman RA
        • Pinkham AE
        • Harvey PD.
        Daily Ecological momentary assessments of happy and sad moods in people with schizophrenia and bipolar disorders: what do participants who are never sad think about their activities and abilities?.
        Schizophr Res Cogn. 2021; 26100202
        • Johnson EI
        • Sibon I
        • Renou P
        • Rouanet F
        • Allard M
        • Swendsen J.
        Feasibility and validity of computerized ambulatory monitoring in stroke patients.
        Neurology. 2009; 73: 1579-1583
        • Mazure CM
        • Weinberger AH
        • Pittman B
        • Sibon I
        • Swendsen J.
        Gender and stress in predicting depressive symptoms following stroke.
        Cerebrovasc Dis. 2014; 38: 240-246
        • Neff AJ
        • Lee Y
        • Metts CL
        • Wong AW.
        Ecological momentary assessment of social interactions: associations with depression, anxiety, pain, and fatigue in individuals with mild stroke.
        Arch Phys Med Rehabil. 2021; 102: 395-405
        • Lenaert B
        • Neijmeijer M
        • van Kampen N
        • van Heugten C
        • Ponds R.
        Poststroke fatigue and daily activity patterns during outpatient rehabilitation: an experience sampling method study.
        Arch Phys Med Rehabil. 2020; 101: 1001-1008
        • Brott T
        • Adams Jr, HP
        • Olinger CP
        • et al.
        Measurements of acute cerebral infarction: a clinical examination scale.
        Stroke. 1989; 20: 864-870
        • Bruno A
        • Shah N
        • Lin C
        • et al.
        Improving modified Rankin Scale assessment with a simplified questionnaire.
        Stroke. 2010; 41: 1048-1050
        • Moore RC
        • Kaufmann CN
        • Rooney AS
        • et al.
        Feasibility and acceptability of ecological momentary assessment of daily functioning among older adults with HIV.
        Am J Geriatr Psychiatry. 2017; 25: 829-840
        • Campbell LM
        • Paolillo EW
        • Heaton A
        • et al.
        Daily activities related to mobile cognitive performance in middle-aged and older adults: an ecological momentary cognitive assessment study.
        JMIR Mhealth Uhealth. 2020; 8: e19579
        • Cromwell DA
        • Eagar K
        • Poulos RG.
        The performance of instrumental activities of daily living scale in screening for cognitive impairment in elderly community residents.
        J Clin Epidemiol. 2003; 56: 131-137
        • Tse T
        • Lentin P
        • Douglas J
        • Carey LM.
        Understanding activity participation 3-months after stroke: a mixed methodology study.
        Disabil Rehabil. 2020 Dec 22; ([Epub ahead of print])
        • Cella D
        • Lai JS
        • Nowinski CJ
        • et al.
        Neuro-QoL: brief measures of health-related quality of life for clinical research in neurology.
        Neurology. 2012; 78: 1860-1867
        • Amtmann D
        • Cook KF
        • Johnson KL
        • Cella D.
        The PROMIS initiative: involvement of rehabilitation stakeholders in development and examples of applications in rehabilitation research.
        Arch Phys Med Rehabil. 2011; 92: S12-S19
        • Hartman-Maeir A
        • Eliad Y
        • Kizoni R
        • Nahaloni I
        • Kelberman H
        • Katz N.
        Evaluation of a long-term community based rehabilitation program for adult stroke survivors.
        NeuroRehabilitation. 2007; 22: 295-301
        • Jiménez-Caballero PE
        • López-Espuela F
        • Portilla-Cuenca JC
        • et al.
        Evaluation of the instrumental activities of daily living following a stroke by means of the Lawton and Brody scale.
        Rev Neurol. 2012; 55: 337-342
        • Katzan IL
        • Thompson NR
        • Uchino K
        • Lapin B.
        The most affected health domains after ischemic stroke.
        Neurology. 2018; 90: e1364-e1371
        • Katzan IL
        • Thompson N
        • Uchino K.
        Innovations in stroke: the use of PROMIS and Neuro-QoL scales in clinical stroke trials.
        Stroke. 2016; 47: e27-e30
        • Administration for Community Living. National Institute on Disability
        Independent Living and Rehabilitation Research (NIDILRR) 2018-2023 long-range plan. NIDILRR, 2021
        • Nasreddine ZS
        • Phillips NA
        • Bédirian V
        • et al.
        The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment.
        J Am Geriatr Soc. 2005; 53: 695-699
        • Pendlebury ST
        • Mariz J
        • Bull L
        • Mehta Z
        • Rothwell PM.
        MoCA, ACE-R, and MMSE versus the National Institute of Neurological Disorders and Stroke-Canadian Stroke Network Vascular Cognitive Impairment Harmonization Standards Neuropsychological Battery after TIA and stroke.
        Stroke. 2012; 43: 464-469
        • Wilcoxon F.
        Individual comparisons of grouped data by ranking methods.
        J Econ Entomol. 1946; 39: 269
        • Kim HY.
        Statistical notes for clinical researchers: chi-squared test and Fisher's exact test.
        Restor Dent Endod. 2017; 42: 152-155
        • Schober P
        • Boer C
        • Schwarte LA.
        Correlation coefficients: appropriate use and interpretation.
        Anesth Analg. 2018; 126: 1763-1768
        • Cohen J.
        Statistical power analysis for the social sciences.
        Erlbaum, Hillsdale, NJ:1988
        • Rosenthal JA.
        Qualitative descriptors of strength of association and effect size.
        J Soc Serv Res. 1996; 21: 37-59
        • Zhang Y
        • Hedo R
        • Rivera A
        • Rull R
        • Richardson S
        • Tu XM.
        Post hoc power analysis: is it an informative and meaningful analysis?.
        Gen Psychiatr. 2019; 32e100069
      1. Pew Research Center. Smartphone ownership is growing rapidly around the world, but not always equally. Available at: Accessed August 2, 2021.

        • Rabinowitz A
        • Hart T
        • Wilson J.
        Ecological momentary assessment of affect in context after traumatic brain injury.
        Rehabil Psychol. 2021; 66: 442-449
        • Kringle EA
        • Campbell G
        • McCue M
        • Barone Gibbs B
        • Terhorst L
        • Skidmore ER
        Development and feasibility of a sedentary behavior intervention for stroke: a case series.
        Top Stroke Rehabil. 2019; 26: 456-463
        • Carlsson GE
        • Möller A
        • Blomstrand C.
        Managing an everyday life of uncertainty–a qualitative study of coping in persons with mild stroke.
        Disabil Rehabil. 2009; 31: 773-782
        • Ali SR
        • Fall K
        • Hoffman T.
        Life without work: understanding social class changes and unemployment through theoretical integration.
        J Career Assess. 2013; 21: 111-126
      2. World Health Organization. International Classification of Functioning, Disability and Health (ICF). Available at: Accessed August 2, 2021.

        • Mazzucchelli TG
        • Kane RT
        • Rees CS.
        Behavioral activation interventions for well-being: a meta-analysis.
        J Posit Psychol. 2010; 5: 105-121
        • Demers M
        • Winstein CJ.
        A perspective on the use of ecological momentary assessment and intervention to promote stroke recovery and rehabilitation.
        Top Stroke Rehabil. 2021; 28: 594-605
        • Zeidan J
        • Hallit S
        • Akel M
        • Louragli I
        • Obeid S.
        Problematic smartphone use and affective temperaments among Lebanese young adults: scale validation and mediating role of self-esteem.
        BMC Psychol. 2021; 9: 136
        • Strømmen AM
        • Christensen T
        • Jensen K.
        Quantitative measurement of physical activity in acute ischemic stroke and transient ischemic attack.
        Stroke. 2014; 45: 3649-3655
        • Moore RC
        • Swendsen J
        • Depp CA.
        Applications for self-administered mobile cognitive assessments in clinical research: a systematic review.
        Int J Methods Psychiatr Res. 2017; 26: e1562
        • Mehl MR.
        The Electronically Activated Recorder (EAR): a method for the naturalistic observation of daily social behavior.
        Curr Dir Psychol Sci. 2017; 26: 184-190
        • Juengst SB
        • Myrga JM
        • Fann JR
        • Wagner AK.
        Cross-lagged panel analysis of depression and behavioral dysfunction in the first year after moderate-to-severe traumatic brain injury.
        J Neuropsychiatry Clin Neurosci. 2017; 29: 260-266