Actigraphic measurement of the upper limbs movements in acute stroke patients

If your stroke team doesn't have an objective description of your motor deficits there is no way they can assign any stroke protocol to help you recover. 

Did your stroke team do anything with these earlier objective measurements?

Development and clinical validation of inertial sensor-based gait-clustering methods in Parkinson’s disease June 2019 

Comprehensive measurement of stroke gait characteristics with a single accelerometer in the laboratory and community: a feasibility, validity and reliability study  December 2017 

Markerless Human Motion Capture for Gait Analysis written in October 2017, referring to research in October 2005. 

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Actigraphic measurement of the upper limbs movements in acute stroke patients

• Chiara Iacovelli,
• Pietro Caliandro,
• Marco Rabuffetti,
• Luca Padua,
• Chiara Simbolotti,
• Giuseppe Reale,
• Maurizio Ferrarin &
• Paolo Maria Rossini 

Journal of NeuroEngineering and Rehabilitation volume 16, Article number: 153 (2019) Cite this article

Abstract

Background

Stroke units provide patients with a multiparametric monitoring of vital functions, while no instruments are actually available for a continuous monitoring of patients motor performance. Our aim was to develop an actigraphic index able both to identify the paretic limb and continuously monitor the motor performance of stroke patients in the stroke unit environment.

Methods

Twenty consecutive acute stroke patients (mean age 69.2 years SD 10.1, 8 males and 12 females) and 17 bed-restrained patients (mean age 70.5 years SD 7.3, 7 males and 10 females) hospitalized for orthopedic diseases of the lower limbs, but not experiencing neurological symptoms, were enrolled. This last group represented our control group. The motor activity of arms was recorded for 24 h using two programmable actigraphic systems showing off as wrist-worn watches. The firmware segmented the acquisition in epochs of 1 minute and for each epoch calculates two motor activity indices: MA_e1 (Epoch-related Motor Activity index) and MA_e2 (Epoch-related Motor Activity index 2). MA_e1 is defined as the standard deviation of the acceleration module and MA_e2 as the module of the standard deviation of acceleration components. To describe the 24 h motor performance of each limb, we calculated the mean value of MA_e1 and MA_e2 (respectively MA_{1_24h} and MA_{2_24h}). Then we obtained two Asymmetry Rate Indices: AR_{1_24h} and AR_{2_24h} to show the motor activity prevalence. AR_{1_24h} refers to the asymmetry index between the values of MA_e1 of both arms and AR_{2_24h} to MA_e2 values.
The stroke patients were clinically evaluated by NIHSS at the beginning (NIHSS_T0) and at the end (NIHSS_T1) of the 24 h actigraphic recordings.

Results

Both MA_{1_24h} and MA_{2_24h} indices were smaller in the paretic than in the unaffected arm (respectively p = 0.004 and p = 0.004). AR_{2_24h} showed a better capability (95% of paretic arms correctly identified, Phi Coefficient: 0.903) to discriminate the laterality of the clinical deficit than AR_{1_24h} (85% of paretic arms correctly identified, Phi Coefficient: 0,698). We also found that AR_{1_24h} did not differ between the two groups of patients while AR_{2_24h} was greater in stroke patients than in controls and positively correlated with NIHSS total scores (r: 0.714, p < 0.001 for NIHSS, IC95%: 0.42–0.90) and with the sub-score relative to the paretic upper limb (r: 0.812, p < 0.001, IC95%: 0.62–0.96).

Conclusions

Our data show that actigraphic monitoring of upper limbs can detect the laterality of the motor deficit and measure the clinical severity. These findings suggest that the above described actigraphic system could implement the existing multiparametric monitoring in stroke units.

Background

Stroke is a disease with a high social impact causing high mortality and severe residual disability. In particular, during the acute phase it is difficult to assess the patient’s functional prognosis, especially with regard to the motor deficits that impair the activity in daily life [1, 2]. After a stroke, hemiparesis is the most common residual disability with a wide range of severity, having the upper limb the lowest functional recovery [3,4,5]. During the acute phase, tracking the motor performance variations of the affected upper limb versus the unaffected arm could be useful to measure clinical severity over time and to formulate a prognosis. Nowadays, the stroke unit represents the gold standard in the management of the acute stroke, since it provides a continuous multi-parametric monitoring that allows the identification of changes in cardiac functioning, blood pressure levels and hematic oxygen saturation. At the moment, the continuous monitoring of motor deficit is not implemented in the stroke unit environment. Actigraphy allows the long-term assessment of the patient’s wrist movements by means of a small solid-state sensor. Several applications of actigraphy based on accelerometers have been proposed. Indeed, actigraphy has proved its usefulness not only in sleep medicine [6], but also in other fields, for example in Parkinson tremor quantification [7]. So far, few papers have reported the use of actigraphy in stroke: these studies provided the first indication that actigraphy might be sensitive enough to detect changes in motor activity during the recovery process and to quantify motor activity in everyday life [8,9,10,11,12,13,14] but, no data is available about the spontaneous upper limb motor performance in the very acute phase of stroke, when the instability of clinical picture can strongly impact on prognosis and future disability and the patient needs to be monitored in an intensive care unit. Page et al. [15] have used actigraphy to evaluate rehabilitative therapies in subacute stroke subjects. Gubbi et al. [16] performed short actigraphic recordings in the hyper-acute post-stroke phase and developed an algorithm capable of calculating an index equivalent to the motor subscore of the National Institutes of Health Stroke Scale (NIHSS) that is a clinical score used to monitor changes of the neurological status during the hospital stay, with a maximum of 42 (severe stroke) and a minimum of 0 (no symptoms) [17]. The same group subsequently used that index to quantify the movement difference between arms by an intra-class correlation coefficient (ICC) analysis. They found that the greater is the difference in activity between the affected and unaffected limb, as measured by ICC, the higher is the NIHSS total score; however, they did not found any correlation between the inter-limbs motor difference and the more specific NIHSS motor sub-score [18]. Reiterer et al. actigraphically monitored motor activity of both arms in 38 patients with transient ischemic attack, ischemic lesion or non-traumatic intracerebral haemorrhage for 24 h in four different time points: 24–36 h after symptoms onset, 5–7 days later, at 3 and 6 months after symptoms onset. They demonstrated that motor performance of paretic and not paretic limbs differ during the first two time points while in the further two time points this difference was attenuated [19]. However, the actigraphic index used by the Authors did not correlate with the clinical severity in the acute phase as assessed by the NIHSS. Moreover, the Authors performed 24 h recordings in a very heterogeneous sample of patients (transient ischemic attack, ischemic lesion and non-traumatic intracerebral hemorrhage), therefore the reported data cannot be considered as representative of the ischemic stroke scenario. Urbin et al. investigated different metrics to measure upper limb motor performance in subacute and chronic ischemic and hemorrhagic stroke patients during motor training and in a free-living environment. They described the asymmetry of motor performance between paretic and non-paretic arm as a ratio between the variability of the paretic arm acceleration relative to variability of the non-paretic arm. They found that the asymmetry correlates with upper extremity function during the rehabilitative process and in a free-living environment [9, 10]. Since the authors enrolled ischemic and hemorrhagic, subacute and chronic stroke patients in an environment very different from that of a stroke unit, their results, although useful to evaluate the efficacy of different parameters, cannot be considered representative of the clinical picture of ischemic stroke patients who require intensive cares in their very acute phase.
In a previous study performed in healthy subjects, Rabuffetti et al. defined a novel numerical index to quantify upper limb motor activity and the between-limb motor asymmetry. The proposed motor activity index only depends on sensor position and not on sensor orientation (i.e. indices invariant to sensor orientation), therefore it could represent a robust approach to monitor spontaneous motor performance in complex environments such as stroke units. Moreover, the proposed asymmetry index is based on epoch-based asymmetry and not on average overall asymmetry [9, 10] therefore it could be theoretically very precise in describing motor performance over time [20]. We hypothesized that such index might effectively track the motor behavior of bed-restrained patients and could be useful to implement the multiparametric monitoring in the stroke unit environment. Therefore the aims of the present study were:
- to verify if the actigraphic asymmetry index, as calculated by Rabuffetti, can identify the paretic arm of acute stroke patients;
- to verify if such asymmetry index can properly quantify the clinical severity of acute stroke patients in the very particular environment of a stroke unit.

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