Measurements DO NOTHING on getting survivors recovered. Useless.
Characterization of stroke-related upper limb motor impairments across various upper limb activities by use of kinematic core set measures
Journal of NeuroEngineering and Rehabilitation volume 19, Article number: 2 (2022)
Abstract
Background
Upper limb kinematic assessments provide quantifiable information on qualitative movement behavior and limitations after stroke. A comprehensive characterization of spatiotemporal kinematics of stroke subjects during upper limb daily living activities is lacking. Herein, kinematic expressions were investigated with respect to different movement types and impairment levels for the entire task as well as for motion subphases.
Method
Chronic stroke subjects with upper limb movement impairments and healthy subjects performed a set of daily living activities including gesture and grasp movements. Kinematic measures of trunk displacement, shoulder flexion/extension, shoulder abduction/adduction, elbow flexion/extension, forearm pronation/supination, wrist flexion/extension, movement time, hand peak velocity, number of velocity peaks (NVP), and spectral arc length (SPARC) were extracted for the whole movement as well as the subphases of reaching distally and proximally. The effects of the factors gesture versus grasp movements, and the impairment level on the kinematics of the whole task were tested. Similarities considering the metrics expressions and relations were investigated for the subphases of reaching proximally and distally between tasks and subgroups.
Results
Data of 26 stroke and 5 healthy subjects were included. Gesture and grasp movements were differently expressed across subjects. Gestures were performed with larger shoulder motions besides higher peak velocity. Grasp movements were expressed by larger trunk, forearm, and wrist motions. Trunk displacement, movement time, and NVP increased and shoulder flexion/extension decreased significantly with increased impairment level. Across tasks, phases of reaching distally were comparable in terms of trunk displacement, shoulder motions and peak velocity, while reaching proximally showed comparable expressions in trunk motions. Consistent metric relations during reaching distally were found between shoulder flexion/extension, elbow flexion/extension, peak velocity, and between movement time, NVP, and SPARC. Reaching proximally revealed reproducible correlations between forearm pronation/supination and wrist flexion/extension, movement time and NVP.
Conclusion
Spatiotemporal differences between gestures versus grasp movements and between different impairment levels were confirmed. The consistencies of metric expressions during movement subphases across tasks can be useful for linking kinematic assessment standards and daily living measures in future research and performing task and study comparisons.
Trial registration: ClinicalTrials.gov Identifier NCT03135093. Registered 26 April 2017, https://clinicaltrials.gov/ct2/show/NCT03135093.
Introduction
The human upper limb can be expressed by seven main degrees of freedom, excluding the hand, that allow for highly variable movements and interactions with the environment. After stroke, this movement complexity can be affected due to a disruption in the cerebral sensorimotor networks that lead to inefficient or abnormal movement activation [1]. Sensitive assessments of the motor function on the level of movement quality and influences of deficits on daily life functionality are important to reveal relevant movement limitations and drive interventions for improving functional restoration [2].
Over the last decades, upper limb kinematic assessments have increasingly been used as primary or secondary outcome measures, next to standard clinical assessments in randomized-controlled trials concerning stroke rehabilitation [3,4,5,6,7,8,9,10,11,12,13,14,15,16]. Upper limb kinematic assessments have been investigated to test the effectiveness of different therapies, namely constraint induced movement therapy [14,15,16], trunk restraint training [17], robotic-assisted training [18,19,20], virtual reality training [21, 22], bilateral arm training [23,24,25], Botulinum toxin [26] and mirror therapy [27]. This tendency demonstrates the additional value of kinematic assessments to complement the standard clinical assessments and their broad evaluation level of movement quality. The advantage of upper limb kinematic measurements, compared to standard clinical assessments, is that different aspects of motion can be tracked objectively and continuously [28]. Alongside with this emerging field, the variability and heterogeneity of kinematic assessment protocols and chosen outcomes increased, making it difficult to interpret findings across studies [29]. A systematic review of upper limb kinematic assessments and metrics in subjects after stroke published criteria regarding upper limb assessment protocols. Out of 151 different metrics, task / movement time, path length ratio, number of velocity peaks, shoulder flexion/extension angle, trunk displacement, and peak velocity were proposed as core set metrics for facilitating the standardization and comparability of upper limb kinematic analysis after stroke [30]. These core set metrics performed best in terms of usage frequency, validity and/ or reliability. It has further been shown that upper limb kinematic measurements after stroke were frequently assessed in relatively fixed measurement surroundings such as camera-based motion laboratories or robot-based measurement systems. These measurements have the strong disadvantage that the movements the patients have to perform are device-specific and often restricted to simple reach-to-point, or tracking motions [30]. It is questionable, to what extent, a device-restraint planar pointing task is representative for movement tasks in daily living. It is unknown, if the movement characteristics of these different tasks are different for the same person as well as between people performing the same task or not. A significant impact of the movement task content and contexts on motor planning and behavior has been reported for pointing, or grasping of simulated or real objects [31, 32] and might be one of the biggest barriers in the interpretation and overall comparison of upper limb movement kinematics. With the exception of some natural tasks such as the standardized task of drinking from a glass [33], it is unknown how the outcomes of the current kinematic assessments relate to real-life performance and other similar functional upper limb movement tasks.
To overcome the described issue of highly variable and complex movements of the human upper limb, effort has been put into the development of a taxonomy for upper limb motion that subdivides motions based on the complexity and duration into activities, functional movements, and functional primitives [34]. The functional movement primitives or movement subphases, such as reaching or transporting, were suggested to be seen as building blocks or even more granular elements of motion, that are consistent across movements [35]. Based on this theorem, it could be assumed that for example reaching to grasp a glass is based on the same primitive or building block as reaching to grasp a phone receiver. Observing upper limb motions on the level of the functional movement primitives or movement subphases could thereby enable across task comparisons of movement quality and overcome issues of anatomical and task-related complexity. In person with stroke-related upper limb impairments, the kinematic analysis on the level of movement subphases could thus help to uncover pathophysiological mal-adaptations and relevant limitations in movement behavior such as diminished elbow extension during reach or arm elevation and hand speed during object transport.
Most of the pre-mentioned research on upper limb kinematic assessments was based on one or two movement tasks narrowing the findings down to a specific type of movement. A wider set of upper limb assessment activities, including non-contact movements such as gestures, or contact movements such as grasping activities, would increase the representativeness and comprehensiveness of the kinematic characterization of upper limb movement quality in daily life. In the present study, a set of 20 movement tasks representative for activities of daily life was used covering the main requirements of movement control of the human upper limb degrees of freedom (DOF) in terms of workspace, grasp configuration, interaction with the environment and complexity [36]. The aim of the study is to characterize and differentiate stroke-related upper limb function and impairment for movements related to activities of daily life. To this end, kinematics presenting the main upper limb spatiotemporal movement characteristics were recorded during gesture and grasping actions.
The first question is whether kinematic characteristics are different between movement types of no-contact-based gesture movements and contact-based grasping. The second question is whether significant effects can be found related to subgroups of no, mild and moderate upper limb impairment. The third question is attributed to the comparability of movement subphases. It is questioned whether phases of reaching distally towards ipsilateral maximum arm length and reaching or transporting proximally towards the head are consistent in terms of spatiotemporal kinematic expressions and relations across different movement tasks and impairment levels.
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