Improving physical movement during stroke rehabilitation: investigating associations between sleep measured by wearable actigraphy technology, fatigue, and key biomarkers

 So this means your doctor is required to have EXACT SLEEP PROTOCOLS!

Improving physical movement during stroke rehabilitation: investigating associations between sleep measured by wearable actigraphy technology, fatigue, and key biomarkers

• Madeleine J. Smith,
• Michael Pellegrini,
• Brendan Major,
• Marnie Graco,
• Stephanie Porter,
• Sharon Kramer,
• Katherine Sewell,
• Sabrina Salberg,
• Zhibin Chen,
• Richelle Mychasiuk &
• Natasha A. Lannin 

Journal of NeuroEngineering and Rehabilitation volume 21, Article number: 84 (2024) Cite this article

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Abstract

Background

Sleep disturbance and fatigue are common in individuals undergoing inpatient rehabilitation following stroke. Understanding the relationships between sleep, fatigue, motor performance, and key biomarkers of inflammation and neuroplasticity could provide valuable insight into stroke recovery, possibly leading to personalized rehabilitation strategies. This study aimed to investigate the influence of sleep quality on motor function following stroke utilizing wearable technology to obtain objective sleep measurements. Additionally, we aimed to determine if there were relationships between sleep, fatigue, and motor function. Lastly, the study aimed to determine if salivary biomarkers of stress, inflammation, and neuroplasticity were associated with motor function or fatigue post-stroke.

Methods

Eighteen individuals who experienced a stroke and were undergoing inpatient rehabilitation participated in a cross-sectional observational study. Following consent, participants completed questionnaires to assess sleep patterns, fatigue, and quality of life. Objective sleep was measured throughout one night using the wearable Philips Actiwatch. Upper limb motor performance was assessed on the following day and saliva was collected for biomarker analysis. Correlation analyses were performed to assess the relationships between variables.

Results

Participants reported poor sleep quality, frequent awakenings, and difficulties falling asleep following stroke. We identified a significant negative relationship between fatigue severity and both sleep quality (r=-0.539, p = 0.021) and participants experience of awakening from sleep (r=-0.656, p = 0.003). A significant positive relationship was found between grip strength on the non-hemiplegic limb and salivary gene expression of Brain-derived Neurotrophic Factor (r = 0.606, p = 0.028), as well as a significant negative relationship between grip strength on the hemiplegic side and salivary gene expression of C-reactive Protein (r=-0.556, p = 0.048).

Conclusion

The findings of this study emphasize the importance of considering sleep quality, fatigue, and biomarkers in stroke rehabilitation to optimize recovery and that interventions may need to be tailored to the individual. Future longitudinal studies are required to explore these relationships over time. Integrating wearable technology for sleep and biomarker analysis can enhance monitoring and prediction of outcomes following stroke, ultimately improving rehabilitation strategies and patient outcomes.

Introduction

Active participation in motor rehabilitation programs is critical after stroke, which emphasizes the importance of understanding factors that enable individuals to engage fully in the rehabilitation process. Following stroke, neuroscience research has demonstrated that the severity of cortical damage [1, 2], inflammatory response to stroke [3], genetic factors [4], circadian disruption [5], and depression and anxiety [6, 7] may affect movement outcomes. While the field of physical rehabilitation has also shown that, in the clinic, the severity of stroke [8], sleep disruption [9,10,11,12,13,14,15], fatigue [16,17,18,19,20,21], inflammation [22,23,24], depression and anxiety [25, 26], and the presence of comorbidities [27,28,29], all coalesce to affect both engagement in rehabilitation and motor recovery. To date, however, there has been little acknowledgement that many of these factors may be influenced by the rehabilitation hospital environment. The disruption of medical patients in acute wardrooms has previously been shown [30], but there is little research investigating the relationships between sleep and motor function in the setting of inpatient rehabilitation wards. Given the pivotal role of inpatient rehabilitation in the stroke recovery pipeline, understanding the impact of these factors, inclusive of hospital environment, on sleep, fatigue, and movement outcomes is key.

The impact of each of these factors (predominantly independent of one another) has previously been discussed, albeit most commonly in community living stroke populations. For instance, post-stroke fatigue is experienced by 25 to 85% of stroke survivors [31], and is influenced by sleep disturbances [32] as well as physical activity and fitness [33], although the relationship between fatigue and objective measures of motor performance and strength remain unclear [34]. Measures of post-stroke mood also correlate significantly with self-reported fatigue [18, 35, 36]. Additionally, stroke survivors with increased circulating interleukin (IL)-1β and c-reactive protein (CRP) have higher levels of post-stroke fatigue [37,38,39]. Further, brain-derived neurotrophic factor (BDNF) allele variations are indicative of stroke survivors motor function [40]. Although the relationship between salivary gene expression and motor function during inpatient rehabilitation has not been specifically investigated, biomarkers are a potential non-invasive screening target. Objective biomarkers offer potential insights into the mechanisms of post-stroke fatigue during motor rehabilitation. The opportunity for research to shape clinical care has been further strengthened by our recent ability to monitor the features of sleep outside of the laboratory environment, permitting a real-time understanding of the impact of the hospital ward environment on sleep parameters.

There have been no previous studies to objectively measure sleep during inpatient rehabilitation and assess its association with motor function. Therefore, the primary aim of this study was to investigate the impact of sleep quality on motor function in people with stroke, by capturing subjective and objective measures of sleep using wearable technology during inpatient rehabilitation. We hypothesized that reduced sleep quality would have a negative impact on motor function following stroke. Additionally, we aimed to determine if there were correlations between fatigue, sleep and motor function during inpatient rehabilitation. Investigating the relationship between post-stroke sleep and objective biomarkers as predictors of motor recovery following stroke is an important step towards developing personalized rehabilitation programs [41]. Therefore, we aimed to determine if salivary biomarkers of stress, inflammation, and neuroplasticity were associated with fatigue or motor function post-stroke.

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