My conclusion is you don't understand ONE GODDAMN THING ABOUT SURVIVOR MOTIVATION, DO YOU? You create EXACT 100% recovery protocols and your survivor will be motivated to do the millions of reps needed because they are looking forward to 100% recovery. GET THERE!
There would be no need for this useless research.
Encouraging arm use in stroke survivors: the impact of smart reminders during a home-based intervention
Journal of NeuroEngineering and Rehabilitation volume 21, Article number: 220 (2024)
Abstract
Background
Upper limb impairment post-stroke often leads to a predominant use of the less affected arm and consequent learned disuse of the affected side, hindering upper limb outcome. Wearable sensors such as accelerometers, combined with smart reminders (i.e., based on the amount of arm activity), offer a potential approach to promote increased use of the affected arm to improve upper limb use during daily life. This study aimed to evaluate the efficacy of wrist vibratory reminders during a six-week home-based intervention in chronic stroke survivors.
Methods
We evaluated the impact of the home-based intervention on the primary outcome, the Motor Activity Log-14 Item Version scores Amount of Use (MAL-14 AOU), and the secondary outcomes MAL-14 Quality of Movement (QOM) and sensor-derived activity metrics from the affected arm. A randomized controlled trial design was used for the study: the intervention group received personalized reminders based on individualized arm activity goals, while the control group did not receive any feedback. Mixed linear models assessed the influence of the group, week of the intervention period, and initial impairment level on MAL-14 and arm activity metrics.
Results
Forty-two participants were enrolled in the study. Overall, participants exhibited modest but not clinically relevant increases in MAL-14 AOU (+ 0.2 points) and QOM (+ 0.2 points) after the intervention period, with no statistically significant differences between the intervention and control group. Feasibility challenges were noted, such as adherence to wearing the trackers and sensor data quality. However, in participants with sufficiently available sensor data (n = 23), the affected arm use extracted from the sensor data was significantly higher in the intervention group (p < 0.05). The initial impairment level strongly influenced affected arm use and both MAL-14 AOU and QOM (p < 0.01).
Conclusions
The study investigated the effectiveness of incorporating activity trackers with smart reminders to increase affected arm activity among stroke survivors during daily life. While the results regarding the increased arm use at home are promising, patient-reported outcomes remained below clinically meaningful thresholds and showed no group differences. Further, it is essential to acknowledge feasibility issues such as adherence to wearing the trackers during the intervention and missing sensor data.
Trial registration
NCT03294187.
Introduction
Stroke affects approximately 13 million people annually and is a leading cause of upper limb impairment, which has a strong negative impact on quality of life [1, 2]. To overcome the limitations of a loss of upper limb sensorimotor function, stroke survivors may develop the tendency to use their less affected side predominately [3, 4]. This shift typically becomes more prominent following discharge from the rehabilitation clinic, where the need to perform any given activity more effectively intensifies, and available extrinsic support from the therapist diminishes. While using the less affected side helps to regain independence in performing activities of daily living, it often results in learned disuse of the affected side that can slow down and even reverse the recovery process [5,6,7]. Especially for individuals with severe impairments, keeping the motivation to perform everyday activities with their affected side is challenging due to limited functional capability [8]. To counteract the disuse, therapists often prescribe self-directed exercise programs [9]. While these programs are informative and initially beneficial, motivation and adherence decline over time due to insufficient supervision and a lack of engaging feedback during daily life [10]. The benefits of active and intensive arm movement in improving affected arm function are sustained even in the chronic phase of stroke survivors. Hence, the need for practical solutions that promote self-rehabilitation and re-integration of the affected arm during daily life, particularly after discharge, becomes essential [11,12,13].
Wearable sensors, such as inertial measurement units or accelerometers, are commonly used to measure physical activity in the healthy population by, for example, tracking steps throughout the day [14]. A positive effect on promoting physical activity has been observed when additional feedback is provided, such as movement reminders and a daily goal that should be reached [15,16,17]. A possible translation of this approach to stroke rehabilitation offers a promising tool to increase the dosage of affected arm use [18,19,20]. When deployed in the home environment, these sensors can monitor arm activity levels for several days [3, 21, 22]. Various metrics can be derived from the collected sensor data to quantify arm activity levels in stroke survivors. Established and well-understood metrics include activity counts [3, 21, 23,24,25,26], the activity ratio of the affected and less affected side [3, 24,25,26,27], as well as the duration of use during the day [23, 25,26,27]. Measuring continuous arm activity data allows for triggering and delivering personalized feedback even outside of a clinical setting. An example would be a combination of visual summary feedback on a mobile application and real-time vibratory feedback on current inactivity levels [20, 28, 29]. Smart reminders carry the potential to counteract the often observed decline in engagement in home-based interventions [30, 31].
Previous research has highlighted the positive effect of real-time feedback and daily summaries on the amount of arm use in stroke survivors to change their arm use behavior [28, 32,33,34,35,36]. However, the majority of research evaluating vibratory movement reminders in stroke survivors focused on short periods of only a few hours or days [32, 37], with a small number of participants [33], in a controlled clinical setting [37, 38], or with reminders triggered in a randomized manner [37, 39]. Therefore, it remains to be seen whether activity tracking in combination with smart reminders based on individual movement goals can influence the affected arm use behavior of stroke survivors over several weeks. Furthermore, there is an open question as to the extent to which any induced behavioral changes translate into improved upper limb function [40]. Finally, the feasibility of interacting with such a feedback device during a home-based intervention over several weeks remains to be investigated, particularly how different impairment levels may influence such an intervention.
In the present study, a randomized controlled trial was conducted during which chronic-stage stroke survivors were equipped with arm activity monitors on both wrists for six weeks at their homes [20]. In the intervention group, participants received smart reminders on their affected side, triggered based on the current daily arm activity level and an individually calculated, personalized arm activity goal. We first report on the effect on clinical outcome measures of such an intervention aiming at increasing arm use, primarily focusing on patient-reported affected arm movement quantity and quality. While a previous analysis of the collected data has already provided insights into the positive short-term effect of reminders on arm use [28], we here further aim to evaluate (1) the long-term effect of the reminders on affected arm use behavior and its ability to promote prolonged engagement over the six-week home-based intervention, and (2) how different upper limb impairment levels relate to arm activity behavior during daily life. We hypothesized that triggering smart reminders in the intervention group would increase perceived and objective (measured by activity counts) affected arm use, improve arm function, decrease the less affected-to-affected arm use ratio, and lead to a longer cumulative duration of active arm movement throughout the day. Moreover, we expected an influence of upper limb impairment level on the observed amount of arm activity, with higher levels of arm activity for less impaired participants and vice versa.
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