Early upper limb rehabilitation after stroke: A study of current upper limb use and the influence of increased upper limb use on post-stroke recovery

Abstract

Upper limb (UL) recovery after stroke is limited. Research has shown that early rehabilitation and increasing UL use are crucial to impact neuroplasticity and maximize recovery after stroke. Past studies have shown that UL use during early inpatient stroke rehabilitation is insufficient. It is therefore important to increase UL use during early rehabilitation and therefore, maximize recovery. To promote UL use, it is important to understand current use in real world environments. After review of the literature, knowledge gaps in UL use have been identified. Firstly, as UL recovery varies according to impairment level it is plausible that people with different levels of impairment may use their paretic UL differently, but no investigations had examined UL use by impairment level early post-stroke. Secondly, limited information on UL use outside therapy has been found. Thirdly, little attention has been given to factors that may influence UL use by impairment level. Most studies have investigated the impact of UL motor impairment on UL use, however there is a breadth of other physical, cognitive-social and environmental factors that have not been fully explored. After better understanding UL use, it is important to consider innovative strategies to increase UL use in the face of increasing stroke burden and limited resources. An early self-directed UL program was developed in this thesis, termed the Self-Empowered UL Repetitive Engagement (SURE) program, to empower people with stroke to increase UL use. The aim of this thesis are to fill the knowledge gaps in early UL use and investigate the feasibility and impact of the SURE program on UL use and post-stroke recovery. This thesis includes five studies to address this aim.Study 1 used both observation and accelerometry measures to characterize UL use in people with different levels of UL impairment (N=12) within 28 days post-stroke. The results showed that people with different levels of UL impairment used their paretic UL differently. Comparison of UL use between observation and accelerometry revealed a moderately-strong correlation (ICC>0.852) across 12 hours of observation, during and outside therapy sessions. This demonstrates that accelerometry can be used to efficiently capture longer periods of UL use during early rehabilitation.To further understand UL use post-stroke in hospital, a prospective cross-sectional study using accelerometry was performed in Study 2 to investigate paretic UL use in people ≤4 weeks post-stroke. Stroke survivors with mild, moderate and severe UL impairment (N=60) were compared with age-matched non-stroke community controls (N=30). Study 2 results highlighted different patterns of UL use in the three impairment groups, with median(IQR) paretic UL use for mild, moderate and severe UL impairment groups of 6.7(3.3), 4.5(3.8), 1.7(0.7) hours respectively. Paretic UL use and use ratio (paretic/non-paretic UL use) were greater during therapy than outside therapy in moderate and severe groups (p 0.118).Taken together, these studies highlight that different strategies may be required to increase UL use in stroke survivors with different impairment levels, as paretic UL use is different across impairment levels during early rehabilitation. A self-directed UL program such as the SURE program is feasible and able to increase UL use. This warrants future research with a larger sample size to determine the efficacy of the SURE program.