Stroke Arm Longitudinal Study Research Articles

Early prediction of upper limb functioning after stroke using clinical bedside assessments: a prospective longitudinal study

Early and accurate prediction of recovery is needed to assist treatment planning and inform patient selection in clinical trials. This study aimed to develop a prediction algorithm using a set of simple early clinical bedside measures to predict upper limb capacity at 3-months post-stroke. A secondary analysis of Stroke Arm Longitudinal Study at Gothenburg University (SALGOT) included 94 adults (mean age 68 years) with upper limb impairment admitted to stroke unit). Cluster analysis was used to define the endpoint outcome strata according to the 3-months Action Research Arm Test (ARAT) scores. Modelling was carried out in a training (70%) and testing set (30%) using traditional logistic regression, random forest models. The final algorithm included 3 simple bedside tests performed 3-days post stroke: ability to grasp, to produce any measurable grip strength and abduct/elevate shoulder. An 86–94% model sensitivity, specificity and accuracy was reached for differentiation between poor, limited and good outcome. Additional measurement of grip strength at 4 weeks post-stroke and haemorrhagic stroke explained the underestimated classifications. External validation of the model is recommended. Simple bedside assessments have advantages over more lengthy and complex assessments and could thereby be integrated into routine clinical practice to aid therapy decisions, guide patient selection in clinical trials and used in data registries.

Clinical interpretation and cutoff scores for manual ability measured by the ABILHAND questionnaire in people with stroke

ABSTRACT Background The ABILHAND questionnaire is recommended to assess perceived manual ability after stroke; however, more knowledge on interpretability is needed to improve the clinical applicability. Objectives To determine clinically meaningful cutoff scores for different levels of perceived manual ability, assessed by ABILHAND, corresponding to established observed and perceived upper extremity assessments post stroke. Methods This cross-sectional study, part of the Stroke Arm Longitudinal Study (SALGOT) at the University of Gothenburg, included 80 participants with upper extremity impairments after stroke. The self-reported upper extremity functioning was assessed with ABILHAND and Stroke Impact Scale Hand (SIS Hand), and the observed functioning was assessed by Fugl-Meyer Assessment for Upper Extremity (FMA-UE) and Action Research Arm Test (ARAT) at 3 months after stroke. Receiver operating characteristic curve, sensitivity, and specificity analyses were used to determine the cutoffs. Results The overall discriminating accuracy was excellent (AUC > 0.90) for most of the cutoffs and sensitivity and specificity values ranged from 0.73 to 1.0. The ABILHAND cutoff score 1.78 discriminated well between low and good functioning resulting in a 95% match with SIS Hand and 87.5% match with ARAT and FMA-UE. Conclusions The determined cutoff scores of the ABILHAND, validated through established upper extremity assessments, will provide a useful tool to clinicians when interpreting the logit scores and when selecting individualized treatment options. ABILHAND matched well with self-reported SIS Hand, but discrepancies found with observed scales implies that self-perceived assessments should be complemented with observed assessments.

Recovery of arm function during acute to chronic stage of stroke quantified by kinematics.

ObjectiveTo quantify the longitudinal changes in upper limb kinematics within the first year after stroke and to identify the factors that are associated with these changes.MethodsA total of 66 individuals with stroke from the Stroke Arm Longitudinal Study at the University of Gothenburg (SALGOT) cohort were included if they were able to perform the target-to-target task. Data from a virtual reality haptic target-to-target task at 6 time-points between 3 days and 12 months after stroke were analysed by linear mixed models, while controlling for the impact of cofactors (stroke severity, age, type and side of stroke, sex and presence of diabetes).ResultsKinematic variables of movement time, mean velocity and number of velocity peaks improved over time and were positively associated with younger age, less severe stroke and ischaemic compared with haemorrhagic stroke. Most of the improvement occurred within 4 weeks after stroke, although movement time and number of velocity peaks also improved between 3 and 6 months after stroke.ConclusionKinematic variables of movement time, mean velocity and number of velocity peaks were effective in quantifying the longitudinal changes in upper limb kinematics within the first year after stroke.LAY ABSTRACTRecovery of arm function after stroke can be measured using virtual reality technology, which, in contrast to traditional clinical assessments, enables objective and highly precise measurement of different aspects of movement, such as speed and smoothness, termed kinematics. This study aimed to measure the recovery of arm movements between 3 days and 12 months after stroke using kinematic measures, and to identify factors that affect recovery. The results showed that movement time, mean velocity and smoothness improved with time after stroke. These data also suggest that younger stroke survivors, those with less severe stroke, and those with stroke caused by a clot, as opposed to a bleed, undergo greater improvements. Most of the improvement was seen early after stroke, within the first 4 weeks, but both movement time and smoothness also continued to improve between 3 and 6 months. The results show that kinematic analysis can effectively show the changes in arm movement within the first year after stroke.

Upper limb kinematics during the first year after stroke: the stroke arm longitudinal study at the University of Gothenburg (SALGOT)

BackgroundReduction of compensation and improved movement quality indicate recovery after stroke. Since clinical measures alone are often inadequate to distinguish between behavioral recovery and compensation, kinematic analysis of functional tasks has been recommended.ObjectiveTo quantify longitudinal changes and residual deficits in movement performance and quality during the first year after stroke using kinematic analysis of drinking task.MethodsA total of 56 participants with first ever stroke causing upper extremity impairment were extracted from a non-selected stroke unit cohort (Stroke Arm Longitudinal Study at the University of Gothenburg-SALGOT). Participants needed to able to perform the drinking task with the more-affected arm at least on 2 occasions out of 6 (3 days, 10 days, 4 weeks, and 3, 6, and 12 months) during the first year to be included. A cohort of 60 healthy individuals was used as reference. Longitudinal changes were analyzed using linear mixed models.ResultsMovement time, number of movement units, peak angular velocity of the elbow, peak hand velocity, and trunk displacement improved significantly over the first 3 months with a peak at 6 months. Movement time and peak hand velocity reached levels comparable to healthy at 3 months, but number of movement units, peak elbow angular velocity, trunk displacement, and arm abduction remained different from healthy over the first year after stroke.ConclusionsEven when the recovery patterns of kinematics follow the known nonlinear pattern, not all kinematic measures reach the levels in par with healthy controls at one year post stroke. Since the number of movement units, peak angular velocity, trunk displacement, and arm abduction remained impaired over the first year, they might be the most suited measures to distinguish behavioral recovery from compensation strategies.Trial registrationClinicalTrials: NCT01115348. 4 May 2010. Retrospectively registered.

Longitudinal changes of self-perceived manual ability the first year after stroke: a cohort study

BackgroundRecovery patterns of motor function and activity capacity of the upper extremity after stroke have been described, but less is known about longitudinal changes of perceived manual activity performance. The aim of this study was to investigate longitudinal changes of self-perceived manual ability at several timepoints from onset until 12 months post-stroke in a cohort of consecutively recruited individuals with mild, moderate and severe stroke.MethodsThe study included 106 participants from a non-selected cohort with first-ever mild, moderate or severe stroke and impaired upper extremity function (Stroke Arm Longitudinal Study at the University of Gothenburg, SALGOT). Self-perceived manual ability was assessed with the ABILHAND Questionnaire at 3 and 10 days, 4 weeks, 3, 6 and 12 months after stroke. Longitudinal change was assessed by linear mixed models (fixed and random effects) and adjusted models were built by adding effects of cofactors age, gender, stroke severity, living condition and affected hand.ResultsSelf-perceived manual ability increased over time the first year after stroke for the total group and the subgroups. The final adjusted model for the total group included fix-effects of time (expected mean change 0.24 logits per month) adjusted by age (− 0.06 per year) and stroke severity (− 0.19 per NIHSS-score). In addition to significant effect of time, the adjusted models for moderate stroke subgroup included fixed effect of age, and for mild and severe subgroups there was an interaction effect between time and age. Further analyses between time-points showed that no significant change of self-perceived manual ability was detected beyond 3 months post-stroke.ConclusionsSelf-perceived manual ability increased over time the first year after stroke, and this change was to some degree modulated by age and stroke severity at onset. Most of the improvements occurred early, predominantly within the first three months after stroke.

Relationship between self-reported and objectively measured manual ability varies during the first year post-stroke

Self-reported outcomes provide unique insights about an individual’s perceived manual ability after stroke. This study aimed at determining how the relationship between objective kinematic variables obtained from the target-to-target pointing task and self-reported manual ability varies during the first year in individuals after stroke. Sixty-six individuals from the Stroke Arm Longitudinal study at the University of Gothenburg (SALGOT) cohort were assessed using ABILHAND questionnaire and kinematic analysis at five timepoints between the 10th day and 12th month after stroke. Kinematic analysis was performed using a target-to-target pointing task in a virtual environment. Spearman’s correlation was used to determine the extent of correlation between ABILHAND logits and kinematic variables. The correlations varied with time within the first year after stroke. The correlations were low or very low early after stroke and became moderate to high after 6 months for objective measures of movement time and smoothness, but remained low to moderate for mean velocity and low for peak velocity. Due to this discrepancy between self-perceived and objective assessments of arm function, a combination of self-reported and objective assessments of upper limb should be used as outcome measures, especially in the acute and subacute stages after stroke.

Level of physical activity is positively correlated with perceived impact on life 12 months after stroke: A cross-sectional study.

To examine the relationship between, and impact of, level of physical activity and perceived impact on life at 12 months post-stroke. Cross-sectional study. A total of 73 participants with first-time stroke included in the Stroke Arm Longitudinal study at the University of Gothenburg (SALGOT study), Sweden. Perceived impact of stroke was assessed with the Stroke Impact Scale and level of physical activity was assessed with the Saltin-Grimby Physical Activity Scale at 12 months post-stroke. Data were presented with descriptive and logistic regression analyses. The physically active group perceived their strength, emotion, mobility, participation and overall stroke recovery as significantly less problematic compared with the inactive group. Being physically active contributed to higher scores in the Strength domain (odds ratio, OR 7.89) and in the Stroke Recovery domain (OR 18.55). In the Participation domain being physically active (OR 8.01) and independent (OR 0.162) contributed to higher scores. A positive correlation was found between level of physical activity at 12 months post-stroke and levels of strength, participation and stroke recovery.

End-point kinematics using virtual reality explaining upper limb impairment and activity capacity in stroke

BackgroundFor evaluation of upper limb impairment and activity capacity, Fugl-Meyer Assessment of Upper Extremity (FMA-UE) and Action Research Arm Test (ARAT) are recommended to be included in stroke trials. To improve the understanding of mechanisms of motor recovery, and differentiate between restitution and compensation, kinematic analysis is also recommended for assessment of upper limb function after stroke.AimTo determine the extent to which end-point kinematic variables obtained from the target-to-target pointing task were associated with upper limb impairment or activity limitation as assessed by traditional clinical scales in individuals with stroke.MethodsSixty-four individuals, from acute stage up to one year after stroke, were included from the Stroke Arm Longitudinal study at the University of Gothenburg (SALGOT) cohort. They performed a target-to-target pointing task in a virtual environment using a haptic stylus which also captured the kinematic parameters. Multiple linear regression was done to determine the amount of variance explained by kinematic variables on FMA-UE and ARAT scores after controlling for confounding variables.ResultsMean velocity and number of velocity peaks explained 11 and 9% of the FMA-UE score uniquely and 16% when taken together. Movement time and number of velocity peaks explained 13 and 10% of the ARAT score respectively.ConclusionThe kinematic variables of movement time, velocity and smoothness explain only a part of the variance captured by using clinical observational scales, reinforcing the importance of multi-level assessment using both kinematic analysis and clinical scales in upper limb evaluation after stroke.Trial registrationThe trial was registered with register number NCT01115348 at clinicaltrials.gov, on May 4, 2010. URL: https://clinicaltrials.gov/ct2/show/NCT01115348.

Self-perceived impact of stroke: A longitudinal comparison between one and five years post-stroke.

To investigate different aspects of self-perceived impact of stroke 1 and 5 years after stroke onset, with a focus on self-perceived participation. Longitudinal cohort study. Forty-five persons diagnosed with first-time stroke included in the Stroke Arm Longitudinal study at University of Gothenburg (SALGOT). Participants responded to the Stroke Impact Scale, the Impact on Participation and Autonomy and the European Quality of Life 5 dimensions at 1 year and 5 years post-stroke. Wilcoxon signed-rank test was used to check for differences in changes over time between groups. In general, the perceived consequences of stroke were more severe after 5 years compared with at 1 year. Strength, emotion and participation were the areas most affected, along with restrictions in social life and autonomy indoors. Global disability (mRS) was moderately correlated with quality of life. The perceived impact of stroke becomes more prominent with time, even for persons with mild-to-moderate stroke. This study highlights the need for long-term support for persons with stroke.

Recovery of kinematic arm function in well-performing people with subacute stroke: a longitudinal cohort study

BackgroundMost motor function improvements in people who have experienced strokes occur within the first 3 months. However, individuals showing complete or nearly complete arm function recovery, as assessed using clinical scales, still show certain movement kinematic deficits at 3 months, post-stroke. This study evaluated the changes in upper extremity kinematics, in individuals demonstrating minor clinical motor impairments, 3–12 months post-stroke, and also examined the association between kinematics and the subjects’s self-perceived hand abilities during the chronic stage, 12 months post-stroke.MethodsForty-two subjects recovering from strokes and having Fugl-Meyer upper extremity motor assessment scores ≥60 were included from the Stroke Arm Longitudinal Study at the University of Gothenburg (SALGOT). Kinematic analyses of a drinking task, performed 3, 6, and 12 months post-stroke, were compared with kinematic analyses performed in 35 healthy controls. The Stroke Impact Scale-Hand domain was evaluated at the 12-month follow-up.ResultsThere were no significant changes in kinematic performance between 3 and 12 months, post-stroke. The patients recovering from stroke showed lower peak elbow extension velocities, and increased shoulder abduction and trunk displacement during drinking than did healthy controls, at all time points. At 12 months, post-stroke, better self-perceived arm functions correlated with improved trunk displacements, movement times, movement units, and time to peak velocity percentages.ConclusionKinematic movement deficits, observed at 3 months post-stroke, remained unchanged at 12 months. Movement kinematics were associated with the patient’s self-perceived ability to use their more affected hand.Trial registrationClinicalTrials: NCT01115348.

Upper Limb Kinematics in Stroke and Healthy Controls Using Target-to-Target Task in Virtual Reality.

Kinematic analysis using virtual reality (VR) environment provides quantitative assessment of upper limb movements. This technique has rarely been used in evaluating motor function in stroke despite its availability in stroke rehabilitation. To determine the discriminative validity of VR-based kinematics during target-to-target pointing task in individuals with mild or moderate arm impairment following stroke and in healthy controls. Sixty-seven participants with moderate (32-57 points) or mild (58-65 points) stroke impairment as assessed with Fugl-Meyer Assessment for Upper Extremity were included from the Stroke Arm Longitudinal study at the University of Gothenburg-SALGOT cohort of non-selected individuals within the first year of stroke. The stroke groups and 43 healthy controls performed the target-to-target pointing task, where 32 circular targets appear one after the other and disappear when pointed at by the haptic handheld stylus in a three-dimensional VR environment. The kinematic parameters captured by the stylus included movement time, velocities, and smoothness of movement. The movement time, mean velocity, and peak velocity were discriminative between groups with moderate and mild stroke impairment and healthy controls. The movement time was longer and mean and peak velocity were lower for individuals with stroke. The number of velocity peaks, representing smoothness, was also discriminative and significantly higher in both stroke groups (mild, moderate) compared to controls. Movement trajectories in stroke more frequently showed clustering (spider's web) close to the target indicating deficits in movement precision. The target-to-target pointing task can provide valuable and specific information about sensorimotor impairment of the upper limb following stroke that might not be captured using traditional clinical scale. The trial was registered with register number NCT01115348 at clinicaltrials.gov, on May 4, 2010. URL: https://clinicaltrials.gov/ct2/show/NCT01115348.

Self-Perceived Participation and Autonomy at 1-Year Post Stroke: A Part of the Stroke Arm Longitudinal Study at the University of Gothenburg (SALGOT Study)

Identifying factors predicting the long-term outcome of participation and autonomy after stroke is essential for developing individualized rehabilitation interventions. The aim was to describe self-assessed participation and autonomy and to explore factors associated with the same at 1 year post stroke. Participants consisted of 79 persons (mean age = 67) with a first-time stroke at the 1-year follow-up. To investigate perceived participation and autonomy at 1 year, a self-assessment questionnaire, the Impact on Participation and Autonomy-English version (IPA-E) was used. Multivariate logistic regression models were performed using age, gender, stroke severity, and functional dependency at discharge as potential contributors to the perceived level of participation and autonomy. A high percentage (70%-88%) evaluated their functions as fair to very good within all domains of the IPA-E at 1 year post stroke. However, around a fifth experienced their Family role as poor to very poor. Participants' functional dependency at discharge significantly influenced the outcome for the domains of Family role (odds ratio [OR] = 5.66, P < .01), Social relations (OR = 3.23, P < .03), and Autonomy indoors (OR = 3.44, P < .04) at 1 year post stroke. Aspects of the Family role domain deserve further attention in interventions aimed at improving participation and autonomy at 1 year post stroke. The results also indicate that supporting indoor autonomy and social relations of persons with stroke during the acute rehabilitation is important to enhance participation and autonomy at 1 year post stroke.

Early prediction of physical activity level 1 year after stroke: a longitudinal cohort study

ObjectiveTo investigate which variables present prior and early after stroke may have an impact on the level of physical activity (PA) 1 year poststroke.DesignProspective longitudinal cohort and logistic regression analysis.SettingStroke...

Upper extremity recovery after ischaemic and haemorrhagic stroke: Part of the SALGOT study.

The purpose was to explore if there are differences in extent of change in upper extremity motor function and activity capacity, in persons with ischaemic versus haemorrhagic stroke, during the first year post stroke. One hundred seventeen persons with stroke (ischaemic n = 98, haemorrhagic n = 19) and reduced upper extremity function 3 days after onset were consecutively included to the Stroke Arm Longitudinal Study at the University of Gothenburg (SALGOT) from a stroke unit. Upper extremity motor function (Fugl-Meyer Assessment Scale for Upper Extremity (FMA-UE)) and activity capacity (Action Research Arm Test (ARAT)) were assessed at 6 assessments during the first year; age and initial stroke severity were recorded. Differences between groups in extent of change over time of upper extremity motor function and activity capacity were analysed with mixed models repeated measurements method. Significant improvements were found in function and activity in both groups within the first month (p = 0.001). Higher age and more severe stroke had a negative impact on recovery in both groups. Larger improvements of function and activity were seen in haemorrhagic stroke compared to ischaemic, both from 3 days to 3- and 12 months, and from 1 month to 3 months. Both groups reached similar levels of function and activity at 3 months post stroke. Although persons with haemorrhagic stroke had initially lower scores than those with ischaemic stroke, they had a larger improvement within the first 3 months, and thereafter both groups had similar function and activity.

A cross sectional study of upper extremity strength ten days after a stroke; relationship between patient-reported and objective measures.

BackgroundReduced upper extremity function early after a stroke is common, and a combination of strength capacity and patient-reported measures contribute to setting realistic goals. The validity of the patient’s perception of upper extremity strength in relation to objective strength assessments early after a stroke needs to be clarified. The objective was to investigate the relationship between perceived upper extremity strength and measured hand strength at ten days post-stroke.MethodsThis study of 99 patients with reduced upper extremity function at 3 days post stroke, were consecutively included from a stroke unit to the Stroke Arm Longitudinal Study at the University of Gothenburg, (the SALGOT-study). The correlations between two questions from the Stroke Impact Scale (SIS 1a and 1b), and a dynamometer measure of hand strength values (percentage of normative values) were investigated. In order to explain differences between the two types of measurements, the accordance between perceived strength in a dichotomized SIS and objective measures was explored. In SIS 1a and 1b, 1–3 points correspond to reduced strength (<80 % or normative strength values). In SIS 1a and 1b, 4–5 points correspond to normal strength (≥80 % of normative strength values).ResultsThe correlation between the measured strength values and perceived arm strength was rho 0.82 (p = <0.001) and with perceived grip strength rho 0.87 (p = <0.001). Using the dichotomized SIS and the 80 % cut-off correctly classified arm strength in 81 % and grip strength in 84 % of the patients, with a sensitivity of 0.86-0.87, a specificity of 0.62-0.77, positive predicted values of 0.87-0.91 and negative predicated values of 0.64-0.67.DiscussionThe discrepancy between assessed strength capacity and self-perceived strength highlights the importanceof including self-perceived assessments early after stroke, in order to increase knowledge of a patient'sawareness of functioning or lack thereof.ConclusionsTen days after stroke in patients without severe cognitive disabilities, this study suggests that despite high correlations between measures, an objective assessment of arm and hand strength does not always reflect the patient’s perspective. A combination of self-reported and objective strength assessment is requested to enhance in setting of realistic goals early after stroke.Trial registrationClinicalTrials.gov: NCT01115348, May 3, 2010

SALGOT - Stroke Arm Longitudinal study at the University of Gothenburg, prospective cohort study protocol

BackgroundRecovery patterns of upper extremity motor function have been described in several longitudinal studies, but most of these studies have had selected samples, short follow up times or insufficient outcomes on motor function. The general understanding is that improvements in upper extremity occur mainly during the first month after the stroke incident and little if any, significant recovery can be gained after 3-6 months. The purpose of this study is to describe the recovery of upper extremity function longitudinally in a non-selected sample initially admitted to a stroke unit with first ever stroke, living in Gothenburg urban area.Methods/DesignA sample of 120 participants with a first-ever stroke and impaired upper extremity function will be consecutively included from an acute stroke unit and followed longitudinally for one year. Assessments are performed at eight occasions: at day 3 and 10, week 3, 4 and 6, month 3, 6 and 12 after onset of stroke. The primary clinical outcome measures are Action Research Arm Test and Fugl-Meyer Assessment for Upper Extremity. As additional measures, two new computer based objective methods with kinematic analysis of arm movements are used. The ABILHAND questionnaire of manual ability, Stroke Impact Scale, grip strength, spasticity, pain, passive range of motion and cognitive function will be assessed as well. At one year follow up, two patient reported outcomes, Impact on Participation and Autonomy and EuroQol Quality of Life Scale, will be added to cover the status of participation and aspects of health related quality of life.DiscussionThis study comprises a non-selected population with first ever stroke and impaired arm function. Measurements are performed both using traditional clinical assessments as well as computer based measurement systems providing objective kinematic data. The ICF classification of functioning, disability and health is used as framework for the selection of assessment measures. The study design with several repeated measurements on motor function will give us more confident information about the recovery patterns after stroke. This knowledge is essential both for optimizing rehabilitation planning as well as providing important information to the patient about the recovery perspectives.Trial registrationClinicalTrials.gov: NCT01115348