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Upper Extremity Use in People with Hemiparesis in the First Few Weeks After Stroke

Lang, Catherine E. PT, PhD; Wagner, Joanne M. PT, PhD, ATC; Edwards, Dorothy F. PhD; Dromerick, Alexander W. MD

Journal of Neurologic Physical Therapy: June 2007 - Volume 31 - Issue 2 - p 56-63
doi: 10.1097/NPT.0b013e31806748bd
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The purposes of this report were to: 1) determine the amount of upper extremity use in people with hemiparesis post stroke during their inpatient rehabilitation stay, and 2) to examine the relationships between upper extremity use and impairments and activity limitations at this early time point after stroke. We studied 34 subjects with mild-to-moderate acute hemiparesis (mean time since stroke = 9.3 days) and 10 healthy control subjects. Upper extremity use was measured over 24 hours using bilateral wrist accelerometers. Upper extremity impairments and activity limitations were measured using standard clinical techniques and tests. We found that healthy control subjects use their dominant and nondominant upper extremities 8–9 hours per day. Hemiparetic subjects used their affected and unaffected upper extremities substantially less than control subjects, 3.3 and 6.0 hours per day, respectively. Seven of ten impairment level measures and each of the activity level measures were related to affected upper extremity use. The impairment measures that were related to upper extremity use were those measures that assessed the ability to activate muscles (ie active range of motion and force production) and the measurement of shoulder pain. Our data show that affected upper extremity use is minimal during the inpatient rehabilitation stay, especially given that patients in this setting are required to have 3 hours of therapy per day. We speculate that accelerometer measurements of upper extremity use could be used in a variety of settings and that the objective information they provide would be of great value to clinicians as they select treatments and evaluate progress.

Program in Physical Therapy (C.E.L., J.M.W., A.W.D), Program in Occupational Therapy (C.E.L., D.F.E., A.W.D), Department of Neurology (C.E.L., D.F.E., A.W.D), Washington University School of Medicine, St. Louis, Missouri; National Rehabilitation Hospital (A.W.D), Washington, DC

Address correspondence to: Catherine E. Lang, E-mail: langc@wustl.edu

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INTRODUCTION

The ultimate goal of stroke rehabilitation is to promote independence and a return to productive activities in the real world, not just in the hospital, clinic, or laboratory. For individuals with upper extremity paresis post stroke, the goal is often to restore sufficient sensorimotor control to the limb so that the person can participate in home and community life as he or she desires. A current challenge facing rehabilitation professionals is to decipher how measurements obtained during a clinical evaluation may relate to “real world” activity. This is a particular challenge in the inpatient rehabilitation setting where the hospital environment is substantially different from the home environment.

We were recently surprised to find that sensorimotor impairments measured during a detailed evaluation were only somewhat related to how the upper extremity moved during a reaching task.1 In people with acute hemiparesis studied during their inpatient rehabilitation stay, impairments in the ability to activate upper extremity muscles (ie active range of motion and isometric force production) had better relationships with reaching performance than measures of somatosensation (ie light touch, joint positions sense, pain) and measures of tone (Modified Ashworth Scale). Yet, the strength of these relationships was modest since all impairments together could predict only 25–44% of the variance in reaching performance. These data highlight the critical need to further investigate relationships between measurement obtained during clinical evaluations and how the upper extremity moves early after stroke, a time when the majority of rehabilitation services are used and rehabilitation monies are spent.2,3 Since reaching is only one of many possible upper extremity movements, we hypothesized that the numerous impairment measures obtained during a clinical evaluation may be more strongly related to overall upper extremity use.

We now extend our earlier work to examine upper extremity use, as measured by accelerometry, in the inpatient rehabilitation setting. Accelerometry has recently been used to assess real world upper extremity use4,5 and wrist accelerometers have been shown to be valid and reliable measures of upper extremity use in people with chronic hemiparesis.6,7 The first purpose of this report was to determine the amount of upper extremity use in people with hemiparesis post stroke during their inpatient rehabilitation stay. The second purpose was to examine the relationships between upper extremity use and impairments and activity limitations at this early time point after stroke.

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METHODS

Subjects

Thirty-four subjects with hemiparesis were evaluated an average of 9.3 ± 4.2 days after stroke while in an inpatient rehabilitation facility (Table 1). In general, our hemiparetic group was comprised of individuals with mild to moderate acute hemiparesis, no or minimal cognitive deficits, and minimal to mild somatosensory loss (Table 2). Hemiparetic subjects were participating in VECTORS (Very Early Constraint-induced Therapy for Recovery of Stroke), a single-center randomized control trial investigating early motor recovery of the UE following stroke conducted at the Washington University School of Medicine. Subjects were included in the trial if they had: 1) an ischemic or hemorrhagic stroke within 28 days of admission to inpatient rehabilitation; 2) persistent hemiparesis as indicated by a score of 1 to 3 on the motor arm item of the National Institutes of Health Stroke Scale (NIHSS); 3) the presence of some upper extremity voluntary activity as indicated by the ability to move proximal and/or distal joints against gravity; 4) evidence of preserved cognitive function, as indicated by scores of 0 or 1 on the consciousness items of the NIHSS; 5) the ability to follow two step commands; and 6) no upper extremity injury or conditions that limited use prior to the stroke. Subjects were excluded from the trial if they: 1) could not give informed consent; 2) had clinically significant fluctuations in mental status in the 72 hours prior to enrollment; 3) had hemispatial neglect; and/or 4) were not expected to survive one year due to other illnesses (eg cardiac disease, malignancy). The data reported in this study are from the subjects’ prerandomization baseline assessment. Subject characteristics and scores on impairment and activity measures are provided in Table 1 and 2; data from this cohort have been reported elsewhere.1,8–10

TABLE 1

TABLE 1

TABLE 2

TABLE 2

Ten age-matched, right-handed healthy control subjects (mean age 59 ± 13 years; 5 females, 5 males) were also studied. These subjects were free of neurologic or orthopedic conditions that might affect their upper extremities. The Institutional Review Board of Washington University School of Medicine approved the protocol for this study. Informed consent was obtained from all subjects prior to testing.

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Measurement Of Upper Extremity Use

Uni-axial accelerometers (model 7164-2.4 Activity Monitors, MTI Health Services, Fort Walton Beach, FL) were placed on each upper extremity following a published protocol.6,7 For the upper extremity and for the duration of time measured, uni-axial accelerometers provide the same information as multi-axial accelerometers about whether or not the limb is moving.11 This may be because upper extremity movements nearly always involve joint rotations in multiple planes of movement, and not in a single plane. Briefly, accelerometers were placed on the distal arm just above the wrist with the axis parallel to the length of the arm. Data was collected for 24 hours, stored in two-second epochs, and downloaded onto a personal computer for subsequent analyses. Subjects were instructed to wear the accelerometer at all times during the 24 hour data collection period except for times when the devices would be exposed to water (eg personal hygiene). The 24 hour period was chosen because: 1) that is the length of one day, enabling us to capture activity that might occur outside of the typical workday or therapy hours, and 2) people with hemiparesis and controls were less interested in participating or less-compliant with wearing them if they had to be worn for longer periods.

We note that accelerometer measures of upper extremity use have some limitations (see Discussion) since they provide information about whether or not the upper extremity was moving, but not information about what it was moving to do (eg functional task versus arm swing during gait). Thus, measures of upper extremity use obtained via accelerometry may be considered small overestimations of the time spent using the upper extremity for functional activities.

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Measurement Of Upper Extremity Impairments

We measured sensorimotor impairments that are commonly assessed by physical and occupational therapists in stroke rehabilitation settings. Light touch sensation was measured at 4 locations on the arm using the 5 monofilament minikit (North Coast Medical, Morgan Hill, CA). The 4 locations were: the dorsal web space between the thumb and index finger, the dorsal aspect of the midforearm, slightly superior to the elbow on the lateral aspect of the arm, and the anterior aspect of the shoulder. The smallest monofilament sensed at each location was recorded and given an ordinal score.12 Ordinal scores were assigned as follows: perception of 2.83 monofilament = 0, perception of 3.61 monofilament = 1, perception of 4.31 monofilament = 2, perception of 4.56 monofilament = 3, perception of 6.65 filament = 4, and unable to perceive the 6.65 monofilament = 5. Because scores across sites were well-correlated (r values ranged from 0.75–0.92, p values < 0.01), a composite light touch sensation score was calculated by averaging the ordinal scores from the 4 test sites. Joint position sense was measured at the 1st metacarpal-phalangeal joint following standard clinical techniques. Joint position sense was scored as normal (correct response ≥ 3 of 5 trials) or impaired (correct response < 3 of 5 trials). Elbow joint spasticity was measured using the Modified Ashworth Scale.13 Shoulder pain was measured immediately prior to testing using a 10 point rating scale. Shoulder flexion, elbow flexion, and wrist extension active ranges of motion (AROM) against gravity were measured while the subject was seated using motion analyses techniques.1 Motion analyses techniques were used because it was part of a larger testing protocol for the VECTORS trial, where subjects underwent kinematic analyses of reaching and grasping movements. AROM in degrees was calculated as the total excursion of the joint against gravity. AROM values from the motion analyses techniques are not different than those that can be obtained with a goniometer. Shoulder flexion values were limited to 90° for all subjects because of the testing protocol. Strength of the shoulder, elbow, and wrist flexor and extensors were measured using a hand-held dynamometer (MICROFET2, Hogan Health Industries, Draper, UT) following a standard protocol14 except that subjects were seated during testing. Maximal voluntary isometric strength values were recorded in lbs. for each muscle group tested. Subjects unable to produce force against the dynamometer were given a score of 0 lbs. for that particular muscle group. The strength of each muscle group was expressed as the ratio of affected side to unaffected side maximal isometric force. Maximum grip strength was measured as part of the Wolf Motor Function Test in kilograms (see below).

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Measurement of Upper Extremity Activity

We measured activity using 3 clinical scales: the Action Research Arm Test (ARAT), the Wolf Motor Function Test (WMFT), and the Functional Independence Measure (FIM). All evaluations were performed by trained study personnel.

The ARAT assesses activity limitations of the upper extremity. It includes 19 items divided into four subscales: grasp, grip, pinch, and gross movement. Reliability (interrater 0.99, test-retest 0.98) and validity of the ARAT have been well established.15–20 Performance on the ARAT is strongly correlated to performance on the upper extremity motor portion of the Fugl-Meyer scale and to performance on the Box and Block test.16,21 Item scores on the ARAT are summed to create subtest and full-scale scores with a maximum score of 57, indicating normal performance.

The WMFT is a 17-item measure used to quantify activity limitations of the upper extremity. It is comprised of 2 strength items and 15 timed task performance items. The task performance items begin with the measurement of simple proximal movements and progress to more complex distal and whole limb movements. The WMFT yields two scores: 1) a functional ability score quantifying quality of performance, and 2) a timed score quantifying speed of performance in seconds. The test has published reliability and validity.22–25 In the VECTORS study, the key use task was not collected, and the results reported do not include this item.

The FIM is an 18 item global activity measure incorporating concepts and items of functional performance including activities of daily living, bowel and bladder function, social cognition, functional communication, and functional mobility.26 The FIM is scored on a 7 point ordinal scale, where a score of 1 indicates dependence and a score of 7 indicates independence. Reliability and validity of the FIM have been well established.27–29 The FIM was included in this report because it is frequently used in many inpatient rehabilitation centers and by other rehabilitation professionals. The 15 items requiring motor function were summed to create a FIM motor score, while a subset of 5 items relating to upper extremity use were summed to create a FIM upper extremity score.10,20 Because of the way the items are worded, upper extremity items could have been completed with the paretic or the nonparetic limb. For this study, the FIM was collected during a patient interview and performance of activities was not observed. Thus, scores reflect the self-perceived ability to complete the items.

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Analyses

The raw data obtained from the accelerometer were in “activity counts”, a unitless number representing the summation of all accelerations recorded during an epoch (here, an epoch = 2 seconds). Custom software was therefore written in the C programming language to transform the raw accelerometer data using an established methodology that provides a valid and reliable measure of the duration of upper extremity use.6,7 The transformation involved dichotomizing the raw value for each two-second epoch around a threshold of 1. This is a low threshold, such that even very slow or very small movements in a paretic upper extremity would be counted as movement. If the raw count for the epoch was ≥ 1, then the upper extremity was considered to have been moving during that 2 second time period. If the raw count for the epoch was < 1, then the upper extremity was considered to have been still for that 2 second time period. The sum of the epochs when the upper extremity moved therefore represented the duration of upper extremity movement over the 24 hour data collection period. For ease of communication, this summed variable was converted from seconds to hours.

Statistical analyses were conducted using SPSS for Windows Version 13.0 and the criterion for statistical significance was p < 0.05. Accelerometry data were normally distributed as assessed by Kolmogorov-Smirnov tests. A repeated measures ANOVA with 2 factors (group, side) was used to look for differences in dominant and nondominant upper extremity use in the control group and unaffected and affected upper extremity use in the hemiparetic group. When significant main and interaction effects were found, post hoc t tests with Bonferroni corrections for multiple comparisons were used to determine where the differences existed. Spearman correlation coefficients were used to examine relationships between upper extremity use and impairment and activity level measures. Nonparametric correlational analyses were chosen because, although upper extremity use was normally distributed, other measures were not normally distributed and/or were measured on ordinal rating scales. Based on our sample size, correlation coefficients greater than 0.33 were significant at p < 0.05 and coefficients greater than 0.42 were significant at the p < 0.01 level. The following criteria are provided to assist in the interpretation of the magnitude of the correlation coefficients. Coefficients of 0.25 or below were considered low, coefficients ranging from 0.26 to 0.50 were considered fair, coefficients from 0.51 to 0.75 were considered good, and those greater than 0.75 were considered excellent.30

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RESULTS

Amount of Use

Using accelerometers, we measured upper extremity use during a 24 hr period in a group of healthy controls and a group of people with acute hemiparesis post stroke (Fig. 1). The control group used their dominant upper extremity 8.7 ± 1.3 hrs (range 6.5–10.5) and used their nondominant upper extremity 8.4 ± 1.2 hrs (range 6.2–10.2). The hemiparetic group used both arms for less time than the control group (main effect of group, p < 0.0001). Affected upper extremity use in the hemiparetic group was 3.3 ± 1.8 hrs (range 0.8–8.1) and unaffected upper extremity use was 6.0 ± 1.6 hrs (range 3.2–9.4). Affected upper extremity use was not different between those with the dominant side affected and those with the nondominant side affected by the stroke (p = 0.40). There was a differential effect of upper extremity use between the two groups (group × side interaction, p = 0.02). Post hoc testing indicated that that dominant and nondominant use were similar in the control group (p = 0.55) and were greater than either affected or unaffected use (p values < 0.01). Affected upper extremity use was less than unaffected upper extremity use in the hemiparetic group (p < 0.0001). Unaffected side use in the hemiparetic group was positively correlated to affected side use (r = 0.55, p < 0.01), such that hemiparetic subjects who used their affected upper extremity for shorter durations often used their unaffected upper extremity for shorter durations also. Age was negatively correlated with affected side use (r = −0.60, P < 0.01) but was not correlated with unaffected side use (r = −0.26, p > 0.05).

FIGURE 1.

FIGURE 1.

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Relationships Between Use and Impairment and Activity Measures

Correlations between affected upper extremity use in the hemiparetic group and impairment and activity level measures are shown in Table 3. For the impairment level measures, AROM, strength, and shoulder pain were positively correlated with affected upper extremity use, while spasticity and somatosensory measures were not significantly correlated. Among the impairment level measures, wrist extension AROM had the highest correlation coefficient with affected upper extremity use, such that increased wrist extension AROM was related to increased use. (Correlations between impairment level measures themselves have been previously reported.1) Clinical tests of upper extremity activity and global activity were correlated with affected upper extremity use (Table 3). Better upper extremity function as measured by the ARAT and WMFT was related to more upper extremity use. Upper extremity use was significantly related to both FIM motor score and FIM upper extremity score. To further illustrate the nature of these relationships and the variability within the data, scatter plots of affected upper extremity use versus wrist extension AROM (Fig. 2A), Wolf Motor Function Test function scores (Fig. 2B), and FIM Motor scores (Fig. 2C) are provided.

TABLE 3

TABLE 3

FIGURE 2.

FIGURE 2.

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DISCUSSION

Healthy, neurologically-intact adults use their dominant and nondominant upper extremities 8–9 hours per day. After mild-to-moderate stroke, people with hemiparesis in the inpatient rehabilitation setting use their affected and unaffected upper extremities substantially less than the healthy adults. Seven of the ten impairment level and each of the activity level measures were related to affected upper extremity use. The impairment measures that were related to upper extremity use were those measures that assessed the ability to activate muscles (i.e. active range of motion and force production) and the measurement of shoulder pain.

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Amount of Use in Control and Hemiparetic Samples

Our small sample of community-dwelling, neurologically-intact adults used their dominant and nondominant upper extremities about 1/3 of the time in a 24 hour period. This amount of use is similar to a preliminary report recording dominant hand, thenar muscle activity during 24 hour periods.31 Thenar muscles may be activated more during the day than other upper extremity muscles since thenar muscles are involved in a variety of grasping tasks when other upper extremity muscle may be more quiescent (eg grasping a steering wheel while driving).32 The fact that our data collected with accelerometers matches this preliminary data collected with surface electromyography provides concurrent validity for both measurement techniques. Earlier surface electromyography studies found other individual upper extremity muscles activated for much smaller periods of time (<2 hours),32–34 using higher thresholds to determine the presence or absence of activity. Interestingly, activity in different upper extremity muscles was not correlated,34 suggesting that longer estimations of amount of overall arm use (which may be closer to the values obtained here) might have been possible if activity of multiple upper extremity muscles had been summed. Our finding that the hours of dominant and nondominant upper extremity use are not different supports observations that the upper extremities are most often used together to perform bimanual tasks during daily activity.35 It may seem unfair to compare upper extremity use in community dwelling, neurologically-intact individuals with upper extremity use in hospitalized individuals with hemiparesis post stroke. In the inpatient setting, many regular daily activities are limited. We consider it likely that the inpatient setting reduces upper extremity use by itself, regardless of whether or not an individual has hemiparesis. This could be tested directly in future studies by including an inpatient control group, such as people with general medical or orthopedic conditions. We chose a community-dwelling control group for the current study because we wanted to see just how close or how far acute hemiparetic upper extremity use was from where it may need to be. Our control group averages can now be used as a goal to which people with hemiparesis post stroke can strive to attain.

As mentioned above, our data on the average duration of hemiparetic upper extremity use was obtained in the inpatient rehabilitation setting. Given that the expectation for therapy services during inpatient rehabilitation in the United States is 3 hours of therapy per day, it is noteworthy that the average upper extremity use for the affected side was 3.3 hours per day. These data from a 24 hour period are consistent with the finding that patients in stroke units are inactive for the majority of their day, as observed from 8 am to 5 pm.36 Thus, even in what is often considered the most intensive rehabilitation setting for people post stroke, the affected upper extremity is being used for only a small portion of the day. The important clinical question that follows from our study is: how can we now increase affected upper extremity use in this population? The answer to this question requires further study. Moreover, a clinically useful answer to this question needs to be both economically feasible and realistic to implement.

We were surprised that upper extremity use on the unaffected side was also lower in the hemiparetic group compared to the control group. Additionally, affected and unaffected upper extremity use in the hemiparetic group were positively correlated, indicating that when the affected hand was used only a small amount, the unaffected hand was generally used only a small amount also. We had wrongly expected that unaffected upper extremity use would be high to compensate for the limited ability to use the affected side. It is possible that the low use on the unaffected side is a due to the fact that subjects were studied while they were inpatients, where the lower accelerometer values in the unaffected side of people with hemiparesis reflect a general decrease in activity. While rehabilitation inpatients are routinely encouraged to do as much as possible for themselves, the hospital environment may not require the daily activities the patient would have to accomplish at home (eg meal preparation, laundry). It is possible that the positive relationship between affected and unaffected upper extremity use would be reversed (a negative correlation) in people with hemiparesis discharged to the home environment.

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Relationships Between Use and Impairment and Activity Measures

Affected upper extremity use was correlated to impairment and activity level measures. Because accelerometer use reflects what the subject actually does during the 24 hour period (versus what they may be capable of doing in the clinic or laboratory), we had anticipated that the strongest correlations would be with similar measurements, ie activity measurements of paretic limb function. We found good correlations between upper extremity use and the FIM motor and FIM upper extremity scores, indicating that individuals who reported greater independence with mobility and self-care tended to use their upper extremity more. This was interesting because, as used here, the FIM scores provide information about the self-perceived global capability and amount of assistance needed for daily activities, but are not specific to paretic limb capabilities. We speculate that these relationships are good because it is early after stroke, and that in other environments (eg home) and at later time points post stroke, these relationships could become much weaker. Equally strong relationships were found between upper extremity use and the WMFT scores, measures that are specific to upper extremity capabilities and were originally designed to be used in a laboratory for research studies.22,23 This strong relationship means that individuals with better hand function used their upper extremity more. The good correlations with the WMFT scores provide evidence for the construct validity of the WMFT. Interestingly, equally strong relationships were also found between upper extremity use and wrist extension active range of motion where those individuals who had greater wrist extension active range of motion used their upper extremity more. Our data lend support to the validity of selecting wrist extension active range of motion as a meaningful criterion for implementing constraint-induced movement therapy in the subacute phase after stroke.37

From a clinical perspective, the good correlation with wrist extension active range of motion implies that this is an important impairment to measure during evaluations of people with hemiparesis post stroke. When making clinical decisions based on examination findings, our data suggest that wrist extension active range of motion measures should be weighted more heavily compared to other impairment measures. The low and nonsignificant correlations between upper extremity use and spasticity and somatosensory measures implies that results from these impairment measures should be weighted less heavily in the clinical decision making process. The positive correlation of 0.41 between upper extremity use and shoulder pain is also highly clinically relevant. This finding indicates that those who used their upper extremity more had greater pain. Overall, average pain ratings were low (1/10) and this positive correlation between use and pain highlights the importance of managing hemiparetic shoulder pain earlier on, before more intense pain may discourage upper extremity use. Lastly, caution should be used when interpreting our correlations with respect to individual patients because there is considerable variability within the sample as can be seen in the scatter plots of Figure 2.

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Limitations

Our study population was recruited for a clinical trial based on the presence of hemiparesis post stroke. Based on the inclusion and exclusion criteria for the clinical trial, our subjects represent a subgroup of people with hemiparesis seen in inpatient rehabilitation. This subgroup had relative pure motor hemiparesis, where muscle strength on the affected side ranged from 0–100% of the strength on the unaffected side (Table 2). They generally had minimal deficits in somatosensation and were largely free of cognitive, attentional, and language deficits due to the exclusion criteria. Thus, the amount of upper extremity use found here cannot be generalized to all patients with hemiparesis post stroke or to other time points post stroke. We speculate that the subpopulation studied here are the individuals who might have the greatest amount of upper extremity use shortly after stroke because they are relatively free of deficits in other domains. If this is the case, then people with stroke-induced deficits in multiple domains might be expected to use their upper extremities for even smaller amounts of time than the values provided here.

We used accelerometry to measure the amount of upper extremity use for a 24 hour period. While wrist accelerometers have been shown to produce valid and reliable measures of upper extremity use in people with hemiparesis,6,7 they are not perfect measurement instruments. The term “upper extremity use” is not synonymous with the term “upper extremity purposeful use”. When obtaining the number of hours with accelerometry, movements such as arm swing during gait are counted equally with movements that are more purposeful, such as feeding oneself. Movements such as riding passively in a wheelchair however do not register on the accelerometers. Thus, the values provided here potentially overestimate actual purposeful upper extremity use in our subjects. It is also possible that collecting data for only 24 hours biased our results in one direction or the other. This could have happened if the accelerometers were worn on a day when a particular subject was unusually active or unusually inactive. We believe however, that additional random error generated with only a 24 hour data collection period (vs a 48 or 72 hour period) would be minimal with our hemiparetic sample size (n = 34).

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CONCLUSIONS

We found that people with hemiparesis post stroke use their affected upper extremity only a small amount while in the inpatient rehabilitation setting. Our data provide information to clinicians about how much the upper extremity is used during acute inpatient rehabilitation and how upper extremity use is related to other clinical measurements they may take.

In the future, accelerometry measurements of upper extremity use could become part of routine clinical practice. Commercially-available accelerometers are slightly larger than a big watch and relatively easy to apply. They require a few minutes of set-up prior to placing them on a patient and a few minutes after removing them to obtain the data. Based on their time and monetary costs, it may be feasible to use them as a clinical tool to measure individual patient’s progress over the course of therapy, especially in the inpatient rehabilitation setting. If the ultimate goal of upper extremity rehabilitation is to promote independence and a return to productive activities in the real world, not just in the hospital, clinic, or laboratory, then objective information about actual upper extremity use provided by wrist accelerometers would be of great value to clinicians as they select treatments and evaluate progress.

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ACKNOWLEDGMENTS

This work was supported by NIH NS41261, HD047669, James S. McDonnell Foundation 21002032, and the Foundation for Physical Therapy Promotion of Doctoral Studies Scholarship. We thank Lily Hu for her assistance with data collection and processing and the therapists who assisted with recruitment and scheduling during this project.

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© 2007 Neurology Section, APTA