Exploring the Complexities of Real World Upper Limb Performance after Stroke

Author's School

Graduate School of Arts and Sciences

ORCID

http://orcid.org/0000-0002-8137-2900

Author's Department/Program

Movement Science

Language

English (en)

Date of Award

Spring 5-15-2019

Degree Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Chair and Committee

Catherine E. Lang

Committee Members

Gammon E. Earhart, Susan L. Stark, Rachel G. Tabak, Linda R. Van Dillen

Abstract

Stroke is the leading cause of long-term disability in the United States. Hemiparesis, or weakness on one side of the body, is a common impairment following a stroke. Approximately 80% of individuals with stroke will experience upper limb paresis, with only a small percentage regaining full functional use of their paretic upper limb. Individuals report ongoing difficulties with incorporating their paretic upper limb into routine activities after a stroke. Rehabilitation interventions often try to increase real world upper limb use by improving what an individual is capable of doing (i.e. capacity) in the rehabilitation clinic. Both clinicians and researchers assume that improving in-clinic capacity translates to increased use (i.e. performance) in daily life. For this dissertation, we explicitly tested the assumption that improved upper limb capacity translates to increased upper limb performance, or use, in daily life. Additionally, we explored known factors that influence human behavior (e.g. confidence, motivation) as they relate to upper limb performance, or use, in adults with stroke.

Using sensors (i.e. wrist-worn accelerometers), we tested the assumption that improved in-clinic upper limb capacity translates to increased upper limb performance, or use, in daily life in adults with chronic (≥ 6 months) upper limb paresis post-stroke. Testing this common assumption provided important insights into the efficacy of an in-clinic intervention for improving upper limb use in the free-living environment.

Many personal, environmental, biological, and psychosocial factors influence human behavior and the activities individuals choose to engage in throughout their day. There is a growing emphasis on the potentially powerful role self-efficacy and other psychosocial factors may play in the stroke recovery process. Currently, there are limited data on how psychosocial factors, specifically related to the upper limb, evolve over the critical period of motor recovery (< 6 months post-stroke). Here, we quantified the natural time course of belief further improvement of the paretic upper limb is possible, confidence, and motivation to use the paretic upper limb in daily life, as well as self-reported barriers to upper limb recovery. These data provide a more robust understanding of how psychosocial factors evolve as overall recovery improves. Additionally, these data provide important information about potential mechanisms for action for future upper limb interventions.

The final project of this dissertation maps the natural trajectory of upper limb performance over the first 12 weeks post-stroke. Presently, no studies have examined the natural trajectory of sensor-measured upper limb performance over the same period of time when majority of upper limb motor recovery occurs. We sought to characterize the relationship between upper limb performance and psychosocial factors by testing belief, confidence, and motivation as potential moderators of upper limb performance in daily life.

The reported findings show that in-clinic improvements in upper limb capacity do not directly translate to increased upper limb performance, or use, in daily life in the chronic phase of stroke recovery. Indeed, improving what someone is capable of doing does not indicate their behavior will change in daily life. These results help distinguish between upper limb capacity and upper limb performance. While conceptually similar, they are distinct constructs. Belief, confidence, and motivation to use the paretic upper limb in daily life are remarkably high early, and remain high over the first 24 weeks (6 months) post-stroke. Upper limb performance in daily life does improve early (<12 weeks) after stroke. This change, however, is not moderated by belief, confidence, and motivation. Together, this dissertation provides multi-dimensional information related to upper limb performance after stroke. These results will lead to a more integrated approach for optimizing upper limb performance outcomes, a top priority for people post-stroke.

DOI

https://doi.org/10.7936/4r6p-7919

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