Date Presented 04/05/19
Nonuse of the paretic arm is highly prevalent after stroke. In the chronic stage of stroke, individuals with neglect have similar patterns of paretic arm use as individuals without neglect when matched for paretic arm motor impairment. These findings highlight how critical it is that stroke rehabilitation therapists address paretic arm nonuse in therapy.
Primary Author and Speaker: Emily Grattan
Additional Authors and Speakers: Michelle Woodbury
PURPOSE: Unilateral neglect (UN) is common post stroke and individuals with UN have greater motor impairment, less motor recovery over time, and greater disability than those without UN (Jehkonen, Laihosalo, & Kettunen, 2006; Nijboer, Kollen, & Kwakkel, 2014). Non-use of the paretic arm is common for those with/without UN, yet discrepancies between capacity (i.e. ability to use) and performance (i.e. actual use) are common (Doman, Waddell, Bailey, Moore, & Lang, 2016). Paretic arm use is vital for use-dependent neural reorganization of the lesioned hemisphere underlying motor recovery (Ganguly & Poo, 2013). Individuals with UN may be at greater risk for paretic arm non-use due to their inattention to one side of the body/space. There is a lack of evidence regarding real-world paretic arm use in stroke survivors with UN which is needed to inform treatment approaches. The purpose of this study was to compare real-world paretic arm use between individuals with/without UN post stroke. We hypothesized that when matched for paretic arm motor impairment, individuals with UN would demonstrate significantly less (p<.05) paretic arm use than those without UN.
DESIGN: We conducted a secondary analysis of data from two stroke rehabilitation studies. Baseline data from a randomized controlled trial and an observational study were combined. Participants were recruited through research registries and clinician referrals. Participants were eligible if they were ≥18 years old, had a unilateral stroke, and were able to initiate forward shoulder movement.
METHODS: Community-dwelling participants were assessed using an assessment battery. The Virtual Reality Lateralized Attention Test was used to determine whether subjects had UN (score <18). The Fugl-Myer Upper Extremity Assessment was used to match groups for arm impairment. Participants wore bilateral ActiGraph wrist accelerometers for 2 days during their typical daily routines. Raw accelerometry data, “activity counts”, were used to calculate the Arm Activity Ratio (AAR). The AAR quantifies paretic arm use relative to non-paretic arm use as the ratio of paretic to non-paretic accelerometry counts. An AAR <1.0 indicates paretic arm use is less than non-paretic arm use. The study hypothesis was tested using non-parametric Mann Whitney-U tests (p<.05) to compare the AAR between individuals with/without UN.
RESULTS: Thirty-four participants (UN=17; no UN=17) were included. There were no significant differences between groups for any demographic characteristics or on any clinical assessments, except the National Institutes of Health Stroke Scale (NIHSS); individuals with UN had significantly (p=.02) higher NIHSS scores indicating greater stroke severity. The mean (SD) AAR value for those with and without UN were .28(.02) and .35(.02). There were no significant differences (U=130.5, p=.62) in AAR for those with (Mdn=.24) and without UN (Mdn=.29).
CONCLUSION: The study hypothesis was not supported. There were no differences in paretic arm use when comparing individuals, matched by arm motor impairment, with/without UN. All participants exhibited low AAR values indicating that the paretic arm was rarely used in daily life. It is clear that UN is not the sole factor underlying this non-use phenomena. Additional factors that contribute to paretic arm use must be explored and innovative interventions must be developed. Future studies should examine patterns of paretic arm use in the earlier stages of recovery to elucidate why different patterns of arm recovery exist for those with/without UN.
IMPACT: This research underscores that stroke survivors do not use their paretic arm in daily life. It is critical that therapists address paretic arm use regardless of whether a client has UN.
References
Doman, C. A., Waddell, K. J., Bailey, R. R., Moore, J. L., & Lang, C. E. (2016). Changes in Upper-Extremity Functional Capacity and Daily Performance During Outpatient Occupational Therapy for People With Stroke. Am J Occup Ther, 70(3), 7003290040p7003290041-7003290040p7003290011. doi:10.5014/ajot.2016.020891
Ganguly, K., & Poo, M.M. (2013). Activity-Dependent Neural Plasticity from Bench to Bedside. Neuron, 80(3), 729-741. doi:10.1016/j.neuron.2013.10.028
Jehkonen, M., Laihosalo, M., & Kettunen, J. (2006). Impact of neglect on functional outcome after stroke: A review of methodological issues and recent research findings. Restorative neurology and neuroscience, 24, 209-215.
Nijboer, T. C., Kollen, B. J., & Kwakkel, G. (2014). The impact of recovery of visuo-spatial neglect on motor recovery of the upper paretic limb after stroke. Plos One, 9(6), e100584. doi:10.1371/journal.pone.0100584
