Autonomy support encourages use of more-affected arm post-stroke

Abstract

Background: Autonomy support, which involves providing individuals the ability to control their own behavior, is associated with improved motor control and learning in various populations in clinical and non-clinical settings. This study aimed to investigate whether autonomy support combined with an information technology (IT) device facilitated success in using the more-affected arm during training in individuals with stroke. Consequently, we examined whether increased success influenced the use of the more-affected arm in mild to moderate subacute to chronic stroke survivors.

Methods: Twenty-six participants with stroke were assigned to the autonomy support or control groups. Over a 5-week period, training and test sessions were conducted using the Individualized Motivation Enhancement System (IMES), a device developed specifically for this study. In the autonomy support group, participants were able to adjust the task difficulty parameter, which controlled the time limit for reaching targets. The control group did not receive this option. The evaluation of the more-affected arm's use, performance, and impairment was conducted through clinical tests and the IMES. These data were then analyzed using mixed-effect models.

Results: In the IMES test, both groups showed a significant improvement in performance (p < 0.0001) after the training period, without any significant intergroup differences (p > 0.05). However only the autonomy support group demonstrated a significant increase in the use of the more-affected arm following the training (p < 0.001). Additionally, during the training period, the autonomy support group showed a significant increase in successful experiences with using the more-affected arm (p < 0.0001), while the control group did not exhibit the same level of improvement (p > 0.05). Also, in the autonomy support group, the increase in the use of the more-affected arm was associated with the increase in the successful experience significantly (p = 0.007).

Conclusions: Combining autonomy support with an IT device is a practical approach for enhancing performance and promoting the use of the more-affected upper extremity post-stroke. Autonomy support facilitates the successful use of the more-affected arm, thereby increasing awareness of the training goal of maximizing its use.

Trial registration: The study was registered retrospectively with the Clinical Research Information Service (KCT0008117; January 13, 2023; https://cris.nih.go.kr/cris/search/detailSearch.do/23875 ).

Keywords: Choice behavior; Hemiparesis; Motivation; Self-efficacy; Upper extremity.

Fig. 1

CONSORT (Consolidated Standards of Reporting Trials) diagram for the present study

Fig. 2

A The 55-inch touchscreen was placed on the table to adjust the height. The participant sat on the chair, and the trunk was constrained with a belt to prevent compensational movement. All participants were able to reach the farthest target by adjusting the table height. B One hundred target locations were predefined for the training session. Forty-five targets (filled circles) were used for the test session. C IMES test conditions and blocks. IMES had a test session with and without a time limit. Each condition had free- and forced-choice blocks, and the forced-choice block started from the less-affected (LA) arm to the more-affected (MA) arm. Movement duration (MD) for each arm was measured during these blocks. D Experiment schedule. The first and last weeks were the pre- and post-training tests, and the middle three weeks were training sessions conducted three times per week. TB, training block

Fig. 3

The group comparison between the autonomy support and control groups after the training. Each participant was represented by a dot, and the gray and white violin plots represented the control and autonomy support groups, respectively. The change in the use of the more-affected arm, measured in the free-choice block of the IMES (A), was higher in the autonomy support group after the training. However, there were no significant differences in the change in AAUT-QOM (D) between the pre- and post-training tests or between the control and autonomy support groups. Significant differences were found in performance, measured in the forced-choice block of the IMES (C), FMA (E), WMFT (F), self-efficacy (G), and the marginal difference was found in the movement duration (B), between the pre-training and post-training tests. However, no significant group differences were observed in these variables. NS non-significant, *p < 0.05, **p < 0.01, ***p < 0.001

Fig. 4

The task difficulty parameter (TDP) for the time limit and successful experience during training sessions. The individual TDP values across training sessions were plotted for both the control group (A) and the autonomy support group (B). The averaged TDP, total use, and successful experience during the early and late phases of training were presented (C–E). The failed experience (F), the success rate (G) and the perseverance (H) during the early and late phases were shown. It was observed that the TDP was lower in the autonomy support group compared to the control group. Additionally, the autonomy support group had significantly higher levels of successful experience compared to the control group. NS non-significant, **p < 0.01, ***p < 0.001

Fig. 5

Correlations between changes in successful experience and variables in the IMES. A There was a significant correlation between changes in the use of the more-affected arm and successful experience (p = 0.007). However, Impairment (B) and performance (C) did not show significant correlations with successful experience. Each data point represents an individual from both the control and autonomy support groups