How Active Are People With Stroke?

Physical Fitness Training after Stroke, Time to Implement what we Know: More Research is Needed

Stroke survivors experience marked reduction in physical activity and fitness. Regular physical fitness training, started early poststroke, could help recovery in the long term and is recommended in many clinical guidelines. However, implementation of programs is hampered by our current lack of knowledge about what interventions are most effective and how best to support stroke survivors to exercise. In the United Kingdom and Australia, there are educational programs for exercise professionals to enable them to safely and effectively deliver exercise to stroke survivors; and in the United Kingdom, community exercise training programs are being developed to follow-on from usual rehabilitation. As with many areas of life after stroke, further research is still needed. We need to know more about the effect of exercise training on common poststroke problems such as fatigue, depression and falls. Importantly, we need to understand the perceived barriers and motivators to exercise after stroke, and how to enhance adherence to the exercise programs that are in current development. However, these knowledge gaps should not prevent us from implementing what we know; and we would urge health professionals to work with exercise professionals to develop pathways into exercise for stroke survivors.

Mood and Balance are Associated with Free-Living Physical Activity of People after Stroke Residing in the community

Purpose. To determine which characteristics are most associated with free-living physical activity in community-dwelling ambulatory people after stroke. Method. Factors (age, gender, side of stroke, time since stroke, BMI, and spouse), sensory-motor impairments (weakness, contracture, spasticity, coordination, proprioception, and balance), and non-sensory-motor impairments (cognition, language, perception, mood, and confidence) were collected on 42 people with chronic stroke. Free-living physical activity was measured using an activity monitor and reported as time on feet and activity counts. Results. Univariate analysis showed that balance and mood were correlated with time on feet (r = 0.42, 0.43, P < 0.01) and also with activity counts (r = 0.52, 0.54, P < 0.01). Stepwise multiple regression showed that mood and balance accounted for 25% of the variance in time on feet and 40% of the variance in activity counts. Conclusions. Mood and balance are associated with free-living physical activity in ambulatory people after stroke residing in the community.

Are patients 1 year post-stroke active enough to improve their physical health?

PURPOSE

This study aimed to quantify physical activity one year post-stroke--by means of a multifaceted approach combining absolute, relative, and self-reported measures of physical activity (PA)--and to investigate their mutual associations. The determinants of PA were explored.

METHOD

Daily PA was measured in 16 mildly disabled stroke patients (median RMA-GF score of 12 (IQR = 10-12.5)) using a heart rate monitor, a pedometer, the Baecke Physical Activity Questionnaire and the Physical Activity Scale for individuals with physical disabilities. Potential determinants were age, gender, functional mobility, peak exercise capacity, mood, participation and hours of daylight.

RESULTS

On average, stroke participants had a good baseline level of activity (44 ± 39 min/day spent moderate active, 6428 ± 4117 steps/day), but only three (19%) performed more than 10,000 steps/day, required for health benefits. Functional mobility, cardiorespiratory fitness, mood and participation were related to the total daily steps, but not to the time spent in moderate intense activities. Discrepancies between absolute (frequency and duration) and relative (intensity) measures of PA exist regarding the achieved quantity and its potential determinants.

CONCLUSIONS

It is not only important to be active, but to be active enough to improve health. Health recommendation for stroke survivors to perform moderate intense PA needs to be translated into a pedometer-based step goal.

Physical activity in the prevention and treatment of stroke

The role of physical activity in the prevention of stroke is of great interest due to the high mortality and significant impact of stroke-related morbidity on the individual and on healthcare resources. The use of physical activity as a therapeutic strategy to maximise functional recovery in the rehabilitation of stroke survivors has a growing evidence base. This narrative review examines the existing literature surrounding the use of exercise and physical therapy in the primary and secondary prevention of stroke. It explores the effect of gender, exercise intensities and the duration of observed benefit. It details the most recent evidence for physical activity in improving functional outcome in stroke patients. The review summaries the current guidelines and recommendations for exercise therapy and highlights areas in which further research and investigation would be useful to determine optimal exercise prescription for effective prevention and rehabilitation in stroke.

The importance of psychological and social factors in influencing the uptake and maintenance of physical activity after stroke: a structured review of the empirical literature

Background. People with stroke are not maintaining adequate engagement in physical activity (PA) for health and functional benefit. This paper sought to describe any psychological and social factors that may influence physical activity engagement after stroke. Methods. A structured literature review of studies indexed in MEDLINE, CinAHL, P&BSC, and PsycINFO using search terms relevant to stroke, physical disabilities, and PA. Publications reporting empirical findings (quantitative or qualitative) regarding psychological and/or social factors were included. Results. Twenty studies from 19 publications (9 surveys, 1 RCT, and 10 qualitative studies) were included. Seventeen studies reported findings pertinent to psychological factors and fourteen findings pertinent to social factors. Conclusion. Self-efficacy, physical activity beliefs, and social support appear particularly relevant to physical activity behaviour after stroke and should be included in theoretically based physical interventions. The Transtheoretical Model and the Theory of Planned Behaviour are candidate behavioural models that may support intervention development.

Exercise perceptions among people with stroke: Barriers and facilitators to participation

BACKGROUND/AIMS: People with stroke continue to lead sedentary lives despite the multiple benefits of exercise. Knowledge regarding stroke survivors' conception of exercise, which is essential for a thorough understanding of the barriers and facilitators to exercise, is lacking. This study aims to explore the perceptions of exercise among stroke survivors, including their concepts and definitions of exercise, as well as their perceptions of barriers and facilitators to exercise. METHODS: This study utilized a qualitative exploratory design. Focus groups were conducted with 11 community dwelling participants with stroke (mean 8 ± 3 years post stroke). Data was analysed using content analysis methods. FINDINGS: Six themes that provided information regarding participants' perceptions of exercise were identified: mobility, balance, self-efficacy, outcomes, support, and exercise as part of an active or healthy lifestyle. Although participants internalized specific benefits of exercise, they did not demonstrate an internalized link between exercise and stroke risk. Low self-efficacy was identified as a barrier to participating in exercise, whereas, support to exercise (e.g., external encouragement, qualified personnel) was identified as a facilitator. CONCLUSION: These findings may provide insight when developing exercise interventions which optimize adherence for people with stroke.

Effects of robot-assisted upper limb rehabilitation on daily function and real-world arm activity in patients with chronic stroke: a randomized controlled trial

OBJECTIVE

To compare the outcome of robot-assisted therapy with dose-matched active control therapy by using accelerometers to study functional recovery in chronic stroke patients.

DESIGN

Prospective, randomized, controlled trial.

SETTING

Stroke units in three medical centres.

SUBJECTS

Twenty patients post stroke for a mean of 22 months.

INTERVENTION

Robot-assisted therapy (n = 10) or dose-matched active control therapy (n = 10). All patients received either of these two therapies for 90-105 minutes each day, 5 days per week, for four weeks.

MAIN MEASURES

Outcome measures included arm activity ratio (the ratio of mean activity between the impaired and unimpaired arm) and scores on the Fugl-Meyer Assessment Scale, Functional Independence Measure, Motor Activity Log and ABILHAND questionnaire.

RESULTS

The robot-assisted therapy group significantly increased motor function, hemiplegic arm activity and bilateral arm coordination (Fugl-Meyer Assessment Scale: 51.20 ± 8.82, P = 0.002; mean arm activity ratio: 0.76 ± 0.10, P = 0.026; ABILHAND questionnaire: 1.24 ± 0.28, P = 0.043) compared with the dose-matched active control group (Fugl-Meyer Assessment Scale: 40.90 ± 13.14; mean arm movement ratio: 0.69 ± 0.11; ABILHAND questionnaire: 0.95 ± 0.43).

CONCLUSIONS

Symmetrical and bilateral robotic practice, combined with functional task training, can significantly improve motor function, arm activity, and self-perceived bilateral arm ability in patients late after stroke.

Disparity between functional recovery and daily use of the upper and lower extremities during subacute stroke rehabilitation

BACKGROUND

Although inpatient rehabilitation may enhance an individual's functional ability after stroke, it is not known whether these improvements are accompanied by an increase in daily use of the arms and legs.

OBJECTIVES

To determine the change in daily use of the upper and lower extremities of stroke patients during rehabilitation and to compare these values with that of community-dwelling older adults.

METHODS

A total of 60 stroke patients underwent functional assessments and also wore 3 accelerometers for 3 consecutive weekdays on admission to rehabilitation and 3 weeks later prior to hospital discharge. The number of steps and upper-extremity activity counts were measured over the waking hours and during daily use for occupational therapy (OT) and physical therapy (PT) sessions. Healthy older adults (n = 40) also wore 3 accelerometers for 5 consecutive days.

RESULTS

Stroke patients demonstrated a significant increase in mobility function, and this was accompanied by an increase in daily walking over the entire day as well as in PT. However, increases in daily walking were found predominantly in patients who were wheelchair users (and not walkers) at the time of admission. Control walking values (5202 steps) were more than 17 times that of stroke patients. Despite significant improvements in paretic hand function, no increase in daily use of the paretic or nonparetic hand was found over the entire day or in PT.

CONCLUSIONS

A disparity between functional recovery and increases in daily use of the upper and lower extremities was found during inpatient stroke rehabilitation.

Reliability and validity of bilateral ankle accelerometer algorithms for activity recognition and walking speed after stroke

BACKGROUND AND PURPOSE

Outcome measures of mobility for large stroke trials are limited to timed walks for short distances in a laboratory, step counters and ordinal scales of disability and quality of life. Continuous monitoring and outcome measurements of the type and quantity of activity in the community would provide direct data about daily performance, including compliance with exercise and skills practice during routine care and clinical trials.

METHODS

Twelve adults with impaired ambulation from hemiparetic stroke and 6 healthy controls wore triaxial accelerometers on their ankles. Walking speed for repeated outdoor walks was determined by machine-learning algorithms and compared to a stopwatch calculation of speed for distances not known to the algorithm. The reliability of recognizing walking, exercise, and cycling by the algorithms was compared to activity logs.

RESULTS

A high correlation was found between stopwatch-measured outdoor walking speed and algorithm-calculated speed (Pearson coefficient, 0.98; P=0.001) and for repeated measures of algorithm-derived walking speed (P=0.01). Bouts of walking >5 steps, variations in walking speed, cycling, stair climbing, and leg exercises were correctly identified during a day in the community. Compared to healthy subjects, those with stroke were, as expected, more sedentary and slower, and their gait revealed high paretic-to-unaffected leg swing ratios.

CONCLUSIONS

Test-retest reliability and concurrent and construct validity are high for activity pattern-recognition Bayesian algorithms developed from inertial sensors. This ratio scale data can provide real-world monitoring and outcome measurements of lower extremity activities and walking speed for stroke and rehabilitation studies.

Duration of physical activity is normal but frequency is reduced after stroke: an observational study

QUESTION

What is the free-living physical activity of community-dwelling people with stroke compared with that of age-matched healthy controls?

DESIGN

A cross-sectional observational study.

PARTICIPANTS

42 people with stroke and 21 age-matched healthy controls aged 52 to 87 years living in Sydney, Australia.

OUTCOME MEASURES

Free-living physical activity was measured using the Intelligent Device for Energy Expenditure and Activity (IDEEA) and reported as duration (time on feet in min) and frequency (activity counts).

RESULTS

People with stroke spent 79 (95% CI 20 to 138) fewer min on their feet and performed 5308 (95% CI 3171 to 7445) fewer activity counts than healthy controls. The observation period of the free-living physical activity of stroke survivors was significantly less than that of the healthy controls. Data adjusted to a fixed observation period (12 hr) showed no relative difference in time on feet between the groups (mean difference 36 min, 95% CI -27 to 99) but that people after stroke still had relatively fewer activity counts than healthy controls (mean difference 4062 counts, 95% CI 1787 to 6337).

CONCLUSIONS

The reduction in physical activity after stroke is not primarily because of a decrease in the time spent being active but rather a decrease in frequency of activity during that time. Future research into physical activity after stroke needs to consider energy expenditure because stroke survivors exhibit a reduced frequency of physical activity due to the nature of their impairments.

Cognitive dysfunction and physical activity after stroke: the Gothenburg cognitive stroke study in the elderly

This study explored the association between cognitive and executive dysfunction and level of physical activity 1 year after stroke. Cognition before stroke and cognitive and executive function in the acute phase and at 1 year after stroke were assessed in 74 subjects. Physical activity was assessed at 1 year after stroke. Factors that appeared to predict low level of physical activity at 1 year after stroke were impaired global cognition before stroke, visual neglect and impaired logical deductive ability in the acute phase, and impaired global cognition, executive function, and visual memory 1 year after stroke. Our findings underscore the importance of identifying stroke patients with impaired cognitive and executive function who are at risk for developing inactivity.

Thrombolysis in acute ischaemic stroke: an update

Stroke is a major cause of mortality and morbidity, and thrombolysis has served as a catalyst for major changes in the management of acute ischaemic stroke. Intravenous alteplase (recombinant tissue plasminogen activator) is the only approved thrombolytic agent at present indicated for acute ischaemic stoke. While the licensed time window extends to 3h from symptom onset, recent data suggest that the trial window can be extended up to 4.5 h with overall benefit. Nonetheless, 'time is brain' and every effort must be made to reduce the time delay to thrombolysis. Intracranial haemorrhage is the major complication associated with thrombolysis, and key factors increasing risk of haemorrhage include increasing age, high blood pressure, diabetes and stroke severity. Currently, there is no direct evidence to support thrombolysis in patients >80 years of age, with a few case series indicating no overt harm. Identification of viable penumbra based on computed tomography/magnetic resonance imaging may allow future extension of the time window. Adjuvant transcranial Doppler ultrasound has the potential to improve reperfusion rates. While intra-arterial thrombolysis has been in vogue for a few decades, there is no clear advantage over intravenous thrombolysis. The evidence base for thrombolysis in specific situations (e.g. dissection, pregnancy) is inadequate, and individualized decisions are needed, with a clear indication to the patient/carer about the lack of direct evidence, and the risk-benefit balance. Patient-friendly information leaflets may facilitate the process of consent for thrombolysis. This article summarizes the recent advances in thrombolysis for acute ischaemic stroke. Key questions faced by clinicians during the decision-making process are answered based on the evidence available.

The relationship between ambulatory step activity, self-reported physical functioning and standardised timed walking in patients with haematological malignancies

PURPOSE

This cross-sectional study investigated the degree of association between the results of ambulatory step activity monitoring (SAM), self-reported physical functioning (SRPF) and the 6-minute standardised walking test (6-MWT) in cancer patients with haematological malignancies.

METHOD

Assessments of ambulatory SAM, SRPF and 6-MWT were assessed in 102 patients up to 122 days (mean 78  ±  35) after haematopoietic stem cell transplantation (HSCT). To determine the association between measures of walking, the Pearson product moment correlation coefficient (r) including the 95%CI and the r(2) were calculated. Simple linear regression analyses were performed to estimate the ambulatory step activity from SRPF and the 6-MWT.

RESULTS

The average age was 47 years (± 12) and body mass index 23.4 (± 4). The correlations were low between ambulatory SAM outputs and SRPF (ranging from -0.32 to 0.34, p < 0.01), and very low between SAM outputs and 6-MWT, (ranging from 0.21 to 0.24). The correlation between SRPF and the 6-MWT was low (0.33, p < 0.01). The correlation between SRPF and the 6-MWT was low (0.33, p < 0.01). The 95%CIs were quite narrow around r. The shared variance (r(2)) between the SAM and SPPF ranged between 4% and 11% and the shared variance between the SAM and 6-MWT ranged between 0.5% and 18%. Linear regression yielded weak relationships and large standard errors of estimate between the SAM, SRPF and 6-MWT.

CONCLUSIONS

SRPF and the 6-MWT do not reflect daily walking activity. In clinical use (e.g. to evaluate the effects of a rehabilitation program), ambulatory step activity outputs can be considered an additional outcome to assess day-to-day walking activity in patients with haematological cancer after HSCT.

Feature extraction and selection for objective gait analysis and fall risk assessment by accelerometry

BACKGROUND

Falls in the elderly is nowadays a major concern because of their consequences on elderly general health and moral states. Moreover, the aging of the population and the increasing life expectancy make the prediction of falls more and more important. The analysis presented in this article makes a first step in this direction providing a way to analyze gait and classify hospitalized elderly fallers and non-faller. This tool, based on an accelerometer network and signal processing, gives objective informations about the gait and does not need any special gait laboratory as optical analysis do. The tool is also simple to use by a non expert and can therefore be widely used on a large set of patients.

METHOD

A population of 20 hospitalized elderlies was asked to execute several classical clinical tests evaluating their risk of falling. They were also asked if they experienced any fall in the last 12 months. The accelerations of the limbs were recorded during the clinical tests with an accelerometer network distributed on the body. A total of 67 features were extracted from the accelerometric signal recorded during a simple 25 m walking test at comfort speed. A feature selection algorithm was used to select those able to classify subjects at risk and not at risk for several classification algorithms types.

RESULTS

The results showed that several classification algorithms were able to discriminate people from the two groups of interest: fallers and non-fallers hospitalized elderlies. The classification performances of the used algorithms were compared. Moreover a subset of the 67 features was considered to be significantly different between the two groups using a t-test.

CONCLUSIONS

This study gives a method to classify a population of hospitalized elderlies in two groups: at risk of falling or not at risk based on accelerometric data. This is a first step to design a risk of falling assessment system that could be used to provide the right treatment as soon as possible before the fall and its consequences. This tool could also be used to evaluate the risk several times during the revalidation procedure.

Awareness of stroke symptomatology and cardiovascular risk factors amongst stroke survivors

BACKGROUND

Effective treatments exist for the acute management and prevention of stroke, but their uptake depends upon public awareness of stroke symptoms and cardiovascular risk factors. We evaluated the extent of both types of knowledge amongst high-risk individuals. Furthermore, we determined whether knowledge of risk factors, and appreciation of personal risk, influences risk avoidance behaviour.

METHODS

A validated comprehensive questionnaire assessing knowledge of stroke symptoms and personal risk factors was completed by stroke survivors across the United Kingdom.

RESULTS

Questionnaires were completed by 622 stroke survivors (age range, 18-91 yrs; mean, 55.4 yrs). Recall of all 3 cardinal stroke symptoms (face, arm or leg, and speech disturbance) was made by only 14% of respondents, with 34% citing none of these symptoms. Knowledge of any established stroke risk factor was cited by 55% of respondents, with the remainder believing that stroke occurs because of chance. Similarly, 45% did not acknowledge that having had a previous stroke predisposed to future cardiovascular disease. Respondents recognising their own personal future risk were more likely to consume less alcohol (P < .0001) and salt (P < .005) and to eat more fruits and vegetables (P < .02).

CONCLUSIONS

Knowledge of stroke symptoms and cardiovascular risk factors is poor amongst high-risk stroke patients. However, an awareness of personal risk of future stroke increased the likelihood of adopting secondary prevention behaviours after stroke. Our results have important implications for the prevention of secondary vascular disease in stroke patients and the effects of public health campaigns on high-risk stroke groups.

Daily physical activity and its contribution to the health-related quality of life of ambulatory individuals with chronic stroke

BACKGROUND

Participation in daily physical activity (PA) post-stroke has not previously been investigated as a possible explanatory variable of health-related quality of life (HRQL). The aims were 1) to determine the contribution of daily PA to the HRQL of individuals with chronic stroke and 2) to assess the relationship between the functional ability of these individuals to the amount of daily PA.

METHODS

The amount of daily PA of forty adults with chronic stroke (mean age 66.5 +/- 9.6 years) was monitored using two measures. Accelerometers (Actical) were worn on the hip for three consecutive days in conjunction with a self-report questionnaire [the PA Scale for Individuals with Physical Disabilities (PASIPD)]. The daily physical activity was measured as the mean total accelerometer activity counts/day and the PASIPD scores as the metabolic equivalent (MET) hr/day. HRQL was assessed by the Physical and Mental composite scores of the Medical Outcomes Study Short-Form 36 (SF-36) in addition to the functional ability of the participants. Correlation and regression analyses were performed.

RESULTS

After controlling for the severity of the motor impairment, the amount of daily PA, as assessed by the PASIPD and accelerometers, was found to independently contribute to 10-12% of the variance of the Physical Composite Score of the SF-36. No significant relationship was found between PA and the Mental Composite Score of the SF-36.The functional ability of the participants was found to be correlated to the amount of daily PA (r = 0.33 - 0.67, p < 0.01).

CONCLUSION

The results suggest that daily PA is associated with better HRQL (as assessed by the Physical composite score of the SF-36) for people living with stroke. Daily PA should be encouraged to potentially increase HRQL. Accelerometers in conjunction with a self-report questionnaire may provide important measures of PA which can be monitored and modified, and potentially influence HRQL.

Circuit class therapy for improving mobility after stroke

BACKGROUND

Circuit class therapy (CCT) offers a supervised group forum for people after stroke to practise tasks, enabling increased practise time without increasing staffing.

OBJECTIVES

To examine the effectiveness and safety of CCT on mobility in adults with stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched October 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2009), MEDLINE (1950 to November 2008), EMBASE (1980 to November 2008), CINAHL (1982 to November 2008) and 14 other electronic databases (to November 2008). We also searched proceedings from relevant conferences, reference lists and unpublished theses; contacted authors of published trials and other experts in the field; and searched relevant clinical trials and research registers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials including people over 18 years old diagnosed with stroke of any severity, at any stage, or in any setting, receiving CCT.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed methodological quality and extracted data.

MAIN RESULTS

We included six trials involving 292 participants. Participants were long-term stroke survivors living in the community or receiving inpatient rehabilitation. All could walk 10 metres with or without assistance. Four studies measured walking capacity and three measured gait speed, demonstrating that CCT was superior to the comparison intervention (Six Minute Walk Test: mean difference (MD), fixed 76.57 metres, 95% confidence interval (CI) 38.44 to 114.70, P < 0.0001; gait speed: MD, fixed 0.12 m/s, 95% CI 0.00 to 0.24, P = 004). Two studies measured balance, showing a superior effect in favour of CCT (Step Test: MD, fixed 3.00 steps, 95% CI 0.08 to 5.91, P = 0.04; activities-specific balance and confidence: MD, fixed 7.76, 95% CI 0.66 to 14.87, P = 0.03). Studies also measured other balance items showing no difference in effect. Length of stay (two studies) showed a significant effect in favour of CCT (MD, fixed -19.73 days, 95% CI -35.43 to -4.04, P = 0.01). Only two studies measured adverse events (falls during therapy): all were minor.

AUTHORS' CONCLUSIONS

CCT is safe and effective in improving mobility for people after moderate stroke and may reduce inpatient length of stay. Further research is required, investigating quality of life, participation and cost-benefits, that compares CCT to standard care and that also investigates the differential effects of stroke severity, latency and age.

Ability to negotiate stairs predicts free-living physical activity in community-dwelling people with stroke: an observational study

QUESTION

Which clinical measures of walking performance best predict free-living physical activity in community-dwelling people with stroke?

DESIGN

Cross-sectional observational study.

PARTICIPANTS

42 community-dwelling stroke survivors.

OUTCOME MEASURES

Predictors were four clinical measures of walking performance (speed, automaticity, capacity, and stairs ability). The outcome of interest was free-living physical activity, measured as frequency (activity counts) and duration (time on feet), collected using an activity monitor called the Intelligent Device for Energy Expenditure and Physical Activity.

RESULTS

Time on feet was predicted by stairs ability alone (B 166, 95% CI 55 to 278) which accounted for 48% of the variance. Activity counts were also predicted by stairs ability alone (B 6486, 95% CI 2922 to 10 050) which accounted for 58% of the variance.

CONCLUSION

The best predictor of free-living physical activity in community-dwelling people with stroke was stairs ability.