Reducing Sitting Time After Stroke: A Phase II Safety and Feasibility Randomized Controlled Trial

The effects of kinesiophobia, fatigue, and quality of life on physical activity in patients with stroke

BACKGROUND

Physical activity decreases after stroke due to various factors and the causes and effects of these factors remain unclear.

OBJECTIVES

This study aimed todetermine the effects of kinesiophobia, fatigue, and quality of life on physical activity in patients with stroke.

METHODS

The study included 32 patients (13 females/19 males), all evaluated using the Stroke Rehabilitation Assessment of Movement, Barthel Index, Tampa Kinesiophobia Scale-fatigue, Fatigue Impact Scale and Stroke-Specific Quality of Life Scale. The SenseWear multisensory activity monitor was worn on the arm of the patients for 1 week to evaluate active energy expenditure, step count, and rest periods in relation to physical activity. Multiple linear regression analysis was used to examine the effects of the independent variables kinesiophobia, fatigue, and quality of life on the dependent variables of active energy expenditure, step count, and rest periods.

RESULTS

The mean age of the patients was 52.31 ± 14.76 years. According to the multiple regression analysis results, kinesiophobia (p = 0.011) and quality of life (p = 0.009) are significant determinants of active energy expenditure and quality of life (p = 0.001) is a significant determinant of the step count in patients with stroke. Kinesiophobia, fatigue, and quality of life were not determinants of rest periods (p > 0.05).

CONCLUSIONS

The study results showed that kinesiophobia and quality of life are important determinants of physical activity in patients with stroke. Combined evaluation in the clinic of motor findings and non-motor factors, which are often ignored, and the application of target-oriented approaches to these problems will make a significant contribution to the success of stroke rehabilitation.

Interventions to Change Movement Behaviors After Stroke: A Systematic Review and Meta-analysis

OBJECTIVE

This systematic review aimed to determine which interventions increase physical activity (PA) and decrease sedentary behavior (SB) based on objective measures of movement behavior in individuals with stroke.

DATA SOURCES

The PubMed (Medline), EMBASE, Scopus, CINAHL (EBSCO), and Web of Science databases were searched for articles published up to January 3, 2023.

STUDY SELECTION

The StArt 3.0.3 BETA software was used to screen titles, abstracts, and full texts for studies with randomized controlled trial designs; individuals with stroke (≥18 years of age); interventions aimed at increasing PA or decreasing SB; and objective measurement instruments.

DATA EXTRACTION

Data extraction was standardized, considering participants and assessments of interest. The risk of bias and quality of evidence of the included studies were assessed.

DATA SYNTHESIS

Twenty-eight studies involving 1855 patients were included. Meta-analyses revealed that in the post-stroke acute/subacute phase, exercise interventions combined with behavior change techniques (BCTs) increased both daily steps (standardized mean difference [SMD]=0.65, P=.0002) and time spent on moderate-to-vigorous intensity physical activities (MVPAs) duration of PA (SMD=0.68, P=.0004) with moderate-quality evidence. In addition, interventions based only on BCTs increased PA levels with very low-quality evidence (SMD (low-intensity physical activity)=0.36, P=.02; SMD (MVPA)=0.56, P=.0004) and decreased SB with low-quality evidence (SMD=0.48, P=.03). In the post-stroke chronic phase, there is statistical significance in favor of exercise-only interventions in PA frequency (steps/day) with moderate-quality evidence (SMD=0.68, P=.002). In general, the risk of bias in the included studies was low.

CONCLUSIONS

In the acute/subacute phase after stroke, the use of BCTs combined with exercise can increase the number of daily steps and time spent on MVPA. In contrast, in the post-stroke chronic phase, exercise-only interventions resulted in a significant increase in daily steps.

The influence of a virtual reality entertainment program on depressive symptoms and sedentary behaviour in inpatient stroke survivors: a research protocol for a pilot randomized controlled trial

Background

Sedentary behaviour among stroke inpatients may be due to high rates of depressive symptoms after stroke. Thus, efforts to address depressive symptoms among stroke inpatients are warranted to in turn lessen sedentary behaviour. Despite evidence that virtual reality (VR) is emerging as a method to help with depression, the use of VR to improve depression among inpatient stroke survivors has yet to be studied. In this paper, we report on the protocol investigating the feasibility of a VR entertainment system at improving depressive symptoms among stroke survivors receiving inpatient rehabilitation.

Methods

In this single-blind randomized controlled trial, 30 inpatient stroke survivors from the rehabilitation unit at Kelowna General Hospital will be randomized to either (1) intervention: 3 times per week of VR entertainment for duration of inpatient rehabilitation or (2) control: usual care. Individuals will be included if they have a confirmed diagnosis of stroke, are 19 years of age or older, able to provide informed consent, have physician clearance to participate in the study (medically stable or fit), or are able to understand English. Outcome measures to address depressive symptoms (primary outcome), sedentary behaviour, motivation, anxiety, stress, and happiness (secondary outcome) will be administered at two timepoints: (1) baseline (T1) and (2) post-intervention (T2). Study analyses will consider study feasibility indicators and clinical (statistical) outcomes. Means and standard deviations (for continuous variables) and frequencies and proportions (for categorical variables) will be used to summarize the variables. Feasibility indicators will be dichotomized into either ‘success’ if they meet the a priori criteria, or ‘revise’ if they do not meet the criteria. Intervention effects post-intervention (T2) for the primary and secondary clinical outcomes will be estimated using linear regression including baseline (T1) controlling for age and sex.

Discussion

The results of this trial will add to our understanding of depression and sedentary behaviour among individuals receiving inpatient stroke rehabilitation as well as the feasibility of a VR entertainment program to improve depressive symptoms, which will in turn may lessen sedentary behaviour in inpatient stroke survivors.

Trial registration

ClinicalTrials.gov Identifier: NCT04011202 . First posted July 8, 2019 (study postponed from March 2020 to July 2021 due to COVID-19).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01189-8.

Feasibility, acceptability, and fidelity of Physical Activity Routines After Stroke (PARAS): a multifaceted behaviour change intervention targeting free-living physical activity and sedentary behaviour in community-dwelling adult stroke survivors

BACKGROUND

Low levels of habitual physical activity and high levels of sedentary behaviour are commonly observed post-stroke. We aimed to assess the feasibility, acceptability and fidelity of a multifaceted, theory- and evidence-informed supported self-management intervention targeting physical activity and sedentary behaviour after stroke: Physical Activity Routines After Stroke (PARAS).

METHODS

Adult stroke survivors and healthcare professionals were recruited from North East England stroke services. Stroke survivor physical activity and sedentary behaviour were targeted by a self-management behavioural intervention supported by healthcare professionals trained in intervention delivery. The main outcomes were protocol and intervention acceptability and feasibility and fidelity of intervention delivery.

RESULTS

Eleven healthcare professionals (9 physiotherapists; 2 occupational therapists) participated in the study. Stroke survivor recruitment was lower than anticipated (19 versus target of up to 35). The healthcare professional training programme was feasible, with fidelity assessment of delivery supporting this finding. Data completeness was acceptable according to a priori criteria (>60%), except for stroke survivor questionnaire return rate (59%) and interview uptake (52%). No serious adverse events occurred. Healthcare professionals and stroke survivors perceived intervention delivery to be feasible and acceptable with minor modifications highlighted including the potential for earlier delivery in the stroke pathway.

CONCLUSIONS

The study protocol and intervention delivery were feasible and acceptable to stroke survivors and healthcare professionals with modifications required before large-scale evaluation.

TRIAL REGISTRATION

ISRCTN35516780 . Registered on October 24, 2018.

Predictors of non-stepping time in people with chronic stroke

BACKGROUND

Sedentary time is an independent construct from active time. Previous studies have examined variables associated with sedentary time to inform behavior change programs; however, these studies have lacked data sets that encompass potentially important domains.

OBJECTIVES

The purpose of this study was to build a more comprehensive model containing previously theorized important predictors of sedentary time and new predictors that have not been explored. We hypothesized that variables representing the domains of physical capacity, psychosocial, physical health, cognition, and environmental would be significantly related to sedentary time in individuals post-stroke.

METHODS

This was a cross-sectional analysis of 280 individuals with chronic stroke. An activity monitor was used to measure sedentary (i.e. non-stepping) time. Five domains (8 predictors) were entered into a sequential linear regression model: physical capacity (6-Minute Walk Test, assistive device use), psychosocial (Activities Specific Balance Confidence Scale and Patient Health Questionnaire-9), physical health (Charlson Comorbidity Index and body mass index), cognition (Montreal Cognitive Assessment), and environmental (Area Deprivation Index).

RESULTS

The 6-Minute Walk Test (β = -0.39, p < .001), assistive device use (β = 0.15, p = .03), Patient Health Questionnaire-9 (β = 0.16, p = .01), and body mass index (β = 0.11, p = .04) were significantly related to non-stepping time in individuals with chronic stroke. The model explained 28.5% of the variability in non-stepping time.

CONCLUSIONS

This work provides new perspective on which variables may need to be addressed in programs targeting sedentary time in stroke. Such programs should consider physical capacity, depressive symptoms, and physical health.

Study protocol for the Shifting Weight using Intermittent Fasting in night shift workers (SWIFt) study: a three-arm randomised controlled trial comparing three weight loss strategies in night shift workers with obesity

INTRODUCTION

Shift workers are at an increased risk of developing obesity and type 2 diabetes. Eating and sleeping out of synchronisation with endogenous circadian rhythms causes weight gain, hyperglycaemia and insulin resistance. Interventions that promote weight loss and reduce the metabolic consequences of eating at night are needed for night shift workers. The aim of this study is to examine the effects of three weight loss strategies on weight loss and insulin resistance (HOMA-IR) in night shift workers.

METHODS AND ANALYSIS

A multisite 18-month, three-arm randomised controlled trial comparing three weight loss strategies; continuous energy restriction; and two intermittent fasting strategies whereby participants will fast for 2 days per week (5:2); either during the day (5:2D) or during the night shift (5:2N). Participants will be randomised to a weight loss strategy for 24 weeks (weight loss phase) and followed up 12 months later (maintenance phase). The primary outcomes are weight loss and a change in HOMA-IR. Secondary outcomes include changes in glucose, insulin, blood lipids, body composition, waist circumference, physical activity and quality of life. Assessments will be conducted at baseline, 24 weeks (primary endpoint) and 18 months (12-month follow-up). The intervention will be delivered by research dietitians via a combination of face-to-face and telehealth consultations. Mixed-effect models will be used to identify changes in dependent outcomes (weight and HOMA-IR) with predictor variables of outcomes of group, time and group-time interaction, following an intention-to-treat approach.

ETHICS AND DISSEMINATION

The study protocol was approved by Monash Health Human Research Ethics Committee (RES 19-0000-462A) and registered with Monash University Human Research Ethics Committee. Ethical approval has also been obtained from the University of South Australia (HREC ID: 202379) and Ambulance Victoria Research Committee (R19-037). Results from this trial will be disseminated via conference presentations, peer-reviewed journals and student theses.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN-12619001035112).

Preliminary efficacy of the "SitLess with MS" intervention for changing sedentary behaviour, symptoms, and physical performance in multiple sclerosis

PURPOSE

People with multiple sclerosis (MS) sit (i.e., are sedentary) more than peers. We examined the preliminary efficacy of an internet-based intervention that focuses on sitting less and moving more for changing sedentary behaviour outcomes, symptoms, QOL, and physical performance in adults with MS.

METHODS

Persons with mild-to-moderate disability from MS took part in a 15-week pre-post trial. Outcomes including sedentary behaviour, representative symptoms (e.g., fatigue, pain), QOL and physical performance measures (e.g., walking speed) were measured at three time points: pre-post intervention and at follow-up. An unstructured linear mixed-effects model was used to determine change over time per outcome.

RESULTS

Forty-one persons with MS participated (age 50 ± 10.3 years). There were significant reductions in total sedentary time (d = 0.34) and the number of long (≥30 min) bouts of sedentary time (d = 0.39) post-intervention. All symptoms and physical performance measures were significantly improved following the intervention, with effects sizes greatest for fatigue (d = 0.61) and depression (d = 0.79). Changes were maintained during the 7-week follow-up, except for all sedentary behaviour outcomes and sleep quality. Cognition did not change.

CONCLUSIONS

This study provides preliminary support for the efficacy of an intervention focused on sitting less and moving more for improving symptoms in adults with MS.IMPLICATIONS FOR REHABILITATIONThis research provides preliminary evidence that an intervention aimed at reducing sedentary behaviour and increasing light intensity activity throughout the day can have an impact.Fatigue, depression and anxiety, symptoms frequently encountered by people with MS, showed the greatest improvement following the intervention.Weekly coaching sessions including discussions about results from activity monitoring provided motivation for participants.

TRIAL REGISTRATION

The "SitLess with MS" feasibility study was registered at ClinicalTrials.gov Trial Registration Number: NCT03136744. Date of registration was 2 May 2017. Find at https://clinicaltrials.gov/ct2/show/NCT03136744.

Using Intervention Mapping to develop and implement a home-based sedentary behavior change intervention after stroke

Prolonged sedentary behavior is a problem immediately following a stroke and it persists from the acute to chronic phases of recovery. Frequently interrupting sedentary time might help to mitigate the associated detrimental health consequences. The purpose of this article was to describe the process followed in the systematic development and implementation of a theory- and home-based sedentary behavior change intervention for people with stroke. The Intervention Mapping protocol was used to design, develop and implement a STand Up Frequently From Stroke (STUFFS) program aimed at reducing prolonged sedentary behavior after stroke. A qualitative inquiry with people with stroke (n = 13) informed the development of the intervention. The systematic approach followed in the development process including the theoretical basis, content development, and evaluation planning were described. Program reception was assessed using thematic content analysis of exit-interview data (n = 25). The 8-weeks STUFFS intervention is a home-based sedentary behavior change program that provides education about the risks of prolonged sedentary behavior and facilitates behavior change, including the use of motivational tools to empower people with stroke to reduce sedentary behavior. The program was well-received and acceptable to people with stroke (89% satisfaction). This article provides information that furthers knowledge about theory-based strategies to reduce sedentary behavior in the home environment after stroke and facilitates implementation of this type of intervention. Trial registration: This study is registered at www.clinicaltrials.gov (No. NCT02980744).

Six-week behaviour change intervention to reduce sedentary behaviour in people with chronic obstructive pulmonary disease: a randomised controlled trial

INTRODUCTION

This study aimed to determine whether a 6-week behaviour change intervention was more effective than a sham intervention for reducing sedentary behaviour (SB) in people with chronic obstructive pulmonary disease (COPD).

METHODS

People with stable COPD on the waitlist for entry into pulmonary rehabilitation were recruited to this multicentre trial with randomisation (independent, concealed allocation) to either an intervention group or sham group, assessor blinding and intention-to-treat (ITT) analysis. The behaviour change intervention consisted of once weekly sessions for 6 weeks with a physiotherapist to reduce SB through education, guided goals setting and real-time feedback on SB. The sham intervention consisted of once weekly phone calls for 6 weeks to monitor health status. SB was measured continuously over 7 days using thigh-worn accelerometry (activPAL3 micro). The primary outcome was time spent in SB. Participants with at least 4 days of ≥10 hours waking wear time were included in the ITT analysis and those who reported achieving ≥70% of goals to reduce SB or who completed all sham calls were included in a per-protocol analysis.

RESULTS

70 participants were recruited and 65 completed the study (mean±SD age 74±9 years, mean FEV₁ 55%±19% predicted, 49% male). At 6 weeks, no between-group differences in time spent in SB were observed in the ITT analysis (mean difference 5 min/day, 95% CI -38 to 48) or per-protocol analysis (-16 min/day, 95% CI -80 to 48).

DISCUSSION

A 6-week behaviour change intervention did not reduce time in SB compared with a sham intervention in people with stable moderate-to-severe COPD prior to pulmonary rehabilitation.

Lifestyle interventions to reduce sedentary behaviour in clinical populations: A systematic review and meta-analysis of different strategies and effects on cardiometabolic health

Cardiometabolic comorbidities are highly prevalent in clinical populations, and have been associated (partly) with their sedentary lifestyle. Although lifestyle interventions targeting sedentary behaviour (SB) have been studied extensively in the general population, the effect of such strategies in clinical populations is not yet clear. Therefore, this systematic review and meta-analysis evaluated the effect of different lifestyle interventions on SB and cardiometabolic health in clinical populations. Randomised controlled trials were collected from five bibliographic databases (PubMed, Embase, Web of Science, The Cochrane Central Register of Controlled Trials, and Scopus). Studies were eligible for inclusion if they evaluated a lifestyle intervention to reduce objectively measured SB, in comparison with a control intervention among persons with a clinical condition. Data were pooled using a random-effects meta-analysis. In total, 7094 studies were identified. Eighteen studies met the inclusion criteria and were categorised in five population groups: overweight/obesity, type 2 diabetes mellitus, cardiovascular, neurological/cognitive and musculoskeletal diseases. Participants reduced their SB by 64 min/day (95%CI: [-91, -38] min/day; p < 0.001), with larger within-group differences of multicomponent behavioural interventions including motivational counselling, self-monitoring, social facilitation and technologies (-89 min/day; 95%CI: [-132, -46] min/day; p < 0.001). Blood glycated haemoglobin concentration (-0.17%; 95% CI: [-0.30, -0.04]%; p = 0.01), fat percentage (-0.66%; 95% CI: [-1.26, -0.06]%, p = 0.03) and waist circumference (-1.52 cm; 95%CI: [-2.84, -0.21] cm; p = 0.02) were significantly reduced in the intervention groups compared to control groups. Behavioural lifestyle interventions reduce SB among clinical populations and improve cardiometabolic risk markers such as waist circumference, fat percentage, and glycaemic control. Sedentary behaviour, Cardiometabolic health, Clinical populations.

An Exploration of Sedentary Behavior Patterns in Community-Dwelling People With Stroke: A Cluster-Based Analysis

BACKGROUND AND PURPOSE

Long periods of daily sedentary time, particularly accumulated in long uninterrupted bouts, are a risk factor for cardiovascular disease. People with stroke are at high risk of recurrent events and prolonged sedentary time may increase this risk. We aimed to explore how people with stroke distribute their periods of sedentary behavior, which factors influence this distribution, and whether sedentary behavior clusters can be distinguished?

METHODS

This was a secondary analysis of original accelerometry data from adults with stroke living in the community. We conducted data-driven clustering analyses to identify unique accumulation patterns of sedentary time across participants, followed by multinomial logistical regression to determine the association between the clusters, and the total amount of sedentary time, age, gender, body mass index (BMI), walking speed, and wake time.

RESULTS

Participants in the highest quartile of total sedentary time accumulated a significantly higher proportion of their sedentary time in prolonged bouts (P < 0.001). Six unique accumulation patterns were identified, all of which were characterized by high sedentary time. Total sedentary time, age, gender, BMI, and walking speed were significantly associated with the probability of a person being in a specific accumulation pattern cluster, P < 0.001 - P = 0.002.

DISCUSSION AND CONCLUSIONS

Although unique accumulation patterns were identified, there is not just one accumulation pattern for high sedentary time. This suggests that interventions to reduce sedentary time must be individually tailored.Video Abstract available for more insight from the authors (see the Video Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A343).

Interventions for reducing sedentary behaviour in people with stroke

BACKGROUND

Stroke survivors are often physically inactive as well as sedentary,and may sit for long periods of time each day. This increases cardiometabolic risk and has impacts on physical and other functions. Interventions to reduce or interrupt periods of sedentary time, as well as to increase physical activity after stroke, could reduce the risk of secondary cardiovascular events and mortality during life after stroke.

OBJECTIVES

To determine whether interventions designed to reduce sedentary behaviour after stroke, or interventions with the potential to do so, can reduce the risk of death or secondary vascular events, modify cardiovascular risk, and reduce sedentary behaviour.

SEARCH METHODS

In December 2019, we searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, Conference Proceedings Citation Index, and PEDro. We also searched registers of ongoing trials, screened reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised trials comparing interventions to reduce sedentary time with usual care, no intervention, or waiting-list control, attention control, sham intervention or adjunct intervention. We also included interventions intended to fragment or interrupt periods of sedentary behaviour.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies and performed 'Risk of bias' assessments. We analyzed data using random-effects meta-analyses and assessed the certainty of the evidence with the GRADE approach.

MAIN RESULTS

We included 10 studies with 753 people with stroke. Five studies used physical activity interventions, four studies used a multicomponent lifestyle intervention, and one study used an intervention to reduce and interrupt sedentary behaviour. In all studies, the risk of bias was high or unclear in two or more domains. Nine studies had high risk of bias in at least one domain. The interventions did not increase or reduce deaths (risk difference (RD) 0.00, 95% confidence interval (CI) -0.02 to 0.03; 10 studies, 753 participants; low-certainty evidence), the incidence of recurrent cardiovascular or cerebrovascular events (RD -0.01, 95% CI -0.04 to 0.01; 10 studies, 753 participants; low-certainty evidence), the incidence of falls (and injuries) (RD 0.00, 95% CI -0.02 to 0.02; 10 studies, 753 participants; low-certainty evidence), or incidence of other adverse events (moderate-certainty evidence). Interventions did not increase or reduce the amount of sedentary behaviour time (mean difference (MD) +0.13 hours/day, 95% CI -0.42 to 0.68; 7 studies, 300 participants; very low-certainty evidence). There were too few data to examine effects on patterns of sedentary behaviour. The effect of interventions on cardiometabolic risk factors allowed very limited meta-analysis.

AUTHORS' CONCLUSIONS

Sedentary behaviour research in stroke seems important, yet the evidence is currently incomplete, and we found no evidence for beneficial effects. Current World Health Organization (WHO) guidelines recommend reducing the amount of sedentary time in people with disabilities, in general. The evidence is currently not strong enough to guide practice on how best to reduce sedentariness specifically in people with stroke. More high-quality randomised trials are needed, particularly involving participants with mobility limitations. Trials should include longer-term interventions specifically targeted at reducing time spent sedentary, risk factor outcomes, objective measures of sedentary behaviour (and physical activity), and long-term follow-up.

Utilization of wearable technology to assess gait and mobility post-stroke: a systematic review

Background

Extremity weakness, fatigue, and postural instability often contribute to mobility deficits in persons after stroke. Wearable technologies are increasingly being utilized to track many health-related parameters across different patient populations. The purpose of this systematic review was to identify how wearable technologies have been used over the past decade to assess gait and mobility in persons with stroke.

Methods

We performed a systematic search of Ovid MEDLINE, CINAHL, and Cochrane databases using select keywords. We identified a total of 354 articles, and 13 met inclusion/exclusion criteria. Included studies were quality assessed and data extracted included participant demographics, type of wearable technology utilized, gait parameters assessed, and reliability and validity metrics.

Results

The majority of studies were performed in either hospital-based or inpatient settings. Accelerometers, activity monitors, and pressure sensors were the most commonly used wearable technologies to assess gait and mobility post-stroke. Among these devices, spatiotemporal parameters of gait that were most widely assessed were gait speed and cadence, and the most common mobility measures included step count and duration of activity. Only 4 studies reported on wearable technology validity and reliability metrics, with mixed results.

Conclusion

The use of various wearable technologies has enabled researchers and clinicians to monitor patients’ activity in a multitude of settings post-stroke. Using data from wearables may provide clinicians with insights into their patients’ lived-experiences and enrich their evaluations and plans of care. However, more studies are needed to examine the impact of stroke on community mobility and to improve the accuracy of these devices for gait and mobility assessments amongst persons with altered gait post-stroke.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12984-021-00863-x.

Association of Barriers, Fear of Falling and Fatigue with Objectively Measured Physical Activity and Sedentary Behavior in Chronic Stroke

Understanding the fostering factors of physical activity (PA) and sedentary behavior (SB) in post-stroke chronic survivors is critical to address preventive and health interventions. This cross-sectional study aimed to analyze the association of barriers to PA, fear of falling and severity of fatigue encountered by stroke chronic survivors with device-measured PA and SB. Ambulatory community-dwelling post-stroke subjects (≥six months from stroke onset) were evaluated and answered the Barriers to Physical Activity after Stroke Scale (BAPAS), Short Falls Efficacy Scale-International (Short FES-I) and Fatigue Severity Scale (FSS). SB and PA were measured with an Actigraph GT3X+ accelerometer for ≥seven consecutive days. Stepwise multiple linear regression analysis was employed to identify factors associated with PA and SB. Fifty-seven participants (58.2 ± 11.1 years, 37 men) met the accelerometer wear–time criteria (three days, ≥eight h/day). The physical BAPAS score explained 28.7% of the variance of the prolonged sedentary time (β = 0.547; p < 0.001). Additionally, the walking speed (β = 0.452) together with physical BAPAS (β = −0.319) explained 37.9% of the moderate-to-vigorous PA time (p < 0.001). In chronic post-stroke survivors, not only the walking speed but, also, the perceived physical barriers to PA are accounted for the SB and PA. Interventions to reverse SB and to involve subjects post-stroke in higher levels of PA should consider these factors.

How Adults With Stroke Conceptualize Physical Activity: An Exploratory Qualitative Study

IMPORTANCE

Physical activity (PA) is recommended for improving physical and cardiovascular function but can be challenging because of stroke-related impairments. A better understanding of how adults with stroke conceptualize PA could assist in developing effective interventions for increasing poststroke PA.

OBJECTIVE

To explore how adults with stroke conceptualize PA.

DESIGN

Phenomenological qualitative design.

SETTING

Participants' homes.

PARTICIPANTS

Community-dwelling adults with chronic (>6 mo) stroke (N = 15).

OUTCOMES AND MEASURES

Semistructured interviews were conducted with participants. Data were analyzed by means of inductive content analysis to identify key themes.

RESULTS

Three key themes emerged: (1) moderate to vigorous PA, which includes exercise-related activities (going to the gym, walking, playing sports); (2) PA necessary for performing daily activities and occupations, which includes basic and instrumental activities of daily living; and (3) avoiding sedentary behavior, which includes not wanting to sit for long periods of time, avoiding boredom, and valuing PA over being sedentary.

CONCLUSIONS AND RELEVANCE

Participants broadly categorized PA, encompassing multiple activity types, which is encouraging because reducing sedentary behavior and increasing PA of any intensity can improve cardiometabolic health. Interventions that complement and enhance these conceptualizations, alone or in combination with other mechanisms of action, should be explored for their efficacy in increasing PA in adults with stroke.

WHAT THIS ARTICLE ADDS

After stroke, perceptions of PA encompass exercise, daily activities and occupations, and avoiding sedentary behavior; these perceptions could be harnessed to promote PA among adults after stroke.

The SitLess With MS Program: Intervention Feasibility and Change in Sedentary Behavior

Objectives

This study reports on the feasibility of the SitLess with MS trial, an intervention targeting sedentary behavior in individuals with multiple sclerosis (MS).

Design

Single group, pre-post intervention design.

Setting

Community.

Participants

Participants (N=41) with mild to moderate disability from MS.

Intervention

The intervention was 15 weeks, with a 7-week follow-up, and included 2 stages: SitLess and MoveMore. During the SitLess stage, participants were encouraged to break up prolonged sitting bouts over a 7-week period, whereas the MoveMore stage promoted increased steps per day and interrupting sitting over a 7-week period. The intervention was delivered through weekly one-on-one coaching sessions via telerehabilitation and an accompanying newsletter based on social-cognitive theory. Activity was monitored throughout the program using a Fitbit.

Main Outcome Measures

Process (eg, recruitment) and resource and management (eg, personnel requirements) metrics were assessed, along with efficacy outcomes (eg, effect). Progression criteria were set a priori and were related to safety, fatigue, satisfaction, and attrition. Sedentary behavior, measured using the ActivPal, was reported pre- and postintervention, as well as 7 weeks postintervention. Effect sizes (pre to post, pre to 7 weeks post) were calculated for the sedentary behavior outcomes (eg, time sitting, transitions from sitting to standing, number of long sitting bouts). Experiences with the intervention were explored through an online survey.

Results

Forty-one participants enrolled, 39 of whom completed the intervention. All participants but 1 were satisfied with the experience. Pre-post intervention effect sizes for change in total sedentary time, number of transitions from sit to stand, and number of long (>30 min) sedentary bouts were 0.34, 0.02, and 0.39 respectively. All a priori progression criteria were met.

Conclusions

The SitLess with MS program, a novel intervention that emphasized and facilitated sitting less and moving more, was feasible and resulted in small changes in sedentary behavior in individuals with MS.

The Effects of Combining Transcranial Direct Current Stimulation and Gait Training with Functional Electrical Stimulation on Trunk Acceleration During Walking in Patients with Subacute Stroke

OBJECTIVES

This study aimed to investigate whether the combination of transcranial direct current stimulation (tDCS) and gait training with FES affected walking speed and trunk accelerometry-based gait characteristics in patients with subacute stroke, compared with FES or tDCS gait training only.

MATERIALS AND METHODS

Stroke patients (n = 34; female 15; mean age, 72.5 ± 11.2 years; mean days poststroke, 38.7) with resultant paresis in the lower extremity (mean Fugl-Meyer score, 25.5) were enrolled. Patients were randomly assigned to one of three groups: combined anodal tDCS and gait training with FES (tDCS+FES, n = 11), anodal tDCS with gait training (tDCS, n = 11), or combined sham tDCS and gait training with FES (FES, n = 12). Participants received the intervention for 20 minutes and a 40-minute conventional rehabilitative intervention daily for a week. Patients' walking ability was evaluated using walking speed, harmonic ratio (HR), autocorrelation coefficient (AC), and root mean square (RMS) along each axis using a wearable trunk accelerometer.

RESULTS

The tDCS+FES group had a significantly greater change in AC in the anteroposterior axis and mediolateral axis than the FES and tDCS groups and FES group, respectively. There were no significant effects on walking speed or other parameters (HR and RMS) among the groups.

CONCLUSIONS

The combination of anodal tDCS and gait training with FES improved the post-stroke patients' gait regularity than FES gait training intervention only. Thus, combined tDCS and FES gait training, as a novel intervention, could be an important therapeutic tool in improving walking performance.

Activating Behavior to Reduce Sedentary Behavior After Stroke: A Nonrandomized Pilot Feasibility Study

Importance: Reducing poststroke sedentary behavior is important for reducing recurrent stroke risk, yet interventions to achieve this are scant.

Objective: To assess the feasibility of, and estimate change in sedentary behavior over time associated with, a behavioral intervention.

Design: Single-arm delayed baseline with postintervention and 8-wk follow-up assessment.

Setting: Community based.

Participants: Ambulatory, community-dwelling people with chronic stroke and reported ≥6 hr daily sitting time (N = 21).

Intervention: Activating Behavior for Lasting Engagement (ABLE) was delivered by an occupational therapist 3×/wk for 4 wk. ABLE involves activity monitoring, activity scheduling, self-assessment, and collaborative problem solving.

Outcomes and Measures: Feasibility (participant safety, adherence, satisfaction, and reliable intervention delivery) was assessed against preestablished benchmarks. Changes over time in sedentary behavior (assessed with an ActivPAL micro3 device) and participation (Stroke Impact Scale–Participation subscale) were described.

Results: ABLE was safe (0 serious adverse events), adhered to (11.95 sessions/participant), and reliably delivered (90.00%–97.50% adherence). Participant satisfaction was unmet (Client Satisfaction Questionnaire–8, M = 28.75, SD = 3.84). ABLE was associated with a mean group reduction in prolonged sitting of 54.95 min (SD = 81.10) at postintervention and 14.08 (SD = 58.95) at follow-up. ABLE was associated with a negligible mean group increase over time in participation at postintervention (M = 1.48%, SD = 8.52) and follow-up (M = 1.33%, SD = 15.38).

Conclusions and Relevance: The ABLE intervention is feasible and may be associated with within-group reduction in sedentary behavior over time. Further refinement is indicated.

What This Article Adds: The ABLE intervention uses engagement in meaningful daily activities to reduce sedentary behavior after stroke. These findings suggest that ABLE can be delivered safely and consistently. Further research is required to enhance participant satisfaction and determine the effects of ABLE on stroke survivors’ sedentary behavior.

A novel behavioural INTErvention to REduce Sitting Time in older adults undergoing orthopaedic surgery (INTEREST): results of a randomised-controlled feasibility study

BACKGROUND

Osteoarthritis is a prevalent condition in older adults that causes many patients to require a hip or knee replacement. Reducing patients' sedentariness prior to surgery may improve physical function and post-operative outcomes.

METHODS

We conducted a pragmatic randomised-controlled feasibility study with 2:1 allocation into intervention or usual care groups. The intervention, based on Self-Determination Theory, involved techniques to reduce sedentary behaviour, including motivational interviewing, setting of behavioural goals, and more. The primary outcome was feasibility, assessed using mixed methods. We included exploratory measures to inform a future definitive trial, such as ActivPal3 accelerometry to measure movement, the Short Physical Performance Battery (SPPB), Basic Psychological Needs, and cardiometabolic biomarkers. Assessments were at baseline, 1-week pre-surgery, and 6-week post-surgery.

RESULTS

We recruited 35 participants aged ≥ 60 years approximately 8 weeks before hip or knee arthroplasty. Participant uptake rate was 14.2%, and retention rate 85.7%. Participants were very satisfied with the study which was found to be feasible with some modifications. Exploratory within-group comparisons found that the intervention has potential to improve SPPB by 0.71 points from baseline to pre-surgery, a clinically significant increase, and reduce sedentary time by up to 66 min d-1.

CONCLUSION

In this older surgical population, it is feasible to use behavioural techniques to displace sedentary time to activity and to conduct a trial spanning the period of surgical intervention. This may improve physical function and surgical outcomes. The INTEREST intervention is now ready for evaluation in a full-scale randomised-controlled trial.

REGISTRATION

This trial was registered on Clinicaltrials.gov on 13/11/2018. ID: NCT03740412.

Sedentary behavior patterns over 6 weeks among ambulatory people with stroke

Objective: To describe patterns of sedentary behavior over 6 weeks among ambulatory people with subacute and chronic stroke.Design: Observational longitudinal study with assessments at baseline (T0) and week 6 (T1).Methods: Community-dwelling people with stroke (n = 39) pooled from two studies who were ≥18 years of age were assessed for sedentary behavior at 2 timepoints (T0, T1). Sedentary behavior was measured with the activPAL micro3 following a 7-day wear protocol to obtain mean daily: total sitting time, sitting time accumulated in bouts ≥30 minutes, number of sit-to-stand transitions, and fragmentation index (sit-to-stand transitions/total sitting hours). Paired samples t-tests were used to calculate mean group differences in sedentary behavior metrics between T0 and T1 (α =.05). Cohen's d was calculated to describe the magnitude of within-person change between T0 and T1.Results: There were no statistically significant within-person differences between T0 and T1 on mean daily sitting time (Cohen's d= -0.21, p=.19), sitting time accumulated in bouts ≥30 minutes (d= -0.27, p=.11), number of sit-to-stand transitions (d= -0.02, p=.53), or the fragmentation index (d= -0.11, p=.92).Conclusions: Sedentary behavior metrics were stable for over 6 weeks. The number of sit-to-stand transitions per day and the fragmentation index appeared to be the most stable indicators over 6 weeks. Future research should confirm these findings and identify correlates of sedentary behavior among people with stroke.

Effect and efficacy of lifestyle interventions as secondary prevention

INTRODUCTION

Improvements in health behaviour are often recommended as part of secondary prevention in patients with stroke and transient ischaemic attack. However, there is a lack of knowledge as to how this is applied in clinical practice.

AIM

In this systematic review and meta-analysis, we examined the effect of counselling or educational intervention directed at individual or multiple behavioural risk factors on blood pressure and other reported outcomes.

METHODS

PubMed, Embase, PsycInfo, CINAHL, Scopus and Web of Science were systematically searched. Meta-analyses were conducted on all outcome measures if appropriate. A qualitative analysis of the content of the interventions was conducted to review which elements the interventions consisted of.

RESULTS

Twenty-nine randomized controlled trials were identified. Fourteen reported effects on systolic blood pressure, and pooled results showed a significant beneficial effect (n = 2,222; -3.85 mmHg [95%CI -6.43; -1.28]). The effect was greatest in the four interventions which included supervised training (n = 174; -9.83 mmHg [95%CI -16.56; -3.09]).

CONCLUSION

Modifying health behaviour in stroke survivors might have a moderate beneficial effect on blood pressure, especially if the intervention includes supervised physical training.

IMAGINE study protocol of a clinical trial: a multi-center, investigator-blinded, randomized, 36-month, parallel-group to compare the effectiveness of motivational interview in rehabilitation of older stroke survivors

BACKGROUND

Rehabilitation pathways are crucial to reduce stroke-related disability. Motivational Interviewing (MI), as a person-centered complex intervention, aimed to empower and motivate, and could be a resource to improve rehabilitation outcomes for older stroke survivors. The IMAGINE project aims to assess the impact of MI, as a complement to standard geriatric rehabilitation, on functional improvement at 30 days after admission, compared to standard geriatric rehabilitation alone, in persons admitted to geriatric rehabilitation after a stroke. Secondary objectives include assessing the impact of MI on physical activity and performance, self-efficacy, safety, cost-utility, participants' experiences and functional status at 3 months.

METHODS

We will conduct a multicenter randomized clinical trial in three geriatric rehabilitation hospitals in Spain. Older adults after mild-moderate stroke without previous severe cognitive impairment or disability will be randomized into the control or intervention group (136 per group, total N = 272). The intervention group will receive 4 sessions of MI by trained nurses, including the design of a personalized rehabilitation plan agreed between stroke survivors and nurses based on stroke survivors´ goals, needs, preferences and capabilities. Main outcome will be the Functional Independence Measure (FIM). In-hospital physical activity will be measured through accelerometers and secondary outcomes using validated scales. The study includes a process evaluation and cost-utility analysis.

DISCUSSION

Final results are expected by end of 2020. This study will provide relevant information on the implementation of MI as a rehabilitation reinforcement tool in older stroke survivors. A potential reduction in post-stroke disability and dependence would increase person's health-related quality of life and well-being and reduce health and social care costs. IMAGINE has the potential to inform practice and policymakers on how to move forward towards shared decision-making and shared responsibilities in the vulnerable population of older stroke survivors.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03434938 , registered on January 2018.

Factors influencing sedentary behaviours after stroke: findings from qualitative observations and interviews with stroke survivors and their caregivers

BACKGROUND

Stroke survivors are more sedentary than healthy, age-matched controls, independent of functional capacity. Interventions are needed to encourage a reduction in overall sedentary time, and regular breaks in prolonged periods of sedentary behaviour. This study captured the views and experiences of stroke survivors and their caregivers related to sedentary behaviour after stroke, to inform the development of an intervention to reduce sedentary behaviour.

METHODS

Mixed-methods qualitative study. Non-participant observations were completed in two stroke services, inclusive of inpatient and community settings in the United Kingdom. Semi-structured interviews were conducted with stroke survivors and their caregivers (if available) at six- or nine-months post-stroke. Underpinned by the capability, opportunity and motivation (COM-B) model of behaviour change, observational data (132 h) were analysed thematically and interview data (n = 31 stroke survivors, n = 12 caregivers) were analysed using the Framework approach.

RESULTS

Observation participants differed in functional ability whereas stroke survivor interviewees were all ambulant. Six themes related to sedentary behaviour after stroke were generated: (1) sedentary behaviour levels and patterns after stroke; (2) the physical and social environment in the stroke service and in the home; (3) standing and movement capability after stroke; (4) emotion and motivation after stroke; (5) caregivers' influence on, and role in influencing stroke survivors' sedentary behaviour; and (6) intervening to reduce sedentary behaviour after stroke. Capability, opportunity and motivation were influenced by the impact of the stroke and caregivers' inclination to support sedentary behaviour reduction. Stroke survivors reported being more sedentary than they were pre-stroke due to impaired balance and co-ordination, increased fatigue, and reduced confidence in mobilising. Caregivers inclination to support stroke survivors to reduce sedentary behaviour depended on factors including their willingness to withdraw from the caregiver role, and their perception of whether the stroke survivor would act on their encouragement.

CONCLUSIONS

Many stroke survivors indicate being open to reducing sedentary behaviour, with appropriate support from stroke service staff and caregivers. The findings from this study have contributed to an intervention development process using the Behaviour Change Wheel (BCW) approach to develop strategies to reduce sedentary behaviour after stroke.

Stepping After Stroke: Walking Characteristics in People With Chronic Stroke Differ on the Basis of Walking Speed, Walking Endurance, and Daily Steps

BACKGROUND

What contributes to free-living walking after stroke is poorly understood. Studying the characteristics of walking may provide further details that guide interventions.

OBJECTIVE

The objectives of this study were to examine how the walking characteristics of bouts per day, median steps per bout, maximum steps per bout, and time spent walking differ in individuals with various walking speeds, walking endurance, and daily steps and to identify cutoffs for differentiating ambulators who were active versus inactive.

DESIGN

This study involved a cross-sectional analysis of data from the Locomotor Experience Applied Post-Stroke trial.

METHODS

Participants were categorized by walking speed, walking endurance (via the 6-minute walk test), and daily steps (via 2 consecutive days of objective activity monitoring). Differences in walking characteristics were assessed. Linear regression determined which characteristics predicted daily step counts. Receiver operating characteristic curves and areas under the curve were used to determine which variable was most accurate in classifying individuals who were active (≥5500 daily steps).

RESULTS

This study included 252 participants with chronic stroke. Regardless of categorization by walking speed, walking endurance, or daily steps, household ambulators had significantly fewer bouts per day, steps per bout, and maximum steps per bout and spent less time walking compared with community ambulators. The areas under the curve for maximum steps per bout and bouts per day were 0.91 (95% confidence interval = 0.88 to 0.95) and 0.83 (95% confidence interval = 0.78 to 0.88), respectively, with cutoffs of 648 steps and 53 bouts being used to differentiate active and inactive ambulation.

LIMITATIONS

Activity monitoring occurred for only 2 days.

CONCLUSIONS

Walking characteristics differed based on walking speed, walking endurance, and daily steps. Differences in daily steps between household and community ambulators were largely due to shorter and fewer walking bouts. Assessing and targeting walking bouts may prove useful for increasing stepping after stroke.

Social isolation during the COVID-19 pandemic can increase physical inactivity and the global burden of cardiovascular disease

Emerging data indicate a substantial decrease in global physical activity levels during the period of social isolation adopted worldwide to contain the spread of the coronavirus disease 2019 (COVID-19). Confinement-induced decreases in physical activity levels and increases in sedentary behavior may provoke a rapid deterioration of cardiovascular health and premature deaths among populations with increased cardiovascular risk. Even short-term (1-4 wk) inactivity has been linked with detrimental effects in cardiovascular function and structure and increased cardiovascular risk factors. In this unprecedented and critical scenario, home-based physical activity programs arise as a clinically relevant intervention to promote health benefits to cardiac patients. Many studies have demonstrated the feasibility, safety, and efficacy of different models of home-based exercise programs in the primary and secondary prevention of cardiovascular diseases and major cardiovascular events among different populations. This body of knowledge can inform evidence-based policies to be urgently implemented to counteract the impact of increased physical inactivity and sedentary behavior during the COVID-19 outbreak, thereby alleviating the global burden of cardiovascular disease.

The effectiveness and complexity of interventions targeting sedentary behaviour across the lifespan: a systematic review and meta-analysis

BACKGROUND

Evidence suggests that sedentary behaviour (SB) is associated with poor health outcomes. SB at any age may have significant consequences for health and well-being and interventions targeting SB are accumulating. Therefore, the need to review the effects of multicomponent, complex interventions that incorporate effective strategies to reduce SB are essential.

METHODS

A systematic review and meta-analysis were conducted investigating the impact of interventions targeting SB across the lifespan. Six databases were searched and two review authors independently screened studies for eligibility, completed data extraction and assessed the risk of bias and complexity of each of the included studies.

RESULTS

A total of 77 adult studies (n=62, RCTs) and 84 studies (n=62, RCTs) in children were included. The findings demonstrated that interventions in adults when compared to active controls resulted in non-significant reductions in SB, although when compared to inactive controls significant reductions were found in both the short (MD -56.86; 95%CI -74.10, -39.63; n=4632; I2 83%) and medium-to-long term (MD -20.14; 95%CI -34.13, -6.16; n=4537; I2 65%). The findings demonstrated that interventions in children when compared to active controls may lead to relevant reductions in daily sedentary time in the short-term (MD -59.90; 95%CI -102.16, -17.65; n=267; I2 86%), while interventions in children when compared to inactive controls may lead to relevant reductions in the short-term (MD -25.86; 95%CI -40.77, -10.96; n=9480; I2 98%) and medium-to-long term (MD -14.02; 95%CI -19.49, -8.55; n=41,138; I2 98%). The assessment of complexity suggested that interventions may need to be suitably complex to address the challenges of a complex behaviour such as SB, but demonstrated that a higher complexity score is not necessarily associated with better outcomes in terms of sustained long-term changes.

CONCLUSIONS

Interventions targeting reductions in SB have been shown to be successful, especially environmental interventions in both children and adults. More needs to be known about how best to optimise intervention effects. Future intervention studies should apply more rigorous methods to improve research quality, considering larger sample sizes, randomised controlled designs and valid and reliable measures of SB.

Lifestyle counselling as secondary prevention in patients with minor stroke and transient ischemic attack: study protocol for a randomized controlled pilot study

BACKGROUND

Most patients with minor stroke or transient ischemic attack (TIA) are discharged with little or no specialised follow-up. Nonetheless, these patients have a high prevalence of cognitive impairments and a considerable risk of recurrent stroke. Smoking cessation, physical activity, and adherence to antihypertensive and antithrombotic medication are highly recommended in patients with minor stroke and TIA. Evidence suggests that simple encouragement to change lifestyle is ineffective. Behavioural interventions might therefore be needed to support patients in managing their own health post-discharge.

OBJECTIVES

We aim to test the (1) feasibility of randomisation acceptance and an early initiated, client-centred lifestyle and behavioural intervention in a clinical setting, and (2) potential effect of the intervention on arterial blood pressure in patients with minor stroke or TIA and (3) explore the participants experience of barriers and facilitators for health behaviour after a stroke, including perceived needs and social support.

METHODS

We will conduct a randomized controlled pilot trial: Eligible patients with acute minor stroke or TIA (n = 40) will be randomly allocated to either early initiated counselling with four weekly post-discharge follow-up sessions for 12 weeks or usual care. The primary outcome will be program feasibility and to discuss the relevance of arterial blood pressure as primary outcome after 12 weeks intervention. Selected participants will be invited to participate in semi-structured interviews, based on purposeful sampling, to evaluate the intervention and explore their experience of life after a stroke. The interviews will be analysed using a five-step thematic analysis approach.

DISCUSSION

The study will provide evidence of the feasibility and potential effect of early initiated counselling on cardiovascular risk factors in patients with minor stroke and TIA. Qualitative interviews will contribute with a more nuanced understanding of the barriers and facilitators of health enhancing behaviour. Optimizing health behaviour counselling and providing formal support to the patients' post-discharge may ease the transition and help more patients adhere to lifestyle and medication recommendations.

TRIAL REGISTRATION

ClinicalTrial.gov, NCT03648957.

Association of Perceived Built Environment Attributes with Objectively Measured Physical Activity in Community-Dwelling Ambulatory Patients with Stroke

There is little evidence on how perceptions of the built environment may influence physical activity among post-stroke patients. This study aimed to explore the associations between perceived built environment attributes and objectively measured physical activity outcomes in community-dwelling ambulatory patients with stroke. This cross-sectional study recruited patients who could walk outside without assistance. We assessed both objectively measured physical activity outcomes such as number of steps and duration of moderate-to-vigorous physical activity (MVPA) with an accelerometer and the patients’ perceived surrounding built environment with the International Physical Activity Questionnaire Environmental Module. Sixty-one patients (67.0 years old) were included. The multiple linear regression analysis showed significant associations of the presence of sidewalks (β = 0.274, p = 0.016) and access to recreational facilities (β = 0.284, p = 0.010) with the number of steps taken (adjusted R² = 0.33). In contrast, no significant associations were found between perceived built environment attributes and MVPA. These findings may help to suggest an approach to promote appropriate physical activity in patients with stroke depending on their surrounding built environment.

Examining daily physical activity in community-dwelling adults with stroke using social cognitive theory: an exploratory, qualitative study

Purpose: A better understanding of psychosocial factors underlying daily physical activity (i.e. physical activity performed throughout the day) in stroke survivors could be used to develop interventions to promote post-stroke physical activity, particularly in individuals for whom exercise is difficult.Methods: In-depth qualitative interviews were conducted with 15 ambulatory, community-dwelling stroke survivors. Interview transcripts were analyzed using directed content analysis, guided by Social Cognitive Theory, to investigate outcomes expectations, self-efficacy, self-regulation, and social-support for daily physical activity.Results: Participants reported that physical and mental health, and independence and recovery, were important outcomes expectations. Self-efficacy was enhanced through mental perceptions and mastery experiences. Planning, problem-solving, reviewing performance, and establishing routines that require physical activity were important self-regulation strategies. Social support provided praise and encouragement and physical assistance, but was also a barrier when friends and family were overprotective.Conclusions: Participants reported that the investigated Social Cognitive Theory constructs were important psychosocial factors for daily physical activity. Future research and clinical investigations should empirically test the use of strategies to modify these factors for promoting daily physical activity in community-dwelling adults with stroke.Implications for rehabilitationInterventions to increase physical activity after stroke are needed.Outcomes expectations, self-efficacy, self-regulation, and social support were reported by participants as important psychosocial factors underlying daily physical activity.These psychosocial factors should be explored with individual patients and clients to determine which are most deficient, and where amenable to change, targeted for intervention to promote daily physical activity.

Self-Efficacy, Self-Regulation, Social Support, and Outcomes Expectations for Daily Physical Activity in Adults with Chronic Stroke: A Descriptive, Exploratory Study

Interventions are needed to increase physical activity throughout the day in adults with chronic stroke, but mechanisms of action for doing so have not been identified. In this descriptive, exploratory study of 36 ambulatory, community-dwelling adults with chronic stroke, participants completed questionnaires investigating self-efficacy, self-regulation, social support, and outcomes expectations for daily physical activity. In the absence of any intervention, participants consistently reported high self-efficacy and outcomes expectations but low use of self-regulation and social support strategies. Discussion of how these results can inform the development of interventions to facilitate daily physical activity in adults with chronic stroke is provided.

Long-Term Effect of Promoting In-Hospital Physical Activity on Postdischarge Patients with Mild Ischemic Stroke

BACKGROUND

Although there are reports on the promotion of physical activity during hospitalization, there is no evidence that promoting in-hospital physical activity continues over time after discharge. The purpose of this study was to evaluate the long-term effect of promoting in-hospital physical activity on postdischarge physical activity and self-efficacy for physical activity in patients with mild ischemic stroke.

METHODS

This was a cross-sectional study of a post hoc analysis of a previous randomized controlled trial. Patients with mild ischemic stroke were divided into the intervention group (in which physical activity was promoted during hospitalization) and a control group. To promote in-hospital physical activity, patients in the intervention group were instructed in the self-monitoring approach. After discharge, we measured physical activity and self-efficacy for physical activity by mailing a questionnaire to the patients. The average number of steps taken was used the index of postdischarge physical activity.

RESULTS

The study sample comprised 30 patients, with 13 patients in the intervention group and 17 patients in the control group. There were no significant differences in physical activity values (6176.8 versus 6112.8 steps/day, P = .932) and self-efficacy for physical activity score (66.0 versus 76.0 points, P = .801) between the 2 groups.

CONCLUSIONS

This study showed that the promotion of in-hospital physical activity did not appear to increase physical activity and self-efficacy for physical activity in patients with mild ischemic stroke after discharge. Additional study is needed to establish a more specific approach to promote physical activity during hospitalization that will carry over during long-term follow-up.

Efficacy of interventions aimed at improving physical activity in individuals with stroke: a systematic review

Purpose: To identify interventions employed to increase post-stroke physical activity, evaluate their efficacy, and identify the gaps in literature.Materials and methods: Randomized controlled trials published until March 2018 were searched in MEDLINE, PEDro, EMBASE, LILACS, and SCIELO databases. The quality of each study and overall quality of evidence were assessed using the PEDro and the GRADE scales.Results: Eighteen studies were included (good PEDro and very low GRADE-scores). In seven, the experimental groups showed significant increases in physical activity (aerobics, resistance, and home-based training; counseling, aerobics, resistance, and home-based training; electrical stimulation during walking; functional-task training; robot-assisted arm therapy; accelerometer-based feedback, and physical activity encouragement). In seven, there were no significant between-group differences (physical activity plan; stretching, use of toe-spreaders, standard treatment; counseling; circuit video-game; functional-task; counseling and cognitive training). The combined experimental and control groups showed significant declines in physical activity in one study (aerobic training or stretching) and increases in three others (aerobic, resistance or sham resistance training; stroke-with advice or only stroke-counseling; aerobic training, educational sessions, standard treatment, and coaching, or mobilization and standard treatment). A meta-analysis could not be performed, due to heterogeneity.Conclusions: Some interventions improved physical activity after stroke. However, the interpretability is limited.Implications for rehabilitationIndividuals with stroke show low physical activity, which may compromise function and health.The use of interventions aimed at improving and maintaining physical activity of individuals with stroke are recommended.Some interventions, such as aerobic, resistance, and combined home-based training, electrical stimulation during walking, functional task training, and arm robot-assisted therapy, could improve the physical activity after stroke.

How should long-term free-living physical activity be targeted after stroke? A systematic review and narrative synthesis

BACKGROUND

Increasing physical activity (PA) levels (regular movement such as walking and activities of daily living) and reducing time spent sedentary improves cardiovascular health and reduces morbidity and mortality. Fewer than 30% of independently mobile stroke survivors undertake recommended levels of PA. Sedentary behaviour is also high in this population. We aimed to systematically review the study characteristics and the promise of interventions targeting free-living PA and/or sedentary behaviour in adult stroke survivors.

METHODS

Seven electronic databases were searched to identify randomised controlled trials (≥3-months follow-up) targeting PA and/or sedentary behaviour in adults with first or recurrent stroke or transient ischaemic attack. The quality assessment framework for RCTs was used to assess risk of bias within and across studies. Interventions were rated as "very", "quite" or "non-promising" based on within- or between-group outcome differences. Intervention descriptions were captured using the TIDieR (Template for Intervention Description and Replication) Checklist. Behaviour change techniques (BCTs) within interventions were coded using the BCT Taxonomy v1, and compared between studies by calculating a promise ratio.

RESULTS

Nine studies fulfilled the review criteria (N = 717 randomised stroke patients) with a high or unclear risk of bias. None of the studies targeted sedentary behaviour. Six studies were very/quite promising (reported increases in PA post-intervention). Studies were heterogeneous in their reporting of participant age, time since stroke, stroke type, and stroke location. Sub-optimal intervention descriptions, treatment fidelity and a lack of standardisation of outcome measures were identified. Face to face and telephone-based self-management programmes were identified as having promise to engage stroke survivors in PA behaviour change. Optimal intensity of contact, interventionist type and time after stroke to deliver interventions was unclear. Nine promising BCTs (ratios ≥2) were identified: information about health consequences; information about social and environmental consequences; goal setting-behaviour; problem-solving; action planning; feedback on behaviour; biofeedback; social support unspecified; and credible source.

CONCLUSIONS

Future research would benefit from establishing stroke survivor preferences for mode of delivery, setting and intensity, including measurement of physical activity. Interventions need to justify and utilise a theory/model of behaviour change and explore the optimal combination of promising BCTs within interventions.

Interventions targeting sedentary behavior in non-working older adults: a systematic review

Sedentary behavior has been found to be associated with negative health outcomes independently of physical activity in older adults. This systematic review collates interventions to reduce sedentary behavior in non-working older adults, assessing whether they are effective, feasible, and safe. A systematic search identified 2560 studies across five databases. Studies were included where participants were ≥60 years on average with none younger than 45, and participants did not work >2 days per week. A total of six studies were identified, three of which included control groups, while the other three were repeated-measures pre-post designs. Only one study randomised participants. The overall level of quality of included studies was poor. A narrative synthesis was conducted, as the level of heterogeneity in outcomes and outcome reporting were too high for a meta-analysis to be performed. The narrative synthesis suggested that interventions have the potential to reduce sitting time in non-working older adults. Included studies reported feasible and safe implementations of their interventions in most samples, except for one subsample from a study of people in sheltered housing. Objectively measured reductions in sitting time were between 3.2% and 5.3% of waking time, or up to 53.9 min per day. Future studies should employ more rigorous designs to assess the effects of reducing sedentary behavior on health and physical function, and should include follow-ups to measure the duration of behavior change.

Effects of aerobic training on physical activity in people with stroke: protocol for a randomized controlled trial

BACKGROUND

Post-stroke physical inactivity is explained by several factors related to the stroke, which have been suggested as the causes and consequences of functional declines and health problems. Therefore, it is important to increase physical activity levels and reduce the time spent in low-energy expenditure activities after a stroke. Since the maintenance of cardiorespiratory fitness is a significant predictor of physical activity levels post-stroke, it may be important to investigate whether aerobic training is effective in increasing physical activity levels and reducing the time spent in low-energy expenditure activities in this population. The efficacy of aerobic training on these variables is not well known. The primary objective of this trial will be to investigate the effects of aerobic treadmill training on physical activity levels and on time spent in low-energy expenditure activities in people with stroke. The secondary aim will be to evaluate the effects of the training on cardiorespiratory fitness, endurance, depression, mobility, quality of life, and participation.

METHODS/DESIGN

A randomized controlled trial, with blinded assessments, will be performed in a community-based setting. Altogether, 22 adults with a diagnosis of stroke (>6 months) who are sedentary or insufficiently active will be included. Participants will be randomly assigned to either: (1) aerobic treadmill training (experimental group, at 60-80% of their heart rate reserve) or (2) walking outside (control group, below 40% of heart rate reserve). Both groups will attend 40-min training sessions, three times per week over 12 weeks, in groups of two to four participants, with a trained physiotherapist. Primary outcomes are physical activity levels and time spent in low-energy expenditure activities (Multi-sensor SenseWear Mini® and Human Activity Profile). Secondary outcomes are cardiorespiratory fitness (peak oxygen uptake VO2peak and ventilatory threshold), endurance, depression, mobility, quality of life, and participation. The effects of the training will be analyzed from the collected data using intention to treat. Between-group differences will be measured by two-way repeated measures ANOVA, considering the baseline, post-training, and 4-week follow-up.

DISCUSSION

The results of this trial will likely provide valuable new information on the effects of aerobic treadmill training on physical activity levels and on time spent in low-energy expenditure activities of individuals with stroke, through changes in cardiorespiratory fitness.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02798237 . Registered on 13 June 2016.

The Feasibility and Longitudinal Effects of a Home-Based Sedentary Behavior Change Intervention After Stroke

OBJECTIVE

To evaluate the feasibility and preliminary effects of a sedentary behavior change intervention on sedentary behavior, physical activity, function, and quality of life following inpatient stroke rehabilitation.

DESIGN

Single-group, longitudinal, intervention study with 1-week baseline, 8-week intervention, and 8-week follow-up.

SETTING

Community.

PARTICIPANTS

Individuals (N=34) with subacute stroke recruited within 1 month following discharge home from inpatient stroke rehabilitation.

INTERVENTION

STand Up Frequently From Stroke (STUFFS) intervention that involved interrupting and replacing sedentary time with upright activities (standing and walking) at home and in the community. A motivational wrist-worn activity monitor was used throughout the intervention.

MAIN OUTCOME MEASURES

Primary outcomes were reach (enrolled/eligible), retention (completed/enrolled), satisfaction, and compliance with the intervention. Secondary outcomes were sedentary behavior, physical activity, lower extremity impairment, self-efficacy, cognitive status, mobility, and quality of life outcomes.

RESULTS

Forty-four participants were eligible to participate. Of the eligible, 34 (77.3%; time since stroke onset: 3.5±1.1 months) were enrolled at baseline and 32 (94.1%) of the enrolled had complete data at follow-up. Satisfaction with the program was 89%. Sedentary time decreased by 54.2±13.7 minutes per day (P<.01) at postintervention and 26.8±14.0 minutes per day (P=.07) at follow-up, relative to baseline. There were significant improvements in walking speed, cognition, impairment, and self-reported quality of life over time (P<.05). Self-efficacy was high across all time points. The number of steps and time spent stepping were not statistically different across both time periods.

CONCLUSIONS

The program was feasible to deliver in the home environment with good retention and satisfaction. Further research is required to test the effectiveness of the STUFFS program compared with usual care.

Feasibility of Ballistic Strength Training in Subacute Stroke: A Randomized, Controlled, Assessor-Blinded Pilot Study

OBJECTIVE

To establish the feasibility and effectiveness of a 6-week ballistic strength training protocol in people with stroke.

DESIGN

Randomized, controlled, assessor-blinded study.

SETTING

Subacute inpatient rehabilitation.

PARTICIPANTS

Consecutively admitted inpatients with a primary diagnosis of first-ever stroke with lower limb weakness, functional ambulation category score of ≥3, and ability to walk ≥14 m were screened for eligibility to recruit 30 participants for randomization.

INTERVENTIONS

Participants were randomized to standard therapy or ballistic strength training 3 times per week for 6 weeks.

MAIN OUTCOME MEASURES

The primary aim was to evaluate feasibility and outcomes included recruitment rate, participant retention and attrition, feasibility of the exercise protocol, therapist burden, and participant safety. Secondary outcomes included measures of mobility, lower limb muscle strength, muscle power, and quality of life.

RESULTS

A total of 30 participants (11% of those screened) with mean age of 50 years (SD 18) were randomized. The median number of sessions attended was 15 of 18 and 17 of 18 for the ballistic and control groups, respectively. Earlier than expected discharge to home (n=4) and illness (n=7) were the most common reasons for nonattendance. Participants performed the exercises safely, with no study-related adverse events. There were significant (P<.05) between-group changes favoring the ballistic group for comfortable gait velocity (mean difference [MD] 0.31m/s, 95% confidence interval [CI]: 0.08-0.52), muscle power, as measured by peak jump height (MD 8cm, 95% CI: 3-13), and peak propulsive velocity (MD 64cm/s, 95% CI: 17-112).

CONCLUSIONS

Ballistic training was safe and feasible in select ambulant people with stroke. Similar rates of retention and attrition suggest that ballistic training was acceptable to patients. Secondary outcomes provide promising results that warrant further investigation in a larger trial.

Excessive sedentary time during in-patient stroke rehabilitation

Background and Purpose Previous research suggests that patients receiving inpatient stroke rehabilitation are sedentary although there is little data to confirm this supposition within the Canadian healthcare system. The purpose of this cross-sectional study was to observe two weeks of inpatient rehabilitation in a tertiary stroke center to determine patients' activity levels and sedentary time. Methods Heart rate (HR) and accelerometer data were measured using an Actiheart monitor for seven consecutive days, 24 h/day, on the second week and the last week of admission. Participants or their proxies completed a daily logbook. Metabolic equivalent (MET) values were calculated and time with MET < 1.5 was considered sedentary. The relationship between patient factors (disability, mood, and social support) and activity levels and sedentary time were analyzed. Results Participants (n = 19; 12 males) spent 10 h sleeping and 4 h resting each day, with 86.9% of their waking hours sedentary. They received on average 8.5 task-specific therapy sessions; substantially lower than the 15 h/week recommended in best practice guidelines. During therapy, 61.6% of physical therapy and 76.8% of occupational therapy was spent sedentary. Participants increased their HR about 15 beats from baseline during physical therapy and 8 beats during occupational therapy. There was no relationship between sedentary time or activity levels and patient factors. Discussion Despite calls for highly intensive stroke rehabilitation, there was excessive sedentary time and therapy sessions were less frequent and of lower intensity than recommended levels. Conclusions In this sample of people attending inpatient stroke rehabilitation, institutional structure of rehabilitation rather than patient-related factors contributed to sedentary time.

Effect of accelerometer-based feedback on physical activity in hospitalized patients with ischemic stroke: a randomized controlled trial

Objective:

To evaluate the effect of accelerometer-based feedback on physical activity in hospitalized patients with ischemic stroke.

Design:

Randomized controlled trial.

Setting:

Acute care hospital.

Subjects:

A total of 55 patients with ischemic stroke who could walk without assistance were randomly assigned to the intervention group ( n = 27) or the control group ( n = 28).

Interventions:

At the baseline measurement, patients did not receive accelerometer-based feedback. At follow-up, a physical therapist provided instruction on accelerometer-based feedback, discussed physical activity targets and encouraged the patients to walk more until discharge.

Main measures:

The average daily number of steps taken was used as the index of daily hospitalized physical activity.

Results:

The study sample consisted of 48 patients, of whom 23 patients comprised the intervention group and 25 patients comprised the control group. Although there were no significant differences in physical activity values between the two groups at the baseline measurement, the values in the intervention group at follow-up were significantly higher than those in the control group (5180.5 ± 2314.9 vs. 3113.6 ± 1150.9 steps/day, P = 0.0003). The effect size of physical activity values (Cohen’s d = 1.15) at follow-up was large between the two groups.

Conclusion:

Exercise training combined with accelerometer-based feedback effectively increased physical activity in hospitalized patients with ischemic stroke.

Use of Mobile Devices to Measure Outcomes in Clinical Research, 2010-2016: A Systematic Literature Review

Background

The use of mobile devices in clinical research has advanced substantially in recent years due to the rapid pace of technology development. With an overall aim of informing the future use of mobile devices in interventional clinical research to measure primary outcomes, we conducted a systematic review of the use of and clinical outcomes measured by mobile devices (mobile outcomes) in observational and interventional clinical research.

Method

We conducted a PubMed search using a range of search terms to retrieve peer-reviewed articles on clinical research published between January 2010 and May 2016 in which mobile devices were used to measure study outcomes. We screened each publication for specific inclusion and exclusion criteria. We then identified and qualitatively summarized the use of mobile outcome assessments in clinical research, including the type and design of the study, therapeutic focus, type of mobile device(s) used, and specific mobile outcomes reported.

Results

The search retrieved 2,530 potential articles of interest. After screening, 88 publications remained. Twenty-five percent of the publications (n = 22) described mobile outcomes used in interventional research, and the rest (n = 66) described observational clinical research. Thirteen therapeutic areas were represented. Five categories of mobile devices were identified: (1) inertial sensors, (2) biosensors, (3) pressure sensors and walkways, (4) medication adherence monitors, and (5) location monitors; inertial sensors/accelerometers were most common (reported in 86% of the publications). Among the variety of mobile outcomes, various assessments of physical activity were most common (reported in 74% of the publications). Other mobile outcomes included assessments of sleep, mobility, and pill adherence, as well as biomarkers assessed using a mobile device, including cardiac measures, glucose, gastric reflux, respiratory measures, and intensity of head-related injury.

Conclusion

Mobile devices are being widely used in clinical research to assess outcomes, although their use in interventional research to assess therapeutic effectiveness is limited. For mobile devices to be used more frequently in pivotal interventional research – such as trials informing regulatory decision-making – more focus should be placed on: (1) consolidating the evidence supporting the clinical meaningfulness of specific mobile outcomes, and (2) standardizing the use of mobile devices in clinical research to measure specific mobile outcomes (e.g., data capture frequencies, placement of device). To that aim, this manuscript offers a broad overview of the various mobile outcome assessments currently used in observational and interventional research, and categorizes and consolidates this information for researchers interested in using mobile devices to assess outcomes in interventional research.

Does a cycling program combined with education and followed by coaching promote physical activity in subacute stroke patients? A randomized controlled trial

BACKGROUND

To investigate the effects of a three month active cycling program followed by coaching on physical activity in subacute stroke patients.

METHODS

Patients (n = 59; mean age =65.4 ± 10.3) aged ≤80 years with first stroke and able to cycle at 50 revolutions/minute enrolled 3-10 weeks post stroke. Patients were randomly allocated to three month active cycling group (n = 33) or to a control group (n = 26), 3 x 30 minutes training/week. Afterwards, the active cycling group was randomized into a coaching (n = 15) versus non-coaching group (n = 16) for nine months. Physical activity was measured by objective and self-reported measures, which were taken before/after the active cycling program and during six and 12 months, except the Baecke-questionnaire, which was used at baseline and 12 months.

RESULTS

A significant difference was found in Baecke/sport (95% confidence interval: 0.06, 2.24; p = 0.039) between the active cycling group and the control group, in patients with severe motor function deficits at baseline. Patients in the control group performed significant less sports at 12 months (mean Baecke/sport_baseline =3.07 ± 1.21, mean Baecke/sport_12months = 1.43 ± 0.98; p = 0.01). Furthermore, all groups showed significant changes over time in all measures at three months (except: Physical Activity Scale for Individuals with Physical Disabilities, diary/Mets*minutes-moderate) and 12 month and additionally in a subgroup with severe motor function deficits (except diary Mets*minutes-sedentary).

CONCLUSION

When active cycling combined with education is used in subacute patients with severe motor function deficits, more sport participation might be observed after one year. No other significant group differences were found over time. In all groups, however, patients showed significant improvement over time in physical activity measures. Future work is needed to explore the most effective coaching approach after an aerobic training program. Implications for Rehabilitation The active cycling program combined with education is applicable in subacute stroke patients as it required little stand-by assistance due to chip cards, the intensity was gradually built and the involvement of caregivers in the educational sessions. This training approach also revealed applicable in severely impaired stroke patients and might facilitate sport participation on the long-term. This randomized controlled study aims to quantify physical activity after stroke by using a combination of objective and self-report measures, which revealed detailed information about different aspects of physical activity levels. There is a need for coaching approaches that facilitate aerobic exercise after ending a supervised program. A coaching approach needs to guide patients in adopting aerobic exercise as a part of a lifestyle change and needs to be less time consuming.

What is the effect of health coaching on physical activity participation in people aged 60 years and over? A systematic review of randomised controlled trials

BACKGROUND

Physical inactivity is common in older age, yet increased activity benefits older people in terms of preventing chronic disease and maximising independence. Health coaching is a behaviour change intervention that has been shown to increase physical activity in clinical populations. This systematic review and meta-analysis investigated the effect of health coaching on physical activity, mobility, quality of life and mood in older people.

METHODS

MEDLINE, EMBASE, CENTRAL, PsycINFO, PEDro, SPORTDiscus, LILACS and CINAHL databases were used to identify randomised controlled trials which evaluated the effect of health coaching on physical activity (primary outcome) among people aged 60+. Secondary outcomes were mobility, quality of life and mood. We calculated standardised mean differences (SMDs, Hedges' g) with 95% CIs from random effects meta-analyses.

RESULTS

27 eligible trials were included. Health coaching had a small, statistically significant effect on physical activity (27 studies; SMD = 0.27; 95% CI 0.18 to 0.37; p<0.001). There was no evidence of an effect of health coaching on mobility (eight studies; SMD = 0.10; 95% CI -0.03 to 0.23; p=0.13), quality of life (eight studies; SMD = 0.07; 95% CI -0.06 to 0.20; p<0.05) or mood (five studies; SMD = 0.02; 95% CI -0.12 to 0.16; p=0.83).

CONCLUSIONS

Health coaching significantly increased physical activity in people aged 60+. There was no evidence of an effect of health coaching on quality of life, mobility and mood, so different approaches may be required to impact on these outcomes.