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Bansal K, Fox EJ, Clark D, Fulk G, Rose DK. Speed- and Endurance-Based Classifications of Community Ambulation Post-Stroke Revisited: The Importance of Location in Walking Performance Measurement. Neurorehabil Neural Repair 2024; 38:582-594. [PMID: 38813947 DOI: 10.1177/15459683241257521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
BACKGROUND Gait speed or 6-minute walk test are frequently used to project community ambulation abilities post-stroke by categorizing individuals as household ambulators, limited, or unlimited community ambulators. However, whether improved clinically-assessed gait outcomes truly translate into enhanced real-world community ambulation remains uncertain. OBJECTIVE This cross-sectional study aimed to examine differences in home and community ambulation between established categories of speed- and endurance-based classification systems of community ambulation post-stroke and compare these with healthy controls. METHODS Sixty stroke survivors and 18 healthy controls participated. Stroke survivors were categorized into low-speed, medium-speed, or high-speed groups based on speed-based classifications and into low-endurance, medium-endurance, or high-endurance groups based on the endurance-based classification. Home and community steps/day were quantified using Global Positioning System and accelerometer devices over 7 days. RESULTS The low-speed groups exhibited fewer home and community steps/day than their medium- and high-speed counterparts (P < .05). The low-endurance group took fewer community steps/day than the high-endurance group (P < .05). Despite vast differences in clinical measures of gait speed and endurance, the medium-speed/endurance groups did not differ in their home and community steps/day from the high-speed/endurance groups, respectively. Stroke survivors took 48% fewer home steps/day and 77% fewer community steps/day than healthy controls. CONCLUSIONS Clinical classification systems may only distinguish home ambulators from community ambulators, but not between levels of community ambulation, especially beyond certain thresholds of gait speed and endurance. Clinicians should use caution when predicting community ambulation status through clinical measures, due to the limited translation of these classification systems into the real world.
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Affiliation(s)
- Kanika Bansal
- Department of Physical Therapy, University of Mount Union, Alliance, OH, USA
- Department of Physical Therapy, University of Florida, Gainesville, FL, USA
| | - Emily J Fox
- Department of Physical Therapy, University of Florida, Gainesville, FL, USA
- Brooks Rehabilitation Clinical Research Center, Jacksonville, FL, USA
| | - David Clark
- Brain Rehabilitation Research Center, Malcolm Randall VAMC, Gainesville, FL, USA
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | - George Fulk
- Division of Physical Therapy, Emory University School of Medicine, Atlanta, GA, USA
| | - Dorian K Rose
- Department of Physical Therapy, University of Florida, Gainesville, FL, USA
- Brooks Rehabilitation Clinical Research Center, Jacksonville, FL, USA
- Brain Rehabilitation Research Center, Malcolm Randall VAMC, Gainesville, FL, USA
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Nayak N, Mahendran N, Kuys S, Brauer SG. What factors at discharge predict physical activity and walking outcomes 6 months after stroke? A systematic review. Clin Rehabil 2024:2692155241261698. [PMID: 39053141 DOI: 10.1177/02692155241261698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
OBJECTIVE This study aimed to identify factors at hospital discharge that predict physical activity and walking outcomes in the first 6 months after stroke. DATA SOURCES Searches were conducted in CINAHL (EBSCO), Web of Science, PubMed and Scopus from inception to 30 April 2024. Reference lists of included articles were manually screened to identify additional studies. REVIEW METHODS Studies of adults with stroke reporting predictors at hospital discharge and outcomes of physical activity or walking across the first 6 months after hospital discharge were included. Two reviewers independently screened titles, abstracts and reviewed full texts. Quality of included studies was assessed with Quality in Prognostic Studies screening tool. A narrative synthesis was undertaken. RESULTS The search strategy retrieved 7834 studies, from which 6 eligible studies were identified, including a total of 1433 participants. Overall, studies had a low risk of bias. Age, balance, walking speed and walking distance at hospital discharge predicted physical activity outcomes after stroke (n = 2 studies). Cognition, lower limb cycling rhythm and self-efficacy for walking at hospital discharge predicted walking outcomes after stroke (n = 4 studies). CONCLUSIONS A range of factors predicted physical activity and walking outcomes 6 months after stroke. Physical capabilities at discharge appear to be a predictor of these outcomes; however, this needs to be interpreted with caution. Diverse measures and time points were used across studies to characterise physical activity and walking outcomes, highlighting the need for consistency in measurement and longitudinal studies in stroke research.
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Affiliation(s)
- Neelam Nayak
- Physiotherapy, School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Australia
| | - Niruthikha Mahendran
- Physiotherapy, School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Australia
| | - Suzanne Kuys
- Physiotherapy, School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia
| | - Sandra G Brauer
- Physiotherapy, School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Australia
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Delhey LM, Shi X, Morgenstern LB, Brown DL, Smith MA, Case EC, Springer MV, Lisabeth LD. Neighborhood Resources and Health Outcomes Among Stroke Survivors in a Population-Based Cohort. J Am Heart Assoc 2024; 13:e034308. [PMID: 38958125 PMCID: PMC11292760 DOI: 10.1161/jaha.124.034308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 06/05/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Stroke survivors believe neighborhood resources such as community centers are beneficial; however, little is known about the influence of these resources on stroke outcomes. We evaluated whether residing in neighborhoods with greater resource density is associated with favorable post-stroke outcomes. METHODS AND RESULTS We included Mexican American and non-Hispanic White stroke survivors from the Brain Attack Surveillance in Corpus Christi project (2009-2019). The exposure was density of neighborhood resources (eg, community centers, restaurants, stores) within a residential census tract at stroke onset. Outcomes included time to death and recurrence, and at 3 months following stroke: disability (activities of daily living/instrumental activities of daily living), cognition (Modified Mini-Mental State Exam), depression (Patient Health Questionnaire-8), and quality of life (abbreviated Stroke-Specific Quality of Life scale). We fit multivariable Cox regression and mixed linear models. We considered interactions with stroke severity, ethnicity, and sex. Among 1786 stroke survivors, median age was 64 years (interquartile range, 56-73), 55% men, and 62% Mexican American. Resource density was not associated with death, recurrence, or depression. Greater resource density (75th versus 25th percentile) was associated with more favorable cognition (Modified Mini-Mental State Exam mean difference=0.838, 95% CI=0.092, 1.584) and among moderate-severe stroke survivors, with more favorable functioning (activities of daily living/instrumental activities of daily living=-0.156 [95% CI, -0.284 to 0.027]) and quality of life (abbreviated Stroke-Specific Quality of Life scale=0.194 [95% CI, 0.029-0.359]). CONCLUSIONS We observed associations between greater resource density and cognition overall and with functioning and quality of life among moderate-severe stroke survivors. Further research is needed to confirm these findings and determine if neighborhood resources may be a tool for recovery.
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Affiliation(s)
- Leanna M. Delhey
- Department of EpidemiologyUniversity of Michigan School of Public HealthAnn ArborMIUSA
| | - Xu Shi
- Department of BiostatisticsUniversity of Michigan School of Public HealthAnn ArborMIUSA
| | - Lewis B. Morgenstern
- Department of EpidemiologyUniversity of Michigan School of Public HealthAnn ArborMIUSA
- Stroke Program, University of Michigan Medical SchoolAnn ArborMIUSA
| | - Devin L. Brown
- Stroke Program, University of Michigan Medical SchoolAnn ArborMIUSA
| | - Melinda A. Smith
- Department of EpidemiologyUniversity of Michigan School of Public HealthAnn ArborMIUSA
| | - Erin C. Case
- Department of EpidemiologyUniversity of Michigan School of Public HealthAnn ArborMIUSA
| | | | - Lynda D. Lisabeth
- Department of EpidemiologyUniversity of Michigan School of Public HealthAnn ArborMIUSA
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Hoffman RM, Davis-Wilson HC, Hanlon S, Swink LA, Kline PW, Juarez-Colunga E, Melanson EL, Christiansen CL. Maximal daily stepping cadence partially explains functional capacity of individuals with end-stage knee osteoarthritis. PM R 2024; 16:532-542. [PMID: 37819260 PMCID: PMC11006829 DOI: 10.1002/pmrj.13082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 06/01/2023] [Accepted: 09/16/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Individuals with end-stage knee osteoarthritis (OA) walk at a lower intensity (ie, slower step cadence) contributing to worse physical function. Previous literature reports daily step counts and sedentary time, with little information regarding stepping bouts or cadence. Determining relationships between daily higher stepping cadence duration and clinical outcomes can move the field toward optimal daily stepping prescription. OBJECTIVE To quantify daily physical activity patterns of individuals with end-stage knee OA and determine the contribution of high stepping cadence to explain functional capacity variability. DESIGN Cross-sectional analysis. SETTING Veterans Administration medical center. PARTICIPANTS U.S. military veterans (n = 104; age: 67.1 years [7.2]; mean [SD]; male [89.3%]) with end-stage knee OA were enrolled. INTERVENTION Not applicable. MAIN OUTCOME MEASURE Functional capacity (6-Minute Walk Test [6MWT]). Physical activity (activPAL wearable sensor; cadence and time sitting, standing, and stepping), pain (Western Ontario and McMaster Universities Osteoarthritis Index-pain subscale) sociodemographic variables, and comorbidities (body mass index and Functional Comorbidity Index) are the main explanatory variables. RESULTS Participants' wake time was mainly sitting (11.0 h/day) in ≥60-minute bouts (29.7% ± 12.7 of sitting time). Standing (3.4 hours/day) and stepping (1.4 h/day) primarily occurred in 0-5 minute bouts (standing: 87.7% ± 14.4 of standing time, stepping: 98.7% ± 12.7 of stepping time) and stepping cadence was predominantly incidental (1-19 spm; 52.9% ± 9.6 of total stepping time). Backward elimination model results indicated shorter medium-to-brisk cadence bout duration, older age, and higher pain significantly explained shorter 6MWT distance (AdjR2=0.24, p < .01). CONCLUSIONS Individuals with knee OA spend most of their waking hours sitting, while standing and stepping occurs in short bouts at very low stepping cadence. Decreased time in high stepping cadence is associated with lower functional capacity. Future studies should explore if increasing the daily time spent in higher step cadence can improve functional capacity in this population.
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Affiliation(s)
- Rashelle M Hoffman
- Department of Physical Therapy, School of Pharmacy and Health Professions, Creighton University, Omaha, Nebraska, USA
| | - Hope C Davis-Wilson
- RTI International, Technology Advancement and Commercialization, Research Triangle Park, North Carolina, USA
| | - Shawn Hanlon
- Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, Colorado, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado, USA
| | - Laura A Swink
- Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, Colorado, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado, USA
| | - Paul W Kline
- Department of Physical Therapy, High Point University, High Point, North Carolina, USA
| | - Elizabeth Juarez-Colunga
- Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, Colorado, USA
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Denver, Colorado, USA
| | - Edward L Melanson
- Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, Colorado, USA
- Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine, University of Colorado, Aurora, Colorado, USA
- Division of Geriatric Medicine, Department of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Cory L Christiansen
- Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, Colorado, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado, USA
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Doren S, Schwab SM, Bigner K, Calvelage J, Preston K, Laughlin A, Drury C, Tincher B, Carl D, Awosika OO, Boyne P. Evaluating the Neural Underpinnings of Motivation for Walking Exercise. Phys Ther 2024; 104:pzad159. [PMID: 37980613 PMCID: PMC10939334 DOI: 10.1093/ptj/pzad159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 06/19/2023] [Accepted: 09/13/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVE Motivation is critically important for rehabilitation, exercise, and motor performance, but its neural basis is poorly understood. Recent correlational research suggests that the dorsomedial prefrontal cortex (dmPFC) may be involved in motivation for walking activity and/or descending motor output. This study experimentally evaluated brain activity changes in periods of additional motivation during walking exercise and tested how these brain activity changes relate to self-reported exercise motivation and walking speed. METHODS Adults without disability (N = 26; 65% women; 25 [standard deviation = 5] years old) performed a vigorous exercise experiment involving 20 trials of maximal speed overground walking. Half of the trials were randomized to include "extra-motivation" stimuli (lap timer, tracked best lap time, and verbal encouragement). Wearable near-infrared spectroscopy measured oxygenated hemoglobin responses from frontal lobe regions, including the dmPFC, primary sensorimotor, dorsolateral prefrontal, anterior prefrontal, supplementary motor, and dorsal premotor cortices. RESULTS Compared with standard trials, participants walked faster during extra-motivation trials (2.43 vs 2.67 m/s; P < .0001) and had higher oxygenated hemoglobin responses in all tested brain regions, including dmPFC (+842 vs +1694 μM; P < .0001). Greater dmPFC activity was correlated with more self-determined motivation for exercise between individuals (r = 0.55; P = .004) and faster walking speed between trials (r = 0.18; P = .0002). dmPFC was the only tested brain region that showed both of these associations. CONCLUSION Simple motivational stimuli during walking exercise seem to upregulate widespread brain regions. Results suggest that dmPFC may be a key brain region linking affective signaling to motor output. IMPACT These findings provide a potential biologic basis for the benefits of motivational stimuli, elicited with clinically feasible methods during walking exercise. Future clinical studies could build on this information to develop prognostic biomarkers and test novel brain stimulation targets for enhancing exercise motivation (eg, dmPFC).
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Affiliation(s)
- Sarah Doren
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sarah M Schwab
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kaitlyn Bigner
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jenna Calvelage
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio, USA
| | - Katie Preston
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio, USA
| | - Abigail Laughlin
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio, USA
| | - Colin Drury
- Department of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Brady Tincher
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio, USA
| | - Daniel Carl
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio, USA
| | - Oluwole O Awosika
- Department of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Pierce Boyne
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio, USA
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Thompson ED, Miller AE, Reisman DS. Characterizing the impact of multiple chronic conditions on return to participation in chronic stroke survivors. Top Stroke Rehabil 2024; 31:97-103. [PMID: 37057761 PMCID: PMC10576011 DOI: 10.1080/10749357.2023.2202018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 04/09/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Each year, 795,000 Americans experience a stroke. As stroke mortality declines, more individuals are in the chronic phase of recovery (>6 months post-stroke). Over 80% of stroke survivors have multiple, chronic health conditions (MCC). While the relationship between MCC and mortality and function during acute recovery has been explored, less is known about how MCC burden affects participation in chronic stroke survivors. OBJECTIVE This study investigated whether MCC burden is related to participation in those with chronic stroke. METHODS Two hundred and sixty-six participants with chronic (≥6 months) stroke were included in this cross-sectional and retrospective analysis. Participants had a mean age of 62.2 ± 12.8 years, and time since stroke (TSS) of 36.0 ± 44.6 months (114F/152 M). Participants completed the 6-minute Walk Test (6MWT), Activities-Specific Balance Confidence Scale (ABC), Modified Cumulative Illness Rating Scale (MCIR) to quantify the presence and severity of chronic illness across 14 body systems, and the Stroke Impact Scale - Participation subscale (SIS-P). Participation (SIS-P) was the dependent variable. Independent variables were entered into a sequential regression model in three blocks: demographic variables, physical capacity (6MWT distance) and balance self-efficacy (ABC), and MCC burden (MCIR). RESULTS After adjusting for age, sex, and time since stroke, physical capacity and balance self-efficacy explained 31.4% (p < 0.001), and the MCC burden explained 2.0% (p = 0.004). Higher participation was related to lower MCC burden. CONCLUSIONS MCC burden is a significant contributor to variance in participation in chronic stroke survivors, above and beyond demographics, physical capacity, and self-efficacy, and therefore should be considered when creating rehabilitation programs to improve participation.
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Affiliation(s)
| | - Allison E Miller
- Department of Physical Therapy, University of Delaware, Newark, DE, USA
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, MO, USA
| | - Darcy S Reisman
- Department of Physical Therapy, University of Delaware, Newark, DE, USA
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Boyne P, Miller A, Kubalak O, Mink C, Reisman DS, Fulk G. Moderate to Vigorous Intensity Locomotor Training After Stroke: A Systematic Review and Meta-analysis of Mean Effects and Response Variability. J Neurol Phys Ther 2024; 48:15-26. [PMID: 37678805 PMCID: PMC10843766 DOI: 10.1097/npt.0000000000000456] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND AND PURPOSE This meta-analysis quantified mean effects of moderate to vigorous intensity locomotor training (LT mv ) on walking outcomes in subacute and chronic stroke, and the magnitude of variability in LT mv response. METHODS Databases were searched for randomized trials comparing LT mv with no intervention, nongait intervention, or low-intensity gait training. Comfortable gait speed (CGS), fastest gait speed (FGS), 6-minute walk test (6MWT), walking activity (steps per day), and adverse effect/event (AE) data were extracted. Pooled estimates were calculated for mean changes, AE relative risks, and the standard deviation of response (SD response ) to LT mv versus control groups, stratified by study chronicity where possible. RESULTS There were 19 eligible studies (total N = 1096): 14 in chronic stroke (N = 839) and 5 in subacute stroke (N = 257). Compared with control interventions, LT mv yielded significantly greater increases in CGS (chronic, +0.06 m/s [95% confidence interval (CI), 0.01-0.10]; subacute, +0.16 [0.12-0.19]; subacute vs chronic, P = 0.03), FGS (chronic, +0.07 m/s [0.02-0.13]; subacute, +0.21 [0.01, 0.41]; P = 0.04), and 6MWT (chronic, +33 m [24-42]; subacute, +51 [26-77]; P = 0.054) but not steps/day (+260 [-1159 to 1679]). There were no treatment-related serious AEs among 398 LT mv participants in 14 AE-reporting studies. SD response estimates indicated substantial response variability: CGS, 0.11 m/s [0.00-0.15]; FGS, 0.14 m/s [-0.00 to 0.20]; and 6MWT, 41 m [27-51]. DISCUSSION AND CONCLUSIONS LT mv improves mean walking capacity outcomes in subacute and chronic stroke and does not appear to have high risk of serious harm. Response magnitude varies within and between chronicity subgroups, and few studies have tested effects on daily walking activity or non-serious AEs.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A452 ).
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Affiliation(s)
- Pierce Boyne
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, OH
| | - Allison Miller
- Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark, DE
| | - Owen Kubalak
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, OH
| | - Caroline Mink
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, OH
| | - Darcy S. Reisman
- Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark, DE
| | - George Fulk
- Department of Rehabilitation Medicine, School of Medicine, Emory University, Atlanta, GA
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Luzum G, Gunnes M, Lydersen S, Saltvedt I, Tan X, Thingstad P, Thrane G, Askim T. Physical Activity Behavior and Its Association With Global Cognitive Function Three Months After Stroke: The Nor-COAST Study†. Phys Ther 2023; 103:pzad092. [PMID: 37440440 PMCID: PMC10733132 DOI: 10.1093/ptj/pzad092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 03/15/2023] [Accepted: 05/22/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVE The purposes of this study were to determine the association between physical activity (PA) behavior and global cognitive function 3 months after stroke and to explore the role of physical capacity as a mediating factor. METHODS Participants with stroke were successively recruited at 5 different hospitals in Norway. PA was measured using accelerometers, with a follow-up period of 7 consecutive days, and global cognitive function was assessed using the Montreal Cognitive Assessment (MoCA). The general pattern of PA and the percentage of participants adhering to World Health Organization PA recommendations (at least 150 minutes of moderate-intensity aerobic PA per week) were investigated using descriptive statistics. Multiple regression and mediator analyses were used to examine the relationship between PA behavior and MoCA scores; physical capacity, measured with the Short Physical Performance Battery, served as the mediating variable. RESULTS A total of 193 women (42.6%) and 260 men (57.4%) with a median age of 73.7 years (25th and 75th percentiles = 65.8 and 80.4, respectively) and a median MoCA score of 25 points (25th and 75th percentiles = 22 and 27, respectively) were included. Mean total time spent walking at moderate intensity was 251.7 (SD = 164.6) min/wk (mean bout length = 20.9 [SD = 7.3] seconds), which indicated 69.3% adherence to World Health Organization guidelines. With each point decrease in the MoCA score, there was an expected 8.6% increase in the odds of nonadherence to PA recommendations. Physical capacity was identified as an important mediating factor, explaining the strength of the association between cognition and PA behavior. CONCLUSIONS In contrast to previous research, in the present study, most participants adhered to the updated global PA guidelines. However, people who had survived stroke and had reduced cognitive function were at higher risk of inactivity, an association mediated by physical capacity. IMPACT A better understanding of the association between cognition and PA behavior after stroke might help for developing more targeted early-onset interventions.
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Affiliation(s)
- Geske Luzum
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Mari Gunnes
- Department of Health Research, SINTEF, Trondheim, Norway
| | - Stian Lydersen
- Department of Mental Health, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Ingvild Saltvedt
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
- Department of Geriatric Medicine, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Xiangchun Tan
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Pernille Thingstad
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
- Department of Health and Welfare Services, City of Trondheim, Trondheim, Norway
| | - Gyrd Thrane
- Department of Health and Care Science, Faculty of Health, The Arctic University of Norway, Tromsø, Norway
| | - Torunn Askim
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
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9
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Bansal K, Clark DJ, Fox EJ, Rose DK. Sympathetic nervous system responses during complex walking tasks and community ambulation post-stroke. Sci Rep 2023; 13:20068. [PMID: 37974001 PMCID: PMC10654447 DOI: 10.1038/s41598-023-47365-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023] Open
Abstract
Stroke survivors frequently report increased perceived challenge of walking (PCW) in complex environments, restricting their daily ambulation. PCW is conventionally measured through subjective questionnaires or, more recently, through objective quantification of sympathetic nervous system activity during walking tasks. However, how these measurements of PCW reflect daily walking activity post-stroke is unknown. We aimed to compare the subjective and objective assessments of PCW in predicting home and community ambulation. In 29 participants post-stroke, we measured PCW subjectively with the Activities-specific Balance Confidence (ABC) Scale and objectively through electrodermal activity, quantified by change in skin conductance levels (SCL) and skin conductance responses (SCR) between outdoor-complex and indoor-steady-state walking. High-PCW participants were categorized into high-change SCL (ΔSCL ≥ 1.7 μs), high-change SCR (ΔSCR ≥ 0.2 μs) and low ABC (ABC < 72%) groups, while low-PCW participants were categorized into low-change SCL (ΔSCL < 1.7 μs), low-change SCR (ΔSCR < 0.2 μs) and high-ABC (ABC ≥ 72%) groups. Number and location of daily steps were quantified with accelerometry and Global Positioning System devices. Compared to low-change SCL group, the high-change SCL group took fewer steps in home and community (p = 0.04). Neither ABC nor SCR groups differed in home or community steps/day. Objective measurement of PCW via electrodermal sensing more accurately represents home and community ambulation compared to the subjective questionnaire.
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Affiliation(s)
- Kanika Bansal
- Department of Physical Therapy, University of Mount Union, 1972, Clark Ave, Alliance, OH, 44601-3993, USA.
| | - David J Clark
- University of Florida, Gainesville, FL, USA
- Brain Rehabilitation Research Center, Malcolm Randall Veterans Affair Medical Center, Gainesville, FL, USA
| | - Emily J Fox
- University of Florida, Gainesville, FL, USA
- Brooks Rehabilitation, Jacksonville, FL, USA
| | - Dorian K Rose
- University of Florida, Gainesville, FL, USA
- Brain Rehabilitation Research Center, Malcolm Randall Veterans Affair Medical Center, Gainesville, FL, USA
- Brooks Rehabilitation, Jacksonville, FL, USA
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10
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Barth J, Lohse KR, Bland MD, Lang CE. Predicting later categories of upper limb activity from earlier clinical assessments following stroke: an exploratory analysis. J Neuroeng Rehabil 2023; 20:24. [PMID: 36810072 PMCID: PMC9945671 DOI: 10.1186/s12984-023-01148-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 02/14/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Accelerometers allow for direct measurement of upper limb (UL) activity. Recently, multi-dimensional categories of UL performance have been formed to provide a more complete measure of UL use in daily life. Prediction of motor outcomes after stroke have tremendous clinical utility and a next step is to explore what factors might predict someone's subsequent UL performance category. PURPOSE To explore how different machine learning techniques can be used to understand how clinical measures and participant demographics captured early after stroke are associated with the subsequent UL performance categories. METHODS This study analyzed data from two time points from a previous cohort (n = 54). Data used was participant characteristics and clinical measures from early after stroke and a previously established category of UL performance at a later post stroke time point. Different machine learning techniques (a single decision tree, bagged trees, and random forests) were used to build predictive models with different input variables. Model performance was quantified with the explanatory power (in-sample accuracy), predictive power (out-of-bag estimate of error), and variable importance. RESULTS A total of seven models were built, including one single decision tree, three bagged trees, and three random forests. Measures of UL impairment and capacity were the most important predictors of the subsequent UL performance category, regardless of the machine learning algorithm used. Other non-motor clinical measures emerged as key predictors, while participant demographics predictors (with the exception of age) were generally less important across the models. Models built with the bagging algorithms outperformed the single decision tree for in-sample accuracy (26-30% better classification) but had only modest cross-validation accuracy (48-55% out of bag classification). CONCLUSIONS UL clinical measures were the most important predictors of the subsequent UL performance category in this exploratory analysis regardless of the machine learning algorithm used. Interestingly, cognitive and affective measures emerged as important predictors when the number of input variables was expanded. These results reinforce that UL performance, in vivo, is not a simple product of body functions nor the capacity for movement, instead being a complex phenomenon dependent on many physiological and psychological factors. Utilizing machine learning, this exploratory analysis is a productive step toward the prediction of UL performance. Trial registration NA.
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Affiliation(s)
- Jessica Barth
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, MO, USA
| | - Keith R Lohse
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, MO, USA
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Marghuretta D Bland
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, MO, USA
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO, USA
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Catherine E Lang
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, MO, USA.
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO, USA.
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.
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11
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Moore SA, Boyne P, Fulk G, Verheyden G, Fini NA. Walk the Talk: Current Evidence for Walking Recovery After Stroke, Future Pathways and a Mission for Research and Clinical Practice. Stroke 2022; 53:3494-3505. [PMID: 36069185 PMCID: PMC9613533 DOI: 10.1161/strokeaha.122.038956] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Achieving safe, independent, and efficient walking is a top priority for stroke survivors to enable quality of life and future health. This narrative review explores the state of the science in walking recovery after stroke and potential for development. The importance of targeting walking capacity and performance is explored in relation to individual stroke survivor gait recovery, applying a common language, measurement, classification, prediction, current and future intervention development, and health care delivery. Findings are summarized in a model of current and future stroke walking recovery research and a mission statement is set for researchers and clinicians to drive the field forward to improve the lives of stroke survivors and their carers.
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Affiliation(s)
- Sarah A Moore
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK, and Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom (S.A.M.)
| | - Pierce Boyne
- Department of Rehabilitation Exercise and Nutritional Science, University of Cincinnati, OH (P.B.)
| | - George Fulk
- Department of Rehabilitation Medicine, Emory University, Atlanta, GA (G.F.)
| | - Geert Verheyden
- Department of Rehabilitation Sciences, KU Leuven, University of Leuven, Belgium (G.V.)
| | - Natalie A Fini
- Medicine Dentistry and Health Sciences, The University of Melbourne, Australia (N.A.F.)
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12
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Fulk G. JNPT and Representation. J Neurol Phys Ther 2022; 46:229-230. [PMID: 35939366 DOI: 10.1097/npt.0000000000000420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Perceived Community Participation and Associated Factors in People With Stroke. Arch Rehabil Res Clin Transl 2022; 4:100210. [PMID: 36123973 PMCID: PMC9482037 DOI: 10.1016/j.arrct.2022.100210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective To examine individual- and environmental-level factors associated with perceived participation performance and satisfaction in people with chronic stroke. Design Cross-sectional study using secondary data analysis of baseline data from a randomized controlled trial. Setting Community-based setting. Participants Community-dwelling adults with mild to moderate stroke (N=113; mean age=57 years; 58 males). Interventions Not applicable. Main Outcome Measures Main outcomes were measured with the Reintegration to Normal Living Index (perceived participation performance) and Patient-Reported Outcome Measure Information System satisfaction with participation in social roles (perceived participation satisfaction). Other variables collected included personal (eg, age, perceived recovery), health-related (eg, time since stroke, number of comorbidities), body function–related (eg, Stroke Impact Scale, Center for Epidemiologic Studies Depression Scale), and environmental (eg, World Health Organization Quality of Life Short Form Environmental subscale) data. Results Depression, fatigue, mobility, and environmental support showed moderate to strong, statistically significant associations with participation performance and satisfaction in people with stroke. Perceived recovery was moderately associated with participation performance but not with participation satisfaction. Conclusions Returning to participation is a complex process after stroke. Results suggest that various personal, body function–related, and environmental factors are associated with participation performance and satisfaction.
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14
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Miller A, McCartney K, Wright T, Reisman D. Predictors of non-stepping time in people with chronic stroke. Top Stroke Rehabil 2022:1-9. [PMID: 35993481 PMCID: PMC9943794 DOI: 10.1080/10749357.2022.2114703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
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.
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Affiliation(s)
- Allison Miller
- Department of Biomechanics and Movement Science Program, University of Delaware, Newark, Delaware, United States of America
| | - Kiersten McCartney
- Department of Biomechanics and Movement Science Program, University of Delaware, Newark, Delaware, United States of America
| | - Tamara Wright
- Department of Physical Therapy, University of Delaware, Newark, Delaware, United States of America
| | - Darcy Reisman
- Department of Biomechanics and Movement Science Program, University of Delaware, Newark, Delaware, United States of America,Department of Physical Therapy, University of Delaware, Newark, Delaware, United States of America
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15
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Hornby TG, Plawecki A, Lotter JK, Scofield ME, Lucas E, Henderson CE. Gains in Daily Stepping Activity in People With Chronic Stroke After High-Intensity Gait Training in Variable Contexts. Phys Ther 2022; 102:pzac073. [PMID: 35670001 PMCID: PMC9396452 DOI: 10.1093/ptj/pzac073] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 11/03/2021] [Accepted: 01/25/2022] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Many physical therapist interventions provided to individuals with chronic stroke can lead to gains in gait speed or endurance (eg, 6-Minute Walk Test [6MWT]), although changes in objective measures of participation are not often observed. The goal of this study was to determine the influence of different walking interventions on daily stepping (steps per day) and the contributions of demographic, training, and clinical measures to these changes. METHODS In this secondary analysis of a randomized clinical trial, steps per day at baseline and changes in steps per day following 1 of 3 locomotor interventions were evaluated in individuals who were ambulatory and >6 months after stroke. Data were collected on 58 individuals who received ≤30 sessions of high-intensity training (HIT) in variable contexts (eg, tasks and environments; n = 19), HIT focused on forward walking (n = 19), or low-intensity variable training (n = 20). Primary outcomes were steps per day at baseline, at post-training, and at a 3-month follow-up, and secondary outcomes were gait speed, 6MWT, balance, and balance confidence. Correlation and regression analyses identified demographic and clinical variables associated with steps per day. RESULTS Gains in steps per day were observed across all groups combined, with no between-group differences; post hoc within-group analyses revealed significant gains only following HIT in variable contexts. Both HIT groups showed gains in endurance (6MWT), with increases in balance confidence only following HIT in variable contexts. Changes in steps per day were associated primarily with gains in 6MWT, with additional associations with baseline 6MWT, lower-extremity Fugl-Meyer scores, and changes in balance confidence. CONCLUSION HIT in variable contexts elicited gains in daily stepping, with changes primarily associated with gains in gait endurance. IMPACT Providing HIT in variable contexts appears to improve measures of participation (eg, daily stepping) that may be associated with clinical measures of function. Gains in multiple measures of mobility and participation with HIT in variable contexts may improve the efficiency and value of physical therapy services.
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Affiliation(s)
- T George Hornby
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Rehabilitation Hospital of Indiana, Indianapolis, Indiana, USA
| | - Abbey Plawecki
- Rehabilitation Hospital of Indiana, Indianapolis, Indiana, USA
| | | | | | - Emily Lucas
- Rehabilitation Hospital of Indiana, Indianapolis, Indiana, USA
| | - Christopher E Henderson
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Rehabilitation Hospital of Indiana, Indianapolis, Indiana, USA
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16
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Miller A, Pohlig RT, Reisman DS. Relationships Among Environmental Variables, Physical Capacity, Balance Self-Efficacy, and Real-World Walking Activity Post-Stroke. Neurorehabil Neural Repair 2022; 36:535-544. [PMID: 35924968 DOI: 10.1177/15459683221115409] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Social and physical environmental factors affect real-world walking activity in individuals with stroke. However, environmental factors are often non-modifiable, presenting a challenge for clinicians working with individuals with stroke whose real-world walking is limited due to environmental barriers. OBJECTIVE The purpose of this work was to test a model hypothesizing the relationships among environmental factors (specifically, living situation and area deprivation), modifiable factors, and real-world walking activity to understand opportunities for intervention. We hypothesized that balance self-efficacy would mediate the relationship between the environment and real-world walking and that physical capacity would moderate this mediation. METHODS This was a cross-sectional study of 282 individuals with chronic (≥6 months) stroke. We tested the indirect effect to determine if mediation was present. Multiple group structural equation modeling was used to test if physical capacity moderated this mediation. A χ2 difference test was used to compare the moderation model against the null (no moderation) model. RESULTS Balance self-efficacy mediated the relationship between area deprivation and real-world walking (indirect effect: β = -0.04, P = .04). Both the moderation and null models fit the data equally well statistically (χ2(5) = 6.9, P = .23). We therefore accepted the simpler (null) model and concluded that the mediation was not moderated. CONCLUSIONS Targeting balance self-efficacy may be an effective approach to improving real-world walking in persons with stroke who experience barriers within the physical environment. A stroke survivor's physical capacity may not impact this approach. Future work should consider utilizing more specific measures of the social and physical environment to better understand their influences on real-world walking activity in individuals with stroke. However, the results of this work provide excellent targets for future longitudinal studies targeting real-world walking activity in stroke.
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Affiliation(s)
- Allison Miller
- Department of Biomechanics and Movement Science Program, University of Delaware, Newark, DE, USA
| | - Ryan T Pohlig
- Department of Biostatistics Core Facility, University of Delaware, Newark, DE, USA
| | - Darcy S Reisman
- Department of Biomechanics and Movement Science Program, University of Delaware, Newark, DE, USA.,Department of Physical Therapy, University of Delaware, Newark, DE, USA
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17
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Núñez-Cortés R, Malhue-Vidal C, Gath F, Valdivia-Lobos G, Torres-Castro R, Cruz-Montecinos C, Martinez-Arnau FM, Pérez-Alenda S, López-Bueno R, Calatayud J. The Impact of Charlson Comorbidity Index on the Functional Capacity of COVID-19 Survivors: A Prospective Cohort Study with One-Year Follow-Up. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19127473. [PMID: 35742722 PMCID: PMC9223623 DOI: 10.3390/ijerph19127473] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 06/16/2022] [Accepted: 06/16/2022] [Indexed: 02/04/2023]
Abstract
Objective: To determine the association between the Charlson comorbidity index (CCI) score after discharge with 6-min walk test (6MWT) 1 year after discharge in a cohort of COVID-19 survivors. Methods: In this prospective study, data were collected from a consecutive sample of patients hospitalized for COVID-19. The CCI score was calculated from the comorbidity data. The main outcome was the distance walked in the 6MWT at 1 year after discharge. Associations between CCI and meters covered in the 6MWT were assessed through crude and adjusted linear regressions. The model was adjusted for possible confounding factors (sex, days of hospitalization, and basal physical capacity through sit-to-stand test one month after discharge). Results: A total of 41 patients were included (mean age 58.8 ± 12.7 years, 20/21 men/women). A significant association was observed between CCI and 6MWT (meters): (i) crude model: β = −18.7, 95% CI = −34.7 to −2.6, p < 0.05; (ii) model adjusted for propensity score including sex, days of hospitalization, and sit-to-stand: β = −23.0, 95% CI = −39.1 to −6.8, p < 0.05. Conclusions: A higher CCI score after discharge indicates worse performance on the 6MWT at 1-year follow-up in COVID-19 survivors. The CCI score could also be used as a screening tool to make important clinical decisions.
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Affiliation(s)
- Rodrigo Núñez-Cortés
- Physiotherapy in Motion Multispeciality Research Group (PTinMOTION), Department of Physiotherapy, University of Valencia, 46010 Valencia, Spain; (R.N.-C.); (C.C.-M.); (F.M.M.-A.); (S.P.-A.)
- Department of Physical Therapy, Faculty of Medicine, University of Chile, Santiago 8380286, Chile;
- Service of Physical Therapy, Hospital Clínico La Florida, Santiago 8240000, Chile; (C.M.-V.); (F.G.); (G.V.-L.)
| | - Constanza Malhue-Vidal
- Service of Physical Therapy, Hospital Clínico La Florida, Santiago 8240000, Chile; (C.M.-V.); (F.G.); (G.V.-L.)
| | - Florencia Gath
- Service of Physical Therapy, Hospital Clínico La Florida, Santiago 8240000, Chile; (C.M.-V.); (F.G.); (G.V.-L.)
| | - Gonzalo Valdivia-Lobos
- Service of Physical Therapy, Hospital Clínico La Florida, Santiago 8240000, Chile; (C.M.-V.); (F.G.); (G.V.-L.)
| | - Rodrigo Torres-Castro
- Department of Physical Therapy, Faculty of Medicine, University of Chile, Santiago 8380286, Chile;
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Carlos Cruz-Montecinos
- Physiotherapy in Motion Multispeciality Research Group (PTinMOTION), Department of Physiotherapy, University of Valencia, 46010 Valencia, Spain; (R.N.-C.); (C.C.-M.); (F.M.M.-A.); (S.P.-A.)
- Department of Physical Therapy, Faculty of Medicine, University of Chile, Santiago 8380286, Chile;
- Section of Research, Innovation and Development in Kinesiology, Kinesiology Unit, San José Hospital, Santiago 8380286, Chile
| | - Francisco M. Martinez-Arnau
- Physiotherapy in Motion Multispeciality Research Group (PTinMOTION), Department of Physiotherapy, University of Valencia, 46010 Valencia, Spain; (R.N.-C.); (C.C.-M.); (F.M.M.-A.); (S.P.-A.)
| | - Sofía Pérez-Alenda
- Physiotherapy in Motion Multispeciality Research Group (PTinMOTION), Department of Physiotherapy, University of Valencia, 46010 Valencia, Spain; (R.N.-C.); (C.C.-M.); (F.M.M.-A.); (S.P.-A.)
| | - Rubén López-Bueno
- Department of Physical Medicine and Nursing, University of Zaragoza, 50009 Zaragoza, Spain
- National Research Centre for the Working Environment, 2100 Copenhagen, Denmark;
- Correspondence:
| | - Joaquín Calatayud
- National Research Centre for the Working Environment, 2100 Copenhagen, Denmark;
- Exercise Intervention for Health Research Group (EXINH-RG), Department of Physiotherapy, University of Valencia, 46010 Valencia, Spain
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