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

Co-design of a walking activity intervention for stroke survivors

Introduction

Stroke survivors may not maintain gains made in gait performance after task-oriented circuit training. Behavior change interventions may enhance the long-term adoption of physical activity. This study uses a co-design methodology to develop an intervention and tools to facilitate physical and exercise therapists in supporting an active lifestyle in stroke survivors, which is defined as a lifestyle that integrates daily walking performance with day-to-day activity.

Objectives

(1) To describe the insights generated during the co-design process; and (2) To describe the tools that were developed during the co-design process.

Methods

A multidisciplinary team consisting of staff members of the Royal Dutch Society for Physical Therapy, exercise and physical therapists specializing in neurorehabilitation and conducting task-oriented circuit class training in primary care settings or day therapy centers within residential care facilities, stroke survivors and their carers, experts in measuring movement behavior in stroke survivors, a company specializing in manufacturing sensors and related software, behavior change specialists, and co-designers all collaborated in a three-stage (define, develop, and deliver) co-design process.

Results

In the design process, the team iteratively developed a prototype accelerometer system for measuring walking performance with a feedback function for stroke survivors and their therapists and a prototype toolbox for therapists to support the facilitation of behavior change in their stroke survivors.

Discussion

This study shows how co-design can be applied to develop interventions for stroke survivors. Both the prototype system for measuring walking performance and the toolbox incorporate behavior change techniques to support a more physically active lifestyle in stroke survivors. Further research will investigate the feasibility of the intervention.

Use of the Capability, Opportunity and Motivation Behaviour model (COM-B) to Understand Interventions to Support Physical Activity Behaviour in People with Stroke: An Overview of Reviews

OBJECTIVE

Physical activity in people with stroke remains low despite considerable research. This overview aimed to provide high-level synthesis and aid clinical decision-making. The Capability, Opportunity, Motivation-Behaviour (COM-B) model was used to classify interventions to understand which components improve physical activity behaviour in people with stroke.

DATA SOURCES

CINAHL, Cochrane Database, MEDLINE, PEDro, PsychINFO, SPORTDiscus.

REVIEW METHODS

A systematic search was conducted (November 2023) to identify reviews of interventions to improve physical activity in people with stroke. Results were screened and assessed for eligibility. Participant characteristics, intervention classification using COM-B, and effect of intervention were extracted. Quality was assessed using AMSTAR2, and Corrected Cover Analysis for study overlap. Narrative synthesis was used to understand components of interventions to improve physical activity behaviour.

RESULTS

1801 references were screened and 29 full-text references assessed for eligibility. Twenty reviews were included. Quality ranged from critically low (n = 3) to high (n = 10). Study overlap calculated using corrected cover area indicated slight overlap (0.028) and minimal reporting bias.The majority of participants were mobile with mild stroke and community dwelling. Twenty-three interventions were classified using COM-B. Three of twelve interventions classified to one aspect of the COM-B were effective. Fourteen of sixteen effective interventions combined at least two COM-B elements, ten of these combined capability and motivation.

CONCLUSION

Interventions including at least two elements of the COM-B are most likely to improve physical activity in mobile stroke survivors. Further research is needed to understand physical activity behaviour in those with moderate to severe stroke.

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.

Impact of Active Physiotherapy on Physical Activity Level in Stroke Survivors: A Systematic Review and Meta-Analysis

BACKGROUND

Stroke survivors are frequently physically inactive. However, evidence of the effectiveness of active physiotherapy on physical activity level in stroke survivors is scarce.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement, covering electronic searches from inception to March 16, 2022. Participants: Stroke survivors living in the community. Intervention: Any active physiotherapy, that is, involving exercises that require voluntary effort. Outcome measure: Objective and subjective physical activity level.

RESULTS

Of 5590 identified references, 25 randomized controlled trials were eligible, and 21 had available data. The random-effects meta-analysis resulted in a small, significant effect size in favor of active physiotherapy measured using objective or subjective tools (21 studies, 1834 participants, standardized mean difference, 0.22 [95% CI, 0.04-0.40]; heterogeneity I2=65%), and a medium significant effect when objective tools were used (9 studies, 424 participants, standardized mean differences, 0.48 [95% CI, 0.03-0.92]; I2=73%). Meta-regression showed that 35% of the variance in trial outcome was explained by the measurement tool (objective or subjective) and 23% by age. None of the variances were associated with a specific dosage in terms of frequency, time, exercise duration, or the severity of the disability.

CONCLUSIONS

Active physiotherapy seems to increase objective physical activity in community-dwelling stroke survivors. However, the evidence is of very low certainty.

REGISTRATION

URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42022315639.

Enhancing Cardiovascular Health and Functional Recovery in Stroke Survivors: A Randomized Controlled Trial of Stroke-Specific and Cardiac Rehabilitation Protocols for Optimized Rehabilitation

BACKGROUND

Stroke is a major contributor to disability and mortality globally. It leads to physical impairments, including weakness and cardiovascular deconditioning, posing significant challenges to stroke survivors' quality of life. Exercise-based cardiac rehabilitation has shown promise as a rehabilitation strategy. This study aims to assess and compare the impacts of stroke-specific rehabilitation and individualized cardiac rehabilitation exercises on various health parameters in stroke patients.

METHODS

A randomized controlled trial was conducted, involving 38 stroke patients aged 40-75 years. Group A received stroke-specific rehabilitation, which consisted of a combination of range of motion exercises, strength training for the paralyzed side, balance and coordination training, gait training, functional mobility exercises, neuromuscular reeducation, and breathing exercises. This program was conducted five days per week for 12 weeks. Group B received individually designed cardiac rehabilitation exercises, in addition to stroke-specific rehabilitation. They engaged in this exercise for at least 30-45 min per day, four days per week, and incorporated two days of resistive training over a 12-week period. Baseline and post-intervention assessments included measures of cardiac autonomic function, balance (Berg Balance Scale), mobility (Timed Up and Go Test), cardiovascular fitness indicators, respiratory parameters, exercise efficiency, and perceived exertion.

RESULTS

Group B receiving individualized cardio rehab showed significant improvements in balance and mobility compared to Group A receiving conventional stroke-specific rehab. Moreover, Group B exhibited enhanced cardiovascular fitness, respiratory performance, exercise efficiency, and autonomic function post-intervention. Notably, Group A displayed no significant improvements in these parameters.

CONCLUSIONS

Individualized cardiac rehabilitation exercises demonstrated favorable outcomes in improving certain health parameters, highlighting the potential benefits of individualized rehabilitation strategies for stroke patients.

Non-therapeutic strategies to promote physical activity of stroke survivors in hospital settings: A systematic review

OBJECTIVE

To systematically summarize the evidence of strategies other than therapy to promote physical activity in hospital settings.

METHODS

Studies testing the various strategies to promote the physical activity of stroke survivors in different hospital settings, including stroke units, hospitals and rehabilitation centres were included. Two independent reviewers screened, extracted data, and assessed the study quality. Quality assessments were performed using standardized checklists. Data synthesis was done from the selected articles and results were reported.

RESULTS

Of the 3396 records retrieved from database searches, 12 studies (n = 529 participants) were included. All the studies were of moderate to good quality. The strategies were grouped into five categories: i) physical environment, ii) device-based feedback, iii) self-management approaches, iv) family presence, and v) education. Physical environmental and device-based feedback were the most common strategies to promote physical activity after a stroke in a hospital setting. Strategies such as family presence and education improved physical activity levels, whereas device-based feedback showed mixed results.

CONCLUSION

Despite the importance of physical activity in early stroke, there is limited literature present to enhance activity levels. Physical environment and device-based feedback were the two most common strategies used in acute stroke survivors. The impact of these strategies remain suboptimal to be considered as effective intervention methods to enhance physical activity.

Development of a tailored intervention targeting sedentary behavior and physical activity in people with stroke and diabetes: A qualitative study using a co-creation framework

Purpose

Type 2 diabetes and sedentary behavior pose serious health risks in stroke survivors. Using a co-creation framework, this study aimed to develop an intervention in collaboration with stroke survivors with type 2 diabetes, relatives, and cross-sectoral health care professionals to reduce sedentary behavior and increase physical activity.

Materials and methods

This qualitative explorative study used a co-creation framework consisting of a workshop and focus group interviews with stroke survivors with type 2 diabetes (n = 3), relative (n = 1), and health care professionals (n = 10) to develop the intervention. A content analysis was used to analyze data.

Results

The developed "Everyday Life is Rehabilitation" (ELiR) intervention consisted of a tailored 12-week home-based behavior change intervention with two consultations of action planning, goal setting, motivational interviewing, and fatigue management including education on sedentary behavior, physical activity, and fatigue. The intervention has a minimalistic setup using a double-page paper "Everyday Life is Rehabilitation" (ELiR) instrument making it implementable and tangible.

Conclusions

In this study, a theoretical framework was used to develop a tailored 12-week home-based behavior change intervention. Strategies to reduce sedentary behavior and increase physical activity through activities of daily living along with fatigue management in stroke survivors with type 2 diabetes were identified.

Exercise prescription, intervention, dissemination, and implementation following transient ischemic attack or stroke: advancing the field through interdisciplinary science

Research has demonstrated that both exercise, and a reduction in cardiovascular disease (CVD) risk factors (i.e., high blood sugar, blood lipids, and blood pressure), following a stroke or transient ischemic attack (TIA) are beneficial for reducing risk of recurrent stroke or TIA and for improving overall quality of life. Despite this evidence, many stroke and TIA survivors remain inactive and sedentary and present with multiple CVD risk factors. The purpose of this commentary is to highlight gaps in the current literature in regard to exercise and behavior interventions for the stroke and TIA populations, present ideas for intervention design, and discuss the dissemination and implementation of research findings. The future research ideas presented in this commentary are based on current research findings, as well as the professional experience of the article authors. Professional experience spans occupational therapy in neurorehabilitation, clinical exercise physiology in rehabilitation, creation and implementation of stroke rehabilitation clinics, stroke and TIA research, and behavioral and implementation science.

Digital Health Behavioural Interventions to Support Physical Activity and Sedentary Behaviour in Adults after Stroke: A Systematic Literature Review with Meta-Analysis of Controlled Trials

Background: As the global prevalence of stroke continues to rise, it becomes increasingly pressing to investigate digital health behaviour change interventions that promote physical activity and reduce sedentary behaviour for stroke patients to support active lifestyles. Purpose: The primary aim of this study is to investigate the effectiveness of digital health interventions in promoting physical activity and reducing sedentary behaviour for stroke patients. The secondary aim is to investigate the intervention components that explain intervention effectiveness to further inform intervention development and policy making. Methods: A systematic search of the literature was conducted in four databases (Scopus, MEDLINE (PubMed), Web of Science, and PsychINFO) to identify the most robust evidence in the form of randomised controlled trials of digital interventions for patients with stroke. A random-effects meta-analysis were utilized to quantify the intervention effects on behaviour change, and subgroup analyses to characterise intervention effective components. Results: In total, 16 RCTs were deemed eligible and included in the systematic review. Meta-analyses suggested significant improvements in physical activity (SMD = 0.39, 95% CI 0.17, 0.61, N = 326, p < 0.001, I2 = 0%), and reductions in time of sedentary behaviour (SMD= −0.45, 95% CI −0.76, -0.14, N = 167, p = 0.00, I2 = 0%) after stroke. The 10 m walk test for physical activity, and the timed up and go test for sedentary behaviour, were the objective outcome measures in the most effective behavioural change interventions. Subgroup analyses found that most effective interventions were underpinned by theories of self-regulation and utilised interactive functions to engage patients with the processes of behaviour change. Conclusions: Digital self-monitoring behavioural interventions are effective in promoting physical activity for stroke patients in adjunct to usual care clinical practice and rehabilitation programmes. Rigorous studies are required to provide evidence to disentangle the most effective intervention components for preventative practices and rehabilitation programs and to inform policymaking for stroke treatment.

General and comparative self-rated health in chronic stroke: an important outcome measure for health professionals

BACKGROUND

After a stroke, several aspects of health and function may influence how individuals perceive their own health. However, self-rated health (SRH), as well as its relationship with functioning, has been little explored in individuals with stroke. The aims of this study were to determine how individuals with chronic post-stroke disabilities evaluate their health, considering general, time- and age-comparative SRH questions and to investigate whether SRH measures would be influenced by the following health and functioning domains: mental/physical functions and personal factors.

METHODS

Sixty-nine individuals with chronic post-stroke disabilities answered the three types of SRH questions and were assessed regarding depressive symptoms (emotional function domain), physical activity levels (physical function domain), and engagement in physical activity practice (personal factor domain). Subjects were divided into the following groups: good/poor for the general SRH question; better, similar, and "worse" for both time- and age-comparative questions. Between-group differences in the three domains for each SRH question were investigated (α = 5%).

RESULTS

General SRH was rated as good by 73% of the participants. Time- and age-comparative SRH was rated as better by 36% and 47% and as similar by 31% and 28% of the subjects, respectively. Significant between-group differences in emotional function were found for both the general and age-comparative questions. For the time-comparative question, significant differences were only observed for physical function.

CONCLUSION

SRH evaluation differed in individuals with chronic post-stroke disabilities according to the types of questions and health/functioning domains.

Association Between Physical Activity and Mortality Among Community-Dwelling Stroke Survivors

BACKGROUND AND OBJECTIVE

To determine the relationship between physical activity (PA) and mortality in community-dwelling stroke survivors.

METHODS

The Canadian Community Health Survey was used to obtain self-reported PA across 4 survey years and was linked to administrative databases to obtain prior diagnosis of stroke and subsequent all-cause mortality. PA was measured as metabolic equivalents (METs) per week and meeting minimal PA guidelines was defined as 10 MET-h/wk. Cox proportional hazard regression models and restricted cubic splines were used to determine the relationship between PA and all-cause mortality in respondents with prior stroke and controls, adjusting for sociodemographic factors, comorbidities, and functional health status.

RESULTS

The cohort included 895 respondents with prior stroke and 97,805 controls. Adhering to PA guidelines was associated with lower hazard of death for those with prior stroke (adjusted hazard ratio [aHR] 0.46, 95% confidence interval [CI] 0.29-0.73) and controls (aHR 0.69, 95% CI 0.62-0.76). There was a strong dose-response relationship in both groups, with a steep early slope and the vast majority of associated risk reduction occurring between 0 and 20 MET-h/wk. In the group of stroke respondents, PA was associated with greater risk reduction in those <75 years of age (aHR 0.21, 95% CI 0.10-0.43) compared to those ≥75 years of age (aHR 0.68, 95% CI 0.42-1.12).

DISCUSSION

PA was associated with lower all-cause mortality in an apparent dose-dependent manner among those with prior stroke, particularly in younger stroke survivors. Our findings support efforts towards reducing barriers to PA and implementation of PA programs for stroke survivors in the community.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that in community-dwelling survivors of stroke, adhering to physical activity guidelines was associated with lower hazard of death.

Clinical value of assessing motor performance in postacute stroke patients

Background

Rehabilitative treatment plans after stroke are based on clinical examinations of functional capacity and patient-reported outcomes. Objective information about daily life performance is usually not available, but it may improve therapy personalization.

Objective

To show that sensor-derived information about daily life performance is clinically valuable for counseling and the planning of rehabilitation programs for individual stroke patients who live at home. Performance information is clinically valuable if it can be used as a decision aid for the therapeutic management or counseling of individual patients.

Methods

This was an observational, cross-sectional case series including 15 ambulatory stroke patients. Motor performance in daily life was assessed with body-worn inertial sensors attached to the wrists, shanks and trunk that estimated basic physical activity and various measures of walking and arm activity in daily life. Stroke severity, motor function and activity, and degree of independence were quantified clinically by standard assessments and patient-reported outcomes. Motor performance was recorded for an average of 5.03 ± 1.1 h on the same day as the clinical assessment. The clinical value of performance information is explored in a narrative style by considering individual patient performance and capacity information.

Results

The patients were aged 59.9 ± 9.8 years (mean ± SD), were 6.5 ± 7.2 years post stroke, and had a National Institutes of Health Stroke Score of 4.0 ± 2.6. Capacity and performance measures showed high variability. There were substantial discrepancies between performance and capacity measures in some patients.

Conclusions

This case series shows that information about motor performance in daily life can be valuable for tailoring rehabilitative therapy plans and counseling according to the needs of individual stroke patients. Although the short recording time (average of 5.03 h) limited the scope of the conclusions, this study highlights the usefulness of objective measures of daily life performance for the planning of rehabilitative therapies. Further research is required to investigate whether information about performance in daily life leads to improved rehabilitative therapy results.

Efficacy of task-specific circuit training on physical activity levels and mobility of stroke patients: A randomized controlled trial

BACKGROUND

Impaired mobility is related to low physical activity (PA) levels observed after stroke. Therapeutic approaches, such as task-specific circuit training (TSCT), used to improve mobility in individuals with stroke, could also improve PA levels.

OBJECTIVE

To investigate the efficacy of TSCT, focused on both upper (UL) and lower (LL) limbs, in improving PA levels and mobility (primary outcomes), as well as muscle strength, exercise capacity, and quality of life (secondary outcomes) in subjects with stroke.

METHODS

A randomized controlled trial with 36 subjects with chronic stroke was conducted. Experimental group: TSCT, involving both UL and LL.

CONTROL GROUP

global stretching, memory exercises, and education sessions. Both groups received 60 minute sessions/week over 12 weeks. Outcomes were measured at baseline, post-intervention and 16 week follow-up.

RESULTS

No changes were found for primary and secondary outcomes (0.11≤p≤0.99), except for quality of life, which improved in the experimental group post-intervention and 16 week follow-up (p = 0.02).

CONCLUSION

TSCT focused on both UL and LL was not effective on PA levels and mobility of individuals with chronic stroke, however, improvements in quality of life were observed. Since this is the first study to investigate this combined training aimed at improving PA levels, future studies are necessary to better understand the impact of this type of intervention.

Measurement properties of self-report physical activity assessment tools for patients with stroke: a systematic review

BACKGROUND

Individuals with stroke demonstrate low levels of physical activity. Self-report measures of physical activity are frequently used and the choice of the best one to use for each purpose and context should take into account the measurement properties of these instruments.

OBJECTIVE

To summarize the measurement properties and clinical utility of self-report measures of physical activity of post-stroke subjects and to evaluate both the methodological quality of the studies and the quality of the measurement properties.

METHODS

Searches were made in MEDLINE, EMBASE, PEDro, LILACS, and SCIELO. Two reviewers independently screened studies that investigated measurement properties or clinical utility of self-report measures of physical activity in post-stroke subjects. The studies' methodological quality, quality of the measurement properties, and clinical utility were evaluated.

RESULTS

From the 11,826 identified studies, 19 were included. Six self-report tools were evaluated: The Activity card sort, Coded activity diary, Frenchay activities index (FAI), Human activity profile (HAP), Multimedia activity recall for children and adults, and the Nottingham leisure questionnaire. The methodological quality of the studies ranged from "poor" to "good". Most of the results regarding the quality of the measurement properties were doubtful. None of the self-report tools had their content validity investigated. The FAI and HAP showed the highest clinical utility scores.

CONCLUSIONS

Content validity needs to be better investigated to determine if the instruments actually measure the physical activity domain. Further studies with good methodological quality are required to assist clinicians and researchers in selecting the best instrument to measure physical activity levels.

The Impact of Physical Activity Before and After Stroke on Stroke Risk and Recovery: a Narrative Review

PURPOSE OF THE REVIEW

Summarising the evidence for pre- and post-stroke physical activity (PA) and exercise to reduce stroke risk, and improve recovery and brain health.

RECENT FINDINGS

Pre-stroke PA reduces the risk of stroke, and post-stroke PA and exercise reduce cardiovascular risk factors, which can moderate the risk of recurrent strokes. Pre-clinical evidence indicates that exercise enhances neuroplasticity. The results from clinical studies showed that exercise changes brain activity patterns in stroke survivors, which can be a signal neuroplasticity. The intensity of pre- and post-stroke PA and exercise is a key factor with higher intensities leading to greater benefits, including improvement in fitness. Having low fitness levels is an independent predictor for increased risk of stroke. Higher intensity leads to greater benefits; however, the optimum intensity of PA and exercise is yet unknown and needs to be further investigated. Strategies to decrease sedentary behaviour and improve fitness need to be considered.

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.