Ambulatory activity of stroke survivors: measurement options for dose, intensity, and variability of activity

Feasibility of a physiotherapist-supervised walking program with telephone coaching to increase physical activity following acquired brain injury

Background Physical activity has health benefits for adults with acquired brain injury, but it is a challenge to increase physical activity during inpatient rehabilitation. The objectives of this pilot study were to determine whether a physiotherapy-supervised inpatient walking program was feasible and able to improve physical activity and sedentary behaviour in the short and medium term. Methods Adults with acquired brain injury receiving inpatient rehabilitation undertook twice-weekly supervised walks plus behavioural therapy for 4 weeks. Feasibility was measured via recruitment, participation and drop out rates, adverse events and intervention delivery costs. Physical activity and sedentary behaviour were measured with an activPAL. Assessments were conducted at baseline, post-intervention and 3-6 months post-intervention. Results The program was safe to deliver (no adverse events), recruitment rate was 55% (16/29) and the participation rate for eligible individuals was high (14/19, 74%). However, the program had a high drop out rate (7/16, 44%) and physical activity and sedentary behaviour did not significantly change during the 4-week intervention. Costs were AU$427.71/participant. Physical activity and sedentary behaviour did improve 3-6 months after the intervention (vs baseline, on average: +3913 steps per day, 95% CI: 671, 7156). Conclusion This pilot study demonstrated a supervised physiotherapy walking program is safe and feasible to recruit in an inpatient setting. However, drop out during the study was high and behaviour change did not occur. More work is required to boost physical activity during sub-acute rehabilitation for acquired brain injury.

Longitudinal changes in physical activity accumulation patterns during 1-year follow-up in stroke survivors

PURPOSE

Few studies have reported changes in the accumulation patterns of physical activity over a year after stroke. This study characterized the longitudinal changes in physical activity levels and their accumulation patterns for a 1-year follow-up period in stroke survivors.

MATERIALS AND METHODS

In this single-center, prospective, longitudinal observational study, 47 stroke survivors were assessed at rehabilitation discharge and at 6 and 12 months post-discharge. Physical activity was evaluated, and measures included the number of steps, walking duration, total number of bouts per day, and intensity (light, moderate-to-vigorous) and spread (short, medium, and long bouts).

RESULTS

There were no significant main or interaction effects of time on any physical activity variables. Light physical activity accounted for 90% of all walking bouts and 70% of walking duration. Regarding moderate-to-vigorous physical activity (MVPA), 85% of walking bouts and 35% of walking duration were accumulated in short and medium bouts. The number of long-bout MVPA was three per day.

CONCLUSIONS

Physical activity levels and accumulation patterns were highly stable throughout the 12-month follow-up period. Accumulating light physical activity and intermittent MVPA is important for maintaining physical activity levels in stroke survivors. These findings will promote a better understanding of disability and rehabilitation practice.IMPLICATIONS FOR REHABILITATIONPhysical activity levels and accumulation patterns were highly stable throughout the 12-month follow-up period.The accumulation of moderate-to-vigorous physical activity in long bouts might be challenging for stroke survivors.Accumulating light physical activity and intermittent moderate-to-vigorous physical activity may be acceptable for stroke survivors.

Natural Walking Intensity in Persons With Parkinson Disease

BACKGROUND AND PURPOSE

Few persons with Parkinson disease (PD) appear to engage in moderate-intensity walking associated with disease-modifying health benefits. How much time is spent walking at lower, yet still potentially beneficial, intensities is poorly understood. The purpose of this exploratory, observational study was to describe natural walking intensity in ambulatory persons with PD.

METHODS

Accelerometer-derived real-world walking data were collected for more than 7 days at baseline from 82 participants enrolled in a PD clinical trial. Walking intensity was defined according to the number of steps in each active minute (1-19, 20-39, 40-59, 60-79, 80-99, or ≥100 steps). Daily minutes of walking and duration of the longest sustained walking bout were calculated at each intensity. Number of sustained 10 to 19, 20 to 29, and 30-minute bouts and greater at any intensity also were calculated. Values were analyzed in the context of physical activity guidelines.

RESULTS

Most daily walking occurred at lower intensities (157.3 ± 58.1 min of 1-19 steps; 81.3 ± 32.6 min of 20-39 steps; 38.2 ± 21.3 min of 40-59 steps; 15.1 ± 11.5 min of 60-79 steps; 7.4 ± 7.0 min of 80-99 steps; 7.3 ± 9.6 min of ≥100 steps). The longest daily sustained walking bout occurred at the lowest intensity level (15.9 ± 5.2 min of 1-19 steps). Few bouts lasting 20 minutes and greater occurred at any intensity.

DISCUSSION AND CONCLUSIONS

Despite relatively high daily step counts, participants tended to walk at remarkably low intensity, in bouts of generally short duration, with relatively few instances of sustained walking. The findings reinforced the need for health promotion interventions designed specifically to increase walking intensity.Video Abstract available for more insight from authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A426 ).

Feasibility and Proof-of-Concept of Delivering an Autonomous Music-Based Digital Walking Intervention to Persons with Parkinson's Disease in a Naturalistic Setting

BACKGROUND

Reduced motor automaticity in Parkinson's disease (PD) negatively impacts the quality, intensity, and amount of daily walking. Rhythmic auditory stimulation (RAS), a clinical intervention shown to improve walking outcomes, has been limited by barriers associated with the need for ongoing clinician input.

OBJECTIVE

To assess the feasibility, proof-of-concept, and preliminary clinical outcomes associated with delivering an autonomous music-based digital walking intervention based on RAS principles to persons with PD in a naturalistic setting.

METHODS

Twenty-three persons with PD used the digital intervention independently for four weeks to complete five weekly 30-minute sessions of unsupervised, overground walking with music-based cues. The intervention progressed autonomously according to real-time gait sensing. Feasibility of independent use was assessed by examining participant adherence, safety, and experience. Intervention proof-of-concept was assessed by examining spatiotemporal metrics of gait quality, daily minutes of moderate intensity walking, and daily steps. Preliminary clinical outcomes were assessed following intervention completion.

RESULTS

Participants completed 86.4% of sessions and 131.1% of the prescribed session duration. No adverse events were reported. Gait speed, stride length, and cadence increased within sessions, and gait variability decreased (p < 0.05). Compared to baseline, increased daily moderate intensity walking (mean Δ= +21.44 minutes) and steps (mean Δ= +3,484 steps) occurred on designated intervention days (p < 0.05). Quality of life, disease severity, walking endurance, and functional mobility were improved after four weeks (p < 0.05).

CONCLUSIONS

Study findings supported the feasibility and potential clinical utility of delivering an autonomous digital walking intervention to persons with PD in a naturalistic setting.

Beyond steps per day: other measures of real-world walking after stroke related to cardiovascular risk

Background

Significant variability exists in how real-world walking has been measured in prior studies in individuals with stroke and it is unknown which measures are most important for cardiovascular risk. It is also unknown whether real-world monitoring is more informative than laboratory-based measures of walking capacity in the context of cardiovascular risk. The purpose of this study was to determine a subset of real-world walking activity measures most strongly associated with systolic blood pressure (SBP), a measure of cardiovascular risk, in people with stroke and if these measures are associated with SBP after accounting for laboratory-based measures of walking capacity.

Methods

This was a cross-sectional analysis of 276 individuals with chronic (≥ 6 months) stroke. Participants wore an activity monitor for ≥ 3 days. Measures of activity volume, activity frequency, activity intensity, and sedentary behavior were calculated. Best subset selection and lasso regression were used to determine which activity measures were most strongly associated with systolic blood pressure. Sequential linear regression was used to determine if these activity measures were associated with systolic blood pressure after accounting for walking capacity (6-Minute Walk Test).

Results

Average bout cadence (i.e., the average steps/minute across all bouts of walking) and the number of long (≥ 30 min) sedentary bouts were most strongly associated with systolic blood pressure. After accounting for covariates (ΔR² = 0.089, p < 0.001) and walking capacity (ΔR² = 0.002, p = 0.48), these activity measures were significantly associated with systolic blood pressure (ΔR² = 0.027, p = 0.02). Higher systolic blood pressure was associated with older age (β = 0.219, p < 0.001), male gender (β = − 0.121, p = 0.046), black race (β = 0.165, p = 0.008), and a slower average bout cadence (β = − 0.159, p = 0.022).

Conclusions

Measures of activity intensity and sedentary behavior may be superior to commonly used measures, such as steps/day, when the outcome of interest is cardiovascular risk. The relationship between walking activity and cardiovascular risk cannot be inferred through laboratory-based assessments of walking capacity.

Are Mobile Persons With Parkinson Disease Necessarily More Active?

BACKGROUND AND PURPOSE

Walking activity in persons with Parkinson disease (PD) is important for preventing functional decline. The contribution of walking activity to home and community mobility in PD is poorly understood.

METHODS

Cross-sectional baseline data (N = 69) were analyzed from a randomized controlled PD trial. The Life-Space Assessment (LSA) quantified the extent, frequency, and independence across 5 expanding levels of home and community mobility, producing individual subscores and a total score. Two additional summed scores were used to represent mobility within (Levels 1-3) and beyond (Levels 4-5) neighborhood limits. An accelerometer measured walking activity for 7 days. Regression and correlation analyses evaluated relationships between daily steps and mobility scores. Mann-Whitney U tests secondarily compared differences in mobility scores between the active and sedentary groups.

RESULTS

Walking activity contributed significantly to the summed Level 1-3 score (β = 0.001, P = 0.004) but not to the summed Level 4-5 (β = 0.001, P = 0.33) or total (β = 0.002, P = 0.07) scores. Walking activity was significantly related to Level 1 (ρ = 0.336, P = 0.005), Level 2 (ρ = 0.307, P = 0.010), and Level 3 (ρ = 0.314, P = 0.009) subscores. Only the summed Level 1-3 score (P = 0.030) was significantly different between the active and sedentary groups.

DISCUSSION AND CONCLUSIONS

Persons with PD who demonstrated greater mobility beyond the neighborhood were not necessarily more active; walking activity contributed more so to home and neighborhood mobility. Compared with LSA total score, the Level 1-3 summed score may be a more useful participation-level measure for assessing the impact of changes in walking activity.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A349).

Sex Differences in Physical Activity in People After Stroke: A Cross-sectional Study

OBJECTIVE

Adequate physical activity after stroke is critical for cardiovascular health. Although sex is a potential factor associated with post-stroke physical activity, its mechanism remains unclear. This study aimed to examine sex differences in human physical activity following stroke.

METHOD

A cross-sectional study with 62 participants (men: 42, women: 20) was conducted. Physical activity was measured for three consecutive days using a step activity monitor. The walking durations per day in light physical activity, moderate-to-vigorous physical activity, and total physical activity were calculated. Sex differences in walking duration were compared using Welch's t-tests or Mann-Whitney U tests.

RESULTS

Women had a significantly greater walking duration in light physical activity and in total than did the men. In contrast, no significant differences were found in moderate-to-vigorous physical activity.

CONCLUSION

This study reported sex differences in the walking duration after stroke. Moreover, it found that women spent more time in low intensity physical activity than men. Our results will be useful for planning interventions to increase physical activity and decrease sedentary behavior after stroke.

Quantifying physical activity in aged residential care facilities: A structured review

BACKGROUND

Engaging aged residential care (ARC) residents with physical activity (PA) may be a useful strategy to decelerate dependence and disability. It is unclear what volume, intensity and patterns of PA ARC residents participate in. This review aims to synthesize the literature to quantify the volume, intensity and pattern of PA that ARC residents participate in across differing care levels (e.g. low, intermediate, high, mixed), and make recommendations for future research.

METHODS

30 studies of 48,760 yielded were reviewed using systematic review strategies.

RESULTS

Questionnaires and technological tools were used to assess PA, with accelerometers employed in 70% of studies. Overall, studies reported low volumes and intensities of PA across all care levels, and suggested limited variation in patterns of PA (e.g. little day-to-day variation in total PA). There was limited inclusion of people with cognitive impairment, potentially causing representativeness bias. Findings were limited by lack of consistency in methodological approaches and PA outcomes.

DISCUSSION

Based on findings and limitations of current research, we recommend that total volume or low-light intensity PA are more useful interventional outcomes than higher-intensity PA. Researchers also need to consider which methodology and PA outcomes are most useful to quantify PA in ARC residents.

Readiness to Change is Related to Real-World Walking and Depressive Symptoms in Chronic Stroke

BACKGROUND AND PURPOSE

The transtheoretical model is a health behavior model used to understand an individual's readiness to change their behavior. This study aims to apply the transtheoretical model in understanding a person with stroke's readiness to change their activity level, as it relates to physical capacity, physical health, depressive symptoms, self-efficacy, and daily stepping activity.

METHODS

This was a cross-sectional analysis of baseline data from a clinical trial. Participants' readiness to change their activity levels was measured via self-report and daily stepping activity was measured using a step activity monitor. Robust regression (M-estimation with robust standard errors) was used to test the relationship between readiness to change and measures of physical capacity (6-minute walk test, self-selected walking speed), physical health (body mass index, age-adjusted Charlson Comorbidity Index), depressive symptoms (Patient Health Questionnaire-9), self-efficacy (Activities-Specific Balance Confidence Scale), and daily stepping (steps per day).

RESULTS

A total of 274 individuals were included in the analysis. Adjusted for age, readiness to change was positively related to daily stepping (β = 0.29, P < 0.001) and negatively related to depressive symptoms (β = -0.13, P = 0.01). Readiness to change was not significantly associated with measures of physical capacity, physical health, or self-efficacy.

DISCUSSION

These results suggest that individuals with stroke in the later stages of change may demonstrate greater daily stepping activity and lower depressive symptoms compared with those in earlier stages.

CONCLUSIONS

Understanding the relationship between readiness to change, daily stepping, and depressive symptoms will help clinicians implement appropriate stage-specific intervention strategies and facilitate greater improvement in activity levels.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A333).

Relationships of Linear and Non-linear Measurements of Post-stroke Walking Activity and Their Relationship to Weather

Background: Stroke survivors are more sedentary than the general public. Previous research on stroke activity focuses on linear quantities. Non-linear measures, such as Jensen-Shannon Divergence and Lempel-Ziv Complexity, may help explain when and how stroke survivors move so that interventions to increase activity may be designed more effectively.

Objectives: Our objective was to understand what factors affect a stroke survivor's physical activity, including weather, by characterizing activity by step counts, structure, and complexity.

Methods: A custom MATLAB code was used to analyze clinical trial (NCT02835313, https://clinicaltrials.gov/ct2/show/NCT02835313) data presented as minute by minute step counts. Six days of data were analyzed for 142 participants to determine the regularity of activity structure across days and complexity patterns of varied cadences. The effect of steps on structure and complexity, the season's effect on steps, structure, and complexity, and the presence of precipitation's effect on steps and complexity were all analyzed.

Results: Step counts and regularity were linearly related (p < 0.001). Steps and complexity were quadratically related (r² = 0.70 for mean values, 0.64 for daily values). Season affected complexity between spring and winter (p = 0. 019). Season had no effect on steps or structure. Precipitation had no effect on steps or complexity.

Conclusions: Stroke survivors with high step counts are active at similar times each day and have higher activity complexities as measured through patterns of movement at different intensity levels. Non-linear measures, such as Jensen-Shannon Divergence and Lempel-Ziv Complexity, are valuable in describing a person's activity. Weather affects our activity parameters in terms of complexity between spring and winter.

Movement behavior remains stable in stroke survivors within the first two months after returning home

BACKGROUND AND PURPOSE

The aim of this study is to investigate changes in movement behaviors, sedentary behavior and physical activity, and to identify potential movement behavior trajectory subgroups within the first two months after discharge from the hospital to the home setting in first-time stroke patients.

METHODS

A total of 140 participants were included. Within three weeks after discharge, participants received an accelerometer, which they wore continuously for five weeks to objectively measure movement behavior outcomes. The movement behavior outcomes of interest were the mean time spent in sedentary behavior (SB), light physical activity (LPA) and moderate to vigorous physical activity (MVPA); the mean time spent in MVPA bouts ≥ 10 minutes; and the weighted median sedentary bout. Generalized estimation equation analyses were performed to investigate overall changes in movement behavior outcomes. Latent class growth analyses were performed to identify patient subgroups of movement behavior outcome trajectories.

RESULTS

In the first week, the participants spent an average, of 9.22 hours (67.03%) per day in SB, 3.87 hours (27.95%) per day in LPA and 0.70 hours (5.02%) per day in MVPA. Within the entire sample, a small but significant decrease in SB and increase in LPA were found in the first weeks in the home setting. For each movement behavior outcome variable, two or three distinctive subgroup trajectories were found. Although subgroup trajectories for each movement behavior outcome were identified, no relevant changes over time were found.

CONCLUSION

Overall, the majority of stroke survivors are highly sedentary and a substantial part is inactive in the period immediately after discharge from hospital care. Movement behavior outcomes remain fairly stable during this period, although distinctive subgroup trajectories were found for each movement behavior outcome. Future research should investigate whether movement behavior outcomes cluster in patterns.

Assessment of physical activity and cognitive function and their potential correlation in convalescent patients of cerebrovascular disease

Physical activity (PA) is known to influence cognitive function. However, the impact of PA on patients with cerebrovascular disease (CVD) has not yet been elucidated. PA and cognitive function have not been measured simultaneously over time, which makes it difficult to evaluate their relationship. The purpose of this study was to investigate the change in the amount of PA recorded by ActiGraph GT3X-BT and six test scores of cognitive function, and the relationship between them in 15 patients with CVD (six women and nine men; 78.0 ± 11.6 years old). Results showed an increase in the amount of PA and scores of cognitive tests, and a significant decrease in the duration of sedentary behavior during the four months (p < 0.05). There were significant correlations between PA Energy Expenditure (PAEE) and Raven's Colored Progressive Matrices test (RCPM) (r = 0.536, p < 0.0001). There were significant correlations between PAEE and Symbol Digit Modalities Test (SDMT) (r = 0.271, p = 0.036). There were significant correlations between sedentary behavior and RCPM (r = -0.606, p < 0.0001). There were significant correlations between sedentary behavior and SDMT (r = -0.355, p = 0.005). There were significant correlations between Light PA (LPA) and RCPM (r = 0.603, p < 0.0001). There were significant correlations between LPA and SDMT (r = 0.362, p = 0.005).

Which impairments, activity limitations and personal factors at hospital discharge predict walking activity across the first 6 months poststroke?

Purpose: To determine which impairments, activity limitations and personal factors at hospital discharge poststroke predict volume, frequency, and intensity of walking activity 1, 3, and 6 months later.Materials and Methods: Prospective longitudinal observational study. Thirty-six people with stroke (71 SD 14 years, 69% male) were recruited at hospital discharge and predictors including fatigue, mood, executive function, walking speed, walking endurance, age, prestroke activity, self-efficacy, and perceived stroke recovery and health were collected. At 1, 3, and 6 months follow-up, participants wore an ActivPAL™ accelerometer to collect measures of walking activity.Results: At 1 month, walking endurance predicted all walking activity (R² > 0.29, p < 0.01). At 3 months, walking endurance and prestroke activity predicted activity volume and intensity (R² = 0.46-0.61, p < 0.001), and prestroke activity predicted activity frequency (R² = 0.31, p = 0.004). At 6 months, age-predicted activity volume and frequency (R² = 0.34-0.35, p < 0.003), while prestroke activity, discharge walking endurance, and executive function together predicted activity intensity (R² = 0.79, p < 0.001).Conclusion: Walking endurance contributes to walking activity outcomes across the first 6 months following hospital discharge poststroke. After 1 month of discharge, factors other than poststroke changes also contribute to activity outcomes, and should be considered when targeting poststroke physical activity.Implications for rehabilitationWalking endurance should be addressed during stroke rehabilitation as higher scores are linked to more walking activity in the first month after discharge.Prestroke factors such as low prestroke activity levels and older age predict reduced walking activity after stroke, so approaches to address barriers these factors may pose are needed in people with stroke.Physical activity interventions should be tailored to the individual, their environment, and context, and take into consideration prestroke factors.

Walking activity and its determinants in free-living ambulatory people in a chronic phase after stroke: a cross-sectional study

Background: Free-living walking activity and its contributing factors in ambulatory people with stroke is poorly investigated.Objective: Evaluating free-living walking activity and identifying factors associated with free-living walking activity.Methods: In this cross-sectional study, participants wore an accelerometer to measure their level of walking activity. They also completed the Berg Balance Scale (BBS) and the Timed Up and Go test for functional balance, the Falls Efficacy Scale, the 10-Metre Walk Test and the Geriatric Depression Scale to investigate the relation between the performance tests and walking activity.Results: The 38 analyzed participants were on average 62 (±11.4) years old and 66 (IQR 64.8) months post stroke. They took an average of 3048.3 ± 1983.1 steps, had 123.3 ± 61.3 walking bouts a day and walked for 32.5 ± 18.2 min a day. Their average speed was 90.3 ± 13.8 steps a minute. The multivariate linear analysis showed that the BBS was the only determinant that was significantly related to all outcomes, except walking bouts.Conclusion: Free-living walking activity levels in ambulatory people with chronic stroke are low. The BBS is an independent significant predictor of free-living walking activity.Implications for rehabilitationFree-living walking activity can be expressed in different outcomes measured by accelerometry.Free-living walking activity levels in ambulatory people with chronic stroke are low, therefore support to sustain walking in the own environment should be part of the rehabilitation program after stroke.Balance is an important related factor to free-living walking activity which needs attention during rehabilitation after stroke.

Accuracy of wearable physical activity trackers in people with Parkinson's disease

INTRODUCTION

The purpose of this study was to determine the accuracy of the Fitbit Charge HR™ and Garmin vívosmart^® HR in measuring steps and reflecting intensity of activity in people with Parkinson's disease (PD).

METHODS

Thirty-three people with mild-moderate PD performed six, two-minute indoor walks at their self-selected walking pace, and at target cadences of 60, 80, 100, 120 and 140 beats/min. A 500 m outdoor walk with terrain challenges was also performed. Step count was recorded by the two wrist-worn activity trackers (Fitbit Charge HR™ and Garmin vívosmart^® HR) and compared to an accelerometer (ActivPAL³™). Intensity was recorded by a portable breath-by-breath gas analyser (VO₂), heart rate and Borg scale.

RESULTS

Both commercial activity trackers had low error (<3%) and moderate to high consistency at self-selected pace both indoors and outdoors (ICC 0.88-0.97; p < 0.05) compared to the ActivPAL³™. The Garmin recorded low error (<5%) and high agreement (ICCs > 0.68; p < 0.001) for all target cadences ≥80steps/min. The Fitbit had higher error was less consistent for all target cadences ≥80steps/min. Cadence measured by the Fitbit and Garmin weakly reflected increases in heart rate (ICCs 0.27-0.28; p < 0.05), and did not reflect VO₂ or Borg (ICCs 0.08-0.15, p > 0.05).

CONCLUSION

The Garmin device was more accurate at reflecting step count across a broader range of walking cadences than the Fitbit, but neither strongly reflected intensity of activity. While not intended to replace research grade devices, these wrist-worn devices may be a clinically useful adjunct to exercise therapy to increase physical activity in people with PD.

Sleep Duration, Sedentary Behavior, Physical Activity, and Quality of Life after Inpatient Stroke Rehabilitation

OBJECTIVE

The aim of this study was to describe accelerometer-derived sleep duration, sedentary behavior, physical activity, and quality of life and their association with demographic and clinical factors within the first month after inpatient stroke rehabilitation.

MATERIALS AND METHODS

Thirty people with stroke (mean ± standard deviation, age: 63.8 ± 12.3 years, time since stroke: 3.6 ± 1.1 months) wore an activPAL3 Micro accelerometer (PAL Technologies, Glasgow, Scotland) continuously for 7 days to measure whole-day activity behavior. The Stroke Impact Scale and the Functional Independence Measure were used to assess quality of life and function, respectively.

RESULTS

Sleep duration ranged from 6.6 to 11.6 hours/day. Fifteen participants engaged in long sleep greater than 9 hours/day. Participants spent 74.8% of waking hours in sedentary behavior, 17.9% standing, and 7.3% stepping. Of stepping time, only a median of 1.1 (interquartile range: .3-5.8) minutes were spent walking at a moderate-to-vigorous intensity (≥100 steps/minute). The time spent sedentary, the stepping time, and the number of steps differed significantly by the hemiparetic side (P < .05), but not by sex or the type of stroke. There were moderate to strong correlations between the stepping time and the number of steps with gait speed (Spearman r = .49 and .61 respectively, P < .01). Correlations between accelerometer-derived variables and age, time since stroke, and cognition were not significant.

CONCLUSIONS

People with stroke sleep for longer than the normal duration, spend about three quarters of their waking hours in sedentary behaviors, and engage in minimal walking following stroke rehabilitation. Our findings provide a rationale for the development of behavior change strategies after stroke.

Objectively assessed physical activity and associated factors of sedentary behavior among survivors of stroke living in Cape Town, South Africa

PURPOSE

To investigate objectively measured physical activity in stroke survivors living in low-income areas of Cape Town, South Africa, specifically to: (a) describe the volume of daily physical activity and time spent in different intensity levels and (b) investigate the association of factors covering the International Classification of Functioning, Disability and Health with sedentary behavior.

MATERIALS AND METHODS

A cross-sectional design was used, where forty-five ambulatory community-dwelling stroke survivors participated. Volume and intensity of physical activity were assessed with accelerometers for three to five consecutive days. Personal and environmental factors, along with body function and activity, were captured. Multiple linear regression was used to investigate factors associated with the percentage of days spent sedentary.

RESULTS

The median number of steps per day was 2393, and of the average 703 minutes of wear time, 80% were spent in sedentary, 15% in light, and 5% in moderate-to-vigorous intensity physical activity. Age, stroke severity, and failing to receive outpatient rehabilitation were independently associated with sedentary, which, taken together, explained 52% of the variance.

CONCLUSIONS

Low volumes of physical activity and high amount of sedentary time emphasize the need to develop strategies that will increase physical activity. Providing outpatient rehabilitation in a systematic manner post-stroke is a potential target of health care programs in order to reduce sedentary behavior. Implications for rehabilitation Objectively measured physical activity among community-dwelling survivors of stroke in Cape Town, South Africa was low in volume, and the majority did not meet the recommendations of 150 minutes of at least moderate intensity physical activity. The majority of stroke survivors in South Africa spent most of their time sedentary, which could further increase the risk of cardiovascular impairments. Outpatient rehabilitation should be provided to all patients after stroke since it appears to reduce sedentary time.

Recovery of ambulation activity across the first six months post-stroke

Stroke survivors commonly adopt sedentary activity behaviours by the chronic phase of recovery. However, the change in activity behaviours from the subacute to chronic phase of stroke is variable. This study explored the recovery of ambulation activity (volume and bouts) at one, three and six months after hospital discharge post-stroke. A total of 42 stroke survivors were recruited at hospital discharge and followed up one, three and six months later. At follow-up, ambulation activity was measured over four days using the ActivPAL™ accelerometer. Measures included volume of activity and frequency and intensity of ambulation activity bouts per day. Linear mixed effects modelling was used to determine changes over time. There was wide variation in activity. Total step counts across all time points were below required levels for health benefits (mean 4592 SD 3411). Most activity was spread across short bouts. While most number of bouts was of low intensity, most time was spent in moderate intensity ambulation across all time points. Daily step count and time spent walking and sitting/lying increased from one month to three and six months. The number of and time spent in short and medium duration bouts increased from one to six months. Time in long duration bouts increased at three months only. Time spent in moderate intensity ambulation increased over time. No change was observed for any other measures. In future, it would be valuable to identify strategies to increase engagement in activity behaviours to improve health outcomes after stroke.

Sedentary Behavior in People with and without a Chronic Health Condition: How Much, What and When?

PURPOSE

To describe sedentary behaviors (duration, bouts and context) in people with and without a chronic health condition.

METHODS

Design: Secondary analysis of two cross-sectional studies. Participants: People with stable chronic obstructive pulmonary disease (COPD) (n = 24, male:female 18:6) and their spousal carers (n = 24, 6:18); stroke survivors (n = 24, 16:8) and age- and sex-matched healthy adults (n = 19, 11:8). Level of physiological impairment was measured with post-bronchodilator spirometry (FEV1 %predicted) for people with COPD, and walking speed for people with stroke. Outcomes: Participants were monitored over seven days (triaxial accelerometer, Sensewear armband) to obtain objective data on daily sedentary time, and prolonged sedentary bouts (≥ 30 min). During the monitoring period, a 24-hour use of time recall instrument was administered by telephone interview to explore the context of sedentary activities (e.g. television, computer or reading). Sedentary time was quantified using accelerometry and recall data, and group differences were explored. Linear regression examined associations between physiological impairment and sedentary time.

RESULTS

Participant groups were similar in terms of age (COPD 75 ± 8, carers 70 ± 11, stroke 69 ± 10, healthy 73 ± 7 years) and body mass index (COPD 28 ± 4, carers 27 ± 4, stroke 31 ± 4, healthy 26 ± 4 kg.m-2). The healthy group had the lowest sedentary time (45% of waking hours), followed by the carer (54%), stroke (60%) and COPD (62%) groups (p < 0.0001). Level of physiological impairment was an independent predictor of waking sedentary time (p = 0.001).

CONCLUSIONS

People with a chronic health condition spent more time sedentary than those without a chronic condition, and there were small but clear differences between groups in the types of activities undertaken during sedentary periods. The study findings may aid in the design of targeted interventions to decrease sedentary time in people with chronic health conditions.

Novel outcome measures for Charcot-Marie-Tooth disease: validation and reliability of the 6-min walk test and StepWatch(™) Activity Monitor and identification of the walking features related to higher quality of life

BACKGROUND AND PURPOSE

Charcot-Marie-Tooth (CMT) disease is the most common inherited neuropathy, but therapeutic options have been limited to symptom management. Past pharmacological trials have failed, possibly due to insensitive outcome measures (OMs). The aim of the current study was to evaluate the validity and reliability of the 6-min walk test (6MWT) and StepWatch(™) Activity Monitoring (SAM) with other previously validated OMs in CMT disease.

METHODS

A prospective multicenter study was performed, consecutively enrolling 168 CMT patients (104 with CMT1A, 27 with CMT1B, 37 with X-linked CMT) from Italian centers specializing in CMT care.

RESULTS

Statistical analysis showed that the 6MWT was highly related with all previously used OMs. Some, but not all, SAM parameters were related to commonly used OMs but may provide more information about quality of life.

CONCLUSIONS

The current study demonstrated the validity and reliability of the 6MWT and SAM as OMs for CMT. Moreover, SAM provides data that correlate better with quality of life measures, making it useful in future rehabilitation trials.

Remote Physical Activity Monitoring in Neurological Disease: A Systematic Review

OBJECTIVE

To perform a systematic review of studies using remote physical activity monitoring in neurological diseases, highlighting advances and determining gaps.

METHODS

Studies were systematically identified in PubMed/MEDLINE, CINAHL and SCOPUS from January 2004 to December 2014 that monitored physical activity for ≥24 hours in adults with neurological diseases. Studies that measured only involuntary motor activity (tremor, seizures), energy expenditure or sleep were excluded. Feasibility, findings, and protocols were examined.

RESULTS

137 studies met inclusion criteria in multiple sclerosis (MS) (61 studies); stroke (41); Parkinson's Disease (PD) (20); dementia (11); traumatic brain injury (2) and ataxia (1). Physical activity levels measured by remote monitoring are consistently low in people with MS, stroke and dementia, and patterns of physical activity are altered in PD. In MS, decreased ambulatory activity assessed via remote monitoring is associated with greater disability and lower quality of life. In stroke, remote measures of upper limb function and ambulation are associated with functional recovery following rehabilitation and goal-directed interventions. In PD, remote monitoring may help to predict falls. In dementia, remote physical activity measures correlate with disease severity and can detect wandering.

CONCLUSIONS

These studies show that remote physical activity monitoring is feasible in neurological diseases, including in people with moderate to severe neurological disability. Remote monitoring can be a psychometrically sound and responsive way to assess physical activity in neurological disease. Further research is needed to ensure these tools provide meaningful information in the context of specific neurological disorders and patterns of neurological disability.

Sitting and Activity Time in People With Stroke

BACKGROUND

Excessive sitting time is linked to cardiovascular disease morbidity. To date, no studies have accurately measured sitting time patterns in people with stroke.

OBJECTIVE

The purpose of this study was to investigate the amount and pattern of accumulation of sitting time, physical activity, and use of time in people with stroke compared with age-matched healthy peers.

DESIGN

This study used an observational design.

METHODS

Sitting time (total and time accumulated in prolonged, unbroken bouts of ≥30 minutes) was measured with an activity monitor. Physical activity and daily energy expenditure were measured using an accelerometer and a multisensory array armband, respectively. All monitors had a 7-day wear protocol. Participants recalled 1 day of activity (during monitor wear time) using the Multimedia Activity Recall for Children and Adults.

RESULTS

Sixty-three adults (40 with stroke and 23 age-matched healthy controls) participated. The participants (35% female, 65% male) had a mean age of 68.4 years (SD=10.0). Participants with stroke spent significantly more time sitting (X̅=10.9 h/d, SD=2.0) compared with controls (X̅=8.2 h/d, SD=2.0), with much of this sitting time prolonged (stroke group: X̅=7.4 h/d, SD=2.8; control group: X̅=3.7 h/d, SD=1.7). Participants with stroke accumulated most of their sitting time while watching television and in general quiet time, whereas control participants spent more time reading and on the computer. Physical activity and daily energy expenditure were lower in the stroke group compared with the control group.

LIMITATIONS

A sample of convenience was used to select participants for the stroke and control groups, which may reduce the generalizability of results.

CONCLUSIONS

Participants with stroke spent more time sitting and less time in activity than their age-matched peers. Further work is needed to determine whether reducing sitting time is feasible and leads to clinically important reductions in cardiovascular risk in this population.

Ambulatory Activity in People with Early Parkinson's Disease

People with Parkinson's disease (PD) are encouraged to participate in physical activity levels equivalent to those recommended for the general population. Understanding factors that influence this activity is important for facilitating this participation. This study examined factors associated with participation in moderate and high intensity daily ambulatory activity in people with mild to moderate PD. Fifty community-dwelling people with mild-moderate PD were monitored with accelerometers over three days to characterise their daily ambulatory activity levels. Personal factors, disease characteristics, gait and cognitive capacity were measured. Prediction models were created to identify factors influencing ambulation activity. People with PD spent approximately 77 minutes walking per day, mostly at a moderate intensity resulting in a median of 6300 steps/day. Disease severity predicted time spent in moderate ambulation bouts (R2 = 0.116, p = .017). Gait (Timed Up and Go (TUG) Test) and executive function together predicted engagement in high intensity ambulatory activity (R2 > 0.170, p < .022). While disease severity, gait performance and executive function were predictive of engagement in moderate and high intensity walking activity, additional personal and social factors should be considered and are likely to also strongly impact on activity levels.

Toward Understanding Ambulatory Activity Decline in Parkinson Disease

BACKGROUND

Declining ambulatory activity represents an important facet of disablement in Parkinson disease (PD).

OBJECTIVE

The primary study aim was to compare the 2-year trajectory of ambulatory activity decline with concurrently evolving facets of disability in a small cohort of people with PD. The secondary aim was to identify baseline variables associated with ambulatory activity at 1- and 2-year follow-up assessments.

DESIGN

This was a prospective, longitudinal cohort study.

METHODS

Seventeen people with PD (Hoehn and Yahr stages 1-3) were recruited from 2 outpatient settings. Ambulatory activity data were collected at baseline and at 1- and 2-year annual assessments. Motor, mood, balance, gait, upper extremity function, quality of life, self-efficacy, and levodopa equivalent daily dose data and data on activities of daily living also were collected.

RESULTS

Participants displayed significant 1- and 2-year declines in the amount and intensity of ambulatory activity concurrently with increasing levodopa equivalent daily dose. Worsening motor symptoms and slowing of gait were apparent only after 2 years. Concurrent changes in the remaining clinical variables were not observed. Baseline ambulatory activity and physical performance variables had the strongest relationships with 1- and 2-year mean daily steps.

LIMITATIONS

The sample was small and homogeneous.

CONCLUSIONS

Future research that combines ambulatory activity monitoring with a broader and more balanced array of measures would further illuminate the dynamic interactions among evolving facets of disablement and help determine the extent to which sustained patterns of recommended daily physical activity might slow the rate of disablement in PD.

Classifying physical activity research following stroke using the behavioral epidemiologic framework

BACKGROUND

Stroke is a significant public health issue in the USA and a need emerges to better understand how to reduce an individual's co-morbidity risk. Physical activity is one approach to improving the health of individuals and comprehensive literature supports increased activity as a means to reduce risk of morbidity and mortality. One approach to examining whether research in a field is addressing a public health issue is through application of the behavioral epidemiological framework.

OBJECTIVE

To classify physical activity research for individuals following stroke into distinct phases so that efforts can be made to systematically address gaps and disseminate evidence-based practice.

METHODS

Specific key words were identified and then searched through EBSCO host, PubMed, and Google Scholar. Physical activity and stroke literature from 2000-2014 was categorized into one of five discrete phases. Research in Phase 1 identified associations between activity and health; Phase 2 established valid measures of activity; Phase 3 examined determinants of behavior; Phase 4 evaluated activity interventions; and Phase 5 disseminated evidence-based practice.

RESULTS

A comprehensive review of literature identified 202 articles with 70% categorized in Phase 1 (n = 141), 11% in Phase 2 (n = 23), 10% in Phase 3 (n = 20), 8% in Phase 4 (n = 15), and 1% in Phase 5 (n = 3).

CONCLUSION

Findings suggest that physical activity research for individuals following stroke is in the early stages of development with less than 10% of research evaluating or disseminating interventions.

Use of Accelerometer-Based Feedback of Walking Activity for Appraising Progress With Walking-Related Goals in Inpatient Stroke Rehabilitation: A Randomized Controlled Trial

BACKGROUND

Regaining independent ambulation is important to those with stroke. Increased walking practice during "down time" in rehabilitation could improve walking function for individuals with stroke.

OBJECTIVE

To determine the effect of providing physiotherapists with accelerometer-based feedback on patient activity and walking-related goals during inpatient stroke rehabilitation.

METHODS

Participants with stroke wore accelerometers around both ankles every weekday during inpatient rehabilitation. Participants were randomly assigned to receive daily feedback about walking activity via their physiotherapists (n = 29) or to receive no feedback (n = 28). Changes in measures of daily walking (walking time, number of steps, average cadence, longest bout duration, and number of "long" walking bouts) and changes in gait control and function assessed in-laboratory were compared between groups.

RESULTS

There was no significant increase in walking time, number of steps, longest bout duration, or number of long walking bouts for the feedback group compared with the control group (P values > .20). However, individuals who received feedback significantly increased cadence of daily walking more than the control group (P = .013). From the in-laboratory gait assessment, individuals who received feedback had a greater increase in walking speed and decrease in step time variability than the control group (P values < .030).

CONCLUSION

Feedback did not increase the amount of walking completed by individuals with stroke. However, there was a significant increase in cadence, indicating that intensity of daily walking was greater for those who received feedback than the control group. Additionally, more intense daily walking activity appeared to translate to greater improvements in walking speed.

Sampling frequency impacts measurement of walking activity after stroke

The purpose of this study was to examine the effect of sampling epoch on total time spent walking and number of walking bouts per day in persons with stroke. Ninety-eight persons with average age of 63.8 yr and average time poststroke of 43.6 mo participated. Participants wore a StepWatch Activity Monitor for 3 to 5 consecutive days. The number of strides taken was collected in consecutive 5 s epochs and down sampled into 10, 20, 30, and 60 s epochs. Total time walking and total number of walking bouts were determined for each day. Low activity days were defined as days below the 25th percentile of total steps per day and high activity days as days above the 75th percentile of total steps per day. Total time walking and total number of bouts were different for each sampling epoch (p < 0.001 for all). The 5 s sampling epoch resulted in calculation of ~40% of the walking time and ~6 times as many bouts as a 60 s sampling epoch. Differences were greater for low activity days (p < 0.001 for all). Sampling epoch affects daily step activity variables whose calculation depends on time, especially during low activity days. Sampling epoch must be carefully considered when designing studies aimed at understanding patterns of daily walking activity.

Physical activity and sedentary behaviors in people with stroke living in the community: a systematic review

BACKGROUND

Regular physical activity is vital for cardiovascular health. Time spent in sedentary behaviors (eg, sitting, lying down) also is an independent risk factor for cardiovascular disease. The pattern in which sedentary time is accumulated is important-with prolonged periods of sitting time being particularly deleterious. People with stroke are at high risk for cardiovascular disease, including recurrent stroke.

PURPOSE

This systematic review aimed to update current knowledge of physical activity and sedentary behaviors among people with stroke living in the community. A secondary aim was to investigate factors associated with physical activity levels.

DATA SOURCES

The data sources used were MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complimentary Medicine Database (AMED), EMBASE, and the Cochrane Library.

STUDY SELECTION

Studies involving people with stroke living in the community and utilizing objective measures of physical activity or sedentary behaviors were included.

DATA EXTRACTION

Data were extracted by one reviewer and checked for accuracy by a second person.

DATA SYNTHESIS

Twenty-six studies, involving 983 participants, were included. The most common measure of activity was steps per day (22 studies), which was consistently reported as less than half of age-matched normative values. Only 4 studies reported on sedentary time specifically. No studies described the pattern by which sedentary behaviors were accumulated across the day. Walking ability, balance, and degree of physical fitness were positively associated with higher levels of physical activity.

LIMITATIONS

This review included only studies of people living in the community after stroke who were able to walk, and the majority of included participants were aged between 65 and 75 years of age.

CONCLUSIONS

Little is known about the time people with stroke spend being sedentary each day or the pattern in which sedentary time is accumulated. Studies using objective, reliable, and valid measures of sedentary time are needed to further investigate the effects of sedentary time on the health of people with stroke.

Physical Activity after Stroke: A Systematic Review and Meta-Analysis

Background and Purpose. Physical activity is beneficial after stroke, but it is unclear how active stroke survivors are. This systematic review and meta-analysis sought to determine levels of activity and factors predicting activity. Summary of Review: Methods. MEDLINE (1946 to present) and EMBASE (1980 to present) were systematically searched until July 2012. All studies quantifying whole-body-free living physical activity by objective and self-reported methods in a community dwelling population with stroke were included. A random effect meta-analysis was performed. Results. Twenty-six studies were included (n=1105), of which eleven (n=315) contained sufficient data for meta-analysis. There were heterogeneous designs, measurements, and procedures. The studies generally recruited small samples of high-functioning participants. Level of physical activity was generally low in quantity, duration and intensity. Poorer walking ability, specific sensorimotor functions, and low mood were correlates of low physical activity. Meta-analysis generated an estimate of 4355.2 steps/day (95% CI: 3210.4 to 5499.9) with no significant heterogeneity (I2 = 0). Conclusions. In high-functioning stroke survivors, physical activity including walking was generally low. Strategies are needed to promote and maintain physical activity in stroke survivors. Research is needed to establish reasons for low physical activity after stroke.

Using wireless technology in clinical practice: does feedback of daily walking activity improve walking outcomes of individuals receiving rehabilitation post-stroke? Study protocol for a randomized controlled trial

BACKGROUND

Regaining independent ambulation is the top priority for individuals recovering from stroke. Thus, physical rehabilitation post-stroke should focus on improving walking function and endurance. However, the amount of walking completed by individuals with stroke attending rehabilitation is far below that required for independent community ambulation. There has been increased interest in accelerometer-based monitoring of walking post-stroke. Walking monitoring could be integrated within the goal-setting process for those with ambulation goals in rehabilitation. The feedback from these devices can be downloaded to a computer to produce reports. The purpose of this study is to determine the effect of accelerometer-based feedback of daily walking activity during rehabilitation on the frequency and duration of walking post-stroke.

METHODS

Participants will be randomly assigned to one of two groups: feedback or no feedback. Participants will wear accelerometers daily during in- and out-patient rehabilitation and, for participants in the feedback group, the participants' treating physiotherapist will receive regular reports of walking activity. The primary outcome measures are the amount of daily walking completed, as measured using the accelerometers, and spatio-temporal characteristics of walking (e.g. walking speed). We will also examine goal attainment, satisfaction with progress towards goals, stroke self-efficacy, and community-integration.

DISCUSSION

Increased walking activity during rehabilitation is expected to improve walking function and community re-integration following discharge. In addition, a focus on altering walking behaviour within the rehabilitation setting may lead to altered behaviour and increased activity patterns after discharge.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01521234.

Physiotherapists systematically overestimate the amount of time stroke survivors spend engaged in active therapy rehabilitation: an observational study

QUESTIONS

How accurately do physiotherapists estimate how long stroke survivors spend in physiotherapy sessions and the amount of time stroke survivors are engaged in physical activity during physiotherapy sessions? Does the mode of therapy (individual sessions or group circuit classes) affect the accuracy of therapists' estimates?

DESIGN

Observational study embedded within a randomised trial.

PARTICIPANTS

People who participated in the CIRCIT trial after having a stroke.

INTERVENTION

47 therapy sessions scheduled and supervised by physiotherapists (n = 8) and physiotherapy assistants (n = 4) for trial participants were video-recorded.

OUTCOME MEASURES

Therapists' estimations of therapy time were compared to the video-recorded times.

RESULTS

The agreement between therapist-estimated and video-recorded data for total therapy time and active time was excellent, with intraclass correlation coefficients (ICC) of 0.90 (95% CI 0.83 to 0.95) and 0.83 (95% CI 0.73 to 0.93) respectively. Agreement between therapist-estimated and video-recorded data for inactive time was good (ICC score 0.62, 95% CI 0.40 to 0.77). The mean (SD) difference between therapist-estimated and video-recorded total therapy time, active time, and inactive time for all sessions was 7.7 (10.5), 14.1 (10.3) and -6.9 (9.5) minutes respectively. Bland-Altman analyses revealed a systematic bias of overestimation of total therapy time and total active time, and underestimation of inactive time by therapists. Compared to individual therapy sessions, therapists estimated total circuit class therapy duration more accurately, but estimated active time within circuit classes less accurately.

CONCLUSION

Therapists are inaccurate in their estimation of the amount of time stroke survivors are active during therapy sessions. When accurate therapy data are required, use of objective measures is recommended.

Cardiovascular responses associated with daily walking in subacute stroke

Despite the importance of regaining independent ambulation after stroke, the amount of daily walking completed during in-patient rehabilitation is low. The purpose of this study is to determine if (1) walking-related heart rate responses reached the minimum intensity necessary for therapeutic aerobic exercise (40%–60% heart rate reserve) or (2) heart rate responses during bouts of walking revealed excessive workload that may limit walking (>80% heart rate reserve). Eight individuals with subacute stroke attending in-patient rehabilitation were recruited. Participants wore heart rate monitors and accelerometers during a typical rehabilitation day. Walking-related changes in heart rate and walking bout duration were determined. Patients did not meet the minimum cumulative requirements of walking intensity (>40% heart rate reserve) and duration (>10 minutes continuously) necessary for cardiorespiratory benefit. Only one patient exceeded 80% heart rate reserve. The absence of significant increases in heart rate associated with walking reveals that patients chose to walk at speeds well below a level that has meaningful cardiorespiratory health benefits. Additionally, cardiorespiratory workload is unlikely to limit participation in walking. Measurement of heart rate and walking during in-patient rehabilitation may be a useful approach to encourage patients to increase the overall physical activity and to help facilitate recovery.

Physical activity, sedentary behaviour and metabolic control following stroke: a cross-sectional and longitudinal study

BACKGROUND

Physical activity and sedentary behaviour are key moderators of cardiovascular disease risk and metabolic control. Despite the importance of a physically active lifestyle, little is known about the effects of stroke on physical activity. We assessed physical activity and sedentary behaviour at three time points following stroke compared to a healthy control group.

METHODS

Physical activity and sedentary behaviour were objectively measured using a portable multi-sensor array in 31 stroke participants (73±9 years, National Institute of Health Stroke Scale 2±2, mobile 10 metres with/without aid) within seven days and at three and six months. Stroke data were compared with an age, sex and body mass index matched healthy control group (n = 31).

RESULTS

Within seven days of stroke, total energy expenditure and physical activity were significantly lower and sedentary time higher in the stroke group compared to controls (total energy expenditure 1840±354 vs. 2220±489 kcal, physical activity 28±32 vs. 79±46 min/day, steps 3111±2290 vs. 7996±2649, sedentary time 1383±42 vs. 1339±44 min/day, p<0.01). At three months physical activity levels had increased (64±58 min/day) but plateaued by six months (66±68 min/day).

CONCLUSIONS

Physical activity levels are reduced immediately post-stroke and remain below recommended levels for health and wellbeing at the three and six month time points. Clinicians should explore methods to increase physical activity and reduce sedentary behaviour in both the acute and later stages following stroke.

Capturing ambulatory activity decline in Parkinson's disease

BACKGROUND AND PURPOSE

Relatively little is known about the natural evolution of physical activity-related participation restrictions associated with Parkinson's disease (PD). We examined this issue prospectively, using continuous monitoring technology to capture the free-living ambulatory activity of persons with PD engaging in life situations. We specifically sought (1) to explore natural, long-term changes in daily ambulatory activity and (2) to compare the responsiveness of ambulatory activity parameters to clinical measures of gait and disease severity.

METHODS

Thirty-three persons with PD participated (Hoehn and Yahr range of 1-3). Participants wore a step activity monitor for up to 7 days at baseline and again at 1-year follow-up. Mean daily values were calculated for parameters indicative of amount, intensity, frequency, and duration of ambulatory activity. Clinical measures included the Unified Parkinson Disease Rating Scale, the 6-Minute Walk, and Maximal Gait Speed. Parametric tests for paired samples were used to investigate changes in ambulatory activity parameters and clinical measures.

RESULTS

Participants had significant declines in the amount and intensity of daily ambulatory activity but not in its frequency and duration (P < 0.007). Declines occurred in the absence of changes in clinical measures of gait or disease severity. The greatest 1-year decline occurred in the number of daily minutes participants spent engaging in at least moderate-intensity ambulatory activity.

CONCLUSION

Continuous monitoring of ambulatory activity beyond mere step counts may serve as a distinct and important means of quantifying declining ambulatory behavior associated with disease progression or improved ambulatory behavior resulting from rehabilitation and medical and/or surgical interventions in persons with PD.

The promise of mHealth: daily activity monitoring and outcome assessments by wearable sensors

Mobile health tools that enable clinicians and researchers to monitor the type, quantity, and quality of everyday activities of patients and trial participants have long been needed to improve daily care, design more clinically meaningful randomized trials of interventions, and establish cost-effective, evidence-based practices. Inexpensive, unobtrusive wireless sensors, including accelerometers, gyroscopes, and pressure-sensitive textiles, combined with Internet-based communications and machine-learning algorithms trained to recognize upper- and lower-extremity movements, have begun to fulfill this need. Continuous data from ankle triaxial accelerometers, for example, can be transmitted from the home and community via WiFi or a smartphone to a remote data analysis server. Reports can include the walking speed and duration of every bout of ambulation, spatiotemporal symmetries between the legs, and the type, duration, and energy used during exercise. For daily care, this readily accessible flow of real-world information allows clinicians to monitor the amount and quality of exercise for risk factor management and compliance in the practice of skills. Feedback may motivate better self-management as well as serve home-based rehabilitation efforts. Monitoring patients with chronic diseases and after hospitalization or the start of new medications for a decline in daily activity may help detect medical complications before rehospitalization becomes necessary. For clinical trials, repeated laboratory-quality assessments of key activities in the community, rather than by clinic testing, self-report, and ordinal scales, may reduce the cost and burden of travel, improve recruitment and retention, and capture more reliable, valid, and responsive ratio-scaled outcome measures that are not mere surrogates for changes in daily impairment, disability, and functioning.

Addressing the nonexercise part of the activity continuum: a more realistic and achievable approach to activity programming for adults with mobility disability?

Participation in physical activity is fundamental for the maintenance of metabolic health and the prevention of major chronic diseases, particularly type 2 diabetes and cardiovascular disease. A whole-of-day approach to physical activity promotion is increasingly advocated and includes not only increasing moderate-intensity physical activity but also reducing sedentary time and increasing light-intensity activity (the "nonexercise" part of the activity continuum). This whole-of-day approach to tackling the challenge of inactivity may be particularly relevant for adults with mobility disabilities, who are among the most inactive segment of the population. Focusing on nonexercise activity by striving to reduce sedentary time and increase light-intensity activity may be a more successful place to begin to change behavior in someone with mobility disability. This article discusses what is known about the metabolic health consequences of sedentary behavior and light-intensity activity in adults with and without mobility disability. The concept of inactivity physiology is presented, along with possible applications or evidence from studies with adults with mobility disability. Mobility disability discussions and examples focus on stroke and spinal cord injury. Finally, clinical implications and future research directions related to sedentary behavior in adults with mobility disability are discussed.

Participation in community walking following stroke: subjective versus objective measures and the impact of personal factors

BACKGROUND

Mobility, specifically community walking, is important, but often limited among survivors of stroke. The factors that influence the recovery of community walking are not clearly understood.

OBJECTIVE

The purpose of this research was to examine mobility disability following stroke, specifically: (1) the association between subjective and objective measures of participation in community walking and (2) the association between personal factors and participation in community walking.

DESIGN

A cross-sectional study design was used.

METHODS

Fifty community-dwelling survivors of stroke, aged 50 to 79 years, were enrolled in the study. Participation in community walking was measured subjectively (perceived difficulty and satisfaction) and objectively using self-report data (number of trips and walking-related activities) and step data (pedometer). The association between subjective and objective measures of participation was analyzed using Pearson correlation. The association of personal factors (age, sex, number of comorbidities, fatigue, depression, balance and fall self-efficacy, and importance of walking) with measures of participation was analyzed using multiple linear regression.

RESULTS

Subjective and objective measures of participation were weakly associated. Self-efficacy was the only personal factor that was strongly associated with both subjective and objective measures of participation. Personal factors explained 27% to 55% of the variability in participation in community walking.

LIMITATIONS

Limitations included a small sample size and limited diversity among participants. Reliability of the pedometer used in this study has not been established in the stroke population.

CONCLUSIONS

Subjective and objective measures of participation in community walking were only weakly correlated, suggesting that they measure different aspects of mobility; thus, to fully capture participation, it is critical to measure both. Personal factors were associated with subjective and objective measures of participation and are important in explaining variability in community walking following stroke.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Deviations in daily physical activity patterns in patients with the chronic fatigue syndrome: a case control study

OBJECTIVES

Deviations in daily physical activity patterns may play an important role in the development and maintenance of fatigue in the chronic fatigue syndrome (CFS). The aim of this study is to gain insight into the objective daily physical activity pattern of patients with CFS in comparison with healthy controls. The secondary objective is studying the awareness in performing physical activities.

METHODS

The objective daily physical activity pattern was measured with a tri-axial accelerometer in 35 patients with CFS and in 35 age- and gender-matched healthy controls. The objective daily physical activity level and distribution of physical activities at low, medium and high intensity levels during the day were measured. Moreover, variability in performing physical activities within and between subjects was computed. Subjective ratings of self-reported daily physical activity levels were assessed at a visual analog scale.

RESULTS

CFS patients were significantly less physically active in the afternoon and evening, and spent fewer activities at high intensity levels and more at low intensity levels. Moreover, CFS patients showed more variability in their own physical activity pattern during the afternoon. The heterogeneity in the physical activity pattern between subjects within the CFS and control group did not differ. Finally, CFS patients were more aware about their daily physical activity level than healthy controls.

CONCLUSION

CFS patients showed deviations in the objectively measured daily physical activity pattern. Future research should elucidate the relation between impaired balances in daily physical activity patterns and fatigue severity in CFS.

Ambulatory activity in individuals with multiple sclerosis

BACKGROUND AND PURPOSE

Specific characteristics of physical activity limitations associated with multiple sclerosis (MS) remain unclear. Our purpose was to examine the impact of MS disability on physical activity behaviors involving ambulation. We also explored relationships among ambulatory activity parameters and clinical measures of gait, balance, and fatigue.

METHODS

Twenty-one adults with MS participated: 11 without ambulatory limitation (Expanded Disability Status Scale [EDSS] score ≤ 4.5) and 10 with ambulatory limitation (EDSS score > 4.5). Participants wore a step activity monitor for up to 7 days. Daily values were calculated for parameters indicative of (1) overall activity, (2) upper limits of activity output, and (3) activity work-rest cycles. Clinical measures included Multiple Sclerosis Walking Scale, Timed 25-Foot Walk, Timed Up and Go test, 6-Minute Walk, Dynamic Gait Index, Berg Balance Scale, Activities-specific Balance Confidence Scale, and Modified Fatigue Impact Scale. Statistical analyses were conducted using nonparametric tests.

RESULTS

Participants without limitation were more active, demonstrated higher upper limits of activity output, and had longer activity bouts than participants with limitation (P < 0.05). Only 1 participant averaged more than 100 steps per minute over a 30-minute period. Of the ambulatory activity parameters, daily step count was most strongly related to gait and balance measures. Of the clinical measures, EDSS and Multiple Sclerosis Walking Scale scores were most strongly related to daily step count.

CONCLUSION

Individuals with MS are not necessarily sedentary, but few may achieve recommended daily physical activity levels. Ambulatory activity characteristics revealed new insights into physical activity limitations in MS. The study findings suggest that disability status should direct physical activity interventions.

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

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A novel approach to ambulatory monitoring: investigation into the quantity and control of everyday walking in patients with subacute stroke

BACKGROUND

Promoting whole body activities, such as walking, can help improve recovery after stroke. However, little information exists regarding the characteristics of daily walking in patients enrolled in rehabilitation poststroke. The objectives of this study were to: (1) examine the quantity of walking and duration of individual bouts of walking during an inpatient day, (2) compare standard laboratory symmetry measures with measures of symmetry captured throughout the day, and (3) investigate the association between quantity of walking and indices of stroke severity.

METHODS

The study examined ambulatory activity among 16 inpatients with subacute stroke who were bilaterally instrumented with a wireless accelerometer above the ankle for approximately 8 continuous hours.

RESULTS

On average, patients demonstrated 47.5 minutes (standard deviation [SD] = 26.6 minutes) of total walking activity and walking bout durations of 54.4 s (SD = 21.5 s). A statistically significant association was found between the number of walking bouts to total walking time (r = .76; P = .006) and laboratory gait speed (r = .51; P = .045) and between laboratory gait speed and balance impairment (r = .60; P = .013). Also, a significant increase in gait asymmetry was observed during day-long measurement compared with the standard laboratory-based assessment (P = .006).

CONCLUSIONS

Rather modest amounts of daily walking were found for these ambulatory inpatients, consistent with previous reports about patients after stroke. Bouts of walking were short in duration, and the gait was more asymmetrical, compared with a standard gait assessment. Unobtrusive monitoring of daily walking exposes the characteristics and temporal qualities of poststroke ambulation.