Ambulatory monitoring of activity levels of individuals in the sub-acute stage following stroke: a case series

Agreement of activity monitors for assessment of patients with sub-acute stroke in an inpatient rehabilitation facility

PURPOSE

Determine the level of agreement of three activity monitors compared with the gold standard (video review) on the activity level of patients with stroke.

METHODS

A prospective, observational, agreement study was performed on 47 individuals with sub-acute stroke in an inpatient rehabilitation facility. Data was collected during one physical therapy session. Individuals wore three device types; Actigraph (AG), Activpal (AP), and stepwatch activity monitor (SAM). Variables assessed were step counts for each limb (hemiparetic and non-hemiparetic) and percent time standing and other.

ANALYSIS

Results from the activity monitors were compared to the video review and assessed for agreement using the intraclass correlation coefficient (ICC) and accuracy of mean difference from video observation.

RESULTS

The step counts with the SAM on the non-hemiparetic limb had the highest ICC for step counts (ICC = 0.98, p < 0.001) and were overestimated with 21% accuracy. The SAM on the hemiparetic limb had 9.7% accuracy (ICC = 0.92, p < 0.001). For percent standing time all devices overestimated with poor reliability. For percent other activity time, the AP had the best accuracy and underestimated for both the hemiparetic limb (9.9% accuracy; ICC = 0.90, p < 0.001) and non-hemiparetic limb (8.3% accuracy; ICC = 0.84, p < 0.001).

CONCLUSIONS

The use of multiple devices may be warranted to capture an accurate understanding of activity levels in this population of individuals with sub-acute stroke. There are concerns with all monitors and clinicians and researchers should be aware of what measures they are wanting to understand about their population.

App-based supplemental exercise in rehabilitation, adherence, and effect on outcomes: a randomized controlled trial

QUESTION

To determine the uptake of an app-based supplemental exercise programme in a rehabilitation setting and the effect of such a programme on length of stay and function compared to usual care physiotherapy.

DESIGN

Randomized controlled trial with random allocation and assessor blinding.

PARTICIPANTS

A total of 144 individuals with mixed diagnoses (orthopaedic, neurological, reconditioning) admitted for inpatient sub-acute rehabilitation.

INTERVENTIONS

Participants were randomly allocated to usual care physiotherapy (control group) or usual care physiotherapy with the addition of an app-based supplemental exercise programme (intervention group).

OUTCOME MEASURES

The primary measure of interest was total supplementary exercise dosage completed by the intervention group. The primary between-group outcome measure was length of stay with secondary measures including walking endurance (Six-Minute Walk Test), walking speed (10-Metre Walk Test), functional mobility (Timed Up and Go Test) and level of disability (Functional Independence Measure).

RESULTS

Participants in the intervention group performed 7 minutes (SD: 9) or 49 repetitions (SD: 48) of supplementary exercise using the app each day. There were no differences between the groups for length of stay (mean difference (MD): -0.5 days, 95% confidence interval (CI): -3.2 to 2.2) or change in any secondary functional outcome measures, including walking speed (MD: -0.1 m/s, 95% CI: -0.2 to 0.0) and disability (MD: -0.9, 95% CI: -3.6 to 1.8).

CONCLUSION

A small supplementary exercise dose was achieved by participants in the intervention group. However, such a programme did not affect length of stay or functional outcomes when compared to usual care.

Excessive sedentary time during in-patient stroke rehabilitation

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

Integrating aerobic training within subacute stroke rehabilitation: a feasibility study

BACKGROUND

Aerobic activity positively affects patients recovering from stroke and is part of best practice guidelines, yet this evidence has not been translated to routine practice.

OBJECTIVE

The objective of this study was to evaluate the feasibility of a model of care that integrated aerobic training in an inpatient rehabilitation setting for patients in the subacute stage of stroke recovery. Key elements of the program were personalized training prescription based on submaximal test results and supervision within a group setting.

DESIGN

This was a prospective cohort study.

METHODS

Participants (N=78) completed submaximal exercise testing prior to enrollment, and the test results were used by their treating physical therapists for exercise prescription. Feasibility was evaluated using enrollment, class attendance, adherence to prescription, and participant perceptions.

RESULTS

Overall, 31 patients (40%) were referred to and completed the exercise program. Cardiac comorbidities were the main reason for nonreferral to the fitness group. Program attendance was 77%; scheduling conflicts were the primary barrier to participation. The majority of participants (63%) achieved 20 minutes of continuous exercise by the end of the program. No adverse events were reported, all participants felt they benefited from the program, and 80% of the participants expressed interest in continuing to exercise regularly after discharge.

LIMITATIONS

Cardiac comorbidities prevented enrollment in the program for 27% of the admitted patients, and strategies for inclusion in exercise programs in this population should be explored.

CONCLUSIONS

This individualized exercise program within a group delivery model was feasible; however, ensuring adequate aerobic targets were met was a challenge, and future work should focus on how best to include individuals with cardiac comorbidities.

Changes in activity levels in the first month after stroke

[Purpose] To quantify the activity levels of individuals in an acute stroke ward, and to determine if their activity levels change within the first month after stroke. [Methods] In this pilot study, participant activity was monitored prospectively over a single day from 8 a.m. to 5 p.m. on two separate occasions. Individuals with confirmed stroke > 18 years of age and less than 15 days post-stroke at the time of recruitment were eligible for inclusion in this study. Activity was recorded using an electronic device. The first day was scheduled within 15 days and the second at four weeks post-stroke. We looked at the following activity categories: number of transitions, and the times spent lying, sitting and in dynamic activity. [Results] Sixteen individuals were included in this study with a median age of 79.5 years (interquartile range 62.5 to 85). Fifty-six % of the participants had mild, 31% had moderate and 13% had severe stroke, according to the NIHSS score. There were no significant changes in number of transitions, or times spent in dynamic activity and lying and sitting. [Conclusion] Activity levels were low at an acute stroke ward and did not significantly change within the first month.

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.

Participants' perspectives on the feasibility of a novel, intensive, task-specific intervention for individuals with chronic stroke: a qualitative analysis

BACKGROUND

Evidence-based practice promotes patient-centered care, yet the majority of rehabilitative research fails to take patient perspectives into consideration. Qualitative research provides a unique opportunity for patients to express opinions and provide valuable insight on intervention processes.

OBJECTIVE

The purpose of this study was to assess the feasibility of a novel, intensive, task-specific intervention from the patient's perspective.

DESIGN

A phenomenological approach to qualitative inquiry was used.

METHODS

Eight individuals with chronic stroke participated in an intensive intervention, 3 hours per day for 10 consecutive days. Participants were interviewed twice regarding their impressions of the therapy, and a focus group was conducted with participants and family members. Data analysis included an analytical thematic approach.

RESULTS

Five major themes arose related to the feasibility of the intervention: (1) a manageable amount of fatigue; (2) a difficult, yet doable, level of intensity; (3) a disappointingly short therapy duration; (4) enjoyment of the intervention; and (5) muscle soreness.

CONCLUSIONS

The findings suggest that participants perceived this novel and intensive, task-specific intervention as a feasible therapeutic option for individuals with chronic stroke. Despite the fatigue and muscle soreness associated with intensive rehabilitation, participants frequently reported enjoying the therapy and stated disappointment with the short duration (10 days). Future research should include a feasibility trial of longer duration, as well as a qualitative analysis of the benefits associated with the intervention.

A case report exploring activity intensity in inpatient rehabilitation after stroke

Background and Purpose. Inpatient rehabilitation in countries other than the United States (US) has been described as a time where patients are often not engaged in intensive physical activity. The purpose of this case report is to explore the amount and intensity of physical activity provided in inpatient rehabilitation after stroke in the US. Methods. This study presents a case report of a person admitted to an inpatient rehabilitation unit after sustaining a first stroke. A customized data collection tracked type of activity, activity intensity and social interaction every 5 minutes during the rehabilitation day. Results. 74 percent of the day was spent in low intensity, often seated, physical activity; 14% of the day was spent resting or sleeping. Only 2.91% the day was spent in moderate or high intensity activity with a mobility focus. Conclusions. Consistent with other studies, this case report suggests a relatively low physical demand to rehabilitation delivered in inpatient stroke rehabilitation. This case begins to raise questions about optimized rehabilitation parameters for acute stroke rehabilitation.

Changes in spatiotemporal gait variables over time during a test of functional capacity after stroke

Background

Gait dysfunction and fatigue are common post-stroke, though it is unclear how extended walking activity, as would be performed during activities of daily living, may change over time. The purpose of this study was to examine if spatial and temporal gait variables deteriorate during an extended bout of walking in a test of functional capacity after stroke.

Methods

24 community dwelling, independently ambulating individuals greater than 3 months after stroke performed the Six-Minute Walk Test (6MWT). Participants walked over a pressure-sensitive mat on each pass of the 30 m course which recorded spatial and temporal parameters of gait. Mean gait speed and temporal symmetry ratio during each two-minute interval of the 6MWT were examined. Additional post hoc analyses examined the incidence of rests during the 6MWT and changes in gait speed and symmetry.

Results

On average, participants demonstrated a 3.4 ± 6.5 cm/s decrease in speed over time (p= 0.02). Participants who rested were also characterized by increased asymmetry in the final two minutes (p= 0.05). 30% of participants rested at some point during the test, and if a rest was taken, duration increased in the final two minutes (p= 0.001). Examination of factors which may have been associated with resting indicated that resters had poorer balance (p= 0.006) than non-resting participants.

Conclusion

This study supports previous findings establishing that walking performance after stroke declines over relatively short bouts of functionally-relevant ambulation. Such changes may be associated with both cardiorespiratory and muscular fatigue mechanisms that influence performance. The findings also indicate that rest duration should be routinely quantified during the 6MWT after stroke, and consequently, further research is necessary to determine how to interpret 6MWT scores when resting occurs.

Accelerometer-based wireless body area network to estimate intensity of therapy in post-acute rehabilitation

Background

It has been suggested that there is a dose-response relationship between the amount of therapy and functional recovery in post-acute rehabilitation care. To this day, only the total time of therapy has been investigated as a potential determinant of this dose-response relationship because of methodological and measurement challenges. The primary objective of this study was to compare time and motion measures during real life physical therapy with estimates of active time (i.e. the time during which a patient is active physically) obtained with a wireless body area network (WBAN) of 3D accelerometer modules positioned at the hip, wrist and ankle. The secondary objective was to assess the differences in estimates of active time when using a single accelerometer module positioned at the hip.

Methods

Five patients (77.4 ± 5.2 y) with 4 different admission diagnoses (stroke, lower limb fracture, amputation and immobilization syndrome) were recruited in a post-acute rehabilitation center and observed during their physical therapy sessions throughout their stay. Active time was recorded by a trained observer using a continuous time and motion analysis program running on a Tablet-PC. Two WBAN configurations were used: 1) three accelerometer modules located at the hip, wrist and ankle (M3) and 2) one accelerometer located at the hip (M1). Acceleration signals from the WBANs were synchronized with the observations. Estimates of active time were computed based on the temporal density of the acceleration signals.

Results

A total of 62 physical therapy sessions were observed. Strong associations were found between WBANs estimates of active time and time and motion measures of active time. For the combined sessions, the intraclass correlation coefficient (ICC) was 0.93 (P ≤ 0.001) for M3 and 0.79 (P ≤ 0.001) for M1. The mean percentage of differences between observation measures and estimates from the WBAN of active time was -8.7% ± 2.0% using data from M3 and -16.4% ± 10.4% using data from M1.

Conclusion

WBANs estimates of active time compare favorably with results from observation-based time and motion measures. While the investigation on the association between active time and outcomes of rehabilitation needs to be studied in a larger scale study, the use of an accelerometer-based WBAN to measure active time is a promising approach that offers a better overall precision than methods relying on work sampling. Depending on the accuracy needed, the use of a single accelerometer module positioned on the hip may still be an interesting alternative to using multiple modules.