Speed- and Endurance-Based Classifications of Community Ambulation Post-Stroke Revisited: The Importance of Location in Walking Performance Measurement

BACKGROUND

Gait speed or 6-minute walk test are frequently used to project community ambulation abilities post-stroke by categorizing individuals as household ambulators, limited, or unlimited community ambulators. However, whether improved clinically-assessed gait outcomes truly translate into enhanced real-world community ambulation remains uncertain.

OBJECTIVE

This cross-sectional study aimed to examine differences in home and community ambulation between established categories of speed- and endurance-based classification systems of community ambulation post-stroke and compare these with healthy controls.

METHODS

Sixty stroke survivors and 18 healthy controls participated. Stroke survivors were categorized into low-speed, medium-speed, or high-speed groups based on speed-based classifications and into low-endurance, medium-endurance, or high-endurance groups based on the endurance-based classification. Home and community steps/day were quantified using Global Positioning System and accelerometer devices over 7 days.

RESULTS

The low-speed groups exhibited fewer home and community steps/day than their medium- and high-speed counterparts (P < .05). The low-endurance group took fewer community steps/day than the high-endurance group (P < .05). Despite vast differences in clinical measures of gait speed and endurance, the medium-speed/endurance groups did not differ in their home and community steps/day from the high-speed/endurance groups, respectively. Stroke survivors took 48% fewer home steps/day and 77% fewer community steps/day than healthy controls.

CONCLUSIONS

Clinical classification systems may only distinguish home ambulators from community ambulators, but not between levels of community ambulation, especially beyond certain thresholds of gait speed and endurance. Clinicians should use caution when predicting community ambulation status through clinical measures, due to the limited translation of these classification systems into the real world.

Implementation and impacts of virtual team-based care planning for older persons in formal care settings: A scoping review

Objective

This scoping review aimed to summarize current knowledge about the implementation, impacts, facilitators and barriers of virtual team-based care planning for older persons in formal care settings (e.g. home and community, primary, long-term and acute care).

Methods

The Joanna Briggs Institute (JBI) methodology was used. The Arksey and O'Malley and Levac, Colquhoun, and O'Brien methodologies provided additional frameworks. Databases accessed included PubMed, EMBASE, CINAHL, AgeLine, PsycInfo and Scopus. Reference lists of selected articles and grey literature retrieved through Google and Google Scholar were also reviewed. Three researchers screened titles, abstracts and conducted full-text reviews. Extracted data were mapped in a table and analysed for summative themes. Older persons and family partners assisted in interpreting findings based on their lived experiences.

Results

A total of 27 studies were included. Virtual team-based care planning led to many positive outcomes for older persons (e.g. decreased depression, reduced falls and improved medication management) and their families (e.g. reduced caregiver stress and improved caregiving skills). Only four studies reported the involvement of older persons and/or families in virtual team-based care planning. Multiple barriers to adopting virtual team-based care planning were found including lack of education/training for older persons and families in using technology.

Conclusion

Despite the multiple advantages that virtual team-based care planning offers for older persons and families, it is important to ensure that this care can be offered to all. There is a need to ensure that health equity is addressed to promote access to care and respond to social determinants of health.

The relationship between sleep and physical activity in an in-patient rehabilitation stroke setting: a cross-sectional study

BACKGROUND

Appropriate sleep and physical activity are known to be important for positive neuroplastic changes in the brain and therefore may affect stroke recovery.

OBJECTIVE

To investigate the relationship between sleep and participation in different intensity levels of physical activity; to investigate the convergent validity of a commercially available device (Fitbit Flex) in measuring sleep and physical activity in people with stroke.

METHODS

A cross-sectional observational study in people with stroke undergoing rehabilitation. Participants wore two accelerometers on their unaffected wrist for seven consecutive days and recorded a sleep log, the Pittsburgh Sleep Quality Index and Fatigue Assessment Scale. Any relationships between sleep and activity were assessed with linear regression. Pearson and intra-class correlation coefficients were used to assess the validity of the two accelerometers (Fitbit Flex against the validated GENEActiv).

RESULTS

Twenty-three patients with stroke were recruited. Twenty complete data sets were analyzed. Participants had approximately 9 hours of sleep and 13 hours of sedentary behavior per day, with 99 minutes spent on physical activity (16 min spent on moderate to vigorous activity). Time spent on sleep was significantly related to sedentary, light and moderate physical activity time (r = -.67, .22, .20). The ICC of the Fitbit Flex in measuring light physical activity was .884 p < .001 but was not correlated for other measures.

CONCLUSIONS

More sleep was related to less sedentary behavior and more time spent on physical activity. Fitbit Flex was only valid for measuring light physical activity.

Barriers to Gait Training among Stroke Survivors: An Integrative Review

Gait recovery is vital for stroke survivors' ability to perform their activities associated with daily living. Consequently, a gait impairment is a significant target for stroke survivors' physical rehabilitation. This review aims to identify barriers to gait training among stroke survivors. An integrative review was conducted following Whittemore and Knafl's methodology. The research was carried out on the electronic databases Scopus, PubMed, and B-on, applying a time span of 2006 to 2022. A total of 4189 articles were initially identified. After selecting and analyzing the articles, twelve studies were included in the sample. This review allowed for the identification of several barriers to gait training among stroke survivors, which can be grouped into three categories: individual, environmental, and rehabilitation workforce-related barriers. These findings highlight that participation in gait training is not solely dependent on the stroke survivor. Instead, the uptake of rehabilitation programs may also depend on environmental and rehabilitation workforce-related factors.

Challenges to Engaging Older Adults in a Group-Based Walking Intervention: Lessons From the Residents in Action Trial

This qualitative research explored older adults' perceptions of participating in group-based walking programs set in independent-living retirement village contexts. Semistructured interviews were conducted with a subset of participants from the Residents in Action Trial. Data were analyzed through a combination of deductive and inductive thematic analysis. Findings were interpreted from a social identity perspective. Five themes were identified: (a) varying levels of social cohesion in retirement villages; (b) degree of shared identity between residents; (c) health, mobility, and preferred pace; (d) devotion to spouse; and (e) busy lives. When designing group-based walking interventions in retirement villages, it is important to consider community-level social cohesion and degree of relatedness between village residents. When attempting to build a sense of shared identity and relatedness between group members, researchers and policy makers should consider differing backgrounds, capabilities, schedules, and interests of participants.

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

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

A Systematic Review on the Prevalence of Physical Activity, and Barriers and Facilitators to Physical Activity, in Informal Carers in the United Kingdom

BACKGROUND

It is estimated that 17% of the UK adult population are informal carers, usually for a family member, with a majority reporting that they are not able to engage in physical activity as much as they would like. The aim of this review is to provide a greater understanding of the prevalence of, and barriers and facilitators to, physical activity of informal carers in the United Kingdom.

METHODS

A systematic review of relevant databases and grey literature was undertaken, following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidance, from its inception until July 17, 2020.

RESULTS

Barriers to physical activity include increasing aging, not wanting to leave the caree alone, the caree being unable to take part in activities, health conditions, fatigue, lack of time, and difficulties in changing the routine for the caree. Facilitators include an appreciation of the benefits of engaging in exercise, previous participation in activities, group activities with similar people, and having some free time.

CONCLUSIONS

Due to the paucity of research into the prevalence of, and barriers and facilitators to, physical activity in informal carers in the United Kingdom, this systematic review highlights the need for further research, focusing primarily on the physical activity of informal carers caring for individuals with a range of conditions. A further systematic review exploring these issues internationally is warranted.

Effect of reactive balance training on physical fitness poststroke: study protocol for a randomised non-inferiority trial

INTRODUCTION

Regular exercise is essential in the chronic phase of stroke recovery for improving or maintaining function, and reducing the risk of a second stroke. To achieve these goals, multiple components of fitness should be targeted with poststroke exercise, including aerobic capacity, strength and balance. However, following the recommended frequency and duration of each component separately can take a long time and lead to fatigue in people with stroke. Therefore, finding types of exercise that target multiple components of fitness all together is valuable.Reactive balance training (RBT) is a novel type of exercise where individuals repeatedly lose their balance in order to practise balance reactions. When people do RBT, they increase their heart rate and exert forces with their leg muscles which could improve aerobic fitness and muscle strength, respectively. This means that RBT could have the potential to improve multiple components of fitness, simultaneously.

METHODS AND ANALYSIS

This is a randomised controlled non-inferiority trial with internal pilot study. Participants with chronic stroke will be randomly assigned to one of two groups: (1) RBT or (2) aerobic and strength training (AST). Participants in both groups will complete 1 hour of exercise, three times/week for 12 weeks. The primary objective is to determine the effect of RBT on aerobic capacity and knee muscles' strength. The secondary objective is to determine the effects of RBT and AST on balance control and balance confidence. We expect to find that RBT is superior to AST in terms of improving balance control and balance confidence, yet not inferior to AST in terms of its effects on aerobic capacity and strength.

ETHICS AND DISSEMINATION

Research ethics approval has been received. Results will be disseminated directly to study participants at the end of the trial, and to other stakeholders via publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT04042961.

Self-Efficacy to Engage in Physical Exercise and Walking Ability Best Predicted Exercise Adherence after Stroke

AIM

To describe exercise preferences and to investigate the contribution of exercise preferences, walking ability, and current levels of physical activity in predicting exercise adherence in individuals with chronic stroke.

METHODS

For this exploratory study, exercise adherence was measured using the first question of the first section of the Exercise Preference Questionnaire (stroke)-Brazil (EPQ (stroke)-Brazil). Nine independent variables were included as potential predictors of exercise adherence: the seven factors of the EPQ (stroke)-Brazil, walking speed, and level of physical activity.

RESULTS

Participated 93 individuals with stroke, who had a mean age of 62 (SD 12) years and a mean time since the onset of the stroke of 58 (SD 67) months. The most preferable exercise was walking. Logistic regression analysis revealed that self-efficacy to engage in physical exercise and walking ability predicted and explained 80% of the variance in exercise adherence.

CONCLUSION

The findings showed that feeling able to perform physical exercise and having higher walking ability predicted higher exercise adherences in individuals with chronic stroke. The knowledge of potential contributors to exercise adherence may help in designing exercise programs for individuals with stroke.

Development and Preliminary Validation of a Stroke Physical Activity Questionnaire

Objective

The aim of the current study was to develop and then to determine preliminary validity of a physical activity questionnaire specifically designed for ambulatory, chronic stroke patients.

Methods

This cross-sectional study recruited 92 chronic stroke patients. In Phase I, the SPAQ was developed and its content validity index (CVI) determined. In Phase II, we examined (1) the concurrent validity of SPAQ vs. the International Physical Activity Questionnaire-Short Form (IPAQ-SF); (2) the convergent validity of SPAQ vs. the Functional Ambulation Category (FAC), vs. the six-minute walk test (6-MWT), vs. the timed up and go test (TUGT), vs. the Motricity Index, vs. the National Institutes of Health Stroke Scale (NIHSS), and vs. the Modified Rankin Scale (MRS); and (3) the discriminant validity of the SPAQ vs. the Montreal Cognitive Assessment (MoCA). The concurrent validity and convergent and divergent validity were analysed using Spearman's rank correlation coefficient. The agreement between the SPAQ and IPAQ-SF was assessed using the Kappa statistic.

Results

The SPAQ has 12 items in 3 main components which covers low (7 items), moderate (3 items), and vigorous (2 items) physical activity. The SPAQ had a CVI of 0.93. Spearman's correlation coefficient (r_s) for SPAQ vs. IPAQ-SF was 0.53 (p < 0.001). The SPAQ yielded substantial agreement with the IPAQ-SF (Kappa = 0.65). For convergent validity, the SPAQ had a moderate correlation with the 6-MWT, MI, NIHSS, FAC, TUGT, and MRS (p < 0.05). For discriminant validity, the SPAQ was not correlated with the MoCA (r_s = 0.061, p = 0.68).

Conclusion

The SPAQ can be used to practically assess physical activity in chronic stroke patients, and it has acceptable psychometric properties which are comparable to other standard physical activity questionnaires. Future work should determine the validity of the SPAQ using an objective device such as an accelerometer.

Perceived barriers to exercise reported by individuals with stroke, who are able to walk in the community

PURPOSE

To identify the perceived barriers to exercise, which could be modified, as well as the associated factors in people at the sub-acute post-stroke stages, who were able to walk in the community.

METHODS

For this exploratory study, barriers to exercise were identified by the Exercise Barrier sub-scale of the Exercise Benefits/Barriers Scale. Step-wise multiple linear regression analysis was employed to identify which of the clinical and sociodemographic variables, that is, age, walking speed, levels of physical activity, socioeconomic status, and depressive symptoms, could significantly predict the Exercise Barrier sub-scale scores.

RESULTS

Ninety-five individuals, who had a mean age of 63 (13) years and a mean time since the onset of the stroke of 4 (1) months participated. The main reported barriers to exercise were related to fatigue, as well as availability and distance from the exercise places. Additional reported barriers were "lack of a person to help" and "knowledge on how to practice exercise." Perceived barriers were associated with depressive symptoms and socioeconomic status. Together, they explained 9% of the variance in the Exercise Barrier sub-scale scores (p < 0.01).

CONCLUSIONS

Fatigue, reduced number of places, and long distances to exercise places were the main reported barriers to exercise. Depressive symptoms and socioeconomic status were the only variables that explained the variance in the Exercise Barrier sub-scale scores. Rehabilitation interventions should include strategies to reduce fatigue during and after exercise, provide guidance regarding both structured and unstructured exercise venues, in addition to screening and managing depressive symptoms. Implications for Rehabilitation Stroke survivors, who are able to walk in the community, should be referred and instructed on how to reduce fatigue through the practice of exercise. Health professionals should guide stroke survivors about the existing places for practice of exercise and how to exercise without structured environments. It is necessary to create or reformulate environments for exercise and provide orientation to practice through qualified professionals. Health professionals should also be able to assess the presence of depressive symptoms and address proper referral and management of the potential barriers to exercise.

Correlating the Physical Activity Patterns of People with Moderate to Severe Multiple Sclerosis Disability and Their Family Caregivers

Purpose: People with multiple sclerosis (PwMS) and their family caregivers often react to the impact of the disease as an interdependent dyad. The aim of this exploratory study was to examine interdependence in the physical activity (PA) patterns of dyads affected by moderate to severe MS disability. Method: A total of 15 pairs of PwMS and their family caregivers wore accelerometers for 7 days. By collecting data simultaneously from both partners, we tested interdependence using the dyad as the unit of analysis. Results: PwMS and caregivers averaged 4,091.3 (SD 2,726.3) and 6,160.2 (SD 1,653.0) steps per day, respectively. The mean number of minutes per day of sedentary, light, and moderate to vigorous activity for PwMS was 566.3 (SD 97.7), 167.4 (SD 94.0), and 7.6 (SD 12.4), respectively, and 551.9 (SD 92.4), 199.6 (SD 63.4), and 21.4 (SD 18.2), respectively, for caregivers. Interdependence between dyads for sedentary, light, moderate to vigorous activity, and step count was low and non-significant (rs=0.20, 0.26, 0.13, and -0.27, respectively; p>0.05). Conclusions: Although our findings do not support the interdependence of PA between caregivers and care recipients with MS, they do show that both partners are not engaging in sufficient PA to achieve important health benefits. These findings are important because they indicate that the dyads are likely to benefit from interventions for changing PA behavior.

Validity of the Fitbit One for Measuring Activity in Community-Dwelling Stroke Survivors

Purpose: We determined the correlation between the Fitbit One and Actical accelerometer for quantifying the 3-day step count and activity levels in community-dwelling individuals with stroke. Method: Twelve participants with a mean age of 62.6 (SD 9.3) years wore both the Fitbit One and the Actical on the non-paretic ankle for 3 days. Regression analyses were performed to examine concurrent validity between the devices for step counts and sedentary, light, moderate, and vigorous activity. The relative error of the Fitbit One compared with the Actical in measuring step count was calculated. Results: Participants spent about 80% of their days being sedentary. The associations between the Fitbit One and the Actical were r>0.80 for step count and light-intensity activity across the 3 days of free-living activity. The overall relative error in measuring step count was 3.8%, with differences between those with walking speeds of less than 0.58 metres per second and 0.58 metres per second or more (27.4% [SD 34.2] vs. -8.0% [SD 10.7], p<0.001). Conclusions: The Fitbit One was associated with the Actical accelerometer in measuring step count and light-intensity activity during free-living activity after stroke, but had lower error in capturing step count for those with faster walking speeds. The Fitbit One may not be valid for capturing higher intensity activity after stroke.

Consumer Wearable Devices for Activity Monitoring Among Individuals After a Stroke: A Prospective Comparison

Background

Activity monitoring is necessary to investigate sedentary behavior after a stroke. Consumer wearable devices are an attractive alternative to research-grade technology, but measurement properties have not been established.

Objective

The purpose of this study was to determine the accuracy of 2 wrist-worn fitness trackers: Fitbit Charge HR (FBT) and Garmin Vivosmart (GAR).

Methods

Adults attending in- or outpatient therapy for stroke (n=37) wore FBT and GAR each on 2 separate days, in addition to an X6 accelerometer and Actigraph chest strap monitor. Step counts and heart rate data were extracted, and the agreement between devices was determined using Pearson or Spearman correlation and paired t or Wilcoxon signed rank tests (one- and two-sided). Subgroup analyses were conducted.

Results

Step counts from FBT and GAR positively correlated with the X6 accelerometer (ρ=.78 and ρ=.65, P<.001, respectively) but were significantly lower (P<.01). For individuals using a rollator, there was no significant correlation between step counts from the X6 accelerometer and either FBT (ρ=.42, P=.12) or GAR (ρ=.30, P=.27). Heart rate from Actigraph, FBT, and GAR demonstrated responsiveness to changes in activity. Both FBT and GAR positively correlated with Actigraph for average heart rate (r=.53 and .75, P<.01, respectively) and time in target zone (ρ=.49 and .74, P<.01, respectively); these measures were not significantly different, but nonequivalence was found.

Conclusions

FBT and GAR had moderate to strong correlation with best available reference measures of walking activity in individuals with subacute stroke. Accuracy appears to be lower among rollator users and varies according to heart rhythm. Consumer wearables may be a viable option for large-scale studies of physical activity.

Promoting Optimal Physical Exercise for Life (PROPEL): aerobic exercise and self-management early after stroke to increase daily physical activity-study protocol for a stepped-wedge randomised trial

INTRODUCTION

Physical exercise after stroke is essential for improving recovery and general health, and reducing future stroke risk. However, people with stroke are not sufficiently active on return to the community after rehabilitation. We developed the Promoting Optimal Physical Exercise for Life (PROPEL) programme, which combines exercise with self-management strategies within rehabilitation to promote ongoing physical activity in the community after rehabilitation. This study aims to evaluate the effect of PROPEL on long-term participation in exercise after discharge from stroke rehabilitation. We hypothesise that individuals who complete PROPEL will be more likely to meet recommended frequency, duration and intensity of exercise compared with individuals who do not complete the programme up to 6 months post discharge from stroke rehabilitation.

METHODS AND ANALYSIS

Individuals undergoing outpatient stroke rehabilitation at one of six hospitals will be recruited (target n=192 total). A stepped-wedge design will be employed; that is, the PROPEL intervention (group exercise plus self-management) will be 'rolled out' to each site at a random time within the study period. Prior to roll-out of the PROPEL intervention, sites will complete the control intervention (group aerobic exercise only). Participation in physical activity for 6 months post discharge will be measured via activity and heart rate monitors, and standardised physical activity questionnaire. Adherence to exercise guidelines will be evaluated by (1) number of 'active minutes' per week (from the activity monitor), (2) amount of time per week when heart rate is within a target range (ie, 55%-80% of age-predicted maximum) and (3) amount of time per week completing 'moderate' or 'strenuous' physical activities (from the questionnaire). We will compare the proportion of active and inactive individuals at 6 months post intervention using mixed-model logistic regression, with fixed effects of time and phase and random effect of cluster (site).

ETHICS AND DISSEMINATION

To date, research ethics approval has been received from five of the six sites, with conditional approval granted by the sixth site. Results will be disseminated directly to study participants at the end of the trial, and to other stake holders via publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT02951338; Pre-results.

Considerations for the Selection of Time-Limited Walk Tests Poststroke: A Systematic Review of Test Protocols and Measurement Properties

BACKGROUND AND PURPOSE

Systematic reviews of research evidence describing the quality and methods for administering standardized outcome measures are essential to developing recommendations for their clinical application. The purpose of this systematic review was to synthesize the research literature describing test protocols and measurement properties of time-limited walk tests in people poststroke.

METHODS

Following an electronic search of 7 bibliographic data-bases, 2 authors independently screened titles and abstracts. One author identified eligible articles, and performed quality appraisal and data extraction.

RESULTS

Of 12 180 records identified, 43 articles were included. Among 5 walk tests described, the 6-minute walk test (6MWT) was most frequently evaluated (n = 36). Only 5 articles included participants in the acute phase (<1 month) poststroke. Within tests, protocols varied. Walkway length and walking aid, but not turning direction, influenced 6MWT performance. Intraclass correlation coefficients for reliability were 0.68 to 0.71 (12MWT) and 0.80 to 1.00 (2-, 3-, 5- and 6MWT). Minimal detectable change values at the 90% confidence level were 11.4 m (2MWT), 24.4 m (5MWT), and 27.7 to 52.1 m (6MWT; n = 6). Moderate-to-strong correlations (≥0.5) between 6MWT distance and balance, motor function, walking speed, mobility, and stair capacity were consistently observed (n = 33). Moderate-to-strong correlations between 5MWT performance and walking speed/independence (n = 1), and between 12MWT performance and balance, motor function, and walking speed (n = 1) were reported.

DISCUSSION AND CONCLUSIONS

Strong evidence of the reliability and construct validity of using the 6MWT poststroke exists; studies in the acute phase are lacking. Because protocol variations influence performance, a standardized 6MWT protocol poststroke for use across the care continuum is needed.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A150).

An exploration of factors influencing physical activity levels amongst a cohort of people living in the community after stroke in the south of England

PURPOSE

To explore factors influencing physical activity (PA) reported by people living in rural/semi-rural communities in the south of England post-stroke, and to understand relationships between personal, interpersonal and environmental barriers and self-reported levels of PA.

METHOD

A survey was mailed to patients of NHS Trusts who were identified as potential participants. Self-reported PA levels, type, and frequency of reported barriers were tabulated. Spearman's rank correlation coefficient was used to explore associations between self-reported PA level and: age, gender, level of physical function, fear of falling, beliefs regarding PA, available supports, and socioeconomic status.

RESULTS

Seventy-six of 322 questionnaires distributed were returned (24%). Only 55.2% of respondents reported undertaking PA of sufficient intensity to meet current guidelines. Personal barriers included fear of falling, stroke-related disability, pain, and fatigue. Interpersonal and environmental barriers included lack of social support, transport, and inclement weather. Significant relationships existed between self-reported PA and fear of falling, functional mobility, and beliefs relating to PA.

CONCLUSIONS

Almost half of the survey cohort reported PA levels insufficient to meet current guidelines. Similar to barriers reported in previous studies in USA and other parts of the UK, numerous interlinking and overlapping personal, interpersonal, and environmental barriers to undertaking PA were identified. Implications for Rehabilitation This study found that although more than 60% of the survey population were able to ambulate >200 m, only 55.2% reported undertaking sufficient PA to meet current guidelines, putting them at increased risk of further stroke and other co-morbidities. Participants reported a number of interlinking and overlapping personal, interpersonal, and environmental barriers to undertaking PA, which may explain this discrepancy between mobility status and self reported activity levels. Rehabilitation professionals and primary care providers are well positioned to address the barriers identified in this survey, such as providing interventions to reduce fear of falling, pain, and fatigue, providing support and education about safely increasing physical activity and addressing unhelpful beliefs about PA. Behaviour change strategies, such as increasing self-efficacy, and partnering with the person with stroke to problem solve strategies to address the barriers identified by this, and related research, are likely to be more successful in increasing PA than providing information alone.

What's keeping people after stroke from walking outdoors to become physically active? A qualitative study, using an integrated biomedical and behavioral theory of functioning and disability

BACKGROUND

In general people after stroke do not meet the recommendations for physical activity to conduct a healthy lifestyle. Programs to stimulate walking activity to increase physical activity are based on the available insights into barriers and facilitators to physical activity after stroke. However, these programs are not entirely successful. The purpose of this study was to comprehensively explore perceived barriers and facilitators to outdoor walking using a model of integrated biomedical and behavioral theory, the Physical Activity for people with a Disability model (PAD).

METHODS

Included were community dwelling respondents after stroke, classified ≥ 3 at the Functional Ambulation Categories (FAC), purposively sampled regarding the use of healthcare. The data was collected triangulating in a multi-methods approach, i.e. semi-structured, structured and focus-group interviews. A primarily deductive thematic content analysis using the PAD-model in a framework-analysis' approach was conducted after verbatim transcription.

RESULTS

36 respondents (FAC 3-5) participated in 16 semi-structured interviews, eight structured interviews and two focus-group interviews. The data from the interviews covered all domains of the PAD model. Intention, ability and opportunity determined outdoor walking activity. Personal factors determined the intention to walk outdoors, e.g. negative social influence, resulting from restrictive caregivers in the social environment, low self-efficacy influenced by physical environment, and also negative attitude towards physical activity. Walking ability was influenced by loss of balance and reduced walking distance and by impairments of motor control, cognition and aerobic capacity as well as fatigue. Opportunities arising from household responsibilities and lively social constructs facilitated outdoor walking.

CONCLUSION

To stimulate outdoor walking activity, it seems important to influence the intention by addressing social influence, self-efficacy and attitude towards physical activity in the development of efficient interventions. At the same time, improvement of walking ability and creation of opportunity should be considered.

Physiotherapists' perspectives on aerobic exercise early after stroke: A preliminary study

Aerobic exercise is recognized as part of comprehensive stroke rehabilitation in best-practice and clinical guidelines, yet many individuals remain physically inactive during their hospitalization. The purpose of this study was to identify the perspectives of physiotherapists on aerobic exercise prescription and implementation at in-patient stroke rehabilitation centers with and without a structured aerobic exercise program. A survey was conducted at three Canadian rehabilitation centers to evaluate physiotherapist perceptions of individuals recovering from stroke, the practice environment, and their training on aerobic exercise in stroke. Physiotherapists at centers without a structured aerobic exercise program (n = 10) reported the lack of necessary resources and therapeutic support staff and the individuals' physical impairment as the greatest barriers. In contrast, physiotherapists at the center with a structured aerobic exercise program (n = 6) reported therapy selection (insufficient time in a single physiotherapy session) and concern for the individuals' cardiovascular risk and cognitive impairment as the greatest barriers. Both groups of physiotherapists indicated that fatigue was a barrier. Only physiotherapists at the center with a structured aerobic exercise program had received continuing education on aerobic exercise in stroke. The lack of resources at rehabilitation centers without a structured aerobic exercise program needs to be addressed. There remains a need for continuing education on aerobic training in stroke, specifically on assessment and prescription using a standardized approach.

Promoting Optimal Physical Exercise for Life: An Exercise and Self-Management Program to Encourage Participation in Physical Activity after Discharge from Stroke Rehabilitation-A Feasibility Study

People with stroke do not achieve adequate levels of physical exercise following discharge from rehabilitation. We developed a group exercise and self-management program (PROPEL), delivered during stroke rehabilitation, to promote uptake of physical activity after discharge. This study aimed to establish the feasibility of a larger study to evaluate the effect of this program on participation in self-directed physical activity. Participants with subacute stroke were recruited at discharge from one of three rehabilitation hospitals; one hospital offered the PROPEL program whereas the other two did not (comparison group; COMP). A high proportion (11/16) of eligible PROPEL program participants consented to the study. Fifteen COMP participants were also recruited. Compliance with wearing an accelerometer for 6 weeks continuously and completing physical activity questionnaires was high (>80%), whereas only 34% of daily heart rate data were available. Individuals who completed the PROPEL program seemed to have higher outcome expectations for exercise, fewer barriers to physical activity, and higher participation in physical activity than COMP participants (Hedge's g ≥ 0.5). The PROPEL program delivered during stroke rehabilitation shows promise for reducing barriers to exercise and increasing participation in physical activity after discharge. This study supports feasibility of a larger randomized trial to evaluate this program.

Body, Person and Environment: Why Promoting Physical Activity (PA) with Stroke Survivors Requires Holistic Thinking

The role of physical activity (PA) after stroke is increasingly recognised as important for function, fitness and wellbeing. Current evidence shows that targeted PA after stroke improves cardiovascular fitness, walking ability and muscle strength and may ameliorate depression and improve quality of life. Secondary stroke prevention and management of cardiovascular risk factors are further health benefits. Despite increasing emphasis on organised exercise classes for stroke, PA levels remain low and effects of organised exercise interventions are not maintained once programmes have finished. Barriers to PA after stroke are complex and innovative approaches to maintaining and promoting long-term engagement in activity are required. This commentary proposes that using the International Classification of Disability and Functioning (ICF) to guide thinking about PA after stroke may help us develop and apply comprehensive solutions that increase PA levels. This approach considers stroke survivors’ PA engagement in terms of Body – the physical impairments imposed by stroke; Person – the role of identity, and psychological factors on PA; and Environment – the physical and social environments that influence PA engagement. The commentary discusses how innovative solutions addressing these issues may enable stroke survivors to be better supported to lead active lifestyles.

Regular exercise and related factors in patients with Parkinson's disease: Applying zero-inflated negative binomial modeling of exercise count data

PURPOSE

This study was conducted to identify risk factors that influence regular exercise among patients with Parkinson's disease in Korea. Parkinson's disease is prevalent in the elderly, and may lead to a sedentary lifestyle. Exercise can enhance physical and psychological health. However, patients with Parkinson's disease are less likely to exercise than are other populations due to physical disability.

METHODS

A secondary data analysis and cross-sectional descriptive study were conducted. A convenience sample of 106 patients with Parkinson's disease was recruited at an outpatient neurology clinic of a tertiary hospital in Korea. Demographic characteristics, disease-related characteristics (including disease duration and motor symptoms), self-efficacy for exercise, balance, and exercise level were investigated. Negative binomial regression and zero-inflated negative binomial regression for exercise count data were utilized to determine factors involved in exercise.

RESULTS

The mean age of participants was 65.85 ± 8.77 years, and the mean duration of Parkinson's disease was 7.23 ± 6.02 years. Most participants indicated that they engaged in regular exercise (80.19%). Approximately half of participants exercised at least 5 days per week for 30 min, as recommended (51.9%). Motor symptoms were a significant predictor of exercise in the count model, and self-efficacy for exercise was a significant predictor of exercise in the zero model.

CONCLUSION

Severity of motor symptoms was related to frequency of exercise. Self-efficacy contributed to the probability of exercise. Symptom management and improvement of self-efficacy for exercise are important to encourage regular exercise in patients with Parkinson's disease.

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.

Protocol variations and six-minute walk test performance in stroke survivors: a systematic review with meta-analysis

Objective. To investigate the use of the six-minute walk test (6MWT) for stroke survivors, including adherence to 6MWT protocol guidelines and distances achieved. Methods. A systematic search was conducted from inception to March 2014. Included studies reported a baseline (intervention studies) or first instance (observational studies) measure for the 6MWT performed by stroke survivors regardless of time after stroke.  Results. Of 127 studies (participants n = 6,012) that met the inclusion criteria, 64 were also suitable for meta-analysis. Only 25 studies made reference to the American Thoracic Society (ATS) standards for the 6MWT, and 28 reported using the protocol standard 30 m walkway. Thirty-nine studies modified the protocol walkway, while 60 studies did not specify the walkway used. On average, stroke survivors walked 284 ± 107 m during the 6MWT, which is substantially less than healthy age-matched individuals. The meta-analysis identified that changes to the ATS protocol walkway are associated with reductions in walking distances achieved. Conclusion. The 6MWT is now widely used in stroke studies. The distances achieved by stroke patients indicate substantially compromised walking ability. Variations to the standard 30 m walkway for the 6MWT are common and caution should be used when comparing the values achieved from studies using different walkway lengths.

Maintenance of physical function in frail older adults

Inactivity leads to frailty and loss of function for older adults. Most older adults are sedentary. Participating in a regular routine of physical activity is recommended for maintaining physical function required to sustain quality of life and independence for older adults. Annual screening for level of physical activity is required to determine changes from year to year. Research shows older adults are more likely to initiate a regular routine of physical activity when a health care provider writes a prescription for physical activity including the type, frequency, and specific duration of physical activity sessions.

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.

A Long-Term Follow-Up Programme for Maintenance of Motor Function after Stroke: Protocol of the life after Stroke-The LAST Study

Background. There are no evidence-based strategies that have been shown to be superior in maintaining motor function for months to years after the stroke. The LAST study therefore intends to assess the effect of a long-term follow-up program for stroke patients compared to standard care on function, disability and health. Design. This is a prospective, multi-site randomised controlled trial, with blinded assessment 18 months after inclusion. A total of 390 patients will be recruited and randomised to a control group, receiving usual care, or to an intervention group 10 to 16 weeks after onset of stroke. Patients will be stratified according to stroke severity, age above 80, and recruitment site. The intervention group will receive monthly coaching on physical activity by a physiotherapist for 18 consecutive months after inclusion. Outcomes. The primary outcome is motor function (Motor Assessment Scale) 18 months after inclusion. Secondary outcomes are: dependency, balance, endurance, health-related quality of life, fatigue, anxiety and depression, cognitive function, burden on caregivers, and health costs. Adverse events and compliance to the intervention will be registered consecutively during follow-up.