Physical activity monitoring in stroke: SenseWear Pro2 Activity accelerometer versus Yamax Digi-Walker SW-200 Pedometer

Validity and reliability of physical activity measures in multiple sclerosis

PURPOSE

The purpose was to evaluate the psychometric properties of physical activity measures in persons with multiple sclerosis (PwMS).

METHODS

Adults with multiple sclerosis were recruited, n = 30 (validation) and n = 57 (test-retest). Steps measured with PiezoRX, Yamax SW200 and ActiGraph GT9X Link (AGlink) and time in different positions measured with AGlink were validated against data from video analysis. Psychometric properties of the Physical Activity and Disability Survey - Revised Swedish version (PADS-R(Sw)) was evaluated.

RESULTS

The most valid measures were AGlink using the low-frequency extension filter, and PiezoRX with median absolute percentage errors (MeAPEs) of 0.9-3.1% and 1.3-3.3%. The MeAPEs were higher for Yamax SW200 (2.9-21.0%), AGlink display (3.6-44.8%) and AGlink normal filter (8.9-48.9%), indicating low validity. AGlink was not valid in measurements of sitting (MeAPE 12.0-12.5%) or lying (MeAPE 31.0-41.7%). The correlation between PADS-R(Sw) and AGlink steps was r = 0.492 (p = .009). The relative reliability of PADS-R(Sw) was ICC_2,1 0.85 (CI 0.76-0.91), and absolute reliability was SEM 0.54.

CONCLUSION

AGlink and PiezoRX were valid measures of steps in PwMS. The questionnaire PADS-R(Sw) was valid, with high relative reliability, but its absolute reliability was unsatisfactory.

How effective is a blended web-based rehabilitation for improving pain, physical activity, and knee function of patients with knee osteoarthritis? Study protocol for a randomized control trial

Due to the chronic nature of knee osteoarthritis (KOA) self-management is considered an essential part of therapy to improve physical function, activity, pain and quality of life (QoL). Web-based rehabilitation may be a potential innovative mode of patient’ training to guide management compared to usual care, especially with the current restrictions pandemic imposed. Moreover, in order to alter KOA patients’ behavior towards physical activity (PA), it may be more attractive and motivating to combine within their rehabilitation program, outdoor real life local activity that could feasible to be sustained in the future. Aim of the current study is to evaluate the effects of a blended web-based rehabilitation compared with structured PA alone in patients with KOA. This is a randomized multi-center study with two prospective arms. Fifty-six eligible participants with KOA will be recruited from the West Attica region (considered as structurally weak areas). After a comprehensive face-to face training session, participants will follow a 6-week web-based rehabilitation program, consisting of exercise, advice material enhanced outdoor structured PA. The control group will be encouraged to follow the outdoor structured PA alone. Baseline, 6-week and 12-week follow up assessments will be performed. The primary outcome is self-reported physical function as measured by the Knee Injury Osteoarthritis Outcome Score (KOOS). Secondary measures include pain, function (Timed Up and Go Test, Sit to Stand test), PA levels (Lower Extremity Activity Scale, Baecke Scale and pedometer), psychological perspective (Tampa Scale of Kinesiophobia) and health-related QoL (Short-Form 12). Baseline-adjusted Analysis of Variance will be used to test for group differences in the primary and secondary outcomes. The study will evaluate the blended web-based exercise and advice material, enhanced with outdoor PA in many respects compared to the outdoor PA alone so as to promote self-management care programs for KOA patients.

Trial registration: Prospectively registered ISRCTN12950684 (27-09-2020).

Types of physical activity performed pre and post stroke

BACKGROUND

The relationship between pre- and post-stroke physical activity levels is underexplored.

OBJECTIVE

To determine whether self-reported physical activity changes from pre-stroke to two years post-stroke; and to explore the relationship between self-reported and objectively measured physical activity post-stroke.

METHODS

Stroke survivors admitted to rehabilitation were included in this observational study. Participants were assessed at rehabilitation discharge (five months post-stroke) and two years later. Participants were asked about their pre-stroke and current activity levels. The Sensewear Armband was worn for one week to measure physical activity at each timepoint. The relationship between self-reported and objectively measured physical activity was explored with Spearman correlation coefficients and multiple regression models.

RESULTS

Sixty-eight stroke survivors (65% male, mean age 64) participated at baseline. Fifty participants reported undertaking physical activity pre-stroke, and 48 of these active participants reported undertaking physical activity two years post-stroke. At two years one third of the active participants reported doing the same type of activity (primarily walking). Approximately one third reported doing the same type of activity and more and approximately one third had to modify the type of activity undertaken. Self-reporting of physical activity time was positively correlated with objective measures of physical activity at two years (r = 0.61, p<0.001). Objectively measured physical activity, age, and sex predicted 26.5% of the variance in self-reported physical activity (p<0.001).

CONCLUSION

In this single-site study of relatively able participants, stroke survivors frequently returned to their pre-stroke types of physical activity. A positive correlation between self-reported and objective measures of physical activity was demonstrated, but self-reported activity overestimates objective physical activity post-stroke.

Feasibility of a home-based physiotherapy intervention to promote post-stroke mobility: A randomized controlled pilot study

Objectives

Home-based physiotherapy interventions to improve post-stroke mobility are successful in high-income countries. These programs require less resources compared to center-based programs. However, feasibility of such an intervention in a low and middle-income setting remains unknown. Therefore, the SunRISe (Stroke Rehabilitation In Suriname) study aimed to assess feasibility and preliminary effectiveness of a home-based semi-supervised physiotherapy intervention to promote post-stroke mobility in a low resource setting.

Design

Prospective randomized controlled trial.

Methods

Chronic stroke patients were recruited and randomized into either an intervention group (IG (N = 20)) or a control group (CG (N = 10)). The IG received a 3-days-a-week home-based physiotherapy program that was supervised in the first 4 weeks and tele-supervised during the second 4 weeks. The physiotherapy program consisted of walking as well as functional and mobilization exercises. The CG received usual care. Feasibility outcome measures included adherence, patient satisfaction and safety. Efficacy measures included functional exercise tolerance (six-minute walking test (6MWT), functional balance (Berg Balance Score (BBS), upper extremity (UE) function (Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire), and UE strength ((non-)paretic handgrip (HG) strength). Two-way analysis of variance was used for data analysis.

Results

Thirty participants (61.8 ± 9.2 years old, 13 men) were enrolled in the study. The intervention was completed by 14 participants (70%). Adherence was affected by rainy season associated infrastructural problems (n = 2), the medical status of participants (n = 3) and insufficient motivation to continue the program without direct supervision (n = 1). No adverse events were noted and participants were satisfied with the program. Functional exercise tolerance (57.2 ± 67.3m, p = 0.02) and UE function (-9.8 ± 15.2, p = 0.04) improved in the IG compared to no change in the CG. HG strength was unaltered and a ceiling effect occurred for BBS.

Conclusion

Our home-based semi-supervised physiotherapy intervention seems safe, associated with moderate to high levels of engagement and patient satisfaction and results in functional improvements.

How Many Hours of Device Wear Time Are Required to Accurately Measure Physical Activity Post Stroke?

Background. Inadequate physical activity participation is a risk factor for secondary stroke. Before implementing appropriate management strategies, we need to accurately measure the physical activity of stroke survivors. We aimed to determine the duration of physical activity monitoring post-stroke that constitutes a valid day. Methods. We sampled stroke survivors’ physical activity for one week following discharge from inpatient rehabilitation using the Sensewear Armband (Bodymedia, Pittsburgh, PA, USA). To determine the impact of total daily wear time on activity estimate (sedentary, light, and moderate to vigorous physical activity) accuracy, we performed simulations, removing one, two, three, or four hours from a 14-h reference day, and analysed them with linear mixed models. Results. Sixty-nine participants (46 male, 65 ± 15 years) with 271 days of physical activity data were included. All physical activity variables were significantly underestimated for all data sets (10, 11, 12, or 13 h) compared to the 14-h reference data set. The number of days classified as not meeting physical activity recommendations increased as daily monitoring duration decreased: 13% misclassification with 10-h compared to 14-h dataset (p = 0.011). Conclusions. The accuracy of physical activity estimates increases with longer daily monitoring periods following stroke, and researchers should aim to monitor post-stroke physical activity for 14 daytime hours.

Cognitive Function is a Predictor of the Daily Step Count in Patients With Subacute Stroke With Independent Walking Ability: A Prospective Cohort Study

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Cognition at admission may predict daily step count.

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Cognitive impairment may increase risk of poor ambulation after subacute stroke.

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Ambulation poststroke is influenced by both physical and cognitive factors.

Objectives

To investigate the physical, cognitive, and psychological factors related to daily step count in patients with subacute stroke.

Design

Prospective cohort study.

Setting

A subacute rehabilitation ward with 160 beds.

Participants

Patients with subacute stroke who could walk independently (N=101). Among the 101 participants enrolled in this study (mean age, 64.5±13.5y), 64.4% (n=65) were men and 69.3% (n=70) were patients with cerebral infarction.

Interventions

We assessed ambulatory activity using a pedometer placed in the pants pocket on the nonparalyzed side continuously for 7 consecutive days. We also obtained demographic and clinical information and recorded the following measurement scores: Stroke Impairment Assessment Set, FIM, Mini-Mental State Examination (MMSE), Self-Rating Depression Scale, and Apathy Scale. All measurements were collected at admission and discharge.

Main Outcome Measures

The outcomes assessed were ambulatory activity, motor and sensory functions, functional disability, cognitive function, depressive symptoms, and motivation.

Results

The median daily steps ambulated at admission and discharge were 5584 steps (interquartile range, 3763-7096 steps) and 5991 steps (interquartile range, 4329-8204 steps), respectively. In the univariate regression analysis, age, sex, serum albumin level, affected side of the brain, and MMSE score at admission were significantly associated with the daily step count at discharge. Multiple regression analysis using these 5 items as independent variables revealed that the MMSE score at admission (reference, 28-30 points; B, −2.07; 95% confidence interval, −3.89 to −0.35; β, −0.22; P=.027) was significantly associated with the daily step count at discharge.

Conclusions

Cognitive function at admission had a significant association with the daily step count at discharge in patients with subacute stroke who could walk independently.

mHealth technologies used to capture walking and arm use behavior in adult stroke survivors: a scoping review beyond measurement properties

PURPOSE

We aimed to provide a critical review of measurement properties of mHealth technologies used for stroke survivors to measure the amount and intensity of functional skills, and to identify facilitators and barriers toward adoption in research and clinical practice.

MATERIALS AND METHODS

Using Arksey and O'Malley's framework, two independent reviewers determined eligibility and performed data extraction. We conducted an online consultation survey exercise with 37 experts.

RESULTS

Sixty-four out of 1380 studies were included. A majority reported on lower limb behavior (n = 32), primarily step count (n = 21). Seventeen studies reported on arm-hand behaviors. Twenty-two studies reported metrics of intensity, 10 reported on energy expenditure. Reliability and validity were the most frequently reported properties, both for commercial and non-commercial devices. Facilitators and barriers included: resource costs, technical aspects, perceived usability, and ecological legitimacy. Two additional categories emerged from the survey: safety and knowledge, attitude, and clinical skill.

CONCLUSIONS

This provides an initial foundation for a field experiencing rapid growth, new opportunities and the promise that mHealth technologies affords for envisioning a better future for stroke survivors. We synthesized findings into a set of recommendations for clinicians and clinician-scientists about how best to choose mHealth technologies for one's individual objective.Implications for RehabilitationRehabilitation professionals are encouraged to consider the measurement properties of those technologies that are used to monitor functional locomotor and object-interaction skills in the stroke survivors they serve.Multi-modal knowledge translation strategies (research synthesis, educational courses or videos, mentorship from experts, etc.) are available to rehabilitation professionals to improve knowledge, attitude, and skills pertaining to mHealth technologies.Consider the selection of commercially available devices that are proven to be valid, reliable, accurate, and responsive to the targeted clinical population.Consider usability and privacy, confidentiality and safety when choosing a specific device or smartphone application.

A 2-Year Longitudinal Study of Physical Activity and Cardiovascular Risk in Survivors of Stroke

OBJECTIVE

The purpose of this study was to explore associations between physical activity, cardiovascular risk factors, mobility, mood, fatigue, and cognition over 2 years following stroke rehabilitation discharge.

METHODS

In this longitudinal observational study, survivors of first-ever stroke were evaluated at rehabilitation discharge and 6, 12, and 24 months later. Moderate to vigorous physical activity (MVPA) duration (minutes/day) assessed with an electronic monitor was the primary outcome. Further outcomes included step count, the number and duration of MVPA and sedentary bouts, cardiovascular risk factors (eg, blood pressure, fasting lipid profile, body mass index [BMI]), gait speed and endurance, mood, fatigue, and cognition. Associations between physical activity and cardiovascular risk factors over time were assessed with random-effects regression modeling. Associations between baseline characteristics and physical activity at 2 years were explored using regression modeling.

RESULTS

Seventy-nine participants (68.4% men) with a mean age of 65 years (SD = 14) and a median gait speed of 1.2 m/s (interquartile range = 0.8 to 1.4) were included at baseline. Associations were found between higher physical activity (MVPA duration, number and duration of MVPA bouts) and lower BMI. Better gait speed, endurance, and cognition at baseline were associated with higher MVPA and step count at 2 years.

CONCLUSIONS

Duration and bouts of MVPA are associated with BMI. Increasing MVPA and bouts of MVPA may be a valuable treatment goal to reduce cardiovascular risk in survivors of stroke.

IMPACT

This 2-year study found that MVPA is associated with important cardiovascular risk factors in people who have survived stroke. Understanding these associations could be useful for developing effective treatments to prevent recurrent stroke.

LAY SUMMARY

Performing MVPA and accumulating in bouts of at least 10 minutes might be challenging, but it could be an important component of treatments to reduce cardiovascular risk after stroke.

Adherence to physical activity and cardiovascular recommendations during the 2years after stroke rehabilitation discharge

BACKGROUND

Objective measurement is essential to represent habitual physical activity. To date only one study has objectively measured physical activity for>12months after stroke.

OBJECTIVES

This study aimed to measure physical activity, cardiovascular risk factors, mobility, mood, fatigue and cognition during the 2years after rehabilitation discharge and to investigate whether stroke survivors meet physical activity and cardiovascular risk recommendations.

METHODS

This was a longitudinal observational study. Survivors of a first-ever stroke admitted to a large metropolitan rehabilitation hospital were recruited. Outcomes were measured at rehabilitation discharge and 6, 12 and 24months later. Outcomes were physical activity measured by the SenseWear Armband (e.g., moderate-vigorous physical activity, steps/day) and cardiovascular risk factors (e.g., blood pressure, fasting lipid profile and plasma glucose, waist circumference, body mass index), mobility, mood, fatigue and cognition. Changes over time were evaluated with random-effects regression modelling.

RESULTS

Participants (n=79, 33% female) had mean (SD) age of 65 (14) years and median gait speed 1.2m/s (interquartile range: 0.8-1.4) at baseline. We found no change in physical activity levels over time. Step count and time spent in bouts of moderate-vigorous physical activity remained low. Many participants achieved the recommended 30min of daily moderate-vigorous physical activity at baseline, but this was decreased at 2years (72% [57/79] versus 65% [37/57]). Adherence to cardiovascular recommendations decreased over time, notably for body mass index, plasma glucose and triglyceride levels. Waist circumference and body mass index increased at each time point relative to baseline (by a mean of 3.2cm and 1.2kg.m², respectively, at 2years, P<0.01).

CONCLUSIONS

This is the largest longitudinal study of objectively measured physical activity after stroke. Adherence to cardiovascular risk recommendations decreased over time post-stroke, and physical activity levels remained low. Stroke survivors may benefit from annual multidisciplinary reviews to identify increasing risk and initiate appropriate interventions.

Pedometers, the frustrating motivators: a qualitative investigation of users' experiences of the Yamax SW-200 among people with multiple sclerosis

Purpose: Self-monitoring may represent a mechanism to enhance physical activity among people with multiple sclerosis. To optimise activity monitoring as a behavioural tool to increase physical activity, user experience must be understood. This study evaluated user experience of the Yamax SW-200 Digi-walker pedometer in a group of people with MS.Methods: Semi-structured interviews were conducted with 15 adults who participated in a 12-week pedometer-supported behavioural change intervention, the iStep-MS trial. Interviews were audio-recorded and transcribed verbatim. Data were analysed using the Framework Method.Results: An overarching theme Pedometers, the frustrating motivators captures the complex and often contradictory experience of the pedometer. Sub-themes include: Increasing activity awareness, which describes the pedometer's utility in raising activity consciousness; Numeric motivation provides insight into dual motivating and demotivating experiences of using an objective feedback device; (Un) usability focuses on practical concerns encountered in the day-to-day use of the monitor.Conclusion: The Yamax SW-200 Digi-walker raised awareness and enhanced participant motivation to engage in physical activity. Accuracy and usability concerns highlighted warrant consideration in the selection of this pedometer within a population with multiple sclerosis. Trial registration: Changing physical activity behaviour in people with MS: the iStep-MS trial; ISRCTN15343862; https://doi.org/10.1186/ISRCTN15343862Implications for rehabilitationUse of self-monitoring tools such as pedometers can enhance physical activity awareness.Objective, numeric step count feedback is an effective motivational tool for physical activity.Accuracy and usability concerns may limit the value of the Yamax SW-200 Digiwalker for people with MS.Identification of individualised, reliable, usable and acceptable tools is important to ensure engagement with self-monitoring.

Using an Accelerometer-Based Step Counter in Post-Stroke Patients: Validation of a Low-Cost Tool

Monitoring the real-life mobility of stroke patients could be extremely useful for clinicians. Step counters are a widely accessible, portable, and cheap technology that can be used to monitor patients in different environments. The aim of this study was to validate a low-cost commercial tri-axial accelerometer-based step counter for stroke patients and to determine the best positioning of the step counter (wrists, ankles, and waist). Ten healthy subjects and 43 post-stroke patients were enrolled and performed four validated clinical tests (10 m, 50 m, and 6 min walking tests and timed up and go tests) while wearing five step counters in different positions while a trained operator counted the number of steps executed in each test manually. Data from step counters and those collected manually were compared using the intraclass coefficient correlation and mean average percentage error. The Bland–Altman plot was also used to describe agreement between the two quantitative measurements (step counter vs. manual counting). During walking tests in healthy subjects, the best reliability was found for lower limbs and waist placement (intraclass coefficient correlations (ICCs) from 0.46 to 0.99), and weak reliability was observed for upper limb placement in every test (ICCs from 0.06 to 0.38). On the contrary, in post-stroke patients, moderate reliability was found only for the lower limbs in the 6 min walking test (healthy ankle ICC: 0.69; pathological ankle ICC: 0.70). Furthermore, the Bland–Altman plot highlighted large average discrepancies between methods for the pathological group. However, while the step counter was not able to reliably determine steps for slow patients, when applied to the healthy ankle of patients who walked faster than 0.8 m/s, it counted steps with excellent precision, similar to that seen in the healthy subjects (ICCs from 0.36 to 0.99). These findings show that a low-cost accelerometer-based step counter could be useful for measuring mobility in select high-performance patients and could be used in clinical and real-world settings.

Low gait speed is associated with low physical activity and high sedentary time following stroke

PURPOSE

This study describes physical activity levels and factors associated with physical activity at the end of stroke rehabilitation.

METHODS

Primary stroke survivors were assessed at completion of physical rehabilitation. Outcomes included physical activity (e.g. step count, moderate-vigorous physical activity duration) and sedentary time measured with the Sensewear Armband, gait speed, and cognition. The number of participants meeting physical activity recommendations was calculated. Differences in physical activity were examined between household ambulators (gait speed <0.4 m/s), limited community ambulators (0.4-0.8 m/s), and unlimited community ambulators (>0.8 m/s). The influence of age, cognition, and gait speed on physical activity was determined by multiple regression.

RESULTS

Seventy-nine stroke survivors participated. Twenty-one participants achieved 30 min/day of moderate-vigorous physical activity accumulated in 10 min bouts. Unlimited community ambulators took more steps/day (median 4975 vs. 469 limited, 355 household, p < 0.001), had higher moderate-vigorous physical activity (median 74 min/day vs. 22 limited, 31 household, p < 0.001) and lower sedentary time (mean 1105 vs. 1239 limited, 1232 household minutes/day, p < 0.001). Age, gait speed, and cognition predicted 21.3% of the variance in moderate-vigorous physical activity (p = 0.001); adding employment status to the model predicted 57.3% of the variance in step count (p < 0.001).

CONCLUSIONS

Physical activity is low following stroke and should be a target for treatment, particularly in those with gait speeds ≤0.8 m/s.Implications for rehabilitationSeventy-three percent of stroke survivors performed ≥30 minutes of moderate to vigorous physical activity throughout the day.Twenty-seven percent of stroke survivors accumulated ≥30 minutes of moderate to vigorous physical activity in 10 minute bouts.Despite relatively good physical ability, daily step count was low in this sample.Those with gait speeds ≤0.8 m/s had lower physical activity levels and higher sedentary time.

Validity of the Walked Distance Estimated by Wearable Devices in Stroke Individuals

Background: Health professionals need valid devices to assess a stroke individual’s ability to walk. The aim was to evaluate the validity of the estimation of the walked distance by wearable devices and the impact of the sensor’s position in stroke individuals. Methods: Post-stroke patients able to walk without human assistance were equipped with several wearable devices: pedometers, Actigraph, and Sensewear Armband placed according to the manufacturers' recommendations. Participants walked for 6 min at a comfortable speed wearing all sensors at the same time. We analyzed the validity of sensor-estimated distances according to their position using Bland–Altman analysis, root-mean-square error, and coefficient of correlation. Results: In total, 35 individuals were included (mean age = 65 ± 15 years). The best estimations were given by the Actigraph worn on the unaffected ankle (mean bias (MB) = 22.6 ± 32.4 m; p = 0.37) and by the pedometer worn on the unaffected hip (MB = 20.5 ± 24.6 m; p = 0.46). The other sensors and positions provided large estimation errors over 95 m (p < 0.05). Conclusion: This study led to a recommendation of a pedometer worn on the unaffected hip or an Actigraph worn on the unaffected ankle to get a valid estimation of the distance walked by stroke individuals.

Pedometers alone do not increase mobility in inpatient rehabilitation: a randomized controlled trial

OBJECTIVE

To test if pedometers, as a motivational tool, could affect mobility outcomes in inpatient rehabilitation.

DESIGN

Randomized controlled clinical trial.

SETTING

Subacute hospital rehabilitation unit in Australia.

PARTICIPANTS

A total of 78 participants with reduced mobility and clinician-determined capacity to improve.

INTERVENTIONS

Both groups received usual care. For the intervention group, a pedometer was worn on the hip with the step count visible to participant and recorded daily on an exercise log. For the control group, a pedometer fixed shut was worn on the hip and they recorded estimated distances walked on an exercise log.

MAIN MEASURES

Primary outcome was functional mobility - De Morton Mobility Index. Secondary outcome measures were walking velocity, functional independence measure, time spent upright and daily step count.

RESULTS

Significant improvements over time (P < 0.001) in functional mobility, comfortable walking velocity and functional independence measure were not influenced by the intervention. The daily average upright time (hours) in the first week of intervention was different (P = 0.004) between the intervention group (median, interquartile range (IQR): 1.67, 1.77) compared to the control group (median, IQR: 1.12, 0.82).

CONCLUSION

Pedometers as a motivational tool without targets do not improve functional mobility in this population. Pedometers may improve daily upright time in this setting.

Two Days of Measurement Provides Reliable Estimates of Physical Activity Poststroke: An Observational Study

OBJECTIVE

The aim of this study was to determine the duration of physical activity (PA) monitoring required for reliable measurements following stroke.

DESIGN

Single-center, prospective, observational study.

SETTING

PA was measured in a community setting.

PARTICIPANTS

Adults (N=70) poststroke.

MAIN OUTCOME MEASURES

The SenseWear armband was used to monitor PA for 5 days (≥10 hours wear per day).

DATA ANALYSIS

Variance among 2, 3, 4, and 5 days of consecutive measurements for PA variables was examined using intraclass correlation coefficients (ICCs). The minimum number of days to achieve acceptable reliability (ICC ≥0.8) was calculated. Differences between weekdays and weekend days were investigated using paired t tests and Wilcoxon signed rank tests.

RESULTS

Two days of measurement was sufficient to achieve an ICC ≥0.8 for daily averages of total energy expenditure, step count, and time spent sedentary (≤1.5 metabolic equivalent tasks [METs]) and in light (1.5-3 METs) and moderate- to vigorous-intensity (>3 METs) PA. At least 3 days were required to achieve an ICC ≥0.8 when investigating the number of and time spent in bouts (≥10 minutes) of moderate to vigorous PA and sedentary behavior. Participants took significantly more steps (P=.03) and spent more time in light PA (P=.03) on weekdays than weekends.

CONCLUSION

Following stroke, 2 days of measurement appears sufficient to represent habitual PA for many simple variables. Three or more days may be necessary for reliable estimates of bouts of PA and sedentary behavior. Consistent inclusion or exclusion of a weekend day is recommended for measuring step count and light PA. Short periods of monitoring provide reliable PA information and may make PA measurement more feasible in the clinical setting.

Effects of dynamic neural mobilization on cerebral cortical activity in patients with stroke

[Purpose] The current study aimed to identify the effects of dynamic neural mobilization on cerebral cortical activity in patients with stroke, and to present efficient intervention methods for stroke management. [Subjects and Methods] A total of 20 hemiplegic patients diagnosed with stroke over the past 6 months were sampled, and randomly divided into groups I (n=10) and II (n=10). Groups I and II underwent neural mobilization and dynamic neural mobilization, respectively, on the paralyzed arm. Both interventions were administered for 30 min, once a day, for 4 days a week, over a course of 4 weeks. β-waves and μ-rhythms in the C3 and C4 areas of the cerebral cortex were measured using electroencephalography, both before and after the intervention. [Results] After the intervention, both groups showed significant changes in the β-waves and μ-rhythms in the C3 area alone. Further, significant inter-group differences in the β-waves and μ-rhythms were only present in the C3 area. [Conclusion] Dynamic neural mobilization is an efficient intervention because it increases β-waves and μ-rhythms in the cerebral cortex. Therefore, the effects of continuous intervention programs involving dynamic neural mobilization in patients with stroke should be investigated in the future.

Wearable sensors for clinical applications in epilepsy, Parkinson's disease, and stroke: a mixed-methods systematic review

OBJECTIVES

Wearable technology is increasingly used to monitor neurological disorders. The purpose of this systematic review was to synthesize knowledge from quantitative and qualitative clinical researches using wearable sensors in epilepsy, Parkinson's disease (PD), and stroke.

METHODS

A systematic literature search was conducted in PubMed and Scopus spanning from 1995 to January 2017. A synthesis of the main findings, reported adherence to wearables and missing data from quantitative studies, is provided. Clinimetric properties of measures derived from wearables in laboratory, free activities in hospital, and free-living environment were also evaluated. Qualitative thematic synthesis was conducted to explore user experiences and acceptance of wearables.

RESULTS

In total, 56 studies (50 reporting quantitative and 6 reporting qualitative data) were included for data extraction and synthesis. Among studies reporting quantitative data, 5 were in epilepsy, 21 PD, and 24 studies in stroke. In epilepsy, wearables are used to detect and differentiate seizures in hospital settings. In PD, the focus is on quantification of cardinal motor symptoms and medication-evoked adverse symptoms in both laboratory and free-living environment. In stroke upper extremity activity, walking and physical activity have been studied in laboratory and during free activities. Three analytic themes emerged from thematic synthesis of studies reporting qualitative data: acceptable integration in daily life, lack of confidence in technology, and the need to consider individualization.

CONCLUSIONS

Wearables may provide information of clinical features of interest in epilepsy, PD and stroke, but knowledge regarding the clinical utility for supporting clinical decision making remains to be established.

Home-based physical activity incentive and education program in subacute phase of stroke recovery (Ticaa'dom): study protocol for a randomized controlled trial

Background

Stroke causes functional decline, psychological disorders and cognitive impairments that affect activities of daily living and quality of life. Although physical activity (PA) is beneficial in stroke recovery, PA recommendations are rarely met after hospital discharge. There is presently no standard strategy for monitoring and inciting PA at home during the subacute phase of stroke recovery. The main aim of this study is to evaluate the effects of a home-based physical activity incentive and education program (Ticaa’dom) on functional capacity in subacute stroke patients.

Methods

This study is a comparative prospective, observer-blinded, monocentric, parallel, randomized controlled clinical trial. This study will include 84 patients: 42 patients in the home-based physical activity incentive group (HB-PAI) and 42 in the control group (CG). The intervention group will follow the HB-PAI program over 6 months: their PA will be monitored with an accelerometer during the day at home while they record their subjective perception of PA on a chart; they will observe a weekly telephone call and a home visit every three weeks. The CG will receive traditional medical care over 12 months. The main study outcome will be the distance on a 6-minute walk test. Secondary outcomes will include measurements of lower limb strength, independence level, body composition, cardiac analysis, fatigue and depression state.

Discussion

The results of this trial will demonstrate the value of implementing the Ticaa’dom program during the subacute phase of stroke recovery.

Trial registration

ClinicalTrials.gov, NCT01822938. Registered on 25 March 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2410-9) contains supplementary material, which is available to authorized users.

What is the relationship between physical activity and cardiovascular risk factors in stroke survivors post completion of rehabilitation? Protocol for a longitudinal study

INTRODUCTION

Physical activity (PA) can modify cardiovascular and other health risks in people with stroke, but we know little about long-term PA in this group. This study aims to describe PA levels and investigate relationships between PA, cardiovascular risk factors, mobility and participant characteristics (eg, age, mood and fatigue) in the 2 years following rehabilitation discharge after first stroke.

METHODS AND ANALYSIS

This is a longitudinal observational study with follow-up at 6, 12 and 24 months after rehabilitation discharge. Inclusion criteria are broad; excluding only those with previous stroke, palliative diagnosis, living more than 2 hours from the centre or admitted less than 5 days.The primary outcome of interest is duration of moderate to vigorous PA (min/day) measured by the Sensewear MF Armband (SWAB). Secondary outcomes include other PA measures measured with the SWAB; cardiovascular risk factors (eg, systolic blood pressure, fasting lipid profile and smoking status), mobility (10 m walk test), the Hospital Anxiety and Depression Scale and the Fatigue Severity Scale. All outcomes, except blood tests, are gathered at each time point.The target sample size is 77. We will explore associations between PA levels, cardiovascular risk factors, mobility and participant characteristics at baseline compared with 6, 12 and 24 months using random-effects regression modelling.The long-term PA of stroke survivors is largely unknown. We hope to identify factors that influence PA and cardiovascular risk in this population, which may help health professionals target the stroke survivors most at risk and implement appropriate treatment, preventative strategies and education.

ETHICS AND DISSEMINATION

Approval was granted from Alfred Hospital and La Trobe University Research Ethics Committees. The study results will be disseminated in a number of ways including journal publication and international conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12613000196741.

Does a cycling program combined with education and followed by coaching promote physical activity in subacute stroke patients? A randomized controlled trial

BACKGROUND

To investigate the effects of a three month active cycling program followed by coaching on physical activity in subacute stroke patients.

METHODS

Patients (n = 59; mean age =65.4 ± 10.3) aged ≤80 years with first stroke and able to cycle at 50 revolutions/minute enrolled 3-10 weeks post stroke. Patients were randomly allocated to three month active cycling group (n = 33) or to a control group (n = 26), 3 x 30 minutes training/week. Afterwards, the active cycling group was randomized into a coaching (n = 15) versus non-coaching group (n = 16) for nine months. Physical activity was measured by objective and self-reported measures, which were taken before/after the active cycling program and during six and 12 months, except the Baecke-questionnaire, which was used at baseline and 12 months.

RESULTS

A significant difference was found in Baecke/sport (95% confidence interval: 0.06, 2.24; p = 0.039) between the active cycling group and the control group, in patients with severe motor function deficits at baseline. Patients in the control group performed significant less sports at 12 months (mean Baecke/sport_baseline =3.07 ± 1.21, mean Baecke/sport_12months = 1.43 ± 0.98; p = 0.01). Furthermore, all groups showed significant changes over time in all measures at three months (except: Physical Activity Scale for Individuals with Physical Disabilities, diary/Mets*minutes-moderate) and 12 month and additionally in a subgroup with severe motor function deficits (except diary Mets*minutes-sedentary).

CONCLUSION

When active cycling combined with education is used in subacute patients with severe motor function deficits, more sport participation might be observed after one year. No other significant group differences were found over time. In all groups, however, patients showed significant improvement over time in physical activity measures. Future work is needed to explore the most effective coaching approach after an aerobic training program. Implications for Rehabilitation The active cycling program combined with education is applicable in subacute stroke patients as it required little stand-by assistance due to chip cards, the intensity was gradually built and the involvement of caregivers in the educational sessions. This training approach also revealed applicable in severely impaired stroke patients and might facilitate sport participation on the long-term. This randomized controlled study aims to quantify physical activity after stroke by using a combination of objective and self-report measures, which revealed detailed information about different aspects of physical activity levels. There is a need for coaching approaches that facilitate aerobic exercise after ending a supervised program. A coaching approach needs to guide patients in adopting aerobic exercise as a part of a lifestyle change and needs to be less time consuming.

Physical Activity Level of Ambulatory Stroke Patients: Is it Related to Neuropsychological Factors?

INTRODUCTION

Physical inactivity is an important risk factor for stroke and stroke recurrence. There is insufficient knowledge about the physical activity (PA) level in stroke patients who are ambulatory in the subacute phase. Our aim was to compare the PA level between ambulatory stroke patients and a population of the same age and to investigate neuropsychological factors that could affect the PA level in the same stroke group.

METHODS

Eighty-five subacute stroke patients and 58 healthy subjects were included. Patients' demographic features, disease-related features, and comorbidities were recorded. The PA level was assessed by the International Physical Activity Questionnaire-Short Version and a pedometer (OMRON Walking style II). The Apathy Rating Scale was applied to determine the apathy level. Depression level was investigated by the Geriatric Depression Scale. The standardized Mini-mental State Examination was performed to assess the cognitive status.

RESULTS

The PA level was significantly higher in the healthy group than in the stroke group (p<0.001). Step count and walking distance were significantly higher in healthy group (p=0.001 and p=0.04, respectively). The PA level of men was significantly higher than that of women (p=0.03). Participants who were classified as level 4 had a lower PA level than those who were classified as level 5 according to the Functional Ambulation Category. There was no relationship between the PA level and the apathy, cognitive, and depression levels in the stroke patients (p>0.05).

CONCLUSION

Subacute stroke patients have a lower PA level than healthy subjects. This is not related to neuropsychological factors. The reasons for minor deficits related to ambulation should be researched further while developing strategies for increasing the PA level of subacute stroke patients.

Physical Activity Monitoring in Patients with Neurological Disorders: A Review of Novel Body-Worn Devices

Aim

The aim was to conduct a systematic review to examine the literature reporting the validity and reliability of wearable physical activity monitoring in individuals with neurological disorders.

Method

A systematic search of the literature was performed using a specific search strategy in PubMed and CINAHL. A search constraint of articles published in English, including human participants, published between January 2008 and March 2017 was applied. Peer-reviewed studies which enrolled adult participants with any neurological disorder were included. For the studies which sought to explore the validity of activity monitors, the outcomes measured using the monitor were compared to a criterion measure of physical activity. The studies' methodological quality was assessed using an adapted version of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) framework. Data extracted from each study included the following: characteristics of the study participants, study setting, devices used, study protocol/methods, outcomes measured, and the validity/reliability of measurement produced.

Results

Twenty-three studies examining the validity and reliability of 16 different monitors were included. The identified studies comprised participants with a range of different disorders of neurological origin. The available evidence suggests that biaxial or triaxial accelerometer devices positioned around the ankle produce the most accurate step count measurements in patients with neurological disorders. The findings regarding the reliability and validity of activity counts and energy expenditure are largely inconclusive in this population.

Discussion

Ankle-worn biaxial or triaxial accelerometer-type devices provide the most accurate measurement of physical activity. However, further work is required in this field before wearable activity monitoring can be more widely implemented clinically. Standardised activity monitoring protocols are required for implementing these devices in clinical trials and clinical practice, and consensus is required as to the reporting and interpretation of derived variables.

Monitoring Step Activity During Task-Oriented Circuit Training in High-Functioning Chronic Stroke Survivors: A Proof-of-Concept Feasibility Study

OBJECTIVE

To explore the amount of practice and progression during task-oriented circuit training (TOCT) in chronic stroke survivors; to test the use of pedometers and observation-based measures in detecting step activity; to verify the possible correlation between step activity and locomotor function improvements.

METHODS

Six community-dwelling chronic stroke survivors underwent 10 TOCT sessions (2 hours/each) over 2 weeks in which they were trained both on a treadmill and on six task-oriented workstations (W1-W6). During the sessions, they wore a piezoelectric pedometer and step activities were recorded. Outcome measures were as follows: % of activities during which pedometers worked properly; pedometer-based measures (total step counts, treadmill steps, workstation steps-total and W2,W3,W5,W6); observation-based measures (number of repetitions in task W1 and W4); walking speed changes measured by the 10-m walking test (10MWT) and walking endurance changes (6-minute walking test) after TOCT.

RESULTS

During TOCT sessions (n=57), activities were recorded through pedometer-based measures in 4 out of the 6 patients. The total amount of step activity was 5,980.05±1,968.39 steps (54.29% in task-oriented workstations, 37.67% on treadmill, and 8.03% during breaks). Exercise progression was highlighted significantly by observational measures (W1, W4). A positive correlation was observed between increased gait speed and observational stair step repetitions progression (W1) (r=0.91, p=0.01) or pedometer-based tandem exercise step progression (W3) (r=0.98, p=0.01).

CONCLUSION

TOCT can be considered a high-intensity, progressive intervention to restore locomotor function in chronic stroke survivors. Pedometer-based measures might help in quantifying TOCT's volume of practice; however, further investigations are required.

Accuracy of the Yamax CW-701 Pedometer for measuring steps in controlled and free-living conditions

Objective

The Yamax Digi-Walker CW-701 (Yamax CW-701) is a low-cost pedometer that includes a 7-day memory, a 2-week cumulative memory, and automatically resets to zero at midnight. To date, the accuracy of the Yamax CW-701 has not been determined. The purpose of this study was to assess the accuracy of steps recorded by the Yamax CW-701 pedometer compared with actual steps and two other devices.

Methods

The study was conducted in a campus-based lab and in free-living settings with 22 students, faculty, and staff at a mid-sized university in the Southeastern US. While wearing a Yamax CW-701, Yamax Digi-Walker SW-200, and an ActiGraph GTX3 accelerometer, participants engaged in activities at variable speeds and conditions. To assess accuracy of each device, steps recorded were compared with actual step counts. Statistical tests included paired sample t-tests, percent accuracy, intraclass correlation coefficient, and Bland–Altman plots.

Results

The Yamax CW-701 demonstrated reliability and concurrent validity during walking at a fast pace and walking on a track, and in free-living conditions. Decreased accuracy was noted walking at a slow pace.

Conclusions

These findings are consistent with prior research. With most pedometers and accelerometers, adequate force and intensity must be present for a step to register. The Yamax CW-701 is accurate in recording steps taken while walking at a fast pace and in free-living settings.

Are Accelerometers and GPS Devices Valid, Reliable and Feasible Tools for Measurement of Community Ambulation After Stroke?

Purpose: To determine validity, reliability and feasibility of accelerometers (ActivPAL™, Sensewear Pro2Armband) and portable global positioning systems (GPS) (Garmin Forerunner 405CX) for community ambulation measurement after stroke.

Methods: Fifteen community-dwelling stroke survivors attended two sessions; completing a 6-minute walk, treadmill walking, and 200-m outdoor circuit. Feasibility was determined by wearing devices over four days. Measures collected included step count, time spent walking, distance, energy expenditure and location. Intra-class correlation coefficients (ICC), Bland–Altman plots and absolute percentage of error (APE) were used to determine validity and reliability.

Results: ActivPAL™had excellent validity and reliability for most measures (ICC: 0.821–0.999, APE: 0%–11.1%), except for good-excellent findings at speeds < 0.42 m/s (ICC: 0.659–0.894, APE: 1.6%–11.1%). Sensewear had missing values for 23% of recordings and high error for all measures. GPS demonstrated excellent validity and reliability for time spent walking and step count (ICC: 0.805–0.999, APE: 0.9%–10%), and 100% accuracy for location. However, it was not valid or reliable for distance (ICC = −0.139, APE = 23.8%). All devices appeared feasible for community ambulation measurement with assistance for setup and data analysis.

Conclusions: ActivPAL™and Garmin GPS appear valid, reliable and feasible tools for community ambulation measurement after stroke, except for distance. Sensewear demonstrated poor validity and reliability when worn on the paretic arm.

Wearable sensors and Mobile Health (mHealth) technologies to assess and promote physical activity in stroke: a narrative review

Stroke is a leading cause of disability worldwide, with approximately one third of people left with permanent deficits impacting on their function. This may contribute to a physically inactive lifestyle and further associated health issues. Current research suggests that people after stroke are not meeting the recommended levels of physical activity, and are less active than people with other chronic illnesses. Thus, it is important to understand how to support people after stroke to uptake and maintain physical activity. Wearable sensors and mobile health (mHealth) technologies are a potential platform to measure and promote physical activity. Some of these technologies may incorporate behaviour change techniques such as real-time feedback. Although wearable activity trackers and smartphone technology are widely available, the feasibility and applicability of these technologies for people after stroke is unclear. This article reviews the devices available for assessment of physical activity in stroke and discusses the potential for advances in technology to promote physical activity in this population.

Physical activity in chronic home-living and sub-acute hospitalized stroke patients using objective and self-reported measures

BACKGROUND

Despite confirmed reduced physical activity (PA) after stroke in various stages of recovery, the type of activities stroke patients executed and the time spent at different activity levels have not been sufficiently verified with stroke-validated assessment tools.

DESIGN

Observational study.

OBJECTIVE

To determine PA of sub-acute stroke patients hospitalized in a rehabilitation centre (HOS) compared to chronic home-living stroke patients (HOM) using objective and self-reported measures during 2 weekdays and 1 weekend day.

METHODS

Fifteen HOS and 15 HOM patients wore a Sense Wear Pro 2 accelerometer (METs*minutes/24 h) and a knee-worn pedometer Yamax Digi Walker SW 200 (steps) and filled in a coded activity diary (kcal/24 h; METs*minutes/24 h) during three consecutive days.

RESULTS

In HOM significantly more steps (stepstotal HOM = 18722.6 ± 10063.6; stepstotal HOS = 7097.8 ± 5850.5) and higher energy expenditure (EE) levels (EEtotal HOM = 7759.34 ± 2243.04; EEtotal HOS = 5860.15 ± 1412.78) were measured. In this group less moderate activity (≥3-6 ≤ METs) was performed on a weekday (pday1 = 0.006; pday2 = 0.027) and in total (p = 0.037). Few therapy hours (physical, occupational and speech therapy, and psychological support) were provided in HOM compared to HOS (p < 0.001). Vigorous activities were only seen in HOM. In both groups few patients executed sport activities.

CONCLUSIONS

In HOM significantly more steps were performed and higher EE values were measured. However, participation in moderate activities and time spent on therapy were less in HOM. Evaluating PA with quantitative measures is feasible in both chronic home-living and sub-acute hospitalized patients with stroke.

Relating wrist accelerometry measures to disability in older adults

OBJECTIVE

This analysis assessed the extent to which: (1) wrist accelerometer measures were associated with difficulty performing specific activities of daily living and instrumental activities of daily living and (2) these measures contributed important information about disability beyond a typical self-reported vigorous activity frequency question.

METHODS

We used data from the National Social Life, Health and Aging Project (NSHAP) accelerometry sub-study (n=738). Activity was assessed using two wrist-accelerometer measures assessed over 3 days (routine activity expressed as mean count/15s epoch during wake time, and immobile time expressed as the proportion of wake time spent immobile), and self-reported average vigorous activity frequency. The association between routine activity, immobile time and difficulty performing fourteen activities of daily living (ADLs) and instrumental activities of daily living (IADLs) plus two summary measures (any ADL or IADL difficulty), was assessed using logistic regression models, with and without controlling for self-reported vigorous activity.

RESULTS

Self-reported activity was mildly correlated with routine activity (r=0.27) and immobile time (r=-0.21). Routine activity, immobile time, and self-reported vigorous activity were significantly associated with twelve, ten, and fourteen disability measures, respectively. After controlling for self-reported activity, significant associations remained between routine activity and eight disabilities, and immobile time and six disabilities.

CONCLUSION

Wrist accelerometry measures were associated with many ADL and IADL disabilities among older adults. Wrist acclerometry in older adults may be useful to help assess disability risks and set individualized physical activity targets.

Living Labs: overview of ecological approaches for health promotion and rehabilitation

PURPOSE

The term "Living Lab" was coined to reflect the use of sensors to monitor human behavior in real life environments. Until recently such measurements had been feasible only within experimental laboratory settings. The objective of this paper is to highlight research on health care sensing and monitoring devices that enable direct, objective and accurate capture of real-world functioning.

METHOD

Selected articles exemplifying the key technologies that allow monitoring of the motor-cognitive activity of persons with disabilities during naturally occurring daily experiences in real-life settings are discussed in terms of (1) the ways in which the Living Lab approach has been used to date, (2) limitations related to clinical assessment in rehabilitation settings and (3) three categories of the instruments most commonly used for this purpose: personal technologies, ambient technologies and external assistive systems.

RESULTS

Technology's most important influences on clinical practice and rehabilitation are in a shift from laboratory-based to field-centered research and a transition between in-clinic performance to daily life activities. Numerous applications show its potential for real-time clinical assessment.

CONCLUSIONS

Current technological solutions that may provide clinicians with objective, unobtrusive measurements of health and function, as well as tools that support rehabilitation on an individual basis in natural environments provide an important asset to standard clinical measures.

IMPLICATIONS FOR REHABILITATION

Until recently objective clinical assessment could not be readily performed in a client's daily functional environment. Novel technologies enable health care sensing and monitoring devices that enable direct, objective and accurate capture of real-world functioning. Such technologies are referred to as a "Living Lab" approach since they enable the capture of objective and non-obtrusive data that clinicians can use to assess performance. Research and development in this field help clinicians support maintain independence and quality of life for people who have disabilities or who are aging, and to promote more effective methods of long-term rehabilitation and maintenance of a healthy life style.

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.

Is a coded physical activity diary valid for assessing physical activity level and energy expenditure in stroke patients?

Objectives

to determine the concurrent validity of a physical activity diary for measuring physical activity level and total energy expenditure in hospitalized stroke patients.

Method

Sixteen stroke patients kept coded activity diaries and wore SenseWear Pro2 multi-sensor activity monitors during daytime hours for one day. A researcher observed the patients and completed a diary. Data from the patients' diaries were compared with observed and measured data to determine total activity (METs*minutes), activity level and total energy expenditure.

Results

Spearman correlations between the patients' and researchers' diaries revealed a high correlation for total METs*minutes (r_s = 0.75, p<0.01) for sedentary (r_s = 0.74,p<0.01) and moderate activities (r_s = 0.71,p<0.01) and a very high correlation (r_s = 0.92, p<0.01) for the total energy expenditure. Comparisons between the patients' diaries and activity monitor data revealed a low correlation (r_s 0.29) for total METs*minutes and energy expenditure.

Conclusion

Coded self-monitoring activity diaries appear feasible as a low-tech alternative to labor-intensive observational diaries for determining sedentary, moderate, and total physical activity and for quantifying energy expenditure in hospitalized stroke patients. Given the poor correlation with objective measurements of physical activity, however, further research is needed to validate its use against a gold-standard measure of physical activity intensity and energy expenditure.