How should we measure physical activity after stroke? An international consensus

The relationship between levels of physical activity and participation in everyday life in stroke survivors: A systematic review and meta-analysis

BACKGROUND

Stroke survivors demonstrate decreased physical activity (PA) and take time to return to participation in everyday life, but the relationship between the two variables is unknown.

OBJECTIVE

To investigate the correlation and trajectory over time between levels of PA and participation in everyday life in stroke survivors.

METHODS

PubMed, Web of Science, Scopus, SPORTDiscus, Rehabilitation&Sport Medicine Source, and PEDro databases were searched from inception to January 2024. Cross-sectional and prospective studies evaluating both levels of PA and participation in stroke survivors were included. Two reviewers independently conducted the study selection, data extraction, and quality assessment. Meta-analyses of pooled correlation coefficients were calculated when at least two studies reported a correlation coefficient between the same PA and participation outcomes.

RESULTS

Of 4962 studies identified, 49 were included in the systematic review. Studies were rated high (55%%) or fair (45%) quality. A wide range of monitoring methodologies for assessing PA and participation were found in the 23 prospective studies. Seven studies were included in the meta-analyses, showing a positive moderate correlation between PA time and participation in activities of daily living (n = 148; r = 0.52; P < 0.01; I2 = 81%) in participants <6 months post-stroke, and between PA time and the participation in all areas (n = 126; r = 0.44; P < 0.01; I2 = 0%) in participants ≥6 months post-stroke. Overall, while PA showed significant improvements over time, participation only showed a tendency.

CONCLUSION

Despite the heterogeneity, consistent positive associations were found between PA time and participation levels in some areas. Establishing consensus is crucial to reduce heterogeneity and facilitate data pooling.

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.

What factors at discharge predict physical activity and walking outcomes 6 months after stroke? A systematic review

OBJECTIVE

This study aimed to identify factors at hospital discharge that predict physical activity and walking outcomes in the first 6 months after stroke.

DATA SOURCES

Searches were conducted in CINAHL (EBSCO), Web of Science, PubMed and Scopus from inception to 30 April 2024. Reference lists of included articles were manually screened to identify additional studies.

REVIEW METHODS

Studies of adults with stroke reporting predictors at hospital discharge and outcomes of physical activity or walking across the first 6 months after hospital discharge were included. Two reviewers independently screened titles, abstracts and reviewed full texts. Quality of included studies was assessed with Quality in Prognostic Studies screening tool. A narrative synthesis was undertaken.

RESULTS

The search strategy retrieved 7834 studies, from which 6 eligible studies were identified, including a total of 1433 participants. Overall, studies had a low risk of bias. Age, balance, walking speed and walking distance at hospital discharge predicted physical activity outcomes after stroke (n = 2 studies). Cognition, lower limb cycling rhythm and self-efficacy for walking at hospital discharge predicted walking outcomes after stroke (n = 4 studies).

CONCLUSIONS

A range of factors predicted physical activity and walking outcomes 6 months after stroke. Physical capabilities at discharge appear to be a predictor of these outcomes; however, this needs to be interpreted with caution. Diverse measures and time points were used across studies to characterise physical activity and walking outcomes, highlighting the need for consistency in measurement and longitudinal studies in stroke research.

Comparing the reliability of physical activity questionnaires in community-dwelling adults with stroke

BACKGROUND

Physical activity (PA) is important for people with stroke, but the reliability of PA questionnaires used in this population has been relatively unexplored.

OBJECTIVE

To compare the internal consistency, test-retest, and absolute reliability of 3 commonly used PA questionnaires in adults with stroke.

METHODS

Participants reported their PA levels twice, 2-3 days apart, using the Physical Activity Scale for Individuals with Physical Disabilities (PASIPD), International Physical Activity Questionnaire (IPAQ), and Global Physical Activity Questionnaire (GPAQ). Intraclass correlation coefficients (ICC2,1) were calculated for test-retest reliability, Cronbach's alpha (α) for internal consistency, and standard error of measurement (SEM) and minimal detectable change (MDC95) for absolute reliability.

RESULTS

Twenty-eight people (64.4 years, 50% female, 5.2 years post-stroke) participated. Internal consistency was acceptable for total scores on the IPAQ (α  = 0.79) and GPAQ (α  = 0.74), but only domain-level scores for the GPAQ (α  = 0.71-0.88). In the full sample, test-retest reliability was good for the PASIPD (ICC2,1 = 0.83) but poor for the IPAQ and GPAQ (ICC2,1 <0.50). After excluding participants self-reporting true changes in PA, all questionnaires had good test-retest reliability (ICC2,1 = 0.77-0.88). SEM and MDC95 were lowest for the PASIPD (188.8 and 523.3 MET-minutes/week, respectively).

CONCLUSIONS

In adults with stroke, the IPAQ and GPAQ had adequate total-questionnaire internal consistency, and the GPAQ had acceptable domain-level internal consistency. When true change in PA did not occur, test-retest reliability was good for all questionnaires. We suggest clinicians and rehabilitation scientists can use any of the three questionnaires, but may consider the GPAQ due to acceptable internal consistency and test-retest reliability.

Patient experiences of physical activity and inactivity in the stroke unit: an interview study

OBJECTIVE

Stroke unit care is highly recommended after stroke, but patients in these units are often physically inactive. The aim of this study was to explore patient experiences of physical activity and inactivity in the stroke unit.

DESIGN

Qualitative interview study.

SUBJECTS

Sixteen participants with stroke; a heterogeneous sample with differences in sex, age, and stroke severity from 8 Swedish stroke units.

METHODS

In-depth interviews 1-2 weeks after discharge analysed using thematic analysis.

RESULTS

The analysis resulted in three themes: 1: Dealing with the challenges of a changed body while striving to become independent; 2: The stroke unit is crucial for physical activity; and 3: Physical activity is important for interaction with others, autonomy, and feeling seen. Participants described how they coped with a new situation when finding new ways to move and function. In addition, they wanted to be involved in their own stroke rehabilitation.

CONCLUSION

The participants expressed the following experiences of being in the stroke unit: movement is more important than physical activity and involves being seen and respected; physical activity and exercise are necessary to achieve independence; process involvement is of importance to regain abilities; physical activity offers the possibility of choosing between community and being alone and influences the ability to connect with others and the outside world.