Association Between Physical Activity and Mortality Among Community-Dwelling Stroke Survivors

A nationwide analysis of physical inactivity and sedentary behavior among stroke survivors in Korea

This study aimed to identify key predictors of physical inactivity and prolonged sedentary behavior among stroke survivors (SSs) using data from the 2016-2020 Korea National Health and Nutrition Surveys. Of the 28,146 participants, 633 had a history of stroke. The results showed that SSs were significantly more likely to be physically inactive and spend longer sedentary times than controls. Multivariate analysis identified that age ≥ 80 years (adjusted odds ratio [aOR] = 5.45, 95% confidence interval [CI] 1.96-15.15), lower education level (≤ 9 years) (aOR = 2.18, 95%CI 1.13-4.18), and living in rural areas (aOR = 1.91, 95%CI 1.11-3.29) were associated with aerobic physical inactivity. Female sex (aOR = 2.36, 95%CI 1.28-4.35) and lower education (aOR = 2.31, 95%CI 1.01-5.34) were linked to insufficient resistance exercises (≤ 1 day per week). Long sedentary time (≥ 8 h daily) was associated with being economically inactive (aOR = 1.90, 95%CI 1.21-2.96), single (aOR = 1.68, 95%CI 1.07-2.64), and perceiving oneself as unhealthy (aOR = 1.59, 95%CI 1.01-2.49). These findings highlight the need for targeted interventions, including community-based exercise programs and policy initiatives, to reduce sedentary behavior and promote physical activity among SSs. Implementing accessible and tailored rehabilitation strategies may help mitigate long-term health risks in this population.

Associations of Physical Activity with Long-Term Mortality Among Peripheral Artery Disease Patients: A Population-Based Cohort Study

BACKGROUND

To investigate the relationship between physical activity and risk of all-cause and cardiovascular disease (CVD) mortality in patients with peripheral artery disease (PAD).

METHODS

We recruited 561 PAD cases of National Health and Nutrition Examination Survey from 1999 to 2004 and linked mortality data through December 31, 2019. We explored the effect of aerobic physical activity and muscle-strengthening activity on the risk of all-cause and CVD mortality employing cox proportional hazard ratios (HRs) with 95% confidence intervals (CIs) from 1999 to 2019.

RESULTS

During an average of 9.8-year follow-up, a total of 435 deaths from all causes of the 561 PAD patients were recorded including 165 CVD deaths. Meeting the guidelines about physical activity released by World Health Organization in 2020 is not related to a lower risk for mortality in PAD patients. PAD patients engaging in moderate-to-vigorous intensity aerobic physical activity (MVPA) ≥ 60 min/week exhibited a significantly 45% (HR = 0.55; 95% CI = 0.37-0.85; P < 0.001) lower all-cause mortality risk and 60% (HR = 0.40; 95% CI = 0.27-0.70; P < 0.001) lower CVD mortality risk. PAD patients reached their maximal survival benefit of HR at 120-239 min/week of MVPA. The survival benefit of aerobic physical activity was notably greater in men and age < 65 years. Furthermore, PAD patients with muscle-strengthening activity 1-4 times/week had a 66% reduction risk of CVD mortality (HR = 0.34; 95% CI = 0.17-0.90; P = 0.011).

CONCLUSIONS

Aerobic physical activity (MVPA ≥ 60 min/week) decreases the all-cause and CVD mortality risk among PAD patients. Muscle-strengthening activity (1-4 times/week) may provide survival benefits of CVD mortality in PAD patients.

Association Between Leisure-Time Physical Activity and All-Cause Mortality Among Stroke Survivors: Findings From National Health and Nutrition Examination Survey

BACKGROUND

Stroke is the second leading cause of death and the third leading cause of disability globally. But little is known about the optimal level of physical activity for stroke survivors. Therefore, we aimed to analyze the dose-response relationship between leisure-time physical activity (LTPA) and all-cause mortality in stroke survivors.

METHODS

One-thousand six hundred and sixty-four stroke survivors form from the 1999 to 2018 National Health and Nutrition Examination Surveys were classified into 6 groups: 0, 1 to 149, 150 to 299, 300 to 599, 600 to 899, and ≥900 minutes per week (based on the Global Physical Activity Questionnaire). Cox proportional hazards regression models with different adjustments of covariates were used to investigate the association between LTPA and all-cause mortality.

RESULTS

Except for stroke survivors with LTPA levels ranging from 600 to 899 minutes per week (P = .055), there was a significant difference in survival rates among stroke survivors with different levels of LTPA compared with those without LTPA. Stroke survivors engaging in LTPA levels exceeding 900 minutes per week exhibited the greatest benefit compared with stroke survivors who did not engage in LTPA (hazard ratio = 0.225; 95% confidence interval, 0.122-0.414).

CONCLUSIONS

Our research findings add to the expanding evidence base that highlights the favorable connection between LTPA and decreased risk of all-cause mortality among individuals who have survived a stroke. Our study emphasizes the significance of incorporating physical activity interventions into the poststroke care regimen and underscores the potential advantages of personalized activity guidance.

Validation of a tri-axial accelerometer for measuring physical activity in patients with subacute stroke

Purpose

This study aimed to validate the accuracy of the Active Style Pro HJA-750C (ASP) in measuring metabolic equivalents (METs) during walking and reaching tasks in individuals with subacute stroke using a respiratory gas analyzer as a reference.

Methods

Twenty-three hospitalized patients with subacute stroke participated in this study. They performed sitting and standing reaching tasks, as well as walking while wearing a VO2 Master respiratory gas analyzer and ASP devices on both the paretic and non-paretic sides. The METs values recorded by the ASP were compared with those obtained using a VO2 Master respiratory gas analyzer. Pearson's correlation coefficients were calculated for each task, and Bland-Altman plots were used to assess the agreement between the two methods.

Results

The ASP demonstrated good concurrent validity, with correlation coefficients of 0.71 and 0.74 for the sitting reaching task, 0.75 and 0.79 for the standing reaching task, and 0.83 and 0.85 for walking when the ASP was placed on the paretic and non-paretic sides, respectively. Bland-Altman analysis indicated no significant fixed or proportional errors. The ASP accurately measures METs whether worn on the affected or unaffected side of the waist.

Conclusion

The ASP provides valid measurements of physical activity during walking and reaching tasks in patients with subacute stroke. These findings suggest that ASP is a valuable tool for monitoring physical activity in clinical rehabilitation settings.

Association of physical activity level and all-cause mortality among stroke survivors: evidence from NHANES 2007-2018

BACKGROUND

Post-stroke disability diminishes the physical activity (PA) level of survivors, potentially affecting their long-term prognosis. This study endeavors to explore the correlation between daily PA level and the all-cause mortality in patients with a history of stoke in the United States.

METHODS

Data of stroke survivors were sourced from the National Health and Nutritional Examination Survey (NHANES) 2007-2018. The population was stratified into three groups based on their PA level. Kaplan-Meier method with log-rank tests for significance was used for survival analysis. Weighted Cox proportional hazards regression models were employed to estimate the hazard ratios (HRs) for all-cause mortality. Subgroup analysis was conducted to strengthen the results.

RESULTS

A total of 1395 participants were recruited, comprising 679 males and 716 females, with a median age of 68 years. Based on their PA levels, 779 individuals were classified as inactive, 156 as insufficiently active, and 460 as sufficiently active. Following a median observation period of 59 months, there were 476 recorded deaths, with 349, 47, and 80 cases in the three respective groups. Compared to the inactive group, the HRs and 95% confidence intervals (CIs) for all-cause mortality in participants who were insufficiently active and sufficiently active were 0.58 (0.40, 0.84) and 0.47 (0.33, 0.67), respectively. The Kaplan-Meier curve revealed a significant difference in overall survival between the three groups, as confirmed by the log-rank test (P < 0.0001). Subgroup analysis further validated our results and demonstrated that the protective impact of PA on stroke prognosis varies according to distinct characteristics.

CONCLUSIONS

The results indicate that increased levels of PA are associated with a protective effect on long-term mortality among stroke survivors. Further prospective longitudinal studies are necessary to elucidate the optional PA level and special exercise guideline targeting this population.

Factors Affecting Level of Physical Activity among Stroke Survivors: A Scoping Review

Physical activity (PA) is crucial for improving stroke survivors' health outcomes and quality of life (QoL). Impaired PA levels are common among stroke survivors, a significant portion of whom spend their days in sedentary occupations. Understanding the factors that influence physical inactivity and addressing the barriers to exercise participation can contribute significantly to improving stroke survivors' health outcomes and prognoses. Therefore, in the current review, we systematically searched five databases (PubMed/Medline, Scopus, SpringerLink, ScienceDirect and Google Scholar) for published studies reporting PA levels among stroke survivors, which yielded 301 potential articles. Based on the identification and screening processes recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR), 13 articles were finally included in the analysis. The results of these studies, covering 1,318 stroke survivors, revealed physical inactivity among most of the participants and significant heterogeneity among the outcome measures used. The factors affecting PA levels among stroke survivors were mainly categorised as physical, psychological, and sociodemographic, and all were significantly associated with PA levels after strokes.

Financial analysis of a locomotor exercise trial for post-stroke recovery: insights from the HIT Stroke Trial

Background

Navigating the complexities of post-stroke recovery trials requires addressing challenges in participant recruitment and retention and effective resource management to ensure trial success. The aim of this study was to examine the financial requirements associated with conducting the Moderate-Intensity Exercise vs. High-Intensity Interval Training to Recover Walking Post-Stroke (HIT Stroke Trial) at a single site encompassing a wide catchment area, recognizing the intricate challenges of participant recruitment and retention inherent in post-stroke recovery trials.

Methods

To determine cost, study expense reports were gathered and divided into seven categories: recruitment, screening assessments, baseline assessments, intervention, outcome assessments, retention, and oversight. Categories were then further divided into chronological order for initial contact and prescreening, consenting, initial screening, and baseline testing. The 12-week intervention was divided into 4-week blocks: intervention block 1, post 4-week outcome testing, intervention block 2, post 8-week outcome testing, intervention block 3, and post 12-week outcome testing.

Results

Total direct cost for site execution was $539,768 with cost per participant approximated as $35,984. Oversight costs accounted for 65.8% of the budget at $355,661. To achieve goals related to inclusive participant recruitment ($21,923) and retention ($28,009), our site costs totaled $49,932. Direct study-related costs included screening assessments ($5,905), baseline assessments ($15,028), intervention ($76,952), and outcome assessments ($36,288).

Discussion

Clinical trials focusing on walking rehabilitation and exercise, particularly those requiring multiple assessment visits, demand rigorous oversight. This cost analysis provides important and critical insight into the expenses required to successfully execute an exercise-based walking rehabilitation trial in the United States.

Financial Cost Analysis Associated with a Locomotor Exercise Randomized Controlled Trial in Chronic Stroke

Background

Post-stroke recovery trials pose distinct recruitment and retention challenges, and understanding the financial requirements of conducting randomized controlled trials is crucial to ensure sufficient resources for successful study execution. The purpose of this analysis was to quantify the costs at a single site with a large catchment area of the Moderate-Intensity Exercise Versus High-Intensity Interval Training to Recover Walking Post-Stroke, HIT Stroke Trial.

Methods

To determine cost, study expense reports were gathered and divided into four categories: oversight, recruitment, retention, and outcome assessments. Categories were then further divided into chronological order for initial contact and prescreening, consenting, initial screening, and baseline testing. The 12-week intervention was divided into 4-week blocks: intervention block 1, post 4-week outcome testing, intervention block 2, post 8-week outcome testing, intervention block 3, and post 12-week outcome testing.

Results

Total direct cost for site execution was $539,768 with cost per participant approximated as $35,984. Oversight costs accounted for 65.8% of the budget at $355,661. To achieve goals related to inclusive participant recruitment ($21,923) and retention ($28,009), our site costs totaled $49,932. Direct study-related costs included screening assessments ($5,905), baseline assessments ($15,028), intervention ($76,952), and outcome assessments ($36,288).

Conclusion

Clinical trials on walking rehabilitation and exercise, especially those involving multiple assessment visits, require intensive oversight. This cost analysis provides important and critical insight into the expenses required to successfully execute an exercise-based walking rehabilitation trial in the United States.

Activity-to-sedentary ratio provides novel insight into mortality reduction among male survivors of cardiovascular disease in the United States: national health and nutrition examination survey, 2007-2014

BACKGROUND

Lower physical activity and sedentary behavior have been identified as modifiable risk factors for cardiovascular disease (CVD). However, the quantitative, dose-response association between activity-to-sedentary ratio (ASR) and mortality is unknown.

METHODS

Prospective cohort studies with participants 50 to 80 years that reported the association between recreational physical activity, sedentary behavior, and all-cause mortality were included from the 2007 to 2014 United States National Health and Nutrition Examination Survey (NHANES) and followed through December 31, 2015. Cox or Weibull regression models and restricted cubic splines were used to determine the association between ASR and all-cause mortality.

RESULTS

Sixty deaths occurred among 498 CVD survivors, with a median of 56 months of follow-up. After accounting for all covariates, CVD survivors with an ASR between 0.21 and 0.57 (hazard ratio [HR], 0.47; 95% confidence interval [CI], 0.25-0.87) and those with an ASR more than 0.57 (HR, 0.40; 95% CI, 0.20-0.81) were at significantly lower risk for mortality than participants with an ASR <  0.21. Moreover, a nonlinear negative association and an L-shaped association were observed for the level of ASR with risk of mortality among CVD survivors (P for nonlinearity = 0.004). What's more, adjusting for covariates, a statistically significant interaction (P for interaction = 0.016) between sex and ASR, an increase of ASR more than and equal to 0.18 was associated with a lower risk of mortality among males (HR, 0.23; 95% CI, 0.12-0.46).

CONCLUSIONS

An negative correlation between ASR and mortality in CVD survivors, especially in males when ASR is more than 0.18. Our novel findings provide further insights into easing the global burden of deaths.

Returning to Leisure Activity Post-Stroke: Barriers and Facilitators to Engagement

OBJECTIVES

To identify barriers and facilitators to engagement when returning to, or participating in, leisure activity post-stroke or Transient Ischemic Attack (TIA).

DESIGN

Sequential explanatory, mixed methods study.

SETTING

21 hospital sites across England, Wales and Northern Ireland.

PARTICIPANTS

Adults with a clinical diagnosis of first/recurrent stroke or TIA. Patients approaching end of life were excluded. Participants were recruited as in-patients or at first clinic appointment and a baseline questionnaire was completed. A 6-month follow-up questionnaire was sent to participants for self-completion. Open-text questions were asked about barriers and facilitators when returning to, or participating in, leisure activity. Responses were thematically analysed and explored by participant characteristics, including type of leisure activity undertaken. Characteristics also included measures of socioeconomic deprivation, mood, fatigue and disability.

RESULTS

2000 participants returned a 6-month follow-up questionnaire (78% stroke, 22% TIA); 1045 participants responded to a question on barriers and 820 on facilitators. Twelve themes were identified and the proportion of responses were reported (%). Barriers: physical difficulties (69%), lower energy levels (17%), loss of independence (11%), psychological difficulties (10%), hidden disabilities (7%), and delay or lack of healthcare provision (3%). Facilitators: family support (35%), healthcare support (27%), well-being and fitness (22%), friendship support (20%), self-management (19%), and returning to normality (9%). 'Physical difficulties' was the most reported barrier across all participant characteristics and activity types. Family support was the most reported facilitator except for those with greater disability, where it was healthcare support and those without fatigue where it was well-being and exercise.

CONCLUSIONS

Physical difficulties and lack of energy are problematic for stroke and TIA survivors who want to return to or participate in leisure activity. Healthcare support alone cannot overcome all practical and emotional issues related to leisure activity engagement. Family support and improving well-being are important facilitators and future research should explore these mechanisms further.

Ambulation status at an acute care hospital predicts pneumonia and mortality in stroke patients: A retrospective cohort study

AIM

Higher post-stroke functional performance is associated with lower mortality in patients with stroke. This study aimed to investigate the relationship between ambulation ability in the acute phase of stroke, and pneumonia and mortality 1 year after stroke onset.

METHODS

This retrospective cohort study included consecutive stroke patients between April 2008 and December 2018. Patients were divided into six groups according to their Functional Ambulation Category score at discharge (0 [unable to walk] to 5 [able to walk independently]). We observed pneumonia cases and all-cause mortality over 1 year, and investigated the association between Functional Ambulation Category score and pneumonia or mortality. Survival analysis was carried out using Kaplan-Meier curves, log-rank tests and Cox regression models.

RESULTS

We analyzed 1727 consecutive patients (median age 77 years; 54% men). During the observation period, 144 patients (8.3%) experienced pneumonia and 157 (9.1%) died. Increasing ambulatory impairment showed stepwise relationships with the risk of pneumonia and mortality. Compared with patients with a Functional Ambulation Category score of 5, those with scores of 4 and 3 showed no significant association with pneumonia risk; a score ≤2 was significantly different. There was a stepwise relationship between increased gait disturbance and risk of death compared with the Functional Ambulation Category 5 group.

CONCLUSIONS

Ambulation ability at discharge from an acute hospital is an important predictor of pneumonia incidence and survival in stroke patients at 1 year; these associations were observed even after controlling for clinical parameters, such as stroke severity and comorbidity. Geriatr Gerontol Int 2022; ••: ••-••.

Determinants of Physical Activity at 90 Days After Acute Stroke or Transient Ischemic Attack in Patients With Home Discharge: A Pilot Study

The aim was to identify the barriers to achieving premorbid physical activity in patients with home discharge after acute minor stroke or transient ischemic attack. Fifty-six patients (median age, 72 years) were analyzed. We assessed total physical activity in the premorbid condition and at 90 days after onset using the International Physical Activity Questionnaire. The patients were divided into two groups according to changes in total physical activity until 90 days after onset: decreased activity (n = 16) and nondecreased activity (n = 40) groups. Outcome measures were examined at discharge. The decreased activity group took significantly longer to perform the timed up and go test (median, 7.19 vs. 6.52 s) and contained more apathetic patients (44% vs. 15%). Apathy at discharge (relative risk 6.05, 95% confidence interval [1.33, 27.6]) was a significant determinant of decreased physical activity. Apathy is a barrier to the restoration of premorbid physical activity in stroke survivors.