Co-designing resources for rehabilitation via telehealth for people with moderate to severe disability post stroke

OBJECTIVES

The COVID-19 pandemic necessitated rapid transition to telehealth. Telehealth presents challenges for rehabilitation of stroke survivors with moderate-to-severe physical disability, which traditionally relies on physical interactions. The objective was to co-design resources to support delivery of rehabilitation via telehealth for this cohort.

DESIGN

Four-stage integrated knowledge translation co-design approach. Stage 1: Research team comprising researchers, clinicians and stroke survivors defined the research question and approach. Stage 2: Workshops and interviews were conducted with knowledge users (participants) to identify essential elements of the program. Stage 3: Resources developed by the research team. Stage 4: Resources reviewed by knowledge users and adapted.

PARTICIPANTS

Twenty-one knowledge users (clinicians n = 11, stroke survivors n = 7, caregivers n = 3) RESULTS: All stakeholders emphasised the complexities of telehealth rehabilitation for stroke and the need for individualised programs. Shared decision-making was identified as critical. Potential risks and benefits of telehealth were acknowledged and strategies to ameliorate risks and deliver effective rehabilitation were identified. Four freely available online resources were co-designed; three resources to support clinicians with shared decision-making and risk management and a decision-aid to support stroke survivors and caregivers throughout the process. Over six months, 1129 users have viewed the webpage; clinician resources were downloaded 374 times and the decision-aid was downloaded 570 times.

CONCLUSIONS

The co-design process identified key elements for delivery of telehealth rehabilitation to stroke survivors with moderate-to-severe physical disability and led to development of resources to support development of an individualised telehealth rehabilitation plan. Future research should evaluate the effectiveness of these resources. CONTRIBUTION OF PAPER.

'How Do I Test the Waters? How Do I Go Forward?': Co-designing a Supportive Pathway after Critical Illness

Rationale: Long-term recovery following critical illness can be affected by Post-intensive Care Syndrome (PICS), a significant burden which can impact return to activities and work. There is need for streamlined support for Intensive Care Unit (ICU) patients in their recovery whilst enduring PICS symptoms. Objectives: To explore critical illness recovery from the experiences, perspectives, and beliefs of former ICU patients, their caregivers, and multidisciplinary clinicians to design a future rehabilitation pathway to support ICU patients. Methods: An experience-based co-design (EBCD) study underpinned by the Behaviour Change Wheel (BCW) framework involving ICU patients ( Collapse

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Affiliation(s)

Alisha A da Silva The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, 85084, Department of Physiotherapy, Melbourne, Victoria, Australia The Royal Melbourne Hospital, 90134, Allied Health, Parkville, Victoria, Australia;
Catherine L Granger The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, 85084, Department of Physiotherapy, Melbourne, Victoria, Australia The Royal Melbourne Hospital, 90134, Allied Health, Parkville, Victoria, Australia
Shaza Abo The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, 85084, Department of Physiotherapy, Melbourne, Victoria, Australia The Royal Melbourne Hospital, 90134, Allied Health, Parkville, Victoria, Australia
Janne Sheehan The Royal Melbourne Hospital, 90134, Allied Health, Parkville, Victoria, Australia
Elizabeth Barson Peter MacCallum Cancer Centre, 3085, Psychology, Melbourne, Victoria, Australia
Lisa Beach The Royal Melbourne Hospital, 90134, Allied Health, Parkville, Victoria, Australia
Gemma Pound St Vincent's Hospital Melbourne Pty Ltd, 60078, Physiotherapy, Fitzroy, Victoria, Australia Monash University Faculty of Medicine Nursing and Health Sciences, 22457, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Clayton, Victoria, Australia
Yasmine Ali Abdelhamid The Royal Melbourne Hospital, 90134, Intensive Care Unit, Parkville, Victoria, Australia The University of Melbourne, 2281, Department of Critical Care, Melbourne Medical School, Melbourne, Victoria, Australia
Kate Fetterplace The Royal Melbourne Hospital, 90134, Allied Health, Parkville, Victoria, Australia The University of Melbourne, 2281, Department of Critical Care, Melbourne Medical School, Melbourne, Victoria, Australia
Natalie A Fini The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, 85084, Department of Physiotherapy, Melbourne, Victoria, Australia
Mark Merolli The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, 85084, Department of Physiotherapy, Melbourne, Victoria, Australia
Evelyn Sloan The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, 85084, Melbourne, Victoria, Australia
Selina M Parry The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, 85084, Department of Physiotherapy, Melbourne, Victoria, Australia The Royal Melbourne Hospital, 90134, Allied Health, Parkville, Victoria, Australia

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Criteria and Indicators for Centers of Clinical Excellence in Stroke Recovery and Rehabilitation: A Global Consensus Facilitated by ISRRA

BACKGROUND

The aim of the International Stroke Recovery and Rehabilitation Alliance is to create a world where worldwide collaboration brings major breakthroughs for the millions of people living with stroke. A key pillar of this work is to define globally relevant criteria for centers that aspire to deliver excellent clinical rehabilitation and generate exceptional outcomes for patients.

OBJECTIVES

This paper presents consensus work conducted with an international group of expert stroke recovery and rehabilitation researchers, clinicians, and people living with stroke to identify and define criteria and measurable indicators for Centers of Clinical Excellence (CoCE) in stroke recovery and rehabilitation. These were intentionally developed to be ambitious and internationally relevant, regardless of a country's development or income status, to drive global improvement in stroke services.

METHODS

Criteria and specific measurable indicators for CoCE were collaboratively developed by an international panel of stroke recovery and rehabilitation experts from 10 countries and consumer groups from 5 countries.

RESULTS

The criteria and associated indicators, ranked in order of importance, focused upon (i) optimal outcome, (ii) research culture, (iii) working collaboratively with people living with stroke, (iv) knowledge exchange, (v) leadership, (vi) education, and (vii) advocacy. Work is currently underway to user-test the criteria and indicators in 14 rehabilitation centers in 10 different countries.

CONCLUSIONS

We anticipate that use of the criteria and indicators could support individual organizations to further develop their services and, more widely, provide a mechanism by which clinical excellence can be articulated and shared to generate global improvements in stroke care.

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

BACKGROUND

Physical activity is important for secondary stroke prevention. Currently, there is inconsistency of outcomes and tools used to measure physical activity following stroke.

AIM

To establish internationally agreed recommendations to enable consistent measurement of post-stroke physical activity.

METHODS

Stroke survivors and carers were surveyed online once regarding what is important in physical activity measurement. Three survey rounds with expert stroke researchers and clinicians were conducted using Keeney's Value-Focused Thinking Methodology. Survey 1 identified physical activity tools, outcomes, and measurement considerations which were ranked in Survey 2. Consensus recommendations on tools were then formulated by the consensus group based on survey responses. In Survey 3, participants reviewed ranked results and evidence gathered to determine their support for consensus recommendations.

RESULTS

Twenty-five stroke survivors, 5 carers, 18 researchers, and 17 clinicians from 16 countries participated. Time in moderate-vigorous physical activity and step count were identified as the most important outcomes to measure. Key measurement considerations included the ability to measure across frequency, intensity, duration domains in real-world settings; user-friendliness, comfort, and ability to detect changes. Consensus recommendations included using the Actigraph, Actical, and Activ8 devices for physical activity intensity; ActivPAL for duration and Step Activity Monitor for frequency; and the IPAQ and PASE questionnaires. Survey 3 indicated 100% support for device and 96% for questionnaire recommendations.

CONCLUSIONS

These consensus recommendations can guide selection of physical activity measurement tools and outcomes. Tool selection will depend on measurement purpose, user-knowledge, and resources. Comprehensive measurement requires the use of devices and questionnaires.

Functional Gait Disorders: Clinical presentations, Phenotypes and Implications for treatment

BACKGROUND

Functional Gait Disorders (FGD) are a common presentation of motor-Functional Neurological Disorders (motor-FND) that affect walking ability.

AIM

To provide a narrative review of the current literature on FGD.

METHODS

A narrative overview of published literature was undertaken, based on a systematic search of relevant databases, authoritative texts and citation tracking.

RESULTS

FGD is multidimensional and disabling, with numerous phenotypes described in the literature, including 'knee buckling,' 'astasia-abasia' and 'excessive slowness.' Motor symptoms such as weakness or tremor, and non-motor symptoms, such as pain and fatigue may contribute to the disability and distress in FGD. Phenotypic features and clinical signs are seen in FGD that demonstrate inconsistency and incongruity with structural disease. A limited number of treatment studies have specifically focussed on FGD, however, reporting of outcomes from motor-FND cohorts has demonstrated short and long-term improvements in walking ability through multidisciplinary rehabilitation.

CONCLUSIONS

The relative contribution of motor and non-motor symptoms in FGD remains unknown, but it is likely that non-motor symptoms increase the illness burden and should be considered during assessment and treatment. Recommended treatment for FGD involves multidisciplinary rehabilitation, but optimum treatment elements are yet to be determined.

Identity, social engagement and community participation impact physical activity levels of stroke survivors: A mixed-methods study

Objective

To explore how personal characteristics and social engagement impact the physical activity levels of chronic stroke survivors.

Design

A mixed-methods study comprising in-depth semi-structured interviews and objective 24-h physical activity monitoring. Interviews were thematically analysed, and activity diaries were compared to activity monitor data to attain a complete picture of physical activity. Triangulation explored the relationship between perceptions, beliefs, activity levels and social engagement.

Setting

Community.

Participants

Community-dwelling, independently mobile, adult stroke survivors (n = 19). The mean age was 74 (11 SD) years, 52% female, mean time post-stroke 41 (SD 61) months.

Main measures

Qualitative and quantitative measures including individual semi-structured interviews, accelerometry, activity diaries, self-efficacy, Frenchay Activities Index and Barthel Index.

Results

Individual identity had the greatest perceived influence on post-stroke physical activity. Pre-stroke identity, meaningful activities and family culture contributed to identity; while social and community activities, self-efficacy, co-morbidities, stroke symptoms and exercise, also impacted physical activity. Participants averaged 5365 (IQR 3378–7854) steps per day and reported a mean self-efficacy for exercise score of 51 (SD 20). Triangulation showed convergent relationships between post-stroke physical activity levels and participant motivation, comorbidities, level of social and community participation, self-efficacy and pre-stroke activity levels.

Conclusion

Personal identity, social engagement and community participation are important factors to consider when implementing a person-centred approach to increasing physical activity participation post-stroke.

Walk the Talk: Current Evidence for Walking Recovery After Stroke, Future Pathways and a Mission for Research and Clinical Practice

Achieving safe, independent, and efficient walking is a top priority for stroke survivors to enable quality of life and future health. This narrative review explores the state of the science in walking recovery after stroke and potential for development. The importance of targeting walking capacity and performance is explored in relation to individual stroke survivor gait recovery, applying a common language, measurement, classification, prediction, current and future intervention development, and health care delivery. Findings are summarized in a model of current and future stroke walking recovery research and a mission statement is set for researchers and clinicians to drive the field forward to improve the lives of stroke survivors and their carers.

Upper-Limb Motor Intervention Elements That Drive Improvement in Biomarkers and Clinical Measures Post-Stroke: A Systematic Review in a Systems Paradigm

Objective

To use a systems paradigm to examine upper limb (UL) motor intervention elements driving biomarker and clinical measure improvement after stroke.

Methods

Databases were searched up to March 2022. Eligibility screening was completed by 2 authors. Studies using biomarkers and clinical measures pre- and post-upper limb intervention were included. Studies of adjunct interventions (eg, brain stimulation) were excluded. Cochrane Risk-of-Bias tools and Template for Intervention Description and Replication were used to rate studies. Studies were synthesized using a systems paradigm: intervention outcome was considered an emergent property of the systemic interactions of 4 intervention elements (demographics, type, quality, and dose) characterized by individual dimensions.

Results

Sixty-four studies (n = 1814 participants) containing 106 intervention groups (66 experimental; 40 control) were included. Combined biomarker and clinical outcomes defined 3 scenarios: restitution, mixed, and unchanged. The restitution scenario included more moderate-to-severely impaired participants in earlier recovery phases (<6 months). Interventions with graded difficulty were more frequently used in the restitution scenario compared with the unchanged scenario. No difference in quality or amount of therapy was identified when examining scenarios that demonstrated restitution compared to those that did not (mixed and unchanged).

Conclusions

A systems paradigm may be one of many approaches to understand UL motor restitution. This review found no single element consistently delivered improvements in biomarkers and clinical measures in the examined intervention groups. Complex patterns formed by multiple interacting intervention elements were observed in participants with and without restitution.

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.

Mobility focussed physical outcome measures over telecommunication technology (Zoom): intra and inter-rater reliability trial (Preprint)

Background

Rehabilitation provided via telehealth offers an alternative to currently limited in-person health care. Effective rehabilitation depends on accurate and relevant assessments that reliably measure changes in function over time. The reliability of a suite of relevant assessments to measure the impact of rehabilitation on physical function is unknown.

Objective

We aimed to measure the intrarater reliability of mobility-focused physical outcome measures delivered via Zoom (a commonly used telecommunication platform) and interrater reliability, comparing Zoom with in-person measures.

Methods

In this reliability trial, healthy volunteers were recruited to complete 7 mobility-focused outcome measures in view of a laptop, under instructions from a remotely based researcher who undertook the remote evaluations. An in-person researcher (providing the benchmark scores) concurrently recorded their scores. Interrater and intrarater reliability were assessed for Grip Strength, Functional Reach Test, 5-Time Sit to Stand, 3- and 4-Meter Walks and Timed Up and Go, using intraclass correlation coefficients (ICC) and Bland-Altman plots. These tests were chosen because they cover a wide array of physical mobility, strength, and balance constructs; require little to no assistance from a clinician; can be performed in the limits of a home environment; and are likely to be feasible over a telehealth delivery mode.

Results

A total of 30 participants (mean age 36.2, SD 12.5 years; n=19, 63% male) completed all assessments. Interrater reliability was excellent for Grip Strength (ICC=0.99) and Functional Reach Test (ICC=0.99), good for 5-Time Sit to Stand (ICC=0.842) and 4-Meter Walk (ICC=0.76), moderate for Timed Up and Go (ICC=0.64), and poor for 3-Meter Walk (ICC=–0.46). Intrarater reliability, accessed by the remote researcher, was excellent for Grip Strength (ICC=0.91); good for Timed Up and Go, 3-Meter Walk, 4-Meter Walk, and Functional Reach (ICC=0.84-0.89); and moderate for 5-Time Sit to Stand (ICC=0.67). Although recorded simultaneously, the following time-based assessments were recorded as significantly longer via Zoom: 5-Time Sit to Stand (1.2 seconds), Timed Up and Go (1.0 seconds), and 3-Meter Walk (1.3 seconds).

Conclusions

Untimed mobility-focused physical outcome measures have excellent interrater reliability between in-person and telehealth measurements. Timed outcome measures took approximately 1 second longer via Zoom, reducing the reliability of tests with a shorter duration. Small time differences favoring in-person attendance are of a similar magnitude to clinically important differences, indicating assessments undertaken using telecommunications technology (Zoom) cannot be compared directly with face-to-face delivery. This has implications for clinicians using blended (ie, some face-to-face and some via the internet) assessments. High intrarater reliability of mobility-focused physical outcome measures has been demonstrated in this study.

Personal and social factors that influence physical activity levels in community-dwelling stroke survivors: A systematic review of qualitative literature

OBJECTIVES

To determine the personal and social factors perceived to influence physical activity levels in stroke survivors.

DATA SOURCES

Four electronic databases (MEDLINE, CINAHL, PubMed and Embase) were searched from inception to November 2020, including reference and citation list searches.

STUDY SELECTION

The initial search yielded 1499 papers, with 14 included in the review. Included articles were peer-reviewed, qualitative studies, reporting on the perceived factors influencing physical activity levels of independently mobile community-dwelling adults, greater than 3 months post stroke.

DATA EXTRACTION

Data extracted included location, study aim, design, participant and recruitment information and how data were collected and analysed.

DATA SYNTHESIS

Thematic analysis was undertaken to identify meanings and patterns, generate codes and develop themes. Five main themes were identified: (i) Social networks are important influencers of physical activity; (ii) Participation in meaningful activities rather than 'exercise' is important; (iii) Self-efficacy promotes physical activity and physical activity enhances self-efficacy; (iv) Pre-stroke identity related to physical activity influences post-stroke physical activity; and (v) Formal programmes are important for those with low self-efficacy or a sedentary pre-stroke identity.

CONCLUSIONS

Physical activity levels in stroke survivors are influenced by social activities and support, pre-stroke identity, self-efficacy levels and completion of activities that are meaningful to stroke survivors.

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.

Dance PREEMIE, a Dance PaRticipation intervention for Extremely prEterm children with Motor Impairment at prEschool age: an Australian feasibility trial protocol

INTRODUCTION

Children born extremely preterm (EP: <28 weeks gestation) and/or extremely low birth weight (ELBW: <1000 g) are at increased risk of motor impairment compared with children born at term. Children with motor impairment have lower rates of physical activity (PA) participation compared with their typically developing peers. PA participation is an important outcome for children with motor impairment, however, there is limited evidence available to support interventions that improve PA participation in this population. The aim of this study is to assess the feasibility, including the recruitment and retention, acceptability and fidelity, of a preschool dance participation intervention for children born EP/EBLW with motor impairment called Dance PaRticipation intervention for Extremely prEterm children with Motor Impairment at prEschool age.

METHODS AND ANALYSIS

This feasibility case series trial will recruit EP/ELBW children with motor impairment (n=10) from the Victorian Infant Collaborative Study 2016/2017 cohort, a prospective longitudinal cohort study. Up to 10 community-based dance teachers will be recruited and provided with physiotherapy-led training and support to facilitate the participation of EP/ELBW children in community dance classes. A mixed-methods approach (quantitative and qualitative) will be used to analyse the primary aim, to determine the feasibility of the intervention from the perspectives of families and dance teachers.

ETHICS AND DISSEMINATION

This study is approved by the Human Research Ethics Committees of The Royal Children's Hospital and The Royal Women's Hospital, Melbourne. Study outcomes will be disseminated through conference presentations, peer-reviewed publications and social media.

TRIAL REGISTRATION NUMBER

ACTRN12619001266156.

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.

Supervised exercise delivered via telehealth in real time to manage chronic conditions in adults: a protocol for a scoping review to inform future research in stroke survivors

INTRODUCTION

Increasing physical activity reduces secondary stroke risk factors, but many stroke survivors have low levels of physical activity. Supervised exercise delivered via telehealth has the potential to overcome barriers to increased physical activity in stroke survivors. Our scoping review will examine the emerging field of supervised exercise delivered via telehealth to map the available evidence in relation to its efficacy, acceptability, safety and feasibility in chronic conditions to inform future research into its ability to increase physical activity.

METHODS AND ANALYSIS

The methodological framework of Arksey and O'Malley will be applied to our scoping review. A systematic search of Medline, CINAHL, Scopus, Cochrane, Pedro and Embase; hand searching of pertinent studies' reference lists; and consultation with experts in the field will identify relevant papers. Studies involving participants with a chronic condition who undertake supervised exercise delivered by a health professional via telehealth targeted at improving secondary stroke risk factors or involving lower limb weight-bearing exercise will be included. Study selection and critical appraisal of individual studies will be carried out independently by two authors with discrepancies resolved by a third author. Quantitative and qualitative data will be charted using a standardised form. Results will be tabulated and narratively summarised to highlight findings relevant to the review's research questions and to inform recommendations for future research.

ETHICS AND DISSEMINATION

Our review will significantly contribute to the knowledge base of exercise and rehabilitation delivered via telehealth and its application in chronic conditions, including stroke. Findings will be relevant to researchers, healthcare workers and policy-makers and will be disseminated through publication and presentations. Only secondary deidentified data will be included, therefore ethics approval will not be sought. This protocol is not registered as PROSPERO currently excludes scoping reviews.

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.

Activity monitors for increasing physical activity in adult stroke survivors

BACKGROUND

Stroke is the third leading cause of disability worldwide. Physical activity is important for secondary stroke prevention and for promoting functional recovery. However, people with stroke are more inactive than healthy age-matched controls. Therefore, interventions to increase activity after stroke are vital to reduce stroke-related disability.

OBJECTIVES

To summarise the available evidence regarding the effectiveness of commercially available, wearable activity monitors and smartphone applications for increasing physical activity levels in people with stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, SPORTDiscus, and the following clinical trial registers: WHO International Clinical Trials Registry Platform, Clinical Trials, EU Clinical Trial Register, ISRCTN Registry, Australian and New Zealand Clinical Trial Registry, and Stroke Trials Registry to 3 March 2018. We also searched reference lists, Web of Science forward tracking, and Google Scholar, and contacted trial authors to obtain further data if required. We did not restrict the search on language or publication status.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) and randomised cross-over trials that included use of activity monitors versus no intervention, another type of intervention, or other activity monitor. Participants were aged 18 years or older with a diagnosis of stroke, in hospital or living in the community. Primary outcome measures were steps per day and time in moderate-to-vigorous intensity activity. Secondary outcomes were sedentary time, time spent in light intensity physical activity, walking duration, fatigue, mood, quality of life, community participation and adverse events. We excluded upper limb monitors that only measured upper limb activity.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology to analyse and interpret the data. At least two authors independently screened titles and abstracts for inclusion. We resolved disagreements by consulting a third review author. We extracted the following data from included studies into a standardised template: type of study, participant population, study setting, intervention and co-interventions, time-frame, and outcomes. We graded levels of bias as high, low, or unclear, and assessed the quality of evidence for each outcome using the GRADE approach.

MAIN RESULTS

We retrieved 28,098 references, from which we identified 29 potential articles. Four RCTs (in 11 reports) met the inclusion criteria.The sample sizes ranged from 27 to 135 (total 245 participants). Time poststroke varied from less than one week (n = 1), to one to three months (n = 2), or a median of 51 months (n = 1). Stroke severity ranged from a median of one to six on the National Institutes of Health Stroke Scale (NIHSS). Three studies were conducted in inpatient rehabilitation, and one was in a university laboratory. All studies compared use of activity monitor plus another intervention (e.g. a walking retraining programme or an inpatient rehabilitation programme) versus the other intervention alone. Three studies reported on the primary outcome of daily step counts.There was no clear effect for the use of activity monitors in conjunction with other interventions on step count in a community setting (mean difference (MD) -1930 steps, 95% confidence interval (CI) -4410 to 550; 1 RCT, 27 participants; very low-quality evidence), or in an inpatient rehabilitation setting (MD 1400 steps, 95% CI -40 to 2840; 2 RCTs, 83 participants; very low-quality evidence). No studies reported the primary outcome moderate-to-vigorous physical activity, but one did report time spent in moderate and vigorous intensity activity separately: this study reported that an activity monitor in addition to usual inpatient rehabilitation increased the time spent on moderate intensity physical activity by 4.4 minutes per day (95% CI 0.28 to 8.52; 1 RCT, 48 participants; low-quality evidence) compared with usual rehabilitation alone, but there was no clear effect for the use of an activity monitor plus usual rehabilitation for increasing time spent in vigorous intensity physical activity compared to usual rehabilitation (MD 2.6 minutes per day, 95% CI -0.8 to 6; 1 RCT, 48 participants; low-quality evidence). The overall risk of bias was low, apart from high-risk for blinding of participants and study personnel. None of the included studies reported any information relating to adverse effects.

AUTHORS' CONCLUSIONS

Only four small RCTs with 274 participants (three in inpatient rehabilitation and one in the community) have examined the efficacy of activity monitors for increasing physical activity after stroke. Although these studies showed activity monitors could be incorporated into practice, there is currently not enough evidence to support the use of activity monitors to increase physical activity after stroke.

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.

How Physically Active Are People Following Stroke? Systematic Review and Quantitative Synthesis

BACKGROUND

Mobility limitations are common following stroke and frequently lead to poor participation in physical activity (PA).

PURPOSE

The purpose of this study was to describe PA across the various stages following stroke (acute, subacute, and chronic).

DATA SOURCES

Searches were conducted in 5 databases.

STUDY SELECTION

Eligible studies included participants with stroke whose PA was quantitatively measured for at least 4 hours in a single session. Two reviewers independently reviewed titles and abstracts.

DATA EXTRACTION

One reviewer extracted data and assessed quality using the Downs and Black checklist. Weighted means were calculated for PA outcomes.

DATA SYNTHESIS

Searches yielded 103 eligible papers including 5306 participants aged 21 to 96 years. Devices (eg, activity monitors) were used in 73 papers, and behavioral mapping (observational monitoring) in 30. Devices show that people with stroke took on average 5535 steps per day (n = 406, 10 studies) in the subacute phase and 4078 steps (n = 1280, 32 studies) in the chronic phase. Average daily walking duration (% measured time) was higher in the chronic phase (9.0%, n = 100) than subacute (1.8%, n = 172), and sedentary time was >78% regardless of time post stroke. Acute data were lacking for these variables. Matched healthy individuals took an average of 8338 steps per day (n = 129). Behavioral mapping showed time in bed was higher in the acute than subacute phase (mean 45.1% versus 23.8%), with similar time spent sitting (mean 37.6% versus 32.6%).

LIMITATIONS

Limitations of this review include not pooling data reported as medians.

CONCLUSIONS

Physical activity levels do not meet guidelines following stroke. Time spent inactive and sedentary is high at all times. Increasing PA and developing standardized activity targets may be important across all stages of stroke recovery.