Ada Tang

Outcomes in People after Stroke Attending an Adapted Cardiac Rehabilitation Exercise Program: Does Time from Stroke Make a Difference?

BACKGROUND Individuals referred to cardiac rehabilitation programs (CRPs) after stroke have demonstrated postprogram improvements in cardiovascular fitness (VO2peak). However, the effect of CRPs on other physiological/quality-of-life outcomes and effect of time from stroke on these results has not been investigated. The objectives of the present study are (1) to evaluate the effects of a CRP in participants with motor impairment after stroke and (2) to explore the effects of elapsed time from stroke on physiological/quality-of-life outcomes. METHODS The CRP included 24 weeks of resistance and aerobic training. Primary outcomes in 120 participants, 25.4±42.3 (mean±standard deviation) months after stroke, included 6-minute walk distance (6MWD), VO2peak, timed repeated sit-to-stand performance, and affected-side isometric knee extensor strength (IKES). Secondary measures included gait characteristics (cadence, step lengths, and symmetry), walking speed, balance (Berg Balance Scale), affected-side range of motion (ROM), elbow flexor and grip strength, anaerobic threshold, and perceptions of participation/social reintegration. RESULTS After adjusting for multiple comparisons, participants demonstrated significant improvements (all P<.001) in 6MWD (283.2±126.6 to 320.7±141.8 m), sit-to-stand performance (16.3±9.5 to 13.3±7.1 seconds), affected-side IKES (25.9±10.1 to 30.2±11 kg as a percentage of body mass), and VO2peak (15.2±4.5 to 17.2±4.9 mL·kg·min(-1)). Participants also demonstrated post-CRP improvements in secondary outcomes: anaerobic threshold, balance, affected-side hip/shoulder ROM, grip and isometric elbow flexor strength, participation, walking speed, cadence (all P<.001), and bilateral step lengths (P<.04). In a linear regression model, there was a negative association between the change in 6MWD and time from stroke (β=-42.1; P=.002) independent of baseline factors. CONCLUSIONS A CRP yields improvements over multiple domains of recovery; however, those who start earlier demonstrate greater improvement in functional ambulation independent of baseline factors. These data support the use of adapted CRPs as a standard of care practice after conventional stroke rehabilitation.

Effects of exercise on cardiovascular risk factors following stroke or transient ischemic attack: a systematic review and meta-analysis

Objective: This review aimed to investigate the effects of exercise-based interventions on cardiovascular risk factors in individuals with stroke or transient ischemic attack. Data sources: MEDLINE, EMBASE, PsycINFO, and CINAHL were searched from inceptions to 28 December 2016. Review methods: Randomized controlled trials were included that involved exercise with or without other interventions, included participants of any age, with diagnosis of transient ischemic attack or stroke, at any stage of severity or time period following the event, and reported cardiovascular risk factor outcomes. Review Manager (version 5.3) was used to aggregate data from all studies and from those involving only exercise interventions. Results: This review included 18 randomized controlled trials (930 participants) in the qualitative synthesis, 14 of which were included in the quantitative analysis (720 participants; ranging from 84 to 438 participants within individual meta-analyses). All interventions were effective in reducing resting systolic blood pressure (mean difference (MD): −5.32 mmHg, 95% confidence interval (CI): −9.46 to −1.18, P = 0.01), fasting glucose (MD: −0.11 mmol/L, 95% CI: −0.17 to −0.06, P < 0.0001), and fasting insulin (MD: −17.14 pmol/L, 95% CI: −32.90 to −1.38, P = 0.03), and increasing high-density lipoprotein cholesterol (MD: 0.10 mmol/L, 95% CI: 0.03–0.18, P = 0.008). Effects were maintained following meta-analysis of only exercise interventions. Conclusion: Findings suggest that exercise-based interventions are effective in reducing systolic blood pressure, fasting glucose, and fasting insulin, and increasing high-density lipoprotein cholesterol after stroke or transient ischemic attack, providing evidence for their implementation as a strategy for secondary prevention.

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

Introduction Physical exercise after stroke is essential for improving recovery and general health, and reducing future stroke risk. However, people with stroke are not sufficiently active on return to the community after rehabilitation. We developed the Promoting Optimal Physical Exercise for Life (PROPEL) programme, which combines exercise with self-management strategies within rehabilitation to promote ongoing physical activity in the community after rehabilitation. This study aims to evaluate the effect of PROPEL on long-term participation in exercise after discharge from stroke rehabilitation. We hypothesise that individuals who complete PROPEL will be more likely to meet recommended frequency, duration and intensity of exercise compared with individuals who do not complete the programme up to 6 months post discharge from stroke rehabilitation. Methods and analysis Individuals undergoing outpatient stroke rehabilitation at one of six hospitals will be recruited (target n=192 total). A stepped-wedge design will be employed; that is, the PROPEL intervention (group exercise plus self-management) will be ‘rolled out’ to each site at a random time within the study period. Prior to roll-out of the PROPEL intervention, sites will complete the control intervention (group aerobic exercise only). Participation in physical activity for 6 months post discharge will be measured via activity and heart rate monitors, and standardised physical activity questionnaire. Adherence to exercise guidelines will be evaluated by (1) number of ‘active minutes’ per week (from the activity monitor), (2) amount of time per week when heart rate is within a target range (ie, 55%–80% of age-predicted maximum) and (3) amount of time per week completing ‘moderate’ or ‘strenuous’ physical activities (from the questionnaire). We will compare the proportion of active and inactive individuals at 6 months post intervention using mixed-model logistic regression, with fixed effects of time and phase and random effect of cluster (site). Ethics and dissemination To date, research ethics approval has been received from five of the six sites, with conditional approval granted by the sixth site. Results will be disseminated directly to study participants at the end of the trial, and to other stake holders via publication in a peer-reviewed journal. Trial registration number NCT02951338; Pre-results.

Cross-cultural adaptation and psychometric testing of the Arabic version of the Patient-Rated Wrist Hand Evaluation (PRWHE-A) in Saudi Arabia

PURPOSES The purposes of this study was to 1) perform a cross-cultural Arabic translation for the Patient-Rated Wrist and Hand Evaluation (PRWHE-A) using standardized guidelines and, 2) to test the psychometrics properties of the translated measure. METHODS A total of 48 patients with variety of hand disabilities, a mean age of 47 ± 16 years were recruited and assessed two times. The intraclass correlation coefficient (ICC) was used for assessing test-retest reliability of the PRWHE-A and its subscales while Cronbachs alpha (CA) was used for assessing the internal consistency. Construct validity was assessed by examining the strength of the correlation between the PRWHE-A and the Arabic version of the Disability of the Arm, Shoulder and Hand (DASH-A). RESULTS The PRWHE-A demonstrated excellent test-retest reliability (ICC= 0.97) and internal consistency (CA= 0.96). The DASH-A demonstrated moderately to low correlation (r= 0.64) with the PRWHE-A. CONCLUSIONS The results of this study indicated that PRWHE-A is a reliable and valid assessment tool and can be used in patients with different wrist/hand disabilities whose primary language is Arabic.

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

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

FIT for FUNCTION: study protocol for a randomized controlled trial

BackgroundThe current state of evidence suggests that community-based exercise programs are beneficial in improving impairment, function, and health status, and are greatly needed for persons with stroke. However, limitations of these studies include risk of bias, feasibility, and cost issues.Methods/DesignThis single-blinded, randomized controlled trial (RCT) of 216 participants with stroke will compare the effectiveness of a 12-week YMCA community-based wellness program (FIT for FUNCTION) specifically designed for community-dwelling persons with stroke to persons who receive a standard YMCA membership. The primary outcome will be community reintegration using the Reintegration to Normal Living Index at 12 and 24 weeks. Secondary outcomes include measurement of physical activity level using the Rapid Assessment of Physical Activity and accelerometry; balance using the Berg Balance Scale; lower extremity function using the Short Physical Performance Battery; exercise capacity using the 6-min walk test; grip strength and isometric knee extension strength using hand held dynamometry; and health-related quality of life using the European Quality of Life 5-Dimension Questionnaire. We are also assessing cardiovascular health and lipids; glucose and inflammatory markers will be collected following 12-h fast for total cholesterol, insulin, glucose, and glycated hemoglobin. Self-efficacy for physical activity will be assessed with a single question and self-efficacy for managing chronic disease will be assessed using the Stanford 6-item Scale. The Patient Activation Measure will be used to assess the patient’s level of knowledge, skill, and confidence for self-management. Healthcare utilization and costs will be evaluated. Group, time, and group × time interaction effects will be estimated using generalized linear models for continuous variables, including relevant baseline variables as covariates in the analysis that differ appreciably between groups at baseline. Cost data will be treated as non-parametric and analyzed using a Mann–Whitney U test.DiscussionThis is a RCT with broad study eligibility criteria intended to recruit a wide spectrum of individuals living in the community with stroke. If positive benefits are demonstrated, results will provide strong research evidence to support the implementation of structured, community-based exercise and education/self-management programs for a broad range of people living in the community with stroke.Trial registrationClinicalTrials.gov, NCT02703805. Registered on 14 October 2014.

Exploring the Association Between Physical Activity, Sedentary Behaviour and High-Sensitivity C-reactive Protein Among Stroke Survivors

Stroke results in low physical activity, high sedentary behavior (SB), and elevated C-reactive protein (CRP), which are associated with stroke recurrence. This study examined the association between physical activity, SB, and CRP in stroke. CRP data from 185 stroke survivors (Mage = 65 years) from the National Health and Nutritional Examination Survey 2009-2010 were analyzed using weighted regression analysis. There was an interaction between physical activity and SB on CRP (estimated-β = -0.079, 95% confidence interval [-0.14, -0.02], p = .011). SB was associated with CRP among those who did not engage in physical activity (estimated-β = 0.068, 95% confidence interval [0.02, 0.11], p = .005), but not among those who did (estimated-β = 0.0003, 95% confidence interval [-0.03, 0.03], p = .988). Physical activity and SB are important modifiable risk factors to lower the risk of recurrent stroke. These findings provide insight into the inflammatory consequences of SB after stroke, particularly among those who also do not engage in physical activity.

Evaluating a community-based exercise intervention with adults living with HIV: protocol for an interrupted time series study

Introduction Our aim was to evaluate a community-based exercise (CBE) intervention with the goal of reducing disability and enhancing health for community-dwelling people living with HIV (PLWH). Methods and analysis We will use a mixed-methods implementation science study design, including a prospective longitudinal interrupted time series study, to evaluate a CBE intervention with PLWH in Toronto, Canada. We will recruit PLWH who consider themselves medically stable and safe to participate in exercise. In the baseline phase (0–8 months), participants will be monitored bimonthly. In the intervention phase (8–14 months), participants will take part in a 24-week CBE intervention that includes aerobic, resistance, balance and flexibility exercise at the YMCA 3 times per week, with weekly supervision by a fitness instructor, and monthly educational sessions. In the follow-up phase (14–22 months), participants will be encouraged to continue to engage in unsupervised exercise 3 times per week. Quantitative assessment: We will assess cardiopulmonary fitness, strength, weight, body composition and flexibility outcomes followed by the administration of self-reported questionnaires to assess disability and contextual factor outcomes (coping, mastery, stigma, social support) bimonthly. We will use time series regression analysis to determine the level and trend of outcomes across each phase in relation to the intervention. Qualitative assessment: We will conduct a series of face-to-face interviews with a subsample of participants and recreation providers at initiation, midpoint and completion of the 24-week CBE intervention. We will explore experiences and anticipated benefits with exercise, perceived impact of CBE for PLWH and the strengths and challenges of implementing a CBE intervention. Interviews will be audio recorded and analysed thematically. Ethics and dissemination Protocol approved by the University of Toronto HIV/AIDS Research Ethics Board. Knowledge translation will occur with stakeholders in the form of presentations and publications in open access peer-reviewed journals. Trial registration number NCT02794415; Pre-results.