Coralie English

Physical Activity and Sedentary Behaviors in People With Stroke Living in the Community: A Systematic Review

Background Regular physical activity is vital for cardiovascular health. Time spent in sedentary behaviors (eg, sitting, lying down) also is an independent risk factor for cardiovascular disease. The pattern in which sedentary time is accumulated is important—with prolonged periods of sitting time being particularly deleterious. People with stroke are at high risk for cardiovascular disease, including recurrent stroke. Purpose This systematic review aimed to update current knowledge of physical activity and sedentary behaviors among people with stroke living in the community. A secondary aim was to investigate factors associated with physical activity levels. Data Sources The data sources used were MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complimentary Medicine Database (AMED), EMBASE, and the Cochrane Library. Study Selection Studies involving people with stroke living in the community and utilizing objective measures of physical activity or sedentary behaviors were included. Data Extraction Data were extracted by one reviewer and checked for accuracy by a second person. Data Synthesis Twenty-six studies, involving 983 participants, were included. The most common measure of activity was steps per day (22 studies), which was consistently reported as less than half of age-matched normative values. Only 4 studies reported on sedentary time specifically. No studies described the pattern by which sedentary behaviors were accumulated across the day. Walking ability, balance, and degree of physical fitness were positively associated with higher levels of physical activity. Limitations This review included only studies of people living in the community after stroke who were able to walk, and the majority of included participants were aged between 65 and 75 years of age. Conclusions Little is known about the time people with stroke spend being sedentary each day or the pattern in which sedentary time is accumulated. Studies using objective, reliable, and valid measures of sedentary time are needed to further investigate the effects of sedentary time on the health of people with stroke.

Loss of skeletal muscle mass after stroke: a systematic review.

Loss of muscle mass after stroke has implications for strength and functional ability and may also contribute to impaired glucose metabolism. Therefore, prevention of muscle loss is desirable. Before interventions to prevent loss of muscle can be designed and evaluated, the expected rate, magnitude and timing of muscle loss need to be understood. A systematic search was undertaken to identify all studies that investigated changes in skeletal muscle mass, volume or cross-sectional area in people after stroke. Studies that used either direct measures of muscle size (computer tomography, magnetic resonance imaging or ultrasound) or measures of lean tissue mass (dual X-ray absorptiometry) were included. Fourteen trials were found and the results were pooled for differences in lean tissue mass between the paretic and the nonparetic leg and arm as well as differences in the midthigh cross-sectional area. In individuals at least 6-month post-stroke, there was significantly less lean tissue mass in the paretic compared with the nonparetic lower limb (MD 342.3 g, 95% confidence interval 247.0–437.6 g) and upper limb (MD 239.9 g, 95% confidence interval 181.7–298.2 g), and significantly less midthigh muscle cross-sectional area (MD 15.4 cm2, 95% confidence interval 13.8–16.9 cm2). There were insufficient data to pool with regard to change in muscle mass over time. There is a significant difference in the regional muscle mass in the paretic vs. the nonparetic limb in individuals greater than 6-months poststroke but little is known about how early and how quickly changes in muscle mass occur.

The sensitivity of three commonly used outcome measures to detect change amongst patients receiving inpatient rehabilitation following stroke.

Objective: To investigate the sensitivity of three commonly used functional outcome measures to detect change over time in subjects receiving inpatient rehabilitation post stroke. Design: Subjects were assessed within one week of admission and one week of discharge from an inpatient rehabilitation facility. Several parameters of sensitivity were calculated, including floor and ceiling effects, the percentage of subjects showing no change and the effect size of the change between admission and discharge. Setting: The medical rehabilitation ward of an inpatient rehabilitation facility. Subjects: Seventy-eight subjects receiving inpatient rehabilitation following a first or recurrent stroke. Measures: Five-metre walk, comfortable pace (gait speed), the Berg Balance Scale and the Motor Assessment Scale. Results: Sixty-one subjects had complete admission and discharge data. Gait speed and the Berg Balance Scale were both sensitive to change and demonstrated large effect sizes. The Motor Assessment Scale item five also showed a large effect size and was able to detect change amongst lower functioning subjects. The other items of the Motor Assessment Scale were less useful, in particular, the effect sizes for upper extremity change scores were small (d=0.36–0.5) and the majority of subjects (44.3–63.9%) showed no change over time on these measures. Conclusion: Gait speed, the Berg Balance Scale and the Motor Assessment Scale item five were sensitive to change over time in this sample.

Ultrasound measures of muscle thickness: intra-examiner reliability and influence of body position

Ultrasound is an inexpensive and practical alternative to gold standard measures of muscle mass. Changes in body position may lead to intra‐muscular fluid shifts that may affect the reliability of ultrasound measures. We assessed test–retest reliability of ultrasound measures of muscle thickness and the effect of position on these measures. Measures of muscle thickness were made from B‐mode ultrasound images in 18 healthy participants. Repeated measurements were made by one examiner from two participant positions; standing and recumbent, from 18 anatomical sites. Results demonstrated high test–retest reliability for measures taken in both participant positions [intra‐class coefficient (ICC) scores 0·65 to 0·94], except for the recumbent posterior lower leg measures (ICC 0·34). Recumbent measures were significantly smaller than those taken with participants standing. Length of time participants spent lying down did not significantly affect measures, indicating that any changes in intra‐muscular fluid related to the time spent recumbent are negligible.

Sitting and activity time in people with stroke

Background Excessive sitting time is linked to cardiovascular disease morbidity. To date, no studies have accurately measured sitting time patterns in people with stroke. Objective The purpose of this study was to investigate the amount and pattern of accumulation of sitting time, physical activity, and use of time in people with stroke compared with age-matched healthy peers. Design This study used an observational design. Methods Sitting time (total and time accumulated in prolonged, unbroken bouts of ≥30 minutes) was measured with an activity monitor. Physical activity and daily energy expenditure were measured using an accelerometer and a multisensory array armband, respectively. All monitors had a 7-day wear protocol. Participants recalled 1 day of activity (during monitor wear time) using the Multimedia Activity Recall for Children and Adults. Results Sixty-three adults (40 with stroke and 23 age-matched healthy controls) participated. The participants (35% female, 65% male) had a mean age of 68.4 years (SD=10.0). Participants with stroke spent significantly more time sitting (X̅=10.9 h/d, SD=2.0) compared with controls (X̅=8.2 h/d, SD=2.0), with much of this sitting time prolonged (stroke group: X̅=7.4 h/d, SD=2.8; control group: X̅=3.7 h/d, SD=1.7). Participants with stroke accumulated most of their sitting time while watching television and in general quiet time, whereas control participants spent more time reading and on the computer. Physical activity and daily energy expenditure were lower in the stroke group compared with the control group. Limitations A sample of convenience was used to select participants for the stroke and control groups, which may reduce the generalizability of results. Conclusions Participants with stroke spent more time sitting and less time in activity than their age-matched peers. Further work is needed to determine whether reducing sitting time is feasible and leads to clinically important reductions in cardiovascular risk in this population.

Standardized measurement of sensorimotor recovery in stroke trials: consensus-based core recommendations from the Stroke Recovery and Rehabilitation Roundtable

Finding, testing and demonstrating efficacy of new treatments for stroke recovery is a multifaceted challenge. We believe that to advance the field, neurorehabilitation trials need a conceptually rigorous starting framework. An essential first step is to agree on definitions of sensorimotor recovery and on measures consistent with these definitions. Such standardization would allow pooling of participant data across studies and institutions aiding meta-analyses of completed trials, more detailed exploration of recovery profiles of our patients and the generation of new hypotheses. Here, we present the results of a consensus meeting about measurement standards and patient characteristics that we suggest should be collected in all future stroke recovery trials. Recommendations are made considering time post stroke and are aligned with the international classification of functioning and disability. A strong case is made for addition of kinematic and kinetic movement quantification. Further work is being undertaken by our group to form consensus on clinical predictors and pre-stroke clinical data that should be collected, as well as recommendations for additional outcome measurement tools. To improve stroke recovery trials, we urge the research community to consider adopting our recommendations in their trial design.

How Physically Active Are People with Stroke in Physiotherapy Sessions Aimed at Improving Motor Function? A Systematic Review

Background. Targeted physical activity drives functional recovery after stroke. This review aimed to determine the amount of time stroke survivors spend physically active during physiotherapy sessions. Summary of Review. A systematic search was conducted to identify published studies that investigated the use of time by people with stroke during physiotherapy sessions. Seven studies were included; six observational and one randomised controlled trial. People with stroke were found to be physically active for an average of 60 percent of their physiotherapy session duration. The most common activities practiced in a physiotherapy session were walking, sitting, and standing with a mean (SD) practice time of 8.7 (4.3), 4.5 (4.0), and 8.3 (2.6) minutes, respectively. Conclusion. People with stroke were found to spend less than two-thirds of their physiotherapy sessions duration engaged in physical activity. In light of dosage studies, practice time may be insufficient to drive optimal motor recovery.

Reliability of real-time ultrasound for measuring skeletal muscle size in human limbs in vivo: a systematic review:

Objective: To systematically review evidence for the reliability of real-time brightness-mode ultrasound for assessing skeletal muscle size in human limbs in vivo and to establish in which populations and anatomical sites the reliability had been tested. Data sources: Articles were retrieved via electronic database searching and expert contact. Study selection: Studies reporting reliability indices of test–retest measures of real-time brightness-mode ultrasound measures of skeletal muscle size within human limbs were included. Data extraction: Articles were assessed for methodological quality by two reviewers, decisions were made by consensus. Participant characteristics, measurement protocol, ultrasound protocol, type of reliability measured and statistical methods were extracted by one reviewer. Data synthesis: Twenty-four articles were included, involving 605 participants. Studies were of low to moderate methodological quality. Most studies were conducted within the healthy population. Only one study demonstrated poor reliability at one site only, and only when the participants were measured in the supine position. Conclusion: There is a moderate amount of low-level evidence that real-time brightness-mode ultrasound has good reliability for measuring muscle size across a number of limb sites in healthy populations. There is limited evidence for the reliability of ultrasound measures of muscle size in clinical populations.

Early Mobilization After Stroke: Early Adoption but Limited Evidence

In the last decade, increasing attention has been paid to understanding the components of care that might contribute to the stroke unit effect. Early mobilization, in its many guises, is one component of care proposed to contribute to the survival and recovery benefits of stroke unit care.1 This topical review provides an overview of the current evidence, research, and practice recommendations for early mobilization after stroke. As a term, early mobilization is problematic. There is no common understanding of the meaning of early (eg, hours, days, weeks, months) or mobilization (movement of, eg, cells, joints, limbs, people). A recurring theme in this review, inadequate definition currently limits our ability to synthesize information on the topic. For example, in some clinical trials of mobility interventions started soon after stroke, mobilization is used to describe a program of task-specific standing and walking retraining (rehabilitation) delivered by therapists or nurses and continued throughout the acute hospital stay.2,3 In other cases, mobilization refers simply to moving a patients’ limbs in bed or sitting them out of bed. The timing of commencement of activity is also highly variable and often hard to determine. As both what we do (intervention type, intensity, frequency, amount), and when we do it, may confer benefit or harm, we highlight variations in definition where relevant. We have focused our review on out-of-bed interventions commencing in the first 24 to 72 hours after stroke, as this is the period of greatest clinical uncertainty. Early mobilization was first discussed at a Swedish consensus conference on stroke care in the mid-1980s (Bo Norving and Bent Indredavik, personal communication, 2014) with several local guidelines in Norway and Sweden recommending the practice. Early mobilization became more prominent in the literature in the early 1990s when Indredavik and colleagues reported their clinical …

Circuit class therapy or seven-day week therapy for increasing rehabilitation intensity of therapy after stroke (CIRCIT): a randomized controlled trial

Background Increased therapy has been linked to improvements in functional ability of people with stroke. Aim To determine the effectiveness of two alternative models of increased physiotherapy service delivery (seven-day week therapy or group circuit class therapy five days a week) to usual care. Method Three-armed randomized controlled trial with blinded assessment of outcome. People admitted with a diagnosis of stroke, previously independently ambulant and with a moderate level of disability were recruited. ‘Usual care’ was individual physiotherapy provided five-days a week. Seven-day week therapy was usual care physiotherapy provided seven-days a week. Participants in the circuit class therapy arm of the trial received physiotherapy in group circuit classes in two 90-min sessions, five-days a week. Primary outcome was distance walked on the six-minute walk test at four-weeks post-randomization. Results Two hundred eighty-three participants were randomized; primary outcome data were available for 259 (92%). In the seven-day arm participants received an additional three hours of physiotherapy and thosein the circuit class armanadditional 22 h. There were no significant between-group differences at four-weeks in walking distance (P = 0·72). Length of stay was shorter for seven-day (mean difference −2·9 days, 95% confidence interval −17·9 to 12·0) and circuit class participants (mean difference −9·2 days, 95% confidence interval −24·2 to 5·8) compared to usual care, but this was not significant. Conclusions Both seven-day therapy and group circuit class therapy increased physiotherapy time, but walking outcomes were equivalent to usual care.