Patricia J. Manns

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.

Addressing the Nonexercise Part of the Activity Continuum: A More Realistic and Achievable Approach to Activity Programming for Adults With Mobility Disability?

Participation in physical activity is fundamental for the maintenance of metabolic health and the prevention of major chronic diseases, particularly type 2 diabetes and cardiovascular disease. A whole-of-day approach to physical activity promotion is increasingly advocated and includes not only increasing moderate-intensity physical activity but also reducing sedentary time and increasing light-intensity activity (the “nonexercise” part of the activity continuum). This whole-of-day approach to tackling the challenge of inactivity may be particularly relevant for adults with mobility disabilities, who are among the most inactive segment of the population. Focusing on nonexercise activity by striving to reduce sedentary time and increase light-intensity activity may be a more successful place to begin to change behavior in someone with mobility disability. This article discusses what is known about the metabolic health consequences of sedentary behavior and light-intensity activity in adults with and without mobility disability. The concept of inactivity physiology is presented, along with possible applications or evidence from studies with adults with mobility disability. Mobility disability discussions and examples focus on stroke and spinal cord injury. Finally, clinical implications and future research directions related to sedentary behavior in adults with mobility disability are discussed.

Ambulatory activity of stroke survivors: measurement options for dose, intensity, and variability of activity.

Background and Purpose— Walking activity is an important part of exercise prescription for stroke survivors. The purpose of this study was to: (1) compare ambulatory activity parameters in subacute stroke survivors over three time periods; and (2) discuss options for measurement of ambulatory activity data with respect to absolute activity, intensity of activity, and variability and pattern of activity. Methods— Ten subacute stroke survivors participated (mean±SD; age: 66±15 years; time from stroke to discharge: 75±31 days). Data collection was completed across three time periods, predischarge, 2 weeks postdischarge, and 6 weeks postdischarge. The Step Activity Monitor (Cyma Corporation) was used to measure daily activity parameters. Parameters representing dose, intensity, and variability/pattern of activity were determined using MatLab. Results— Minutes of activity and length of activity bouts significantly increased from predischarge to 6 weeks postdischarge (P=0.030). Conclusions— The measurement of a variety of ambulatory activity parameters may aid clinicians and stroke survivors to determine whether exercise recommendations are being met with daily activity.

Reliability of the Performance and Safety Scores of the Wheelchair Skills Test Version 4.1 for Manual Wheelchair Users

OBJECTIVE To evaluate the interrater, intrarater, and test-retest reliability of the total performance and safety scores of the Wheelchair Skills Test version 4.1 (WST 4.1) for manual wheelchairs operated by adult wheelchair users. DESIGN Cohort study. SETTING University research setting. PARTICIPANTS People (N=11) who used manual wheelchairs for community locomotion. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Participants were videotaped as they completed the WST 4.1 (30 skills) on 2 separate occasions 1 to 2 weeks apart. Subsequently, raters scored the WST 4.1 from the video recordings and each participant received a total score for performance and safety. Using those scores, interrater, intrarater, and test-retest reliability were determined by using intraclass correlation coefficients (ICCs). Percentages of agreement between raters for individual skills also were calculated. RESULTS Mean ± SD overall WST 4.1 scores for performance and safety were 80.1%±8.5% and 98.0%±2.8%. ICCs for the interrater, intrarater, and test-retest reliability of the performance component were .855, .950, and .901 (P<.001). Safety component ICC scores were .061 (P=.243), .228 (P=.048), and .254 (P=.041). Percentages of agreement between raters for each test item for both the performance and safety scales ranged from 68% to 100%. CONCLUSIONS Reliability of the performance component of the WST 4.1 was excellent, whereas ICCs for the safety component indicated only slight to fair agreement, probably because of the low variability in safety scores. Additional study is needed to further evaluate the reliability of the safety component with a larger and more diverse sample group.

Accelerometer‐Derived Pattern of Sedentary and Physical Activity Time in Persons with Mobility Disability: National Health and Nutrition Examination Survey 2003 to 2006

To describe objectively determined sedentary and activity outcomes (volume and pattern) and their associations with cardiometabolic risk biomarkers in individuals with and without mobility disability.

SenseWear Armband and Stroke: Validity of Energy Expenditure and Step Count Measurement during Walking

The purpose of this study was to test the validity of the SenseWear Pro Armband (SWA) for the measurement of energy expenditure (EE) and step count against a criterion in persons with stroke. Twelve participants with chronic stroke (mean age 64.2 ± 10.4 years; mean gait speed 0.67 ± 0.25 m/sec) completed two trials of a six-minute walk test, while wearing a SenseWear Armband (SWA) on each arm and being continuously monitored using a portable metabolic cart. Agreement between estimates of energy expenditure from the SWA and the metabolic cart was fair for the armband on the hemiplegic arm (intraclass correlation cefficient (ICC) = 0.586) and good for the armband on the unaffected arm (ICC = 0.702). Agreement between the SWA estimate of step count, and step count as measured by the Step Activity Monitor was poor (ICC < 0.352), with significant underestimation by the SWA. Our results show that, for these moderately impaired persons with stroke, the SWA should be used with caution for the measurement of energy expenditure and should not be used to measure step count.

Role of conceptual models in a physical therapy curriculum: application of an integrated model of theory, research, and clinical practice.

The Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada, recently implemented a Master of Physical Therapy (MPT) entry-level degree program. As part of the curriculum design, two models were developed, a Model of Best Practice and the Clinical Decision-Making Model. Both models incorporate four key concepts of the new curriculum: 1) the concept that theory, research, and clinical practice are interdependent and inform each other; 2) the importance of client-centered practice; 3) the terminology and philosophical framework of the World Health Organizations International Classification of Functioning, Disability, and Health; and 4) the importance of evidence-based practice. In this article the general purposes of models for learning are described; the two models developed for the MPT program are described; and examples of their use with curriculum design and teaching are provided. Our experiences with both the development and use of models of practice have been positive. The models have provided both faculty and students with a simple, systematic structured framework to organize teaching and learning in the MPT program.

Chronic disease self-management for individuals with stroke, multiple sclerosis and spinal cord injury

Purpose. The purpose of this study was to explore the experience of people with neurological conditions who take the chronic disease self-management (CDSM) programme. The CDSM programme is used to teach skills to manage chronic conditions, and prevent secondary conditions. Few studies have explored the use of the CDSM programme with people with neurological conditions, in spite of the long standing and sometimes unpredictable nature of those conditions. Method. This qualitative study explored the experience of people with stroke, multiple sclerosis (MS) and spinal cord injury (SCI) who participated in the CDSM programme. We completed individual interviews using a semi-structured interview guide with 22 individuals with stroke, MS and SCI. Results. Five categories emerged from the interview discussions including: (1) pre-programme influences; (2) group; (3) factors affecting learning opportunities; (4) workshop content and (5) outcomes. Conclusions. The results of this study provide insights regarding the optimal way to present the CDSM programme to people with neurological conditions.

Cardiac Reserve and Pulmonary Gas Exchange Kinetics in Patients With Stroke

Background and Purpose— Cardiovascular and pulmonary factors contributing to impaired peak oxygen uptake (&OV0312;O2) in patients with stroke (SP) are not well known. We assessed cardiovascular function, pulmonary gas exchange, and ventilation in SP and healthy age, gender, and activity-matched control subjects. Methods— Ten hemiparetic SP and 10 control subjects were enrolled. Subjects completed cycle ergometry testing to assess peak and reserve &OV0312;O2, carbon dioxide production, ventilation (tidal volume; breathing frequency; minute ventilation), and cardiac output. &OV0312;O2, carbon dioxide production, and minute ventilation were measured throughout peak exercise recovery (off-kinetics) and at exercise onset (on-kinetics) along with heart rate during low-level exercise. Results— Peak &OV0312;O2 was 43% lower (P<0.001) in SP secondary to reduced peak and reserve cardiac output and minute ventilation. The impaired cardiac output reserve (P<0.001) was due to a 34% lower heart rate reserve (P=0.001). The impaired minute ventilation reserve (P=0.013) was due to a 41% lower tidal volume reserve (P=0.009). Stroke volume and breathing frequency reserve were preserved. &OV0312;O2 off-kinetics were 29% slower in SP (P<0.001) and related to peak &OV0312;O2 (R=−0.72, P<0.001) and peak cardiac output (R=−0.75, P<0.001) for the study group. Additionally, carbon dioxide production (P=0.016) and minute ventilation (P=0.023) off-kinetics were prolonged in SP. &OV0312;O2 on-kinetics were 29% slower (P=0.031) during low-level exercise in SP. Conclusions— The impaired peak &OV0312;O2 in SP is secondary to a decline in peak and reserve cardiac output and ventilation. Prolonged &OV0312;O2 kinetics in SP are associated in part with deconditioning and may be mediated by reduced O2 availability and/or the rate of muscle O2 use.

Use of the Continuous Scale Physical Functional Performance Test in Stroke Survivors

OBJECTIVE To (1) determine the feasibility of the continuous scale physical functional performance 10-item test (CS-PFP10) for the measurement of physical function in stroke survivors, (2) characterize physical functional performance of stroke survivors and their matched controls, and (3) explore the associations among physical functional performance, ambulatory activity, and peak oxygen uptake (VO2peak). DESIGN Case control. SETTING University research setting. PARTICIPANTS Ten participants with stroke and 10 healthy controls matched for age, sex, and physical activity. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The CS-PFP10 test was used to measure functional ability. The test requires performance of 10 serial tasks that range from low to high difficulty. The step activity monitor was used to measure absolute ambulatory activity and was reported as the average number of steps a day over a 4-day period. VO2peak was determined using a metabolic cart and a recumbent cycle ergometer. RESULTS Stroke survivors scored lower than healthy controls on all individual tasks, domains, and the total score on the CS-PFP10. Higher VO2peak was associated with higher total scores on the CS-PFP10 in both stroke survivors and controls. In stroke survivors, lower levels of impairment (as indicated by the Chedoke-McMaster stroke assessment) were associated with higher total CS-PFP10 scores. CONCLUSIONS The CS-PFP10 is a measure of physical performance that is feasible to use with ambulatory participants with stroke. Future investigations with people with stroke should explore the ability of the CS-PFP10 to provide meaningful information about change in CS-PFP10 subscales with interventions that target items on the subscales, such as balance or upper extremity strength.