Sarah A. Moore

Physical activity, sedentary behaviour and metabolic control following stroke: a cross-sectional and longitudinal study.

Background Physical activity and sedentary behaviour are key moderators of cardiovascular disease risk and metabolic control. Despite the importance of a physically active lifestyle, little is known about the effects of stroke on physical activity. We assessed physical activity and sedentary behaviour at three time points following stroke compared to a healthy control group. Methods Physical activity and sedentary behaviour were objectively measured using a portable multi-sensor array in 31 stroke participants (73±9 years, National Institute of Health Stroke Scale 2±2, mobile 10 metres with/without aid) within seven days and at three and six months. Stroke data were compared with an age, sex and body mass index matched healthy control group (n = 31). Results Within seven days of stroke, total energy expenditure and physical activity were significantly lower and sedentary time higher in the stroke group compared to controls (total energy expenditure 1840±354 vs. 2220±489 kcal, physical activity 28±32 vs. 79±46 min/day, steps 3111±2290 vs. 7996±2649, sedentary time 1383±42 vs. 1339±44 min/day, p<0.01). At three months physical activity levels had increased (64±58 min/day) but plateaued by six months (66±68 min/day). Conclusions Physical activity levels are reduced immediately post-stroke and remain below recommended levels for health and wellbeing at the three and six month time points. Clinicians should explore methods to increase physical activity and reduce sedentary behaviour in both the acute and later stages following stroke.

Effects of Community Exercise Therapy on Metabolic, Brain, Physical, and Cognitive Function Following Stroke A Randomized Controlled Pilot Trial

Background. Exercise therapy could potentially modify metabolic risk factors and brain physiology alongside improving function post stroke. Objective. To explore the short-term metabolic, brain, cognitive, and functional effects of exercise following stroke. Methods. A total of 40 participants (>50 years, >6 months post stroke, independently mobile) were recruited to a single-blind, parallel, randomized controlled trial of community-based exercise (19 weeks, 3 times/wk, “exercise” group) or stretching (“control” group). Primary outcome measures were glucose control and cerebral blood flow. Secondary outcome measures were cardiorespiratory fitness, blood pressure, lipid profile, body composition, cerebral tissue atrophy and regional brain metabolism, and physical and cognitive function. Results. Exercise did not change glucose control (homeostasis model assessment 1·5 ± 0·8 to 1·5 ± 0·7 vs 1·6 ± 0·8 to 1·7 ± 0·7, P = .97; CI = −0·5 to 0·49). Medial temporal lobe tissue blood flow increased with exercise (38 ± 8 to 42 ± 10 mL/100 g/min; P < .05; CI = 9.0 to 0.1) without any change in gray matter tissue volume. There was no change in medial temporal lobe tissue blood flow in the control group (41 ± 8 to 40 ± 7 mL/100 g/min; P = .13; CI = −3.6 to 6.7) but significant gray matter atrophy. Cardiorespiratory fitness, diastolic blood pressure, high-density lipoprotein cholesterol, physical function, and cognition also improved with exercise. Conclusion. Exercise therapy improves short-term metabolic, brain, physical, and cognitive function, without changes in glucose control following stroke. The long-term impact of exercise on stroke recurrence, cardiovascular health, and disability should now be explored.

Measuring Energy Expenditure After Stroke Validation of a Portable Device

Background and Purpose— Current means of assessing physical activity and energy expenditure have restrictions in stroke, limiting our understanding of its role in therapeutic management. This study validates a portable multisensor array for measuring free-living total energy expenditure compared with a gold standard method (doubly labeled water) in individuals with stroke. Methods— Daily energy expenditure was measured in 9 participants with stroke (73±8 years) over a 10-day period with 2 techniques: a portable multisensor array and doubly labeled water. Results— Bland-Altman analysis revealed a mean difference of 94 kcal/day (3.8%) in total energy expenditure measures given by the multisensor array in comparison to doubly labeled water with lower and upper limits of agreement of −276 to 463.8 kcal/day (2473±468 versus 2380±551, P=0.167). There was strong agreement between the multisensor array and labeled water methods of capturing total daily energy expenditure (r=0.850, P=0.004). Conclusions— The multisensor array is a portable and accurate method of capturing daily energy expenditure and may assist in understanding how stroke influences free-living energy expenditure and aid in clinical management.

Non-alcoholic fatty liver disease is associated with higher levels of objectively measured sedentary behaviour and lower levels of physical activity than matched healthy controls

Background and aims Physical activity is a key determinant of metabolic control and is recommended for people with non-alcoholic fatty liver disease (NAFLD), usually alongside weight loss and dietary change. To date, no studies have reported the relationship between objectively measured sedentary behaviour and physical activity, liver fat and metabolic control in people with NAFLD, limiting the potential to target sedentary behaviour in clinical practice. This study determined the level of sedentary behaviour and physical activity in people with NAFLD, and investigated links between physical activity, liver fat and glucose control. Methods Sedentary behaviour, physical activity and energy expenditure were assessed in 37 adults with NAFLD using a validated multisensor array over 7 days. Liver fat and glucose control were assessed, respectively, by 1H-MRS and fasting blood samples. Patterns of sedentary behaviour were assessed by power law analyses of the lengths of sedentary bouts fitted from raw sedentary data. An age and sex-matched healthy control group wore the activity monitor for the same time period. Results People with NAFLD spent approximately half an hour extra a day being sedentary (1318±68 vs1289±60 mins/day; p<0.05) and walked 18% fewer steps (8483±2926 vs 10377±3529 steps/day; p<0.01). As a consequence, active energy expenditure was reduced by 40% (432±258 vs 732±345 kcal/day; p<0.01) and total energy expenditure was lower in NAFLD (2690±440 vs 2901±511 kcal/day; p<0.01). Power law analyses of the lengths of sedentary bouts demonstrated that patients with NAFLD also have a lower number of transitions from being sedentary to active compared with controls (13±0.03 vs15±0.03%; p<0.05). Conclusions People with NAFLD spend more time sedentary and undertake less physical activity on a daily basis than healthy controls. High levels of sedentary behaviour and low levels of physical activity represent a therapeutic target that may prevent progression of metabolic conditions and weight gain in people with NAFLD and should be considered in clinical care.

Physical activity intensity but not sedentary activity is reduced in chronic fatigue syndrome and is associated with autonomic regulation

BACKGROUND Chronic fatigue syndrome (CFS) is a common debilitating condition associated with reduced function and impaired quality of life. The cause is unknown and treatments limited. Studies confirm that CFS is associated with impaired autonomic regulation and impaired muscle function. AIM Define the relationship between sedentary behaviour, physical activity and autonomic regulation in people with CFS. DESIGN Cohort study. METHODS Physical activity was assessed objectively in 107 CFS patients (Fukuda) and age, sex and body mass index (BMI)-matched sedentary controls (n= 107). Fatigue severity was determined using the Fatigue Impact Scale in all participants and heart rate variability performed in the CFS group. RESULTS The CFS group had levels and patterns of sedentary behaviour similar to non-fatigue controls (P > 0.05). Seventy-nine percent of the CFS group did not achieve the WHO recommended 10,000 steps per day. Active energy expenditure [time >3 METs (metabolic equivalents)] was reduced in CFS when compared with controls (P < 0.0001). Physical activity duration was inversely associated with resting heart rate (P = 0.04; r(2) = 0.03), with reduced activity significantly associating with reduced heart rate variability in CFS. There were no relationships between fatigue severity and any parameter of activity. Thirty-seven percent of the CFS group were overweight (BMI 25-29.9) and 20% obese (BMI ≥ 30). CONCLUSION Low levels of physical activity reported in CFS represent a significant and potentially modifiable perpetuating factor in CFS and are not attributable to high levels of sedentary activity, rather a decrease in physical activity intensity. The reduction in physical activity can in part be explained by autonomic dysfunction but not fatigue severity.

Discrepancy Between Cardiac and Physical Functional Reserves in Stroke

Background and Purpose— Understanding the physiological limitations to exercise after stroke will assist the development of targeted therapies to improve everyday function. This study defines (1) whether exercise capacity is limited by the cardiovascular system (oxygen supply) or skeletal muscles (oxygen utilization); and (2) cardiac function and pumping capability in people with stroke. Methods— Twenty-eight male participants with mild ischemic stroke (70±6 years of age, 18±20 months poststroke) and 25 male, age-matched healthy control subjects performed a graded cardiopulmonary exercise test with gas exchange and noninvasive hemodynamic measurements. Maximal oxygen extraction was calculated as the ratio between peak oxygen consumption and peak cardiac output. Cardiac function and pumping capability were assessed by peak exercise cardiac power output (expressed in watts) and cardiac output. Results— Peak oxygen consumption (18.4±4.6 versus 26.8±5.5 mL/kg/min, P<0.01) and arterial–venous O2 difference (9.3±2.5 versus 12.6±1.9 mlO2/100 mL of blood, P<0.01) were both reduced in stroke participants compared with healthy control subjects. In contrast, peak exercise cardiac power output (4.79±0.79 versus 4.51±0.96 W, P=0.49), cardiac output (16.4±3.1 versus 17.1±2.5 L/min, P=0.41), and the pressure-generating capacity of the heart (127±11 versus 125±14 mm Hg, P=0.97) were similar between stroke participants and healthy control subjects. Conclusions— The ability of skeletal muscles to extract oxygen is diminished after stroke. However, cardiac function and pumping capability are maintained. Appropriate therapies targeting muscle oxygen uptake such as exercise rehabilitation may improve exercise capacity after stroke.

A study of physical activity comparing people with Charcot-Marie-Tooth disease to normal control subjects

Abstract Purpose: Charcot Marie Tooth disease (CMT) describes a group of hereditary neuropathies that present with distal weakness, wasting and sensory loss. Small studies indicate that people with CMT have reduced daily activity levels. This raises concerns as physical inactivity increases the risk of a range of co- morbidities, an important consideration in the long-term management of this disease. This study aimed to compare physical activity, patterns of sedentary behavior and overall energy expenditure of people with CMT and healthy matched controls. Methods: We compared 20 people with CMT and 20 matched controls in a comparison of physical activity measurement over seven days, using an activity monitor. Patterns of sedentary behavior were explored through a power law analysis. Results: Results showed a decrease in daily steps taken in the CMT group, but somewhat paradoxically, they demonstrate shorter bouts of sedentary activity and more frequent transitions from sedentary to active behaviors. No differences were seen in energy expenditure or time spent in sedentary, moderate or vigorous activity. Conclusion: The discrepancy between energy expenditure and number of steps could be due to higher energy requirements for walking, but also may be due to an over-estimation of energy expenditure by the activity monitor in the presence of muscle wasting. Alternatively, this finding may indicate that people with CMT engage more in activities or movement not related to walking. Implications for Rehabilitation Charcot-Marie-Tooth disease: • People with Charcot-Marie-Tooth disease did not show a difference in energy expenditure over seven days compared to healthy controls, but this may be due to higher energy costs of walking, and/or an over estimation of energy expenditure by the activity monitor in a population where there is muscle wasting. This needs to be considered when interpreting activity monitor data in people with neuromuscular diseases. • Compared to healthy controls, people with Charcot-Marie-Tooth disease had a lower step count over seven days, but exhibited more frequent transitions from sedentary to active behaviors • High Body Mass Index and increased time spent sedentary were related factors that have implications for general health status. • Understanding the profile of physical activity and behavior can allow targeting of rehabilitation interventions to address mobility and fitness.

Exercise Induces Peripheral Muscle But Not Cardiac Adaptations After Stroke: A Randomized Controlled Pilot Trial

Objective To explore the physiological factors affecting exercise-induced changes in peak oxygen consumption and function poststroke. Design Single-center, single-blind, randomized controlled pilot trial. Setting Community stroke services. Participants Adults (N=40; age>50y; independent with/without stick) with stroke (diagnosed >6mo previously) were recruited from 117 eligible participants. Twenty participants were randomized to the intervention group and 20 to the control group. No dropouts or adverse events were reported. Interventions Intervention group: 19-week (3times/wk) progressive mixed (aerobic/strength/balance/flexibility) community group exercise program. Control group: Matched duration home stretching program. Main Outcome Measures (1) Pre- and postintervention: maximal cardiopulmonary exercise testing with noninvasive (bioreactance) cardiac output measurements; and (2) functional outcome measures: 6-minute walk test; timed Up and Go test, and Berg Balance Scale. Results Exercise improved peak oxygen consumption (18±5 to 21±5mL/(kg⋅min); P<.01) and peak arterial-venous oxygen difference (9.2±2.7 to 11.4±2.9mL of O2/100mL of blood; P<.01), but did not alter cardiac output (17.2±4 to 17.7±4.2L/min; P=.44) or cardiac power output (4.8±1.3 to 5.0±1.35W; P=.45). A significant relation existed between change in peak oxygen consumption and change in peak arterial-venous oxygen difference (r=.507; P<.05), but not with cardiac output. Change in peak oxygen consumption did not strongly correlate with change in function. Conclusions Exercise induced peripheral muscle, but not cardiac output, adaptations after stroke. Implications for stroke clinical care should be explored further in a broader cohort.

The effect of a community exercise intervention on physiological and physical function following stroke: a randomized, controlled trial

This abstract looks at establishing the effectiveness of combined walking and cognitive training in long-term stroke through a series of N-of-1 studiesIntroduction: To overcome the limitations of the current activity monitoring methods and to effectively investigate early stage functional activities post stroke, we are developing a new computerised Real Time Location System (RTLS).Having previously established excellent RTLS reliability (Intraclass Correlation Coefficients≥0.90), this study aims to determine its validity by comparing it to the Observational Behaviour Mapping Technique (OBMT). Methods: All rooms routinely accessed by patients are fitted with infra-red room locators which send their location codes to specialised Radio-Frequency Identification (RFID) tags. The RFID tags that have in-built motion sensors transmit their location and movement signals to a computer. All participating patients and staff members wear the tags and additional tags are attached to equipment like walking-aids and wheelchairs. Simultaneously, on various days, OBMT is being used to record patients’ location, interaction and activity every ten minutes. Descriptive statistics and Pearson’s Correlation Coefficients (PCCs) are being used for statistical analysis. Results: So far, we have analysed the results for the location category of three patients and have observed only small differences between the two systems for mean time spent in own room (diff=7min; OBMT=550, RTLS=557) and in therapy room (diff=4min; OBMT=90, RTLS=86). Further analysis will involve comparing the methods for time spent in categories like interacting with staff members, doing therapeutic and non therapeutic activities and using equipment. Conclusion: Based on results, we hope to determine that the RTLS is a valid system for continuous, unobtrusive patient activity measurement and can provide much needed quantifiable information about functional recovery post stroke.order Oral Presentations Acute Care 1 Case Reports and Interesting Cases Secondary Prevention Rehabilitation 1 Audit 1 Education Good Practice in User Involvement Health Economics and Impact of Stroke Service Development and Delivery 1 Other Communication Swallowing Nutrition Vision Social and Community Care Vascular Cognitive Impairment Acute Care 2 Rehabilitation 2 Cognitive, Emotional and Psychological Genetics Basic Neuroscience Imaging Audit 2 Service Development and Delivery 2 TIA Primary Prevention Risk Factors of Stroke Exercise After Stroke Assistive Technology IJS_960_Front index.indd iv 11/1/2012 6:33:11 PM

Effects of exercise therapy on metabolic risk factors, brain atrophy and cerebral blood flow following stroke: A randomised controlled trial

Introduction: Impaired cough is associated with higher incidence of pneumonia in acute stroke patients. RMT may improve respiratory muscle and cough function and reduce pneumonia risk. We investigated whether RMT improves cough flow and respiratory muscle function in acute stroke patients. Method: We conducted a single-blind randomised placebo-controlled trial in stroke patients within 2 weeks of onset. Participants were masked to treatment allocation and randomised to 4 weeks of daily inspiratory, expiratory or sham training, using threshold resistance devices. Primary outcome was the change in Peak Expiratory Flow (PEF) of maximal voluntary cough from baseline to 4 weeks. Results: Participants (n = 82, 49 men) had a mean age of 64 (SD 14) years and a median National Institutes of Health Stroke Scale (NIHSS) score of 8 (range 3–25). Mean (SEM) outcomes for the inspiratory, expiratory and sham training group, respectively, were: change in PEF of voluntary cough of 91 (42), 49 (27) and 84 (34) L/min, p = 0.46; change in PEF of reflex cough of –4 (28), 17 (19) and 32 (18) L/min, p = 0.41; change in maximal expiratory mouth pressure of 20 (4), 12 (3) and 12 (4) cmH2O, p = 0.35; and change in maximal inspiratory mouth pressure of 18 (4), 10 (3) and 14 (3) cmH2O, p = 0.40. Pneumonia occurred in 3 (11%), 6 (21%) and 4 (15%) participants per group, respectively (p = 0.65). Discussion: PEF of voluntary cough and maximal mouth pressures improved in all groups, but there was no treatment effect of the interventions. RMT did not augment natural recovery of cough in stroke patients.