Torunn Askim

Evaluation of a Body-Worn Sensor System to Measure Physical Activity in Older People With Impaired Function

Background There is limited information on reliable and valid measures of physical activity in older people with impaired function. Objective This study was conducted to compare the accuracy of single-axis accelerometers in recognizing postures and transitions and step counting with the accuracy of video recordings in people with stroke (n=14), older inpatients (n=14), people with hip fracture (n=8), and a reference group of 10 adults who were healthy. Design This was a cross-sectional study, evaluating the concurrent validity of small body-worn accelerometers against video observations as the criterion measure. Methods Activity data were collected from 3 sensors (activPAL) attached to the thighs and the sternum and from registration of the same activities from video recordings. Participants performed a test protocol of in-bed, transfer, and walking activities. Results The sensor system was highly accurate in classifying lying, sitting, and standing positions (100%) and in recognizing transitions from lying to sitting positions and from sitting to standing positions (100%). Placement of a sensor on the nonaffected leg resulted in less underestimation of step counts than placement on the affected leg. Still, the sensor system underestimated step counts during walking, especially at slow walking speeds (≤0.47 m/s) (limits of agreement=−2.01 to 16.54, absolute percent error=40.31). Limitations The study was performed in a controlled setting and not during the natural performance of activities. Conclusions The activPAL sensor system provides valid measures of postures and transitions in older people with impaired walking ability. Step counting needs to be improved for the sensor system to be acceptable for this population, especially at slow walking speeds.

Motor Network Changes Associated With Successful Motor Skill Relearning After Acute Ischemic Stroke : A Longitudinal Functional Magnetic Resonance Imaging Study

Background. Motor learning mechanisms may be operative in stroke recovery and possibly reinforced by rehabilitative training. Objectives. To assess early motor network changes after acute ischemic stroke in patients treated with very early mobilization and task-oriented physical therapy in a comprehensive stroke unit, to investigate the association between neuronal activity and improvements in hand function, and to qualitatively explore the changes in neuronal activity in relation to motor learning. Methods. Patients were assessed by functional magnetic resonance imaging and by clinical tests within the first week after stroke and 3 months later. After discharge, all participants were offered functional training of the affected arm according to individual needs. Results. A total of 359 patients were screened, with 12 patients experiencing first-ever stroke, excluding primary sensorimotor cortex (MISI), with severe to moderately impaired hand function fulfilling the inclusion criteria. Laterality indexes (LIs) for MISI increase significantly during follow-up. There is increased cerebellar and striatal activation acutely, replaced by increased activation of ipsilesional MISI in the chronic phase. Bilateral somatosensory association areas and contralesional secondary somatosensory cortex (SII) area are also more active in the chronic phase. Activation of the latter region also correlates positively with improved hand function. Conclusions. Restoration of hand function is associated with highly lateralized MISI. Activity in bilateral somatosensory association area and contralesional SII may represent cortical plasticity involved in successful motor recovery. The changes in motor activity between acute and chronic phases seem to correspond to a motor learning process.

Short- and long-term outcome of constraint-induced movement therapy after stroke: a randomized controlled feasibility trial

Objective: Constraint-induced movement therapy (CIMT) is a method to improve motor function in the upper extremity following stroke. The aim of this trial was to determine the effect and feasibility of CIMT compared with traditional rehabilitation in short and long term. Design: A randomized controlled trial. Setting: An inpatient rehabilitation clinic. Subjects: Thirty patients with unilateral hand impairment after stroke. Intervention: Six hours arm therapy for 10 consecutive weekdays, while using a restraining mitten on the unaffected hand. Main measures: The patients were assessed at baseline, post-treatment and at six-month follow-up using the Wolf Motor Function Test as primary outcome measure and the Motor Activity Log, Functional Independence Measure and Stroke Impact Scale as secondary measurements. Results: The CIMT group (n=18) showed a statistically significant shorter performance time (4.76 seconds versus 7.61 seconds, P= 0.030) and greater functional ability (3.85 versus 3.47, P= 0.037) than the control group (n=12) on the Wolf Motor Function Test at post-treatment assessment. There was a non-significant trend toward greater amount of use (2.47 versus 1.97, P= 0.097) and better quality of movement (2.45 versus 2.12, P=0.105) in the CIMT group according to the Motor Activity Log. No such differences were seen on Functional Independence Measure at the same time. At six-month follow-up the CIMT group maintained their improvement, but as the control group improved even more, there were no significant differences between the groups on any measurements. Conclusions: CIMT seems to be an effective and feasible method to improve motor function in the short term, but no long-term effect was found.

Evaluation of an extended stroke unit service with early supported discharge for patients living in a rural community. A randomized controlled trial

Objective: To evaluate the effect of an extended stroke unit service (extended service), with early supported discharge and co-ordination of further rehabilitation in co-operation with the primary health care system in three rural municipalities. Design: A randomized controlled trial comparing extended service with ordinary stroke unit service (ordinary service). Subjects: Sixty-two eligible patients with acute stroke living in the rural municipalities of Malvik, Melhus and Klñ bu. Main measures: The primary outcome was the proportion of patients who were independent according to Modified Rankin Scale (mRS) (independence = mRS < 2) 52 weeks after onset of stroke. Secondary outcomes were mRS at 6 and 26 weeks and Barthel Index (BI), Nottingham Health Profile (NHP) and Caregiver Strain Index (CSI) at 6, 26 and 52 weeks. Mortality and length of stay were registered during the 52 weeks. Results: Twelve patients (39%) in the extended service group versus 16 patients (52%) in the ordinary service group were independent according to mRS at 52 weeks (p= 0.444). The odds ratio for independence (extended service versus ordinary service) was 0.33 (95% confidence interval (CI) 0.088 –1.234). According to outcome by secondary measures there were no significant differences except less social isolation on NHP in the extended service group at 26 weeks (p= 0.046). There were no significant differences in length of stay. Conclusion: An extended stroke unit service with early supported discharge seems to have no positive effect on functional outcome for patients living in rural communities, but might give a trend toward better quality of life. There were no significant differences in length of stay.

Effects of a Community-Based Intensive Motor Training Program Combined With Early Supported Discharge After Treatment in a Comprehensive Stroke Unit A Randomized, Controlled Trial

Background and Purpose— Increased amount of therapy seems to be beneficial for motor recovery after stroke. The primary aim of the present study was to evaluate the effect of a 4-week community-based intensive motor training program combined with early supported discharge after initial treatment in a comprehensive stroke unit on balance. Secondary aims were to evaluate the effect on other functional outcome measures. Methods— This was a single-blind, randomized, controlled trial with a 26-week follow-up. Sixty-two patients were recruited within 14 days after stroke and were randomly allocated to a standard treatment group (n=32) or to an intensive motor training group (n=30) receiving 3 sessions of physical therapy and a structured home exercise program in addition to standard treatment every week for the first 4 weeks after discharge from hospital. Primary outcome measure was Berg Balance Scale. Secondary measures were Barthel Index, Motor Assessment Scale, Step Test, 5-meter Walk Test, and Stroke Impact Scale. Results— The mean (SD) minutes of physical therapy per week was 171.0 (65.8) in the intensive motor training group vs 85.6(69.9) in the standard treatment group. There were no statistical significant differences between the groups on any measure at end of follow-up except for a trend toward higher Motor Assessment Scale score (P=0.059) and gait speed (P=0.095) in the intensive motor training group. Conclusion— In this randomized, controlled trial, a community-based intensive motor training program, doubling the amount of physical therapy during the first 4 weeks after discharge, did not show significant improvement of balance or any other functional outcomes.

ARM uSE IN PATIENTS WITH SuBACuTE STRoKE MoNIToRED BY ACCELERoMETRY: ASSoCIATIoN WITH MoToR IMPAIRMENT AND INFLuENCE oN SELF-DEPENDENCE

OBJECTIVE To assess the effect of arm motor impairment on actual arm use in the early post-stroke period and explore its association with self-care dependency. SUBJECTS Thirty-one patients recruited within the 30 first days after stroke. METHODS Motor impairment of the upper extremity was measured with Fugl-Meyer Motor Assessment (FMA) and arm use was measured with accelerometry. Arm movement ratio (AMR), the ratio of arm use duration between the more and less affected arm, was calculated. Self-care dependency was defined as needing personal assistance in primary self-care activities. RESULTS FMA of the more affected arm was strongly associated with AMR (Spearmans correlation coefficient -0.851, p>0.001), although some patients deviated considerably from the regression line. Covariates did not have any influence on this relation. Both arm motor function and actual arm use related to self-care dependency, but were no longer significant when we controlled for lower extremity motor function. CONCLUSION FMA and AMR correlated highly in the early post-stroke period. These measures relate to different dimensions of the International Classification of Functioning and Health, and could be supplementary measures to reveal non-use of the affected arm. Arm use and arm impairment were not significantly associated with self-care dependency in our sample.

Stroke patients do not need to be inactive in the first two-weeks after stroke: results from a stroke unit focused on early rehabilitation

Background Although stroke unit care with early rehabilitation is recommended for most stroke patients, the content of the treatment given to acute stroke patients differs a lot. Aim The primary aim of this study was to describe the activity patterns of acute stroke patients managed in a stroke unit focused on early rehabilitation. Methods Patients admitted to the stroke unit at St. Olavs Hospital, Trondheim, with the diagnosis of stroke were asked to participate. Patients were eligible if they were less than 14 days post stroke and did not receive palliative care. Patients were observed every 10 mins from 8:00 am to 5:00 pm, and activity, location, and who helped them were recorded. Results A total of 117 patients (mean age 78·7 years; 56% male) were included. In total, patients spent 30·3% of time in bed, 46·4% of time in sitting out of bed, and 19·9% of time in higher motor activities such as transferring, standing, walking, or climbing stairs. Patients with mild, moderate, and severe stroke spent 79·5%, 59·2%, and 31·0% of observed time sitting out of bed or engaged in higher motor activities, respectively. Conclusion This study shows that it is possible for acute stroke patients to spend most of the active day out of bed and to engage in higher motor activities up to 20% of the time. It also shows that it is feasible for severely affected stroke patients to stay out of bed in the early phase after stroke.

Efficacy of Constraint-Induced Movement Therapy in Early Stroke Rehabilitation A Randomized Controlled Multisite Trial

Background. There is limited evidence for the effects of constraint-induced movement therapy (CIMT) in the early stages of stroke recovery. Objective. To evaluate the effect of a modified CIMT within 4 weeks poststroke. Methods. This single-blinded randomized multisite trial investigated the effects of CIMT in 47 individuals who had experienced a stroke in the preceding 26 days. Patients were allocated to a CIMT or a usual care (control) group. The CIMT program was 3 h/d over 10 consecutive working days, with mitt use on the unaffected arm for up to 90% of waking hours. The follow-up time was 6 months. The primary outcome was the Wolf Motor Function test (WMFT) score. Secondary outcomes were the Fugl-Meyer upper-extremity motor score, Nine-Hole Peg test (NHPT) score, the arm use ratio, and the Stroke Impact Scale. Analyses of covariance with adjustment for baseline values were used to assess differences between the groups. Results. After treatment, the mean timed WMFT score was significantly better in the CIMT group compared with the control group. Moreover, posttreatment dexterity, as tested with the NHPT, was significantly better in the CIMT group, whereas the other test results were similar in both the groups. At the 6-month follow-up, the 2 groups showed no significant difference in arm impairment, function, or use in daily activities. Conclusions. Despite a favorable effect of CIMT on timed movement measures immediately after treatment, significant effects were not found after 6 months.

High-Intensity Aerobic Interval Training for Patients 3–9 Months After Stroke. A Feasibility Study

BACKGROUND AND PURPOSE High-intensity aerobic interval training (AIT) has shown to be beneficial in patients with cardiac and pulmonary diseases. Presumably, patients with stroke also benefit from such treatment. However, the feasibility and potential efficacy of high-intensity AIT should be investigated for patients early after stroke. METHODS This was a single-group, pre-test-post-test, intervention study. The intervention consisted of a 6-week high-intensity AIT programme, performed twice a week. The AIT comprised 4 × 4-minute intervals, at 85-95% of peak heart rate, interrupted by 3-minute active breaks. Adherence to the protocol, compliance and adverse events were registered to assess feasibility. Cardiorespiratory fitness and functional outcomes were assessed before and after the intervention and at 6 and 12 weeks follow-up. RESULTS Ten men and five women (mean age 70.0 ± 7.7; range 61-85 years) with mild to moderate stroke were included, 3-9 months after onset. One patient was diagnosed with cancer during follow-up. There were three minor events, but no serious adverse events occurred. All patients accomplished all training sessions and reached the 85% intensity level, except one patient who discontinued the last session. The mean peak oxygen uptake showed no significant improvement from pre-treatment, 28.7 ± 3.8 ml kg(-1)  min(-1), to post-treatment, 29.6 ± 3.6 ml kg(-1)  min(-1), p = 0.189, whereas the mean 6-minute walk test improved from 410.7 ± 101.4 m to 461.0 ± 99.6 m, p = 0.001, and the median (interquartile range) Rivermead Motor Assessment Scale improved from 12.0 (11.0-13.0) to 13.0 (11.0-13.0) points, p = 0.100. These improvements continued after the intervention was concluded. CONCLUSIONS This study has shown that high-intensity AIT is feasible for a selected group of stroke patients. However, the training should be accomplished in line with the American College of Sports Medicine guidelines for high-risk populations to ensure safety. The participants achieved a clinically highly significant improvement in walking distance. This intervention should be tested out in a randomized controlled trial to assess if it is superior to other interventions.

CHANges IN PHysICAl ACtIvIty ANd relA ted fuNCtIoNAl ANd dIsAbIlIty levels IN tHe fIrst sIX moNtHs After stroke: A loNgItudINAl follow-uP study

OBJECTIVE To investigate how physical activity changes over the first 6 months after stroke, and how activity is related to function. DESIGN A longitudinal study with an initial assessment within 14 days after stroke (in hospital) and follow-up assessments 1, 3 and 6 months later (in-patient rehabilitation or at home). SUBJECTS Patients with acute stroke. METHODS An accelerometer with a switch tilt was used to measure activity over a period of 24 h on each occasion. The Barthel Index (BI) and Berg Balance Scale (BBS) were applied as functional measures. RESULTS A total of 28 out of 44 recruited patients were included in the analysis (15 men (53.6%), mean age 79 years). The median time in the upright position increased from 92 min at baseline to 144 min 6 months later. A generalized least-square regression models showed that time in the upright position increased by 2.0 min for every day from baseline to 1 month later (p = 0.003). A single point increase on the BBS was associated with an extra 4.3 min in the upright position (p < 0.001), while a single point increase on the BI was associated with an extra 2.1 min in the upright position (p < 0.001). CONCLUSION Activity levels are very low during the first 6 months after stroke. However, time in the upright position was found to increase as function improved.