Background and Purpose. Physical activity is beneficial after stroke, but it is unclear how active stroke survivors are. This systematic review and meta-analysis sought to determine levels of activity and factors predicting activity. Summary of Review: Methods. MEDLINE (1946 to present) and EMBASE (1980 to present) were systematically searched until July 2012. All studies quantifying whole-body-free living physical activity by objective and self-reported methods in a community dwelling population with stroke were included. A random effect meta-analysis was performed. Results. Twenty-six studies were included ( ), of which eleven ( ) contained sufficient data for meta-analysis. There were heterogeneous designs, measurements, and procedures. The studies generally recruited small samples of high-functioning participants. Level of physical activity was generally low in quantity, duration and intensity. Poorer walking ability, specific sensorimotor functions, and low mood were correlates of low physical activity. Meta-analysis generated an estimate of 4355.2 steps/day (95% CI: 3210.4 to 5499.9) with no significant heterogeneity ( = 0). Conclusions. In high-functioning stroke survivors, physical activity including walking was generally low. Strategies are needed to promote and maintain physical activity in stroke survivors. Research is needed to establish reasons for low physical activity after stroke. 1. Introduction Physical activity is defined as “any bodily movement produced by skeletal muscle that results in energy expenditure above a basal level” [1] and is associated with improved cardiovascular risk factors including reduced blood pressure [2]. The risk of a first-ever stroke, ischaemic or haemorrhagic, is associated with lower amounts of physical activity [3, 4]. Risk modelling studies, based on data from primary prevention studies, have suggested that physical activity is likely to reduce the risk of recurrent stroke [5]. Thus, the American Heart Association (AHA) recommends 20–60 minutes medium to high intensity exercise (expressed as 40–70% of either peak oxygen uptake or heart rate reserve) in 3–7 days per week for stroke survivors [6]. Therefore, it is important to understand whether stroke survivors meet AHA recommendations for physical activity after stroke and the factors associated with the amount and intensity of physical activity patterns. The most methodologically robust way to synthesise results of observational studies is by systematic review and meta-analysis. To our knowledge, the amount of physical activity performed after stroke has
References
[1]
C. J. Caspersen, K. E. Powell, and G. Christenson, “Physical activity, exercise and physical fitness: definitions and distinctions for health-related research,” Public Health Reports, vol. 100, no. 2, pp. 126–131, 1985.
[2]
G. Jennings, L. Nelson, and P. Nestel, “The effects of changes in physical activity on major cardiovascular risk factors, hemodynamics, sympathetic function, and glucose utilization in man: a controlled study of four levels of activity,” Circulation, vol. 73, no. 1, pp. 30–40, 1986.
[3]
G. C. W. Wendel-Vos, A. J. Schuit, E. J. M. Feskens et al., “Physical activity and stroke. A meta-analysis of observational data,” International Journal of Epidemiology, vol. 33, no. 4, pp. 787–798, 2004.
[4]
M. J. O'Donnell, X. Denis, L. Liu et al., “Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study,” The Lancet, vol. 376, no. 9735, pp. 112–123, 2010.
[5]
D. G. Hackam and J. D. Spence, “Combining multiple approaches for the secondary prevention of vascular events after stroke: a quantitative modeling study,” Stroke, vol. 38, no. 6, pp. 1881–1885, 2007.
[6]
N. F. Gordon, M. Gulanick, F. Costa et al., “Physical activity and exercise recommendations for stroke survivors: an American Heart Association scientific statement from the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council,” Stroke, vol. 35, no. 5, pp. 1230–1240, 2004.
[7]
T. West and J. Bernhardt, “Physical activity in hospitalised stroke patients,” Stroke Research and Treatment, Article ID 813765, 2012.
[8]
H. Kumahara, H. Tanaka, and Y. Schutz, “Daily physical activity assessment: what is the importance of upper limb movements vs whole body movements?” International Journal of Obesity, vol. 28, no. 9, pp. 1105–1110, 2004.
[9]
S. H. Downs and N. Black, “The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions,” Journal of Epidemiology and Community Health, vol. 52, no. 6, pp. 377–384, 1998.
[10]
J. L. Neyeloff, S. C. Fuchs, and L. B. Moreira, “Meta-analyses and Forest plots using a microsoft excel spreadsheet: step-by-step guide focusing on descriptive data analysis,” BMC Research Notes, vol. 5, article 52, 2012.
[11]
M. Alzahrani, C. Dean, and L. Ada, “Relationship between walking performance and types of community-based activities in people with stroke: an observational study,” Revista Brasileira de Fisioterapia, vol. 15, no. 1, pp. 45–51, 2011.
[12]
M. A. Alzahrani, L. Ada, and C. M. Dean, “Duration of physical activity is normal but frequency is reduced after stroke: an observational study,” Journal of Physiotherapy, vol. 57, no. 1, pp. 47–51, 2011.
[13]
M. A. Alzahrani, C. M. Dean, and L. Ada, “Ability to negotiate stairs predicts free-living physical activity in community-dwelling people with stroke: an observational study,” Australian Journal of Physiotherapy, vol. 55, no. 4, pp. 277–281, 2009.
[14]
M. A. Alzahrani, C. M. Dean, L. Ada, S. Dorsch, and C. G. Canning, “Mood and balance are associated with free-living physical activity of people after stroke residing in the community,” Stroke Research and Treatment, vol. 2012, Article ID 470648, 8 pages, 2012.
[15]
I. Baert, H. Feys, D. Daly, T. Troosters, and Y. Vanlandewijck, “Are patients 1 year post-stroke active enough to improve their physical health?” Disability and Rehabilitation, vol. 34, no. 7, pp. 574–580, 2012.
[16]
G. Boysen, L.-H. Krarup, X. Zeng et al., “ExStroke Pilot Trial of the effect of repeated instructions to improve physical activity after ischaemic stroke: a multinational randomised controlled clinical trial,” British Medical Journal, vol. 339, no. 7715, pp. 273–275, 2009.
[17]
A. Danielsson, C. Willén, and K. S. Sunnerhagen, “Physical activity, ambulation, and motor impairment late after stroke,” Stroke Research and Treatment, vol. 2012, Article ID 818513, 5 pages, 2012.
[18]
A. Danielsson, C. Willén, and K. S. Sunnerhagen, “Is walking endurance associated with activity and participation late after stroke?” Disability and Rehabilitation, vol. 33, no. 21-22, pp. 2053–2057, 2011.
[19]
B. H. Dobkin, X. Xu, M. Batalin, S. Thomas, and W. Kaiser, “Reliability and validity of bilateral ankle accelerometer algorithms for activity recognition and walking speed after stroke,” Stroke, vol. 42, no. 8, pp. 2246–2250, 2011.
[20]
G. D. Fulk, C. Reynolds, S. Mondal, and J. E. Deutsch, “Predicting home and community walking activity in people with stroke,” Archives of Physical Medicine and Rehabilitation, vol. 91, no. 10, pp. 1582–1586, 2010.
[21]
E. Haeuber, M. Shaughnessy, L. W. Forrester, K. L. Coleman, and R. F. Macko, “Accelerometer monitoring of home- and community-based ambulatory activity after stroke,” Archives of Physical Medicine and Rehabilitation, vol. 85, no. 12, pp. 1997–2001, 2004.
[22]
L. A. Hale, J. Pal, and I. Becker, “Measuring free-living physical activity in adults with and without neurologic dysfunction with a triaxial accelerometer,” Archives of Physical Medicine and Rehabilitation, vol. 89, no. 9, pp. 1765–1771, 2008.
[23]
M. Lindahl, L. Hansen, A. Pedersen, T. Truelsen, and G. Boysen, “Self-reported physical activity after ischemic stroke correlates with physical capacity,” Advances in Physiotherapy, vol. 10, no. 4, pp. 188–194, 2008.
[24]
P. J. Manns and E. Baldwin, “Ambulatory activity of stroke survivors measurement options for dose, intensity, and variability of activity,” Stroke, vol. 40, no. 3, pp. 864–867, 2009.
[25]
P. J. Manns, C. R. Tomczak, A. Jelani, M. E. Cress, and R. Haennel, “Use of the continuous scale physical functional performance test in stroke survivors,” Archives of Physical Medicine and Rehabilitation, vol. 90, no. 3, pp. 488–493, 2009.
[26]
P. J. Manns, C. R. Tomczak, A. Jelani, and R. G. Haennel, “Oxygen uptake kinetics: associations with ambulatory activity and physical functional performance in stroke survivors,” Journal of Rehabilitation Medicine, vol. 42, no. 3, pp. 259–264, 2010.
[27]
K. Michael and R. F. Macko, “Ambulatory activity intensity profiles, fitness, and fatigue in chronic stroke,” Topics in Stroke Rehabilitation, vol. 14, no. 2, pp. 5–12, 2007.
[28]
K. M. Michael, J. K. Allen, and R. F. Macko, “Fatigue after stroke: relationship to mobility, fitness, ambulatory activity, social support, and falls efficacy,” Rehabilitation Nursing, vol. 31, no. 5, pp. 210–217, 2006.
[29]
K. M. Michael, J. K. Allen, and R. F. MacKo, “Reduced ambulatory activity after stroke: the role of balance, gait, and cardiovascular fitness,” Archives of Physical Medicine and Rehabilitation, vol. 86, no. 8, pp. 1552–1556, 2005.
[30]
S. Mudge, P. A. Barber, and N. S. Stott, “Circuit-based rehabilitation improves gait endurance but not usual walking activity in chronic stroke: a randomized controlled trial,” Archives of Physical Medicine and Rehabilitation, vol. 90, no. 12, pp. 1989–1996, 2009.
[31]
S. Mudge and N. S. Stott, “Timed walking tests correlate with daily step activity in persons with stroke,” Archives of Physical Medicine and Rehabilitation, vol. 90, no. 2, pp. 296–301, 2009.
[32]
S. Mudge and S. N. Stott, “Test-retest reliability of the StepWatch Activity Monitor outputs in individuals with chronic stroke,” Clinical Rehabilitation, vol. 22, no. 10-11, pp. 871–877, 2008.
[33]
M. Y. C. Pang, M. C. Ashe, and J. J. Eng, “Tibial bone geometry in chronic stroke patients: influence of sex, cardiovascular health, and muscle mass,” Journal of Bone and Mineral Research, vol. 23, no. 7, pp. 1023–1030, 2008.
[34]
M. Y. C. Pang, J. J. Eng, A. S. Dawson, H. A. McKay, and J. E. Harris, “A community-based fitness and mobility exercise program for older adults with chronic stroke: a randomized, controlled trial,” Journal of the American Geriatrics Society, vol. 53, no. 10, pp. 1667–1674, 2005.
[35]
D. Rand, J. J. Eng, P.-F. Tang, C. Hung, and J.-S. Jeng, “Daily physical activity and its contribution to the health-related quality of life of ambulatory individuals with chronic stroke,” Health and Quality of Life Outcomes, vol. 8, article 80, 2010.
[36]
D. Rand, J. J. Eng, P.-F. Tang, J.-S. Jeng, and C. Hung, “How active are people with stroke?: use of accelerometers to assess physical activity,” Stroke, vol. 40, no. 1, pp. 163–168, 2009.
[37]
B. Resnick, K. Michael, M. Shaughnessy et al., “Inflated perceptions of physical activity after stroke: pairing self-report with physiologic measures,” Journal of Physical Activity and Health, vol. 5, no. 2, pp. 308–318, 2008.
[38]
C. A. Robinson, A. Shumway-Cook, M. A. Ciol, and D. Kartin, “Participation in community walking following stroke: subjective versus objective measures and the impact of personal factors,” Physical Therapy, vol. 91, no. 12, pp. 1865–1876, 2011.
[39]
M. Shaughnessy, K. M. Michael, J. D. Sorkin, and R. F. Macko, “Steps after stroke: capturing ambulatory recovery,” Stroke, vol. 36, no. 6, pp. 1305–1307, 2005.
[40]
L. F. Teixeira-Salmela, R. Devaraj, and S. J. Olney, “Validation of the human activity profile in stroke: a comparison of observed, proxy and self-reported scores,” Disability and Rehabilitation, vol. 29, no. 19, pp. 1518–1524, 2007.
[41]
L. F. Teixeira-Salmela, S. J. Olney, S. Nadeau, and B. Brouwer, “Muscle strengthening and physical conditioning to reduce impairment and disability in chronic stroke survivors,” Archives of Physical Medicine and Rehabilitation, vol. 80, no. 10, pp. 1211–1218, 1999.
[42]
R. J. Van Den Berg-Emons, J. B. Bussmann, and H. J. Stam, “Accelerometry-based activity spectrum in persons with chronic physical conditions,” Archives of Physical Medicine and Rehabilitation, vol. 91, no. 12, pp. 1856–1861, 2010.
[43]
R. Van Swigchem, J. Vloothuis, J. Den Boer, V. Weerdesteyn, and A. C. H. Geurts, “Is transcutaneous peroneal stimulation beneficial to patients with chronic stroke using an ankle-foot orthosis? A within-subjects study of patients' satisfaction, walking speed and physical activity level,” Journal of Rehabilitation Medicine, vol. 42, no. 2, pp. 117–121, 2010.
[44]
E. Viosca, J. L. Martínez, P. L. Almagro, A. Gracia, and C. González, “Proposal and validation of a new functional ambulation classification scale for clinical use,” Archives of Physical Medicine and Rehabilitation, vol. 86, no. 6, pp. 1234–1238, 2005.
[45]
K. Yoneyama, K. Saito, T. Kamo et al., “Effects of indeloxazine hydrochloride on activities of daily living in cerebrovascular disease: evaluation by accelerometer,” Current Therapeutic Research, vol. 54, no. 4, pp. 413–419, 1993.
[46]
K. R. Zalewski and L. Dvorak, “Barriers to physical activity between adults with stroke and their care partners,” Topics in Stroke Rehabilitation, vol. 18, no. 1, pp. 666–675, 2011.
[47]
C. Tudor-Locke, G. R. Jones, A. M. Myers, D. H. Paterson, and N. A. Ecclestone, “Contribution of structured exercise class participation and informal walking for exercise to daily physical activity in community-dwelling older adults,” Research Quarterly for Exercise and Sport, vol. 73, no. 3, pp. 350–356, 2002.
[48]
C. Tudor-Locke, C. L. Craig, W. J. Brown et al., “How many steps/day are enough? for adults,” International Journal of Behavioral Nutrition and Physical Activity, vol. 8, article 79, 2011.
[49]
J. Morris, T. Oliver, T. Kroll, and S. MacGillivray, “The importance of psychological and social factors in influencing the uptake and maintenance of physical activity after stroke: a structured review of the empirical literature,” Stroke Research and Treatment, vol. 2012, Article ID 195249, 20 pages, 2012.
[50]
R. F. Macko, E. Haeuber, M. Shaughnessy et al., “Microprocessor-based ambulatory activity monitoring in stroke patients,” Medicine and Science in Sports and Exercise, vol. 34, no. 3, pp. 394–399, 2002.
[51]
D. W. Esliger and M. S. Tremblay, “Technical reliability assessment of three accelerometer models in a mechanical setup,” Medicine and Science in Sports and Exercise, vol. 38, no. 12, pp. 2173–2181, 2006.
[52]
H. P. van der Ploeg, K. R. M. Streppel, A. J. van der Beek, L. H. V. van der Woude, M. Vollenbroek-Hutten, and W. van Mechelen, “The physical activity scale for individuals with physical disabilities: test-retest reliability and comparison with an accelerometer,” Journal of Physical Activity & Health, vol. 4, no. 1, pp. 96–100, 2007.
[53]
A. J. Schult, E. G. Schonten, K. R. Westerterp, and W. H. M. Saris, “Validity of the Physical Activity Scale for the Elderly (PASE): according to energy expenditure assessed by the doubly labeled water method,” Journal of Clinical Epidemiology, vol. 50, no. 5, pp. 541–546, 1997.
