Determinants of cardiorespiratory fitness at 3, 6 and 12 months poststroke

Purpose: To better delineate intervention programs, knowledge of the factors that are associated with physical fitness in stroke survivors is crucial. This study aimed to predict cardiorespiratory fitness based on standardized measures along the several dimensions of the International Classification of Functioning, Disability and Health (ICF) model at several time intervals in the first year after stroke. Methods: Forty patients were assessed at 3, 6 and 12 months poststroke. A symptom-limited graded cycle ergometer test was used to assess cardiorespiratory fitness. Outcome variables were VO(2) peak and the Oxygen Uptake Efficiency Slope (OUES). Impairments, activity limitations, participation restrictions, personal and environmental factors were assessed to determine predictive factors. Results: Explained variance at 3, 6 and 12 months poststroke was 39%, 55% and 91% for VO(2) peak and 55%, 63% and 79% for OUES. A strong association between knee muscle strength and cardiorespiratory fitness was found at each measurement time, explaining up to 72 % of the variance in fitness. At 12 months poststroke, functional mobility, body mass index (BMI) and emotional status also contributed to explain variance. Conclusions: Knee muscle strength was found to be a very strong predictor of cardiorespiratory fitness during the first year after stroke and functional mobility became important at 12 months poststroke. [Box: see text].     

Perspective on neuromuscular factors in poststroke fatigue

Purpose: To summarize the potential origins of fatigue poststroke from a neuromuscular perspective, including stroke-induced alterations at the cortical, spinal and muscle levels. Method: Perspective based on narrative literature review. Results: Fatigue is a highly prevalent, but poorly understood symptom poststroke. Neuromuscular fatigue has central and peripheral origins. Individuals with stroke experienced greater central fatigue and less peripheral fatigue during voluntary contractions of the paretic leg in comparison to healthy participants. Neuromuscular adaptations to stroke create an increased susceptibility to central fatigue, which may be a contributing factor to the increased perception of tiredness during performance of activities of daily living. Future studies should investigate whether intervention-induced cortical plasticity, gains in muscle strength and endurance will attenuate self-reported fatigability. Conclusions: Fatigue is a common and debilitating consequence of stroke. Neuromuscular fatigue of central origin may contribute to self-reported fatigue. Continued focused and properly designed research studies should provide substantial insight into the therapeutic interventions that will improve the management of fatigue poststroke.

Implications for Rehabilitation

• Fatigue is a common and debilitating consequence of stroke, which has received little attention in clinical rehabilitation.

• Insufficient understanding of the pathophysiology of poststroke fatigue limits advances in its treatment.

• Neuromuscular fatigue of central origin may contribute to the self-reported fatigue poststroke.

• Although speculative, rehabilitation interventions that foster neuroplasticity, muscle strength and endurance may have a role in the management of fatigue poststroke.

     

Predictors of cardiorespiratory fitness in female and male adults with different body mass index: National Health and Nutrition Examination Survey 1999–2004 dataset

Background: The aim of this study was to explore factors affecting cardiorespiratory fitness in males and females with different body mass index (BMI).

Methods: The National Health and Nutrition Examination Survey 1999–2004 data were used for this retrospective study. Estimated maximal oxygen uptake (VO_2max) is surrogate for cardiorespiratory fitness (CRF). Univariate and multivariate linear regression analyses were performed to explore whether study variables were associated with estimated VO_2max stratified by gender and BMI categories.

Results: A total of 3292 subjects 20–49 years of age were included in the analysis. CRF significantly decreased as BMI increased in both females and males. Ethnic difference was found in normal BMI in both genders and obese females; homocysteine was significantly negatively associated with estimated VO_2max, as was total cholesterol. Obese male subjects with diabetes had a lower estimated VO_2max than those without diabetes, and C-reactive protein (CRP) level and vitamin B12 level were significantly negatively associated with CRF. Female subjects with diabetes had higher estimated VO_2max than those without diabetes. Folate was significantly positively correlated with estimated VO_2max, whereas CRP was negatively correlated in obese female.

Conclusions: There are different predictors of CRF in males and females, and in individuals with different BMI.

• Key messages

• Different BMI classes are associated with different predictors of cardiorespiratory fitness.

• Indicators of cardiorespiratory fitness differ between sexes.

     

Are patients 1 year post-stroke active enough to improve their physical health?

Purpose: This study aimed to quantify physical activity one year post-stroke ? by means of a multifaceted approach combining absolute, relative, and self-reported measures of physical activity (PA) ? and to investigate their mutual associations. The determinants of PA were explored. Method: Daily PA was measured in 16 mildly disabled stroke patients (median RMA-GF score of 12 (IQR?=?10–12.5)) using a heart rate monitor, a pedometer, the Baecke Physical Activity Questionnaire and the Physical Activity Scale for individuals with physical disabilities. Potential determinants were age, gender, functional mobility, peak exercise capacity, mood, participation and hours of daylight. Results: On average, stroke participants had a good baseline level of activity (44?±?39?min/day spent moderate active, 6428?±?4117 steps/day), but only three (19%) performed more than 10,000 steps/day, required for health benefits. Functional mobility, cardiorespiratory fitness, mood and participation were related to the total daily steps, but not to the time spent in moderate intense activities. Discrepancies between absolute (frequency and duration) and relative (intensity) measures of PA exist regarding the achieved quantity and its potential determinants. Conclusions: It is not only important to be active, but to be active enough to improve health. Health recommendation for stroke survivors to perform moderate intense PA needs to be translated into a pedometer-based step goal.

Implications for Rehabilitation

• On average, stroke survivors had a good baseline level of physical activity (PA), but only some reached a level which could improve their physical health.

• Health recommendations for stroke survivors on amount of moderate intense PA should be translated into a pedometer-based step goal.

     

Psychometric properties of the Activities-Specific Balance Confidence Scale in persons 0–14 days and 3 months post stroke

Purpose: To test the internal consistency and validity of a Swedish translation of the Activities-specific Balance Confidence Scale (ABC) 0–14 days and 3 months post stroke. Method: 37 persons were tested at 0–14 days (median 5 days) post stroke and 31 were retested 3 months later (median 87 days). In addition to the ABC, the Functional Ambulation Categories, modified Rivermead Mobility Index, timed up and go test, 10-meter timed walk, SF-36 and the 12-item Walking Scale were used. Results: The internal consistency was high at α?=?0.94 to 0.97. Kendall correlation-τ coefficients were moderate and varied somewhat depending on time poststroke. At 0–14 days post stroke the highest correlation was found between the ABC and the 12-item Walking Scale (?0.55, p?<?0.01). At 3 months poststroke, the correlations with the Functional Ambulation Categories was 0.49 (p?<?0.01), timed up and go test ?0.43 (p?<?0.01), 10-meter timed walk ?0.41 (p?<?0.01), and modified Rivermead Mobility Index 0.46 (p?<?0.01). Divergent validity was established by the non-significant correlation (0.12) between the ABC and SF-36 mental component summary. Conclusions: The Swedish version of ABC has high internal consistency and is valid for measuring balance confidence in the acute and sub acute phases of stroke.

Implications for Rehabilitation

• The ABC is a valid measure of balance confidence in persons in the acute and sub acute phases after stroke.

• A moderate convergent validity was found between the ABC and measures of physical function.

     

Predicting health related quality of life 6 months after stroke: the role of anxiety and upper limb dysfunction

Purpose: This study examined the role of anxiety and upper limb dysfunction, amongst other variables, as predictors of health related quality of life (HRQOL) 6 months after stroke. Method: Participants: Stroke survivors (n = 85) who had previously participated in a randomised controlled trial of a physiotherapy intervention. Dependent variable: HRQOL – Nottingham Health Profile (NHP). Predictor variables: Mood – Hospital Depression and Anxiety Scale; Upper Limb Functioning - Action Research Arm Test; Rivermead Motor Assessment; Activities of Daily Living – Modified Barthel Index; Clinical and demographic factors. Results: Anxiety and depression significantly predicted 49% of variance in overall HRQOL (p < 0.05), but only anxiety significantly predicted NHP pain (13% variance, p < 0.001), emotional reactions (41% variance, p < 0.001), sleep (19% variance, p = 0.02) and social isolation (23% variance, p = 0.02). Depression and anxiety together significantly predicted 30% variance in energy level (p < 0.001). UL motor impairment and activities of daily living predicted 36% of variance in NHP physical activity score (p < 0.001). Conclusions: This study indicates that where anxiety is assessed, it appears more important in determining HRQOL than depression. UL impairment and ADL independence predicted perceived physical activity. Management strategies for anxiety and therapy for UL recovery long after stroke onset are likely to benefit perceived HRQOL.

Implications for Rehabilitation

• Anxiety is a major predictor of quality of life six months after stroke.

• Post-stroke anxiety should be routinely assessed in rehabilitation.

• Appropriate management strategies for anxiety should occur during rehabilitation with follow-up into the chronic post-stroke period.

• Upper limb impairment is a stronger predictor of perceptions of physical activity than independence in activities daily living six months after stroke.

• Rehabilitation of the upper limb should continue into the chronic post-stroke period.

     

Predictors of post-traumatic growth in stroke survivors

Abstract

Purpose: The development of post-traumatic growth was studied longitudinally within 14?months poststroke. The predictions of two models of post-traumatic growth were examined.

Method: Forty-three stroke survivors were investigated at two time points (i.e., time 1 and time 2), six months apart. Each completed the Post-traumatic Growth Inventory, Rumination Scale, Impact of Events Scale, Multidimensional Scale of Social Support, the Barthel Index and the COPE scale.

Results: Post-traumatic growth was evident four to five months after stroke, increasing significantly over the next six months at which point levels resembled those reported in cross-sectional stroke studies. Active and denial coping and rumination at time 1 were positively associated, and age was negatively associated, with post-traumatic growth at time 2, but acceptance coping was not associated. Neither active coping nor rumination mediated the effect of social support on post-traumatic growth as predicted. As predicted, rumination mediated the relationship between post-traumatic stress and post-traumatic growth. Exploratory stepwise regression demonstrated rumination and active coping at time 1 accounted for 45% of variance in post-traumatic growth at time 2.

Conclusions: Post-traumatic growth can develop soon after stroke. Deliberate rumination is a key factor in post-traumatic growth. Both active coping and denial coping were associated with post-traumatic growth demonstrating the psychological complexity of poststroke adjustment.

• Implications for rehabilitation

• Therapists can expect stroke survivors to show post-traumatic growth in the first months after stroke.

• Therapists should look to promote post-traumatic growth and positive adjustment through working with survivors to increase active coping (attempts to deal effectively with the impact of stroke) and rumination (cognitive processing of the impact of the stroke).

• Since denial coping was also associated with posttraumatic growth, stroke survivors who maintain overly optimistic views about the severity and impact of their stroke are likely to benefit from therapists continually facilitating capacity for growth and well-being.

     

Are cardiovascular and metabolic responses to field walking tests interchangeable and obesity-dependent?

Purpose: To investigate if cardiovascular and metabolic responses to the six-minute walk test (6MWT) and incremental shuttle walking test (ISWT) are in agreement with cardiopulmonary exercise testing (CPX) and determine if both submaximal tests are interchangeable in obese and eutrophic individuals.

Method: Observational and cross-sectional study included 51 obese women (ObG) and 21 controls (CG) (20–45 years old). Subjects underwent clinical evaluation, CPX, the 6MWT and ISWT. We applied Bland–Altman plots to assess agreement between walking tests and CPX. Correlation analysis assessed relationships between key variables.

Results: There was an agreement between CPX and both the 6MWT [oxygen uptake (VO₂ mL?kg^?1?min^?1)?=?6.9 (CI: 5.7–8.1), and heart rate (bpm)?=?37.0 (CI: 33.3–40.7)] and ISWT [VO₂ (mL?kg^?1?min^?1)?=?6.1 (CI: 4.9–7.3), and heart rate (bpm)?=?36.2 (CI: 32.1–40.3)]. We found similar cardiovascular and metabolic responses to both tests in the ObG but not in the CG. Strong correlations were demonstrated between 6MWT and ISWT variables: VO₂ ( r?=?0.70); dyspnoea (r?=?0.80); and leg fatigue (r?=?0.70).

Conclusions: 6MWT and ISWT may both hold interchangeable clinical value when contrasted with CPX in obese women and may be a viable alternative in the clinical setting when resources and staffing are limited.

• Implications for Rehabilitation

• Obesity is a worldwide epidemic, with high prevalence in women, and it is associated to impaired cardiorespiratory fitness and functional capacity as well as high mortality risk.

• Assessing oxygen uptake by means of cardiopulmonary exercise testing is the gold standard method for evaluating and stratifying cardiorespiratory fitness, however it is not ever applied due to costs and staffing.

• Walking field tests may be a cost-effective approach that provides valuable information regarding the functional capacity in agreement to metabolic and cardiovascular responses of cardiopulmonary exercise testing.

     

Anxiety and depression after stroke: a 5 year follow-up

Purpose: The aim was to document the prevalence and predictors of anxiety and depression 5 years after stroke, across four European centres. Method: A cohort of 220 stroke patients was assessed at 2, 4 and 6 months and 5 years after stroke. Patients were assessed on the Hospital Anxiety and Depression Scale and measures of motor function and independence in activities of daily living. Results: At 5 years, the prevalence of anxiety was 29% and depression 33%, with no significant differences between centres. The severity of anxiety and depression increased significantly between 6 months and 5 years. Higher anxiety at 6 months and centre were significantly associated with anxiety at 5 years, but not measures of functional recovery. Higher depression scores at 6 months, older age and centre, but not measures of functional recovery, were associated with depression at 5 years. Conclusions: Anxiety and depression were more frequent at 5 years after stroke than at 6 months. There were significant differences between four European centres in the severity of anxiety and depression. Although the main determinant of anxiety or depression scores at 5 years was the level of anxiety or depression at 6 months, this accounted for little of the variance. Centre was also a significant predictor of mood at 5 years. There needs to be greater recognition of the development of mood disorders late after stroke and evaluation of variation in management policies across centres.

Implications for Rehabilitation

• Depression and anxiety persisted up to 5 years after stroke in about a third of patients.

• Variation in the rates of anxiety and depression between different European centres suggest management policies rather than stroke related factors may determine their persistence.

• The effect of variations in stroke management policies should be investigated.

• Patients’ mood should be monitored over time in order to detect those with late onset mood disorders after stroke.

     

Acute phase factors associated with the course of depression during the first 18 months after first-ever stroke

Purpose: The aim of this study was to describe the course of post-stroke depression (PSD) during the first 18 months after first-ever stroke and to examine differences in the course of depressive symptoms in relation to patient demographic and clinical characteristics in the acute phase. Methods: As part of a longitudinal cohort study, data were collected from medical records and in face-to-face interviews using standardized questionnaires within 15 days after stroke and 6, 12 and 18 months later. The sample consisted of 94 patients with first-ever stroke. PSD was measured with the Beck Depression Inventory II. Repeated measures analysis of variance was used to evaluate the course of depressive symptoms over time and in relation to demographic and clinical variables. Results: Depression levels were stable during the 18 months after first-ever stroke. However, depression scores were significantly higher among patients who had lower physical functioning in the acute phase, were living alone or were not employed at the time of stroke. Conclusions: Several demographic and acute phase factors were associated with a more severe PSD course following stroke. Psychosocial support that begins in the acute phase and continues throughout the rehabilitation process may be helpful in improving both physical and psychological outcomes following stroke.

• Implications for Rehabilitation

• Depression levels are stable during the first 18 months after first-ever stroke.

• The course of post-stroke depression is related to the level of physical functioning in the acute phase, whether the stroke survivors live alone and their employment status at the time of stroke.

• Psychological support that begins in the acute phase and continues throughout the rehabilitation process may be helpful in improving both physical and psychological outcomes following stroke.

     

Factors predicting community participation in patients living with stroke,in the Western Cape,South Africa

Abstract

Purpose: An important focus of poststroke rehabilitation is the attainment of community participation. However, several factors may influence participation some of which vary from setting to setting. The aim of this study is to investigate the factors influencing community participation among community-dwelling stroke survivors in the Western Cape, South Africa.

Materials and methods: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) and the Social Support Questionnaire 6 (SSQ6) were the instruments used to collect data. Participant demographics, clinical features and domain-specific scores of the WHODAS 2.0 were used as potential predictors. Correlation analysis and multiple regression models were used to examine determinants of community participation. All assessments were conducted using face-to-face interviews.

Results: One hundred and six stroke survivors enrolled in this cross-sectional study. Risk factors, cognition, mobility, self-care, getting along with people, household activities and total WHODAS 2.0 score were associated with participation. Four predictors of community participation were identified from multiple regression, namely mobility (38%), cognition (11%), life activities (4%) and stroke risk factors (1%). Determinants varied by gender and age group. Mobility predominated in males and younger adults, while cognition was more pronounced in females and the elderly. Lastly, the influence of social support on community participation was largely defined by the gender and age of stroke survivors.

Conclusion: The findings suggest focusing stroke rehabilitation on important factors such as mobility, cognition, life activities and risk factors to advance patients’ participation. It also emphasizes giving specific consideration to key factors specific for gender and age of stroke survivors.

• Implications for Rehabilitation

• Community participation in the general population of stroke survivors’ is largely determined by their mobility function.

• Determinants of community participation among stroke survivors essentially vary according to age and gender.

• Clinically, this study suggests that focusing on specific determinants of improved community participation according to stroke patients’ demographic categories (gender and age) may be an important impetus to enhance rehabilitation outcome.

     

Predicting sickness impact profile at six months after stroke: further results from the European multi-center CERISE study

Abstract

Purpose: To develop prognostic models and equations for predicting participation at six months after stroke. Methods: This European prospective cohort study recruited 532 consecutive patients from four rehabilitation centers. Participation was assessed at six months after stroke with the Sickness Impact Profile (SIP), which consists of a physical, psychosocial and independent dimension. Twenty-six independent variables on admission to the rehabilitation center and 13 additional variables measured at two months post stroke were included in the analysis. A multiple logistic regression analysis was conducted predicting good participation (SIP?<?20%). Sensitivity, specificity, positive and negative predictive values were calculated. Results: The prognostic models for the three dimensions provided independent predictors containing demographics, complications, diagnostic, and disability measures. Sensitivity ranged from 64–84%, specificity 66–85%, positive predictive value 70–78%, and negative predictive value 76–87%. Barthel Index on admission, Euroqol Health State at two months and Caregiver Strain Index at two months were retained in all prediction models. Conclusions: A combination of variables was found in the prognostic models of the three dimensions of the SIP at six months after stroke. Already from the early beginning of stroke rehabilitation it seems important to focus on personal activities of daily living as well as caregivers' strain.

• Implications for Rehabilitation

• Prognostic factors predicting participation, measured by the three dimensions of the Sickness Impact Profile at six months post stroke include demographic variables, post-stroke complications, diagnostic parameters and disability measures.

• Significant prognostic variables for all three dimensions of the Sickness Impact Profile were a higher Barthel Index score on admission to the rehabilitation center, a higher Euroqol Health State score at two months post stroke and a lower Caregiver Strain Index score at two months post stroke.

• Early stroke therapy should therefore further emphasize rehabilitation of personal activities of daily living such as mobility, walking, feeding, dressing, and toilet use, as well as considering strategies to reduce caregiver strain such as giving support, providing information and training carers.

     

Wheeled-mobility correlates of life-space and social participation in adult manual wheelchair users aged 50 and older

Purpose: To characterize the life-space mobility and social participation of manual wheelchair users using objective measures of wheeled mobility.

Method: Individuals (n?=?49) were included in this cross-sectional study if they were aged 50 or older, community-dwelling and used their wheelchair on a daily basis for the past 6 months. Life-space mobility and social participation were measured using the life-space assessment and late-life disability instrument. The wheeled mobility variables (distance travelled, occupancy time, number of bouts) were captured using a custom-built data logger.

Results: After controlling for age and sex, multivariate regression analyses revealed that the wheeled mobility variables accounted for 24% of the life-space variance. The number of bouts variable, however, did not account for any appreciable variance above and beyond the occupancy time and distance travelled. Occupancy time and number of bouts were significant predictors of social participation and accounted for 23% of the variance after controlling for age and sex.

Conclusions: Occupancy time and distance travelled are statistically significant predictors of life-space mobility. Lower occupancy time may be an indicative of travel to more distant life-spaces, whereas the distance travelled is likely a better reflection of mobility within each life-space. Occupancy time and number of bouts are significant predictors of participation frequency.

• Implications for rehabilitation

• Component measures of wheelchair mobility, such as distance travelled, occupancy time and number of bouts, are important predictors of life-space mobility and social participation in adult manual wheelchair users.

• Lower occupancy time is an indication of travel to more distant life-spaces, whereas distance travelled is likely a better reflection of mobility within each life-space.

• That lower occupancy time and greater number of bouts are associated with more frequent participation raises accessibility and safety issues for manual wheelchair users.

     

Longitudinal changes in activity participation in the first year post-stroke and association with depressive symptoms

Abstract

Research question: 1. Does activity participation improve over time in the first year after stroke? 2. What is the association of depressive symptoms on retained activity participation 12-months post-stroke adjusting for neurological stroke severity and age? 3. Is an improvement in activity participation associated with a decrease in depressive symptoms between 3- and 12-months post-stroke?

Design: Longitudinal observational study of activity participation and depressive symptoms in ischemic stroke survivors.

Participants: A total of 100 stroke survivors with mild neurological stroke severity.

Methods: A total of 100 stroke survivors were recruited from five metropolitan hospitals and assessed at 3- and 12-months post-stroke using measures of activity participation (Activity Card Sort-Australia (ACS-Aus)) and depressive symptoms (Montgomery–Asberg Depression Rating Scale Structured Interview Guide (MADRS-SIGMA)).

Results: There was a significant association between time (pre-stroke to 3-months post-stroke) and current activity participation (?5.2 activities 95% CI ?6.8 to ?3.5, p?<?0.01) and time (pre-stroke to 12-months) and current activity participation (?2.1 activities 95% CI ?3.7 to ?0.5, p?=?0.01). At 12-months post-stroke, a one-point increase in depressive symptoms was associated with a median decrease of 0.3% (95% CI ?1.4% to ?0.1%, p?=?0.02) of retained overall activity participation, assuming similar neurological stroke severity and age. A decrease in depressive symptoms between 3- and 12-months post-stroke was associated with an improvement of 0.31 (95% CI ?0.5 to ?0.1, p?=?0.01) in current activity participation.

Conclusions: Activity participation improves during the first year of recovery post-stroke in stroke survivors with mild neurological stroke severity and is associated with depressive symptoms over time and at 12-months post-stroke.

• Implications for rehabilitation

• Improvements in participation occur in the first 3-months post-stroke and continue to a lesser degree in the first year after stroke.

• Depressive symptoms are associated with lower participation at 12-months.

• A multidimensional approach targeting depressive symptoms and increasing participation in the early months post-stroke and throughout the first-year after stroke is recommended to increase overall recovery following stroke.

• A focus on increasing leisure activity participation is recommended to improve depressive symptoms.

Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12610000987066.     

Post-stroke self-management interventions: a systematic review of effectiveness and investigation of the inclusion of stroke survivors with aphasia

Purpose: To systematically review self-management interventions to determine their efficacy for people with stroke in relation to any health outcome and to establish whether stroke survivors with aphasia were included.

Method: We searched MEDLINE, EMBASE, PsycINFO, CINAHL, The Cochrane Library, and IBSS and undertook gray literature searches. Randomized controlled trials were eligible if they included stroke survivors aged 18?+?in a “self-management” intervention. Data were extracted by two independent researchers and included an assessment of methodological quality.

Results: 24 studies were identified. 11 out of 24 reported statistically significant benefits in favor of self-management. However, there were significant limitations in terms of methodological quality, and meta-analyses (n=?8 studies) showed no statistically significant benefit of self-management upon global disability and stroke-specific quality of life at 3?months or ADL at 3 or 6?months follow-up. A review of inclusion and exclusion criteria showed 11 out of 24 (46%) studies reported total or partial exclusion of stroke survivors with aphasia. Four out of 24 (17%) reported the number of stroke survivors with aphasia included. In nine studies (38%) it was unclear whether stroke survivors with aphasia were included or excluded.

Conclusions: Robust conclusions regarding the effectiveness of poststroke self-management approaches could not be drawn. Further trials are needed, these should clearly report the population included.

• Implications for rehabilitation

• There is a lack of evidence to demonstrate the effectiveness of self-management approaches for stroke survivors.

• It is unclear whether self-management approaches are suitable for stroke survivors with aphasia, particularly those with moderate or severe aphasia.

• Further research is needed to understand the optimal timing for self-management in the stroke pathway and the format in which self-management support should be offered.