Purpose—The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke. Methods—Writing group members were nominated by th...

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association

Purpose—This scientific statement provides an overview of the evidence on physical activity and exercise recommendations for stroke survivors. Evidence suggests that stroke survivors experience phy...

Physical Activity and Exercise Recommendations for Stroke Survivors A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

Purpose—The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke. Methods—Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council’s Scientific Statement Oversight Committee and the AHA’s Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. Results—Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness Guidelines for Adult Stroke Rehabilitation and Recovery A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Guidelines for Adult Stroke Rehabilitation and Recovery.

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.

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Physical Activity and Sedentary Behaviors in People With Stroke Living in the Community: A Systematic Review

Background Mobility limitations are common following stroke and frequently lead to poor participation in physical activity (PA). Purpose The purpose of this study was to describe PA across the various stages following stroke (acute, subacute, and chronic). Data sources Searches were conducted in 5 databases. Study selection Eligible studies included participants with stroke whose PA was quantitatively measured for at least 4 hours in a single session. Two reviewers independently reviewed titles and abstracts. Data extraction One reviewer extracted data and assessed quality using the Downs and Black checklist. Weighted means were calculated for PA outcomes. Data synthesis Searches yielded 103 eligible papers including 5306 participants aged 21 to 96 years. Devices (eg, activity monitors) were used in 73 papers, and behavioral mapping (observational monitoring) in 30. Devices show that people with stroke took on average 5535 steps per day (n = 406, 10 studies) in the subacute phase and 4078 steps (n = 1280, 32 studies) in the chronic phase. Average daily walking duration (% measured time) was higher in the chronic phase (9.0%, n = 100) than subacute (1.8%, n = 172), and sedentary time was >78% regardless of time post stroke. Acute data were lacking for these variables. Matched healthy individuals took an average of 8338 steps per day (n = 129). Behavioral mapping showed time in bed was higher in the acute than subacute phase (mean 45.1% versus 23.8%), with similar time spent sitting (mean 37.6% versus 32.6%). Limitations Limitations of this review include not pooling data reported as medians. Conclusions Physical activity levels do not meet guidelines following stroke. Time spent inactive and sedentary is high at all times. Increasing PA and developing standardized activity targets may be important across all stages of stroke recovery.

How Physically Active Are People Following Stroke? Systematic Review and Quantitative Synthesis

The aim of this paper was to examine the amount and type of physical activity engaged in by people hospitalised after stroke. Method. We systematically reviewed the literature for observational studies describing the physical activity of stroke patients. Results. Behavioural mapping, video recording and therapist report are used to monitor activity levels in hospitalised stroke patients in the 24 included studies. Most of the patient day is spent inactive (median 48.1%, IQR 39.6%–69.3%), alone (median 53.7%, IQR 44.2%–60.6%) and in their bedroom (median 56.5%, IQR 45.2%–72.5%). Approximately one hour per day is spent in physiotherapy (median 63.2 minutes, IQR 36.0–79.5) and occupational therapy (median 57.0 minutes, IQR 25.1–58.5). Even in formal therapy sessions limited time is spent in moderate to high level physical activity. Low levels of physical activity appear more common in patients within 14 days post-stroke and those admitted to conventional care. Conclusions. Physical activity levels are low in hospitalised stroke patients. Improving the description and classification of post stroke physical activity would enhance our ability to pool data across observational studies. The importance of increasing activity levels and the effectiveness of interventions to increase physical activity after stroke need to be tested further.

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Physical activity in hospitalised stroke patients.

Background. Comprehensive stroke unit care, incorporating acute care and rehabilitation, may promote early physical activity after stroke. However, previous information regarding physical activity specific to the acute phase of stroke and the comprehensive stroke unit setting is limited to one stroke unit. This study describes the physical activity undertaken by patients within 14 days after stroke admitted to a comprehensive stroke unit. Methods. This study was a prospective observational study. Behavioural mapping was used to determine the proportion of the day spent in different activities. Therapist reports were used to determine the amount of formal therapy received on the day of observation. The timing of commencement of activity out of bed was obtained from the medical records. Results. On average, patients spent 45% (SD 25) of the day in some form of physical activity and received 58 (SD 34) minutes per day of physiotherapy and occupational therapy combined. Mean time to first mobilisation out of bed was 46 (SD 32) hours post-stroke. Conclusions. This study suggests that commencement of physical activity occurs earlier and physical activity is at a higher level early after stroke in this comprehensive stroke unit, when compared to studies of other acute stroke models of care.

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Physical activity patterns of acute stroke patients managed in a rehabilitation focused stroke unit.

Background. Common models of acute stroke care include the acute stroke unit, focusing on acute management, and the comprehensive stroke unit, incorporating acute care and rehabilitation. We hypothesise that the rehabilitation focus in the comprehensive stroke unit promotes early physical activity and discharge directly home. Methods. We conducted a two-centre prospective observational study of patients admitted to a comprehensive or acute stroke unit within 14 days poststroke. We recruited 73 patients from each site, matched on age, stroke severity, premorbid function, and walking ability. Patient activity was measured using behavioural mapping. Therapy activity was recorded by therapist report. Time to first mobilisation, discharge destination, and length of stay were extracted from the medical record. Results. The comprehensive stroke unit group included more males, fewer partial anterior circulation infarcts, more lacunar infarcts, and more patients ambulant without aids prior to their stroke. Patients in the comprehensive stroke unit spent 14.4% more (95% CI: 8.9%-19.8%; P < 0.001) of the day in moderate or high activity, 18.5% less time physically inactive (95% CI: 5.0%-32.0%; P = 0.008), and were more likely to be discharged directly home (OR 3.7; 95% CI 1.4-9.5; P = 0.007). Conclusions. Comprehensive stroke unit care may foster early physical activity, with likely discharge directly home.

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Early physical activity and discharge destination after stroke: a comparison of acute and comprehensive stroke unit care.

Purpose: To compare physical activity levels of patients in the first week after myocardial infarction (MI) and stroke. Method: We conducted an observational study using behavioural mapping. MI patients were consecutively recruited from Alfred Hospital, Melbourne. Data for stroke patients (Royal Perth Hospital or Austin Hospital, Melbourne) were retrieved from an existing database. Patients were observed for 1 min every 10 min from 8 am to 5 pm. At each observation, the patient’s highest level of physical activity, location and people present were recorded. Details of physiotherapy and occupational therapy sessions were recorded by the therapists. Results: Proportion of the day spent physically inactive was lower in MI (n = 32, median 48%) than stroke (n = 125, median 59%) patients, but this difference was not significant in univariate or multivariate (adjusting for age, walking ability and days post-event) regression. Time spent physically active was higher in MI (median 23%) than stroke (median ...

Is early rehabilitation a myth? Physical inactivity in the first week after myocardial infarction and stroke.

Background: Stroke unit care is advocated for all acute stroke patients. Varying models of stroke unit care exist and there is a need to identify how these models differ and how these differences may affect patient outcomes. This review explores the difference between the comprehensive stroke unit model, which includes rehabilitation, and the acute stroke unit model, which does not. Content: A review of descriptive information regarding comprehensive and acute stroke units was performed to determine the differences in the underlying components of care. Conclusion: A greater emphasis on acute medical care appears to exist in the acute stroke unit, with higher levels of nurse staffing, earlier assessment and investigation, more intensive physiological monitoring and an increased use of thrombolysis and anti-platelet therapy. In contrast, the availability of a period of rehabilitation in the comprehensive stroke unit appears to create a greater emphasis on rehabilitation, even in the acute phase, with greate...

Tanya West

Papers

Physical activity in hospitalised stroke patients.

Physical activity patterns of acute stroke patients managed in a rehabilitation focused stroke unit.

Early physical activity and discharge destination after stroke: a comparison of acute and comprehensive stroke unit care.

Is early rehabilitation a myth? Physical inactivity in the first week after myocardial infarction and stroke.

How do comprehensive and acute stroke units differ? A critical review