Physical Activity after Stroke: A Systematic Review and Meta-Analysis

Table 1

Characteristics and results of studies using objective measures of physical activity.

Reference	Design	Participants		Time since stroke	Measure of physical activity	Level of physical activity	Study quality; max. = 20
		Sex (M = male; F = female)	Age (yr)
Alzahrani et al. [11–14]	Cross-sectional	Stroke: M = 29; F = 13.; Control: M = 11; F = 10.	Stroke: Mean = 70 (SD = 10); Control: Mean = 69 (SD = 7)	Mean = 2.8 yrs; (SD = 1.4)	Intelligent device for energy expenditure and activity (five accelerometers); Duration: two separate randomly allocated days, not nights.	Adjustment to 12 hr observation period: Mean time on feet (mins) strokes = 256 (SD = 128) versus controls = 292 (SD = 97) [difference = −36 (95% CI −99 to −27)].; Mean activity counts: strokes = 6284 (SD = 4546) versus controls = 10346 (SD = 3590) [difference = −4062 (95% CI −6337 to −1787)].	15
Baert et al. [15]	Cross-sectional	M = 12; F = 4.	Mean = 61.9 (SD = 11.9)	1 year	Yamax SW-200 pedometer AND Polar RS-400 HR monitor, activity diary.; Duration: 5 consecutive weekdays, not nights.; Self-reported BPAQ*; Self-reported PASIPD^† (physical activity in previous 7 days).	Mean (SD, range): Heart rate monitor: (𝑛=12) Minutes/day of light activity = 149 (107, 37–368); Minutes/day of moderate activity = 44 (39, 0–132); Pedometer (𝑛=16): steps/day 6428 (4117, 1456–15604); BPAQ (sport index, range 1–5) 2.2 (0.7, 1.3–3.5); BPAQ leisure index 2.2 (0.6, 1.3–3.3); PASIPD (Mets hour/day range 0–199.5) 7.8 (7.6, 0.3–27.0)	14
Dobkin et al. [19]	Cross-sectional; (Validity/reliability study)	M = 8; F = 4.	Mean = 58.9; range = 36–73	Mean = 27.25 months (median = 14.5 months, IQR = 3.5–31.5, range = 2–112 months)	Wireless triaxial accelerometer; Log of mobility activity; Duration: 24 hrs, not nights.	Steps per day: mean = 3759.9 (median = 3096.5, IQR = 2025.5–4475.25, range = 383–12082); Hours monitored: mean = 8.75 (median = 8.375, IQR = 7.5–10.75, range = 4.75–13.25).	11
Fulk et al. [20]	Cross-sectional	Stroke = 19.; Control = 13; (not stratified by sex)	Stroke: mean = 65.7 (SD = 11.9); Control: mean = 65.3 (SD = 8.5)	Mean = 42.1 months (SD = 36.1)	SAM^‡ accelerometer; Duration: 1 week; not nights.	Mean steps per day: all stroke survivors = 3838.25 (SD = 1963.6) versus healthy control = 6294.0 (SD = 1768.0) [significantly fewer steps 𝑃<0.05].	12
Haeuber et al. [21]	Cross-sectional	Total = 17; (not stratified by sex)	Mean = 65; (SD = 6)	Mean = 41.6 months (range = 9–120 months)	SAM^‡ accelerometer; Caltrac accelerometer (total caloric expenditure); Duration: two separate 48 hour periods within 3 weeks; including nights.	Mean steps per day: test period 1 = 3049 (SD = 1918); test period two = 3021 (SD = 2042); total mean = 3035 (SD = 1944, range 336–6472).; Caloric expenditure (Kcal/day): test period 1 = 294 (SD = 154); test Period 2 = 347 (SD = 279); total mean = 321 (SD = 187, range = 83–1222)	13
Hale et al. [22]	Cross-sectional	Stroke: M = 10; F = 10.; Controls: M = 1, F = 8.	Stroke: mean = 72 (SD = 7.1, range = 57–86); control: mean = 51 (SD = 18.1, range = 28–76)	Not reported (at least >6 months).	TriTrac RT3 triaxial accelerometer; Daily activity log, 7-day recall questionnaire.; Duration: 7 consecutive days (Test 1) (repeated 8 weeks later (Test 2)); not nights.	Mean vector magnitude (MVM) in activity counts (AU) (7 days): [stroke: test 1 = 673,920 (SD = 379,495); test 2 = 573,403 (SD = 266,993)] [controls: test 1 = 1,385,760 (SD = 719,868); test 2 = 1,490,363 (SD = 510,675)].; 7-day Recall Q (Kcal in seven days): [stroke: test 1 = 3645 (SD = 572); Test 2 = 2633 (SD = 607)] [controls: test 1 = 2413 (SD = 354); Test 2 = 2363 (SD = 327)].	16
Manns and Baldwin [24]	Longitudinal	M = 6; F = 4.	Mean = 66.3 (SD = 15.0)	Mean time from stroke to discharge (days) = 74.7 (SD = 31.1)	SAM^‡ accelerometer.; Duration: 2 days; not nights; repeated predischarge (T1) and for 3 days at two weeks post discharge (T2) and again at six weeks post discharge (T3).	Steps per day (mean (SD)): T1 = 5541.4 (1845.8); T2 = 5506.2 (2196.6); T3 = 6195.0 (2068.0) [no significant difference between T1 and T3].; Absolute activity (mins/day) (mean (SD)): T1 = 182.6 (38.5); T2 = 198.5 (69.0); T3 = 228.8 (65.4) [significantly more minutes of activity in T3 compared to T1 (𝑃=0.030)].; Intensity of activity (proportion of strides at <15, ≥15 to <40, ≥40 strides/minute) (%): low: T1 = 62.6 (8.6) T2 = 68.0 (12.5) T3 = 68.5 (8.4); moderate: T1 = 31.2 (7.4); T2 = 24.7 (7.3); T3 = 26.2 (5.4). High: T1 = 6.2 (5.0); T2 = 7.3 (10.7); T3 = 5.4 (5.8) [Intensity of activity did not vary significantly between T3 and T1].	12
Manns et al. [25, 26]	Cross-sectional	M = 4; F = 6.; (and 10 matched controls)	Stroke: mean = 54.3 (SD = 3); controls: Mean = 54 (SD = 3)	7.5 (SD = 8.3, median = 4.2)	SAM^‡ accelerometer.; Duration: 4 days, not nights.	Steps per day (mean (SD)): strokes = 7379 (SD = 3107) versus controls = 14730 (SD = 4522) [significantly lower in strokes (𝑃<0.001)].	14
Michael et al. [27–29]	Cross-sectional	M = 42; F = 37.	Mean = 65 (range = 45–84)	Mean = 10.3 months (range = 6–166 months)	SAM^‡ accelerometer, log of activities.; Duration: 48 hrs, not nights.	Mean steps per day: Total steps = 1,389 (SD = 798, range = 256–4,476); Number of steps at low intensity	15
						(<16 steps/minute) = 624 (SD = 289, range 120–1,545); medium intensity (≥16 and <30 steps/minute) = 640 (SD = 536, range = 12–3,217); high intensity (≥30 steps/minute) = 83 (SD = 168, range = 0–846).
Mudge et al. [30]	Randomised Controlled Trial	Control: M = 13; F = 14.; Experimental: M = 19; F = 12.	Control: median = 71.0 (range = 44.0–86.0); experimental: median = 76.0 (range = 39.0–89.0)	Control: median = 5.8 yrs (range = 0.5–18.7); experimental: median = 3.33 yrs (range = 0.6–13.3)	SAM^‡ accelerometer; Duration: 3 consecutive days, not nights.; Self-reported PADS§ score.	Baseline activity: Mean steps per day: control = 4616 (SD = 2618) versus experimental = 6679 (SD = 3792) (significantly different 𝑃=0.021).; Peak activity index (steps/min): control = 52.0 (SD = 15.9) versus experimental = 66.6 (SD = 23.3) (significantly different 𝑃=0.008); Percentage time inactive (%): control = 84.1 (SD = 7.0) versus experimental = 81.6 (SD = 8.3) (not significantly different, 𝑃=0.235); PADS: control = 63.6 (SD = 77.0) versus experimental = 75.2 (SD = 57.5) (not significantly different, 𝑃=0.516).	17
Mudge and Stott [31]	Cross-sectional	M = 29; F = 20.	Mean = 67.4 (SD = 12.5, range = 38–89)	Mean = 66 months (SD = 61, range = 6–219)	SAM^‡ accelerometer; Duration: 3 consecutive days; not nights.	Steps per day: median = 4765 (range = 1225–21,273); Percentage of time with no steps: median = 83% (range 53–96); number of steps at: low rate (<30 steps/min): mean = 2334 (SD = 565, range = 493–5331); high rate (>60 steps/min): median = 655 (range = 0–10,590); Peak activity index (Steps/min): mean = 58.7 (SD = 10.6, range = 17–112).	15
Mudge and Stott [32]	Cross-sectional	M = 23; F = 17.	Mean = 69.2 (SD = 12.6)	Mean = 5.1 yrs (SD = 5.1)	SAM^‡ accelerometer; Duration: 3 consecutive days; not nights.	Total step count: mean = 6247 (SD = 4439); No. steps at high rate (>60 steps/min): mean = 1614 (SD = 2252); no. steps at low rate (<30 steps/min): mean = 2338 (SD = 1051); Peak activity index: mean = 58 (SD = 22).	13
Rand et al. [35, 36]	Cross-sectional	M = 13; F = 27.	Mean = 66.5 (SD = 9.6, range = 49–82)	Mean = 2.9 (SD = 2.4)	Actical triaxial accelerometer; Duration: 3 consecutive days; not nights.; Self-reported PASIPD^† (max 199.5 MET h/d) (physical activity in preceding seven days);	Mean activity counts per day: paretic Hip = 55,886 (SD = 5696); nonparetic Hip = 53,075 (SD = 83,476); mean energy expenditure per day (Kcal/day): paretic hip = 163.1 (SD = 149.4); nonparetic hip = 155.9 (SD = 140.7); average time wearing accelerometer = 15 hrs/day (SD = 1.8, range = 10–18); inactive hours awake = 13 hrs/day (SD = 2); PASIPD (MET hr/day, 0–199.5): median = 10.3 (IQR = 6.1–17.1).	15
Resnick et al. [37]	Cross-sectional	M = 51; F = 36.	Mean = 63.7 (SD = 12.3)	Not reported (at least >6 months).	SAM^‡ accelerometer; Duration of measurement: 48 hrs; including nights.; Self-reported YPAS⊗: (total activity time and Kcal expended in a week)	Steps per 48 hrs: mean = 4055 (SD = 2401.2, range = 66–13,429); YPAS: minutes of activity per week: mean = 3021.84 (SD = 2539.92, range = 0.00–9967.50); minutes of moderate activity (exercise): mean = 753.94 (SD = 950.72, range = 0.00–5670.00).	10
Robinson et al. [38]	Cross-sectional	M = 27; F = 23.	Mean = 65.0 (SD = 8.4, median = 65.0 range = 50–79)	Mean = 85.0 months (SD = 89.9, median = 34.5, range = 6–358)	VKR fitness twin step pedometer.; Duration of measurement: 7 days, excluding nights.	Steps per day (pedometer (𝑛=44)): mean = 2,540 (SD = 2176); median = 2,140 (range 0–10,754).	15
Shaughnessy et al. [39]	Longitudinal	M = 10; F = 11.	Mean = 68 (SD = 12.8, range = 48–91)	Not reported	SAM^‡ accelerometer; Duration: not reported	Mean daily steps (SAM) (𝑛=19): Time 1 (baseline): 1536 (SD = 106); Time 2 (3 months later): 2765 (SD = 1677) (significant increase from baseline (80%) at 3 months (𝑃<0.001)).	12
Van Den Berg-Emons et al. [42]	Cross-sectional	M = 20; F = 18.	Mean = 57 yrs (SD = 13)	Not reported	Four uniaxial piezoresistive accelerometers (on wrists if depended on wheelchair); Duration: 24 hrs, including nights.	Duration physical activities (% of 24 hrs) = 6.8 (SD = 4.5); % subnormal (average duration of physical activities in stroke survivors divided by average duration in able-bodied age-mates × 100) = 61% (significantly lower than able bodied subjects (𝑃≤0.01)).	11
van Swigchem et al. [43]	Prospective cohort nonrandomised, noncontrolled trial	M = 19; F = 5.	Mean = 52.8 (range = 21–68)	Mean = 38 months (range = 7–105)	Pedometer (Yamax Digiwalker SW-650); Duration: 7 days; nights unknown.	Mean steps per day: AFO = 5541 (SD = 2900); FES = 5733 (SD = 2516) (no significant difference between the two scores (𝑃=0.548)).	14
Viosca et al. [44]	Cross-sectional validation	M = 20; F = 11.	Mean = 64 (SD = 7.8)	Not reported	Two pedometers; Duration: 48 hrs, not nights.	Mean number of steps per 48 hrs categorised by functional ambulation classification (Level 0 = absolute walking incapacity; Level 3 = patients walk indoors, outdoors and climb occasional stair; Level 5 = normal): Level 0 = 8; Level 1 = 395; Level 2 = 2728; Level 3 = 10,503; Level 4 = 11,572; Level 5 = 19,169.	13
Yoneyama et al. [45]	Randomised Controlled Trial	Not reported; Indeloxazine group = 12; Ticlopidine group = 5.	Indeloxazine: mean = 71.2 (SD = 7.4); Ticlopidine: mean = 72.6 (SD = 10.4)	Range = 1–3 months	Actigraph triaxial accelerometer; Duration: 24 hrs; including nights.	Movements per 24 hr at baseline for each treatment group: Indeloxazine group: Mean = 74,438 (SD = 22,697); Ticlopidine group: Mean = 86,222 (SD = 17,433).	7
Zalewski and Dvorak [46]	Cross-sectional	Stroke: M = 14; F = 3.; Control: M = 3; F = 16.	Stroke: mean = 71.3 (SD = 9.5); control: mean = 68.1 (SD = 7.0).	Not reported; mean time since discharge from rehabilitation = 2.2 yrs (range = 8 months to 7.2 years)	SAM^‡ accelerometer; Duration: 3 days (taking full 24 hrs of day 2 to calculate activity scores); including nights.; Self-reported 7-day PAR^# (measures energy expenditure).	Steps per day: stroke: mean = 2,990 (SD = 2,488); control: 6,378 (SD = 2,149) (significantly different (𝑡 test, 𝑃<0.05)); Energy expenditure (unclear units) (7-day PAR): stroke: mean = 19,177 (SD = 6,457); control: mean = 19,918 (SD = 4,744) (not significantly different).	12

∗Baecke Physical Activity Questionnaire; ^†Physical Activity Scale for Individuals with Physical Disabilities; ^‡StepWatch Activity Monitor; §Physical Activity and Disability Scale; ⊗Yale Physical Activity Survey; ^#7-day Physical Activity Recall Questionnaire.