Exercise as it relates to Disease/Physical activity trends in an older population post-stroke

This page is a critique of the research article: Birgit Vahlberg Med Dr, PT, Annika Bring Med Dr, PT, Karin Hellström PT & Lena Zetterberg Med Dr, PT (2019) 'Level of physical activity in men and women with chronic stroke'. Physiotherapy Theory and Practice, 35:10, 947-955.

It was undertaken as an assignment for the Health, Disease and Exercise Unit (8340) at the University of Canberra in Semester 2, 2020.

What is the background to this research?
Low physical activity (PA) levels are a common trend amongst stroke survivors. In order to improve PA levels, a better understanding of the factors influencing participation must be enhanced. This study examined gender differences in PA, physical functioning and psychological factors and the association between these factors and PA in men and women 1–3 years post-stroke. The American Heart Association recommends at least 20–60 minutes of medium - high level intensity exercise (expressed as 40–70% of either peak oxygen uptake or heart rate reserve) 3 or more days per week for stroke survivors.

Stroke is a major global health issue. About 25.7 million people were living with a stroke in 2013, one-quarter of which are often recurrent. Physical, psychological, and psychosocial problems following stroke have been linked to a reduction in PA participation. The reason as to why PA participation is so low is not as well documented, therefore making this study quite valuable. It examines gender differences and whether they play a significant role in PA, something that has been given minimal attention in stroke research.

Where is the research from?
This study consisted of 187 community-dwelling individuals, aged between 65 and 85, with history of a stroke in the last 1–3 years. Males made up the majority of the cohort at 71%, with the remaining 29% being female. Any individual's with dementia or severe cognitive or language dysfunctions were excluded from the study.

The research was published in 'Physiotherapy Theory and Practice: An International Journal of Physical Therapy'. Vahlberg, Bring, Hellström and Zetterberg conducted their research at the Uppsala University, Uppsala, Sweden. Despite the study being conducted overseas, it is still very relevant for Australians. All four authors have a good reputation in the Department of Neuroscience field, with over one hundred publications between them. Hellström would have the most experience in the field, as shown with her 55 publications alone.

What kind of research was this?
This research was a secondary analysis based on previously obtained data from a cross-sectional study. The evidence surrounding lack of PA post-stroke is undeniable, however the reason as to why this is occurring is not so clear. Given the objective of the study was to analyse different factors between genders, psychological and physical functioning, the study design is fitting.

What did the research involve?
Data was collected from the 187 community-dwelling individuals in a range of index and scale type formats. These included:


 * 1) Charlson Comorbidity Index
 * 2) Physical Activity Scale for the Elderly (PASE)
 * 3) Short Physical Performance Battery (SPPB)
 * 4) Modified Motor Assessment Scale (M-MAS)
 * 5) Berg Balance Scale (BBS)
 * 6) 10-metre walking test (10mWT)
 * 7) Geriatric Depression Scale (GDS-20)
 * 8) Short Portable Mental Status Questionnaire (SPMSQ)
 * 9) Falls Efficacy Scale, Swedish version (FES(S))
 * 10) EQ-5D index.

All of these scales have been used in previous stroke research in elderly individuals, proving to be reliable and valid forms of measurement.

All performance based tests (i.e PASE, GDS-20, FES(S), EQ-5D) were conducted by the first author (Vahlberg) at the Uppsala hospital. The other tests were sent to each participants' homes to be completed and brought back with them. Once the data was collected, Statistical Package for Social Sciences (SPSS) Version 24 was used to analyse the statistics.

Small bias may exist in some aspects of the data in relation to the self-reporting. Some may under or over estimate their PA levels, leading to a skew in the results. Perhaps a more even spread of male and female participants would have been more desirable.

What were the basic results?
Of the 187 individuals within the cohort, the mean age was 74 years, with a median time of 13 months since their stroke for both men and women. No comorbidities were observed for 57% of males and 67% of females. There were no gender differences in the level of self-reported PA. In men, a significant correlation was found between PASE and: age (r = −0.19; p = 0.033); BBS (r = 0.55; p < 0.001); EQ-5D (r = 0.48; p < 0.001); SPPB (r = 0.59; p < 0.001); walking speed (r = 0.51; p < 0.001); FES(S) (r = 0.48; p < 0.001); GDS (r = −0.29; p < 0.001); M-MAS (r = 0.49; p < 0.001); and SPMSQ (r = 0.26; p = 0.003). No significant correlation was found between PASE and FOF (r = −0.12; p = 0.26) or falls (r = −0.1; p = 0.28).

In women, a significant correlation was found between PASE and: BBS (r = 0.42; p = 0.001); EQ-5D (r = 0.37; p = 0.006); SPPB (r = 0.48; p > 0.001); walking speed (r = 0.33; p = 0.015); FES(S) (r = 0.43; p = 0.001); GDS (r = −0.39; p = 0.003); and M-MAS (r = 0.54; p < 0.001). No significant correlation was found between PASE and age (r = −0.03; p = 0.83) or SPMSQ (r = 0.05; p = 0.69).

The researchers found that the self-reported PA, as measured by PASE, was associated with walking speed in men, and self-reported PA was associated with balance, as measured by the BBS, in women. The regression model explained 29% of the variance in the PASE outcome for males, and 23% of the variance in the PASE outcome for females.

What conclusions can we take away from this research?
This research is advantageous for anyone affected by a stroke in some way, whether it be personally or someone they know. First and foremost, having the knowledge of the benefits of PA is paramount. Following PA guidelines set out by the American Heart Association is a great starting point, and something to follow as closely as possible in order to maximise health post-stroke.

The study found that a gender-specific approach could be effective in optimising strategies to increase PA 1 – 3 years post-stroke. The information from other studies regarding gender differences in PA is scarce, therefore this is an area of study that should be looked into further to help increase the rate of PA in stroke survivors.

Practical advice
Based on the evidence available, it is recommended that stroke survivors should undertake different forms of PA each week to assist them in their day-to-day life. This includes strength, flexibility, balance and coordination training (2-3 times per week for each modality) to enhance independence, increase range of movement and prevent deformities. Aerobic exercise should also be carried out a few times per week at a moderate intensity for at least 20 – 60 minutes at a time, which will help improve physical capabilities and decrease the risk of other issues, such as cardiovascular disease.

It would be in the best interest of an individual to see a doctor or some other healthcare professional in order to safely prescribe a rehabilitation program for them. This will minimise any risk factors that may come with PA after suffering a stroke.

Further information/resources

 * https://www.stroke.org
 * https://www.mayoclinic.org/diseases-conditions/stroke/in-depth/stroke-rehabilitation/art-20045172
 * https://www.ahajournals.org/doi/epub/10.1161/STR.0000000000000211
 * https://www.webmd.com/stroke/home-after-stroke