Reduced physical activity level was associated with poorer quality of life during the early phase of the COVID-19 pandemic: a sub-study of the last-long trial.

OBJECTIVES: To assess how physical activity levels changed in a stroke cohort during the COVID-19 (SARS-CoV-2) pandemic, and how these changes were associated with quality of life (QoL). METHODS: Between March and July 2021, 150 patients with stroke already included in the Life after Stroke (LAST-long) trial in Norway were invited to participate in this cross-sectional survey. Participants were asked to complete a questionnaire assessing changes in physical activity and self-reported health following the pandemic. Univariate and multivariate logistic regression analyses were used to explore the association between physical activity, loneliness, mental health, social activity and QoL. RESULTS: In all, 118 (79%) participants completed the questionnaire. A total of 80 (68%) reported less physical activity, 46 (39%) felt lonelier, and 43 (37%) reported worse mental health, while 50 (42%) reported reduced QoL compared with before the lockdown. In the univariate analyses less physical activity, feeling lonelier and changes in mental health were associated with reduced QoL. In the multivariate analysis only less physical activity odds ratio (OR) = 4.04 (95% confidence interval (95% CI) 1.44-11.34, p = 0.008) was significantly associated with reduced QoL. CONCLUSION: More than two-thirds of patients with stroke reported reduced physical activity during the COVID-19 pandemic, and less physical activity was strongly associated with reduced QoL.

Multimodal individualised intervention to prevent functional decline after stroke: protocol of a randomised controlled trial on long-term follow-up after stroke (LAST-long).

INTRODUCTION: Multimodal interventions have emerged as new approaches to provide more targeted intervention to reduce functional decline after stroke. Still, the evidence is contradictory. The main objective of the Life After Stroke (LAST)-long trial is to investigate if monthly meetings with a stroke coordinator who offers a multimodal approach to long-term follow-up can prevent functional decline after stroke. METHODS AND ANALYSIS: LAST-long is a pragmatic single-blinded, parallel-group randomised controlled trial recruiting participants living in six different municipalities, admitted to four hospitals in Norway. The patients are screened for inclusion and recruited into the trial 3 months after stroke. A total of 300 patients fulfilling the inclusion criteria will be randomised to an intervention group receiving monthly follow-up by a community-based stroke coordinator who identifies the participants' individual risk profile and sets up an action plan based on individual goals, or to a control group receiving standard care. All participants undergo blinded assessments at 6-month, 12-month and 18-month follow-up. Modified Rankin Scale at 18 months is primary outcome. Secondary outcomes are results of blood tests, blood pressure, adherence to secondary prophylaxis, measures of activities of daily living, cognitive function, physical function, physical activity, patient reported outcome measures, caregiver's burden, the use and costs of health services, safety measures and measures of adherence to the intervention. Mixed models will be used to evaluate differences between the intervention and control group for all endpoints across the four time points, with treatment group, time as categorical covariates and their interaction as fixed effects, and patient as random effect. ETHICS AND DISSEMINATION: This trial was approved by the Regional Committee of Medical and Health Research Ethics, REC no. 2018/1809. The main results will be published in international peer-reviewed open access scientific journals and to policy-makers and end users in relevant channels. TRIAL REGISTRATION NUMBER: ClincalTrials.gov Identifier: NCT03859063, registered on 1 March 2019.

Relationship between pre-stroke physical activity and symptoms of post-stroke anxiety and depression: An observational study.

OBJECTIVES: To explore mechanisms affecting mental health in patients with stroke. The aims were to investigate the association between pre-stroke physical activity and symptoms of anxiety and depression 3 months after stroke, and to investigate how self-reported physical activity changed from before to 3 months after the stroke. DESIGN: Secondary analyses of a prospective observational multicentre study. PATIENTS: Stroke patients from 11 Norwegian stroke units. METHODS: Symptoms of anxiety and depression were measured using the Hospital Anxiety and Depression Scale, and physical activity was assessed by self-report. Negative binomial regression was used to analyse associations. RESULTS: The analysed sample consisted of 205 patients; mean age was 74 years (standard deviation (SD) 11.5); 46% were women. Higher activity levels before stroke were associated with fewer symptoms of depression in multivariable analyses with regression coefficient of 0.84 (95% confidence interval 0.73-0.97), p = 0.015. Eighty-five (41.5%) patients reported similar activity levels before and after stroke. CONCLUSION: In this group of patients with mild symptoms of emotional distress, it seems that pre-stroke physical activity might be protective against post-stroke depression, but not anxiety. Many patients with mild-to-moderate stroke report being equally active before and after the stroke.

Correction to: Time spent lying, sitting, and upright during hospitalization after stroke: a prospective observation study.

The original version of this article.

New-onset pain in the early phase and three months following stroke - data from a multicenter study.

BACKGROUND: The reported prevalence of pain after stroke varies considerably, depending on how pain is measured, time after stroke, and characteristics of the selected population. The aims of this study were to investigate the prevalence and distribution of new-onset pain initially and three months after stroke in a general Norwegian cohort, and to examine whether symptoms of anxiety or depression were associated with new-onset pain after stroke. MATERIAL AND METHODS: Stroke patients were included from eleven different hospitals within 14 days after stroke onset. Pain was assessed at inclusion and three months after stroke, and the distribution of pain was marked on a body map. New-onset pain was defined as pain reported by the patients to have occurred after the stroke. Symptoms of anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale. RESULTS: A total of 390 patients were included. Pain data were available in 142 patients at both inclusion and follow-up, while 245 patients had available data for the regression analysis. In patients with follow-up data, new-onset pain occurred in 14 (9.9%) patients at inclusion and in 31 (21.8%) patients three months later, P=0.005. New-onset pain in the affected upper limb and bilaterally in the lower limbs was more common at three months than initially after stroke. Symptoms of anxiety were associated with new-onset pain (OR=1.13, 95% CI 1.01-1.27, P=0.030). CONCLUSION: This study shows that new-onset pain occurs in one out of ten patients initially after stroke and in one out of five patients three months after stroke, and it was associated with symptoms of anxiety. This raises the question of whether easing symptoms of anxiety might help to prevent or treat new pain after stroke.

Time spent lying, sitting, and upright during hospitalization after stroke: a prospective observation study.

BACKGROUND: Early mobilization has been an important part of acute stroke unit treatment. However, early and intense mobilization within the first 24 h post stroke may cause an unfavorable outcome. Recently, objective measurements using body-worn sensors have been applied, enabling continuous monitoring of physical activity in the hospital setting. This study aimed to use body-worn sensors to quantify the amount of physical activity and how activity levels changed over time during hospitalization in patients with acute stroke. We also wanted to investigate which factors were associated with upright and sitting activity. METHODS: This was a prospective study including patients admitted to hospital within seven days after onset of stroke. Physical activity was measured by two sensors (ActivPALs from PAL Technologies Ltd., Glasgow, UK), one attached on sternum and one on the thigh of the unaffected side, monitoring continuously from inclusion until discharge. Data were processed in Matlab R 2015B and provided information about daily time in lying, sitting, and upright positions, and daily average duration of sitting and upright bouts. A linear mixed model was used to analyze changes over time. RESULTS: 58 patients were included (31 women, mean (SD) age; 75.1 (12.0)). Patients were hospitalized for 12.1 (7.6) days and had a mean score on the National Institute of Health Stroke Scale of 6.2 (5.5) points. Time spent sitting and time spent upright increased per day during hospitalization by 22.10 min (95% Confidence interval (CI): 14.96, 29.24) and 3.75 min (95% CI: 1.70, 5.80) respectively. Increased time upright was associated with improved Modified Rankin Scale scores (- 38.09 min, 95% CI: -61.88, - 14.29) and higher Short Physical Performance Battery scores (6.97 min, 95% CI: 1.99, 11.95), while prolonged bouts of sitting were associated with more severe stroke (4.50 min, 95% CI: 0.80, 8.19), and older age (1.72 min, 95% CI: 0.20, 3.26). CONCLUSIONS: Patients increased their daily time spent sitting and upright during the initial hospital stay after stroke. Prolonged bouts of sitting were associated with older age and more severe strokes. Hence future research should investigate the benefit of interventions aimed at breaking up sitting time after stroke.

Upright activity within the first week after stroke is associated with better functional outcome and health-related quality of life: A Norwegian multi-site study.

OBJECTIVE: To assess the amount of early upright activity of patients managed in Norwegian stroke units and its association with functional outcome and health-related quality of life 3 months later. DESIGN: A prospective observational multi-centre study. SUBJECTS: A total of 390 acute stroke patients, mean age 76.8 years, 48.1% men, less than 14 days post-stroke, recruited from 11 Norwegian stroke units. METHODS: Time spent in different activity categories (in bed, sitting out of bed, upright) was observed with a standard method. Outcome was assessed by modified Rankin Scale (mRS), and health-related quality of life by EuroQol-5 Dimension 5 level (EQ-5D-5L) 3 months later. Ordinal logistic and linear regression analyses were used to examine the association between activity categories and mRS and EQ-5D-5L, respectively. Age, National Institute of Health Stroke Scale (NIHSS) score, premorbid mRS, sex, and hospital-site were added as covariates. RESULTS: The odds ratio (OR) (95% confidence interval (CI)) for poorer functional outcome (higher mRS) decreased as time spent in upright activities increased (OR 0.97 (95% CI 0.94-1.00)). There was also a significant positive association between time in upright activity and higher EQ-5D-5L, Beta 0.184 (95% CI 0.001- 0.008) 3 months later. CONCLUSION: This study confirms the beneficial effect of upright activity applied during hospital stay in Norwegian stroke units.

Prevalence of fatigue in patients 3 months after stroke and association with early motor activity: a prospective study comparing stroke patients with a matched general population cohort.

BACKGROUND: Fatigue is a common complaint after stroke. Reasons for higher prevalence are still unclear. This study aimed to determine if fatigue prevalence in stroke patients is different to that of age and gender matched general population controls, and to explore whether early motor activity was associated with reduced likelihood of fatigue three months after stroke. METHODS: This was a prospective multicenter cohort study of stroke patients admitted to eleven regional Norwegian hospitals, within 14 days after stroke. Stroke patients (n = 257) were age and gender matched to participants in a general population health survey (HUNT3-survey) carried out in a regional county of central Norway. The single-item fatigue questionnaire from the HUNT3-survey was administered to both groups to compare prevalence. The association between early motor activity (time in bed, time sitting out of bed, and time upright) and fatigue at three months after stroke (Fatigue Severity Scale) was tested with logistic regression. Simple models including each activity outcome, with adjustment for stroke severity and pre-stroke function, were tested, as well as a comprehensive model that included additional independent variables of depression, pain, pre-stroke fatigue, age and gender. RESULTS: Prevalence was higher after stroke compared with the general population: 31.1% versus 10.9%. In the simple regression models, none of the early motor activity categories were associated with fatigue three months after stroke. In the comprehensive model, depression, pain and pre-stroke fatigue were significantly associated with post-stroke fatigue. Time in bed through the daytime during hospital stay approached statistical significance (p = 0.058) with an odds ratio for experiencing fatigue of 1.02 (95% CI 1.00-1.04) for each additional 5.4 minutes in bed. CONCLUSIONS: Stroke patients had higher prevalence of fatigue three months after stroke than the age and gender matched general population sample, which may be partly explained by the stroke population being in poorer health overall. The relationship between early motor activity (and inactivity) and fatigue remains unclear. Further research, which may help drive development of new treatments to target this challenging condition, is needed.

Hospital differences in motor activity early after stroke: a comparison of 11 Norwegian stroke units.

BACKGROUND: Activity levels in patients early after stroke vary across the world. The primary aim of this study was to assess the variation in motor activity in patients admitted to multiple Norwegian stroke units and to identify factors which explained the variation between hospitals. METHODS: Eligible patients were those less than 14 days after stroke, more than 18 years, not receiving palliative care. Activity levels, people present, and location were recorded by the use of a standard method of observation between 8 am and 5 pm. Hospital policy on serving meals in communal areas was also registered. Mixed general binomial model was used to analyze, which factors explained variation in activity levels between hospitals, after adjusting for age and stroke severity. RESULTS: A total of 393 patients from 11 stroke units were included. The patients spent 44.1% of the day in bed, 43.2% sitting out of bed, and 8.3% in higher motor activities (4.4% were not observed). Increased physical activity was associated with spending more time with a physical therapist, odds ratio (OR), 1.05 (95% confidence interval [CI], 1.03-1.08, P < .001) and admitted to a hospital serving the meals in communal areas, OR, 1.46 (95% CI, 1.09-1.95, P = .011). CONCLUSIONS: Despite variation between the hospitals, patients admitted to Norwegian stroke units spend most of the day out of bed. Time spent with a physical therapist and hospitals having a policy of serving meals in communal areas explained most of the variation in activity between hospitals.

High-intensity aerobic interval training for patients 3-9 months after stroke: a feasibility study.

BACKGROUND AND PURPOSE: High-intensity aerobic interval training (AIT) has shown to be beneficial in patients with cardiac and pulmonary diseases. Presumably, patients with stroke also benefit from such treatment. However, the feasibility and potential efficacy of high-intensity AIT should be investigated for patients early after stroke. METHODS: This was a single-group, pre-test-post-test, intervention study. The intervention consisted of a 6-week high-intensity AIT programme, performed twice a week. The AIT comprised 4 × 4-minute intervals, at 85-95% of peak heart rate, interrupted by 3-minute active breaks. Adherence to the protocol, compliance and adverse events were registered to assess feasibility. Cardiorespiratory fitness and functional outcomes were assessed before and after the intervention and at 6 and 12 weeks follow-up. RESULTS: Ten men and five women (mean age 70.0 ± 7.7; range 61-85 years) with mild to moderate stroke were included, 3-9 months after onset. One patient was diagnosed with cancer during follow-up. There were three minor events, but no serious adverse events occurred. All patients accomplished all training sessions and reached the 85% intensity level, except one patient who discontinued the last session. The mean peak oxygen uptake showed no significant improvement from pre-treatment, 28.7 ± 3.8 ml kg(-1) min(-1), to post-treatment, 29.6 ± 3.6 ml kg(-1) min(-1), p = 0.189, whereas the mean 6-minute walk test improved from 410.7 ± 101.4 m to 461.0 ± 99.6 m, p = 0.001, and the median (interquartile range) Rivermead Motor Assessment Scale improved from 12.0 (11.0-13.0) to 13.0 (11.0-13.0) points, p = 0.100. These improvements continued after the intervention was concluded. CONCLUSIONS: This study has shown that high-intensity AIT is feasible for a selected group of stroke patients. However, the training should be accomplished in line with the American College of Sports Medicine guidelines for high-risk populations to ensure safety. The participants achieved a clinically highly significant improvement in walking distance. This intervention should be tested out in a randomized controlled trial to assess if it is superior to other interventions.

Feasibility and changes in symptoms and functioning following inpatient cancer rehabilitation.

AIM: The aim was to assess feasibility of a 3 + 1 week inpatient rehabilitation program for cancer survivors, to explore characteristics of the attending participants and examine changes in work status, symptoms and functioning, level of fatigue, exercise and physical performance following rehabilitation. METHODS: This was an open intervention study involving cancer survivors having completed primary cancer treatment. The multidisiplinary program consisted of physical training, patient education and group sessions. Participant were assessed at primary stay (T0), at follow-up stay 8-12 weeks later (T1), and six months after T1 (T2). Symptoms and functioning were assessed by the European Organization for Research and Treatment Core Quality-of-Life Questionnaire, physical fatigue by Fatigue Questionnaire, physical exercise by The Nord- Trøndelag Health Study Physical Activity Questionnaire and physical performance by aerobic capacity (VO(2max)), 30 second Sit-to-stand (STS) and Maximum Step Length (MSL). Linear mixed models were used in analyses. RESULTS: One hundred and thirty-four of 163 included participants (82%) completed both rehabilitation stays and returned questionaires at T2. The majority of completers were females (81%), breast cancer survivors (60%), highly educated and with mean age of 52.8 years (SD of 8.1). Participants had higher level of symptoms and fatigue and lower functioning at admission compared to a Norwegian reference population. However, they reported higher physical exercise level and 47% reported improved work status from T0 to T2. Symptoms and functioning, fatigue, physical exercise and physical performance improved significantly from T0 to T1 and were maintained at T2. CONCLUSIONS: The rehabilitation program was feasible and symptoms and functioning normalized following rehabilitation. The program mainly recruited well-educated breast cancer survivors, reporting relative high level of physical exercise. More focus should be put on recruiting and selecting those who need comprehensive inpatient rehabilitation and also compare the effects of inpatient with outpatient rehabilitation programs.