Effects on walking performance and lower body strength by short message service guided training after stroke or transient ischemic attack (The STROKEWALK Study): a randomized controlled trial.

OBJECTIVE: To evaluate whetherdaily mobile-phone delivered messages with training instructions during three months increase physical activity and overall mobility in patients soon after stroke or transient ischemic attack. DESIGN: Randomised controlled trial with intention-to-treat analyses. SETTING: University hospital. Data collection from November 2016 until December2018. SUBJECTS: Seventy-nine patients (mean (SD) age 63.9 (10.4) years, 29 were women) were allocated to either intervention (n = 40) or control group (n = 39). Participants had to be independent (modified Ranking Scale ⩽2) and able to perform the six-minute walking test at discharge from the hospital. INTERVENTIONS: The intervention group received standard care and daily mobile phone instructional text messages to perform regular outdoor walking and functional leg exercises. The control group received standard care; that is, primary care follow-up. MAIN MEASURES: Walking performance by six-minute walking test (m), lower body strength by five times chair-stand test (s), the short physical performance battery (0-12 points) and 10-metres walk test (m/s) were assessed at baseline and after three months. RESULTS: The estimated median difference in the six-minute walking test was in favour of the intervention group by 30 metres (95% CI, 55 to 1; effect size 0.64; P = 0.037) and in the chair-stand test by 0.88 seconds (95% CI, 0.02 to 1.72; effect size 0.64; P = 0.034). There were no differences between groups on the short physical performance battery or in 10-metres walking time. CONCLUSIONS: Three months of daily mobile phone text messages with guided training instructions improved composite mobility measures; that is, walking performanceand lower body strength. CLINICAL TRIAL REGISTRY: The study is registered with ClinicalTrials.gov, number NCT02902367.

Functional performance, nutritional status, and body composition in ambulant community-dwelling individuals 1-3 years after suffering from a cerebral infarction or intracerebral bleeding.

BACKGROUND: Muscle wasting and obesity may complicate the post-stroke trajectory. We investigated the relationships between nutritional status, body composition, and mobility one to 3 years after stroke. METHODS: Among 279 eligible home-dwelling individuals who had suffered a stroke (except for subarachnoid bleeding) 1-3 years earlier, 134 (74 ± 5 years, 69% men) were examined according to the Mini Nutritional Assessment-Short Form (MNA-SF, 0-14 points), including body mass index (BMI, kg/m(2)), body composition by bio-impedance analyses (Tanita BC-545), the Short Physical Performance Battery (SPPB, 0-12 points) combining walking speed, balance, and chair stand capacity, and the self-reported Physical Activity Scale for the Elderly (PASE). RESULTS: BMI ≥ 30 kg/m(2) was observed in 22% of cases, and 14% were at risk for malnutrition according to the MNA-SF. SPPB scores ≤ 8 in 28% of cases indicated high risk for disability. Mobility based on the SPPB was not associated with the fat-free mass index (FFMI) or fat mass index (FMI). Multivariate logistic regression indicated that low mobility, i.e., SPPB ≤ 8 points, was independently related to risk for malnutrition (OR 4.3, CI 1.7-10.5, P = 0.02), low physical activity (PASE) (OR 6.5, CI 2.0-21.2, P = 0.02), and high age (OR 0.36, CI 0.15-0.85, P = 0.02). Sarcopenia, defined as a reduced FFMI combined with SPPB scores ≤ 8 or reduced gait speed (<1 m/s), was observed in 7% of cases. None of the individuals displayed sarcopenic obesity (SO), defined as sarcopenia with BMI > 30 kg/m(2). CONCLUSIONS: Nutritional disorders, i.e., obesity, sarcopenia, or risk for malnutrition, were observed in about one-third of individuals 1 year after stroke. Risk for malnutrition, self-reported physical activity, and age were related to mobility (SPPB), whereas fat-free mass (FFM) and fat mass (FM) were not. Nutrition and exercise treatment could be further evaluated as rehabilitation opportunities after stroke.

Factors associated with changes in walking performance in individuals 3 months after stroke or TIA: secondary analyses from a randomised controlled trial of SMS-delivered training instructions in Sweden.

OBJECTIVES: This study aimed to identify factors related to changes in walking performance in individuals 3 months after a stroke or TIA. DESIGN: Cross-sectional study with post hoc analysis of a randomised controlled study. SETTING: University Hospital, Sweden. PARTICIPANTS: 79 individuals, 64 (10) years, 37% women, who were acutely hospitalised because of stroke or TIA between November 2016 and December 2018. Inclusion criteria were patients aged 18 or above and the major eligibility criterion was the ability to perform the 6 min walking test. INTERVENTION: The intervention group received standard care plus daily mobile phone text messages (short message service) with instructions to perform regular outdoor walking and functional leg exercises in combination with step counting and training diaries. The control group received standard care. OUTCOME MEASURES: Multivariate analysis was performed and age, sex, group allocation, comorbidity, baseline 6 min walk test, body mass index (BMI), cognition and chair-stand tests were entered as possible determinants for changes in the 6 min walk test. RESULTS: Multiple regression analyses showed that age (standardised beta -0.33, 95% CI -3.8 to -1.05, p<0.001), sex (-0.24, 95% CI -66.9 to -8.0, p=0.014), no comorbidity (-0.16, 95% CI -55.5 to 5.4, p=0.11), baseline BMI (-0.29, 95% CI -8.1 to -1.6, p=0.004), baseline 6 min walk test (-0.55, 95% CI -0.5 to -0.3, p<0.001) were associated with changes in 6 min walk test 3 months after the stroke event. The regression model described 36% of the variance in changes in the 6 min walk test. CONCLUSIONS: Post hoc regression analyses indicated that younger age, male sex, lower BMI and shorter 6 min walk test at baseline and possible no comorbidity contributed to improvement in walking performance at 3 months in patients with a recent stroke or TIA. These factors may be important when planning secondary prevention actions. TRIAL REGISTRATION NUMBER: NCT02902367.

Factors related to performance-based mobility and self-reported physical activity in individuals 1-3 years after stroke: a cross-sectional cohort study.

BACKGROUND: Low mobility and low level of physical activity is common after stroke. The objective of this study was to relate these outcomes to physical, psychological, and demographic determinants. METHODS: In this cross-sectional cohort study, a consecutive sample of 195 community-living individuals, 65-85 years of age (74±5 years, 71% men) with a previous stroke was included. Exclusion criteria were severe aphasia and severe cognitive dysfunction. Mobility status was measured by the Short Physical Performance Battery (SPPB, 0-12 points), and physical activity was measured using the Physical Activity Scale for the Elderly (PASE). RESULTS: Mobility (SPPB, median 9 points) and level of physical activity were low (mean PASE 97±66 points), and walking speed was slow (1.10±.86 m/s), in relation to a healthy population-based sample. In multiple regression analyses, age (P=.001), physical activity (P<.001), fall-related self-efficacy (P=.001), and health-related quality of life (HRQoL) (P=.02) were associated with mobility (SPPB). Mobility (P<.001), HRQoL (P=.014), and fall-related self-efficacy (P=.031) were likewise associated with self-reported physical activity as the dependent variable. The regression models described 42% and 31% of the variance in mobility and physical activity, respectively. CONCLUSIONS: Individuals perceived disabilities that are partly potentially modifiable 1-3 years after stroke. Future poststroke rehabilitation studies need to evaluate if actions to improve fall-related self-efficacy and mobility could promote the physical activity level in this patient population.

Potential effects on cardiometabolic risk factors and body composition by short message service (SMS)-guided training after recent minor stroke or transient ischaemic attack: post hoc analyses of the STROKEWALK randomised controlled trial.

OBJECTIVES: To evaluate effects of mobile phone text-messaging exercise instructions on body composition, cardiometabolic risk markers and self-reported health at 3 months after stroke. DESIGN: Randomised controlled intervention study with per-protocol analyses. SETTING: University Hospital in Sweden. PARTICIPANTS: Seventy-nine patients (mean (SD) age 64 (10) years, 37% female) ≥18 years with good motor function (modified Rankin Scale ≤2) and capable to perform 6 min walking test at hospital discharge were randomised to either intervention (n=40) or control group (n=39). Key exclusion criteria: subarachnoid bleeding, uncontrolled hypertension, severe psychiatric problems or cognitive limitations. INTERVENTIONS: The intervention group received beyond standard care, daily mobile phone instructional text messages to perform regular outdoor walking and functional leg exercises. The control group received standard care. MAIN OUTCOME MEASURES: Fat mass and fat-free mass were estimated by bioelectric impedance analysis. Cardiometabolic risk factors like blood lipids, glycated haemoglobin and blood glucose were analysed at baseline and after 3 months. RESULTS: Both groups changed favourably in fat-free mass (1.83 kg, 95% CI 0.77 to 2.89; p=0.01, effect size (ES)=0.63 vs 1.22 kg, 95% CI 0.39 to 2.0; p=0.05, ES=0.54) and fat mass (-1.30 kg, 95% CI -2.45 to -0.14; p=0.029, ES=0.41 vs -0.76 kg, 95% CI -1.74 to 0.22; p=0.123, ES=0.28). Also, many cholesterol related biomarkers improved; for example, total cholesterol -0.65 mmol/L, 95% CI -1.10 to -0.2; p=0.06, ES: 0.5 vs -1.1 mmol/L, 95% CI -1.47 to -0.56; p>0.001, ES=0.8. However, there were no between-group differences. At 3 months, 94% and 86%, respectively, reported very good/fairly good health in the text messaging and control groups. CONCLUSIONS: No clear effect of 3 months daily mobile phone delivered training instructions was detected on body composition, cardiovascular biochemical risk factors or self-perceived health. Further research is needed to evaluate secondary prevention efforts in larger populations after recent stroke. TRIAL REGISTRATION NUMBER: NCT02902367.

Vestibular rehabilitation for persons with stroke and concomitant dizziness-a pilot study.

BACKGROUND: Dizziness is common among patients with first time stroke. It affects self-perceived health and is a risk factor for falls. Vestibular rehabilitation (VR) is effective for treating dizziness among various conditions, but the effect of dizziness with origin in the central nervous system is poorly studied.This pilot study of a randomized controlled trial aimed at investigating a vestibular rehabilitation programme among patients with first time stroke and concomitant dizziness. A second aim was to study the feasibility of performing the randomized controlled trial. METHODS: The participants were computer generated randomized to either an intervention or a control group. The intervention comprised of four different vestibular rehabilitation exercises, adapted for each patient and usual rehabilitation. The control group received usual rehabilitation without the vestibular rehabilitation exercises. Outcome measures used were The Activities-specific Balance Confidence Scale, the Berg Balance Scale, the Functional Gait Assessment Scale and the EuroQol-5D. Feasibility was studied in terms of recruitment, adherence and retention rates, also as the ability to collect primary and secondary outcomes as well as to find indications of treatment differences. RESULTS: Self-rated health improved for all participants. No other differences between baseline and follow-up were detected neither within nor between groups. Recruitment rate was 23%, adherence to the intervention 90%, retention rate 69% and ability to collect outcome measures 90%. No adverse events occurred. CONCLUSION: Both the intervention and the control groups improved in self-perceived health. The measures of feasibility were satisfactory in this study, apart from a low recruitment rate.

Fear of falling, fall-related self-efficacy, anxiety and depression in individuals with chronic obstructive pulmonary disease.

OBJECTIVE: To examine the risk and frequency of falls, prevalence of fear of falling and activity avoidance, the magnitude of fall-related self-efficacy, and anxiety and depression in patients with chronic obstructive pulmonary disease. DESIGN AND SETTINGS: A cross-sectional study in patients with a diagnosis of chronic obstructive pulmonary disease who visited a lung clinic at a university hospital in Sweden. SUBJECTS: Successive inclusion from autumn 2005 to spring 2006 of 80 patients with a mean age of 65 years. INTERVENTION: Nil. MAIN MEASURES: A questionnaire about fall history and consequences of fall, The Falls Efficacy Scale, Swedish version, and the Hospital Anxiety and Depression Scale were used. RESULTS: Twenty patients (25%) reported at least one fall in the last year and 29% displayed fear of falling. Odds ratio for falling was 4-5 times higher in patients with severe chronic obstructive pulmonary disease. Older patients, women and patients with previous falls had a higher rate of fear of falling, and those with fear of falling had lower fall-related self-efficacy, increased level of anxiety and depression, more activity avoidance and use of assistive device. CONCLUSION: The increased risk of falls in patients with chronic obstructive pulmonary disease warrants attention in order to reduce serious and adverse health consequences of falls.

Level of physical activity in men and women with chronic stroke.

Introduction: Community-dwelling stroke survivors generally show low levels of physical activity (PA). An improved understanding of the factors influencing participation in PA after stroke is imperative to improve levels of PA. Furthermore, gender differences in PA have received little attention in stroke research. The objective of this study was to examine gender differences in PA, physical functioning and psychological factors and the association between these factors and PA in men and women 1-3-year post-stroke. Materials and methods: A total of 187 community-dwelling individuals with stroke (65-85 years old, 29% women) were included in a secondary analysis based on data from a cross-sectional study. The exclusion criteria were severe cognitive or language dysfunction or dementia. The level of PA was measured by the Physical Activity Scale for the Elderly. Physical function included balance, walking speed and mobility. Psychological factors included depression, health-related quality of life and fall-related self-efficacy. Falls and fear of falling were each measured with a single question. Results: There were no significant differences in PA levels between men and women. In multiple regression analyses, walking speed (p < 0.001) was associated with PA in men, and balance (p = 0.038) was associated with PA in women. Conclusions: The results indicate that strategies to increase PA levels 1-3-year post-stroke could be improved by considering gender-specific factors.

Protocol and pilot study of a short message service-guided training after acute stroke/transient ischemic attack to increase walking capacity and physical activity.

Physical activity in community-living individuals after a stroke is usually scarce. This protocol describes a study that will evaluate a method to increase physical activity by performing a 3-month outdoor walking and muscle strengthening program and will examine the 3-month and 1-year effects of this program on individuals with acute stroke (AS) or transient ischemic attack (TIA). In a prospective randomized controlled trial in Uppsala, Sweden, 80 individuals with AS or TIA who maintained cognitive and motor function will be randomized into groups for continuous training for three months or for regular standard care. The training will be supervised by daily cellphone-delivered messages (short message services; SMS), and the intensity, duration and workload will be gradually increased. The primary outcome is a change in walking capacity according to the 6-Minute Walk Test and chair-rising at three months. Secondary outcomes include mobility, gait speed, handgrip strength, body composition (fat mass and muscle mass), biochemical risk-markers, health-related quality of life, and cardiovascular events. Adherence to the training program will be documented with a self-reported diary and step counts over two weeks. The major study started in November 2016, and results are expected in 2019. In a pilot study of 15 subjects post-stroke (mean-age 65 years), we observed improved walking capacity (increasing from 23 to 255 m) and chair-rising (decreasing 2.42 s) from baseline to three months. SMS-guided outdoor training will be tested as a potential therapeutic strategy to increase physical activity and thereby improve walking capacity and physical function following a stroke.

Body composition and physical function after progressive resistance and balance training among older adults after stroke: an exploratory randomized controlled trial.

PURPOSE: To evaluate whether improvements in physical function are related to changes in body composition after a three-month progressive resistance and balance exercise program among individuals approximately one to three years after stroke. METHODS: In this randomized controlled trial, 43 community-dwelling subjects (65-85 years, mean age 73 ± 5 years, 73% men) were allocated to a progressive resistance and balance exercise program twice weekly for three months (intervention group [IG], n = 20) or a control group (n = 23). The main outcome measures were fat mass (kg) and fat-free mass (kg), as measured by bioelectrical impedance analyses (Tanita®). Physical function was measured using the six-minute walk test. RESULTS: Complete case analyses revealed reduced fat mass in the IG compared with the control (-1.5 vs. (0).13% of body weight, respectively; effect size =0.62; p = 0.048). In contrast, no between-group difference in fat-free mass was observed. The six-minute walk test was improved (25 vs. -10 m, respectively, effect size =0.69, p = 0.039) at three months in favor of the IG. The reduced fat mass was associated with an improved six-minute walk test (r = 0.48, p = 0.038) in the IG. CONCLUSIONS: Three-month progressive resistance and balance training was associated with reduced fat mass, which was related to improvements in walking capacity in older adults approximately one year after stroke. Implications for rehabilitation This three-month PRB group exercise program supported by motivational discussions and daily home-based exercises indicate the following: • Improved walking capacity was associated with a reduction in fat mass. • IGF-1 is reduced, possibly indicating improved insulin sensitivity.

Short-term and long-term effects of a progressive resistance and balance exercise program in individuals with chronic stroke: a randomized controlled trial.

PURPOSE: To evaluate the effects of progressive resistance and balance (PRB) exercises on physical and psychological functions of post-stroke individuals. MATERIALS AND METHODS: In a randomized controlled trial with follow-up at 3, 6 and 15 months, 67 community-living individuals (76% male; 65-85 years) with a stroke 1-3 years previously were allocated to an intervention group (IG, n = 34; PRB exercises combined with motivational group discussions twice weekly for 3 months) or a control group (CG, n = 33). The primary outcomes were balance (Berg Balance Scale, 0-56 points) and mobility (Short Physical Performance Battery, 0-12 points) at 3 months. The secondary outcomes were 10 m comfortable walking speed, physical activity levels, health-related quality of life, depression and fall-related self-efficacy. RESULTS: At 3 months, the IG exhibited significant improvements in balance (MD 2.5 versus 0 points; effect size [ES], 0.72; p < 0.01) and comfortable walking speed (MD 0.04 versus -0.05 m/s; ES, 0.68; p = 0.01) relative to the CG. A faster walking speed persisted at 6 months. No differences were found for the other outcomes. CONCLUSIONS: In chronic stroke patients, 3 months of PRB exercises and motivational discussions induced improvements in balance at 3 months and in walking speed at 3 and 6 months. Implications for Rehabilitation A progressive resistance and balance exercise program supported by motivational group discussions and one home-based exercise appears to be an effective means of improving the short-term balance and the walking speed in individuals with chronic stroke. People with poor balance and motor function discontinued the study more often and may require additional support. There is a need for powerful and cost-effective strategies that target changes in behavior to obtain long-term changes in physical function after exercising.