Abstract
Although post-stroke exercise training programmes improve aerobic capacity and functional capacities in the short-term, the impact on exercise performance at home has not been established.
Objectives
To assess compliance with prescribed physical activity by hemiplegic stroke patients. To compare the patients’ stated activity with their actual activity.
Patients and methods
This was a prospective pilot study of nine hemiplegic patients following an exercise training programme. Each patient’s activity was measured using an activity monitor (the ActivPAL™) before, during and immediately after the programme and then 3 months after the end of the programme. The activity actually performed was compared with the levels recommended after a stroke (at least 30 minutes of non-stop activity three times a week). Three months after the end of the programme, the patient’s stated and actual activities (in terms of frequency and duration) were compared.
Results
Activity patterns changed immediately after the end of the programme. Short-term compliance was good for four patients. However, 3 months later, only one patient was performing regular activity in accordance with the guidelines. Hence, medium-term compliance was poor. Most patients overestimated both the duration and frequency of their activity sessions.
Conclusion
Three months after the end of the supervised training programme, compliance with physical activity guidelines was low. The ActivPAL™ activity monitor is easy to use and performs satisfactorily. It can be used as a tool for activity assessment and education intervention. The use of an actimeter may increase the efficacy of health education interventions, which promote physical activity.
Résumé
Un réentraînement à l’effort en post-AVC améliore les capacités à l’effort et fonctionnelles à court terme. Son impact sur les performances en milieu ordinaire est peu connu.
Objectifs
Évaluer l’observance d’une activité physique chez des patients hémiplégiques d’origine vasculaire. Comparer l’activité auto-estimée par ces patients à l’activité réalisée.
Patients et méthode
Étude pilote prospective réalisée chez neuf patients hémiplégiques depuis plus de trois mois, bénéficiant d’un réentraînement. L’activité des patients est mesurée par accélérométrie (ActivPAL™) avant, pendant, en fin de programme et après trois mois. L’activité réalisée est comparée aux recommandations des sociétés savantes. À distance du réentraînement, l’activité déclarée, évaluée par questionnaire est comparée à l’activité enregistrée par accélérométrie : fréquence et durée des séances.
Résultats
Immédiatement après le programme, quatre patients pratiquent le volume d’activité recommandé. À trois mois, un seul patient poursuit une activité conforme aux recommandations. Huit patients surestiment l’activité réalisée pour la fréquence et la durée des séances.
Conclusion
À trois mois de l’arrêt d’un programme, l’observance d’une activité physique est faible. Le monitorage d’activité par accélérométrie, facile d’usage et acceptable, peut servir d’outil d’évaluation et d’éducation. La connaissance objective des données d’activité doit contribuer à l’amélioration de l’éducation thérapeutique.
1
English version
1.1
Introduction
In hemiplegic vascular stroke patients, supervised physical exercise programmes performed in a rehabilitation centre or at home have been shown to improve (at least in the short-term) fitness and quality of life and decrease cardiometabolic and cardiovascular risk factors . Rehabilitation is defined by the World Health Organisation as “the sum of activities required to ensure patients the best possible physical, mental and social conditions so that they may, by their own efforts, regain as normal as possible a place in the community and lead an active and productive life”.
The principal objective of post-stroke medical rehabilitation is to ensure the lasting benefit of a physical exercise programme. This helps improve performance and social participation but also serves as an effective means of secondary prevention.
Health education includes lifestyle and dietary measures and the regular performance of physical activity, which is recommended as part of secondary prevention. The goal is to act on modifiable cardiovascular risk factors . In post-stroke situations, the Stroke Council of the American Heart Association recommends performing moderate-intensity physical activity for at least 30 to 45 min a day, three times a week .
As with all therapeutic measures (and notably a programme in which a given duration of exercise is prescribed), subsequent long-term compliance is essential for efficacy.
Portable, accelerometer-based activity monitors can provide information on a subject’s activity in his/her everyday setting . Thanks to recent technological progress, these “real-life” measurement tools are reliable and well tolerated by the user and have been used to evaluate compliance with activity recommendations in chronic lower back pain patients .
1.2
Objectives
The objectives are:
- •
to quantitatively evaluate compliance with regular physical activity following a supervised exercise programme and physical activity education;
- •
to establish and compare the stated activity with that actually performed by hemiplegic stroke patients before, during, immediately after and then 3 months after a physical exercise programme (i.e. the patient’s ability to correctly estimate his/her level of activity).
1.3
Patients and methods
1.3.1
Population
1.3.1.1
Inclusion criteria
Over a 6-month period, we included neurologically stable patients having suffered an ischaemic stroke at least 3 months previously and who had enrolled in an exercise programme in a Physical Medicine and Rehabilitation centre. All included patients were able to walk on their own (with or without a technical aide) but presented physical deconditioning, as evidenced by the results of an exercise tolerance test with measurement of VO 2 .
1.3.1.2
Non-inclusion criteria
We excluded patients presenting contra-indications to exercise training: chronic obstructive or restrictive pulmonary disorders, severe valvulopathies, congestive heart disease, severe, progressing arrhythmias or conduction disorders, intracavitary cardiac thrombus, myocardial infarction or cardiac surgery within the previous 6 months, peripheral arterial occlusive disease (Leriche and Fontaine stage 3 or 4), severe phasic or cognitive disorders (Folstein’s Mini Mental State Examination score < 16 ), severe hemisensory neglect likely to interfere with the ability to understand instructions, sensorimotor impairments and, lastly, severe praxic or memory disorders likely to interfere with the ability to use a portable activity monitor.
1.3.2
The exercise training programme
The patients followed a personalized physical exercise programme prescribed and monitored by one and the same cardiologist with specific expertise in cardiovascular training and rehabilitation.
The programme included:
- •
endurance work at the ventilatory threshold (on a cycle ergometer, rowing machine, arm ergometer and/or treadmill, depending on the patient’s impairments) and segmental muscle strengthening sessions. We used the Borg Perceived Exertion Scale and the threshold heart rate (determined in a cycle ergometer exercise tolerance test with ventilatory gas analysis) to set the work level close to the ventilatory threshold (corresponding to a Borg score of 12 to 14) . The use of the Borg scale has not been specifically validated for stroke patients but it has already been used in studies evaluating post-stroke cardiac rehabilitation ;
- •
health education on cardiovascular risk factors and the need for regular physical exercise. The objective was to ensure that the patient understood the frequency and duration of the physical activity that should be performed (at least 30 to 45 minutes a day, three times per week, according to international guidelines ) and the effort intensity (i.e. learning to use functional signs: the dyspnoea scale and the Borg scale ). The following healthcare professionals were involved in the training and education programme: a cardiologist (consultation), physiotherapists (exercise sessions) and a dietician (group information sessions on health and dietary guidelines).
1.3.3
Study protocol
1.3.3.1
Schedule for evaluating the physical activity actually performed
Each patient’s level of activity in his/her everyday setting was evaluated over a week before the start of the programme (T0), during the programme (T1), immediately after the end of the programme (T2) and 3 months after the end of the programme (T3). The intermediate evaluation (T1) took place during a break in training for some patients and during a training week for others.
Evaluations were performed over a 7-day period (as in the studies by Hurley et al. and McDonough et al. ), in order to avoid measurement bias related to a possible difference in activity between the weekend and weekdays . Tudor et al. and Ward et al. recommend measuring for more than 3 days, in order to limit bias related to intra-individual variations in activity.
1.3.3.2
Evaluation tools
The evaluation looked at stated activity and that actually performed:
- •
a semi-structured activity questionnaire: the type of activity performed and the duration and frequency of the activity sessions over the week;
- •
activity monitoring with an ActivPAL™ Professional single-axis accelerometer (PAL Technologies Ltd, Glasgow, UK).
1.3.3.3
Parameters evaluated
ActivPAL™ parameters (data were extracted and analyzed using the PAL docking station):
- •
mean number of steps (per day);
- •
number of continuous walking periods lasting between 15 and 30 min (per week);
- •
number of continuous walking periods lasting more than 30 min (per week);
- •
number of steps performed during continuous walking periods lasting more than 30 min as a percentage of the total number of steps performed during the evaluation. This value was considered as “therapeutic” walking because its target value was set according to the guidelines:
- ∘
from the activity questionnaire;
- ∘
- •
the total duration of activity stated by the patient at the 3-month evaluation: the duration and frequency of the activity periods over the week. This was compared with the total duration of activity measured by the ActivPAL™.
1.3.3.4
Statistical tests
Quantitative variables were compared with Wilcoxon’s non-parametric paired test. A p value < 0.05 was considered to be statistically significant. Given the small sample size, quantitative variables are quoted as the median and the interquartile range (median [Q1–Q3]).
1.4
Results
1.4.1
The study population
The study population consisted of two women and seven men. The median age was 45 (43–47) ( Table 1 ). Five patients presented cognitive disorders: hemisensory neglect, anosognosia or memory, praxic or neurovisual disorders.
| Gender | Age | Handedness | Profession | Stroke | Aetiology of the stroke | Level of activity before the stroke (CLAS) | Initial motor impairment | Persistent motor impairment | Cognitive disorders | MMS | FIM | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | M | 39 | Right-handed | Transport company employee | R | Atheroma | S | Hp P L | Absent | Anosognosia | 27 | 119 |
| Sylvian segment | Hemisensory neglect | |||||||||||
| 2 | F | 45 | Right-handed | Shelf filler | L | No established aetiology | S | Hp BF R | Absent | Anosognosia | 27 | 118 |
| Sylvian segment | Memory disorders | |||||||||||
| 3 | F | 44 | Right-handed | Cleaner and home help | R | No established aetiology | A | Hp P L | Arms: testing 0d 2p | None | 27 | 122 |
| Sylvian segment | ||||||||||||
| 4 | M | 58 | Right-handed | Delivery receptionist | R | Atheroma | A | Hp BF L | Legs: testing 4p 2d | None | 29 | 121 |
| Sylvian segment | Arms: testing 2 | |||||||||||
| 5 | M | 47 | Left-handed | Delivery receptionist | L | Atheroma | A | Hp BF R | Absent | Attention disorders | 30 | 124 |
| Sylvian segment | ||||||||||||
| 6 | M | 43 | Right-handed | Industrial designer | L | Arterial dissection | C | Hp P R | Absent | Neurovisual disorders | 27 | 119 |
| Sylvian segment | ||||||||||||
| 7 | M | 58 | Right-handed | Construction worker | R | Atheroma | A | Hp BF L | Absent | Hemisensory neglect | 19 | 118 |
| Sylvian segment | Praxic and memory disorders | |||||||||||
| 8 | M | 45 | Right-handed | Driver | R | Atheroma | A | Hp P L | Absent | None | 30 | 126 |
| Sylvian segment | ||||||||||||
| 9 | M | 38 | Right-handed | Driver and reserve policeman | L | No established aetiology | L | Hp BF R | Absent | None | 27 | 126 |
| Sylvian segment | ||||||||||||
1.4.2
The training programme
The median time between the stroke and the beginning of the exercise training programme was 5.5 months (4.5–9). The programme included 38 sessions (35–42) and lasted for 3 months (3–4) ( Table 2 ).
| Time since stroke (months) | Duration (months) | Number of sessions | Tools used a | |
|---|---|---|---|---|
| 1 | 3 | 4 | 38 | 1, 2, 3, 4 |
| 2 | 9 | 5.5 | 47 | 1, 2, 3 |
| 3 | 19.5 | 1.5 | 18 | 2, 3 |
| 4 | 9 | 3.5 | 42 | 1, 2, 3 |
| 5 | 3.5 | 3 | 35 | 1, 2, 4 |
| 6 | 4.5 | 5 | 41 | 1, 2, 3, 4 |
| 7 | 7 | 3 | 58 | 1, 2, 3 |
| 8 | 4 | 3 | 31 | 1, 2, 3, 4 |
| 9 | 5.5 | 3 | 38 | 1, 2, 3, 4 |
a 1: arm ergometer; 2: cycle ergometer; 3: treadmill; 4: rowing machine.
1.4.3
Stated activity and activity actually performed
1.4.3.1
Evaluation of the activity performed during the training programme
At the T1 evaluation, periods of continuous walking for over 30 min were more frequent in patients evaluated during a training week (patients 5, 7, 8 and 9) ( Tables 3 and 4 ). The percentage of “therapeutic” walking was also higher for these patients.
| Stated activity at 3 months | Measured activity at 3 months | |||
|---|---|---|---|---|
| Session duration (min) | Session frequency (per week) | Session duration | Session frequency | |
| 1 | 60 | 7 | 0 | 0 |
| 2 | 30 | 7 | 45 | 1 |
| 15 | 2 | |||
| 3 | 20 | 7 | 15 | 6 |
| 4 | 60 | 3 | 0 | 0 |
| 30 | 7 | |||
| 5 | 45 | 9 | 15 | 8 |
| 6 | 60 | 5 | 30 | 2 |
| 15 | 1 | |||
| 7 | 45 | 5 | 45 | 1 |
| 30 | 2 | |||
| 15 | 3 | |||
| 8 | 60 | 2 | 15 | 1 |
| 45 | 5 | |||
| 9 | 30 | 4 | 30 | 1 |
| 15 | 1 | |||
| Mean number of steps | “Therapeutic” steps (%) | |||||||
|---|---|---|---|---|---|---|---|---|
| T0 | T1 | T2 | T3 | T0 | T1 | T2 | T3 | |
| 1 | 5958 | 4410 | 7382 | 4172 | 0 | 0 | 11 | 0 |
| 2 | 5964 | 8418 | 9018 | 7481 | 0 | 11 | 0 | 10 |
| 3 | 6712 | Nt | 3563 | 4786 | 14 | Nt | 0 | 0 |
| 4 | 7421 | 7509 | 10,571 | 7088 | 0 | 0 | 21 | 0 |
| 5 | 9138 | 10,210 a | 8947 | 6407 | 18 | 30 a | 14 | 0 |
| 6 | 12,039 | 7660 | 11,683 | 8630 | 20 | 16 | 31 | 17 |
| 7 | 3679 | 7081 a | 11,536 | 6015 | 22 | 45 a | 61 | 30 |
| 8 | 4961 | 10,206 a | 6473 | 5206 | 7 | 31 a | 0 | 0 |
| 9 | 6889 | 11,350 a | 9747 | 7563 | 0 | 25 a | 31 | 10 |
1.4.3.2
End-of-programme evaluation T2: activity performed during the week immediately after the end of the exercise training programme
Two different activity profiles emerged, with different changes over time ( Tables 3 and 4 ):
- •
maintenance of a walking activity level which was greater than or equivalent to the level performed during the exercise training programme and greater than or equivalent to the recommended level of activity. Four patients (4, 6, 7 and 9) displayed good short-term compliance (as illustrated for patient 9 in Fig. 1 );
- •
non-maintenance of this activity and a return to baseline levels. Hence, five patients (1, 2, 3, 5 and 8) displayed poor short-term compliance (as illustrated for patient 5 in Fig. 2 ) and below-target levels of activity.
1.4.3.3
The activity evaluation performed 3 months after the end of the exercise training programme (T3)
The results for the population as a whole (except for patient 7) revealed the lack of changes in walking activity versus the initial activity, despite completion of the exercise training programme and provision of health education; the level of activity was below the guideline value and so mid-term compliance was poor ( Tables 3 and 4 ). There was significant drop in the average number of steps between the end of the exercise training programme and the evaluation at 3 months ( p = 0.02). The percentage of “therapeutic” walking also fell significantly between the end of the programme and the evaluation at 3 months ( p = 0.03).
1.4.3.4
Comparison of the activity actually performed and the activity stated in the evaluation at 3 months
The stated level of activity did not accurately reflect the measured activity ( Table 5 ). For eight patients, the frequency and the duration of stated activity were higher than those actually measured (i.e. overestimation). The total duration of stated activity was significantly greater than that measured by the accelerometer ( p = 0.01). For the only patient who correctly evaluated the actual level of activity (patient 3), the session duration was shorter than that recommended by the guidelines.
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