Associate Professor Coralie English

© 2019 American Physical Therapy Association. Background. Exercise after stroke improves cardiorespiratory fitness and walking capacity; however, the effect of altering exercise dose (via frequency, intensity, time, and type) on fitness or walking capacity is unclear. Purpose. The purpose of this study was to synthesize the current evidence for the effects of different doses of exercise on cardiorespiratory fitness and walking capacity in people after stroke. Data Sources. Seven relevant electronic databases were searched using keywords relating to stroke and cardiorespiratory fitness. Study Selection. Trials that compared more than 1 dose of exercise for people (? 18 years old) after stroke and measured peak oxygen consumption or 6-minute walk test distance as an outcome were included. Two reviewers independently appraised all trials. Data Extraction. Two reviewers independently extracted data from included articles. Intervention variables were extracted in accordance with the Template for Intervention Description and Replication checklist. Data Synthesis. Data were synthesized narratively. Nine trials involving 279 participants were included. Three of 5 trials comparing exercise intensity showed that higherintensity training was associated with greater improvements in cardiorespiratory fitness. The effects of other exercise dose components (frequency, time, and type) on fitness were not determined. Overall, walking capacity improved as program length increased. Limitations. All trials had a high risk of bias, and most had a high rate of attrition. Most trials included people more than 6 months after stroke and who walked independently, limiting the generalizability of the findings. Conclusions. Exercising at an intensity greater than 70% of heart rate reserve can be more effective in increasing cardiorespiratory fitness after stroke than exercising at lower intensities. More trials that compare exercise doses by manipulating only 1 dose parameter at a time for people after stroke are needed.

© 2019, © 2019 The Author(s). Published with license by Taylor & Francis Group, LLC. Background: High levels of sedentary time increases the risk of cardiovascular disease, including recurrent stroke. Objective: This study aimed to identify factors associated with high sedentary time in community-dwelling people with stroke. Methods: For this data pooling study, authors of published and ongoing trials that collected sedentary time data, using the activPAL monitor, in community-dwelling people with stroke were invited to contribute their raw data. The data was reprocessed, algorithms were created to identify sleep-wake time and determine the percentage of waking hours spent sedentary. We explored demographic and stroke-related factors associated with total sedentary time and time in uninterrupted sedentary bouts using unique, both univariable and multivariable, regression analyses. Results: The 274 included participants were from Australia, Canada, and the United Kingdom, and spent, on average, 69% (SD 12.4) of their waking hours sedentary. Of the demographic and stroke-related factors, slower walking speeds were significantly and independently associated with a higher percentage of waking hours spent sedentary (p = 0.001) and uninterrupted sedentary bouts of >30 and >60 min (p = 0.001 and p = 0.004, respectively). Regression models explained 11¿19% of the variance in total sedentary time and time in prolonged sedentary bouts. Conclusion: We found that variability in sedentary time of people with stroke was largely unaccounted for by demographic and stroke-related variables. Behavioral and environmental factors are likely to play an important role in sedentary behavior after stroke. Further work is required to develop and test effective interventions to address sedentary behavior after stroke.

© 2018 Introduction: Having a low level of physical activity is an established risk factor for stroke, but little is known about the importance of common sedentary behavior¿television viewing¿to stroke risk. Methods: We conducted a retrospective analysis of data that were collected as part of the longitudinal Australian Diabetes, Obesity, and Lifestyle study. Stroke events reported during the study (between baseline assessment in 1999-2000 and April 2011) were confirmed using adjudication based on medical records. Baseline data on minutes per week spent watching television were used as the exposure variable. Other variables were collected in assessments at wave 2 (2004-05) and wave 3 (2011-2012). Univariable and multivariable logistic regression analyses were performed. Results: Among the full Australian Diabetes, Obesity, and Lifestyle study population (n = 11,247), there were 153 participants with confirmed stroke during the study period, and 9207 participants with no stroke in this period. Participants who went on to have their first stroke during the study had significantly higher levels of TV viewing time at baseline than those who did not have a stroke (P =.001). This association was not present (P =.83), however, when age and sex were included in the regression model. Conclusion: In the Australian Diabetes, Obesity, and Lifestyle study dataset, there was no evidence that more TV viewing is independently associated with risk of stroke, although analyses may have been underpowered.

© 2018 Elsevier Inc. Objective: The prevalence of post-stroke fatigue differs widely across studies, and reasons for such divergence are unclear. We aimed to collate individual data on post-stroke fatigue from multiple studies to facilitate high-powered meta-analysis, thus increasing our understanding of this complex phenomenon. Methods: We conducted an Individual Participant Data (IPD) meta-analysis on post-stroke fatigue and its associated factors. The starting point was our 2016 systematic review and meta-analysis of post-stroke fatigue prevalence, which included 24 studies that used the Fatigue Severity Scale (FSS). Study authors were asked to provide anonymised raw data on the following pre-identified variables: (i) FSS score, (ii) age, (iii) sex, (iv) time post-stroke, (v) depressive symptoms, (vi) stroke severity, (vii) disability, and (viii) stroke type. Linear regression analyses with FSS total score as the dependent variable, clustered by study, were conducted. Results: We obtained data from 14 of the 24 studies, and 12 datasets were suitable for IPD meta-analysis (total n = 2102). Higher levels of fatigue were independently associated with female sex (coeff. = 2.13, 95% CI 0.44¿3.82, p = 0.023), depressive symptoms (coeff. = 7.90, 95% CI 1.76¿14.04, p = 0.021), longer time since stroke (coeff. = 10.38, 95% CI 4.35¿16.41, p = 0.007) and greater disability (coeff. = 4.16, 95% CI 1.52¿6.81, p = 0.010). While there was no linear association between fatigue and age, a cubic relationship was identified (p < 0.001), with fatigue peaks in mid-life and the oldest old. Conclusion: Use of IPD meta-analysis gave us the power to identify novel factors associated with fatigue, such as longer time since stroke, as well as a non-linear relationship with age.

© 2018 World Stroke Organization. Background: Stroke survivors sit for long periods each day. Uninterrupted sitting is associated with increased risk of cardiovascular disease. Breaking up uninterrupted sitting with frequent, short bouts of light-intensity physical activity has an immediate positive effect on blood pressure and plasma clotting factors in healthy, overweight, and type 2 diabetic populations. Aim: We examined the effect of frequent, short bouts of light-intensity physical activity on blood pressure and plasma fibrinogen in stroke survivors. Methods: Prespecified secondary analyses from a three-armed randomized, within-participant, crossover trial. Participants were 19 stroke survivors (nine female, aged 68 years old, 90% able to walk independently). The experimental conditions were sitting for 8 h uninterrupted, sitting with 3 min bouts of light-intensity exercise while standing every 30 min, or sitting with 3 min of walking every 30 min. Blood pressure was measured every 30 min over 8 h and plasma fibrinogen at the beginning, middle, and end of each day. Intention-to-treat analyses were performed using linear mixed models including fixed effects for condition, period, and order, and a random intercept for participant to account for repeated measures and missing data. Results: Sitting with 3 min bouts of light-intensity exercise while standing every 30 min decreased systolic blood pressure by 3.5 mmHg (95% CI 1.7¿5.4) compared with sitting for 8 h uninterrupted. For participants not taking antihypertensive medications, sitting with 3 min of walking every 30 min decreased systolic blood pressure by 5.0 mmHg (95% CI -7.9 to 2.0) and sitting with 3 min bouts light-intensity exercise while standing every 30 min decreased systolic blood pressure by 4.2 mmHg (95% CI -7.2 to -1.3) compared with sitting for 8 h uninterrupted. There was no effect of condition on diastolic blood pressure (p = 0.45) or plasma fibrinogen levels (p = 0.91). Conclusion: Frequent, short bouts of light-intensity physical activity decreases systolic blood pressure in stroke survivors. However, before translation into clinical practice, the optimal duration and timing of physical activity bouts needs to be determined. Clinical trial registration: Australian and New Zealand Clinical Trials Registry http://www.anzctr.org.au ANZTR12615001189516.

© 2018 World Stroke Organization. Objectives: People with stroke sit for long periods each day, which may compromise blood glucose control and increase risk of recurrent stroke. Studies in other populations have found regular activity breaks have a significant immediate (within-day) positive effect on glucose metabolism. We examined the effects of breaking up uninterrupted sitting with frequent, short bouts of light-intensity physical activity in people with stroke on post-prandial plasma glucose and insulin. Methods: Randomized within-participant crossover trial. We included people between 3 months and 10 years post-stroke, ambulant with minimal assistance and not taking diabetic medication other than metformin. The three experimental conditions (completed in random order) were: sitting for 8 h uninterrupted, sitting with 3 min bouts of light-intensity exercise while standing every 30 min, or sitting with 3 min of walking every 30 min. Meals were standardized and bloods were collected half- to one-hourly via an intravenous cannula. Results: A total of 19 participants (9 female, mean [SD] age 68.2 [10.2]) completed the trial. The majority (n = 12, 63%) had mild stroke symptoms (National Institutes of Stroke Scale score 0¿13). There was no significant effect of experimental condition on glucose (mean [SD] positive incremental area [+iAUC] mmol·L·h-1 under the curve during sitting 42.3 [29.5], standing 47.4 [23.1], walking 44.6 [26.5], p = 0.563) or insulin (mean + iAUC pmol·L·h-1 sitting 14,161 [7,560], standing 14,043 [8,312], walking 14,008 [8,269], p = 0.987). Conclusion: Frequent, short bouts of light-intensity physical activity did not have a significant effect on post-prandial plasma glucose and insulin in this sample of people with stroke. Further studies are needed to identify strategies that improve inactivity-related glucose metabolism after stroke.

© 2017 National Stroke Association Background Exercise has established benefits following stroke. We aimed to describe self-reported exercise 5 and 10 years after stroke, change in exercise over time, and to identify factors associated with long-term exercise. Methods Data on exercise (defined as 20 minutes' duration, causing sweating and increased heart rate) were obtained by questionnaire from a population-based stroke incidence study with 10-year follow-up. For change in exercise between 5 and 10 years (n = 276), we created 4 categories of exercise (no exercise, ceased exercising, commenced exercising, continued exercising). Multinomial regression determined associations between exercise categories and exercising before stroke, receiving exercise advice and functional ability and demographic factors. Results The prevalence of exercise at 5 years (n = 520) was 18.5% (n = 96) (mean age 74.7 [standard deviation {SD} 14] years, 50.6% male) and 24% (n = 78) at 10 years. In those with data at both 5 and 10 years (mean age 69 [standard deviation 14] years, 52.9% male), 15% (n = 42) continued exercising, 10% (n = 27) commenced exercising, 14% (n = 38) ceased exercising, and 61% (n = 169) reported no exercise. Continued exercise was associated with younger age (relative risk [RR].47 95% confidence interval [CI].25-0.89), greater Barthel score (RR 2.97 95% CI 1.00-8.86), independent walking (RR 2.32 95% CI 1.16-4.68), better quality of life (RR 10.9 95% CI 2.26-52.8), exercising before stroke (RR 16.0 95%CI 4.98-51.5), and receiving advice to exercise (RR 2.99 95% CI 1.73-5.16). Conclusions Few people exercise after stroke and fewer commence exercise long term. Innovative interventions to promote and maintain exercise are required after stroke.

© 2017, © 2017 World Stroke Organization. Finding, testing and demonstrating efficacy of new treatments for stroke recovery is a multifaceted challenge. We believe that to advance the field, neurorehabilitation trials need a conceptually rigorous starting framework. An essential first step is to agree on definitions of sensorimotor recovery and on measures consistent with these definitions. Such standardization would allow pooling of participant data across studies and institutions aiding meta-analyses of completed trials, more detailed exploration of recovery profiles of our patients and the generation of new hypotheses. Here, we present the results of a consensus meeting about measurement standards and patient characteristics that we suggest should be collected in all future stroke recovery trials. Recommendations are made considering time post stroke and are aligned with the international classification of functioning and disability. A strong case is made for addition of kinematic and kinetic movement quantification. Further work is being undertaken by our group to form consensus on clinical predictors and pre-stroke clinical data that should be collected, as well as recommendations for additional outcome measurement tools. To improve stroke recovery trials, we urge the research community to consider adopting our recommendations in their trial design.

© 2017 Taylor & Francis. Introduction: Attitudes are recognized as influencing research implementation. However, little is known about the process by which physiotherapists¿ attitudes and beliefs shape their use of 7-day per week therapy and circuit class therapy research findings. Understanding beliefs may assist in addressing barriers to research uptake. Methods: Fifteen physiotherapists from six rehabilitation centers who ranged in seniority, experience, and education levels consented to be interviewed. The transcribed interviews were analyzed using a qualitative content analysis drawing on the Theory of Planned Behavior. Findings: Participants felt that they had autonomy in adopting new approaches when the evidence was supported by social norms. Participants believed that 7-day per week therapy delivers a seamless service that increases physiotherapy time, which helps maintain patient improvement, but needs to accommodate patient choice and expectations. Circuit class therapy was viewed positively as it provides more physiotherapy time, increases patient social interaction, and motivation. However, this was qualified by a belief that patients would not receive individualized, quality of movement focused therapy, particularly for patients with limited capacities. Conclusion: Implementation of a new approach depends on the past experience, coherence with individual beliefs regarding important elements of therapy content, and opportunities to control barriers to implementation.

© 2016 Australian Physiotherapy Association. Questions: Among people receiving inpatient rehabilitation after stroke, does additional weekend physiotherapy and/or occupational therapy reduce the length of rehabilitation hospital stay compared to those who receive a weekday-only service, and does this change after controlling for individual factors? Does additional weekend therapy improve the ability to walk and perform activities of daily living, measured at discharge? Does additional weekend therapy improve health-related quality of life, measured 6 months after discharge from rehabilitation? Which individual, clinical and hospital characteristics are associated with shorter length of rehabilitation hospital stay? Design: This study pooled individual data from two randomised, controlled trials (n = 350) using an individual patient data meta-analysis and multivariate regression. Participants: People with stroke admitted to inpatient rehabilitation facilities. Intervention: Additional weekend therapy (physiotherapy and/or occupational therapy) compared to usual care (5 days/week therapy). Outcome measures: Length of rehabilitation hospital stay, independence in activities of daily living measured with the Functional Independence Measure, walking speed and health-related quality of life. Results: Participants who received weekend therapy had a shorter length of rehabilitation hospital stay. In the un-adjusted analysis, this was not statistically significant (MD -5.7 days, 95% CI -13.0 to 1.5). Controlling for hospital site, age, walking speed and Functional Independence Measure score on admission, receiving weekend therapy was significantly associated with a shorter length of rehabilitation hospital stay (ß = 7.5, 95% CI 1.7 to 13.4, p = 0.001). There were no significant between-group differences in Functional Independence Measure scores (MD 1.9 points, 95% CI -2.8 to 6.6), walking speed (MD 0.06 m/second, 95% CI -0.15 to 0.04) or health-related quality of life (SMD -0.04, 95% CI -0.26 to 0.19) at discharge. Discussion: Modest evidence indicates that additional weekend therapy might reduce rehabilitation hospital length of stay. Clinical Trial Registration: ACTRN12610000096055, ACTRN12609000973213. [English C, Shields N, Brusco NK, Taylor NF, Watts JJ, Peiris C, et al. (2016) Additional weekend therapy may reduce length of rehabilitation stay after stroke: a meta-analysis of individual patient data. Journal of Physiotherapy 62: 124-129].

© 2016, © 2016 World Stroke Organization. Background: Fatigue is a common and debilitating symptom after stroke. The last decade has seen rapid expansion of the research literature on post-stroke fatigue, but prevalence remains unclear. Aims: To estimate post-stroke fatigue prevalence and to identify the contributing factors to fatigue, by conducting a systematic review and meta-analysis. Summary of review: We included all studies of adult stroke survivors that used a recognized assessment scale for fatigue (search date September 2014). Two reviewers independently reviewed all full texts for inclusion. Data were extracted by one reviewer and independently cross-checked by a second. Risk of bias was evaluated using a critical appraisal tool. From an overall yield of 921 studies, 101 full text papers were screened, and 49 of these met inclusion criteria. The most widely used measure of fatigue was the Fatigue Severity Scale (n = 24 studies). Prevalence estimates at a cut-off score of > or = 4 were available for 22 of these 24 studies (total n = 3491), and ranged from 25 to 85%. In random effects meta-analysis, the pooled prevalence estimate was 50% (95% CI 43¿57%), with substantial heterogeneity (I2 = 94%). Neither depression status nor time point post-stroke explained the heterogeneity between studies. In post-hoc analysis, fatigue prevalence was found to be lower in the four Asian studies (35%; 95% CI 20¿50; I2 = 96%). Conclusions: Our results confirm that fatigue is a widespread issue for stroke survivors, although it may be less prevalent in Asia. Further research is needed to explain the wide variability in prevalence estimates between studies.