Dr Heidi Janssen

Background: Low physical activity levels in people with stroke may contribute to higher risk of cardiovascular disease morbidity and mortality. Differences in economic status, culture and the built environment may influence the applicability of interventions developed in high income countries (HIC) for stroke survivors in low to middle-income countries (LMIC). Purpose: To compare physical activity levels of stroke survivors in HIC and LMIC and to explore the influence of lower limb impairment on physical activity levels. Methods and Materials: An exploratory secondary analysis of observational data on physical activity levels of stroke survivors from Australia (HIC) and India (LMIC). Physical activity variables (step count, light physical activity (LPA) and moderate-to-vigorous physical activity (MVPA)) were measured by accelerometery. Comparisons of physical activity levels between (a) Australian and Indian stroke survivors and (b) participants with and without lower limb impairments were performed using independent t-tests or Mann-Whitney U tests. Results: There were no significant differences in physical activity levels between (i) Australian and Indian stroke survivors (step count mean difference 201 steps [-1375 to 974], LPA mean difference -24 min [-22 to 69], MVPA mean difference 2 min [-8 to 3]), and (ii) stroke survivors with and without lower limb impairments in either country. Conclusion: Stroke survivors were highly inactive in both countries. Despite differences in economic status, cultural influences and the built environment, the physical activity of stroke survivors in Australia and India did not differ. People with and without lower limb impairment also had similar physical activity levels.

Purpose: Boredom may impede engagement in inpatient rehabilitation following an acquired brain injury. This review aimed to: (1) describe the experience and (2) quantify the incidence of boredom; (3) identify measurement tools used to quantify boredom; (4) summarize factors contributing to boredom, and (5) outline evidence-based interventions shown to reduce boredom during inpatient rehabilitation. Methods: Two researchers independently screened publications retrieved from electronic database searches. Publications presenting patient, carer or staff data relating to boredom in inpatients with acquired brain injuries were included. Results: Two thousand four hundred and ninety-nine references were retrieved, 88 full texts were reviewed, with 24 studies included. The majority of studies reported qualitative data indicating boredom to be a common experience of patients with acquired brain injuries (n = 14 studies +1 review). The incidence of boredom post acquired brain injury is unknown. Personal and organizational factors and the physical environment may contribute to boredom (n = 11 studies +2 reviews). Qualitative work (n = 9 studies) indicates that use of the creative-arts or exposure to environmental enrichment may help alleviate boredom in patients with acquired brain injuries during inpatient rehabilitation. Conclusion: Further mixed-methods research is required to establish the incidence of and contributing factors to boredom in patients with acquired brain injuries undergoing rehabilitation. Understanding this will help inform future research aimed at improving patient engagement in inpatient rehabilitation.Implications for rehabilitation Boredom is commonly reported by hospitalised patients with ABI to negatively affect their rehabilitation yet the scope of the problem has not been measured. Boredom is a complex phenomenon, likely influenced by a number of personal and environmental factors that are not fully understood in this population. Through a better understanding of boredom, interventions may be developed to improve patient engagement in inpatient rehabilitation programs.

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.

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.

Background We sought to determine whether Australasian health professionals' opinions regarding early mobilization after stroke changed between 2008 and 2014, when a large international trial of early mobilization (A Very Early Rehabilitation Trial, AVERT) was underway. Methods Attendees at the two major Australasian stroke conferences in 2008 and 2014 were surveyed. Participants rated their agreement with statements about the risks and benefits of commencing mobilization within 24 hours of hemorrhagic and ischemic stroke using a 5-point Likert scale. Participants in 2014 were asked about their awareness of AVERT. Logistic regressions were performed to determine whether the time point (2008 versus 2014) or awareness of AVERT influenced opinions about early mobilization. Results Surveys were completed by 443 health professionals (2008: N¿=¿202; 2014: N¿=¿241). Most respondents in 2014 reported that early mobilization was beneficial and not harmful to people with ischemic and hemorrhagic stroke. Opinions regarding mobilization after ischemic stroke did not change significantly between 2008 and 2014. In 2014, a significantly greater proportion of respondents believed that early mobilization after hemorrhagic stroke was helpful (2008: n¿=¿98 of 202 [49%] versus 2014: n¿=¿170 of 241 [71%], P¿<¿.01). Awareness of AVERT was significantly associated with the opinion that early mobilization was beneficial and not harmful to patients with stroke (P¿<¿.05). Conclusions Australasian health professionals' opinions of early mobilization after hemorrhagic stroke changed between 2008 and 2014, prior to reporting of the AVERT trial. Our results suggest that awareness of an ongoing research trial can lead to changes in opinions before the efficacy of the experimental intervention is known.

Background: Data highlight the importance of undertaking intense and frequent repetition of activities within stroke rehabilitation to maximise recovery. An enriched environment (EE) provides a medium in which these activities can be performed and enhanced recovery achieved. An EE has been shown to promote neuroplasticity in animal models of stroke, facilitating enhanced recovery of motor and cognitive function. However, the benefit of enriching the environment of stroke survivors remains unknown. Aim: To qualitatively explore stroke survivors' experience of implementation of exposure to an EE within a typical stroke rehabilitation setting, in order to identify facilitators and barriers to participation. Methods: Semi-structured interviews with 10 stroke survivors (7 females and 3 males, mean age of 70.5 years) exposed to an EE for a 2-week period following exposure to routine rehabilitation within a stroke rehabilitation ward. An inductive thematic approach was utilised to collect and analyse data. Results: Qualitative themes emerged concerning the environmental enrichment paradigm including: (1) "It got me moving"-perceived benefits of participation in an EE; (2) "You can be bored or you can be busy."-Attenuating factors influencing participation in an EE; (3) "I don't like to make the staff busier"-limitations to use of the EE. Conclusions: This study provides preliminary support for the implementation of an EE within a typical stroke rehabilitation setting from a patient perspective. Reported benefits included (1) increased motor, cognitive and sensory stimulation, (2) increased social interaction, (3) alleviation of degree of boredom and (4) increased feelings of personal control. However, participants also identified a number of barriers affecting implementation of the EE. We have previously published findings on perceptions of nursing staff working with stroke survivors in this enriched rehabilitation environment who identified that patients benefited from having better access to physical, cognitive and social activities. Together, results contribute to valuable evidence for future implementation of an EE in stroke rehabilitation settings.Implications for RehabilitationStroke survivor access to an enriched environment (EE):Results identified that participation in both individual and communal forms of environment enrichment within the stroke rehabilitation ward resulted in increased access to activities providing increased opportunities for enhanced motor, cognitive and sensory stimulation.Increased access to and participation in activities of the environmental enrichment (individual and communal) interrupted the ongoing cycle of boredom and inactivity experienced by many participants.This study provides preliminary support for the implementation of an EE within a typical stroke rehabilitation setting from a patient perspective.

Background: Clinician interest in the role of tablet technology in commercially available tablet devices (i.e. iPads) following stroke is rising. Tablets have the potential to encourage engagement in therapeutic activities. We aimed to explore stroke survivor acceptability of and experience of tablet use during the first three months of stroke recovery. Design: A qualitative study using an inductive thematic approach incorporating the process of constant comparison was utilized to collect and analyse data. Setting: Community dwelling stroke survivors in metropolitan Newcastle, New South Wales, Australia. Participants: Twelve stroke survivors (8 male, 4 female; median age of 73 (IQR 58-83) years). Main outcome measures: Qualitative outcomes were participants' perceptions using in-depth, semi-structured interviews. Results: Participants' found tablets easy to use and beneficial. Most stroke survivors used the tablet to engage in therapeutic and leisure activities on most days during the three months. Three key themes emerged: (1) Getting established on the iPad: "It just became easier and easier", (2) Technology as a means for increased stimulation: "Something to keep me interested", and (3) Personal experiences of access to an iPad: "It's been very helpful". Conclusions: Incorporating tablet technology into the delivery of stroke rehabilitation appears to be feasible and acceptable at a patient level. This process has the potential to improve participation in therapeutic and or leisure; however further evaluation towards the impact of tablet technology on patient outcome and quality of life is required.

Objective: To determine physical, cognitive and social activity levels of stroke patients undergoing rehabilitation, and whether these changed over time. Design: Observational study using behavioural mapping techniques to record patient activity over 12 hours on one weekday and one weekend day at baseline (week 1) and again two weeks later (week 2). Setting: A 20-bed mixed rehabilitation unit. Subjects: Fourteen stroke patients. Interventions: None. Main measures: Percentage of day spent in any activity or physical, cognitive and social activities. Level of independence using the Functional Independence Measure (FIM) and mood using the Patient Health Questionniare-9 (PHQ-9). Results: The stroke patients performed any activity for 49%, social activity for 32%, physical activity for 23% and cognitive activity for 4% of the day. Two weeks later, physical activity levels had increased by 4% (95% confidence interval (CI) 1 to 8), but levels of any activity or social and cognitive activities had not changed significantly. There was a significant: (i) positive correlation between change in physical activity and change in FIM score (r = 0.80), and (ii) negative correlation between change in social activity and change in PHQ-9 score (r = -0.72). The majority of activity was performed by the bedside (37%), and most physical (47%) and cognitive (54%) activities performed when alone. Patients undertook 5% (95% CI 2 to 9) less physical activity on the weekends compared with the weekdays. Conclusions: Levels of physical, cognitive and social activity of stroke patients were low and remained so even though level of independence and mood improved. These findings suggest the need to explore strategies to stimulate activity within rehabilitation environments. © The Author(s) 2013.

Background. Regular exercise reduces the risk of a first-ever stroke and is associated with smaller infarcts. Although evidence has suggested that therapeutic exercise following stroke is beneficial, we do not yet know whether exercise reduces stroke severity and improves functional recovery. The mechanisms underlying any benefit remain unclear.