UPPSALA UNIVERSITY Department of Neuroscience Physiotherapy program Bachelor’s thesis 15 points
THE LEVEL OF PHYSICAL ACTIVITY AND
QUALITY OF LIFE AMONG STROKE SURVIVORS
IN THAILAND
A QUANTITATIVE CROSS-SECTIONAL STUDY
GRADEN AV FYSISK AKTIVITET OCH
LIVSKVALITET HOS STROKEÖVERLEVARE I
THAILAND
EN KVANTITATIV TVÄRSNITTSSTUDIE
Authors Supervisor
Persson, Adam & Svensson, Patric Hellström, Karin Associate Professor
Department of Neuroscience, Physical Therapy
Abstract
Background: Stroke is one of the largest health concerns, and the number of stroke cases is increasing globally, especially in development countries. Stroke can lead to permanent disability or death, and physical therapy is vital in order to regain functions. Patients’ mental condition post-stroke is a strong predictor of the rehabilitation progress. Physical activity (PA) and exercise has shown positive effects on a biopsychosocial level and may improve patients’ functionality.
Objective: To investigate the level of PA, health related quality of life (HRQoL), and to clarify the relation between PA and HRQoL in people with stroke in Thailand. A secondary objective was to investigate the correlation between PA and depression in the same
population.
Method: PA was monitored objectively with accelerometer for 7 consecutive days, and subjectively with the Physical Activity Scale for People with Physical Disabilities. HRQoL and level of depression was assessed by index-score and Visual Analog Scale (EQ-VAS) from the EuroQoL 5-Dimension 5-Level questionnaire.
Results: The group was not physically active but experienced a high HRQoL. A significant positive correlation was found between HRQoL assessed with EQ-VAS and PA assessed both subjectively and objectively. No correlation was found between PA and depression.
Conclusion: PA was associated with a higher HRQoL in stroke patients in Thailand. The participants showed an overall low PA compared to WHO guidelines, and an overall high HRQoL, including low depression. Stroke patients in Thailand should be encouraged to be more physically active, in order to gain the health benefits that PA can give.
Sammanfattning
Bakgrund: Stroke är ett av våra största hälsoproblem, och antalet strokefall ökar globalt sett, särskilt i utvecklingsländer. Stoke kan leda till permanent funktionsnedsättning eller död, och fysioterapi är avgörande för att återfå funktioner. Patientens mentala tillstånd efter en
strokeincident är en stark faktor till hur effektiv rehabiliteringen blir. Fysisk aktivitet och träning har visat positiva biopsykosociala effekter och kan förbättra patientens funktion efter stroke.
Syfte: Att undersöka graden av fysisk aktivitet, hälsorelaterad livskvalitet (HRQoL), och relationen mellan fysisk aktivitet och HRQoL hos strokeöverlevare i Thailand. Ett sekundärt syfte är att undersöka korrelationen mellan fysisk aktivitet och depression i samma
population.
Metod: Fysisk aktivitet mättes objektivt med accelerometer under sju konsekutiva dagar, och subjektivt med Physical Activity Scale for People with Physical Disabilities (PASIPD). HRQoL och depression mättes genom index-score samt Visual Analog Scale (EQ-VAS) från frågeformuläret EuroQoL 5-Dimension 5-Level (EQ-5D-5L).
Resultat: Gruppen var inte fysiskt aktiv men upplevde en hög HRQoL. En signifikant positiv korrelation hittades mellan HRQoL bedömt med EQ-VAS och fysisk aktivitet genom både subjektiv och objektiv mätning. Ingen korrelation hittades mellan fysisk aktivitet och depression.
Konklusion: Fysisk aktivitet var associerat med en högre HRQoL hos strokepatienter i Thailand. Deltagarna visade en övergripande låg fysisk aktivitetsgrad jämfört med WHO:s riktlinjer, och en övergripande hög hälsorelaterad livskvalité, inklusive låg depressions grad. Strokepatienter i Thailand bör bli uppmuntrade till att bli mer fysiskt aktiva, för att få de hälsofördelar som fysisk aktivitet kan ge.
Table of contents
1. Background 1
1.1 Introduction 1
1.2 Stroke 1
1.3 Rehabilitation after stroke 2
1.4 Physiotherapeutic interventions after stroke 2
1.5 Depression and quality of life after stroke 3
1.6 Physical activity post stroke 4
1.7 Stroke in Thailand 6
1.8 Global health and global goals 6
1.9 Mahidol University, Bangkok 7
2. Problem statement 7 3. Purpose 7 4. Questions 8 5. Method 8 5.1 Design 8 5.2 Sample 8
5.3 Data collection method 9
5.4 Procedure 10
5.5 Data analysis method 11
5.6 Ethical consideration 13
6. Results 13
7. Discussion 18
7.1 Summary of the results 18
7.2 Discussion of results 18
7.4 The clinical relevance 24
8. Conclusion 24
9. References 26
Appendix I - EQ-5D-5L
Appendix II – Informed Consent Appendix III – Contract of approval
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1. Background
1.1 IntroductionStroke is one of the largest global health concerns, and can lead to disability or even death. The number of stroke cases have been increasing, probably due to the generally ageing population of the world, and the number seems to keep increasing the next 20 years,
specifically in developing countries (1,2). Stroke can lead to permanent disability or death. Rehabilitation after a stroke is fundamental as an attempt to regain loss of function as much as possible, and for the patients to independently do activities of daily living (ADL) (3).
1.2 Stroke
Stroke, or cerebrovascular disease, is a broad term and can occur in different ways. The general pathophysiology is characterized by reduced blood flow to the brain, causing neural damage due to ischemia in the affected area. There are two types of stroke; hemorrhagic and ischaemic stroke (4).
Hemorrhagic stroke
Hemorrhagic stroke describes a ruptured blood vessel that causes bleeding into the surrounding brain tissue. There are further two types of hemorrhagic strokes; intracerebral hemorrhage and intracranial hemorrhage. Intracerebral hemorrhage occurs when a blood vessel bursts, causing a haematoma to build up to the near area. Subarachnoid hemorrhage is caused by bleeding that accumulates blood within the skull. The leaking of blood can be caused by e.g. trauma, drug use or hypertension (5).
Ischaemic stroke
Ischaemic stroke occurs when the blood supply to a part of the brain is blocked, causing ischemia to that specific area, which can lead to cell death of brain tissue. (6).
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1.3 Rehabilitation after stroke
Stroke rehabilitation is ideally delivered by a multidisciplinary healthcare team, to ensure that the patient gets the best care (5). Research has shown that multimodal approaching treatment reduces long term disability, mortality rates, and enhances the recovery, ADL and independence ability. In an early stage of stroke rehabilitation, active and passive (if needed) mobilization are prioritized treatments in order to minimize the risk of developing decubitus, respiratory complications and contractures (5,8).
The rehabilitation process continues with determination of the amount of impairments and resources an individual has during the process of mobilization and further examinations (8). The identification of impairments and resources provides an indicator of how the
individual future rehabilitation program can be tailor-made, with the emphasis on concretizing the assessment of a baseline (5). The baseline assessment further is used to set short- and long term treatment goals together with the patient, and the effects of the interventions in the rehabilitation program can further adjust the assessment and modifications of the goal setting (5). Research has shown that the most efficient component of movement re-training can be accomplished with repeated and task-specific training. This principle of re-education of movement has been promising for especially stair walking, standing up and sitting down, and gait (5,8,9).
Stroke patients are in need of a continuous and organized network, which includes the multidisciplinary team, but also family, friends and caregivers are important in order to provide social support and health care. This can maximize the possibility to improve every lost or affected function. A stroke incidence can be an overwhelming experience, which can give rise to depression and fatigue symptoms, why psychosocial interventions are essential for stroke survivors (8).
A research study emphasizes that a patient's mental condition post-stroke is a strong predictor of the success of rehabilitation, considering both the mental and functional state. Psychosocial interventions with focus on perceived self-efficacy, depressive symptoms and acceptance of illness for example should be taken into account, in order to increase the chance of a successful rehabilitation (10).
1.4 Physiotherapeutic interventions after stroke
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components are aimed to restore what has been damaged, but it is not always possible to reestablish what is damaged post stroke, why therapists should in that case focus on
compensatory strategies in order for the patient to accomplish functional tasks. This can be seen as a problem solving approach when an isolated movement is not possible to accomplish, due to a paretic arm for an example (5).
Secondary complications can occur post store, e.g. contractures and hypoxia. Prevention actions against such secondary complications should be initiated as soon as possible after a stroke occurred. The process of rehabilitation initiates as soon as the patient’s medical state allows, and it can continue for several months depending on how major the impairments are (5).
Evidence based research emphasizes that repetitive and task-specific training is an important principle in motor learning, which have shown itself highly effective (5). Repetitive task training should have a functional goal setting, and be executed repetitively during
training sessions. It’s believed that this form of training can lead to strengthening of sensorimotor connections between neurons which contributes adaptation and recovery of neuronal pathways (9). The principle of repetitive training has particularly higher evidence for re-education of the basal motoric movements, e.g. standing up, sitting down and gait, which comes along with improvements in balance ability. Training that is task-specific should target the goals that are relevant for the patient’s needs, and the aim is to successfully perform a functional task automatically with full range of motion (5).
1.5 Depression and quality of life after stroke
The burden of stroke can affect many aspects of health-related quality of life (HRQoL). There is a consensus that stroke survivors have poorer HRQoL compared to the general population. The reason is partly due to disabilities that affect physical activity (PA) and social activities (11–13), and depression is one among other factors that has an impact on HRQoL. A research study in Thailand concluded that post stroke depression is a common
complication, where factors such as urinary incontinence and complications at discharge were significantly correlated with depression (14).
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A cohort study that examined stroke rehabilitation in Thailand showed that
rehabilitation services improve the quality of life of stroke survivors as well as functional status (17). Further, another study concluded that there is a big portion of stroke patients in Thailand who have insufficient knowledge about stroke and recommendations on
rehabilitation. This lack of educational knowledge about stroke can increase the risk of continuing with an unhealthy lifestyle and greater sedentary behavior (SB), which can lead to a greater risk of recurrent stroke. This can be compared with a hypothesis that stroke patients who had more information about stroke and recommendations on rehabilitation are more likely to follow a healthy lifestyle (18).
1.6 Physical activity post stroke What is physical activity?
Physical activity (PA) has shown positive effects on both physical and psychosocial factors. According to The World Health Organization (WHO), PA is defined as “...any bodily movement produced by skeletal muscles that requires energy expenditure.” (19). Physical activity is often confused with the term exercise. The difference between PA and exercise is that exercise is also planned and with an objective to improve or maintain physical fitness (20).
Stroke and physical activity
Amongst stroke survivors with initial leg paralysis, 35 % cannot regain their physical function, and 20-25 % are in need of full physical assistance in order to walk. More than half (65 %) of stroke survivors six months post stroke are unable to use the hand on their affected side in daily activities. Impairments like these often lead to a sedentary lifestyle, which indorse a vicious cycle of inactivity and functional decline. Physical exercise, especially aerobic exercise, may break the vicious cycle and help patients improve their functionality (21).
A qualitative research from Scotland states that a vast number of stroke survivors have an inactive lifestyle. The study concludes that PA promotion by health professionals, and support from caregivers are important factors for facilitating recovery, this promotion influences a greater PA behavior on stroke survivors. Further, the study suggests that a person-centered support regarding PA should be designed and shared amongst
physiotherapists, caregivers and stroke survivors, in order to have a joint rehabilitation program (22).
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view of an individual’s PA pattern in the form of energy expenditure, MET rates, PA intensity and estimated number of steps per day, etc (23,24). A systematic research study concluded that 1 or a maximum of 2 accelerometers which are worn on the body are more advantageous, considering the result measurements and the perceived burden for patients. An accelerometer is a small device that records activity, and is strapped on the ankle, wrist, or hip (23).
Benefits with physical activity and exercise
There are many health-related benefits with PA and exercise. Strong scientific evidence shows that being engaged in an active lifestyle is generally linked with a lower premature mortality. Concrete examples are reduced risk for coronary heart disease, type 2 diabetes, hypertension, osteoporosis, and stroke as well. Further scientific proven benefits are reduction of depression, anxiety and promotion of psychological well-being. A moderate to high
intensity exercise has shown to be more efficient to achieve health-benefits, and especially high intensity is characteristic for facilitating neuroplasticity in the brain (5,25).
Exercise in combination with other treatment post-stroke such as, among other things, controlled diet and cholesterol-lowering medication can reduce the risk of getting a recurrent stroke by 80 % (26). Physical exercise has long been primarily assigned to improve physical function after stroke, but recent studies suggest that it also affects psychological health in positive manners. Physical exercise may improve depressive symptoms, cognitive functions such as memory and executive functioning (27). It also has shown to have a positive impact on HRQoL after stroke (28) and reduce post-stroke fatigue (27).
In general, the medical condition stroke is a secondary pathophysiology where an underlying heart- or blood vessel disease is the primary pathophysiology (4). These
underlying factors often go under the term cardiovascular risk factors, which every individual has more or less of considering their cardiovascular ability. Cardiovascular risk factors (e.g. hypertension, arterial function) tend to increase the likelihood of suffering a stroke. This risk can be decreased with the right amount of PA over a period of time (29).
Previous studies conclude that the relationship between PA and quality of life (QoL) in people with physical disability (PWPD) is inconclusive. A study from 2016 that was executed in Thailand suggests that PA, measured with physical activity scale for individuals with physical disabilities (PASIPD), is not significantly associated with QoL. Although, PA had influence on other factors, such as life satisfaction and self-esteem (30).
Recommendations post-stroke
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days per week, and 20-60 minutes per session (29). National guidelines for stroke in the UK and the Netherlands on the other hand, recommends that patients should exercise at least 45 minutes per weekday (31). Previous research concludes that higher intensity is not just better, but essential for progression in post-stroke rehab training, and the intensity is individually tailored for the patient’s present ability. It is also valuable to have clear functional goals in the training, together with repeating functional movements with slight variations (31).
1.7 Stroke in Thailand
A stroke epidemiology research published 2014, implied that stroke is the leading cause of death and long term disability in Thailand, with approximately 250,000 stroke incidents annually. Approximately 20 % from all who suffer a stroke die. The stroke prevalence has a male predominance, and the main risk factors for stroke in Thailand are hypertension, diabetes and smoking (31). More epidemiology studies concluded that the stroke prevalence is more abundant in regions with a higher economic status, with the capital city Bangkok, as leading region (32,33). It is predicted that the stroke incident trend will rise, with ischemic stroke as its major stroke subtype. This prediction underlies partly because of urbanization and a greater sedentary behavior, which leads to a higher likelihood that traditional home-cooked food is replaced with fast-food, because of the greater accessibility in urban areas (32).
1.8 Global health and global goals
It is a human right that every individual has the right to adequate health care. Good health and well-being is the third global goal of the United Nations (UN) Sustainable Development Goals (SDG), which stands for “Ensure healthy lives and promote well-being for all at all ages”. Factors such as adequate and equal health services, and how stroke rehabilitation differ among countries, can be included into this goal, and therefore this bachelor thesis is based upon this goal (34,35). This bachelor thesis will therefore be based upon the third SDG, and together with the World Confederation of Physical Therapy’s (WCPT) strategic plan for 2017-2021. Some of the outcomes mentioned in the strategic plan are to unify the profession of PT internationally, and contribute to the development of global health (36).
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increasing. In line with health transitions, the country has undergone major economic changes as well, to a flourishing industrialized system. This shift has led to urbanization, contributing to changes in diet and less PA, which as a result leads to a higher incidence of cardiovascular diseases (32).
1.9 Mahidol University, Bangkok
The collection of data for this bachelor thesis took place at Mahidol University in Bangkok, Thailand. Mahidol University was established 1888, and is the oldest institution of higher education in Thailand. According to their website it is one of the most prestigious universities in the country and internationally known and recognized for its exceptional research and teaching (38).
2. Problem statement
Stroke is a global burden and it is one of the largest causes of long term disability and mortality (1,2,39). A vast amount of studies report that multidisciplinary stroke rehabilitation reduces disability, maximizes functional ability and promotes psychological factors (5,8,17). PA have an essential role within the stroke rehabilitation, since being active can e.g. minimize the risk of having a recurrent stroke and reduce secondary complications (5,8). Other studies showed that rehabilitation service, information and recommendations regarding stroke rehabilitation are important parameters for quality of life, and can decrease the risk of a sedentary lifestyle (17,18).
PA data extracted from accelerometers such as Actigraph and from PASIPD in stroke survivors in Thailand are scarce to the authors’ knowledge, and also the correlation with experienced HRQoL measured with EQ-5D. A study from 2016, concluded that there is no clear relationship between PA and QoL in PWPD (30). The ambition from the authors is that the data from this study will further provide information to PTs within the field of stroke rehabilitation. The ambition is also to better understand the effects that PA has on the perceived HRQoL within stroke survivors.
To reach the third sustainable development goal, which is aiming for good health and well-being (34), and also the WCPT strategic plan for 2017-2021 (36), these fields are in need to be further investigated.
3. Purpose
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correlations between the level of PA, perceived HRQoL and depression among patients with stroke.
4. Questions
1. What level of PA, measured with Actigraph and PASIPD, had patients ≥3 months after their stroke?
2. How did the patients experience their HRQoL measured with EQ-5D ≥3 months after their stroke?
3. What was the correlation between the level of PA, measured with Actigraph and PASIPD, and perceived HRQoL, measured with EQ-5D, in the patients ≥3 months after their
stroke?
4. What was the correlation between the level of PA, measured with Actigraph and PASIPD, and perceived depression, measured with EQ-5D, in the patients ≥3 months after their stroke?
5. What was the correlation between measuring PA with Actigraph compared to PASIPD?
5. Method
5.1 Design
This research was a quantitative observation study with a cross-sectional, descriptive and correlational design. The data was collected at one point in time without any intervention before or after the measurements (40). Questions 1 and 2 are answered with descriptive data. To answer questions 3 and 4, attained data were analyzed to discover any relationship between PA, perceived HRQoL and depression (40).
5.2 Sample
The participants were recruited with a convenience sample through an ongoing research study led by the master student Ms. Nattakitta at Mahidol University, with prof. Chutima Jalayondeja as supervisor. Jalayondeja was also the project supervisor, in Thailand, for this research study, and the participants were recruited through her and Ms. Nattakitta from patients at the physical therapy clinic at Mahidol University, Salaya campus. The volunteer sample, of 41 persons with subacute stroke, were living in Bangkok and Nakhonpathom province, Thailand.
Including criteria / excluding criteria
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patients needed to be at least 18 years old, and that they have good communication and cognition measured by Thai Mini Mental State Examination (TMMSE), with the score > 18. Exclusion criteria was individuals with acute stroke, and non-independent gait.
5.3 Data collection method Actigraph GT3X
The collection of PA data was collected with an accelerometer, Actigraph GT3X, placed on the right hip with a waist strap. The Actigraph GT3X is a triaxial accelerometer that captures movement in 3 orthogonal planes; vertical, anteroposterior and mediolateral. With this function it is possible to objectively measure PA (42). Earlier research studies have shown that the reliability and validity of triaxial accelerometers when used by individuals with stroke are good, where the valid and reliable data was in relation to their gait (23,41). In order to estimate the level of PA over a 7 day period, data from at least 4 days with 10 waking hours each day is required to provide a valid measurement. Further, hip placement of the accelerometer produces accurate results, with no significant difference between left or right hip accelerometer placement (43).
Daily activity log
When receiving the actigraph, the participants were also handed a study-specific daily activity log to write a brief journal for the 7 days of wearing the actigraph. The activity log was designed with 7 columns, one for each day of the period, with large boxes to give enough space for writing. In the top row, each day was written by the authors to match the patient’s 7 day period to make it clear for the patient where to write what, and to help remind what day the period started and would end. In the left margin there was text, in Thai language,
indicating for the patient where to write down time for waking up and going to sleep each day. Between “waking up” and “going to sleep”, there was space for noting other causes for taking the GT3X off (e.g. showering or swimming), see appendix IV for details but translated into English.
EQ-5D-5L
The collection of the perceived quality of life was collected through the EQ-5D-5L questionnaire (appendix I), in the Thai version. Multiple studies have concluded that the instrument EQ-5D-5L has accepted reliability, validity and responsiveness when measuring the quality of life in subacute stroke patients (16,44,45).
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slight problems; moderate problems; severe problems; extreme problems). The health status measurements from each dimension can be converted to a single utility value (EQ-index score). The visual analogue scale of EQ-5D-5L (EQ-VAS) allows a valuation of the health state, where patients can estimate their health between 0 - 100, where 0 = worst possible health and 100 = best possible health (15,16). The EQ-index score from the questionnaire was calculated in a table, which gives a value ranging from -0.224 to 1. The value reflects the current health state where 0, 1 and negative values correspond to death, full health, and states worse than death (46).
For the correlation between the level of PA and depression, the dimension
“anxiety/depression” in the EQ-5D-5L were analyzed separately and compared with the level of PA through spearman’s rho. The levels of question 5 range from “I am not anxious or depressed” (1 point), to “I am extremely anxious or depressed” (5 points).
PASIPD
The PASIPD is a questionnaire comprising 13 questions, used for determining the physical activity in people with disability. The questionnaire contains questions about leisure time activity, household activity and work-related activity, with a high test-retest reliability and good-excellent reliability and validity. The PASIPD records type of PA, frequency and duration of each activity in the last 7 days. The scores from the 13 questions are calculated with a given algorithm, which gives an indication of PA in the MET-hour per day ranging from 0 to 199 MET-hr/day (47). The subjective PASIPD questionnaire, translated from English (appendix V) to Thai has been considered to have a good reliability (48). The PASIPD was used to further collect information regarding PA level together with the objective data from the accelerometers in order to improve the validity of the data. Background data
Demographic information was collected by extracting information from medical records of the participants (performed by authorized master student Ms. Nattakitta), and through asking the participants, in order to assemble variables for the background data. The variables collected was age, gender, stroke type, time since the stroke incident and affected side. Further assessment of the background data was assembled in a form specific to the study by the authors together with Ms. Nattakitta and PhD student Mr. Bukhari when meeting with the participants. These characteristics were weight, height, dominant side and walking speed. Walking speed was measured through a 10-meter walking test (10MWT), where the participants walked with self-selected walking speed (49).
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Individual oral and written information (appendix II) about the study was given to the patients in Thai, translated by two local physiotherapists from Mahidol University, Bangkok. Concerning the language barrier between the authors and participants during the procedure, master student Ms. Nattakitta and prof. Jalayondeja helped with the translation. The
participants received individual instructions on how to wear the Actigraph GT3X device, and how to complete the daily activity log in thai (appendix IV). If the patient then agreed to participate, a written contract of approval (appendix III) was signed by the person in order to participate in the study. For the participants who were unable to complete the activity log, it was advised that another person should complete it under the participant's instruction. The Actigraph device was attached to the right hip approximately spina iliaca anterior superior (SIAS), for 7 consecutive days. The participants were advised to wear the device at all times except when being in contact with water and lying in bed. The Actigraph and the daily activity log was collected by the authors 7 days later, when the patients returned to Mahidol University. The data from the device was then downloaded to a password protected computer and processed through the software Actilife®, version 6.3.2, at Mahidol University. At this point the PASIPD was administered to assess the self-reported physical activity level over the last 7 days when the participants wore the Actigraph. The authors brought 35 Actigraph GT3X devices from Uppsala University.
Background data and data from the official Thai version of EQ-5D-5L questionnaire was collected at one time, on the same day as each participant started the accelerometer measurements. The 10MWT was performed at the same occasion. For the 10MWT, the participants were asked to walk in a fast, comfortable and yet safe manner from one cone to another, 10 meters away. The time was measured with a manual stopwatch from when the patient’s first leg crossed a marker 2 meters in, to when the patient’s first leg crossed another marker 8 meters in to measure the middle 6 meters. In this way, errors in speed while
accelerating and stopping the gait was prevented (50).
All of the participants were telephoned once during the 7-day period of wearing the Actigraph, to make sure there were no problems and reminded to wear the Actigraph and to complete the activity log.
5.5 Data analysis method Actilife®
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receiving the accelerometers from the patients after the 7 day period, the data were
downloaded in epoch lengths of 60s. Further, Choi (2011) algorithm were used to validate wear-time, Freedson Combination (1998) for energy expenditure, Troiano Adult (2008) for cut points, and Freedson Adult (1998) for the calculation of MET score. Wear-time validation was analyzed and validated when comparing the activity per minute through Actilife® with the participants daily activity log. An appropriate 10 hr filter for each day was set individually when extracting the activity data, if the participants reached a wear time of 10 hr/day. Since the patients had varying time sleeping and being active during their days of wearing the Actigraph, the filters were set individually to match each patient’s activity time, aiming to filter away non-wear time. If a participant had less than 6 days with 10 hr of wear time each day, the participant would be excluded from the study. If there was sufficient data for 7 days of 10 hour wear-time for a patient, a mean of those 7 days were analyzed in that case, if there was only sufficient wear-time for 6 days, a mean of 6 days were analyzed. The data obtained with the 10 hour filter was saved as Excel spreadsheets. Since Choi algorithm was used for wear time validation, there was no need to exclude the time the participants took off the GT3X short periods e.g. for showering, since the algorithm starts to record non wear time after 90 minutes of inactivity.
PASIPD
The score from PASIPD was analyzed with a standardized algorithm to calculate a MET hr/day value.
EQ-5D-5L
HRQoL was answered through EQ-index score and VAS estimation of health-status. The results were normally distributed, and therefore presented with mean value and standard deviation (46). The correlation between PA and HRQoL was calculated with Spearman’s correlation coefficient rho (r), since the data were non-normally distributed in at least one factor (51). For correlation between PA and depression/anxiety, the results were also analyzed with Spearman’s rho, since the scale of measure is ordinal, and the data is non-parametric. Correlation and descriptive analysis
To calculate correlation levels, the background data, the data from PASIPD- and EQ-5D-5L questionnaires and the data from Actilife®, was gathered in an Microsoft Excel® worksheet. The data from the worksheet was then extracted to the software IBM SPSS Statistics®, where it could be analyzed with descriptive analysis and Spearman’s rho.
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mean value and standard deviation. Remaining factors regarding PA in stroke patients had skewed results, and were therefore presented with median and interquartile range, since the scales are ratio scales (51). The parameters for PA in this study are MET score obtained with both GT3X and PASIPD, and step count (SC), moderate- to vigorous physical activity (MVPA) and sedentary time (ST), also measured with GT3X. Further PA background variables are Kcal expenditure measured with GT3X and gait speed.
5.6 Ethical consideration
Informed consent (appendix II) was given, and the participants were informed that they were able to quit at any time without further explanation. The information from the patients have been confidential during the thesis process. All of the results were saved on a computer with password protection, that only the authors have access to. All the information and data regarding patients will be deleted once the thesis is approved. Further, the results are presented on a group level.
A risk with this study could be misunderstanding, due to the differences in language and culture between the authors and the interpreters and patients. One benefit with this study, is to gain further information within the field of PA and HRQoL in poststroke patients in Thailand. In a global aspect, the study contributes to a future international cooperation and exchange between Sweden and Thailand regarding PT. The study was approved by the Mahidol University Central Institutional Review Board (MUIRB).
6. Results
Altogether 41 participants with stroke were recruited (mean age 59.7 years ±12.68) and answered the EQ-5D-5L form. Of the 41 participants, n = 2 withdrew from the study, n = 33 (80.5%) managed to record ≥ 6 days of sufficient Actigraph data during the 7 days period, and n = 29 completed the PASIPD form, see figure 1. Table 1 represents the demographic
information of the participants.
Table 1. Participant demographic characteristics, n = 33.
Characteristics Mean (SD), median (IQR) or
n (%)
Age (years), mean (SD) 59.7 (土12.68)
Sex M/F, n (%) 17(51) / 16(49)
BMI (kg/m^2), mean (SD) 22.8 (土3.13)
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Ischaemic 20 (61)
Hemorrhagic 13 (39)
Side of lesion n (%)
Left/Right 16(49) / 17(51)
Time since stroke (months), median (IQR) 22 (58) Gait speed (m/s), median (IQR) 0.49 (0.80) BMI = body mass index.
Figure 1. Participant flow in the study.
Accelerometer and PASIPD validation
From the n = 33 included participants, n = 4 did not complete the subjective PA measurement through the form PASIPD, resulting in n = 29 that could be compared with the objective way of measuring PA through Actigraph, with n = 33. The correlation between average kcal per 10 hr/day assessed with accelerometer and MET hr/day assessed with PASIPD was found to be low with no significance (r = 0.223, p = 0.245). The PA level was overestimated in PASIPD compared to the objective measurements with accelerometer. Level of PA, measured with Actigraph and PASIPD, in patients ≥3 months after their stroke.
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minutes (土 66.66) each day. The average total activity for each day was the remaining 22.37 %, i.e. 134.22 minutes, and the median percentage value of a MVPA intensity was 0.23 % (IQR 0.70). Further, the median value of step count per day was 1641 steps (IOR 2621). The subjective measured physical activity level, assessed with PASIPD, had a mean value of 15.22 MET hr/day (土 8.17). See table 2 for additional information.
Table 2. Physical activity factors in patients > 3 months after their stroke.
Mean SD Median Min/max Interquartile Range
ST (%), n=33 77.63 11.11 77.92 49.41/92.72 18.22 MVPA (%), n=33 0.66 1.26 0.23 0.00/6.64 0.70 Kcal, n=33 80.15 58.20 64.43 15.40/249.31 76.52 PASIPD, n=29 15.22 8.18 15.66 1.30/37.12 9.55 MET, n=33 1.02 0.04 1.01 1.00/1.18 0.04 SC, n=33 2183 1828 1641 325.71/9116.57 2621
ST = Sedentary Time, percentage of 10h per day; MVPA = Moderate to Vigorous Physical Activity in percent per 10h day; Kcal = Kilocalories spent per 10h day; PASIPD = MET hr/day scoring in Physical Activity Scale for Individuals with Physical Disabilities; MET = Metabolic Equivalent of Task rate per hour; SC = Step Count per day
Quality of life, measured with EQ-5D-5L, in the patients ≥3 months after their stroke The experienced HRQoL in the patient group had a mean EQ-index score of 0.776 (土 0.205), and a mean EQ-VAS score of 72.15 (土 1.36). See Table 3 for additional
information.
Table 3. HRQoL, measured with EQ-5D, in patients ≥3 months after their stroke
Mean SD Median Min/max Interquartile Range EQ-5D Index, n=33 0.776 0.205 0.811 -0.056/1.000 0.205
EQ-5D VAS, n=33 72.15 16.36 75.00 40.00/99.00 30.00
Question 5, n=33 1.76 0.936 1 1/4 1
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The highest correlation and strongest significance found in this study, regarding this question, was between MET score assessed with PASIPD and HRQoL assessed with EQ-VAS (r = 0.482, p < 0.01), showing a positive relationship between a higher level of PA and high self-estimated HRQoL (see figure 2 and 3). The same MET score had a low, reversed, correlation and no significance, with EQ-index (r = -0.056, p = 0.915). MET score assessed with Actigraph also had a significant and high positive correlation with EQ-VAS (r = 0.413, p = 0.017), and a weak reversed correlation with the EQ-index (r = -0.022, p 0.902), see Table 4.
Other findings were that SC, ST and MVPA, all assessed with accelerometer, each had significant correlation with HRQoL assessed with EQ-VAS (SC: r = 0.416, p = 0.016; ST: r = -0.354, p = 0.043; MVPA: r = 0.300, p = 0.090). These findings show a positive
relationship between PA and self-estimated HRQoL, and a correspondent negative
relationship between sedentary behaviour and self-estimated HRQoL. SC and ST assessed with accelerometer, and HRQoL measured with EQ-index, both had low correlation with no significance (SC: r = 0.019, p = 0.915; ST: r = 0.015, p = 0.932). The correlation between MVPA assessed with accelerometer, and HRQoL measured with EQ-index was slightly higher but also weak (r = -0.074, p = 0.681).
Table 4. EQ-index and EQ-VAS correlations and significance levels with different PA
values.
ST (%) MVPA (%) Kcal PASIPD SC MET
EQ-index
Spearman’s correlation coefficient (r) 0.02 -0.07 0.03 -0.06 0.02 -0.02
p-value 0.93 0.68 0.89 0.77 0.92 0.90
N 33 33 33 29 33 33
EQ-VAS
Spearman’s correlation coefficient (r) -0.35* 0.30 0.41* 0.48** 0.42* 0.41*
p-value 0.04 0.09 0.02 0.01 0.02 0.02
N 33 33 33 29 33 33
Question 5
Spearman’s correlation coefficient (r) -0.03 0.14 0.05 0.13 0.04 0.11
p-value 0.85 0.45 0.78 0.49 0.84 0.55
N 33 33 33 29 33 33
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ST = Sedentary Time, percentage of 10h per day; MVPA = Moderate to Vigorous Physical Activity in percent per 10h day; Kcal = Kilocalories spent per 10h day; PASIPD = MET hr/day scoring in Physical Activity Scale for Individuals with Physical Disabilities; MET = Metabolic Equivalent of Task rate per hour; SC = Step Count per day
Figure 2. Scatter plot for EQ-VAS and PASIPD
Figure 3. Scatter plot for EQ-VAS and MET rate measured with accelerometer
The correlation between the level of PA, measured with Actigraph and PASIPD, and perceived depression, measured with EQ-5D, in the patients ≥3 months after their stroke.
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The correlation between PA and depression assessed with EQ-5D question 5 was generally very small, showing no significant relationship between depression and PA. The correlations that was found indicated on a positive relationship between PA and depression, yet with a very low correlation level and poor significance, see table 4.
7. Discussion
7.1 Summary of the results
Data from 33 participants were analyzed and presented. The mean age of the
participants was 60 (土 12.68) years, with 17 males and 16 females. The mean percentage of sedentary time (ST) during 10 hours was 77.63 % (土 11.11) per day. During the 10hr filter, the participants had a median MVPA intensity at 0.23 % (IQR 0.70). Steps per day had a big variety ranging from 325 to 9116 steps, and therefore presented as median at 1641 (IQR 2621) steps per day. The subjective experience PA over one week measured with PASIPD had a mean value at 15.22 MET hr/day (土 8.18).
Data from EQ-5D-5L was normally distributed, and the EQ-5D index score for the patient group had a mean value at 0.776 (土 0.205). Current health state measured with VAS had the mean value 72.15 (土 16.36).
The highest correlation and strongest significance found in this study regarding correlation between PA and HRQoL, was between MET score assessed with PASIPD and HRQoL assessed with EQ-VAS (r = 0.482, p < 0.01). MET score assessed with Actigraph also had a significant and high positive correlation with EQ-VAS (r = 0.413, p = 0.017). These findings show a positive relationship between a higher level of PA, measured with subjective and objective instruments, and high self-estimated HRQoL. The significance of the correlations between the different PA scores and EQ-VAS was much stronger (p = 0.008 - 0.09), than the significance of the correlations with EQ-index, which was almost absent (p = 0.681 - 0.932). The correlation between PA and depression assessed with EQ-5D question 5 was generally absent, with very weak significance, showing no significant relationship between depression and PA.
7.2 Discussion of results
The data collection of the level of PA were made with different PA variables, both objectively and subjectively, in order to assemble a wide range of information. This study shows that individuals with stroke had a significantly higher ST compared to what is
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active only 134.22 minutes per day. The activity had a predominantly light intensity, with only a median percentage value of 0.23 % (1 minute and 19 seconds per 10 hr day) in MVPA. Similar findings regarding ST have been seen in other studies of patients with stroke and PA (52). According to the WHO, people 65 years and above should achieve 150 minutes in a moderate-intensity level, or 75 minutes of vigorous aerobic PA throughout a week (53). When compared to WHO recommendations, this can be seen as a low result. Engaging in a
sedentary behavior has increasingly been recognized as a factor that is increasing the risk of secondary complications, cardiovascular diseases for instance (54).
A cross-sectional observational study examined the amount and context of ST in people with stroke, mean age 67 years, compared with age-matched healthy individuals over 7 days. Further, they examined the time spent in different intensities of PA and daily energy
expenditure in these 2 groups. Big differences were presented, where people with stroke had a significantly higher ST and less time engaging in all intensities of PA than the control group. A ST mean value of 75.8 % per day during waking hours, and a mean value of 23.4 % spent in light physical activity (LPA), and 0.52 % spent in MVPA (55). These objective data results are very much like ours, and consistent with previous studies, regarding ST and PA in people with stroke (52,54). When it comes to subjective measures of PA with the instrument
PASIPD, there are fewer studies to the authors’ knowledge. A study comparable to this, measured the level of PA with PASIPD among PWPD from Thailand, and one of the
subgroups is hemiplegia. This subgroup consisted of 20 participants, and had a mean value of 25.48 (土 17.98) MET hr/day, a quite big difference compared to this study’s results, which was 15.22 (土 8.18) MET hr/day. The subgroup of the study had most likely younger
participants, since the mean value of the study group, n=146, is 25.2 (土 6.0) years, compared to 59.7(土 12.68) years in the present study. The difference in age could be a factor which influences the PA behavior (30). Another study examined the correlation of the activity counts/day, measured during the waking hours of 3 consecutive days by wearing an
accelerometer, and with PASIPD. The participants of the study had chronic stroke, with the mean age was 66.5 (土 9.6) years and all of the participants could walk independently. The median value of the PASIPD was 10.3 (IQR 6.1-17.1) MET/hr per day, and had a significant correlation with the accelerometer measurements (r = 0.45, p < 0.01) (56). In contrast, the correlation in the present study between average kcal per 10 hr/day assessed with
accelerometer, and MET hr/day assessed with PASIPD was found to be low with no
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compared to the objective measurements with accelerometer. What is important to take into consideration is that the PASIPD records activities of all waking hours of a day, while the Actigraph records 10 waking hours per day. Which could partly explain the difference, as well as the insecurity of subjective measurements (57).
Steps per day
The result of the present study showed that the participants had a median value of 1641 (IQR 2621) steps per day, which can be comparable with a study that presents steps per day guidelines for older adults. The guidelines imply that an individual living with disability or chronic disease should walk 4600-5500 steps per day (58). In the present study, only three participants reached these guidelines. This result is not unexpected though for adults with disabilities or chronic disease. Studies have concluded that people with stroke take much lower than 5000 steps per day, and a prominent reason is that it is perceived as very difficult to engage in PA of at least moderate intensity (58). It may not be realistic therefore to reach these guidelines. Instead, it might be more realistic to shift the focus from guidelines and instead empathize the promotion of a physically active lifestyle. In order to preserve physical function and independence (58,59). The gait speed of the patients was low (table 1.)
compared to similar studies (52,55), which might have affected the number of steps per day, and thus the general PA.
EQ-5D-5L
The perceived HRQoL of this population, presented with EQ-5D index score and VAS estimation, showed overall high results. The EQ-5D index score had a mean value of 0.776 ( 土 0.205), and current health state measured with VAS had the mean value of 72.15 (土 16.36). The EQ-5D-5L index score of 1 is equivalent to “Full health”, and 100 at the VAS scale is equivalent to “The best health you can imagine”. Since the data had a normal distribution, with high scores and low standard deviation respectively in both measures, indicates a good HRQoL for this population. These results can be compared with a similar study, Chen P et al (16), who measured the HRQoL 4 months poststroke through EQ-5D-5L. The mean value of 112 patients in the EQ-index score was 0.691 (SD 0.267), and 60.7 (22.4) in the EQ-VAS score.
Depression is one dimension of EQ-5D-5L, and according to earlier studies, depression is common in post-stroke patients (14), but the population in this study rated a low level of depression with almost no spread (see table 3).
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earlier studies about PA and HRQoL (11-13,58). This indicates that there are other variables that affect HRQoL other than PA. When comparing the HRQoL results to other studies, this study had equal results as a similar study on eldely without stroke (60).
Correlation
It’s well established that stroke survivors have a lower HRQoL, and one major reason for this is due to disabilities that affect PA and social activities (11-13). Being engaged in a PA lifestyle is important in order to improve HRQoL among elderly, and there are findings suggesting that 4500-5500 steps/day is correlated to higher HRQoL results (58). Results from other studies also support that there is a positive correlation between HRQoL and PA
(56,61,62). From this study, there is a significant correlation between PA and HRQoL in both subjective measurements of PA (MET score from PASIPD), and objective measurements of PA (MET score, ST and MVPA from accelerometer). These results support the hypothesis that PA is positively correlated with HRQoL. A peculiar finding was that all PA factors had reversed correlation with EQ-index compared to EQ-VAS. MVPA and both MET scores had a negative correlation with EQ-index, and positive correlation with EQ-VAS, while ST had the opposite relationship to EQ-index and EQ-VAS. This is a finding to discuss further in the method discussion.
No correlation between PA and depression was found in this study, probably because of the narrow spread of results in the EQ-5D-5L question concerning depression/anxiety. Earlier studies conclude that stroke survivors who are actively engaged in exercise might have a small beneficial effect on depressive symptoms (8). The fact that the PA levels of the patients in this study was low, as well as the depression rate, indicates that there are other variables that affect depression other than PA. One reason for these results might be the low PA levels in the population for this study. Studies show that physical exercise decreases depression, and no one of the patients in this study reached the level of PA that could be seen as exercise. Generalization
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With accepting the alternative hypothesis we say that the correlations belong to the 5 % most extreme correlations it is possible to obtain by chance, and the results with the most significant correlations might be speaking for all stroke survivors in Bangkok, Thailand (51). 7.3 Method discussion
This study has some methodological strengths, and one major strength lies in the use of laboratory equipment to objectively measure PA variables over a 7-day monitoring period, which allows the most precise measure accessible for the same interest. To validate the objective data from the Actigraphs, subjective measures were used where the participants filled in the daily activity log and answered the PASIPD questionnaire. The daily activity log validated the wear time of the Actigraph, and PASIPD were used to further collect PA information over a 7-day period in order to improve the validity of the data. Using these validating measures allows us to critically analyze the results to a greater extent.
By utilizing PASIPD which captures the level of PA over 7 days together with an objective measure which captures PA during 10hr/day during 6 ≤ 7 days, gives a good description of an individual’s level of activity.
The sample of this study was originally 41 participants which can be considered as an acceptable number of participants in a bachelor thesis. Further, 4 participants of the patients included in the study did not complete the PASIPD questionnaire. A research study concluded with the purpose of estimating the level of PA over a 7-day period with an accelerometer, data from at least 4 days with 10 waking hours each day is required to provide a valid
measurement (43). The majority of the patient group in the present study had an
accelerometer wear-time ≥ 6 days with ≥ 10hr/day recorded data, and therefore would a patient with less wear-time be excluded. Compliance was very high, and the PA estimation over a 7-day period becomes more accurate with more data, thus increases this study’s validity and reliability.
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sedentary, Choi is the more suitable algorithm to distinguish non wear-time from SB in this target group according to the authors (63).
Questioning a potential bias of the inter-reliability when giving the participants instructions about the Actigraph, and the collecting of data for EQ-5D-5L and PASIPD are difficult for the authors. Since it was done in the Thai language by two local physiotherapists, master student Ms. Nattakitta and PhD Mr. Bukhari. This circumstance can therefore be considered as a limitation of the study, and a reliability problem.
The authors of the study wrote the information and instructions for the Actigraph and designed the daily activity log (appendix IV), which were later translated to Thai by our colleagues. Our colleagues then followed the translated appendix when explaining it to the participants, and which were later handed out to the participants. One of the including criterias of this study was that the participants have good communication and cognition measured by Thai Mini Mental State Examination (TMMSE), with a score > 18, total score is 30 (64). This criteria minimizes the risk for potential misunderstandings between the
participant and instructors. Some of the patients was accompanied by a caregiver, who listened to the information and instructions which were given to the participant.
When collecting data for the EQ-5D-5L and PASIPD measurements after the 7-day monitoring period, the colleagues followed exclusively the standard manual of the
measurements respectively, and answered potential follow-up questions. The risk of misunderstanding the questions of both measurements is something that cannot be denied. The authors believe that the risk of misunderstanding the questions of the EQ-5D-5L is greater than misunderstanding the EQ-VAS. The deviation between EQ-VAS and EQ-index might disclose a lack of reliability in the method for measuring HRQoL in either EQ-VAS or EQ-index. In other similar studies with PA and HRQoL, the results show positive
correlations(56,61,62), which supports that the EQ-index measurement in this study might have been flawed, and EQ-VAS might be the more valid measurement of HRQoL.
Furthermore, subjective measures of PA tend to lead to overestimation (39).
The authors and colleagues aimed for maintaining a standardized protocol with the participants during the process of giving out information and instructions, and further the data collecting of EQ-5D-5L and PASIPD.
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study (65). The observers of the study did not recognize this potential validity problem during the procedure when interacting with the participants. The risk for this could have been
minimized by informing the participants to act like normal when wearing the accelerometer. A potential speculation was that the participants enhanced their PA in the beginning of the monitoring period, which would later decrease because of lack of motivation. When analysing the individual activity level between different days during the 7-day period in the software Actilife®, no significant differences could be seen.
7.4 The clinical relevance
Previous research studies in Thailand similar to this are few to the authors’ knowledge, and providing more data of PA and HRQoL to this field could be beneficial. Recognizing the activity level and HRQoL amongst stroke survivors can further have a useful aspect for instances that have the opportunity to influence resources.
The study suggests that PA benefits HRQoL within stroke survivors from a biopsychosocial perspective, since the EQ-5D-5L covers a wide range of dimensions: mobility; self-care; usual activities; pain/discomfort; anxiety/depression. This might support multimodal actions that motivate stroke patients to engage in a more physically active life- style, in order to gain HRQoL.
This was a small study with no intervention, showing a small but significant correlation between PA and HRQoL. To further investigate the impact of PA on HRQoL in stroke patients, a larger study with an intervention group and a control group could be interesting. The intervention could be based on actions to increase PA matching WHO’s
recommendations for a longer period, and to measure HRQoL and PA before and after the intervention.
8. Conclusion
25
Acknowledgements
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Appendix II – Informed Consent
Information letter - “Level of physical activity and perceived quality of life among stroke survivors in Thailand”
We are Adam Persson and Patric Svensson, two students from the physiotherapy program at Uppsala University in Sweden. The aim of our study is to investigate the level of physical activity and see how it correlates with the perceived quality of life and depression amongst individuals who suffered from a stroke in Bangkok, Thailand.
We are asking for your participation in this study, and as a participant you sign up for: 1. Completing a short questionnaire about your perceived quality of life.
2. Performing a 10 minute walking test, which includes walking fast and safe for 10 meters between two markers.
3. Wearing an accelerometer on the hip for 7 days at all times except when being in contact with water and lying in bed.
As you signed this contract you agree to participate in the study. You can at any point withdraw your participation and correct or edit you answers in the questionnaire. Further, the accelerometer is to be returned to the authors after use. The data from the questionnaire and accelerometer are saved on a password protected computer and will be saved there during the thesis process, and then deleted once the thesis is approved. Your answers will be handled confidentially and in the results presentation of the study. The data will be analyzed by the authors and discussed together with their supervisor in Sweden (Karin Hellstrom). If an interpreter is needed, our supervisor in Thailand (Chutima Jalayondeja) will also be present during the process of filling the questionnaire, and giving information on how to use the accelerometer.
Handouts of the accelerometers and questionnaires together with instructions and information will be given on the same day. The location of this day is held preferably at the University of Mahidol. After completed or aborted participation, the Actigraph has to be returned to the authors.
Best regards
Patric Svensson & Adam Persson
Supervisor in Thailand: Prof. Dr. Chutima Jalayondeja Supervisor in Sweden: As. Prof. Karin Hellström
Contact:
