Stroke Subjects with Higher Levels of Physical Activity Report Lower Levels of Fatigue

Special Article - Stroke Rehabilitation

Phys Med Rehabil Int. 2015;2(3): 1036.

Stroke Subjects with Higher Levels of Physical Activity Report Lower Levels of Fatigue

Faria GS1, Teixeira-Salmela LF1 and Polese JC1,2*

1Department of Physical Therapy, Universidade Federal de Minas Gerais, Brazil

2Department of Physical Therapy, University of Sydney, Australia

*Corresponding author: Polese JC, Departamento de Fisioterapia, Universidade Federal de Minas Gerais, Avenida Antônio Carlos, 6627, Campus Pampulha, 31270-901 Belo Horizonte, Minas Gerais, Brazil

Received: January 08, 2015; Accepted: February 18, 2015 Published: February 19, 2015


Background: If the associations between levels of physical activity and fatigue were established, specific, directed and more effective interventions could be developed to prevent the onset of fatigue.

Objective: Therefore, the present study aimed to compare the levels of fatigue between subjects with different physical activity levels and to investigate the associations between self-reported levels of fatigue and physical activity of chronic stroke subjects.

Method: This is a cross-sectional study, where 55 participants, with a mean age of 58.8 years and a mean time since the onset of the stroke of 25.5 months, had their fatigue and physical activity levels assessed by the Brazilian versions of the Fatigue Severity Scale (FSS) and the Human Activity Profile (HAP), respectively.

Results: Forty percent of the participants were classified as impaired, 51% as moderately active, and 9% as active. One-way ANOVA revealed significant differences between the groups regarding their fatigue levels (F=9.60, p<0.001). The LSD post-hoc analyses revealed that the differences were significant between the impaired and moderately active (p<0.001, 95%CI: 0.57 to 2.19) and between the impaired and active groups (p<0.001, 95%CI: 1.2 to 4.0). No differences were observed between the moderately active and active groups (p=0.08, 95%CI: -0.1 to 2.6). Pearson correlation coefficient showed an inverse and good association between the HAP and the FSS scores (r=-0.60, p<0.001).

Conclusions: Individuals with lower levels of physical activity reported higher levels of self-perceived fatigue, than those of the moderately active and active groups. Additionally, an inverse and good association was found between self reported physical activity and fatigue levels.

Keywords: Fatigue; Motor Activity; Rehabilitation; Stroke


FSS: Fatigue Severity Scale; HAP: Human Activity Profile; AAS: Adjusted Activity Score


Fatigue is a subjective symptom, which is often present and distressing for stroke survivors [1]. Within clinical settings, there is a frequent complaint regarding post-stroke fatigue [2], since it is a potential detrimental factor for physical recovery [3]. It is well known that the stroke subjects have higher levels of fatigue, when compared with community-dwelling, healthy elderly [2]. In a prospective study with 1,080 individuals with stroke, Mead et al. [4] found that fatigue, by itself, was associated with reduced survival.

In general, low levels of physical activity are observed even in stroke subjects with mild motor impairments [5], favoring the onset of deconditioning. Once estabilished, deconditioning after stroke could probably lead to the onset of fatigue [1], and would be explained by the fact that there is a general decrease in the exercise capacity [6] experienced by these individuals. In this sense, a twoyear prospective cohort study with more than 3,600 stroke survivors found severe self-reported fatigue to importantly affect functional ability [7]. Additionally, fatigue was observed to be an independent predictor of dependence on the functioning of activities of daily living [7]. Besides, previous studies reported self-perceived fatigue as possibly one of the main causes for stroke survivors not returning to work [8] and it has also been demonstrated that fatigue by itself is associated with increased long-term mortality irrespective of stroke severity [9].

Due to the decline of mortality after stroke [10] and a longer life expectancy observed over the last decades, it is crucial to understand the whole panomara of sequelaes that follow the survivors, to provide the best approach and management methods. Associated with the fact that the improvements of activity levels are crucial concerns during rehabilitation, if the associations between physical activity levels and self-reported fatigue were established, specific, direct, and more effective interventions could be developed to individuals post stroke [1].

Therefore, the research questions for this study were:



Individuals with unilateral stroke, who had residual weakness and/ or increased tonus of the paretic lower limb muscles, were recruited on a volunteer basis from the general community of Belo Horizonte, Brazil, from August 2013 to August 2014, according to the following criteria: Were older than 20 years; had a time since stroke of at least six months; and showed no cognitive impairments, as determined by the following education-adjusted cut-off scores on the Mini Mental State Examination: 18/19 for the individuals with illiteracy and 24/25 for those with basic education [11]. All participants provided consent, based upon previous approval by the ethical review board from the Universidade Federal de Minas Gerais (CAAE-0254.0.203.000-11).

Instruments and procedures

Initially, the participants underwent a physical examination and an interview for the collection of anthropometric, demographic, and clinical data, such as age, gender, body weight, height, time since the onset of stroke, paretic side and the use of medications. For characterization purposes, their walking speeds were assessed by the 10-meter walking test, following previously recommended procedures [12, 13].

Levels of fatigue

Levels of fatigue were assessed by the Brazilian version of the FSS [14]. The FSS was first developed to be used with multiple sclerosis patients, but it has been frequently used with other neurological conditions, such as Parkinson and stroke [15]. It is a self-reported questionnaire with nine affirmatives, which the individual should score on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree) [15, 16]. Mean scores ≥4 were established as indicative of fatigue [15, 16]. The FSS-Brazil showed adequate validity and reliability (ICC= 0.91) for individuals with neurological disorders [14].

Physical activity levels

The Brazilian version of the HAP [17] was employed to determine the participants’ physical activity levels. This is a self-report questionnaire, which showed appropriated validity and reliability for the Brazilian population [17]. The HAP adjusted activity scores (AAS) provide information regarding the individuals’ current activity levels. The physical activity levels were classified based upon their AAS scores, as impaired (<53), moderately active (53-74), or active (>74) [17, 18]. The HAP showed adequate validity and reliability (ICC=0.89) with stroke subjects [19].

Statistical analyses

Descriptive statistics, tests for normality, and equality of variances were carried out with the SPSS software (release 17.0). One-way analysis of variance (ANOVA), followed by LSD post-hoc tests, were employed to investigate differences between the groups (impaired, moderately active, and active) regarding their fatigue levels. Pearson correlation coefficients were calculated to explore the relationships between the fatigue and physical activity levels, which were classified as follows: little or none (0.00<r< 0.25), fair (0.25<r< 0.50), moderate to good (0.50<r<0.75), and good to excellent (r>0.75) [20]. For all analyses, the significance levels was set at 5%.


Participants’ characteristics

An initial list of subjects enrolled on public rehabilitation centres from Belo Horizonte consisted of 141 participants. However, only 55 individuals with stroke, 33 men, with a mean age of 58.8 (SD 13.5) years and a mean time since the onset of stroke of 25.5 (SD 13.9) months, were evaluated. Box 1 reported the total number of losses and the main reasons for it. About 93% of the participants had ischemic stroke and 61.8% had their right side affected. No significant differences between the three physical activity level groups were observed, regarding the participants’ time since the onset of stroke (F=1.77, p=0.18), number of medications (F=3.10, p=0.06), body mass index (F=1.61, p=0.21), and MMSE scores (F=0.50, p=0.61). The mean walking speed values for the impaired, moderately active, and active groups were respectively 0.69m/s, 0.90m/s, and 1.13m/s. According to their AAS scores, forty percent of the participants were classified as impaired, 51% as moderately active, and 9% as active. The mean FSS-BR for the impaired group was 5.38 (min: 3.56; max:7.00), for the moderately active 3.87 (min:1.67; max:7.00), and for the active group 3.33 (min:1.89; max:5.75).