Self-reported Physical Activity after Stroke and its Determinants

Research Article

Phys Med Rehabil Int. 2016; 3(7): 1106.

Self-reported Physical Activity after Stroke and its Determinants?

Van de Port IGL¹*, Van der Werf H², Schepers VPM³ and Kwakkel G4

¹Revant Rehabilitation, Breda, The Netherlands

²Merem Rehabilitation Center ‘De Trappenberg, Huizen, The Netherlands

³Brain Center Rudolf Magnus and Center of Excellence for Rehabilitation Medicine, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht, The Netherlands

4Department of Rehabilitation Medicine, VU University Medical Centre, Amsterdam, The Netherlands

*Corresponding author: Van de Port IGL, Revant Rehabilitation, 4817 JW Breda, The Netherlands

Received: November 06, 2016; Accepted: November 29, 2016; Published: December 01, 2016


Studies show that the physical activity level of individuals after stroke is low. Since this population is at risk for secondary complaints physical activity is an important outcome. Self reported questionnaires give insight in the amount and intensity of physical activity. In addition, identifying related factors can help to guide interventions to increase physical activity.

Objectives: To examine physical activity as measured by the Physical Activity Scale for Individuals with Physical Disability (PASIPD) in people in the chronic phase after stroke and investigate factors that predict physical activity measured with PASIPD.

Methods: In this longitudinal study, stroke survivors completed the Dutch version of the PASIPD, a 7-day recall self-report questionnaire including 12 items capturing physical activity in recreation, household and occupational domain. Total physical activity is expressed in metabolic equivalent (MET) hours per day. Possible determinants, i.e. patient and stroke characteristics and clinical outcomes, were measured at the end of inpatient rehabilitation. The PASIPD was collected at least one year after finishing the studied outpatient rehabilitation period.

Results: Mean PASIPD score of the 116 participants was 17.1 (SD 12.4) MET h day-1. Multivariate analysis showed that a higher education level, a positive score on the letter cancellation task and a higher score on the fatigue severity scale were significantly (p<.05) related to a lower score on the PASIPD, explaining 13% of the variance.

Conclusion: Physical activity is low after stroke. Level of education, visuospatial neglect and fatigue should be taken into account in clinical care and designing future interventions.

Keywords: Stroke; Physical activity; Self-report questionnaire; Prognosis


Stroke survivors often suffer from functional limitations which lead to a reduction in physical activity (PA), deconditioning and predisposition to a sedentary lifestyle [1-4]. Different studies show that physical activity levels of patients after stroke are far below agematched normative values [5]. Since it is known that an inactive lifestyle may contribute to a heightened risk for recurrent stroke and secondary complications like heart diseases, monitoring physical activity is important in people after stroke [2,6]. Especially in the chronic phase after stroke, a decrease in physical activity has been identified. Despite an often very intensive and effective rehabilitation period. Being able to identify the determinants that are related to physical inactivity is valuable to further improve the care and behavior changing interventions to stimulate physical activity in this population.

Physical activity is a multidimensional construct that includes intensity, frequency, duration and variety [7]. A recent review of English et al. [5] highlighted a lack of knowledge about the amount and intensity of physical activity amongst post stroke people. However, previous studies suggested that a certain intensity of the exercise is needed to lead to a cardio protective effect, which underlines the importance of also getting insight in the intensity of the physical activity.

The Physical Activity Scale for Individuals with Physical Disability (PASIPD) is a self-reported questionnaire relating physical activities including leisure, household, and work-related activities to metabolic equivalents (METS) [8]. Using this outcome measure will give insight in the amount, variety and intensity of the physical activity. In the PASIPD, patients are asked to report the frequency of each activity in the previous week. Each activity is weighted with a metabolic equivalent that reflects the intensity of that specific activity. With that, not only the type and amount of physical activity is measured, but also an estimate is given of the intensity of the conducted activities.

The aims of the present study are 1) to examine the level of physical activity as measured by the PASIPD in people in the chronic phase after stroke and 2) to investigate factors that are predictive for amount of physical activity according to the PASIPD. Based on the current literature in the healthy and stroke population [9-11] we include demographic and stroke characteristics such as age, gender and stroke severity, physical outcome measures, mood and fatigue as possible determinants related to physical activity.


Participants and design

Stroke survivors who participated from 2009 until 2011 in the FIT-stroke trial were approached. The FIT-stroke trial is a prospective single blinded randomized controlled trial conducted by specially trained staff in nine rehabilitation centers in the Netherlands [12]. All subjects completed an inpatient rehabilitation program in one of the nine rehabilitation centres. The following inclusion criteria were used: verified stroke according to the World Health Organization (WHO) definition (19), ability to walk a minimum of 10m without physical assistance from a therapist (Functional Ambulation Categories =3), discharged home from a rehabilitation centre, need to continue physiotherapy during outpatient care to improve walking competency and/or physical condition, giving informed consent and being motivated to participate in 24 fitness training sessions over a 12-week period, or in usual care. Patients were excluded if they had severe cognitive deficits as evaluated by the Mini-Mental State Examination (<24 points), were unable to communicate (i.e. <4 points on the Utrechts Communicatie Onderzoek; UCO) or lived more than 30km from the rehabilitation centre. After inclusion, the participants received an outpatient rehabilitation program of either 12 week task oriented circuit class training or regular face-to-face physiotherapy after discharge from their inpatient rehabilitation period. Primary outcome measure was the Stroke Impact Scale [12,13]. The present study concerns a sub analysis of the FIT-stroke population including an extra follow up measurement at least one year after finishing the FIT-Stroke outpatient rehabilitation period. Data of both the control and intervention group was included.


The participants were addressed by mail and requested to complete and return a questionnaire about physical activity. Three weeks after the questionnaire was sent non-responders were contacted once by telephone and were requested to return de questionnaire. Informed consent was obtained from all the participants during the FIT-stroke trial. The study was approved by the Medical Ethics Committee of the University Medical Centre of Utrecht, the Netherlands and registered in the Dutch Trial Register (trial number NTR1534).


Physical activity level is measured by the Physical Activity Scale for Individuals with Physical Disabilities (PASIPD). The PASIPD is 7-day recall self-report questionnaire capturing physical activity in three domains (recreation, household and occupational activities). It consists of 13 questions [14]. We used the Dutch version: a 12 item questionnaire in which question 10 on lawn work and question 11 on outdoor gardening are merged, because this better represents the Dutch situation. Domain scores can be calculated for Leisure Activities (item 2-6), Household activities (item 7-11) and Work/ volunteer (item 12). The total physical activity is expressed in metabolic equivalent hours per day (MET h day-1) and is calculated by the sum of the average hours of physical activity daily multiplied with a metabolic equivalent value associated with the intensity of the activity for each item. The maximum score of the Dutch version is 182.3 MET h day-1 compared to 199.5 MET h day-1 in the original PASIPD. The Dutch PASIPD has been found to have a test-retest reliability of r = 0.77 (p< 0,05) [8].

The possible predictors of physical activity, i.e. the independent factors were determined at completion of the outpatient rehabilitation program of 12 weeks in the FIT-stroke trial. Patient characteristics were age, gender, living situation, level of education, employment before stroke, sport participation before stroke and participation in circuit class training in outpatient rehabilitation. Level of education was dichotomized, being scored “high” for patients with intermediate vocational education or higher. Sport participation before stroke was dichotomized, being scored “yes” when the patient weekly participated in sports or walked or cycled more than two hours weekly. Stroke characteristics were time since stroke and type of stroke. In addition different clinical outcomes were determined. Visuo-spatial neglect was measured by the Letter Cancellation Task (LCT). This measure was dichotomized being scored “positive” when patients scored three omissions or more on the hemiplegic side, compared to the other side. The Six Minute Walking Test (6 MWT) was used to measure basic functional mobility and endurance. The patient is asked to walk six minutes at a comfortable speed, the distance walked is measured. The Time Up and Go test (TUG) is a test of basic functional mobility. The patient is asked to rise from a chair and walk 3 meters as fast as possible, cross a line, turn and walk back and sit down again. This test has been shown to identify patients at risk for falling. The fear of falling was measured by the Falls Efficacy Scale (FES), a 13 item questionnaire which determines perceived selfefficacy at avoiding falls during essential, non-hazardous activities of daily living. The Fatigue Severity Scale (FSS) was used to determine fatigue. It consists of 9 items, and scores for each item range from 1 to 7. In a reliability study with two independent observers and 18 stroke patients, FSS showed an intra-observer correlation coefficient (ICC) of 0.82. The Hospital Anxiety and Depression Scale (HADS) was used to determine anxiety and depression. It is a simple measure to determine mood, emotional distress, anxiety depression and emotional disorder. The questionnaire consists of 14 items (7 anxiety, 7 depression), each with a 4-point rating scale (0-3) and has proved to be responsive to change. More detailed description and references of the used measures can be found in the study protocol of FIT-stroke trial [13].

Statistical analysis

Baseline characteristics were analyzed using descriptive statistics at the end of the 12 weeks intervention period. Baseline characteristics where compared between included patients, who returned a valid questionnaire and non-included patients, who did not return a (valid) questionnaire by the independent-samples T test for normally distributed data, Mann-Whitney-U test for not normally distributed data and Chi-square test for nominal data. Data were considered normally distributed when skewness values were between -1 and 1. The relations between the PASIPD score and the independent variables (i.e. patient characteristics, stroke characteristics, and clinical outcomes) was first analyzed using bivariate regression analysis. Variables with a level of significance lower than 0.2 were included in the multiple regression analysis. Multicollinearity diagnostics was applied between candidate determinants for the outcome of PASIPD score. In case of multicollinearity (r >0.8) only the variable with the highest correlation to the PASIPD score was included in the multivariate regression analysis. The remaining variables were used in a backward regression analysis two tailed using p<0.05 as the level of significance. Data were analyzed with statistical package SPSS (version 22.0).


After completion of the FIT stroke trial 190 of the 242 participants agreed to be approached for further research. These participants were addressed by mail at least one year after completion of the 12 weeks outpatient intervention (Figure 1). In total 111 participants returned the questionnaire (58%). Of the non-responders (N=79), 56 were contacted by phone. Twenty-eight of the phoned non-responders returned the questionnaire, resulting in a response rate of 73% (139 of 190). Of the 139 returned questionnaires 19 were incomplete, one was invalid because the participant had an abdominal surgery in the recent history which interfered with physical activity, and three questionnaires were misinterpreted by the responder, leaving data of 116 participants available for analysis.