Use of the Capability, Opportunity and Motivation Behaviour model (COM-B) to Understand Interventions to Support Physical Activity Behaviour in People with Stroke: An Overview of Reviews.

OBJECTIVE: Physical activity in people with stroke remains low despite considerable research. This overview aimed to provide high-level synthesis and aid clinical decision-making. The Capability, Opportunity, Motivation-Behaviour (COM-B) model was used to classify interventions to understand which components improve physical activity behaviour in people with stroke. DATA SOURCES: CINAHL, Cochrane Database, MEDLINE, PEDro, PsychINFO, SPORTDiscus. REVIEW METHODS: A systematic search was conducted (November 2023) to identify reviews of interventions to improve physical activity in people with stroke. Results were screened and assessed for eligibility. Participant characteristics, intervention classification using COM-B, and effect of intervention were extracted. Quality was assessed using AMSTAR2, and Corrected Cover Analysis for study overlap. Narrative synthesis was used to understand components of interventions to improve physical activity behaviour. RESULTS: 1801 references were screened and 29 full-text references assessed for eligibility. Twenty reviews were included. Quality ranged from critically low (n = 3) to high (n = 10). Study overlap calculated using corrected cover area indicated slight overlap (0.028) and minimal reporting bias.The majority of participants were mobile with mild stroke and community dwelling. Twenty-three interventions were classified using COM-B. Three of twelve interventions classified to one aspect of the COM-B were effective. Fourteen of sixteen effective interventions combined at least two COM-B elements, ten of these combined capability and motivation. CONCLUSION: Interventions including at least two elements of the COM-B are most likely to improve physical activity in mobile stroke survivors. Further research is needed to understand physical activity behaviour in those with moderate to severe stroke.

A long-term self-managed handwriting intervention for people with Parkinson's disease: results from the control group of a phase II randomized controlled trial.

OBJECTIVE: To report on the control group of a trial primarily designed to investigate exercise for improving mobility in people with Parkinson's disease (pwP). The control group undertook a handwriting intervention to control for attention and time spent practising a specific activity. DESIGN: Secondary analysis of a two-arm parallel phase II randomized controlled trial with blind assessment. SETTING: Community. PARTICIPANTS: PwP able to walk ⩾100 m and with no contraindication to exercise were recruited from the Thames Valley, UK, and randomized (1:1) to exercise or handwriting, via a concealed computer-generated list. INTERVENTION: Handwriting was undertaken at home and exercise in community facilities; both were delivered through workbooks with monthly support visits and involved practice for 1 hour, twice weekly, over a period of six months. MAIN MEASURES: Handwriting was assessed, at baseline, 3, 6 and 12 months, using a pangram giving writing speed, amplitude (area) and progressive reduction in amplitude (ratio). The Movement Disorder Society (MDS)-Unified Parkinson's Disease Rating Scale (UPDRS) item 2.7 measured self-reported handwriting deficits. RESULTS: In all, 105 pwP were recruited (analysed: n = 51 handwriting, n = 54 exercise). A total of 40 pwP adhered to the handwriting programme, most completing ⩾1 session/week. Moderate effects were found for amplitude (total area: d = 0.32; 95% confidence interval (CI): -0.11 to 0.7; P = 0.13) in favour of handwriting over a period of12 months; effects for writing speed and ratio parameters were small ≤0.11. Self-reported handwriting difficulties also favoured handwriting (UPDRS 2.7: odds ratio (OR) = 0.55; 95% CI: 0.34 to 0.91; P = 0.02). No adverse effects were reported. CONCLUSION: PwP generally adhere to self-directed home handwriting which may provide benefit with minimal risk. Encouraging effects were found in writing amplitude and, moreover, perceived ability.

Phase II randomised controlled trial of a 6-month self-managed community exercise programme for people with Parkinson's disease.

BACKGROUND: Evidence for longer term exercise delivery for people with Parkinson's disease (PwP) is deficient. AIM: Evaluate safety and adherence to a minimally supported community exercise intervention and estimate effect sizes (ES). METHODS: 2-arm parallel phase II randomised controlled trial with blind assessment. PwP able to walk ≥100 m and with no contraindication to exercise were recruited from the Thames valley, UK, and randomised (1:1) to intervention (exercise) or control (handwriting) groups, via a concealed computer-generated list. Groups received a 6-month, twice weekly programme. Exercise was undertaken in community facilities (30 min aerobic and 30 min resistance) and handwriting at home, both were delivered through workbooks with monthly support visits. Primary outcome was a 2 min walk, with motor symptoms (Movement Disorder Society Unified Parkinson's Disease Rating Scale, MDS-UPDRS III), fitness, health and well-being measured. RESULTS: Between December 2011 and August 2013, n=53 (n=54 analysed) were allocated to exercise and n=52 (n=51 analysed) to handwriting. N=37 adhered to the exercise, most attending ≥1 session/week. Aerobic exercise was performed in 99% of attended sessions and resistance in 95%. Attrition and adverse events (AEs) were similar between groups, no serious AEs (n=2 exercise, n=3 handwriting) were related, exercise group-related AEs (n=2) did not discontinue intervention. Largest effects were for motor symptoms (2 min walk ES=0.20 (95% CI -0.44 to 0.45) and MDS-UPDRS III ES=-0.30 (95% CI 0.07 to 0.54)) in favour of exercise over the 12-month follow-up period. Some small effects were observed in fitness and well-being measures (ES>0.1). CONCLUSIONS: PwP exercised safely and the possible long-term benefits observed support a substantive evaluation of this community programme. TRIAL REGISTRATION NUMBER: NCT01439022.

Interventions for fatigue in Parkinson's disease: A systematic review and meta-analysis.

The authors sought to review the efficacy of interventions for fatigue in Parkinson's disease. A search was conducted of PubMed, Cinahl, Psychinfo, EMBASE, and Web of Knowledge up to November 2013. Methodological quality was assessed using the PEDro scale. For meta-analyses, studies were weighted on variance. Effect sizes were calculated with 95% confidence interval (CI); overall effect was presented by means of a Z-score; heterogeneity was investigated using the I(2) . Fourteen articles (n = 1,890) investigating drugs and behavioral therapy were eligible. Ten studies demonstrated excellent, three good, and one fair methodological quality. Three articles (investigating amphetamines) were appropriate for meta-analysis, which was performed according to scales used: Multidimensional Fatigue Inventory: mean difference, -6.13 (95%CI: -14.63-2.37, Z = 1.41, P = 0.16; I(2) = 0); Fatigue Severity Scale: mean difference, -4.00 (95%CI: -8.72-0.72, Z = 1.66, P = 0.10; I(2) = 0). Currently insufficient evidence exists to support the treatment of fatigue in PD with any drug or nondrug treatment. Further study is required.

Sensory impairments of the lower limb after stroke: a pooled analysis of individual patient data.

OBJECTIVE: To obtain more generalizable information on the frequency and factors influencing sensory impairment after stroke and their relationship to mobility and function. METHOD: A pooled analysis of individual data of stroke survivors (N = 459); mean (SD) age = 67.2 (14.8) years, 54% male, mean (SD) time since stroke = 22.33 (63.1) days, 50% left-sided weakness. Where different measurement tools were used, data were recorded. Descriptive statistics described frequency of sensory impairments, kappa coefficients investigated relationships between sensory modalities, binary logistic regression explored the factors influencing sensory impairments, and linear regression assessed the impact of sensory impairments on activity limitations. RESULTS: Most patients' sensation was intact (55%), and individual sensory modalities were highly associated (κ = 0.60, P < .001). Weakness and neglect influenced sensory impairment (P < .001), but demographics, stroke pathology, and spasticity did not. Sensation influenced independence in activities of daily living, mobility, and balance but less strongly than weakness. CONCLUSIONS: Pooled individual data analysis showed sensation of the lower limb is grossly preserved in most stroke survivors but, when present, it affects function. Sensory modalities are highly interrelated; interventions that treat the motor system during functional tasks may be as effective at treating the sensory system as sensory retraining alone.

Weekly exercise does not improve fatigue levels in Parkinson's disease.

BACKGROUND: Fatigue is one of the most disabling non-motor symptoms for people with Parkinson's disease. Exercise may modify fatigue. This study examines prescribed exercise effects on physical activity levels, well-being, and fatigue in Parkinson's disease. METHODS: In this single-blinded trial, participants were randomly assigned to either a 12 week community exercise program or control group. Primary outcome measures were fatigue (Fatigue Severity Scale) and physical activity. RESULTS: Thirty-nine people with Parkinson's disease were included: 20 in exercise and 19 in control. Sixty-five percent of the study group were fatigued (n = 24, mean 4.02, SD 1.48). Increased fatigue was associated with lower mobility and activity (P < .05). Individuals participated in a mean of 15 (SD 10) exercise sessions with no significant change in fatigue, mobility, well-being, or physical activity after exercise (P ≥ .05). CONCLUSION: Participation in weekly exercise did not improve fatigue in people with Parkinson's Disease.

Supported community exercise in people with long-term neurological conditions: a phase II randomized controlled trial.

OBJECTIVE: Adults with long-term neurological conditions have low levels of participation in physical activities and report many barriers to participation in exercise. This study examines the feasibility and safety of supporting community exercise for people with long-term neurological conditions using a physical activity support system. DESIGN: A phase II randomized controlled trial using computer-generated block randomization, allocation concealment and single blind outcome assessment. SETTING: Oxfordshire and Birmingham community Inclusive Fitness Initiative gyms. SUBJECTS: Patients with a long-term neurological condition. INTERVENTIONS: The intervention group (n = 51) received a 12-week, supported exercise programme. The control group (n = 48) participants received standard care for 12 weeks and were then offered the intervention. MAIN MEASURES: Physical activity, adherence to exercise, measures of mobility, health and well-being. RESULTS: Forty-eight patients (n = 51) completed the intervention, achieving 14 gym attendances (range 0-39) over the 12 weeks. Overall activity did not increase as measured by the Physical Activity Scale for the Elderly (change score mean 14.31; 95% confidence interval (CI) −8.27 to 36.89) and there were no statistically significant changes in body function and health and well-being measures. CONCLUSIONS: People with long-term neurological conditions can safely exercise in community gyms when supported and achieve similar attendance to standard exercise referral schemes, but may reduce other life activities in order to participate at a gym.

A population-based study of the prevalence of fatigue after transient ischemic attack and minor stroke.

BACKGROUND AND PURPOSE: Fatigue is common after stroke and can be attributable to the increased physical effort associated with severe neurological deficits; however, its presence in those with little motor deficit raises the possibility of confounding by other factors, such as comorbidity, anxiety, and medication. To control for such factors and determine the extent of stroke-specific fatigue, we compared patients with minor stroke who had little or no residual neurological deficit with patients with TIA; both groups had undergone similar investigations and treatment. METHODS: The prevalence of fatigue 6 months after TIA or minor stroke was assessed in consecutive patients using the Chalder fatigue scale in a population-based incidence study (Oxford Vascular Study). Patients were included if they were independent in self-care Barthel Index (>or=18/20) and without major cognitive impairment (Mini-Mental State Examination >or=24/30). Stroke severity at baseline was assessed with the National Institute of Health Stroke Scale (NIHSS). Other potential causes of fatigue were assessed including anxiety, depression, recent life events, medication, and abnormalities in biochemistry or hematologic tests. RESULTS: Seventy-six participants had minor stroke (mean age, 74.1 years; 42 men) and 73 had TIA (mean age, 72.5 years; 40 men). At 6-month follow-up, median Barthel Index score was 20 (interquartile range, 20-20) in both groups. However, fatigue was more common after stroke than TIA (56% vs 29%; OR, 3.14; 95% CI, 1.51-6.57; P=0.0008). This difference was present both in patients with modified Rankin score of 0 at 6 months (23.8% vs 10.3%) and patients with modified Rankin score >or=1 (69.2% vs 48.6%), and remained more frequent in stroke patients after adjustment for potential confounders. Within the group of patients with stroke, the prevalence of fatigue increased with initial stroke severity (87% NIHSS >or=4 vs 48% NIHSS

Pedometer step counts in individuals with neurological conditions.

OBJECTIVE: To examine the accuracy of measuring step counts using a pedometer in participants with neurological conditions and healthy volunteers in relation to a manual step count tally. SETTING: Oxford Centre for Enablement, Nuffield Orthopaedic Centre NHS Trust, Oxford, UK. SUBJECTS: Healthy adults (n = 13, age: mean 29, SD = 12) and adults with neurological conditions (n=20 stroke, n=16 multiple sclerosis, n=5 muscular dystrophy, n=1 spinal cord injury, n=1 traumatic brain injury; age: mean 54, SD=13). MAIN MEASURES: Individuals walked for 2 minutes at self-selected walking speeds (SSWS) wearing a pedometer. Healthy individuals were then asked to walk at slow walking speeds (SWS). Step counts were recorded manually and using a pedometer. RESULTS: In healthy individuals there was no difference between manually measured and pedometer counts during walking (P>0.05). In adults with neurological conditions the pedometers undercounted (P = 0.003); bias (random error): 27 (111); percentage variability 30% and intraclass correlation coefficient (ICC) 0.66. In neurological adults, from regression analysis the relationship between error and walking speed was cubic, with walking speed accounting for 29% of pedometer error. Healthy individuals showed greater variability and undercounting at SWS bias (random error): 10 (31), percentage variability 8% and ICC 0.73, compared with SSWS bias (random error): -3 (13), percentage variability 3% and ICC 0.84. CONCLUSIONS: Pedometers may undercount when used for people with neurological conditions. There may be variability in pedometer accuracy but this was not strongly related to walking speed. The suitability of pedometer use for exercise monitoring should be individually determined.

Somatosensory recovery: a longitudinal study of the first 6 months after unilateral stroke.

PURPOSE: The aim of this study was to characterize the recovery pattern of stroke patients in the first 6 months following stroke. METHOD: Using the Rivermead Assessment of Somatosensory Performance (RASP), the Motricity index and the Barthel Activities of Daily Living (ADL) index, a case series of serial somatosensory and motor measurements was made on 18 patients with a diagnosis of a first ever stroke. Patients comprised 2 distinct groups, acute and subacute. The acute group were seen weekly for the first month post onset and the subacute group were seen monthly for 6 months. Participants were seen at hospital, regional rehabilitation unit and/or the participant's home. Standard local rehabilitation was given. RESULTS: The somatosensory subtest of proprioception demonstrated the greatest level of recovery. No patient achieved full recovery on all somatosensory subtests. Motor and functional recovery demonstrated continual improvement over time, somatosensory recovery showed marked variation in subtests both within and between patients. CONCLUSION: Of the 18 patients tested there were no consistent, generalizable, recognizable patterns of sensory recovery demonstrated.

The Rivermead Assessment of Somatosensory Performance (RASP): standardization and reliability data.

OBJECTIVE: To develop a standardized, clinically relevant, quantitative assessment of somatosensory performance in patients with stroke. DESIGN: Prospective observational study and test evaluation. SETTING: Local Oxford hospitals and a regional neurological rehabilitation centre. SUBJECTS: Stroke patients with a first, lateralized acute stroke in hospital, and age-matched control subjects. METHOD: Each patient was assessed in a structured way using a new battery of formal tests of somatosensory performance. RESULTS: A total of 100 patients and 50 controls were fully investigated. Control subjects performed at or near ceiling on all tests, but patients showed impaired performance on all tests. The Rivermead Assessment of Somatosensory Performance (RASP) showed good intra-rater and inter-rater reliability for all subtests. There were however only weak relationships between scores of sensory impairment and scores of motor impairment or mobility and dependence. CONCLUSIONS: The RASP provides a practical and reliable assessment of sensory loss, which provides the clinician with a comprehensive picture of the patient's performance and can be used to inform and monitor rehabilitation and recovery.