+

Activity Levels And The Functional Outcomes Of

Patients Affected By Stroke At An Inpatient
Rehabilitation Center
By Veronica Valencia Victoria and Steven Franks
+ Literature Review
+
Literature Review
● Strokes are the most prevalent and disabling neurologic condition of adult
life.1

● According to the Centers for Disease Control and Prevention (CDC),

strokes are the fifth leading cause of death in the United States.2

● Strokes are characterized by brain cell death which can ultimately lead to
brain damage, long-term disability, and even death.2
+
Literature Review
● After the initial emergency management, inpatient rehabilitation is
recommended for survivors of stroke that meet certain criteria.3

● The average length of stay between the years of 2009 and 2011 was 8.9
days for mild patients, 13.9, for moderate patients, and 22.2 severely
impaired patients.4

● Some common impairments addressed by PT specifically at inpatient

rehabilitation centers include: weakness and loss of control, muscle
activation deficits, hypotonicity, spasticity, loss of alignment, pain, edema,
and shoulder subluxation.5
+
Literature Review
● In order to more accurately monitor progress and ascertain the efficacy of
stroke rehabilitation efforts, therapists use standardized instruments to
examine functional mobility skills, basic skills in activities of daily living
(ADL), instrumental ADL skills and functional disability.
●
● The most commonly used instrument at inpatient rehabilitation centers
throughout the nation is the Functional Independence Measure (FIM)6

● The Brief Inventory for Mental Status (BIMs) is a required short

performance-based cognitive screener.7
+
Literature Review
● There is extensive research providing evidence of the reduced patient
morbidity and improved likelihood of returning home that is associated
with inpatient rehabilitation for patients affected by stroke.8

● The specific mechanisms that lead to these overall improvements in patient

outcomes are still unclear.

● Increased levels of physical activity have been proposed as a possible

contributing factor
+
Literature Review
● Very few quantitative studies have been conducted to examine the amount
of physical activity in which patients affected by stroke partake during their
stay at inpatient rehabilitation centers.

● Previous behavioral mapping studies have shown that a large proportion of

the time spent by patients at stroke rehabilitation centers is spent inactive,
with little time spent in moderate to high level physical activities. 9

● Physical inactivity is not only a problem in the inpatient setting, as

evidence has shown that this physical inactivity may continue once the
patient has returned home. 10
+ Purpose
+
Purpose
● The purpose of this pilot study was to explore the outcome measures of
participants and to provide information about the current levels of activity
of patients affected by stroke at one inpatient rehabilitation centers.
●
● This is part of a larger, multi phase, longitudinal study, which has been
undertaken to track and analyze the activity levels of patients affected by
stroke at The Brookdale Center for Healthy Aging & Rehabilitation
(Brookdale) and correlate this to any of the functional outcome measures
used by the rehabilitation team at Brookdale
+ Methods
+
Participants
● Over a period of 3 months, patients admitted to Brookdale post stroke were
considered for this pilot study.
● The participant inclusion criteria included:
1) Patient admitted to Brookdale Center for Healthy Aging &
Rehabilitation with primary diagnosis of cerebrovascular accident
2) Medically cleared to participate in normal physical activity required in
inpatient rehabilitation
3) Able to walk greater than ten feet with no more than maximal assist of
one physical therapist
4) Patient treatment plan includes walking retraining,
5) Brief Inventory of Mental Status (BIMS) score greater than 7
+
Participants

● The exclusion criteria include the following:

1) Not medically cleared to participate in moderate activity and

2) Unable to walk without maximal assistance from one physical therapist.

+
Evaluation

● After consent into the study, research assistants equipped participants with
2 activity monitors:
○ CamNTech MotionWatch8 (Boerne, TX)
○ Fitbit Charge (San Francisco, CA).
● The Brookdale rehabilitation team also performed and collected scores for
the following functional measures:
○ TUG (also scored at discharge)
○ FIM (also scored at discharge)
○ BIMS
+
CamNtech MotionWatch8 FitBit Charge
+
Measures
● Participant data collected included: ● FitBit Charges collected data
○ Gender regarding steps taken.
○ Height ● MotionWatch8 collected data
○ Weight with time spent in:
○ BMI ○ Vigorous level activity
○ Age ○ Moderate level activity
● Also collected was: ○ Low level activity
○ Number and type of therapy
units
○ Length of Stay (LOS)
+
Data Collection
● Participants wore the activity monitors for seven days then research staff
removed the monitors, downloaded the data, and the activity monitors were
re-programed.
● This process took place every Tuesday until the patient was discharged.
● Once the participant was discharged, data from the activity monitors was
collected and downloaded to a laptop computer.
● Once the data was collected, it was tested for normality.
+
Procedure
1. Patient was admitted into Brookdale after experiencing a stroke.
2. The lead physical therapist discussed the study with patients and asked to participate.
3. If the patient was interested in participating, the patient received informed consent
form.
4. A member of the research team equipped the patient with the activity monitor.
5. The patient wore the activity monitor continuously for seven days, then the monitors
were removed, the data collected, and then the monitors were re-equipped.
6. Upon discharge, activity monitors were collected and data were downloaded from
monitors onto a laptop computer.
7. BIM, Stroke Type and demographic data was collected from participant’s medical
chart.
8. FIM and TUG scores were collected at time of admission and upon discharge.
9. Data was analyzed using Microsoft Excel (Redmond, WA) and SPSS (Chicago, IL).
+ Data Analysis
+
Data Analysis
● Data was analyzed using Microsoft Excel (Redmond, WA) and SPSS
(Chicago, IL).
● The functional outcome measures were performed at participant admission
(FIM and BIM) and discharge (FIM). The functional outcome measures
data was regarded as aggregate data.
● Data from the CamNTech Motion Watch 8 was collected and converted to
daily and weekly averages.
● Data from the FitBits was also converted to daily and weekly averages.
+ Results
+
Results
Participant Age LOS Gender Height Weight BMI Stroke Type BIM
(days) (m) (Kg) (Kg/m2)

1 86 16 Male 1.9 92.6 27.1 R frontal lobe 14

ischemic CVA

2 82 7 Female 1.6 62.1 25.9 Acute lacunar 15

ischemic infarcts in R
precentral gyrus and R
occipital lobe gyrus

4 81 18 Female 1.7 90.0 31.1 R parietal lobe infarct 10

5 58 15 Male 1.8 93.0 29.4 Acute ischemic infarct 15

involving posterior
limb of L internal
capsule
+
Results
Participant FIM @ FIM @ Change Avg. Avg. Avg. Avg.
Admin Discharge in FIM Vigorous Moderate Vigorous Moderate
Activity / Activity / Activity / Activity /
Day (min) Day (min) Week Week
(min) (min)

1 68 107 39 13.3 62.9 186 440

2 87 113 26 46.8 112.3

4 53 89 36 29.58 69.97 213.5 511.25

5 69 105 36 172.7 165.23 1308 1159.5

+
Results
Participant FIM @ Admin. FIM @ Change in FIM Avg. Steps Per
Discharge Day

1 68 107 39 964.26

2 87 113 26 1135.83

4 53 89 36 425.5

5 69 105 36 4311.67
+
Results
Participant Change in FIM Total PT (min) Total OT (min) Total ST (min)

1 39 1290 1110 465

2 26 655 510 310

4 36 895 1080 870

5 36 840 1050 1728

+ Discussion
+
Discussion
● This pilot study aimed to explore the trends between patient activity level
and scores on functional outcome measures.
● The American College of Sports Medicine (ACSM) recommends a
frequency of 5 days per week of moderate intensity aerobic activity or 3
days per week of vigorous intensity for adults. Duration recommendations
are 30 to 60 minutes per day of moderate intensity (≥ 150 minutes per
week) or 20 to 60 minutes per day of vigorous intensity (≥ 75 minutes per
week).11
● This duration can be broken up throughout the day in at least 10-minute
bouts of exercise. In addition, ACSM guidelines recommend a volume of
steps per day between 5400 to 7900 steps.11
+
Discussion
● Our results showed that our patients met total physical activity
recommendations but did not perform any bouts longer than 10 minutes.
●
● The Motion Watch 8 contains an accelerometer that provides details on
physical activity spikes throughout the participants days.12
●

● For example, on day three, participant 4 spent nearly 90 total minutes

performing moderate level physical activity, but did not perform a single
continuous bout of 10 minutes or more.
+
Discussion

● A possible reason for not achieving 10 minute bouts, is that the subacute
stroke population require more frequent rest breaks due to elevated energy
costs with movement following stroke.13
● The average FIM score upon admission was 69.25 and the total possible
score of the FIM achievable is 126. Thus, the participants of this study
scored at 54.9%. The low admission scores on the FIM relate to lower
physical function and inability to participate in higher levels of physical
activity for prolonged periods of time.
+
Discussion
● Within the American Heart Association’s Guidelines for Adult Stroke
Rehabilitation and Recovery published in 2016, it was reported that the
LOS for patients with stroke in an inpatient rehabilitation facility was on
average 15 days, with a range of 8 to 30 days.14

● The participants of this study had an average LOS of 14 days with a range
of 7 to 18 days, which is on par with a study utilizing a much larger sample
size.
+ Limitations
+
Limitations

● The small sample size of 4 participants.

● Multiple days of missing data collected from FitBits regarding daily steps
taken.
● Missing functional outcomes data.
+ Conclusion
+
Conclusion
● Higher levels of activity have been thought to correlate with better
functional outcomes and a shorter LOS in the inpatient rehabilitation
setting.
● Conclusions drawn from the results of this study are limited.
● However, the results of this study showed a trend that a longer LOS was
associated with greater changes in FIM scores.
● In addition to a longer LOS, those who had the greatest positive changes in
FIM scores also received the most total minutes of therapy.
+
Conclusion
● Further research, with larger sample sizes, is necessary in order to further
evaluate the correlation between activity levels and outcome measures.
● Future studies should also focus on the correlation between functional
outcomes and type of therapy received.
● In addition, more research can help to determine whether
moderate-to-vigorous PA in less than 10-minute bouts provides health
benefits to stroke survivors.
● As shown by this study, the use of activity monitors is a practical medium
to measure activity levels, in order to provide more insight about the
mechanisms for recovery at inpatient rehabilitation centers.
+ References
+
References
8. Egerton T, Maxwell DJ, Granat MH. Mobility activity of stroke patients during inpatient rehabilitation. Hong Kong
Physiotherapy Journal. 2006. 24(1):8–15. doi:10.1016/s1013-7025(07)70003-9.

9. West T, Bernhardt J. Physical activity in Hospitalised stroke patients. Stroke Research and Treatment. 2012:1–13.
doi:10.1155/2012/813765

10. Persson CU, Hansson P, Lappas G, Danielsson A. Physical activity levels the first year after stroke. Physiotherapy.
2015;101:e1198. doi:10.1016/j.physio.2015.03.2124.

11. American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. 9th ed. Lippincott
Williams & Wilkins, 2014: 166–178, 208.

12. MotionWatch 8 Overview. camntech.com.

https://www.camntech.com/products/motionwatch/motionwatch-8-overview. Accessed April, 10, 2018.

13. Billinger SA, Arena R, Bernhardt J, et al. Physical Activity and Exercise Recommendations for Stroke Survivors: a
Statement for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke.
2014; 45(8), 2532-2553. http://stroke.ahajournals.org/content/45/8/2532. Accessed March 29, 2018.
+
References
1. Carr JH, Shepherd RB. Stroke rehabilitation - guidelines for exercise and training to optimize motor skill. Edinburgh: Elsevier
Health Sciences; 2002:3–15.

2. Centers for Disease Control and Prevention. Stroke information. https://www.cdc.gov/stroke/. Accessed June 25, 2016.

3. Dobkin BH. Rehabilitation after stroke. N Engl J Med. 2005;352(16):1677–1684. doi:10.1056/nejmcp043511

4. Camicia M, Wang H, DiVita M, Mix J, Niewczyk P. Length of stay at inpatient rehabilitation facility and stroke patient
outcomes. Rehabil Nurs. 2015;41(2):78–90. doi:10.1002/rnj.218

5. Umphred DA, Lazaro RT, Lazaro OT. Neurological Rehabilitation. 5th ed. Roller M, Burton GU, eds. Philadelphia, PA, United
States: Elsevier Health Sciences; 2006:711–752.

6. Sullivan JE, Crowner BE, Kluding PM, et al. Outcome measures for individuals with stroke: Process and recommendations from
the American physical therapy association Neurology section task force. Phys Ther. 2013;93(10):1383–1396.
doi:10.2522/ptj.20120492

7. Saliba D, Buchanan J, Edelen MO, et al. MDS 3.0: Brief interview for mental status. J Am Med Dir Assoc; 2012; 13(7):611-7.
+
References
14. Winstein CJ, Stein J, Arena R, et al. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for
Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke. 2016; 47(6): e45.
https://www.aan.com/Guidelines/Home/GetGuidelineContent/744. Accessed March 22, 2018.