Interventions for reducing sedentary behaviour in people with stroke

David H Saunders, Gillian E Mead, Claire Fitzsimons, Paul Kelly, Frederike van Wijck, Olaf Verschuren, Karianne Backx, Coralie English, David H Saunders, Gillian E Mead, Claire Fitzsimons, Paul Kelly, Frederike van Wijck, Olaf Verschuren, Karianne Backx, Coralie English

Abstract

Background: Stroke survivors are often physically inactive as well as sedentary,and may sit for long periods of time each day. This increases cardiometabolic risk and has impacts on physical and other functions. Interventions to reduce or interrupt periods of sedentary time, as well as to increase physical activity after stroke, could reduce the risk of secondary cardiovascular events and mortality during life after stroke.

Objectives: To determine whether interventions designed to reduce sedentary behaviour after stroke, or interventions with the potential to do so, can reduce the risk of death or secondary vascular events, modify cardiovascular risk, and reduce sedentary behaviour.

Search methods: In December 2019, we searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, Conference Proceedings Citation Index, and PEDro. We also searched registers of ongoing trials, screened reference lists, and contacted experts in the field.

Selection criteria: Randomised trials comparing interventions to reduce sedentary time with usual care, no intervention, or waiting-list control, attention control, sham intervention or adjunct intervention. We also included interventions intended to fragment or interrupt periods of sedentary behaviour.

Data collection and analysis: Two review authors independently selected studies and performed 'Risk of bias' assessments. We analyzed data using random-effects meta-analyses and assessed the certainty of the evidence with the GRADE approach.

Main results: We included 10 studies with 753 people with stroke. Five studies used physical activity interventions, four studies used a multicomponent lifestyle intervention, and one study used an intervention to reduce and interrupt sedentary behaviour. In all studies, the risk of bias was high or unclear in two or more domains. Nine studies had high risk of bias in at least one domain. The interventions did not increase or reduce deaths (risk difference (RD) 0.00, 95% confidence interval (CI) -0.02 to 0.03; 10 studies, 753 participants; low-certainty evidence), the incidence of recurrent cardiovascular or cerebrovascular events (RD -0.01, 95% CI -0.04 to 0.01; 10 studies, 753 participants; low-certainty evidence), the incidence of falls (and injuries) (RD 0.00, 95% CI -0.02 to 0.02; 10 studies, 753 participants; low-certainty evidence), or incidence of other adverse events (moderate-certainty evidence). Interventions did not increase or reduce the amount of sedentary behaviour time (mean difference (MD) +0.13 hours/day, 95% CI -0.42 to 0.68; 7 studies, 300 participants; very low-certainty evidence). There were too few data to examine effects on patterns of sedentary behaviour. The effect of interventions on cardiometabolic risk factors allowed very limited meta-analysis.

Authors' conclusions: Sedentary behaviour research in stroke seems important, yet the evidence is currently incomplete, and we found no evidence for beneficial effects. Current World Health Organization (WHO) guidelines recommend reducing the amount of sedentary time in people with disabilities, in general. The evidence is currently not strong enough to guide practice on how best to reduce sedentariness specifically in people with stroke. More high-quality randomised trials are needed, particularly involving participants with mobility limitations. Trials should include longer-term interventions specifically targeted at reducing time spent sedentary, risk factor outcomes, objective measures of sedentary behaviour (and physical activity), and long-term follow-up.

Trial registration: ClinicalTrials.gov NCT02731235 NCT01467206 NCT02712385 NCT02494245 NCT01070459 NCT01792349 NCT02798237 NCT01846247 NCT03507894 NCT00431821 NCT01763203 NCT04069767.

Conflict of interest statement

D Saunders: none known.

C Fitzsimons: Grants and contracts: (1) Programme grant to develop and evaluate strategies to reduce sedentary behaviour in patients after stroke and improve outcomes (ongoing until September 2024), National Institute for Health Research, (2) Research grant for a qualitative study to explore sedentary behaviour in stroke survivors and inform intervention development (completed), Chief Scientist Office of the Scottish Government, (3) Research grant for a feasibility study to explore how to provide feedback and remote monitoring to stroke survivors on their sedentary behaviour (completed), Edinburgh and Lothians Health Foundation.

P Kelly: none known.

C English: Author of one of the included studies (English 2016b) and was not included in screening, data extraction or analysis of the study.

O Verschuren: none known.

K Backx: none known.

F van Wijck: none known.

GE Mead: Grants and contracts: (1) Grant holder in a study of sedentary behaviour after stroke, Chief Scientist Office, Scottish Government, (2) Grant holder in RECREATE trial, NIHR UK. Royalties or licenses: (1) Course on exercise after stroke, Later life training, (2) Book on physical fitness training after stroke, Elsevier.