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Effects of Physical Activity on Balance, Cognitive Function, and Depression in Stroke Survivors
Other Title
Effects of Physical Activity on Balance, Cognitive Function, and Depression in Stroke Survivors
Type
thesis
Date Issued
2022-06-30
Author(s)
RENNY WULAN APRILIYASARI
Advisor
TSAI, PEI-SHAN
Subjects
系所名稱：護理學系博士班
Publisher
護理學系博士班
Description
口試委員：WANG, TSAE-JYY WANG, TSAE-JYY;TAN, MAW-PIN TAN, MAW-PIN;CHIU, HSIAO-YEAN CHIU, HSIAO-YEAN;HOU, WEN-HSUAN HOU, WEN-HSUAN;TSAI, PEI-SHAN TSAI, PEI-SHAN
開放校內, 開放日期為2022-07-22;校外, 開放日期為2027-07-22
開放校內, 開放日期為2022-07-22;校外, 開放日期為2027-07-22
Abstract
Background
Stroke is the leading cause of disability. Stroke survivors with physical impairments (e.g., balance performance) and neuropsychiatric impairments (e.g., cognitive dysfunction and depression symptoms) experience a meaningful impact on their functional independence, recovery, and quality of life. Physical impairments are the most prioritized area of research related to life after stroke. Important outcomes related to physical impairments include balance and walking problems. Previous systematic reviews have supported the a beneficial of proprioceptive exercise in improving motor function, balance, and functional ability among healthy and various disease populations. However, its effectiveness for people with stroke has never been assessed using a systematic review and meta-analysis. Therefore, there is a need to assess up-to-date evidence to determine the effectiveness of proprioceptive training on balance, gait, trunk control, and basic functional mobility in stroke survivors.
Another top priority related to life after stroke is cognitive function. Although the effectiveness of interventions that involve physical activity components for improving cognitive function in the elderly has been widely studied, there has been no systematic review summarizing the effects of interventions that have physical activity components on cognitive function in the stroke population.
Moreover, adequate physical activities are crucial for the psychological health of an individual with stroke. Physical activity could be a potential predictor of depressive symptoms. However, there have been conflicting results regarding the association between physical activity and poststroke depression. Most importantly, the association between physical activity and depression in the adult population with stroke in Indonesia has yet to be determined in a population-based study using nationwide data. To this end, determining whether meeting guidelines-recommended levels of physical activity is associated with a lower likelihood of depression among the Indonesian stroke population using a nationally representative sample is of clinical importance.
Objective
The specific aims of this dissertation were to: (1) investigate the effect of proprioceptive training on balance, gait, trunk control, and basic functional mobility in stroke survivors by conducting a meta-analysis of RCTs (study 1); (2) evaluate the effectiveness of physical activity-related interventions for improving cognitive function in stroke survivors by conducting a systematic review of RCTs (study 2); (3) conduct a secondary analysis of data from the 2018 Basic Health Research (Riset Kesehatan Dasar, RISKESDAS) to examine the association between physical activity and depression in Indonesian adults who reported having had a stroke (study 3).
Methods
In study 1, a systematic review and meta-analysis of randomized controlled trials was conducted. Searches of published articles in five electronic databases, including PubMed, Science Direct, Cochrane, Embase, and Medline, were performed from inception to July 26, 2021. Two reviewers independently screened the titles and abstracts of potentially eligible articles that were identified based on the search criteria. Methodological quality was determined using version 2 of the Cochrane risk of bias tool for randomized trials. Data were analyzed using Comprehensive Meta-Analysis software. The treatment effect was estimated by calculating Hedges' g and 95% confidence interval (CI) using a random-effects model. Statistical heterogeneity was assessed according to the I2 value. The primary outcome was balance performance, and secondary outcomes were trunk control, gait speed, and basic functional mobility.
In study 2, a systematic review of up-to-date evidence was conducted. We searched six electronic databases, namely PubMed, Cochrane, Embase, Medline Ovid, Scopus, and CINAHL, from inception to June 10, 2021. Studies that used a randomized controlled trial design and assessed the effects of an intervention that involved any type of physical activity were included.
In study 3, a cross-sectional study involving 3,234 adults with stroke based on the 2018 RISKESDAS data was conducted. Physical activity levels in metabolic equivalents (MET)-minutes per week averages were determined using the Global Physical Activity Questionnaire according to the World Health Organization (WHO) guidelines on physical activity and sedentary behavior recommendations. Depression was assessed using the Mini-International Neuropsychiatric Interview (MINI). Multivariate binomial logistic regression analysis was performed to calculate the odds ratio (OR) of depression in those who met the WHO recommendation of physical activity compared with those did not after adjustment for confounders.
Results
Study 1
We included 17 studies with 447 stroke patients. Proprioceptive training had a significant impact on balance (Hedges’ g = 0.69, 95% CI=0.36 to 1.01), gait speed (Hedges’ g = 0.57, 95% CI = 0.19 to 0.94), trunk control (Hedges’ g = 0.75, 95% CI = 0.33 to 1.17), and basic functional mobility (Hedges’ g = 0.63, 95% CI = 0.31 to 0.94) among stroke survivors.
Study 2
A total of 23 trials involving 1695 stroke survivors were included. Results from this review showed that physical activity-related interventions combined with cognitive training, acupuncture, or repetitive transcranial magnetic stimulation tend to have better results in improving cognitive function in stroke survivors compared with physical activity-related intervention alone.
Study 3
Adults with stroke who met the WHO recommendation of physical activity were significantly associated with lower odds of depression after adjustment for confounders (OR = 0.757, p = 0.017).
Conclusion
In stroke survivors, proprioceptive training was found to effectively improve motor functions, including balance performance, gait speed, trunk control, and basic functional mobility. Moreover, physical activity-related interventions in combination with cognitive training and or acupuncture or repetitive transcranial magnetic stimulation revealed beneficial effects for improving cognitive function. Lastly, performing physical activity according to the WHO recommendation is associated with a reduced likelihood of depression among Indonesian adults with stroke.
Stroke is the leading cause of disability. Stroke survivors with physical impairments (e.g., balance performance) and neuropsychiatric impairments (e.g., cognitive dysfunction and depression symptoms) experience a meaningful impact on their functional independence, recovery, and quality of life. Physical impairments are the most prioritized area of research related to life after stroke. Important outcomes related to physical impairments include balance and walking problems. Previous systematic reviews have supported the a beneficial of proprioceptive exercise in improving motor function, balance, and functional ability among healthy and various disease populations. However, its effectiveness for people with stroke has never been assessed using a systematic review and meta-analysis. Therefore, there is a need to assess up-to-date evidence to determine the effectiveness of proprioceptive training on balance, gait, trunk control, and basic functional mobility in stroke survivors.
Another top priority related to life after stroke is cognitive function. Although the effectiveness of interventions that involve physical activity components for improving cognitive function in the elderly has been widely studied, there has been no systematic review summarizing the effects of interventions that have physical activity components on cognitive function in the stroke population.
Moreover, adequate physical activities are crucial for the psychological health of an individual with stroke. Physical activity could be a potential predictor of depressive symptoms. However, there have been conflicting results regarding the association between physical activity and poststroke depression. Most importantly, the association between physical activity and depression in the adult population with stroke in Indonesia has yet to be determined in a population-based study using nationwide data. To this end, determining whether meeting guidelines-recommended levels of physical activity is associated with a lower likelihood of depression among the Indonesian stroke population using a nationally representative sample is of clinical importance.
Objective
The specific aims of this dissertation were to: (1) investigate the effect of proprioceptive training on balance, gait, trunk control, and basic functional mobility in stroke survivors by conducting a meta-analysis of RCTs (study 1); (2) evaluate the effectiveness of physical activity-related interventions for improving cognitive function in stroke survivors by conducting a systematic review of RCTs (study 2); (3) conduct a secondary analysis of data from the 2018 Basic Health Research (Riset Kesehatan Dasar, RISKESDAS) to examine the association between physical activity and depression in Indonesian adults who reported having had a stroke (study 3).
Methods
In study 1, a systematic review and meta-analysis of randomized controlled trials was conducted. Searches of published articles in five electronic databases, including PubMed, Science Direct, Cochrane, Embase, and Medline, were performed from inception to July 26, 2021. Two reviewers independently screened the titles and abstracts of potentially eligible articles that were identified based on the search criteria. Methodological quality was determined using version 2 of the Cochrane risk of bias tool for randomized trials. Data were analyzed using Comprehensive Meta-Analysis software. The treatment effect was estimated by calculating Hedges' g and 95% confidence interval (CI) using a random-effects model. Statistical heterogeneity was assessed according to the I2 value. The primary outcome was balance performance, and secondary outcomes were trunk control, gait speed, and basic functional mobility.
In study 2, a systematic review of up-to-date evidence was conducted. We searched six electronic databases, namely PubMed, Cochrane, Embase, Medline Ovid, Scopus, and CINAHL, from inception to June 10, 2021. Studies that used a randomized controlled trial design and assessed the effects of an intervention that involved any type of physical activity were included.
In study 3, a cross-sectional study involving 3,234 adults with stroke based on the 2018 RISKESDAS data was conducted. Physical activity levels in metabolic equivalents (MET)-minutes per week averages were determined using the Global Physical Activity Questionnaire according to the World Health Organization (WHO) guidelines on physical activity and sedentary behavior recommendations. Depression was assessed using the Mini-International Neuropsychiatric Interview (MINI). Multivariate binomial logistic regression analysis was performed to calculate the odds ratio (OR) of depression in those who met the WHO recommendation of physical activity compared with those did not after adjustment for confounders.
Results
Study 1
We included 17 studies with 447 stroke patients. Proprioceptive training had a significant impact on balance (Hedges’ g = 0.69, 95% CI=0.36 to 1.01), gait speed (Hedges’ g = 0.57, 95% CI = 0.19 to 0.94), trunk control (Hedges’ g = 0.75, 95% CI = 0.33 to 1.17), and basic functional mobility (Hedges’ g = 0.63, 95% CI = 0.31 to 0.94) among stroke survivors.
Study 2
A total of 23 trials involving 1695 stroke survivors were included. Results from this review showed that physical activity-related interventions combined with cognitive training, acupuncture, or repetitive transcranial magnetic stimulation tend to have better results in improving cognitive function in stroke survivors compared with physical activity-related intervention alone.
Study 3
Adults with stroke who met the WHO recommendation of physical activity were significantly associated with lower odds of depression after adjustment for confounders (OR = 0.757, p = 0.017).
Conclusion
In stroke survivors, proprioceptive training was found to effectively improve motor functions, including balance performance, gait speed, trunk control, and basic functional mobility. Moreover, physical activity-related interventions in combination with cognitive training and or acupuncture or repetitive transcranial magnetic stimulation revealed beneficial effects for improving cognitive function. Lastly, performing physical activity according to the WHO recommendation is associated with a reduced likelihood of depression among Indonesian adults with stroke.