training)  that differ from the present systematic review that includes studies of the effectiveness of any type of intervention increasing physicalactivity.
Nevertheless, no systematic reviews have focused on the efficacy of any type of interventions aiming at improving physicalactivity of individuals with stroke. Only 2 systematic reviews on this subject were found. However, the interventions were specific: one study targeted methods such as counseling, advice, or behavioral change, with or without exercises, while focusing on increasing physicalactivity ; whereas the other focused on problem-solving, goal-setting, decision-making, self-monitoring, coping strategies, or other interventions to facilitate behavioral change, aiming at improving physicalactivity . The strengths of these 2 reviews were that, they followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines [13,14], and included various types of study designs. However, both reviews had strict inclusion criteria, such as follow-ups for above 3 months  and included community-dwelling individuals for the research , which might have prevented the inclusion of important trials. Among these reviews, 5 of the 11 studies (in the first review) , while 3 of the 5 studies (in the second review) , reported significant improvements inphysicalactivityafter tailored counseling  and self- management programs . However, because of the high risk of bias involved with the included studies that potentially impacted the strength of the conclusions; the authors of both the reviews stated that, the interpretation of the efficacy of the investigated interventions investigated is limited [11,12]. In addition, since the interventions were specific, other strategies, such as aerobic training, were not considered. Hence, the overall efficacy of different interventions aimed at improving physicalactivityinindividuals with stroke remained uncertain. Therefore, the objective of this systematic review was to identify which interventions have been employed for increasing physicalactivity of individuals with stroke and to evaluate their efficacy. Furthermore, the ultimate goal was to identify the gaps in the literature so far, to facilitate the planning and development of future studies.
After a stroke, a low level of physicalactivity contributes to several secondary physical and psychological disorders, including poor health-related quality of life . Being involved with personally meaningful activities, such as community-based activities , is essential for life satisfaction . A person capacity to go into the community is commonly predicted by walking speed [2,4]. After a stroke however, there is often a discrepancy between what a person can do (motor capacity, such as clinical walking speed tests) and what a person actually does (motor performance) during the day [5,6]. The number of steps individuals take during the day is a good indicator of community-based activities and walking performance [7,8], and thus informs clinicians about the related physical and psychological components of health [1,9]. Healthcare professionals and researchers need precise devices, evaluated by well-defined protocols, to assess and inquire on walking performance in the community. Ideally, the devices should be precise regardless of the individuals’ sensorimotor and functional levels of deficit, which are heterogeneous among post- strokeindividuals .
Social support, a potential correlate of leisure time physical ac- tivity (LTPA), can broadly be defined as resources provided by other persons. 3 It is a multidimensional concept; emotional sup- port provides love and caring, whereas practical support provides tangible assistance with a task or goal. 3 Lack of social support has repeatedly been associated with higher morbidity and mortality. 4,5 It is possible that part of this relationship is attributable to the association between social support and LTPA, mental health being a plausible intermediary factor. For example, social ties and inte- gration in social networks play a role in the maintenance of psy- chological well-being, which in turn might motivate self-care inindividuals, including regular physical exercise. 6 High levels of social support are also assumed to increase self-esteem, self-efficacy and perceptions of control over the environment, 7 all of which can
Individuals post-stroke have activity limitations related to various locomotor 35
impairments, such as reduced walking speed (Balaban & Tok, 2014; Richards et al., 2015), asymmetrical gait pattern (Balaban et al., 2014; Patterson et al., 2008), and static (Tasseel- Ponche et al., 2015) and dynamic balance deficits (Kao et al., 2014; Nott et al., 2014). Post- stroke gait is less stable during the paretic stance phase as revealed by the alteration of the displacements of the centre of pressure under the paretic foot (Chisholm et al., 2011) or the 40
Conclusions: Although this study is limited by a small sample size, our results showed that energy expenditure and physicalactivitylevels can be easily monitored during everyday life using the ambu- latory SenseWear Armband TM system. This device still needs to be fully validated in PD but it opens interesting perspectives to monitor sustained motor effects after therapeutic interventions including a physical reconditioning program. In this case, the aerobic triangular test may also be indicated for longitudinal follow up.
assessments remain accurate despite changes in technology (30). Although selected schools included a mix of schools serving students with differing sociodemographic profiles, the results of this study may not be generalizable to adolescents in other populations. For example, 92% of participants were born in Canada, and it is possible that PA and screen time levels differ among students born in other countries. The results would likely also generalize to students in urban settings but less so to rural settings where the opportunities for PA may differ. Students living in rural areas could manifest different PA or screen time trajectories over the course of adolescence. Our examination of the association between PA and screen time did not consider covariates (other than sex) or potential confounders. Finally, the group- based trajectory modeling method has limitations - PA and screen time groups only provide an approximation of a more complex underlying reality of the two behaviours (31). While GBTM offers a convenient method to summarize longitudinal patterns identified in a dataset, it does not necessarily imply that these trajectories constitute real entities that individuals do not deviate from.
Among these general effects, the central one is obviously the substantial increase in exercise tolerance, which is the exact response expected from a training program built on pathophysiological bases. By using individualized training programs, it is possible to induce better aerobic fitness ( V! O 2 max and VTh) in asthmatics (Ahmaidi, Varray, Savy-Pacaux, & Prefaut, 1993; Varray, Mercier, Terral, & Prefaut, 1991) and patients with COPD, although with a lower magnitude in this population (Vallet et al., 1994). The improvement in VTh means that the ventilatory requirement is lowered at submaximal intensities, since the moment of an exponential increase in ventilation is delayed. In addition, several studies have shown ventilatory savings in asthmatics for any exercise intensity (Hallstrand, Bates, & Schoene, 2000; Varray, Mercier, & Prefaut, 1995) and in COPD patients for heavy exercise workloads (Vallet et al., 1997). As mentioned in the pathophysiological section, these results are of prime importance, since the dyspnea will be reduced for any given exercise intensity and thus the dyspnea feeling is lessened. More specifically, in asthmatics, this represents a decreased risk of EIB and the possibility of reduced heart-lung interactions. Another very interesting finding is that after training, the breathing pattern is modified with a systematic decrease in breathing frequency for a given ventilation level in both populations. This means that alveolar ventilation will be higher for a given ventilatory flow, reflecting a decrease in dynamic hyperinflation in asthmatics (Ramazanoglu & Kraemer, 1985) and COPD patients (Porszasz et al., 2005). Thus by changing the breathing pattern, the main ventilatory effects are maximized.
Non-pharmacological treatment Physical therapy
The basic treatment for all patients presenting spasticity is physical therapy [73, 74]. Limiting muscle contractures and reducing hyperactivity for at least a short period of time can be helpful. The aim of stretching is to improve the viscoelastic properties of the muscle-tendon unit and to increase its extensibility. Other structures can also be put under tension, such as tendons or connective, vascular, dermal or neural tissue [75, 76]. There is, however, no consensus about the optimal frequency, intensity, velocity and duration of stretch- ing. A recent systematic review of the effectiveness of stretching to treat and prevent contracture in patients with brain injuries concluded that stretching does not induce significant changes in joint mobility, pain, spasticity or activity limitation . Casting, a stretching method that immobilizes the limb in a stretch position, induces prolonged muscle stretching. This technique aims to improve muscle length, increase joint range of motion and to reduce contrac- ture, pain and spasticity . There are no guidelines yet, nor any scientific evidence that this method can reduce spasticity caused by neurological disorders . Beside muscle stretching, muscle strength training is also used to recover functional motricity . One of the most widely used approaches is the Progressive Resistance Strength Training, although, at this time, there is no gold standard for strengthening protocols .
- Booth, S.L., Sallis, J.F., Ritenbaugh, C., Hill, J.O., Birch, L.L., Franck, L.D., Glanz, K., Himmelgreen, D.A., Mudd, M., Popkin, B.M., Rickard, K.A., Jeor, S.ST, Hays, N.P. (2001). Environmental and Societal Factors Affect Food Choice and PhysicalActivity: Rationale, Influences, and Leverage Points. Nutrition Reviews, 59, 3, 21-39. - American College of Sports Medicine, Nike, International Council of Sports
by t- and χ 2 tests. MIXED linear models were used to predict insulin sensitivity, adjusted for age
classes (<40, 40-49, ≥ 50 years) and for recruitment centre as a random factor, and for gender when men and women were combined. Mean insulin sensitivity (95% confidence interval) is shown according to evenly spaced classes of total activity, percent time sedentary, and activity intensity, and tested for linear trends. Beta coefficients quantify the relations between insulin sensitivity and activity variables; additional adjustments were made for other activity variables and for potential confounding factors (BMI, waist, fasting glucose, alcohol intake, smoking, diabetes in family, menopause). The relations between insulin sensitivity and activity variables were linear, as
Conclusions—These preliminary findings suggest that CVR heterogeneities may account for task-related BOLD signal
changes in patients afterstroke. (Stroke. 2005;36:1146-1152.)
Key Words: hyperventilation 䡲 magnetic resonance imaging, functional 䡲 motor activity 䡲 stroke, ischemic
T o investigate mechanisms of recovery and cortical reor- ganization related to stroke, functional magnetic reso- nance imaging (fMRI) has become a widely used noninvasive neuroimaging technique based on blood oxygen level- dependent (BOLD) signal. Although the neurovascular cou- pling remains incompletely understood, several studies per- formed in steady-state animal preparations and in healthy human volunteers reported a linear relationship between neural activity and the BOLD signal. 1 However, the hemo-
Hardman, K., & Marshall, J. (2000). The State and Status of Physical Education in Schools in International Context. European Physical Education Review, 6, 3, 203-229.
Hardman, K. (2005). Rhetoric and reality school physical education in Europe: The evidence of research. In, F. Carreiro da Costa, M. Cloes & M. Gonzalez Valeiro (Eds.), The art and science of teaching inphysical education and sport. A homage to Maurice Piéron (pp.63-87) . Cruz Quebrada, Portugal: Faculdade de Motricidade Humana.
Stroke Research and Treatment 7
study population is not representative of stroke patients. The inclusion criteria used in the STROKDEM cohort had led to the inclusion of patients with mild neurological deficits. In fact, only one-third of our sample had residual focal deficits at 6 months. Therefore, results cannot be generalized to patients with more severe strokes. Second, our sample size was limited and this could partly explain negative results. We cannot exclude that some associations could have been overlooked due to the lack of adequate statistical power to detect small effects. This is particularly true for antidepressant and antihypertensive drugs: the association between presence of PSF and these categories of treatment was not significant but there was a tendency for more severe fatigue in patients receiving antidepressant or antihypertensive drugs (when analyzing CFS score as a continuous variable). In a posterior power calculation, we calculated the smallest significant between-group difference (expressed as effect size using odd ratio) that our study sample size (81 patients with PSF and 72 without) allowed us to detect with a 80% power. Assuming an exposure prevalence of 20% and 40% in patients without PSF, we could, respectively, detect an OR of 2.74 and 2.49. Third, due to a limited sample size of our cohort and the absence of conclusive evidence in the literature of an association between PSF and lesion site [23, 59], we decided to consider three groups for stroke location (right hemispheric, left hemispheric, and posterior fossa lesions). We did not find any relationship between stroke location and PSF. Moreover, evaluating the influence of stroke lesion on PSF at month 6 was not the scope of our study, whose aim was to evaluate potential relationship between PSF and medication use. There is, from our point of view, no background supporting the idea that this relationship could be modified by stroke location. Finally, in this study, fatigue was not evaluated before stroke and at the acute phase afterstroke. As a consequence, we do not have data concerning the time at which fatigue has occurred. This leads to the impossibility to build up a real causality relationship between PSF and medication use. However, the STROKDEM study aims to assess long term cognitive and behavioral outcomes afterstroke: our patients are currently followed-up (at 1, 3, and 5 years), which will allow an evaluation of the influence of treatments on persistent fatigue.
The reliability of MR results relies on 3 main assumptions (data available from Open Science Framework, ﬁgure e-1, osf. io/b57sq/), which can be violated by population stratiﬁcation, canalization, and pleiotropy. Population stratiﬁcation was minimized because we restricted the study populations to European-descent individuals. We could not directly test whether canalization may have inﬂuenced the results. Cana- lization refers to compensatory processes during development that alleviate the genetic eﬀect. Such feedback mechanisms would bias the results toward the null and cannot explain the observed association between serum magnesium concentra- tion and cardioembolic stroke. Pleiotropy occurs when a ge- netic variant is associated with more than one phenotype. We conducted several sensitivity analyses to explore and adjust for pleiotropy. The association of genetically predicted serum magnesium concentrations with cardioembolic stroke, but not the other subtypes or overall stroke, was robust in these sensitivity analyses and the MR-Egger analysis provided no evidence of directional pleiotropy.
Since 1990 to nowadays, few studies focused on the effects of interventions for preventing falls in people afterstroke, and among them, few were randomized controlled trials (which is a main condition to compare interventions). Since the last systematic review published on the topic in 2013, about 30 new studies may be found in international databases. An update was necessary. We found 12 articles, from which we analyzed 8 which had a sufficient quality score (≥10/20). Two studies reported effectiveness on secondary criteria: the dual task program reducing number of injurious falls (12) and a multifactorial fall prevention program which reduced the rate of falls for participants who totally adhered to the intervention (19). Most of studies reported non-significant results. We analyzed the possible influence of biases on this relatively negative result, using the Cochrane risk of bias tool (Higgins & Green, 2011).
Our findings with respect to body fat % are consistent with the majority of observational studies on physicalactivity and adiposity in youth, which report a protective, albeit weak relationship (18-20, 57, 58). Moreover, like others (33, 39, 59), we observed stronger and more consistent relationships when using body fat % rather than BMI as the indicator of adiposity. Our results on BMI may exemplify that this indicator is a poor marker of change in adiposity in adolescent populations. Although BMI is strongly associated with body fat, children and adolescents in particular can have a wide range of body fat % for a given BMI value (37), and variations in BMI within general pediatric populations are largely due to differences in lean mass (60). Thus, the counterintuitive positive association between physicalactivity and BMI observed in this study may reflect loss of muscle mass subsequent to dropping high intensity activities. This is possible since participation in each specific sports decline in this population over time, and vigorous intensity sports are the least likely to be sustained (61).
NIHSS Day 1: NIHSS at admission; HAD: Hospital Anxiety and Depression scale; Spatial WM Owen’s test: spatial working memory Owen’s test
Interpretation of odds ratios in ordinal logistic regression is close to binary logistic regression. For example, for an increase of 1 point in the NIHSS going from 0 to 1, the odds from a lower WSAS category compared with a higher category are changed by a factor 1.17, holding all other variables constant. We tested a possibility of interaction between Owen’s SWM and the level of education in the ordinal logistic model. The interaction did not reach statistical significance (P=0.09), the patients with a low level of education were more severely affected than those with a high level.
J EREMY B ONNI & M ARC C LOES , U NIVERSITY OF L IEGE
The reform of education, which the Wallonia-Brussels Federation (FWB – French speaking part of Belgium) is about to introduce, directly affects the training of teachers. In the framework of the new core curriculum required in the “Pact for Excellence in Education” (PEE) and, more specifically, in the field of “Physical Activities, Wellness and Health”, the implementation of actions in health education should indeed, like it is found in other countries (Canada, Scotland, etc.), be instituted and strengthened in school curricula. A group of experts from the 12 French-speaking institutions responsible for training teachers inphysical education (universities and colleges) has been mandated by the Ministry of Education to identify, design and share teaching devices and tools for implementation of the new common core of the PEE.
Discussion and further work
PA determinants identified by physiotherapists were similar to the findings proposed by the “Eurobarometer study” (Sjöström, 2006). Their intervention must be adapted to these motivational variables in order to mobilize appropriate promoting strategies at each level of action (OMS, 2006).
Physiotherapists are aware of their crucial role in PA promotion. Nevertheless, this responsibility is implicit and so far little used and implemented in the field. The establishment of specific trainings, dealing with physicalactivity promotion aiming at informing physiotherapists, might be an interesting step which should be easily organized.