Review article (meta-analysis)| Volume 99, ISSUE 9, P1876-1889, September 2018

Factors Associated With Post-Stroke Physical Activity: A Systematic Review and Meta-Analysis

Published:October 19, 2017DOI:



      To integrate the literature investigating factors associated with post-stroke physical activity.

      Data Sources

      A search was conducted from database inception to June 2016 across 9 databases: Cochrane, MEDLINE, ProQuest, Web of Science, PsycINFO, Scopus, Embase, CINAHL, and Allied and Complementary Medicine Database. The reference lists of included articles were screened for secondary literature.

      Study Selection

      Cohort and cross-sectional studies were included if they recruited community-dwelling stroke survivors and measured factors associated with physical activity.

      Data Extraction

      Risk of bias was evaluated using the Quality in Prognosis Studies checklist. A meta-analysis was conducted for correlates where there were at least 2 studies that reported a correlation value. Correlation values were used in an effect size measure and converted to a standardized unit with Fisher r to z transformation and conversion back to r method. Results were described qualitatively for studies that could not be pooled.

      Data Synthesis

      There were 2161 studies screened and 26 studies included. Age (meta r=−.17; P≤.001) and sex (meta r=−.01; P=.02) were the nonmodifiable factors that were found to be associated with post-stroke physical activity. The modifiable factors were physical function (meta r=.68–.73; P<.001), cardiorespiratory fitness (meta r=.35; P≤.001), fatigue (meta r=−.22; P=.01), falls self-efficacy (meta r=−.33; P<.001), balance self-efficacy (meta r=.37; P<.001), depression (meta r=−.58 to .48; P<.001), and health-related quality of life (meta r=.38–.43; P<.001). The effect of side of infarct, neglect, and cognition on post-stroke physical activity was inconclusive.


      Age, sex, physical function, depression, fatigue, self-efficacy, and quality of life were factors associated with post-stroke physical activity. The cause and effect of these relations are unclear, and the possibility of reverse causality needs to be addressed.


      List of abbreviations:

      6MWT (6-minute walk test), BBS (Berg Balance Scale), CI (confidence interval), ES (effect size), FSS (Fatigue Severity Scale), HRQOL (health-related quality of life), MMSE (Mini-Mental State Examination), MoCA (Montreal Cognitive Assessment)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Mendis S.
        Stroke disability and rehabilitation of stroke: World Health Organization perspective.
        Int J Stroke. 2013; 8: 3-4
        • Scherbakov N.
        • Doehner W.
        Sarcopenia in stroke—facts and numbers on muscle loss accounting for disability after stroke.
        J Cachexia Sarcopenia Muscle. 2011; 2: 5-8
        • Hafer-Macko C.E.
        • Ryan A.S.
        • Ivey F.M.
        • Macko R.F.
        Skeletal muscle changes after hemiparetic stroke and potential beneficial effects of exercise intervention strategies.
        J Rehabil Res Dev. 2008; 45: 261
        • Borschmann K.
        • Pang M.Y.
        • Bernhardt J.
        • Iuliano-Burns S.
        Stepping towards prevention of bone loss after stroke: a systematic review of the skeletal effects of physical activity after stroke.
        Int J Stroke. 2012; 7: 330-335
        • Pang M.Y.
        • Charlesworth S.A.
        • Lau R.W.
        • Chung R.C.
        Using aerobic exercise to improve health outcomes and quality of life in stroke: evidence-based exercise prescription recommendations.
        Cerebrovasc Dis. 2013; 35: 7-22
        • Kernan W.N.
        • Ovbiagele B.
        • Black H.R.
        • et al.
        Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2014; 45: 2160-2236
        • Morris J.H.
        • Oliver T.
        • Kroll T.
        • Joice S.
        • Williams B.
        From physical and functional to continuity with pre-stroke self and participation in valued activities: a qualitative exploration of stroke survivors', carers' and physiotherapists' perceptions of physical activity after stroke.
        Disabil Rehabil. 2015; 37: 64-77
        • Ashe M.C.
        • Miller W.C.
        • Eng J.J.
        • Noreau L.
        Older adults, chronic disease and leisure-time physical activity.
        Gerontology. 2009; 55: 64-72
        • Gebruers N.
        • Vanroy C.
        • Truijen S.
        • Engelborghs S.
        • De Deyn P.P.
        Monitoring of physical activity after stroke: a systematic review of accelerometry-based measures.
        Arch Phys Med Rehabil. 2010; 91: 288-297
        • Caspersen C.J.
        • Powell K.E.
        • Christenson G.M.
        Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research.
        Public Health Rep. 1985; 100: 126-131
        • English C.
        • Manns P.J.
        • Tucak C.
        • Bernhardt J.
        Physical activity and sedentary behaviors in people with stroke living in the community: a systematic review.
        Phys Ther. 2014; 94: 185-196
        • Field M.J.
        • Gebruers N.
        • Shanmuga Sundaram T.
        • Nicholson S.
        • Mead G.
        Physical activity after stroke: a systematic review and meta-analysis.
        ISRN Stroke. 2013; 2013: 1-13
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        Ann Intern Med. 2009; 151: 264-269
        • Booth A.
        • Clarke M.
        • Dooley G.
        • et al.
        The nuts and bolts of PROSPERO: an international prospective register of systematic reviews.
        Syst Rev. 2012; 1: 1-9
        • Hayden J.A.
        • van der Windt D.A.
        • Cartwright J.L.
        • Côté P.
        • Bombardier C.
        Assessing bias in studies of prognostic factors.
        Ann Intern Med. 2013; 158: 280-286
        • Field A.P.
        Meta-analysis of correlation coefficients: a Monte Carlo comparison of fixed- and random-effects methods.
        Psychol Methods. 2001; 6: 161-180
        • Fisher R.A.
        Statistical methods for research workers.
        14th ed. Oliver and Boyd, Edinburgh1970
        • Hedges L.V.
        • Olkin I.
        Statistical methods for meta-analysis.
        Academic Press, Orlando1985
        • Greenland S.
        • Pearl J.
        • Robins J.M.
        Causal diagrams for epidemiologic research.
        Epidemiology. 1999; 10: 37-48
        • Krenn P.J.
        • Titze S.
        • Oja P.
        • Jones A.
        • Ogilvie D.
        Use of global positioning systems to study physical activity and the environment: a systematic review.
        Am J Prev Med. 2011; 41: 508-515
        • Portney L.
        • Watkins M.
        Foundations of clinical research: applications to practice.
        3rd ed. Pearson, New York2009
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        Int J Surg. 2010; 8: 336-341
        • Manns P.J.
        • Tomczak C.R.
        • Jelani A.
        • Cress M.E.
        • Haennel R.
        Use of the continuous scale physical functional performance test in stroke survivors.
        Arch Phys Med Rehabil. 2009; 90: 488
        • Manns P.J.
        • Tomczak C.R.
        • Jelani A.
        • Haennel R.G.
        Oxygen uptake kinetics: Associations with ambulatory activity and physical functional performance in stroke survivors.
        J Rehabil Med. 2010; 42: 259
        • Michael K.
        • Macko R.F.
        Ambulatory activity intensity profiles, fitness, and fatigue in chronic stroke.
        Top Stroke Rehabil. 2007; 14: 5-12
        • Fulk G.D.
        • Reynolds C.
        • Mondal S.
        • Deutsch J.E.
        Predicting home and community walking activity in people with stroke.
        Arch Phys Med Rehabil. 2010; 91: 1582-1586
        • Fini N.A.
        • Holland A.E.
        • Keating J.
        • Simek J.
        • Bernhardt J.
        How is physical activity monitored in people following stroke?.
        Disabil Rehabil. 2015; 37: 1717-1731
        • Michael K.M.
        • Allen J.K.
        • Macko R.F.
        Reduced ambulatory activity after stroke: the role of balance, gait, and cardiovascular fitness.
        Arch Phys Med Rehabil. 2005; 86: 1552
        • Mudge S.
        • Stott N.S.
        Timed walking tests correlate with daily step activity in persons with stroke.
        Arch Phys Med Rehabil. 2009; 90: 296-301
        • Macko R.F.
        • Haeuber E.
        • Shaughnessy M.
        • et al.
        Microprocessor-based ambulatory activity monitoring in stroke patients.
        Med Sci Sports Exerc. 2002; 34: 394-399
        • Paul L.
        • Brewster S.
        • Wyke S.
        • et al.
        Physical activity profiles and sedentary behaviour in people following stroke: a cross-sectional study.
        Disabil Rehabil. 2016; 38: 362-367
        • Rand D.
        • Eng J.I.
        • Tang P.F.
        • Jeng J.S.
        • Hung C.
        How active are people with stroke? Use of accelerometers to assess physical activity.
        Stroke. 2009; 40: 163-168
        • Robinson C.A.
        • Noritake Matsuda P.
        • Ciol M.A.
        • Shumway-Cook A.
        Participation in community walking following stroke: the influence of self-perceived environmental barriers.
        Phys Ther. 2013; 93: 620-627
        • Rand D.
        • Eng J.J.
        • Tang P.F.
        • Hung C.
        • Jeng J.S.
        Daily physical activity and its contribution to the health-related quality of life of ambulatory individuals with chronic stroke.
        Health Qual Life Outcomes. 2010; 8: 80
        • Robinson C.A.
        • Shumway-Cook A.
        • Ciol M.A.
        • Kartin D.
        Participation in community walking following stroke: subjective versus objective measures and the impact of personal factors.
        Phys Ther. 2011; 91: 1865-1876
        • Robinson C.A.
        • Shumway-Cook A.
        • Matsuda P.N.
        • Ciol M.A.
        Understanding physical factors associated with participation in community ambulation following stroke.
        Disabil Rehabil. 2011; 33: 1033-1042
        • Salbach N.M.
        • Brooks D.
        • Romano J.
        • Woon L.
        • Dolmage T.E.
        Cardiorespiratory responses during the 6-minute walk and ramp cycle ergometer tests and their relationship to physical activity in stroke.
        Neurorehabil Neural Repair. 2014; 28: 111
        • Shaughnessy M.
        • Michael K.M.
        • Sorkin J.D.
        • Macko R.F.
        Steps after stroke: capturing ambulatory recovery.
        Stroke. 2005; 36: 1305-1307
        • Vahlberg B.
        • Cederholm T.
        • Lindmark B.
        • Zetterberg L.
        • Hellström K.
        Factors related to performance-based mobility and self-reported physical activity in individuals 1-3 years after stroke: a cross-sectional cohort study.
        J Stroke Cerebrovasc Dis. 2013; 22: 426-434
        • Zalewski K.R.
        • Dvorak L.
        Barriers to physical activity between adults with stroke and their care partners.
        Top Stroke Rehabil. 2011; 18: 666-675
        • Teixeira-Salmela L.F.
        • Devaraj R.
        • Olney S.J.
        Validation of the human activity profile in stroke: a comparison of observed, proxy and self-reported scores.
        Disabil Rehabil. 2007; 29: 1518-1524
        • English C.
        • Healy G.N.
        • Coates A.
        • Lewis L.K.
        • Olds T.
        • Bernhardt J.
        Sitting time and physical activity after stroke: physical ability is only part of the story.
        Top Stroke Rehabil. 2016; 23: 36-42
        • French M.A.
        • Moore M.F.
        • Pohlig R.
        • Reisman D.
        Self-efficacy mediates the relationship between balance/walking performance, activity, and participation after stroke.
        Top Stroke Rehabil. 2016; 23: 77-83
        • Ainsworth B.
        • Cahalin L.
        • Buman M.
        • Ross R.
        The current state of physical activity assessment tools.
        Prog Cardiovasc Dis. 2015; 57: 387-395
        • Shaughnessy M.
        • Resnick B.M.
        • Macko R.F.
        Testing a model of post-stroke exercise behavior.
        Rehabil Nurs. 2006; 31: 15-21
        • Wolf T.
        • Koster J.
        Perceived recovery as a predictor of physical activity participation after mild stroke.
        Disabil Rehabil. 2013; 35: 1143-1148
        • Bonomi A.G.
        • Goris A.
        • Yin B.
        • Westerterp K.R.
        Detection of type, duration, and intensity of physical activity using an accelerometer.
        Med Sci Sports Exerc. 2009; 41: 1770-1777
        • Kunkel D.
        • Fitton C.
        • Burnett M.
        • Ashburn A.
        Physical inactivity post-stroke: a 3-year longitudinal study.
        Disabil Rehabil. 2015; 37: 304-310
        • Alzahrani M.A.
        • Dean C.M.
        • Ada L.
        Ability to negotiate stairs predicts free-living physical activity in community-dwelling people with stroke: an observational study.
        Aust J Physiother. 2009; 55: 277-281
        • Alzahrani M.A.
        • Dean C.M.
        • Ada L.
        • Dorsch S.
        • Canning C.G.
        Mood and balance are associated with free-living physical activity of people after stroke residing in the community.
        Stroke Res Treat. 2012; : 1-8
        • Baert I.
        • Feys H.
        • Daly D.
        • Troosters T.
        • Vanlandewijck Y.
        Are patients 1 year post-stroke active enough to improve their physical health?.
        Disabil Rehabil. 2012; 34: 574-580
        • Katoh J.
        • Murakami M.
        • Hirayama M.
        • Nagata Y.
        • Hayakawa M.
        • Tanizaki T.
        Correlation of pedometric measurement of daily physical activity with exercise endurance by oxygen uptake kinetics in ambulatory stroke patients.
        J Phys Ther Sci. 2002; 14: 77
        • Mudge S.
        • Stott N.S.
        Test–retest reliability of the StepWatch Activity Monitor outputs in individuals with chronic stroke.
        Clin Rehabil. 2008; 22: 871-877
        • Haeuber E.
        • Shaughnessy M.
        • Forrester L.W.
        • Coleman K.L.
        • Macko R.F.
        Accelerometer monitoring of home-and community-based ambulatory activity after stroke.
        Arch Phys Med Rehabil. 2004; 85: 1997-2001
        • Mahendran N.
        • Kuys S.S.
        • Downie E.
        • Ng P.
        • Brauer S.G.
        Are accelerometers and GPS devices valid, reliable and feasible tools for measurement of community ambulation after stroke?.
        Brain Impair. 2016; 17: 151-161
        • Alzahrani M.A.
        • Ada L.
        • Dean C.M.
        Duration of physical activity is normal but frequency is reduced after stroke: an observational study.
        J Physiother. 2011; 57: 47-51
        • Lim K.
        • Taylor L.
        Factors associated with physical activity among older people—a population-based study.
        Prev Med. 2005; 40: 33-40
        • Stubbs B.
        • Hurley M.
        • Smith T.
        What are the factors that influence physical activity participation in adults with knee and hip osteoarthritis? A systematic review of physical activity correlates.
        Clin Rehabil. 2015; 29: 80-94
        • Bauman A.E.
        • Reis R.S.
        • Sallis J.F.
        • Wells J.C.
        • Loos R.J.
        • Martin B.W.
        Correlates of physical activity: why are some people physically active and others not?.
        Lancet. 2012; 380: 258-271
        • Motl R.W.
        • Snook E.M.
        • McAuley E.
        • Scott J.A.
        • Douglass M.L.
        Correlates of physical activity among individuals with multiple sclerosis.
        Ann Behav Med. 2006; 32: 154-161
        • Kinne S.
        Correlates of exercise maintenance among people with mobility impairments.
        Disabil Rehabil. 1999; 21: 15-22
        • Bijleveld-Uitman M.
        • van de Port I.
        • Kwakkel G.
        Is gait speed or walking distance a better predictor for community walking after stroke?.
        J Rehabil Med. 2013; 45: 535-540
        • Lee K.B.
        • Lim S.H.
        • Ko E.H.
        • Kim Y.S.
        • Lee K.S.
        • Hwang B.Y.
        Factors related to community ambulation in patients with chronic stroke.
        Top Stroke Rehabil. 2015; 22: 63-71
        • Newitt R.
        • Barnett F.
        • Crowe M.
        Understanding factors that influence participation in physical activity among people with a neuromusculoskeletal condition: a review of qualitative studies.
        Disabil Rehabil. 2016; 38: 1-10
        • Dohrn I.M.
        • Hagströmer M.
        • Hellénius M.L.
        • Ståhle A.
        Gait speed, quality of life, and sedentary time are associated with steps per day in community-dwelling older adults with osteoporosis.
        J Aging Phys Act. 2016; 24: 22-31
        • Duncan F.
        • Lewis S.J.
        • Greig C.A.
        • et al.
        Exploratory longitudinal cohort study of associations of fatigue after stroke.
        Stroke. 2015; 46: 1052-1058
        • Garber C.E.
        • Friedman J.H.
        Effects of fatigue on physical activity and function in patients with Parkinson's disease.
        Neurology. 2003; 60: 1119-1124
        • Reider N.
        • Salter A.R.
        • Cutter G.R.
        • Tyry T.
        • Marrie R.A.
        Potentially modifiable factors associated with physical activity in individuals with multiple sclerosis.
        Res Nurs Health. 2017; 40: 143-152
        • Pendlebury S.T.
        • Cuthbertson F.C.
        • Welch S.J.
        • Mehta Z.
        • Rothwell P.M.
        Underestimation of cognitive impairment by Mini-Mental State Examination versus the Montreal Cognitive Assessment in patients with transient ischemic attack and stroke.
        Stroke. 2010; 41: 1290-1293
        • Shaughnessy M.
        • Resnick B.M.
        • Macko R.F.
        Reliability and validity testing of the short self-efficacy and outcome expectation for exercise scales in stroke survivors.
        J Stroke Cerebrovasc Dis. 2004; 13: 214-219
        • Hamilton M.
        • Williams G.
        • Bryant A.
        • Clark R.
        • Spelman T.
        Which factors influence the activity levels of individuals with traumatic brain injury when they are first discharged home from hospital?.
        Brain Inj. 2015; 29: 1572-1580
        • Martin Ginis K.A.
        • Ma J.K.
        • Latimer-Cheung A.E.
        • Rimmer J.H.
        A systematic review of review articles addressing factors related to physical activity participation among children and adults with physical disabilities.
        Health Psychol Rev. 2016; 10: 478-494
        • Melanson E.L.
        • Knoll J.R.
        • Bell M.L.
        • et al.
        Commercially available pedometers: considerations for accurate step counting.
        Prev Med. 2004; 39: 361-368
        • Mao H.F.
        • Hsueh I.P.
        • Tang P.F.
        • Sheu C.F.
        • Hsieh C.L.
        Analysis and comparison of the psychometric properties of three balance measures for stroke patients.
        Stroke. 2002; 33: 1022-1027