Journal of Rehabilitation Medicine 51-10 | Page 36

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M. R. Bovim et al.
symptoms of anxiety and depression 3 months later.
We hypothesized that patients who reported more PA
before stroke would have fewer symptoms of anxiety
and depression at 3 months post-stroke. The secondary
aim was to examine how activity levels changed from
before to 3 months after stroke. The secondary hypo-
thesis was that patients would report a lower level of
activity after stroke than before stroke.
PATIENTS AND METHODS
Study design
This was a secondary analysis of data from a Norwegian pro-
spective observational multicentre study, the LEAST study
(22). The primary aim of the LEAST study was to examine the
amount and quality of early mobilization provided to stroke
patients in Norwegian stroke units. Patients were recruited
from 11 different stroke units from December 2011 to June
2013. Hospitals were screened for eligible patients once every
fortnight, and inclusion was performed if 2 or more eligible
patients were hospitalized.
Patient sample
Patients were eligible if they were diagnosed with acute stroke
according to the World Health Organization’s definition (23)
within 14 days before inclusion, were over 18 years of age,
and were able to speak and understand the Norwegian langu-
age. Patients could consent for themselves or, in keeping with
Norwegian consent procedures, could be included if unable to
consent for themselves when their next of kin did not oppose
participation. To be included in the analyses, the Hospital
Anxiety and Depression Scale (HADS) and questions concer-
ning pre-stroke and post-stroke activity needed to be complete.
Patients were excluded if they received palliative care, or were
discharged from hospital before the required information was
assessed at baseline. After discharge from hospital, all patients
were followed according to the National Norwegian Guidelines.
Inclusion and follow-up were performed by 4 trained research
assessors: 1 physician, 1 physiotherapist, 1 nurse and 1 medical
student. None of these had a therapeutic relationship with the
patients. The study was approved by the Regional Committee
for Medical and Health Research Ethics in Norway (REC no
2011/1428).
Procedure and outcome variables
Patients were included within 14 days after stroke, and reasses-
sed 3 months later. The 3-month follow-up was conducted in an
outpatient clinic, by home visit or by telephone.
At baseline, patient characteristics, such as sex, age and type
of stroke, were recorded. Stroke severity was obtained using
the National Institutes of Health Stroke Scale (NIHSS) (24).
Functional levels before and 3 months after stroke were assessed
using the modified Rankin Scale (mRS) (25).
The primary outcome was symptoms of anxiety and depres-
sion 3 months after stroke, which was measured using the HADS
(26). This questionnaire consists of 14 questions; 7 covering
anxiety symptoms and 7 covering depressive symptoms. HADS
is not a diagnostic tool, but can be used to score symptoms of
anxiety and depression. Each question scores from 0 to 3, with
www.medicaljournals.se/jrm
a maximum total score of 42; 21 for each subscale. A higher
score indicates more severe symptoms. It is recommended that
the subscales are used separately (27). A cut-off score of 8 is
suggested for case finding, giving an optimal balance between
sensitivity and specificity (28), and is used when describing the
data in this study. The scale format of the HADS has been used
in the regression analyses. Patients with a very high score were
seen by a physician in relation to the project unless they were
already receiving adequate care.
Self-reported physical activity (PA) was measured at inclu-
sion and at the 3-month follow-up by using questions from
the HUNT2-questionnaire. This is a short questionnaire that
is easy to administer, asking the participants to rate how many
hours they had spent in light and in hard PA during a certain
time-period (29). At inclusion, patients were asked how many
hours (mean per week) they had spent in light and hard PA for
the past year (pre-stroke). Light activity was defined as activity
without sweating or becoming out of breath, while hard activity
was characterized as sweating or becoming out of breath. Re-
sponse opportunities were: none, ≤ 1 h, 1–2 h or ≥ 3 h for both
categories. Three months after stroke, patients were asked the
same questions, considering activity level since the stroke. In
order to merge the 2 PA categories (light and hard activity) into
1 variable, they were summarized according to an algorithm
used in a previous study, and further divided into 5 categories;
none, very low, low, moderate and high PA (30). Definitions
are described in Table I. Only patients who had completed the
HADS and the questions on PA were included in the analyses.
Statistical analysis
Proportions were analysed and p-values generated using the
Pearson’s χ 2 test. Mann–Whitney U test was used to compare
groups for variables with a skewed distribution and independent
sample t-test was used for variables that complied with normal
distribution.
Associations between PA and symptoms of anxiety and de-
pression were analysed using negative binomial regression, as
responses to the HADS score were not normally distributed.
Using this statistical method made it possible to keep the scale
format of the dependent variables, as opposed to dichotomizing
them, omitting valuable information. Univariate and multiva-
riate analyses were performed with covariates that, based on
the literature and clinical judgement, were thought to influence
symptoms of anxiety and depression (2, 31).
Wilcoxon signed-rank test was used to compare levels of
activity before and after stroke. Collinearity was tested using
the variance inflation factor (VIF). In the regression analysis,
the activity categories “none” and “very low” activity were
merged, due to the low number of patients in the no-activity
group. p-value < 0.05 was considered significant in the analyses.
Statistical analyses were performed in SPSS 25 and Stata 15.
Table I. Definition of physical activity categories
Activity
category
None
Very low
Low
Moderate
High
Reported activity per week
No light or hard activity
< 3 h light activity and no hard activity
≥ 3 h light activity and no hard activity or < 1 h hard activity
and <3 h light activity
≥ 3 h light activity and < 1 h hard activity or 1–2 h hard
activity with any light activity
≥ 3 h hard activity with any light activity