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was used more at weekends to compensate for the
limited ability of the affected arm. Since neither phy-
siotherapists nor occupational therapists were present
at weekends, it can be expected that less focus was
possibly paid to affected arm use at weekends.
In the current study the use of less-affected arm at
weekdays was the only metric that reached comparable
activity levels to healthy controls. This corroborates
findings from previous studies, showing that the acti-
vity levels are, in general, low after stroke. The added
knowledge from the current study is that the arm acti-
vity was lower and asymmetry increased at weekends
irrespective of the hand dominance of the affected
side; and that the leg activity remained low regardless
of whether the person was independent in walking or
using a wheelchair. It has been proven that it is diffi-
cult for patients to bridge the gap between supervised
and unsupervised practice and maintain the activity
levels when alone (5, 33). Many promising attempts
to promote increased activity among stroke survivors
have been made, including elements from enriched
environment, group exercise and use of technology,
but challenges still remain (16, 34, 35).
The strength of the current study is that accelera-
tion data were provided as acceleration rather than
activity counts (14). The data were collected as raw
signal and common non-proprietary post-processing
methods were employed. Since direct comparisons
between different accelerometer metrics is difficult,
we also included a healthy control group. Activity
levels from healthy controls can be used as goal es-
timates representing activity levels in people without
disabilities. Another strength was that the activity logs
were gathered, which provided a possibility to verify
accelerometer data when needed. Use of activity logs,
however, require extra effort and time and will be a
limitation in clinical settings (12). A set of 5 sensors
was used, which allowed a more comprehensive
and differentiated analysis of activity levels. In our
data-set no difference was found between weekdays
and weekends in trunk activity. The placement of the
trunk sensor was also perceived as most inconvenient
for the participants. Thus, information from arms and
legs may be enough to capture most of the activities of
daily living, e.g. walking, transfers using either arms
or legs, and manual activities.
A limitation of the study is the missing data. In
total, out of all collected data from 5 sensors in 38
participants in 2 sessions (380 measurements), missing
or incomplete data due to technical errors accounted
for 12.6%. Reporting of missing data due to technical
errors is not extensive, but similar levels ranging from
14% to 23% have been reported previously (36–38).
To be fully clinically feasible, the missing data from
www.medicaljournals.se/jrm
accelerometers need to be minimal. In addition, use of
accelerometers that allowed raw data handling was an
advantage in the current study, but it also enclosed a
disadvantage, since it required manual time-consuming
post-processing. Accelerometers used were not wa-
terproof and individual adjustments were needed for
sensor placement. These disadvantages were reflected
in the feasibility evaluation, where the participants
commented that the sensors were in the way when get-
ting dressed and that the straps, and particularly for the
trunk sensor, were uncomfortable. Thus, these elements
also need to be more convenient for the user before
they can be used in clinical practice. Participants were
aware of measurements, which may have motivated
them to be more active. However, this bias might be
negligible, since the current evidence indicates that the
use of commercial activity monitors does not have an
effect on daily step counts in people with stroke (39).
In conclusion, people with stroke in inpatient reha-
bilitation settings use not only their more-affected, but
also their less-affected, upper and lower limbs less at
weekends than on weekdays. To our knowledge this is
the first study to report acceleration data (m/s 2 ) from
all extremities and the trunk in people with stroke in
the inpatient rehabilitation setting. Wearing sensors
for a total of 4 days was acceptable for the majority of
subjects, although the trunk sensor was perceived as the
most uncomfortable. A need for customized application
of sensors on the body and manual data-processing were
the main barriers to clinical feasibility. There is strong
evidence that neural repair and functional recovery, to
a large extent, take place during the subacute stage after
stroke, which means that the therapeutic interventions
at this stage may have the strongest impact on patients’
recovery. Thus, the challenge during inpatient rehabi-
litation is to identify patients who might need extra
support to be able to maintain their physical activities
at weekends, facilitate activity on all days of the week,
and take full advantage of the recovery process.
ACKNOWLEDGEMENTS
The authors thank all participants in this study.
The study was funded by the Swedish Foundation for Strategic
Research (SBE13-0086), the Swedish state under the agreement
between the Swedish government and the country councils, the
ALF-agreement (ALFGBG-775561), Swedish National Stroke
Association, Rune and Ulla Amlöv Foundation for Neurology
Research, JB Wenneström Foundation, Promobilia Foundation.
The authors have no conflicts of interest to declare.
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