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Physiotherapy and physical functioning post-stroke: Exercise habits and

functioning 4 years later? Long-term follow-up after a 1-year long-term
intervention period: A randomized co...

Article  in  Brain Injury · June 2014

DOI: 10.3109/02699052.2014.919534 · Source: PubMed

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ISSN: 0269-9052 (print), 1362-301X (electronic)

Brain Inj, 2014; 28(11): 1396–1405

! 2014 Informa UK Ltd. DOI: 10.3109/02699052.2014.919534

ORIGINAL ARTICLE

Physiotherapy and physical functioning post-stroke: Exercise habits and

functioning 4 years later? Long-term follow-up after a 1-year long-term
intervention period: A randomized controlled trial
Birgitta Langhammer1, Birgitta Lindmark2, & Johan K. Stanghelle3
1
Faculty of Health, Oslo and Akershus University College, Oslo, Norway, 2Department of Neurosciences, Uppsala University, University Hospital,
Uppsala, Sweden, and 3Faculty of Medicine, Sunnaas Rehabilitation Hospital, University of Oslo, Oslo, Norway
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Abstract Keywords
Introduction: Physical activity is mandatory if patients are to remain healthy and independent Function, intervention, longitudinal follow-up,
after stroke. rehabilitation, stroke
Objective: Maintenance of motor function, tone, grip strength, balance, mobility, gait,
independence in personal and instrumental activities of daily living, health-related quality- History
of-life and an active lifestyle 4 years post-stroke.
Methods: A prospective randomized controlled trial. Received 9 December 2013
Results: Four years post-stroke, 37 of the 75 participating persons were eligible for follow-up; Revised 7 April 2014
19 (54.3%) from the intensive exercise group and 18 (45%) from the regular exercise group. Accepted 26 April 2014
Both groups were performing equally well with no significant differences in total scores on the Published online 19 June 2014
For personal use only.

BI (p ¼ 0.3), MAS (p ¼ 0.4), BBS (p ¼ 0.1), TUG (p ¼ 0.08), 6MWT (p ¼ 0.1), bilateral grip strength
(affected hand, p ¼ 0.8; non-affected hand, p ¼ 0.9) nor in the items of NHP (p40.005).
Independence in performing the IADL was 40%, while 60% had help from relatives or
community-based services.
Conclusion: This longitudinal study shows that persons with stroke in two groups with different
exercise regimes during the first year after stroke did not differ in long-term outcomes. Both
groups maintained function and had a relatively active life style 4 years after the acute incident.
The results underline the importance of follow-up testing and encouragement to exercise, to
motivate and sustain physical activity patterns, to maintain physical function, not only in the
acute but also in the chronic phase of stroke.

Introduction physical capacity and muscle strength, leading to dependency

and decreased life expectancy [7, 8]. Persons suffering from
Long-term rehabilitation and follow-up after early rehabilita-
stroke are, therefore, especially in need of long-term
tion given in the stroke unit seldom occurs. Studies have
rehabilitation services to reduce disability, build up physical
shown that, in order to maintain physical functioning and
capacity and help to change lifestyle behaviour.
physical capacities, persons suffering a stroke need to do as
In this follow-up study, persons diagnosed with a stroke for
much physical activity as the general population [1–6]. The
the first time and who had participated in an earlier RCT with
opportunities for such activity are limited for persons with
intensive vs. regular exercise in the first year after stroke were
stroke with moderate-to-severe disabilities. The inactivity that
invited to be tested 3 years after the intervention had ended.
often follows can be devastating for a person with borderline
The results from the 1-year intervention vs. control have been
physical capacity after a stroke.
presented elsewhere [4], but may be summarized as follows:
Stroke is also closely linked to lifestyle diseases such as
persons randomized to the intervention group received
diabetes and coronary diseases and the increased mortality
physiotherapy on a scheduled basis for a whole year, whereas
rate related to these conditions. This means that not only may
the control group was tested regularly, but decided for
reduced motor or cognitive function be a reality after stroke,
themselves on this basis what physical activities they would
but also the secondary effects after inactivity, such as reduced
undertake [9]. After this initial year there were no scheduled
exercises in any group and all the participants were respon-
sible for their exercise until 3 years after the post-intervention
Correspondence: Birgitta Langhammer, Associate professor, PhD, follow-up, i.e. 48 months after the onset of stroke.
Oslo and Akershus University College, Faculty of Health,
The same persons with stroke who had participated in this
Physiotherapy Programme, Box 4, St Olavs pl, 0130 Oslo 4, Norway.
Tel: + 47 22 45 25 10. Fax: + 47 22 45 25 05. E-mail: birgitta. first trial were contacted and invited for a new test session
langhammer@hioa.no 3 years post-intervention.
 DOI: 10.3109/02699052.2014.919534
Thus, the aim with this study was to investigate how motor
function, balance, gait, performance of the personal and
instrumental activities of daily living and health-related
quality-of-life were maintained 4 years after the onset of
stroke in both groups. Another goal was to investigate
whether and how an active lifestyle was maintained 4 years
after stroke.
Methods
Subjects
The study was designed as a single-blind, intention to treat,
longitudinal randomized controlled stratified trial. Persons
with stroke admitted to the stroke unit in a local hospital were
recruited and randomized into two different groups, an
intensive exercise group and a regular exercise group. The
included persons were stratified for gender and hemisphere of
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lesion. Randomization was performed at discharge from the
general hospital by an independent person not involved in
the study.
The protocol was sealed from the start of the study, until
the last patient included had been followed up and tested
12 months later. Inclusion criteria were first-time-ever stroke
confirmed by neurological signs and computer tomography
and that participation in the study was voluntary.
Exclusion criteria were subarachnoid bleeding, tumour,
other serious illness and brain stem or cerebellar stroke.
For personal use only.
Patients who fulfilled the inclusion criteria were consecu-
tively included in the trial as they were admitted to the general
hospital.
On the basis of an earlier study [1], a power calculation
was made and it was estimated that 29 participants were
required in each group to detect a difference in motor function
with a significance level of 0.05 and a power of 80%. In the
follow-up 4 years later the procedure followed was that of
intention to treat, with the last observation carried forward
(LOCF) [10]. Since there were no statistical differences
between the groups in the earlier trials, this would give a
conservative estimate of outcomes.
Informed consent was given by all participants for methods
approved by the Norwegian Regional Committee of Medical
Research Ethics.
Data collection outcome measures
A test protocol was set up, consisting of well-known clinical
measurements that could be implemented anywhere without
laboratory equipment. Instruments included were the Barthel
Index (BI) [11], the Personal Activities of Daily Living
(PADL) [11], the Instrumental Activities of Daily Living
(IADL) tested according to Fillenbaum [12], 6-Minute Walk
Test (6MWT) [13, 14], Berg Balance Scale (BBS) [15],
Timed-Up-and-Go (TUG) [13, 16], grip strength (Martin
vigorimeter) [17], Health-Related Quality-of-Life (HRQoL)
with Nottingham Health Profile (NHP) and Modified
Ashworth Scale [18]. Pulse monitoring during activities was
also included, with the aim of obtaining complementary
information on perceived energy expenditure.
On the one hand, BI, IADL, 6MWT, BBS, TUG and NHP
can be said to represent measures of activity and participation
Exercise habits and function 4 years post-stroke 1397
according to the International Classification of Function
(ICF), World Health Organization [19]. Grip strength and
muscle tone, on the other hand, are tests on the body organ/
body structure level, according to the same classification [19].
The patients were tested on admission, at discharge, 3, 6,
12 and 48 months after the stroke incident by an experienced
investigator, blinded to group allocation. The tests were
performed in the general hospital, in the patients’ homes or in
community service centres.
The Barthel Index of the Activities of Daily Living (BI) is a
test of the performance of the personal activities of daily
living, developed by Mahoney and Barthel [11] for the
purpose of measuring functional independence in personal
care and mobility. The scores reflect the amount of time and
assistance required by a client. A score of 0 (complete
dependence), 5, 10 or 15 is assigned to each level, with a
possible total score of 100 [11].
Information about IADL was recorded according to the
Duke Older Americans Resources and Service Procedures
(OARS), Multidimensional Functional Assessment of Older
Adults by Fillenbaum [12], where the part relating to self-care
capacity captures the dimensions of PADL and IADL. The
information was collected by a structured interview with the
persons with stroke and their families [12].
The Motor Assessment Scale (MAS) is an eight-part test
of motor function developed by Carr et al. [20]. Each item
scores from 0–6. Hence, the total scores range between 0–48
[20].
Walking capacity was monitored by the 6-Minute Walk
Test (6MWT) using a standardized protocol [13, 14]. Distance
walked (m) and gait velocity (m s1) were measured by the
investigator. The 6-Minute Walk Test was performed in a
hospital or institution corridor 85 m long. Indoors in patients’
homes the longest possible stretch was chosen, but this was
done only twice with two patients, 6 and 12 months post-
stroke. Patients were encouraged to walk as fast and as long a
distance as they could in 6 minutes. The test is also used to
assess exercise tolerance [21, 22], thus measuring functional
exercise capacity.
The Berg Balance Scale (BBS) is a balance test, consisting
of 14 items, scored from 0–4. It has been used in many studies
and has been found to have satisfactory reliability and validity
[15]. The Berg Balance Scale is especially sensitive for
the detection of the risk of falls in frail elderly persons. An
overall score of less than 45 points, out of a maximum of 56,
is associated with a 2.7-times increase in the risk of a future
fall [23].
Timed-Up-and-Go (TUG) is a functional mobility test that
is used in clinics to evaluate dynamic balance, gait and
transfers. The patient is asked to get up from a chair (46 cm
high), with support for the arms, walk 3 metres, turn, go back
and sit down, one trial and one test round. The physiotherapist
monitors the time taken from the start to the end, when the
patient is seated again [13, 16].
Grip strength was monitored in the patient’s affected and
the non-affected hand. It was measured with a Martin
vigorimeter, consisting of a manometer with rubber tubing
and three rubber squeeze bulbs available in three different
sizes depending on the size of the hand. The manometer gives
the respective reading in bars (1 bar ¼ 1019 kp (kp cm2)
 1398 B. Langhammer et al.
[17]. All of these tests have reported satisfactory reliability
and validity, as described in earlier publications [2–4].
The Modified Ashworth Scale is a clinical measure of
muscle tone with an ordinal scale to grade the resistance
encountered during a passive muscle stretch, graded 0, i.e. no
increase in tone, to 4, when the affected part is rigid in flexion
or extension. The inter-rater and intra-rater reliability are both
reported to be fair to very good [18, 23] for some muscle
groups, but the reliability and validity of this test have not
been established for all muscle groups. The reliability seems
to be better in the upper limb [24]. There is some controversy
as to what component of muscle function the scale is
measuring and its validity as a measure of spasticity or muscle
tone is, hence, unclear [24].
The Health-Related Quality–Lfe (HRQoL) was evaluated
with the Nottingham Health Profile (NHP), a two-part
questionnaire, part 2 of which is optional. The NHP is a
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self-report, yes/no answer, two-part generic quality-of-life
measure. Part 1, used in this study, consists of a 38-item
questionnaire with six sub-scales: emotional reactions (nine
items), physical mobility (eight items), pain (eight items),
sleep (five items), social isolation (five items) and energy
level (three items). The items refer to problems with normal
functioning that a person may experience as a result of ill
health. Each affirmative answer is scored and weighted. The
scores range from 0 (no perceived stress) to 100 for each sub-
scale and the total score, where a high score indicates poor
For personal use only.
HRQoL. This measure has been used for assessing HRQoL in
persons with stroke [25, 26]. It is has been found to have good
reliability and validity [26, 27].
Pulse rate was measured with a pulse monitor, Sport tester
TM PE 3000, made by Polar Electro, Finland. The pulse
monitor consists of a belt placed around the patient’s thorax
and a wrist pulse monitor, held by the examiner during the
test. Pulse at rest was monitored at the beginning of the test
procedure after 15 minutes rest and pulse in activity was
recorded during the 6-Minute Walk Test, where the mean of
three measurements of the highest pulse rates was recorded.
Treatment
Inpatient training was functional task-oriented training
tailored according to their specific needs during the acute
period of rehabilitation. The amount of such training was
equal in the two groups, with two periods per day, a total of
1 hour of physiotherapy, in combination with other specia-
lized therapies as required. At discharge patients were
randomized into an intensive exercise group and a regular
exercise group. Patients allocated to the intensive exercise
group were scheduled after discharge to have four periods of
physiotherapy during the first year after their stroke, with a
minimal total amount of 80 hours. This was distributed into a
minimum of 20 hours every third month after their initial
incident (Figure 1). The first intervention period started
immediately after discharge with sessions 2- or 3-times
weekly, up to a total of at least 20 hours, whether the patients
were seen in their own home or in a private physiotherapy
practice. This intervention was repeated after 3, 6 and
12 months. The patients in the regular exercise group did
not receive any compulsory treatment, but if there was need of
Brain Inj, 2014; 28(11): 1396–1405
follow-up treatment or rehabilitation they were assigned to
that. No specific treatment was recommended to this group,
but they were encouraged to keep activity levels high, as
described in earlier publications [2–4]. After this initial year
the research team did not initiate any intervention until the
patients were followed up 36 months later, but the participants
were, of course, entitled to care under the general healthcare
system.
Statistical analysis
The results were analysed in an SPSS program version 20.
Descriptive statistics were used to summarize demographic,
stroke and baseline characteristics. All analyses were per-
formed on an intention-to-treat basis. Mean (M) and standard
deviation (SD) were calculated. A general linear model with
one-way analysis of repeated measures (ANOVA) was
performed, inserting total score as a dependent variable for
BI, BBS, 6MWT, TUG, grip strength, MAS and for each of
the sub-scales of NHP with treatment group as a fixed factor
and baseline total score for motor function as a covariate.
The non-parametric Kruskal-Wallis one-way between-
groups’ analysis of variance was performed for scores of the
Instrumental Activities of Daily living, Berg Balance Scale
and Modified Ashworth Scale. The significance level was set
at p50.05.
Results
A total of 37 of the 75 participating persons with stroke at
baseline were eligible for follow-up tests 4 years post-stroke,
that is 3 years after the intervention period during the first
year. Of these, 19 (54.3%) came from the intensive exercise
group and 18 (45%) from the regular exercise group
(Figure 1). The main reason for not participating was that
they were impossible to contact: 12 did not respond and could
not be traced, 13 withdrew because they were ‘too busy’ or
‘did not want to participate’, 10 were dead and three had
developed severe dementia. Participants who withdrew pre-
sented significantly higher scores on MAS at baseline than
participants who remained in the study. Surprisingly enough,
so did participants who developed dementia. Participants who
had died during the study had low scores at baseline on the
same MAS (Table I). The majority of the remaining
participants from both groups (78%) were still actively
doing exercises, either in a community setting with an
individual coach, in an exercise group or by themselves at
home (Table II). There was a slightly higher incidence of
other diseases in the former intensive exercise group than in
the former control group 4 years after the stroke. Pain, as
measured with NHP, was also reported as greater in the
former intensive exercise group. At this time, the use of
medication and assistive devices, falls and fatigue were
approximately the same in the two groups (Table II).
Blood pressure was stabilized by medication and did not
vary much between the 3-month post-stroke test and the test
at 36 months, neither did pulse rate at rest nor the pulse rate in
activity (Table III).
Motor function improved in the first 6 months and was
stabilized and maintained on the same level up to 4 years
post-stroke in the intervention group and improved slightly in
 DOI: 10.3109/02699052.2014.919534
Assessed for eligibility (n = 185)
Allocated to intensive exercise group (n = 35)
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Lost to follow-up (dead) (n = 1)
Discontinued intervention (withdrawal) (n = 2)
Analysed 3 months (n = 32)
For personal use only.
Analysed 6 months (n = 32)
Analysed 12 months (n = 32)
Analysed 48 months (n = 19)
♦ lost to follow-up: dead = 4, dementia = 2,
withdrawal = 5, lost to follow-up = 2
Figure 1. Flowchart for persons with stroke included in the study, 2003–2008.
Table I. The difference between patients participating and dropping out during the study in baseline total Motor Assessment Scale (MAS) score
presented as means and standard deviations (SD).
Patients Patients with
participating (n ¼ 37) dementia (n ¼ 3)
MAS tot 32.3 (16.7) 33.0 (18.3)
the non-intervention group (Figure 2). Walking distance and
walking speed showed improvement during the first year post-
stroke in both groups and then stabilized or slightly declined
during the rest of the 4-year period (Figure 3, and Table IV).
Overall grip strength improved in both the affected and non-
affected hand up to 1 year post-stroke and then stabilized or
slightly declined for the remainder of the 4 years (Figure 4).
Exercise habits and function 4 years post-stroke 1399
Excluded (n = 110)
♦ Not meeting inclusion criteria
(n = 110)
Randomized (n = 75)
Allocated to regular exercise group (n = 40)
Lost to follow-up (dead) (n = 3)
Discontinued intervention (withdrawal) (n = 2)
Analysed 3 months (n = 35)
Analysed 6 months (n = 33)
Lost to follow-up: dead = 1, withdrawal = 1
Analysed 12months (n = 31)
♦ lost to follow-up (dead = 2)
Analysed 48 months (n = 18)
♦ lost to follow-up: dead = 6, dementia = 1,
withdrawal = 5, lost to follow-up = 1
Patients withdrawing Patients died during Patients not
from the study (n ¼ 12) the study (n ¼ 10) located (n ¼ 13) p Values
44.0 (4.2) 12.3 (12.7) 30 (20.1) 0.01
Muscle tone as measured with Modified Ashworth Scale
[18] varied, but the majority of the persons with stroke (75%)
displayed no change in tone on admission. Of the 25%
presenting impaired tone on admission, 10% presented
decreased tone and 15% increased tone. The patients with
no or slightly marked increased tone were persons who
displayed decreased motor function on admission, indicating
 1400 B. Langhammer et al. Brain Inj, 2014; 28(11): 1396–1405

Table II. Demographics of participants with stroke 36 months a more extensive brain injury and tone remained fairly stable
post-intervention.
until the 1-year follow-up test. At the 48 months follow-up
Intervention Regular exercise
test 78% presented no increase in tone (‘normal tone’), 16%
group (n ¼ 19) group (n ¼ 18) p Value presented minor increased tone and 6% major increased tone.
Timed Up-and- Go, Berg’s Balance Scale and the Barthel
Age 77.7 (8.9) 72.3 (14.2) 0.2
Medication 1–2 2 2 0.05 Index registered improvements for the first 6 months,
Medication 3–4 1 5 stabilized and were maintained on the same level up to
Medication 5+ 16 9 3 years post-intervention in the intensive exercise group and
Pain 12 5 0.03
improved slightly in the regular exercise group (Table IV).
Exercising on their own 8 6 0.3
Exercising with a 6 9 There were significant or near significant differences in the
coach/group items relating to feeding, bathing, grooming, dressing and
No exercise 5 3 defecation in favour of the regular exercise group at 12 and
Activities and socializing 11 10 0.03
with family and friends
48 months.
Sports, hobbies 5 10 Health-related quality-of-life (HRQoL measured with
Falls indoors 4 3 0.7 NHP) had declined in the intervention group at 1 and
Falls outdoors 0 1 3 months post-stroke, whereas it was reported as improved in
Fatigue 6 2 0.13
New stroke 1 3 0.2 the regular exercise group (Table V) on the same test
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Other diseases 8 3 occasions. However, the differences between the groups were
not significant (Table V). In general, the intensive exercise
group reported somewhat higher scores than the regular
Table III. Mean blood pressure and pulse registration on admission, at exercise group, indicating a lower HRQoL in this group.
3 months, 6 months, 12 months and 48 months post-stroke.
These results were fairly stable throughout the remaining
Intensive exercise Regular exercise
4-year test period.
group (n ¼ 35) group (n ¼ 40) There were no significant differences at baseline in the
performance of any of the items of the Instrumental Activities
Blood Pulse Pulse Blood Pulse Pulse
pressure rest active pressure rest active of Daily Living Test. Both groups reported greater activity in
all the items at 3, 6, 12 and 48 months post-stroke (Table VI).
Admission 166/90 74 108 156/89 76 103
For personal use only.

3 months 142/75 81 116 141/79 73 114 At 3, 6, 12 and 48 months post-stroke 40% of both
6 months 144/76 77 116 143/77 76 111 groups were independent, while 60% relied on help from
12 months 140/77 74 117 136/80 76 118 relatives or community-based services. Relatives and the
36 months 131/73 77 102 127/78 73 112 community-based services provided an equal amount of help
All participants were on medication for high blood pressure. (item 9 IADL, Table VI).

Figure 2. Motor Assessment Scale (MAS)

(maximum score ¼ 48) total score in the two
groups, mean and standard error of mean
at baseline, discharge and 3, 6, 12 and
48 months later.
 DOI: 10.3109/02699052.2014.919534 Exercise habits and function 4 years post-stroke 1401
Figure 3. 6-Minute Walk Test (6MWT) in the
groups at baseline, discharge and 3, 6 and
12 months after debut and 36 months after
intervention.
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For personal use only.

Table IV. Barthel Index (BI), Berg Balance Scale (BBS), Timed Up-and-Go (TUG) and 6-Minute Walk Test (6MWT) (m s1) total score presented as
means (M) and standard deviations (SD) on six different test occasions.

Intensive exercise group Regular exercise group

Admission Discharge 3 months 6 months 12 months 48 months Admission Discharge 3 months 6 months 12 months 48 months
(n ¼ 35) (n ¼ 35) (n ¼ 32) (n ¼ 32) (n ¼ 32) (n ¼ 19) (n ¼ 40) (n ¼ 36) (n ¼ 33) (n ¼ 33) (n ¼ 31) (n ¼ 18)
BI ADL 56.6 75.5 82.9 84.5 80.8 79.2 66.0 75.8 87.6 91.2 90.8 89.0
(0–100)
38.9 30.6 26.4 23.9 29.5 31.2 39.0 30.4 21.5 19.9 23.3 24.3
BBS 25.9 35.6 38.5 40.4 38.3 37.8 32.9 38.7 43.9 46.6 48.7 47.1
(0–56)
23.1 17.8 16.9 16.9 19.5 19.4 24.2 19.5 16.0 13.6 11.7 12.9
TUG (s) 12.7 17.9 17.2 18.9 20.8 21.1 11.7 19.2 15.1 15.1 11.4 11.9
13.4 19.9 18.2 19.4 26.7 27.0 13.4 29.2 13.8 18.4 11.0 11.5
6MWT 0.52 0.76 0.86 0.91 0.96 0.96 0.63 0.78 1.1 1.1 1.3 1.3
(m s1)
0.6 0.5 0.6 0.6 0.7 0.7 0.6 0.5 0.6 0.6 0.7 0.6

Discussion
This longitudinal follow-up study shows that most of these
persons with stroke had maintained their exercise levels and
kept up a social life and activities they enjoyed 4 years after
their acute stoke, 12/19 in the intensive exercise group and 16/
18 in the regular exercise group. This is contrary to an earlier
study that followed persons with stroke in the same
geographic area who received no follow-up treatment or
tests [1] and showed a tendency towards poor functional
performance, a high degree of dependence and little or no
social activities. The differences between the two studies may
be explained by the difference in follow-up procedures. All
patients, independent of group allocation, received their test
results at each test occasion and encouragement to continue to
exercise. Patients were conversely asked of their activity
levels both at 1 and 4 years follow-up and the results indicate
equal levels of activity patterns in the groups. Thus, it is
postulated that it has been of importance for these patients to
be involved in the first year’s project with encouragement
towards physical activity. Less disability after stroke indicates
that the treatment of stroke in the acute phase is effective
[2–5, 28–31]. Walking capacity and walking speed improved
during the first year post-stroke in both groups, as reported
earlier [30] (Table IV). The walking capacity was stable
during the 4 years post-stroke but was less than that of healthy
senior citizens of comparable age [32]. The same observations
were made about balance and mobility (TUG) (Table IV). The
BBS scores remained relatively stable from 6 months
 1402 B. Langhammer et al. Brain Inj, 2014; 28(11): 1396–1405

Table V. Health-related quality-of-life (HRQoL) measured with Nottingham Health Profile; higher scores indicate perceived lower HRQoL.1

The intensive exercise group The regular exercise group

Admission 3 Months 6 Months 12 Months 48 Months Admission 3 Months 6 Months 12 Months 48 Months
(n ¼ 35) (n ¼ 32) (n ¼ 32) (n ¼ 32) (n ¼ 19) (n ¼ 40) (n ¼ 33) (n ¼ 31) (n ¼ 31) (n ¼ 18)
Energy, M 31.3 17.3 35.8 34.9 33.1 33.1 17.2 14.0 19.2 15.6
SD 37.8 25.8 85.1 37.5 31.8 35.9 23.8 24.6 29.5 25.6
Pain, M 33.5 24.9 20.9 19.8 14.7 23.1 15.0 15.2 11.9 9.2
SD 29.7 29.7 22.1 27.8 17.4 30.3 22.9 23.8 17.8 15.6
Em.reac., M 29.7 13.6 19.4 26.1 19.4 22.05 11.9 13.3 11.4 8.8
SD 25.6 14.9 24.6 26.6 20.2 22.9 13.6 17.9 17.7 17.1
Sleep, M 32.2 36.3 32.0 29.7 28.0 35.8 28.7 25.8 23.6 23.5
SD 31.5 37.5 37.2 32.9 32.4 35.7 32.0 31.5 29.5 31.4
Soc.isol., M 25.1 12.8 19.0 24.3 22.2 18.4 12.8 20.5 13.4 6.8
SD 28.6 17.4 26.5 31.5 30.1 26.9 17.4 26.7 19.7 13.1
Phys.Mob., M 57.5 40.1 34.6 36.6 32.1 42.6 32.2 23.8 17.9 21.4
SD 35.9 34.1 36.8 38.1 34.6 37.2 35.8 29.3 25.8 27.9
Total, M 34.8 24.2 26.9 28.6 24.9 29.2 19.6 18.7 16.2 14.2
SD 22.2 18.7 25.8 25.1 20.0 22.1 16.1 17.3 16.1 15.8
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1
Scores for energy, pain, emotional reactions (Em.reac.), sleep, social isolation (Soc.isol.), physical mobility (Phys.Mob.) and the total are presented as
means (M and standard deviations (SD) on admission and at 3, 6, 12 and 48 months later.

Table VI. Performance of the Instrumental Activities of Daily Living (IADL-OARS) (n) from day 1 until 4 years post-stroke.

Intervention group Regular training group

Admission 48 months Admission 48 months
(n ¼ 35) Discharge 3 months 6 months 12 months (n ¼ 19) (n ¼ 40) Discharge 3 months 6 months 12 months (n ¼ 18)
1 Can you use the telephone?
For personal use only.

2 13 16 17 18 17 10 21 20 27 29 29 16
1 6 8 6 6 7 4 7 8 3 2 1 1
0 16 11 9 8 8 5 12 8 3 2 1 1
2 Can you make use of transport alone?
2 11 14 16 20 17 10 17 13 20 24 23 14
1 4 10 6 2 5 3 8 13 8 7 7 2
0 20 11 10 10 10 6 15 10 5 2 1 2
3 Are you able to do your own shopping?
2 7 8 10 15 14 7 13 14 15 21 21 13
1 5 8 9 4 4 4 8 5 9 8 5 2
0 23 19 13 13 14 8 19 17 9 4 5 3
4 Do you cook your own food?
2 7 9 10 15 12 8 13 13 16 19 19 11
1 4 6 6 4 7 3 6 7 9 9 6 2
0 24 20 16 13 13 8 21 16 8 5 6 5
5 Do you do housework?
2 7 9 9 15 11 8 13 12 15 17 19 10
1 5 6 7 4 8 5 6 8 9 11 7 3
0 23 20 16 13 13 6 21 16 9 5 5 5
6 Medication by yourself?
2 9 12 13 17 16 8 12 12 17 17 20 12
1 5 5 4 3 3 3 8 12 9 9 5 1
0 21 18 15 12 13 8 20 12 7 7 6 5
7 Do you do your own housekeeping/finance?
2 9 10 11 15 13 7 12 12 15 15 19 11
1 4 5 6 4 6 4 7 9 8 8 4 1
0 22 20 15 13 13 8 21 15 10 10 8 6
8 Is somebody helping you with transport, finance and housekeeping?
2 7 6 9 11 10 6 12 12 11 15 17 5
1 8 12 10 10 10 5 7 11 15 14 8 7
0 20 17 13 11 12 8 21 13 7 4 6 6
9 Who assists?
Relatives 11 15 16 16 15 7 11 16 18 16 15 5
Institution/ 23 12 9 8 9 8 29 13 6 5 7 5
community
services
Independent 1 7 7 8 8 4 7 9 12 9 8

Scores: independent ¼ 2, some help ¼ 1 and totally dependent ¼ 0.

 DOI: 10.3109/02699052.2014.919534
onwards, although indicating a higher risk of falls for both
groups [15, 23]. Although relatively few falls were reported in
this study (n ¼ 8), the reduced balance underlines the
importance of focusing on preventing falls among the stroke
population [33, 34]. The most effective interventions may be
exercise, in order to maintain the ability to keep one’s
balance, but others are nutrition, adaptations of the environ-
ment, proper light conditions and the use of assistive devices
[34, 35]. The mobility scores (TUG) highlight an observed
reduced velocity (Table IV). The reduction in velocity might
be explained by the reduced motor function (Table III), but
Figure 4. Grip strength in bar, in affected
and non-affected hand in the two groups on
admission, discharge, 3, 6, 12 and
48 months post-stroke.
Brain Inj Downloaded from informahealthcare.com by Hogskolen i Oslo og Akershus on 11/05/14
For personal use only.
Exercise habits and function 4 years post-stroke 1403
probably the reduced velocity was a strategy adopted in order
to maintain balance while doing a complex task [36] and also
an effect of ageing.
Performance of the activities of daily living (BI) seemed
stable during the whole period from 3 months onwards
(Table IV). This independence was a pre-requisite for living at
home, as the majority still were. The regular exercise at the
long-term follow-up may be one explanatory factor for
independent living [3, 30, 37]. However, many of the
participants received help with transport, finance and house-
keeping (Table VI). The help was equally divided between
 1404 B. Langhammer et al.
relatives and community services, indicating that many
persons with stroke, despite relatively good physical
functioning, needed some help with performing I-ADL.
The dependence on help and support from the family is in
line with other recent reports on stroke [29]. However,
compared to the healthy elderly, those with stroke were more
dependent. This dependence in the performance of I-ADL
may indicate that persons with stroke perceive themselves as
less healthy [38].
There were no significant differences between the groups
in total scores on the BI (p ¼ 0.3), MAS (p ¼ 0.4), BBS
(p ¼ 0.1), TUG (p ¼ 0.08), 6MWT (p ¼ 0.1) or in bilateral
grip strength (affected hand, p ¼ 0.8; non-affected hand,
p ¼ 0.9), indicating that both groups were performing equally
well 4 years post-stroke (Tables III and IV). These results
confirm the earlier observations and underline the importance
of follow-up testing to motivate and sustain physical activity
Brain Inj Downloaded from informahealthcare.com by Hogskolen i Oslo og Akershus on 11/05/14
patterns [3–5]. However, compulsory exercises, as initiated
and followed up by the physiotherapist in the intensive
exercise group, added no benefits to the maintenance of
functional performance. Rather to the contrary, the results
indicate the importance of the individual’s self-control/
determination to make progress after rehabilitation.
It was noted that the intensive exercise group experienced a
more reduced HRQoL compared to the control group and one
might speculate whether this was influenced by the compul-
sory regime of exercises [3]. The compulsory regime may be
For personal use only.
viewed as an external motivational factor. The therapists are
in control of when and how exercise should be performed,
thus ‘driving’ the scenario and indirectly being motivators for
exercise. This is in contrast to the regular exercise group who
may have been driven by internal motivation, relating to test
results and were themselves in control of how and when to
exercise [39]. One may speculate if this self-driven activity
influenced the individual with stroke’s empowerment and
coping abilities in a positive way [40]. In conclusion, the tests
may serve as indicators as to how an individual should
proceed in order to maintain capacity, physical functioning
and their motivational input, in addition to the opportunity of
getting expert advice and recommendations on type of
exercise [3].
The mortality rate of 13% 4 years after the onset of stroke
was less than the expected 40–60% [41, 42]. It is also in
contrast to the mortality rates of 40% recorded in the same
hospital and area 10 years previously [1]. The lower mortality
rate in this latest follow-up study indicates that the early
stroke treatment and the follow-up with regular tests may have
an impact on life expectancy [43]. This notion is supported by
and in line with current guidelines [28]. Furthermore,
10 persons with stroke withdrew (27%) from the invitation
to follow-up and reported that they considered themselves
‘healthy’ and did not identify themselves as stroke patients.
As a consequence they did not feel a need for more tests.
There is a trend towards reduced disability after stroke and
this might be seen in relation to the improved routines in acute
stroke care and possibly also in better primary and secondary
prevention [29, 43]. There are few longitudinal intervention
studies of stroke and this study presents interesting data in this
respect. However, longitudinal studies on stroke are often
hampered by small numbers and poor adherence, as was this
Brain Inj, 2014; 28(11): 1396–1405
follow-up study. It underlines the difficulties of making
longitudinal studies in this population. The impact of the
stroke on the patient, the complexity of the stroke condition
with disability, fatigue and often a need for help in the
performance of the personal and instrumental activities
of daily living, complicate the long-term follow-up studies
[1, 4, 44]. A follow-up procedure over several years in a
population of elderly and disabled persons is bound to
experience drop out for several reasons and so did this study.
Approximately 50% of the study population was captured for
follow-up and did return to the hospital for testing. This
relatively low percentage weakens the power of the results
and the results must be seen in the light of these weaknesses.
However, 17% of the participants reported that they
experienced little or no problems after the initial stroke and
did not want to participate in the last follow-up test after
4 years. One may speculate whether these 17% would have
strengthened the positive outcomes of the study, if their
results had been included. Furthermore, the reduced mortality
reported in this study indicates an influence of a positive input
of follow-up procedures for persons with stroke.
Conclusion
This longitudinal follow-up study shows that persons with
stroke in two different groups with exercise regimes during
the first year after stroke had a relatively active lifestyle
4 years following the acute incident, contrary to other studies.
The study shows the importance of regular exercise regimen
during the first year after a stoke incident.
Clinical message
 The importance and effect of exercise in order to maintain
physical function for persons with stroke in the acute and
the chronic phase of stroke was confirmed in this
longitudinal study.
 The importance of follow-up testing and encouragement to
exercise, to motivate and sustain physical activity patterns
in the chronic phase was found to be effective means to
achieve the goal.
Declaration of interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of the paper.
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