Relationships Among Environmental Variables, Physical Capacity, Balance Self-Efficacy, and Real-World Walking Activity Post-Stroke

Abstract

Background: Social and physical environmental factors affect real-world walking activity in individuals with stroke. However, environmental factors are often non-modifiable, presenting a challenge for clinicians working with individuals with stroke whose real-world walking is limited due to environmental barriers. Objective: The purpose of this work was to test a model hypothesizing the relationships among environmental factors (specifically, living situation and area deprivation), modifiable factors, and real-world walking activity to understand opportunities for intervention. We hypothesized that balance self-efficacy would mediate the relationship between the environment and real-world walking and that physical capacity would moderate this mediation. Methods: This was a cross-sectional study of 282 individuals with chronic (≥6 months) stroke. We tested the indirect effect to determine if mediation was present. Multiple group structural equation modeling was used to test if physical capacity moderated this mediation. A χ2 difference test was used to compare the moderation model against the null (no moderation) model. Results: Balance self-efficacy mediated the relationship between area deprivation and real-world walking (indirect effect: β = −0.04, P = .04). Both the moderation and null models fit the data equally well statistically (χ2(5) = 6.9, P = .23). We therefore accepted the simpler (null) model and concluded that the mediation was not moderated. Conclusions: Targeting balance self-efficacy may be an effective approach to improving real-world walking in persons with stroke who experience barriers within the physical environment. A stroke survivor’s physical capacity may not impact this approach. Future work should consider utilizing more specific measures of the social and physical environment to better understand their influences on real-world walking activity in individuals with stroke. However, the results of this work provide excellent targets for future longitudinal studies targeting real-world walking activity in stroke.

Moderate to Vigorous Intensity Locomotor Training After Stroke: A Systematic Review and Meta-analysis of Mean Effects and Response Variability

“…A lack of meaningful change in walking activity with LT mv would be consistent with recent findings that gains in walking capacity do not automatically translate into gains in daily walking activity poststroke 53,54. This limited translation may be due to the complex, multifactorial nature of daily walking activity, which requires sufficient walking capacity but can also be influenced by many other personal and environmental factors 55–58. The multifactorial nature of this measure may also explain the extremely large (albeit nonsignificant) response variability we observed in walking activity changes from LT mv (pooled SD response : 2021 steps per day [95% CI, −7135 to 7686]).…”

“…53,54 This limited translation may be due to the complex, multifactorial nature of daily walking activity, which requires sufficient walking capacity but can also be influenced by many other personal and environmental factors. [55][56][57][58] The multifactorial nature of this measure may also explain the extremely large (albeit nonsignificant) response variability we observed in walking activity changes from LT mv (pooled SD response : 2021 steps per day [95% CI, −7135 to 7686]). Further studies assessing daily walking activity are needed to develop its CID benchmarks, more precisely estimate LT mv effects, and augment the effects of LT mv on this outcome.…”

Moderate to Vigorous Intensity Locomotor Training After Stroke: A Systematic Review and Meta-Analysis of Mean Effects and Individual Response Variability

“…52,53 This limited translation may be due to the complex, multifactorial nature of daily walking activity, which requires sufficient walking capacity but can also be influenced by many other personal and environmental factors. 54-57 The multifactorial nature of this measure may also explain the extremely large (albeit non-significant) individual variability we observed in walking activity changes from LT mv (pooled SD IR : 2,021 steps/day [95% CI: -7,135, 7,686]). Further studies assessing daily walking activity are needed to develop its CID benchmarks, more precisely estimate LT mv effects, and augment the effects of LT mv on this outcome.…”

The effects of dynamic motion instability system training on motor function and balance after stroke: A randomized trial

“…In a study conducted by Pollock et al (2011), approximately 88% of all stroke patients discharged from the hospital had insufficient walking abilities. Furthermore, 26-33% of stroke patients living at home were still unable to walk unassisted in public (Conroy et al, 2022;Miller et al, 2022), probably owing to difficulties with stairs, inclines, or uneven surfaces (Lord et al, 2004). As a result, gait recovery has been identified as an important goal in stroke therapy (Moreira et al, 2013).…”