ABSTRACT
Objectives:
There is a lack of evidence regarding the association between whole-body exercise and independence in urination and defecation. This study aimed to evaluate the effect of chair-stand exercise on improving urination and defecation independence in post-stroke patients with sarcopenia.
Methods:
A retrospective study was conducted on stroke patients admitted to a community rehabilitation hospital between 2015 and 2021. Patients diagnosed with sarcopenia who required assistance with bladder and bowel management were included. The primary outcomes were the Functional Independence Measure (FIM) scores for urination (FIM-Bladder) and defecation (FIM-Bowel) at discharge. Multiple regression analysis was used to examine the association between chair-stand exercise and the outcomes, adjusting for potential confounders.
Results:
Of 586 patients, 187 patients (mean age 79.3 years, 44.9% male) were included in the urination analysis, and 180 patients (mean age 79.3 years, 44.4% male) were included in the defecation analysis. Multiple regression analysis showed that the number of chair-stand exercises was independently positively associated with FIM-Bladder at discharge (β=0.147, P=0.038) and FIM-Bladder gain (β=0.168, P=0.038). Similarly, the number of chair-stand exercises was independently positively associated with FIM-Bowel at discharge (β=0.149, P=0.049) and FIM-Bowel gain (β=0.166, P=0.049).
Conclusions:
Chair-stand exercise was positively associated with improved urination and defecation independence in post-stroke patients with sarcopenia. Incorporating whole-body exercises, such as chair-stand exercise, in addition to conventional rehabilitation programs may help improve voiding independence, reduce incontinence, and enhance quality of life in these patients.
Keywords: cognitive function, convalescent rehabilitation, dysphagia, motor function, stroke
INTRODUCTION
Incontinence and non-independence of urination and defecation are important sequelae of stroke. Risk factors for urinary incontinence include age, body mass index (BMI), smoking, diabetes, pregnancy, hysterectomy, poor general health, and stroke.1,2) Risk factors for fecal incontinence include age, obesity, poor general health, physical inhibition, and stroke.3,4) Poststroke constipation is a common complication during inpatient rehabilitation.5,6,7) Older adults with incontinence are at increased risk of depression, social isolation, falls, loss of independence, and institutionalization.8,9,10) In addition, poor incontinence control can significantly affect an individual’s quality of life (QOL), not only in terms of physical function, but also in terms of social relationships.11,12,13,14) The relationship between incontinence symptom intensity and QOL underscores the importance of improving bladder control in older adults.9)
Sarcopenia is negatively associated with activities of daily living (ADL) and QOL. It is caused by aging, disease, low activity, and poor nutrition, and is diagnosed by loss of skeletal muscle mass, muscle strength, and physical function.15) Sarcopenia is estimated to affect between 1% and 29% of community-dwelling older adults,16,17) particularly in patients undergoing rehabilitation, where the prevalence of sarcopenia is about 50%.16) Sarcopenia is also associated with adverse outcomes such as decreased physical activity, falls, fractures, dysphagia, and death.18,19,20) It has also been reported that the presence of sarcopenia on admission to a convalescent rehabilitation ward is negatively associated with greater independence in urination and defecation at discharge.21) Therefore, prevention, diagnosis, and treatment of sarcopenia are important.
Exercise therapy can improve physical function in older adults, such as muscle strength and balance, and ADL, such as age-related functional decline, walking speed, and stair climbing.22,23) In older adults with sarcopenia, a comprehensive exercise program combining resistance exercise and other forms of exercise such as balance, endurance, and aerobic exercise improves muscle mass, strength, and physical function.24,25) Among exercise therapies, chair-stand exercise has been reported to be positively associated with improvements in sarcopenia and ADLs.26) Therefore, exercise therapy is important for all older adults.26,27,28,29) However, there is a lack of evidence linking exercise therapy to improved urination and defecation control.30,31,32)
Given that sarcopenia is negatively associated with independence in urination and defecation, it is expected that exercise therapy would be effective in improving independence in urination and defecation. Therefore, we conducted a retrospective study in post-stroke patients with sarcopenia to determine the effect of chair-stand exercise on improving independence in urination and defecation.
MATERIALS AND METHODS
Participants and Settings
The study was conducted in a 135-bed community rehabilitation hospital, including three convalescent rehabilitation units (45 beds each). The study focused on stroke patients admitted to the hospital for the first time between January 2015 and December 2021. The study included patients who were identified as having sarcopenia on admission and who needed assistance with bladder and bowel management. Patients were excluded if they refused to participate, had incomplete data, were not fully conscious, had significant swelling or hydration changes, or had a pacemaker. The observation period for each patient was from the date of admission to the date of discharge.
Data Collection
At admission, data collection included: patient age, sex, medical conditions as assessed by the Charlson Comorbidity Index (CCI),33) premorbid ADL as assessed by the Modified Rankin Scale (mRS),34) history of stroke, type of stroke, BMI, swallowing ability as assessed by the Food Intake Level Scale (FILS),35) nutritional assessment as assessed by the Geriatric Nutritional Risk Index (GNRI), and level of paralysis as assessed by the Brunnstrom Scale (BRS), among other baseline details. Tests of higher brain function were used to test for higher brain dysfunction, such as attention deficit and aphasia. Information on the use of balloon catheters and laxatives was also collected from medical records. Within the first 72 h of admission, BMI, skeletal muscle, and fat mass were assessed by bioelectrical impedance analysis (BIA) using the InBody S10 device (InBody S10; InBody, Tokyo, Japan), handgrip strength (HG), and the Functional Independence Measure (FIM)36) to assess physical and cognitive abilities. HG was measured using a Smedley hand dynamometer (TTM, Tokyo, Japan) with the non-dominant or non-paralyzed hand in a standing or sitting position with the arm extended, taking the best of three attempts. BIA measurements were performed with proper hydration, 4 h after a meal, with the patient resting in bed for 1 h prior to testing, and without recent fever, tremor, or acute illness. The FIM evaluation also included the FIM-Toileting and FIM-Transfer to the toilet, two FIM sub-items that may be relevant to voiding.
Sarcopenia Diagnosis
The diagnosis of sarcopenia, according to the 2019 guidelines of the Asian Working Group for Sarcopenia,18) requires the presence of both reduced skeletal muscle mass index (SMI) determined by BIA and reduced muscle strength assessed by HG, with thresholds tailored to the Asian elderly population. A validated multifrequency BIA device was used to measure skeletal muscle and fat mass. SMI was calculated by dividing skeletal muscle mass by height in meters squared. The cutoff values for SMI to define sarcopenia were less than 7.0 kg/m2 for men and less than 5.7 kg/m2 for women. The cutoff values for HG to define sarcopenia were less than 28 kg for men and less than 18 kg for women.
Chair-stand Exercise
In addition to the usual rehabilitation program, patients were given “chair-stand exercises” as full-body resistance training. The chair-stand exercises involved the use of a standard chair, a platform, and a wheelchair, with the seat height adjusted to each patient’s body size, ranging from 40 to 50 cm. Supportive equipment such as parallel bars and handrails were used as needed. Rehabilitation therapists provided assistance to those who had difficulty standing independently. Sessions lasted 20 min, during which individuals performed sit-to-stand movements up to 120 times, maintaining a rhythm of approximately one sit-to-stand cycle every 8 s. The intensity of the exercise was individualized, with the number of repetitions increasing progressively to increase muscle strength and endurance. These exercises were significantly slower and gentler than other full-body workouts for older adults, at 20%–30% of the maximum number of repetitions per repetition. The number of chair-stand exercises was determined by each assigned therapist based on the severity of symptoms, the patient’s motivation, and the amount of pain and assistance required. Each patient was encouraged to participate in as many standing exercises as possible. These exercises were considered a safe and effective method for increasing muscle mass and strength in older adults with diminished physical abilities.37)
Outcomes
The primary outcome was defined as the sphincter control items of the FIM at discharge from a convalescent ward: urination (FIM-Bladder) and defecation (FIM-Bowel). The FIM is divided into two sections: the motor domain (FIM-motor), which includes 13 items, and the cognitive domain (FIM-cognitive), which includes 5 items; both the FIM-Bladder and FIM-Bowel fall into the FIM-motor category. The FIM total score ranges from 18 to 126, the FIM motor score from 13 to 91, and the FIM cognitive score from 5 to 35. Sphincter control is assessed by the timely contraction of the sphincter at appropriate times for urination or defecation. Scoring considered both the frequency of incontinence and the amount of assistance required, with the lower score being recorded. Clothing manipulation before and after urination, wiping the buttocks, and transferring the patient were not included in the evaluation. Tasks were rated on a 7-point ordinal scale from 1 (complete assistance) to 7 (complete independence), with lower scores indicating greater dependency. The secondary outcomes were the FIM-Bladder gain and the FIM-Bowel gain. The FIM-Bladder gain and FIM-Bowel gain were calculated by subtracting the admission scores from the discharge scores of FIM-Bladder and FIM-Bowel, respectively.
Sample Size Calculation
The sample size was calculated using data from our previous study,38) the results of which showed that the standard deviations of FIM-Bladder and FIM-Bowel of patients on hospital admission were 2.46 and 2.25, respectively. If the true difference in means between patients with low and high frequency of chair-stand exercise is 1.00, we would need to study 83 and 81 participants in each group, respectively, to reject the null hypothesis that the population means of the experimental and control groups are equal with a power of 0.80. The Type I error probability associated with this test of the null hypothesis was 0.05.
Statistical Analysis
All analyses were performed with SPSS version 21 (IBM, Armonk, NY, USA). Results were reported as mean ± standard deviation (SD) for parametric data, median [interquartile range; IQR] for nonparametric data, and number (percentage) for categorical data. Based on the median daily frequency of chair-stand exercise, patient backgrounds were compared between two groups: the high-frequency chair-stand exercise (HF) group and the low-frequency chair-stand (LF) exercise group. FIM-Bladder at discharge and FIM-Bowel at discharge and FIM-Bladder gain and FIM-Bowel gain were compared between the HF group and the LF group using the Mann–Whitney U test. Multiple regression analysis was used to examine the association between FIM-Bladder at discharge and chair-stand exercise and between FIM-Bladder gain and chair-stand exercise. Multiple regression analysis was also used to examine the association between FIM-Bowel at discharge and chair-stand exercise and between FIM-Bowel gain and chair-stand exercise. The covariates used for adjustment as potential confounders of outcomes were age, sex, length of hospital stay, premorbid mRS, CCI, HG, SMI, lower limb BRS, rehabilitation therapy, FIM-Total, aphasia, higher brain dysfunction, voiding management at admission (FIM-Bladder or FIM-Bowel), FIM-Transfer to the toilet on admission, and FIM-Toileting on admission, all of which are reported to be clinically relevant to rehabilitation outcomes. Multicollinearity was assessed using Variance Inflation Factor (VIF), with VIF less than 10 considered as no multicollinearity; P <0.05 was considered statistically significant.
Ethics
The study was approved by the Institutional Review Board of Kumamoto Rehabilitation Hospital, Kumamoto, Japan (approval number 222–230414). Participants were free to withdraw from the study at any time via an opt-out option. Written informed consent was not obtained because of the retrospective nature of the study. The study was conducted in accordance with the principles of the Declaration of Helsinki and ethical standards for medical and health research involving human subjects.
RESULTS
One thousand and eighteen stroke patients were consecutively admitted to our convalescent wards between 2015 and 2021. Of these, 586 patients were selected after the exclusion of 432 patients: 116 patients who were non-compliant with the BIA, 36 patients with severe impaired consciousness, and 280 patients with missing data. A further 329 patients without sarcopenia were excluded, leaving 257 patients with sarcopenia to be included. For the analysis of urination, 187 patients were included in the final analysis after the exclusion of 70 patients with FIM-Bladder scores of 6 or higher on admission. For the analysis of defecation, 180 patients were included in the final analysis after the exclusion of 77 patients with FIM-Bowel scores of 6 or higher on admission (Fig. 1).
Fig. 1.
Flowchart of participant screening and inclusion.
Table 1 summarizes the baseline characteristics and comparisons between the two groups of post-stroke sarcopenia patients according to their frequency of chair-stand exercise. The analysis of urination included 187 subjects, with a mean age of 79.3 years and 44.9% were male. The median [IQR] for FIM-Bladder at admission was 1 [1–2] in the Total group, 2 [1–3] in the HF group, and 1 [1–1] in the LF group. The median number of chair-stand exercises was 43.8. The median [IQR] number of chair-stand exercises was 74.0 [57.3–103.5] in the HF group and 19.5 [9.1–33.3] in the LF group. FILS, GNRI, BRS, FIM scores (total, motor, cognitive, toileting, transfer to the toilet), and HG were significantly higher in the HF group than in the LF group (P <0.001). Aphasia was present in 67 patients (35.8%) and higher brain dysfunction in 83 patients (44.4%), but no significant difference was observed between the two groups. Balloon catheters were used by 8 patients (4.3%) at admission: 2 in the HF group and 6 in the LF group.
Table 1. Baseline characteristics of post-stroke patients with sarcopenia and comparison of LF and HF groups.
| Characteristic | Patients dependent in urination (FIM-Bladder ≤ 5) | Patients dependent in defecation (FIM-Bowel ≤ 5) | ||||||
| Total | HF group | LF group | P value | Total | HF group | LF group | P value | |
| n=187 | n=94 | n=93 | n=180 | n=90 | n=90 | |||
| Age, years | 79.3 ± 9.9 | 78.3 ± 9.9 | 80.3 ± 10.0 | 0.181 | 79.3 ± 10.2 | 78.3 ± 10.1 | 80.3 ± 10.2 | 0.1901) |
| Sex (male) | 84 (44.9) | 47 (50.0) | 37 (39.8) | 0.187b | 80 (44.4) | 43 (47.8) | 37 (41.1) | 0.368b |
| Length of stay, days | 123 [84–151] | 121 [84–150] | 126 [83–151] | 0.730c | 125 [84–151] | 123 [86–152] | 127 [82–151] | 0.933c |
| Chair-stand exercise, frequency/day | 43.8 [19.5–75.5] | 74.0 [57.3–103.9] | 19.5 [9.1–33.3] | <0.001c | 43.1 [18.7–75.7] | 75.6 [57.3–103.5] | 18.7 [8.7–33.0] | <0.001c |
| CCI | 3 [2–4] | 3 [1–4] | 3 [2–4] | 0.080c | 3 [2–4] | 3 [1–4] | 3 [2–4] | 0.242c |
| Premorbid mRs | 1 [0–3] | 1 [0–3] | 1 [0–3] | 0.321c | 1 [0–3] | 1 [0–2] | 1 [0–3] | 0.128c |
| History of stroke | 64 (34.2) | 34 (36.2) | 29 (31.2) | 0.537b | 61 (33.9) | 33 (36.7) | 28 (31.1) | 0.431b |
| Stroke type | ||||||||
| Cerebral infarction | 108 (57.8) | 54 (57.4) | 53 (57.0) | 1.000b | 103 (57.2) | 52 (57.8) | 51 (56.7) | 0.880b |
| Cerebral hemorrhage | 71 (39.4) | 37 (39.4) | 34 (36.6) | 0.764b | 68 (37.8) | 35 (38.9) | 33 (36.7) | 0.758b |
| Subarachnoid hemorrhage | 8 (2.8) | 2 (2.1) | 6 (6.5) | 0.169b | 8 (4.4) | 2 (2.2) | 6 (6.7) | 0.139b |
| BMI, kg/m2 | 20.6 [18.4–23.1] | 20.7 [18.4–23.1] | 20.6 [18.9–23.1] | 0.995c | 20.7 [18.5–23.0] | 20.8 [18.5–22.8] | 20.6 [18.9–23.1] | 0.962c |
| FILS | 7 [2–8] | 7 [6–9] | 4 [2–7] | <0.001c | 7 [2–8] | 7 [6–9] | 3 [2–7] | <0.001c |
| GNRI | 88.1 [80.9–94.7] | 91.4 [83.5–98.5] | 85.0 [79.8–91.4] | <0.001c | 88.0 [80.1–94.6] | 91.2 [83.5–98.3] | 84.7 [79.5–90.9] | <0.001c |
| BRS | ||||||||
| Upper limb | 3 [1–5] | 4 [2–5] | 2 [1–4] | 0.001c | 3 [1–5] | 4 [2–5] | 2 [1–5] | 0.003c |
| Finger | 3 [1–5] | 4 [2–5] | 2 [1–4] | <0.001c | 3 [1–5] | 4 [2–5] | 2 [1–5] | 0.001c |
| Lower limb | 4 [2–5] | 5 [2–5] | 2 [1–5] | <0.001c | 3 [1–5] | 4 [2–5] | 2 [1–5] | <0.001c |
| FIM | ||||||||
| Total | 32 [21–48] | 44 [30–58] | 23 [19–33] | <0.001c | 31 [24–46] | 41 [29–53] | 23 [19–33] | <0.001c |
| Motor | 18 [13–28] | 25 [16–40] | 14 [13–18] | <0.001c | 16 [13–26] | 23 [16–35] | 14 [13–18] | <0.001c |
| Transfer to the toilet | 1 [1–1] | 1 [1–3] | 1 [1–1] | <0.001c | 1 [1–2] | 2 [1–3] | 1 [1–1] | <0.001c |
| Toileting | 5 [2–6] | 2 [1–4] | 1 [1–1] | <0.001c | 1 [1–1] | 1 [1–2] | 1 [1–1] | <0.001c |
| Sphincter control | - | - | - | - | - | - | - | - |
| Bladder | 1 [1–2] | 2 [1–3] | 1 [1–1] | <0.001c | - | - | - | - |
| Bowel | - | - | - | - | 1 [1–2] | 2 [1–2] | 1 [1–1] | <0.001c |
| Cognitive | 12 [7–18] | 14 [11–20] | 9 [6–15] | <0.001c | 12 [7–17] | 14 [10–20] | 9 [6–15] | <0.001c |
| HG, kg | 9.9 [0–15.4] | 12.9 [8.0–19.3] | 4.5 [0–12.9] | <0.001c | 9.4 [0–15.2] | 12.4 [7.5–19.3] | 4.3 [0–12.8] | <0.001c |
| SMI, kg/m2 | 5.1 [4.5–5.9] | 5.3 [4.7–6.2] | 5.1 [4.4–5.8] | 0.084c | 5.2 [4.6–5.9] | 5.4 [4.7–6.2] | 5.1 [4.4–5.7] | 0.108c |
| Rehabilitation therapy, units/day |
8.1 [7.2–8.5] | 8.3 [7.7–8.6] | 7.9 [6.7–8.3] | <0.001c | 8.1 [7.2–8.5] | 8.3 [7.7–8.6] | 7.8 [6.7–8.3] | <0.001c |
| Aphasia | 67 (35.8) | 38 (40.4) | 29 (31.2) | 0.223 | 64 (35.6) | 37 (41.1) | 27 (30.0) | 0.161 |
| Higher brain dysfunction | 83 (44.4] | 45 (47.9) | 38 (40.9) | 0.378 | 80 (44.4) | 43 (47.7) | 37 (41.1) | 0.453 |
| USN | 42 (22.5) | 20 (21.3) | 22 (23.7) | 0.729 | 42 (23.3) | 21 (23.3) | 21 (23.3) | 1.000 |
| Use of balloon catheter | 8 (4.3) | 2 (2.2) | 6 (6.5) | 0.169 | - | - | - | - |
| Laxatives | - | - | - | - | 34 (18.9) | 17 (18.9) | 17 (18.9) | 1.000 |
Parametric data are presented as mean ± SD; nonparametric data as median [IQR]; categorical data as number (percentage).
Rehabilitation therapy: physical, occupational, and speech therapy; USN, unilateral spatial neglect.
at-test; b chi-square test; c Mann–Whitney U test
The analysis of defecation included 180 subjects, with a mean age of 79.3 years, and 44.4% were male. The median number of chair-stand exercises was 43.1. The median [IQR] number of chair-stand exercises was 75.6 [57.3–103.5] in the HF group and 18.7 [8.7–33.0] in the LF group. The HF group had significantly higher scores in swallowing status (FILS), nutritional status (GNRI), paralysis severity (BRS), FIM (total, motor, cognitive, toileting, transfer to the toilet), and HG (P <0.001). Sixty-four patients (35.6%) had aphasia and 80 (44.4%) had higher brain dysfunction, but there was no significant difference between the two groups. Laxatives were used by 34 patients (18.9%) at admission: 17 in the HF group and 17 in the LF group.
Table 2 shows the bivariate analysis of outcomes between the HF and LF groups. Analysis of urination outcomes showed that FIM-Bladder at discharge was significantly higher (P<0.001) in the HF group: HF group, 6 [3–7]; LF group, 2 [1–4]. The FIM scores indicated that the majority of patients in the LF group required assistance with urination at discharge. FIM-Bladder gain was significantly higher (P<0.001) in the HF group: HF group, 2 [1–5]; LF group, 0 [0–3]. When comparing defecation-related outcomes, FIM-Bowel at discharge was significantly higher (P<0.001) in the HF group: HF group, 6 [3–7]; LF group, 2 [1–5]. Many patients in the LF group required assistance with defecation at discharge. FIM-Bowel gain was also significantly higher in the HF group (P<0.001).
Table 2. Bivariate analysis of outcomes between HF and LF groups.
| Total | HF group | LF group | P value a | |
| Urination | ||||
| Not independent on admission | n=187 | n=94 | n=93 | |
| FIM-Bladder on admission | 1 [1–2] | 2 [1–3] | 1 [1–1] | <0.001 |
| FIM-Bladder on discharge | 3 [1–6] | 6 [3–7] | 2 [1–4] | <0.001 |
| FIM-Bladder gain | 2 [0–4] | 2 [1–5] | 0 [0–3] | <0.001 |
| Defecation | ||||
| Not independent on admission | n=180 | n=90 | n=90 | |
| FIM-Bowel on admission | 1 [1–2] | 2 [1–2] | 1 [1–1] | <0.001 |
| FIM-Bowel on discharge | 4 [1–6] | 6 [3–7] | 2 [1–5] | <0.001 |
| FIM-Bowel gain | 2 [0–4] | 2 [1–5] | 1 [0–3] | <0.001 |
Data given as median [IQR].
a Mann–Whitney U test.
Table 3 shows the results of the multiple regression analysis with FIM-Bladder at discharge and FIM-Bladder gain as dependent variables. No multicollinearity between variables was observed. All multiple regression analyses included the same covariates. Multiple regression analysis showed that the number of chair-stand exercises was independently positively associated with FIM-Bladder at discharge (β=0.147, P= 0.038) and FIM-Bladder gain (β=0.168, P=0.038).
Table 3. Multivariate analysis for FIM-Bladder at hospital discharge and FIM-Bladder gain.
| Factor | FIM-Bladder on discharge | FIM-Bladder gain | ||
| β | P value | β | P value | |
| Age | −0.137 | 0.038 | −0.157 | 0.038 |
| Sex | −0.243 | 0.006 | −0.277 | 0.006 |
| Length of stay | 0.102 | 0.120 | 0.117 | 0.120 |
| Premorbid mRS | −0.170 | 0.010 | −0.194 | 0.010 |
| CCI | 0.008 | 0.889 | 0.010 | 0.889 |
| HG | 0.138 | 0.091 | 0.158 | 0.091 |
| SMI | 0.102 | 0.222 | 0.116 | 0.222 |
| Lower-limb BRS | 0.152 | 0.041 | 0.173 | 0.041 |
| Rehabilitation therapy | −0.038 | 0.526 | −0.044 | 0.526 |
| FIM-Total | 0.434 | 0.001 | 0.496 | 0.001 |
| FIM-Bladder on admission | 0.130 | 0.138 | −0.442 | 0.000 |
| FIM-Transfer to toilet on admission | −0.153 | 0.158 | −0.174 | 0.158 |
| FIM-Toileting on admission | −0.040 | 0.673 | −0.046 | 0.673 |
| Higher brain dysfunction | −0.034 | 0.572 | −0.039 | 0.572 |
| Aphasia | 0.046 | 0.461 | 0.053 | 0.461 |
| Chair-stand exercise | 0.147 | 0.038 | 0.168 | 0.038 |
Table 4 shows the results of the multiple regression analysis with FIM-Bowel at discharge and FIM-Bowel gain as dependent variables. No multicollinearity was found between the variables. Multiple regression analysis showed that the number of chair-stand exercises was independently positively associated with FIM-Bowel at discharge (β=0.149, P=0.049) and FIM-Bowel gain (β=0.166, P=0.049).
Table 4. Multivariate analysis for FIM-Bowel at hospital discharge and FIM-Bowel gain.
| Factor | FIM-Bowel on discharge | FIM-Bowel gain | ||
| β | P value | β | P value | |
| Age | −0.159 | 0.025 | −0.176 | 0.025 |
| Sex | −0.207 | 0.025 | −0.230 | 0.025 |
| Length of stay | 0.095 | 0.182 | 0.105 | 0.182 |
| Premorbid mRS | −0.153 | 0.030 | −0.170 | 0.030 |
| CCI | −0.001 | 0.991 | −0.001 | 0.991 |
| HG | 0.124 | 0.149 | 0.138 | 0.149 |
| SMI | 0.136 | 0.124 | 0.151 | 0.124 |
| Lower-limb BRS | 0.154 | 0.047 | 0.171 | 0.047 |
| Rehabilitation therapy | −0.069 | 0.286 | −0.076 | 0.286 |
| FIM-Total | 0.445 | 0.445 | 0.494 | 0.003 |
| FIM-Bowel on admission | 0.072 | 0.072 | −0.517 | 0.000 |
| FIM-Transfer to toilet on admission | −0.182 | 0.099 | −0.202 | 0.099 |
| FIM-Toileting on admission | −0.054 | 0.621 | −0.060 | 0.621 |
| Higher brain dysfunction | 0.029 | 0.654 | 0.032 | 0.654 |
| Aphasia | −0.003 | 0.062 | −0.004 | 0.062 |
| Chair-stand exercise | 0.149 | 0.049 | 0.166 | 0.049 |
DISCUSSION
This study evaluated the effect of chair-stand exercise on improvement in urination and defecation independence in post-stroke patients with sarcopenia. The results showed that chair-stand exercise was positively associated with improved urinary independence and improved defecation independence in these patients.
Chair-stand exercise was positively associated with improved urinary independence. To the best of our knowledge, this is the first reported evidence of this association. The mechanism behind the positive association may be related to the ability of resistance exercise to boost muscle strength and mass. Sarcopenia entails a gradual decline in muscle mass, strength, and function, potentially resulting in incontinence and reduced autonomy in urination. Chair-stand exercises can increase muscle strength and mass,26) thereby promoting improved urinary independence in patients with sarcopenia.39) Furthermore, because chair-stand movements are directly related to ADLs, repeated practice of this exercise may have facilitated improvement in voiding movements. In addition, because FIM was used in this study to assess ADLs, gaining toileting skills would improve FIM scores. Because chair-stand exercise is significantly associated with improvement in FIM-Motor, it is likely that the ability to stop using diapers and use the toilet for bowel movements contributed to the improvement in urinary independence. Therefore, we consider that chair-stand exercises should be incorporated into routine rehabilitation programs for patients with decreased urinary independence.
Chair-stand exercise was positively associated with improved defecation independence. The mechanism for this association is likely to be similar to that associated with urinary independence. We believe that chair-stand exercise improved sarcopenia and indirectly contributed to improved defecation independence. A recent study found a 23% prevalence of fecal incontinence in patients with dysphagia, and sarcopenia was independently associated with fecal incontinence, suggesting the presence of “anal sarcopenia”.39) Therefore, it is possible that the chair-stand exercise improved muscle strength of the whole body and lower extremities, resulting in improved strength of the pelvic floor muscle group, abdominal pressure, and other muscle groups involved in bowel movements.6,39) In addition, the repetitive movements associated with orthostatic exercises have a direct impact on movements associated with voiding, such as transferring to the toilet and toileting, which may also be a factor in improving FIM scores.
Whole-body exercise may be effective in improving urination and defecation independence. Resistance training, balance exercise, and aerobic exercise have been shown to improve muscle strength and walking ability in older patients with sarcopenia,24) and improving physical function may lead to improved independence in urination and defecation.37,39) Furthermore, given that chair-stand exercises are low-intensity resistance exercises that are easy to perform and do not require special equipment or space, these patients should be actively encouraged to perform this exercise in addition to their daily program of conventional rehabilitation.23)
This study has several limitations. First, it was conducted in a single community-based rehabilitation hospital in Japan, which may limit the generalizability of the findings. Second, because of the retrospective nature of the study, it may have been influenced by unexplained confounding factors, such as medical treatment during the study period. Third, incontinence was not diagnosed according to medical diagnostic criteria. In this study, the FIM-Bladder and FIM-Bowel subscales of FIM were used to assess urinary and defecation independence, which may not accurately assess the degree of independence of incontinence. In the future, high-quality prospective multicenter studies should be conducted to elucidate the causal relationship between chair-stand exercise and improvement in urination and defecation independence.
CONCLUSION
Chair-stand exercise was positively associated with urination and defecation independence in stroke patients with sarcopenia. To improve voiding independence and incontinence and further improve QOL, whole-body exercises such as chair-stand exercise should be performed by these patients in addition to their conventional rehabilitation programs.
ACKNOWLEDGMENTS
The authors thank all the study participants for their support.
Footnotes
CONFLICTS OF INTEREST: The authors declare no conflict of interest.
REFERENCES
- 1.Subak LL,Richter HE,Hunskaar S: Obesity and urinary incontinence: epidemiology and clinical research update. J Urol 2009;182:S2–S7. 10.1016/j.juro.2009.08.071 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Shamliyan T,Wyman J,Bliss DZ,Kane RL,Wilt TJ: Prevention of urinary and fecal incontinence in adults. Evid Rep Technol Assess (Full Rep) 2007;1–379. [PMC free article] [PubMed] [Google Scholar]
- 3.Matthews CA,Whitehead WE,Townsend MK,Grodstein F: Risk factors for urinary, fecal, or dual incontinence in the Nurses’ Health Study. Obstet Gynecol 2013;122:539–545. 10.1097/AOG.0b013e31829efbff [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Harari D,Coshall C,Rudd AG,Wolfe CD: New-onset fecal incontinence after stroke: prevalence, natural history, risk factors, and impact. Stroke 2003;34:144–150. 10.1161/01.STR.0000044169.54676.F5 [DOI] [PubMed] [Google Scholar]
- 5.Su Y,Zhang X,Zeng J,Pei Z,Cheung RT,Zhou QP,Ling L,Yu J,Tan J,Zhang Z: New-onset constipation at acute stage after first stroke: incidence, risk factors, and impact on the stroke outcome. Stroke 2009;40:1304–1309. 10.1161/STROKEAHA.108.534776 [DOI] [PubMed] [Google Scholar]
- 6.Li J,Yuan M,Liu Y,Zhao Y,Wang J,Guo W: Incidence of constipation in stroke patients: a systematic review and meta-analysis. Medicine (Baltimore) 2017;96:e7225. 10.1097/MD.0000000000007225 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Lin CJ,Hung JW,Cho CY,Tseng CY,Chen HY,Lin FC,Li CY: Poststroke constipation in the rehabilitation ward: incidence, clinical course and associated factors. Singapore Med J 2013;54:624–629. 10.11622/smedj.2013222 [DOI] [PubMed] [Google Scholar]
- 8.Vaughan CP,Markland AD,Smith PP,Burgio KL,Kuchel GA, American Geriatrics Society/National Institute on Aging Urinary Incontinence Conference Planning Committee and Faculty: Report and research agenda of the American Geriatrics Society and National Institute on Aging Bedside‐to‐Bench Conference on Urinary Incontinence in Older Adults: a translational research agenda for a complex geriatric syndrome. J Am Geriatr Soc 2018;66:773–782. 10.1111/jgs.15157 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Corrado B,Giardulli B,Polito F,Aprea S,Lanzano M,Dodaro C: The impact of urinary incontinence on quality of life: a cross-sectional study in the Metropolitan City of Naples. Geriatrics (Basel) 2020;5:96. 10.3390/geriatrics5040096 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Chiarelli PE,Mackenzie LA,Osmotherly PG: Urinary incontinence is associated with an increase in falls: a systematic review. Aust J Physiother 2009;55:89–95. 10.1016/S0004-9514(09)70038-8 [DOI] [PubMed] [Google Scholar]
- 11.Grimby A,Milsom I,Molander U,Wiklund I,Ekelund P: The influence of urinary incontinence on the quality of life of elderly women. Age Ageing 1993;22:82–89. 10.1093/ageing/22.2.82 [DOI] [PubMed] [Google Scholar]
- 12.Coyne KS,Zhou Z,Thompson C,Versi E: The impact on health‐related quality of life of stress, urge and mixed urinary incontinence. BJU Int 2003;92:731–735. 10.1046/j.1464-410X.2003.04463.x [DOI] [PubMed] [Google Scholar]
- 13.Wald A,Scarpignato C,Kamm MA,Mueller-Lissner S,Helfrich I,Schuijt C,Bubeck J,Limoni C,Petrini O: The burden of constipation on quality of life: results of a multinational survey. Aliment Pharmacol Ther 2007;26:227–236. 10.1111/j.1365-2036.2007.03376.x [DOI] [PubMed] [Google Scholar]
- 14.Gotoh M,Matsukawa Y,Yoshikawa Y,Funahashi Y,Kato M,Hattori R: Impact of urinary incontinence on the psychological burden of family caregivers. Neurourol Urodyn 2009;28:492–496. 10.1002/nau.20675 [DOI] [PubMed] [Google Scholar]
- 15.Cruz-Jentoft AJ,Bahat G,Bauer J,Boirie Y,Bruyère O,Cederholm T,Cooper C,Landi F,Rolland Y,Sayer AA,Schneider SM,Sieber CC,Topinkova E,Vandewoude M,Visser M,Zamboni M, Writing Group for the European Working Group on Sarcopenia in Older People 2 (EWGSOP2), and the Extended Group for EWGSOP2: Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing 2019;48:16–31. 10.1093/ageing/afy169 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Yoshimura Y,Wakabayashi H,Bise T,Tanoue M: Prevalence of sarcopenia and its association with activities of daily living and dysphagia in convalescent rehabilitation ward inpatients. Clin Nutr 2018;37:2022–2028. 10.1016/j.clnu.2017.09.009 [DOI] [PubMed] [Google Scholar]
- 17.Mayhew AJ,Amog K,Phillips S,Parise G,McNicholas PD,de Souza RJ,Thabane L,Raina P: The prevalence of sarcopenia in community-dwelling older adults, an exploration of differences between studies and within definitions: a systematic review and meta-analyses. Age Ageing 2019;48:48–56. 10.1093/ageing/afy106 [DOI] [PubMed] [Google Scholar]
- 18.Chen LK,Woo J,Assantachai P,Auyeung TW,Chou MY,Iijima K,Jang HC,Kang L,Kim M,Kim S,Kojima T,Kuzuya M,Lee JS,Lee SY,Lee WJ,Lee Y,Liang CK,Lim JY,Lim WS,Peng LN,Sugimoto K,Tanaka T,Won CW,Yamada M,Zhang T,Akishita M,Arai H: Asian Working Group for Sarcopenia: 2019 consensus update on sarcopenia diagnosis and treatment. J Am Med Dir Assoc 2020;21:300–307. 10.1016/j.jamda.2019.12.012 [DOI] [PubMed] [Google Scholar]
- 19.Yoshimura Y,Wakabayashi H,Bise T,Nagano F,Shimazu S,Shiraishi A,Yamaga M,Koga H: Sarcopenia is associated with worse recovery of physical function and dysphagia and a lower rate of home discharge in Japanese hospitalized adults undergoing convalescent rehabilitation. Nutrition 2019;61:111–118. 10.1016/j.nut.2018.11.005 [DOI] [PubMed] [Google Scholar]
- 20.Park HM: Current status of sarcopenia in Korea: a focus on Korean geripausal women. Ann Geriatr Med Res 2018;22:52–61. 10.4235/agmr.2018.22.2.52 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Kido Y,Yoshimura Y,Wakabayashi H,Momosaki R,Nagano F,Bise T,Shimazu S,Shiraishi A: Sarcopenia is associated with incontinence and recovery of independence in urination and defecation in post-acute rehabilitation patients. Nutrition 2021;91-92:111397. 10.1016/j.nut.2021.111397 [DOI] [PubMed] [Google Scholar]
- 22.Gschwind YJ,Kressig RW,Lacroix A,Muehlbauer T,Pfenninger B,Granacher U: A best practice fall prevention exercise program to improve balance, strength/power, and psychosocial health in older adults: study protocol for a randomized controlled trial. BMC Geriatr 2013;13:105. 10.1186/1471-2318-13-105 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Papa EV,Dong X,Hassan M: Resistance training for activity limitations in older adults with skeletal muscle function deficits: a systematic review. Clin Interv Aging 2017;12:955–961. 10.2147/CIA.S104674 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Lu L,Mao L,Feng Y,Ainsworth BE,Liu Y,Chen N: Effects of different exercise training modes on muscle strength and physical performance in older people with sarcopenia: a systematic review and meta-analysis. BMC Geriatr 2021;21:708. 10.1186/s12877-021-02642-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Zhao H,Cheng R,Song G,Teng J,Shen S,Fu X,Yan Y,Liu C: The effect of resistance training on the rehabilitation of elderly patients with sarcopenia: a meta-analysis. Int J Environ Res Public Health 2022;19:15491. 10.3390/ijerph192315491 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Yoshimura Y,Wakabayashi H,Nagano F,Bise T,Shimazu S,Shiraishi A,Kido Y,Matsumoto A: Chair-stand exercise improves sarcopenia in rehabilitation patients after stroke. Nutrients 2022;14:461. 10.3390/nu14030461 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Yoshimura Y,Wakabayashi H,Yamada M,Kim H,Harada A,Arai H: Interventions for treating sarcopenia: a systematic review and meta-analysis of randomized controlled studies. J Am Med Dir Assoc 2017;18:553.e1–553.e16. 10.1016/j.jamda.2017.03.019 [DOI] [PubMed] [Google Scholar]
- 28.Dent E,Morley JE,Cruz-Jentoft AJ,Arai H,Kritchevsky SB,Guralnik J,Bauer JM,Pahor M,Clark BC,Cesari M,Ruiz J,Sieber CC,Aubertin-Leheudre M,Waters DL,Visvanathan R,Landi F,Villareal DT,Fielding R,Won CW,Theou O,Martin FC,Dong B,Woo J,Flicker L,Ferrucci L,Merchant RA,Cao L,Cederholm T,Ribeiro SM,Rodríguez-Mañas L,Anker SD,Lundy J,Gutiérrez Robledo LM,Bautmans I,Aprahamian I,Schols JM,Izquierdo M,Vellas B: International clinical practice guidelines for sarcopenia (ICFSR): screening, diagnosis and management. J Nutr Health Aging 2018;22:1148–1161. 10.1007/s12603-018-1139-9 [DOI] [PubMed] [Google Scholar]
- 29.Chou CH,Hwang CL,Wu YT: Effect of exercise on physical function, daily living activities, and quality of life in the frail older adults: a meta-analysis. Arch Phys Med Rehabil 2012;93:237–244. 10.1016/j.apmr.2011.08.042 [DOI] [PubMed] [Google Scholar]
- 30.Shamliyan TA,Kane RL,Wyman J,Wilt TJ: Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med 2008;148:459–473. 10.7326/0003-4819-148-6-200803180-00211 [DOI] [PubMed] [Google Scholar]
- 31.Fink HA,Taylor BC,Tacklind JW,Rutks IR,Wilt TJ: Treatment interventions in nursing home residents with urinary incontinence: a systematic review of randomized trials. Mayo Clin Proc 2008;83:1332–1343. 10.4065/83.12.1332 [DOI] [PubMed] [Google Scholar]
- 32.Thomas LH,Coupe J,Cross LD,Tan AL,Watkins CL: Interventions for treating urinary incontinence after stroke in adults. Cochrane Database Syst Rev 2019;2019:CD004462. 10.1002/14651858.CD004462.pub4 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Charlson ME,Pompei P,Ales KL,MacKenzie CR: A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–383. 10.1016/0021-9681(87)90171-8 [DOI] [PubMed] [Google Scholar]
- 34.Banks JL,Marotta CA: Outcomes validity and reliability of the modified Rankin scale: implications for stroke clinical trials: a literature review and synthesis. Stroke 2007;38:1091–1096. 10.1161/01.STR.0000258355.23810.c6 [DOI] [PubMed] [Google Scholar]
- 35.Kunieda K,Ohno T,Fujishima I,Hojo K,Morita T: Reliability and validity of a tool to measure the severity of dysphagia: the Food Intake LEVEL Scale. J Pain Symptom Manage 2013;46:201–206. 10.1016/j.jpainsymman.2012.07.020 [DOI] [PubMed] [Google Scholar]
- 36.Ottenbacher KJ,Hsu Y,Granger CV,Fiedler RC: The reliability of the Functional Independence Measure: a quantitative review. Arch Phys Med Rehabil 1996;77:1226–1232. 10.1016/S0003-9993(96)90184-7 [DOI] [PubMed] [Google Scholar]
- 37.Yoshimura Y,Wakabayashi H,Nagano F,Bise T,Shimazu S,Shiraishi A: Chair‐stand exercise improves post‐stroke dysphagia. Geriatr Gerontol Int 2020;20:885–891. 10.1111/ggi.13998 [DOI] [PubMed] [Google Scholar]
- 38.Shiraishi A,Yoshimura Y,Wakabayashi H,Tsuji Y: Poor oral status is associated with rehabilitation outcome in older people. Geriatr Gerontol Int 2017;17:598–604. 10.1111/ggi.12763 [DOI] [PubMed] [Google Scholar]
- 39.Mizuno S,Wakabayashi H,Yamakawa M,Wada F,Kato R,Furiya Y,Nishioka S,Momosaki R: Sarcopenia is associated with fecal incontinence in patients with dysphagia: implication for anal sarcopenia. J Nutr Health Aging 2022;26:84–88. 10.1007/s12603-021-1711-6 [DOI] [PubMed] [Google Scholar]