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. 2025 Sep 1;37(9):486–492. doi: 10.1589/jpts.37.486

Association between walking space and physical activity for hospitalized patients with stroke: a cross-sectional study

Sota Kobayashi 1,2,*, Satoshi Hasegawa 3, Shun Yamazaki 4, Tsubasa Tsugane 4, Shigeru Takahashi 3, Mieko Kaneko 3, Tomoyuki Asakura 5, Shigeru Usuda 5
PMCID: PMC12399302  PMID: 40895760

Abstract

[Purpose] This study aimed to investigate the associations among physical activity, sedentary patterns, and walking spaces in patients hospitalized after stroke. [Participants and Methods] This cross-sectional observational study included 52 patients (mean age, 72.6 ± 11.3 years) hospitalized following stroke. A triaxial accelerometer worn at the waist on the nonparetic side was used to estimate the time spent in sedentary behavior, light intensity physical activity, and moderate-to-vigorous intensity physical activity. Duration of sedentary behavior was categorized into two groups (either short bouts of 1 to 29 min or prolonged bouts of 30 min or more). Walking ability was categorized into four groups: Group D, walking dependence; Group R, walking independence within the room; Group W, walking independence within the ward; and Group F, walking independence within the facility. [Results] Groups W and F showed significantly longer durations of light intensity physical activity and shorter durations of prolonged sedentary behaviors (more than 30 min) compared to Group D. No differences in light intensity physical activity, sedentary behavior, or prolonged sedentary bouts were observed between groups R and D. Multivariate regression analysis revealed that walking ability was significantly associated with time spent in sedentary behavior and light intensity physical activity. [Conclusion] Increasing physical activity levels during hospitalization in patients with stroke depends not only on walking independence but also on the extent of available walking space.

Keywords: Sedentary behavior, Locomotion, Motor activity

INTRODUCTION

The cumulative risk of death at 10 years after first-ever stroke is increased compared to the general population of the same age and sex, with direct effects of the initial stoke and cardiovascular disease as the major causes of death1). In particular, physical inactivity provides the strongest predictor of stroke recurrence2). A systematic review reported that stroke survivors living in the community show a lower daily step count than age-matched healthy individuals3). Moreover, patients hospitalized following stroke are even more inactive than stroke survivors living in the community4,5,6). Decreasing sedentary behavior (SB) and increasing physical activity among patients hospitalized for stroke therefore represents an urgent issue.

A systematic review highlighted several modifiable factors influencing physical activity among stroke survivors, such as physical function, fatigue, and self-efficacy7). Among physical functions in patients with stroke, walking independence was associated with high levels of physical activity including step count8), time spent performing light-intensity physical activity (LPA; defined as activities with an intensity of 1.6–2.9 metabolic equivalents [METs])9), and standing or walking time10). Prior studies have focused on whether walking independence, however, the impact of the walking space (e.g., within the hospital room, ward, or facility) has not been examined.

SB is defined as “any waking behavior characterized by an energy expenditure ≤1.5 METs while in a sitting or reclining posture”11). The World Health Organization recommends reducing SBs across all age groups and abilities12). Among SBs, the concept of “sedentary bouts” (continuous sedentary time) has recently been used to characterize patterns of SB, and has been associated with physical function in older adults13, 14). Further, stroke survivors living in the community showed longer total time of >30-min sedentary bouts than age-matched healthy controls15). Sedentary bouts thus appear to provide an important measure of physical activity among community-dwelling stroke survivors, but have not been investigated for associations with the walking space in patients hospitalized for stroke. Stroke patients are less physically active than stroke survivors living in the community4,5,6), which may take the form of longer sedentary bouts.

Clarifying how much the walking space is associated with physical activity levels and sedentary bouts may provide useful information for promoting physical activity in patients hospitalized following stroke. We hypothesized that walking space within the ward and facility would increase physical activity and reduce prolonged sedentary bouts, because patients tend to spend most of their time in bed when they are in their rooms16). The aim of this study was thus to examine the association between physical activity level and walking space.

PARTICIPANTS AND METHODS

This cross-sectional observational study was conducted in the convalescent rehabilitation unit of a single hospital in Japan from March 2021 to June 2022. The inclusion criteria were: 1) participants admitted with a diagnosis of stroke; and 2) ability to manage an accelerometer during the day. Exclusion criteria were: 1) unstable conditions requiring medical treatment; 2) complications or past medical history affecting ambulation; or 3) discharge within 1 week. This study was approved by the ethics review committee of Nanokaichi Public Hospital (approval no. 20200120). All participants provided both verbal and written informed consent. This study conformed to the criteria of the Strengthening the Reporting of Observational Studies in Epidemiology statement17).

Age, sex, height, weight, body mass index, type of stroke (cerebral infraction or intracerebral hemorrhage), paretic side (right or left), and date of onset were collected from the electronic medical records at the time of admission. Time since stroke was calculated based on the date of onset and the start of accelerometer measurement. Brunnstrom recovery stage of the paretic lower extremity18), Mini-Mental State Examination (MMSE)19) and Berg Balance Scale (BBS)20) were evaluated by the physiotherapist and occupational therapist in charge within 1 week of admission.

Physical activity and sedentary bouts were measured using an Active Style Pro HJA-750C triaxial accelerometer (ASP-750C; Omron Healthcare Co., Kyoto, Japan). The ASP-750C has the same algorithm as its predecessor, the Active Style Pro HJA-350IT. The accelerometer can calculate METs in 10-s and 60-s epochs based on diverse body movement and allows highly accurate assessment of activity21,22,23). The accelerometer has also been used in patients hospitalized following stroke, and its reliability and validity have been verified24, 25). Activity intensity was classified as: SB, ≤1.5 METs26); LPA, 1.6–2.9 METs; or moderate-to-vigorous intensity physical activity (MVPA), ≥3.0 METs. Based on previous studies13, 15), SB bouts were divided into two groups to investigate sedentary patterns: 1- to 29-min SB bouts; and ≥30-min SB bouts.

Measurements of physical activity and sedentary bouts were made on three weekdays from the second to third week after admission. The first week after admission was used as a period for evaluation and explanation of the study, including whether the patient met all the inclusion criteria and none of the exclusion criteria. The ASP-750C was attached to the waist of the patient on the non-paretic side before 08:30 and removed after 17:00 by the principal investigator. Days of wearing were set to exclude bathing days whenever possible. For those days of wearing on which the patient did bathe, they were asked to note what time they bathed and self-report this information. Bathing times were then excluded during data processing. Physical activity was measured by averaging the activity time from 08:30 to 17:00 over the 3-day period.

Patients were categorized into groups according to the walking space, as follows: Group D, walking dependence; Group R, walking independence within own room; Group W, walking independence within the ward (a straight 100-m corridor); and Group F, walking independence within the facility (inside the 1st to 4th floors of the hospital), based on the electronic medical records during the period in which the patient was fitted with the ASP-750C. The classification of walking independence was performed referring to the Life-Space Assessment in Institutionalized Settings and the nursing home life-space diameter27, 28). The walking space for patients was determined by physical therapists, occupational therapists, doctors, and nurses in consultation, based on assessments of balance (BBS), cognitive function (MMSE), and actual performance. And we identified at least one activity occurring in the walking space, as defined by the electronic medical record.

All statistical analyses were performed using SPSS Statistics version 27.0 (IBM, Tokyo, Japan). Values of p<0.05 were considered significant. Descriptive statistics are presented as numbers and percentages or means and standard deviations. Physical activity and SB were presented for each mobility group. To confirm whether there is a main effect on walking space, one-way analysis of variance (ANOVA) was used. Multiple comparisons after ANOVA were performed using Dunnett’s test with Group D as the control group.

In multivariate regression analysis, SB, LPA and MVPA times were designated as dependent variables, and age, sex, walking space, MMSE score, and BBS score as independent variables, based on previous studies8, 29,30,31,32). Sex was converted to a dummy coded variable with 1 for men and 0 for women. Walking space was categorized using the following ordinal scale: 1 for walking dependence, 2 for walking independence within own room, 3 for walking independence within the ward, 4 for walking independence within the facility. Sample size calculations were not performed because this study was conducted as a secondary analysis of another study33).

RESULTS

Participant flow through the present study is shown in Fig. 1. Of the 337 patients hospitalized in the rehabilitation unit during the study period, 75 patients met the inclusion criteria. Of these 75 eligible patients, 22 patients were then excluded (8 patients declined to participate, 3 patients were discharged within 1 week, 7 patients were in an unstable condition, 3 patients had complications or a relevant medical history, and 1 patient represented a duplicate case). One patient was discontinued because of discomfort while fitting the accelerometer. Finally, 52 patients with a mean age of 72.6 ± 11.3 years were included in the present study. Patient demographic and clinical characteristics are shown in Table 1. In terms of the walking space, 16 patients were categorized to Group D, 12 patients to Groups R, 15 patients to Group W, and 9 patients to Group F.

Fig. 1.

Fig. 1.

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Participant flow in this study.

Table 1. Patient demographic and clinical characteristics.

Age, years 72.6 ± 11.3
Sex (male), n (%) 40 (75.5)
Height, cm 161.2 ± 9.5
Weight, kg 58.9 ± 12.6
Body mass index, kg/m2 22.5 ± 3.6
Type of stroke, n (%)
Cerebral infraction 41 (78.8)
Intracerebral hemorrhage 11 (21.2)
Affected side, n (%)
Right 26 (50.0)
Left 26 (50.0)
Time since stroke, days 29.9 ± 8.6
Brunnstrom recovery stage of lower extremity
Stage II, n (%) 1 (1.9)
Stage III, n (%) 2 (3.8)
Stage IV, n (%) 2 (3.8)
Stage V, n (%) 21 (40.4)
Stage VI, n (%) 26 (50.0)
Mini-Mental State Examination, points 24.8 ± 4.0
Berg Balance Scale, points 41.3 ± 16.4
Walking space
Group D 16 (30.8)
Group R 12 (23.1)
Group W 15 (28.8)
Group F 9 (17.3)
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Group D, walking dependence; Group R, walking independence within own room; Group W, walking independence within the ward; Group F, walking independence within the facility.

Table 2 shows mean physical activity and sedentary pattern for each walking space group. Both Group W and Group F showed significantly higher LPA times than Group D. Group W showed significantly higher MVPA times than Group D. For sedentary pattern, both Group W and Group F showed lower SB times and total time for ≥30-min SB bouts than Group D. Total time for 1- to 29-min SB bouts did not differ significantly between walking abilities groups.

Table 2. Physical activity and sedentary bouts for each level of walking space.

All participants Group D (n=16) Group R (n=12) Group W (n=15) Group F (n=9) p-value
SB time, min 385.8 ± 53.7 423.6 ± 44.8 392.7 ± 25.4 366.7 ± 39.6†† 341.4 ± 71.7†† **
Time of 1- to 29-min SB bouts, min 188.8 ± 57.0 169.4 ± 63.9 184.1 ± 51.1 201.2 ± 62.2 208.9 ± 34.0
Time of ≥30-min SB bouts, min 197.0 ± 95.7 254.2 ± 103.4 208.6 ± 71.3 165.5 ± 87.4† 132.5 ± 68.3†† **
LPA time, min 115.1 ± 44.3 84.1 ± 43.6 113.6 ± 22.6 127.5 ± 30.6†† 151.3 ± 53.7†† **
MVPA time, min 7.7 ± 13.1 2.3 ± 1.8 2.5 ± 1.8 14.4 ± 17.8† 13.2 ± 17.7 **
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Values are given as mean ± standard deviation.

**p<0.05; †p<0.05 compared with walking dependence; ††p<0.01 compared with waking dependence. One-way ANOVA was used to investigate differences among walking space. Dunnett’s test with dependence as a control shows the significance of walking space.

SB: sedentary behavior; BST: breaks in sedentary time; LPA: light-intensity physical activity; MVPA: moderate-to-vigorous intensity physical activity.

The results of a multiple regression analysis are shown in Table 3. SB time and LPA time were significantly associated with the walking space. MVPA time was not associated with any variables.

Table 3. Multivariate regression analysis for physical activity.

SB (adjusted R2=0.29) LPA (adjusted R2=0.25) MVPA (adjusted R2=0.13)
β B (SE) 95% CI p-value β B (SE) 95% CI p-value β B (SE) 95% CI p-value
Age 0.133 0.635 (0.612) −0.597 to 1.866 0.305 −0.099 −0.389 (0.518) −1.432 to 0.654 0.457 −0.139 −0.161 (0.166) −0.495 to 0.173 0.336
Sex 0.086 10.877 (16.892) −23.13 to 44.880 0.523 −0.137 −14.269 (14.309) −43.07 to 14.533 0.324 0.061 1.875 (4.578) −7.340 to 11.090 0.410
MMSE −0.142 −1.894 (1.655) −5.226 to 1.438 0.258 0.111 1.215 (1.402) −1.607 to 4.037 0.391 0.167 0.543 (0.449) −0.360 to 1.445 0.146
BBS −0.125 −0.412 (0.578) −1.576 to 0.752 0.480 0.124 0.337 (0.490) −0.649 to 1.323 0.495 0.088 0.071 (0.157) −0.245 to 0.386 0.654
Walking space −0.428 −20.943 (8.491) −38.03 to −3.851 0.017 0.410 16.517 (7.192) 2.040 to 30.994 0.026 0.285 3.404 (2.301) −1.228 to 8.036 0.146
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SE: standard error; 95% CI: 95% confidence interval; SB: sedentary behavior; LPA: light-intensity physical activity; MVPA: moderate-to-vigorous intensity physical activity; MMSE: Mini-Mental State Examination; BBS: Berg balance scale.

DISCUSSION

The aim of this study was to clarify the association between physical activity and sedentary pattern and walking space. Our results suggested that the walking space was associated with physical activity, and only the ability to walk independently within the hospital room was not associated with increased physical activity. This finding shows that not only the achievement of independence, but also the walking space for which independence is achieved represent important factors for increasing physical activity, and that inpatients may benefit from increased physical activity.

Both Group W and Group F showed higher LPA times than Group D. These results support findings from a previous study that patients with independent walking displayed higher physical activity than patients with dependent walking8,9,10). Independent walking thus appears important for increasing physical activity. However, this study also found that Group R showed no significant difference in physical activity or sedentary pattern compared to the Group D controls. Previous study is reported that patients with stroke spend approximately 65% of their time in bed when in their room between 8:00 and 17:0016). This means that physical activity may be less likely to increase during the time spent in the room, as much of the time is spent in bed. Our suggestion is that increasing the physical activity undertaken by patients with stroke needs to consider space of walking independence.

Regarding SB time and the total time of ≥30-min SB bouts, Groups W and F showed significantly lower results than Group D, although the time for 1- to 29-min SB bouts did not differ significantly between groups. Overall, participants in this study spent 197.0 ± 95.7 min (38.6 ± 18.8%) in ≥30-min SB bouts. Stroke survivors living in the community spent 285 ± 132 min (43 ± 20%) in ≥30-min SB bouts, and matched pairs of older adults showed a time of 255 ± 115 min (33 ± 15%) in a previous study15). The present results were similar to those of stroke survivors in terms of the high percentage of ≥30-min SB bouts. Stroke survivors might thus spend more time in ≥30-min SB bouts regardless of community or hospital settings. Prolonged sedentary bouts are associated detrimental cardiometabolic effects like higher insulin in healthy adults34). While sitting with 3 min of LPA exercise while standing every 30 min are decreased systolic blood pressure compared with sitting for 8 h uninterrupted in stroke survivors35). Therefore, to prevent recurrence stroke, interventions are needed not only to increase physical activity but also to reduce prolonged SB. Furthermore, based on the results of this study, encouraging reductions in prolonged SB is clinically important, especially in patients with walking dependence.

A key strength of this study was that walking ability was divided into walking space. Previous studies have reported that walking independence is more physically active than walking dependence8,9,10), but have not mentioned the environment in which such independence was enacted. The findings of this study suggest that clinicians should not only determine whether walking independence has been achieved, but also note the environment in which independence is achieved. Another strength was that this study clarified the sedentary pattern, such as SB bouts in patients after stroke. SB bouts have been reported for community-dwelling patients15), but have not yet been clarified for hospitalized patients. This study is the first to report on SB bouts in hospitalized patients.

This study had several limitations that need to be kept in mind. First, because this study used a cross-sectional design, directions of causality remain unclear. Second, while some groups in this study were divided according to the walking space, the frequency of walking could not be examined. How often patients with stroke were active in the walking space (i.e., daily or other) thus remains unclear. Third, this study did not conduct sample size calculations before analysis because of the secondary analysis. The limited sample size may have increased the risk of type II error, potentially leading to an inability to detect statistical differences. Post-hoc analysis showed that statistical power was below 0.8 for the comparison of 1–29 bouts in a one-way ANOVA (power=0.34) and for MVPA examined using multiple regression analysis (power=0.49). To address this limitation, subsequent research should include a larger sample to enhance the generalizability of the findings; specifically, at least 144 participants for univariate analysis and 92 participants for multiple regression analysis are required to ensure adequate statistical power. Fourth, this study was unable to perform a multivariate analysis that included all factors that could influence the amount of physical activity, because this study was performed using participants from only a single hospital. In the future, multivariate analysis should be performed using data with greater external validity from other facilities.

In conclusion, this study examined the association between physical activity and walking ability relative to dependence. LPA and MVPA time were significantly higher in Group W and F patients with stroke than Group D patients. The SB was significantly lower in stroke patients in Groups W and F than in Group D, especially for bouts lasting more than 30 min. Expanding the space for independent walking is important to increase physical activity during hospitalization.

Funding

This work received no funding.

Conflict of interest

The authors declare no conflicts of interest.

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