Review question
We reviewed the evidence that examines the effects of treatments to reduce the amount of sedentary behaviour in people after stroke.
Background
'Sedentary behaviour' refers to sitting or lying down (e.g. sitting watching the television) during the daytime rather than being active and 'up and about'. After any kind of stroke, it is very common for people to spend a lot of time in sedentary behaviour. This is common both among stroke patients who are in hospital as well as those who have been discharged home. Sedentary behaviours are known to be damaging to health; they increase the risk of heart attacks and strokes, and increase the chance of dying. Spending less time sitting after stroke could reduce these risks for people during life after stroke. If sedentary time is reduced then, by definition, physical activity (such as walking) must increase. In combination, this could not only reduce health risks but also improve the way people with stroke move and the way they feel.
Study characteristics
In December 2019, after comprehensively searching the scientific literature, we identified 10 randomised controlled trials for inclusion in the review. The studies involved a total of 753 participants at all stages of care, including being in hospital or back to living at home. Most of the people who took part were able to walk and stand on their own. The interventions ranged in duration from six weeks up to 18 months and all involved some element of increased physical activity. Studies included exercise alone (one study) or in combination with education and coaching (one study); physical activity alone (one study) or in combination with a mobile phone 'app' (one study), multi-component lifestyle interventions including physical activity (four studies), and additional inpatient physiotherapy (one study). One study used an intervention specifically aimed at breaking up long periods of continuous sitting.
Because of problems in the ways they were conducted, and in the ways they were reported by the research teams, all studies were at high or unclear risk of bias.
Key results
Currently, the evidence shows that interventions to reduce sedentary behaviour do not increase or reduce death, cardiovascular events, falls or other adverse events, or amount of time spent sitting. However, even though the evidence is incomplete, there may still be value in people after stroke trying to sit less, providing it is safe to do so.
Certainty of the evidence
We assessed the 'certainty' of the evidence with the GRADE methodology. Our certainty about the effects of these interventions on death, cardiovascular events, and falls is low, and for their effects on other adverse events it is moderate. The certainty of the effects on sedentary behaviour itself is very low. Interest in sedentary behaviour after stroke is relatively recent; the main problem with the evidence is that very few studies have examined this to date. The available evidence tends to be restricted to patients after stroke who are more mobile. Many studies were not conducted for long enough periods to show longer-term changes in sitting behaviour, or changes in the risk of illness or death.
Sedentary behaviour research in stroke seems important, yet the evidence is currently incomplete, and we found no evidence for beneficial effects. Current World Health Organization (WHO) guidelines recommend reducing the amount of sedentary time in people with disabilities, in general. The evidence is currently not strong enough to guide practice on how best to reduce sedentariness specifically in people with stroke.
More high-quality randomised trials are needed, particularly involving participants with mobility limitations. Trials should include longer-term interventions specifically targeted at reducing time spent sedentary, risk factor outcomes, objective measures of sedentary behaviour (and physical activity), and long-term follow-up.
Stroke survivors are often physically inactive as well as sedentary,and may sit for long periods of time each day. This increases cardiometabolic risk and has impacts on physical and other functions. Interventions to reduce or interrupt periods of sedentary time, as well as to increase physical activity after stroke, could reduce the risk of secondary cardiovascular events and mortality during life after stroke.
To determine whether interventions designed to reduce sedentary behaviour after stroke, or interventions with the potential to do so, can reduce the risk of death or secondary vascular events, modify cardiovascular risk, and reduce sedentary behaviour.
In December 2019, we searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, Conference Proceedings Citation Index, and PEDro. We also searched registers of ongoing trials, screened reference lists, and contacted experts in the field.
Randomised trials comparing interventions to reduce sedentary time with usual care, no intervention, or waiting-list control, attention control, sham intervention or adjunct intervention. We also included interventions intended to fragment or interrupt periods of sedentary behaviour.
Two review authors independently selected studies and performed 'Risk of bias' assessments. We analyzed data using random-effects meta‐analyses and assessed the certainty of the evidence with the GRADE approach.
We included 10 studies with 753 people with stroke. Five studies used physical activity interventions, four studies used a multicomponent lifestyle intervention, and one study used an intervention to reduce and interrupt sedentary behaviour. In all studies, the risk of bias was high or unclear in two or more domains. Nine studies had high risk of bias in at least one domain.
The interventions did not increase or reduce deaths (risk difference (RD) 0.00, 95% confidence interval (CI) -0.02 to 0.03; 10 studies, 753 participants; low-certainty evidence), the incidence of recurrent cardiovascular or cerebrovascular events (RD -0.01, 95% CI -0.04 to 0.01; 10 studies, 753 participants; low-certainty evidence), the incidence of falls (and injuries) (RD 0.00, 95% CI -0.02 to 0.02; 10 studies, 753 participants; low-certainty evidence), or incidence of other adverse events (moderate-certainty evidence).
Interventions did not increase or reduce the amount of sedentary behaviour time (mean difference (MD) +0.13 hours/day, 95% CI -0.42 to 0.68; 7 studies, 300 participants; very low-certainty evidence). There were too few data to examine effects on patterns of sedentary behaviour.
The effect of interventions on cardiometabolic risk factors allowed very limited meta-analysis.