In the past few decades, researchers have attempted to quantify physical activity accurately in stroke survivors. This is important to develop future strategies for improving upper and lower limb functions, as well as increasing the quality of life for this specific population after a stroke.

1 in 3 people make a full recovery after stroke

Stroke is one of the leading causes of death in Singapore and worldwide. Physical activity plays a crucial role in facilitating functional recovery and lowering mortality rates. Research has shown that the lack of physical activity can result in adverse outcomes such as evitable loss of muscle mass and decreased functional independence. To promote physical activity among stroke survivors, the accurate measurement of physical activity is of paramount importance.

Measuring physical activity

A convenient method to measure physical activity is using accelerometers. Accelerometers such as the wGT3X-BT by Actigraph are useful in capturing metrics such as step count, activity duration and intensity. However, accelerometers are unable to assess the quality of physical activity accurately, such as whether the movements are functional, bilateral, or part of activities of daily living (ADL).

Development of the Behavioural Mapping Protocol

The research team from the Health and Social Sciences cluster at the Singapore Institute of Technology (SIT) has developed a behavioural map that can be used to assess the quality of physical activity in residential stroke survivors across different institutional settings in Singapore. Although requiring long observation hours, behavioural mapping is deemed the gold standard in mapping detailed physical activity as it involves direct observation. It also allows a greater understanding of the context of physical activity, i.e., where, when, and with who the physical activity was undertaken.

Led by Principal Investigator SIT Assistant Professor Choo Pei Ling, the research team worked on the development and validation of the behavioural map. This involved residential stroke survivors across four community hospitals and nursing homes to capture a myriad of rehabilitation settings. “We hope the behavioural map helps researchers and clinicians in Singapore assess the quality of physical activity after stroke and thus design effective strategies to increase physical activity and functional recovery of stroke survivors. The research work can also help pave the way for future accelerometers to be able to discern the quality aspect of physical activity.” said Principal Investigator SIT Assistant Professor Choo Pei Ling.

During data collection, residential stroke survivors recruited into the study donned three activity monitors for 24 hours and were observed for their physical activity during the day of up to 9 hours. Data collection was undertaken by the research team, which comprised Research Assistant Kam Jia En as well as seven undergraduate physiotherapy students who undertook the real-world applied research as part of their Honours research.

A nursing home stroke survivor ambulating during physiotherapy. The activity monitors are worn on both his wrists and right ankle to capture his upper and lower limb physical activity during the same period of behavioural mapping.

“We found that observers were able to classify all types of physical activity data while using the behavioural map. Observers were also able to gain insights on the amount and type of therapy provided to the stroke survivors. The behavioural map was also purposively tested across different stroke severities.” said Kam Jia En, a SIT Research Assistant.

“The behavioural map helps us to gain a better insight on what activities a stroke patient does in a day and which limb is engaged more.” said Juliana Wang, project collaborator and Senior Physiotherapist in Kwong Wai Shiu Hospital, on the benefits of the newly designed behavioural mapping protocol.

Echoing the same sentiment, Geetha Kunasaigaran, project collaborator and Principal Physiotherapist in Ang Mo Kio-Thye Hua Kwan Hospital, shared “The behavioural map allows us to understand the meaningful time spent amongst stroke patients in hospitals and what can be done to improve further on their care.”

This study is led by Principal Investigator Assistant Choo Pei Ling.

SIT Research Team – Assistant Professor Choo Pei Ling, Principal Investigator; Kam Jia En, Research Assistant; Physiotherapy students Sakinah Rafiq Tan Hui Ling, Tan Yi Wei, Teng Zhe Wei, Amoz Choy Zheng Rong, Jacelyn Tham Jie Ling, Lim Tongli, and Yeoh Xintong Velene.

Acknowledgements – We would like to thank the following organizations for supporting this research: Kwong Wai Shiu Hospital, Ang Mo Kio-Thye Hua Kwan Hospital, Saint Luke’s Hospital, United Medicare Centre, Active Global, Abilities Beyond Limitations and Expectations (ABLE), Methodist Welfare Services and Saint Luke’s ElderCare.

This study is funded by Singapore Institute of Technology.