Contextual factors associated with walking performance after stroke: a systematic review and meta-analysis

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 Contextual factors associated with walking performance after stroke: a systematic review and meta-analysis

Yi ZhangLan Xu^*Xi Pan^*Lei ChenWeiying ZhongJiaxuan Li

• The First Affiliated Hospital of Soochow University, Suzhou, China

Objective: To describe the walking performance of patients with stroke and summarize the contextual factors associated with walking performance.

Methods: PubMed, Web of Science, Embase, and the Cochrane Library were searched from the inception to September 4, 2024. Observational studies on the walking performance of people with stroke and their contextual factors were eligible for inclusion. The relationship between contextual factors and walking performance was evaluated using Fisher’s z-value, which was then converted to correlation values (r).

Results: Thirty studies were included. Walking performance measures included step count, time, distance, and bouts; step count was most common, with pooled results showing a mean 4,296 steps/day after stroke. Guided by the contextual factors classification framework, we stratified the contextual factors of walking performance among subjects with stroke into three dimensions: user context, environmental context, and task context. Meta-analysis showed that walking endurance (r = 0.60; 95% CI, 0.46 to 0.71) was strongly correlated with the number of daily steps. Moderate correlations were found between daily step counts and gait speed (r = 0.41; 95% CI, 0.23 to 0.56), quality of life (r = 0.46; 95% CI, 0.34 to 0.56), self-efficacy (r = 0.30; 95% CI, 0.21 to 0.39), cardiorespiratory fitness (r = 0.36; 95% CI, 0.09 to 0.59), balance (r = 0.37; 95% CI, 0.02 to 0.65), and Rivermead Motor Assessment (r = 0.49; 95% CI, 0.26 to 0.65). Furthermore, age (r = −0.10; 95% CI, −0.18 to −0.02) and area deprivation index (r = −0.15; 95% CI, −0.24 to −0.06) were associated with the number of daily steps after stroke, but effect sizes were small.

Conclusion: Daily step counts among individuals with stroke were not guideline-compliant. Contextual factors can inform the design of context-aware interventions aimed at increasing daily step counts.

1 Introduction

Stroke is the second leading cause of death and the third leading cause of disability worldwide (1). Physical activity (PA) is defined as physical movement in which skeletal muscle contraction induces energy expenditure (2). PA has a robust health-promoting effect and improves the prognosis of patients with stroke. Adequate PA can improve cardiovascular health (3) and promote the functional recovery of patients with stroke (4, 5). In addition, PA can decrease negative emotions (depression, anxiety, etc.) after stroke (6, 7). Walking is the most frequent form of physical activity among individuals with stroke. In contrast to walking capacity (capability of a walking task in a clinical setting), walking performance refers to walking activities (i.e., daily steps, walking distance or duration of walking) in real-world settings (8). However, existing studies suggest that the walking performance of patients with stroke is much less than that recommended by the guidelines (9, 10). Therefore, improving walking performance among patients with stroke remains a priority for rehabilitation after stroke. Recently, mobile health (mHealth) has gradually become a research hotspot in the field of walking performance intervention because it fits the spatial and temporal dynamic characteristics of walking activities. Context-aware intervention is an emerging mobile intervention design that dynamically adjusts interventions based on an individual’s contextual information. Its core lies in the real-time optimization of intervention timing or content according to an individual’s contextual factors, which are defined as all information describing the status of entities, to enhance the accuracy, personalization, and effectiveness of the intervention (11, 12). Understanding and accurately obtaining contextual information can optimize intervention decisions. A systematic review indicated that context-aware interventions can effectively support behavioral changes to improve the health behaviors of users (13). However, the key contextual determinants of walking performance after stroke currently remain unclear.

To date, systematic reviews in this field have predominantly focused on physical activity (PA) among post-stroke individuals and its contextual factors, with no emphasis on walking performance as a distinct outcome. For instance, a systematic review by Thilarajah et al. (14) reported that factors such as age, gender, physical function, depression, fatigue, self-efficacy, and quality of life were significantly associated with PA. Although a number of studies included in this review utilized walking performance as an indicator of PA, their conclusions cannot be directly extrapolated to walking performance. This constraint, specifically, stems from the absence of subgroup analyses stratified by PA assessment methods. In addition, the heterogeneity among the existing studies in the selection of walking performance assessment indicators (e.g., frequency, intensity, etc.) and the measurement of the contextual factors has limited the comparison between studies.

To date, no standardized classification method for contextual factors has been established. A comprehensive classification framework was proposed by Chen (15), which categorizes contextual factors into user context, environmental context, and task context based on the requirements of context-aware technology and a user-centered approach. The user context dimension includes user attributes, living habits, and behavioral habits. The environmental context dimension includes the natural physical environment, comprising time, location, sunlight, and social environment (national customs and religious habits). Task context refers to the attributes and states of the behaviors associated with the user’s completion of the current task. The framework may provide a theoretical basis for the integration of multi-source contextual factors. Therefore, this study aimed to synthesize and categorize the contextual factors influencing walking performance in individuals with stroke, drawing on the contextual factor classification framework proposed by Chen (15) and to identify through quantitative synthesis those contextual factors demonstrating significant associations with walking performance. These efforts seek to provide a theoretical foundation for context-aware intervention development. Additionally, the study aimed to describe walking performance in individuals with stroke using real-world data, thereby updating the current status of walking performance among patients with stroke.

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