Physical activity in stroke patients: A scoping review

Stroke is the second leading cause of disability and death worldwide with 5.9 million deaths annually. Stroke can be followed by various clinical problems. Impaired motoric function of the extremities is the most severe post stroke disorder experienced and impacts on limitations of daily activities. The main treatment is by doing regular physical activity exercises. This review was conducted to identify physical activities that can be performed by stroke patients. This scoping review was compiled using Arksey and O'Malley's five-stage framework. A total of three databases (i.e., Pubmed, Proquest, and DOAJ) was searched with relevant keyword "physical activity OR exercise AND stroke". The articles selected are published in the last 5 years, in English, and in full text. The literature search retrieved 164 studies to be screened based on the exclusion-inclusion criteria which finally resulted in the 11 studies included in the review. The remaining 11 studies were fully read and data were extracted regarding the type of physical activity, goals, settings and outcomes. Qualitative (i.e., theme analysis) methods have been used to synthesis the data. Based on the results of the review, there are several physical activities that stroke patients can do, such as progressive resistance and balance (PRB) exercises, locomotors exercises: (walking on a treadmill with body weight support and walking on the ground), selective movements of the upper and lower trunk body in the Supine and sit using a stable support / pad or unstable support (Swiss ball), core stability training, aerobic (AT) and resistance training (RT), aerobic training, walking exercises, and task-oriented training. Several physical exercises have been identified where each of these exercises has a purpose and benefit in the recovery of physical functional stroke patients. Physical activity should be done regularly and take into account the duration, intensity, and frequency of the exercise based on patient’s ability and stamina.


Introduction
Stroke is the second leading cause of disability and death worldwide with 5.9 million deaths annually 1,2 . Stroke can be followed by various clinical problems. However, impaired motor function of the extremities is a major problem that is often found among sufferers. As much as 50% of stroke survivors experience hemiplegic and hemi paresis, fatigue, and instability of posture and balance that cause difficulty in walking and carrying out daily activities 3,4 . Six months after stroke, the problems can persist and result in long-term disability 4,5 .
The main handling of motor function disorders of the extremities can be through routine physical activity, both light to moderate physical activity.
Physical activity exercise increases muscle strength, functional capacity, ability to perform daily activities, gait, balance, improved cardiorespiratory measures and quality of life, and prevents cerebrovascularrelated risks [6][7][8][9][10][11] . Accordingly, post stroke patients are required to perform routine physical activity exercises in the rehabilitation phase so that the decrease in motor function of the extremities does not lead to long-term disability.
Stroke sufferers with low physical activity (less than four hours per week) have a 91% chance of experiencing secondary complications such as disability, pressure ulcer, pneumonia, and heart problems 6,12 . Low physical activity / sedentary behavior also has the potential to trigger complications of diabetes mellitus, repeated strokes and death [13][14][15][16] . Improving the stationary time (sedentary lifestyle) by 25-30 minutes per day can lower the risk of cardiovascular disease by 1% Amin et al.
Physical activity in stroke patients 15,16 . Therefore, stroke sufferers are advised to start physical activity exercise as soon as possible when the post stroke condition has stabilized. Thus, this review was conducted to identify various forms of physical activity for stroke patients. The results can be used to establish evidence-based, valid and reliable information concerning rehabilitation through physical exercise for stroke patients.

Method
This scoping review was compiled using Arksey and O'Malley's five-stage framework 17 . More details on our research protocol can be found below. In this section, we provide an overview of the steps.

Identifying the research question
Based on the purpose of this review, the formulation of this research question was: what physical activity can stroke patients do.

Identifying studies
Literature search was performed on the PubMed, Proquest, and DOAJ databases using the keywords: "physical activity OR exercise AND stroke". The articles selected are: (a) articles published in the last 5 years (2015-2020), (b) in English, and (c) in full text. The articles that were excluded were articles that were not in accordance with the objectives of the scoping review and articles in the form of a review.

Selecting studies
Researchers independently screened the published papers, first using the title and abstract approaches. Titles and abstracts were checked and then articles within the last 5 years of publication were scanned. Articles were also screened by excluding duplicate articles. To avoid duplication, all articles detected during the search were entered in the Mendeley application to detect duplicated articles. The screening results then were screened according to the inclusion and exclusion criteria

Charting the data
Data extraction for each included article was in the form of a matrix (table). The articles that have Physical activity in stroke patients been included were then extracted based on the details of publication and research, the author, year of publication, exercise/physical activity, setting, and results. The data obtained were analyzed and arranged systematically.

Collating, summarizing, and reporting results
Descriptive qualitative content analysis methods were used to synthesis and analysis the data

Search Result
Based on predetermined keywords, there were 164 identified articles. After the inclusion criteria were applied, the duplication of articles screened and their suitability for the purpose of writing this literature review, 11 articles were selected to be included in this literature review.

Physical activity of stroke patients
Based on the results of the analysis (Table 1), the authors identified physical activity / physical exercise that can be performed by stroke patients including progressive resistance and balance (PRB) training 18,19 , locomotors training: (walking on a treadmill with body weight support and walking on the ground) 18 , selective movements of the upper and lower trunk of the body in a supine position and sitting using a stable support / base or unstable support (Swiss ball) 20 , core stability training 21,22 , aerobic (AT) and resistance training (RT) 23,24 , aerobic training 25 , walking exercises 26 , and task-oriented training 27,28 .

Discussion
Physical activity that can be performed by stroke patients consists of several types, including balance exercises (i.e., core stability training, progressive resistance and balance (PRB) training, selective movements of the upper and lower trunk of the body in a supine position and sitting using a stable support / base or unstable support (Swiss ball)), walking exercises (i.e., locomotors training: (walking on a treadmill with body weight support and walking on the ground) and walking exercises), physical fitness training (i.e., aerobic training, aerobic (AT) and resistance training (RT), and exercise modification in the form of daily activities, namely task-oriented training.
Physical activity is an important part of the rehabilitation phase for stroke patients. Full family or caregiver assistance predisposes the patient to immobility. As a result, the body, especially the limbs, becomes weaker, gets tired easily and feels heavy movement. This sedentary pattern in turn increases the risk of recurrent stroke and secondary complications 25 .
Physical activity is the main health behavior for stroke sufferers as a form of health management and maintenance. Physical activity with certain modifications can reduce the risk of cardiovascular disease and protect the incidence of stroke recurrence. Modifications can be made in the form of basic activities such as daily activities at home 29,30 . Physical activity programs are structured based on the basic principles of motor learning such as intensive, specific tasks, included challenges and exercises 31 .
The duration, intensity, and frequency of exercise are also the main things to consider in order obtaining the best exercise outcome. Based on this literature review, it can be stated that almost all physical activity is done with duration of 30 minutes -1 hour for approximately 2-3 times a week. The core stability training is carried out with a relatively shorter duration of 15-20 minutes but the frequency is increased up to 5 times a week. This schedule is in accordance with the basic principles of an exercise program including specificity, repetition, meaningful movements, and intensity 32 . In fact, physiological exercise will activate the stimulus signal to increase protein synthesis of actin fibers and muscle myosin. Therefore, with intense exercise, the amount of actin protein and muscle myosin will increase progressively and will increase muscle energy and strength, ultimately developing better coordination, so that the patient can support the body and perform movements 33,34 .
Thus, the results of this review can be used as a supporting guideline for determining exercises/ physical activities that can be recommended to stroke rehabilitation patients so that the patient's   Step count and regularity were linearly correlated (p <0.001). The measures and their associated complexity were squared (r2 = 0.70 for mean, 0.64 for daily values). The complexity is affected by the seasons between spring and winter (p = 0. 019). Season has no effect on steps or structure. Rainfall has no effect on steps or complexity. Task

Conclusion
Through this review, empirical evidence identified findings regarding physical activity in stroke patients which provides the basis for routine implementation. Several physical activity exercises were identified to be the exercises that stroke patients can perform with each of them having goals and benefits in the physical functional recovery of stroke patients. Physical activity should be done regularly and take into account the duration, intensity, and frequency of the exercise in relation to a patient's ability and stamina. This review reveals how physical activity plays an important role in the physical improvement of stroke patients.