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Effects on sedentary behaviour of
an approach to reduce sedentary
behaviour in patients with minor
ischaemic stroke: A randomised
controlled trial
Ryota Ashizawa
1
, Hiroya Honda
2,3
, Koki Take
4
,
Kohei Yoshizawa
2,5
, Yuto Kameyama
2,5
,
and Yoshinobu Yoshimoto
2
Abstract
Objectives: To determine the effects on sedentary behaviour of an approach that promotes reduction in
sedentary behaviour in patients with minor ischaemic stroke after intervention and at follow-up.
Design: A randomised controlled trial.
Setting: During hospitalisation and after hospital discharge
Subjects: In total, 86 patients with minor ischaemic stroke admitted to an acute care hospital were
assigned to the intervention (n =43) and control (n =43) groups.
Intervention: An intervention group that received an approach to reduce sedentary behaviour upon hos-
pital admission until 3 months after discharge (education, self-monitoring, phone calls, etc.) and a control
group that received the usual care during hospitalisation. From 3 to 6 months after discharge, no group
received any intervention.
Main Outcome: The primary outcome was the change (%) in sedentary behaviour from baseline to post-
intervention (3 months after discharge) and follow-up (6 months after discharge). Sedentary behaviour was
measured at baseline (upon hospital admission), post-intervention, and at follow-up using accelerometers.
Results: At the post-intervention stage, the intervention group showed a significantly greater change in
sedentary behaviour from baseline than that shown by the control group (sedentary behaviour: interven-
tion group, −22.7%; control group, −14.9%; P=0.013; effect size =0.58). At follow-up too, the interven-
tion group showed a significantly greater change in sedentary behaviour from baseline than that shown by
1
Department of Rehabilitation, Seirei Mikatahara General Hospital, Hamamatsu, Japan
2
Division of Rehabilitation Science, Seirei Christopher University Graduate School, Hamamatsu, Japan
3
Department of Rehabilitation, Hanadaira Care Center, Hamamatsu, Japan
4
Visiting Nurse Station Sumiyoshi-daini, Seirei Care Center Sumiyoshi-daini, Hamamatsu, Japan
5
Department of Rehabilitation, Hamamatsu City Rehabilitation Hospital, Hamamatsu, Japan
Corresponding author:
Ryota Ashizawa, Department of Rehabilitation, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu-shi,
Shizuoka 433-8558, Japan.
Email: 19dr01@g.seirei.ac.jp
Original Research Article
Clinical Rehabilitation
1–12
© The Author(s) 2022
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/02692155221135412
journals.sagepub.com/home/cre
the control group (sedentary behaviour: intervention group, −20.4%; control group, −13.6%; P=0.025;
effect size =0.54).
Conclusions: An approach to reduce sedentary behaviour in patients with minor ischaemic stroke effect-
ively reduces sedentary behaviour, which is sustained up to follow-up.
Trial registration: This study is registered at www.umin.ac.jp/ctr/index/htm UMIN000038616.
Keywords
sedentary behaviour, minor ischaemic stroke, randomised controlled trial, post-intervention, follow-up
Received May 5, 2022; accepted October 10, 2022
Introduction
Cumulative recurrence rates in patients with ischae-
mic stroke are as high as approximately 5%–17% at
1 year, 14%–26% at 5 years, and 51% at 10 years
after ischaemic stroke.
1
Most ischaemic strokes
are minor strokes
2
; therefore, the prevention of
recurrence is important. Reducing sedentary behav-
iour is recommended for the prevention of recurrent
ischaemic stroke.
3
Behavioural change and environmental approaches
are effective in reducing sedentary behaviour,
4,5
but
published studies on the effectiveness from discharge
until follow-up are few, and evidence is sparse.
6
Since
sedentary behaviour is more common in patients with
minor ischeamic stroke than in healthy individuals,
7
it
is necessary to clarify the effectiveness of approaches
to reduce sedentary behaviour in this cohort. Although
we previously established the effectiveness of an
approach to promote the reduction of sedentary
behaviour in patients with minor ischaemic stroke,
8
the sample size was small, suggesting the need for
further study.
Considering the high cumulative recurrence rate
of ischaemic stroke,
1
long-term continuation of
behavioural change to reduce sedentary behaviour
and prevent recurrence is important. However, in a
systematic review of adult patients with stroke,
9,10
it was noted that there were no studies examining
the effects of approaches to reduce sedentary behav-
iour up to follow-up. Our previous study
8
also did
not report effects lasting until follow-up.
This study aimed to determine the effects on sed-
entary behaviour of an approach that promotes
reduction in sedentary behaviour in patients with
minor ischaemic stroke post-intervention and at
follow-up using a randomised controlled trial design.
Methods
Study Design
This randomised control trial investigated two groups:
the intervention group (approaches to promote a
reduction in sedentary behaviour) and the control
group (usual care). All data were collected from
Hamamatsu, Japan. The study protocol was approved
by our institutional review board (19057, 19–46) and
registered with the University Hospital Medical
Information Network (UMIN000038616). Written
informed consent was obtained from all the partici-
pants. This study was conducted in compliance with
the guidelines of the Declaration of Helsinki.
Participants
Participants were hospitalized for ischaemic stroke in
an acute care hospital between December 2019 and
June 2021. Inclusion criteria were (i) age >50 years
and (ii) no history of mental disorder. Minor ischae-
mic stroke was defined as a National Institute of
Health Stroke Scale score (NIHSS) ≤5 in accordance
with previous studies.
11,12
Therefore, exclusion cri-
teria were (i) NIHSS ≥6, (ii) cognitive impairment
including mild cognitive impairment (Mini-Mental
State Examination Japan version score of < 24),
(iii) did not agree to participate in the study (iv)
2Clinical Rehabilitation 0(0)
had worsening neurological symptoms during hospi-
talization and a NIHSS of ≥6.
Assignment to the intervention or control groups
was performed by block randomisation with four
blocks and six samples in a random number table
created using Microsoft Excel 2016 (Microsoft,
Washington, USA).
All interventions, evaluations, and analyses
were performed by the principal investigator and
two collaborators. Therefore, we were not blinded
in the intervention, evaluation, and analysis.
Interventions During Hospitalisation
Participants in the intervention group received
approaches to reduce sedentary behaviour, whereas
those in the control group received usual care during
hospitalisation. Intervention during hospitalisation
periods and frequencies were similar between the
intervention and control groups. Both intervention
and control group participants received the approach
twice (20 min/session) during hospitalization.
Interventions During Hospitalisation
Intervention Group
The intervention group received (1) education on
reducing sedentary behaviour using a pamphlet,
(2) goal setting for sedentary behaviour after hos-
pital discharge, and (3) self-monitoring of screen
time and the number of steps using a checklist
Education on reducing sedentary behaviour
included the importance of reducing sedentary
behaviour, target values for sedentary behaviour,
and ‘do not sit’,‘stand,’and ‘move more’instruc-
tions. Regarding the target values for sedentary
behaviour, we set a target for screen time, which
was representative of sedentary behaviour, and
the target was <3 h per day. Specific targets for
screen time are not defined. Since the average
screen time of the elderly in Japan is estimated to
be about 200–300 min,
13
this study set a target of
fewer than 180 min (3 h), which is lower than the
average value for the elderly in Japan. In the self-
monitoring of screen time and steps using a check-
list, we instructed the participants to record daily
screen time, steps, and sedentary behaviour and
provide feedback on their records once a week.
Self-monitoring using a checklist was based on a
previous study.
14
The intervention group received
only education and goal setting regarding the pro-
motion of sedentary behaviour reduction. Since
the accelerometer displays the number of steps
taken, only the recommended target number of
steps was provided, and self-monitoring of the
number of steps was performed.
Control Group
The control group was not given approaches to
reduce sedentary behaviour but was educated to
increase physical activity and provided with infor-
mation on recommended step targets as well as
time and frequency of physical activity.The control
group received (1) education on increasing physical
activity levels using a pamphlet and (2) self-
monitoring of the number of steps using a checklist
education on increasing physical activity levels
included explaining the importance of physical
activity and target values. In the self-monitoring of
steps using a checklist, we instructed the participants
to record their daily steps and provide feedback on
their records once a week.
Intervention After Hospital Discharge
Intervention Group
After hospital discharge, the intervention group
continued with self-monitoring of screen time and
the number of steps using a checklist, received
stickers containing information about reducing sed-
entary behaviour, and received phone calls once
every 2 weeks for encouragement and feedback.
We checked the screen time on the checklist and
provided feedback on whether we met our goals.
Once a month, after the accelerometer was
replaced, feedback was also given on sedentary
behaviour (%), and participants were encouraged
to further reduce screen time and sedentary behav-
iour．The stickers contained words and figures,
encouraging people to reduce their sedentary
behaviour. We sent 10 stickers to each participant
and informed them to place them in visible
Ashizawa et al. 3
locations. We also provided feedback on sedentary
behaviour and the number of steps obtained
recorded by the accelerometer．
Control Group
The control group only wore the accelerometer. In
Japan, a post-discharge approach is not usually
used for patients with minor ischaemic stroke after
discharge from the hospital, so the control group
was approached only during hospitalisation.
The follow-up period
The follow-up period was from post-intervention (3
months after discharge) to 6 months after discharge,
during which no approach was provided.
Behaviour Change Techniques
As education, goal-setting, feedback and telephone
interventions have been reported to be effective in
behaviour change in previous studies,
15–17
these
techniques were used in this study.
Assessments
The primary outcome was the change (%) in seden-
tary behaviour from baseline to post-intervention (at
3 months after hospital discharge) and follow-up (at 6
months after hospital discharge) The secondary out-
comes were the change in light-intensity physical
activity, moderate-to-vigorous-intensity physical
activity, number of steps, screen time and self-
efficacy physical activity scale, depressive symptoms
by the Geriatric Depression Scale 15, and sleep dis-
orders according to the Japanese version of the
Pittsburgh Sleep Quality Index . The primary and
secondary outcomes were measured at baseline
(upon admission), post-intervention, and follow-up.
Sedentary behaviour was measured using an
accelerometer (Active Style Pro HJA-750C,
OMRON, Kyoto, Japan). Sedentary behaviour
was defined as an ‘activity of ≤1.5 metabolic
equivalents of task’,
18
and the percentage of time
spent performing the activities that require ≤1.5
metabolic equivalents of tasks was defined as the
sedentary behaviour percentage. The metabolic
equivalents of tasks were calculated every 10 s. A
previous study reported the reliability and validity
of accelerometers.
19,20
The validity of acceler-
ometers has also been reported in patients with
stroke.
21,22
We used only data from participants
who wore the accelerometer for at least 10 h per
day for at least 3 days.
23
The average value of the
adopted data was used as the representative value.
Participants wore the accelerometers continuously
during hospitalisation and until 3 months after hos-
pital discharge.Then, for follow-up assessments,
participants were reattached to the accelerometer
from 5 to 6 months after hospital discharge．
Data obtained from accelerometers can be classi-
fied into light-intensity physical activity and
moderate-to-vigorous-intensity physical activity
according to the metabolic equivalents values of
tasks.
24
In this study, 1.6–2.9 metabolic equivalents
of tasks were considered light-intensity physical activ-
ity, and more than 3.0 metabolic equivalents of tasks
were considered moderate-to-vigorous-intensity phys-
ical activity. In this study, the percentage of activity
time between 1.6–2.9 METs for the total wearing
time was defined as light-intensity physical activity
(%) and activity time above 3.0 METs as moderate-
to-vigorous-intensity physical activity (%).The total
number of steps recorded by each accelerometer was
calculated as the number of steps taken by each par-
ticipant. Metabolic equivalents of tasks values and
step counts obtained from accelerometers are more
accurate at higher walking speeds,
25
and since the
average walking speed of a participant in this study
was 1.4 m/s, which is equivalent to that of healthy
older adults, the validity of the metabolic equivalents
of tasks and step counts obtained from this study is
assured.
Based on previous studies, we investigated the
amount of screen time (leisure time computer/
Internet usage, TV/video/DVD viewing, and com-
puter gaming) within a normal week.
26
The base-
line was the screen time before admission, which
was determined using the recall method. Screen
time at 3 months and 6 months after discharge
was assessed using the original questionnaire
(appendix). Previous studies have shown this
scale to be reliable and valid.
26
Self-efficacy was measured using the Japanese
version of the Self-Efficacy Physical Activity
4Clinical Rehabilitation 0(0)
Scale.
27
This scale measures five activity load
classes for four physical activities: walking, stair-
climbing, weightlifting, and push-ups. Possible
responses ranged from 0% (cannot do at all) to
100% (can absolutely be done), with higher
scores indicating greater self-efficacy. We con-
verted the five activity load values into 0–100
points, with the average value considered as the
representative value. In this study, we adopted
only the self-efficacy physical activity values for
walking. The Self-Efficacy Physical Activity
Scale has been shown to be reliable for assessing
physical activity levels in frail older people and
patients with cardiovascular disease.
27,28
Depressive symptoms were assessed using the
Geriatric Depression Scale 15 (GDS15). GDS15,
a 15-item assessment of depression, is a shortened
version of the original 30-item GDS.
29
Each item
is answered with a choice of “yes”or “no”and
evaluated with a score of 0 or 1. The total score
ranges from 0 to 15.
30
A score of 6 or more was
considered as having “depressive symptoms”with
reference to previous studies.
31
The reliability and
validity of the GDS15 have been reported,
30,32
and used in previous stroke patients.
33
Sleep disorders were assessed using the Japanese
version of the Pittsburgh Sleep Quality Index, which
comprises questions about sleep quality, time one
falls asleep, sleep duration, and the use of sleeping
pills,
34
each of which was coded on a 4-point scale
(0–3 points), with a score ranging from 0 to 21
points. A score of 6 or higher indicated the presence
of a sleep disorder. Previous studies have reported
the reliability and validity of the Japanese version
34
and it has been used in previous stroke patients.
35
Data regarding the characteristics of the partici-
pants, including sex, age, body mass index, marital
status, number of people living with the patient,
employment status before admission, alcohol con-
sumption before admission, smoking status before
admission, history of falls in the past year, driving
time before admission, dog breeding before admis-
sion, and length of hospitalisation were obtained
from medical records and through interviews. We
measured the National Institute of Health Stroke
Scale and Mini-Mental State Examination scores at
the beginning of rehabilitation. In addition, we
measured their 6-min walking distance, 10-metre
maximum walking speed, and 30-s chair stand
within 3 days of independent walking.
Samlpe Size
G*power (version 3.1; HU Düsseldorf) was used to
calculate the sample size required to identify the differ-
ences in the primary outcomes between the two
groups. The sample size was 66 (33 per group) with
an alpha level of 0.05 and power of 80%, referring to
the effect size d =0.62 in a previous study.
36
With ref-
erence to our previous study,
37
we assumed a dropout
rate of 25% and a target sample size of 88 participants.
Statistical Analyses
We compared the characteristics of the participants
and baseline outcomes between the two groups
using an unpaired t-test or chi-square test. We com-
pared the change from baseline in primary and sec-
ondary outcomes at post-intervention and follow-up
with an unpaired t-test. Prevalence of sleep disorders
and depressive symptoms at post-intervention and
follow-up were compared using the chi-square test.
We obtained the effect size d for the parametric ana-
lysis of the change between the two groups. All stat-
istical analyses were conducted using SPSS Statistics
(version 24.0; IBM, Illinois, USA), and the level of
statistical significance was set at an alpha of 0.05.
Results
Of 181 patients recruited, 95 were excluded and 86
patients were randomised (average age, 71.6 years;
58 males). Of the 86 patients 78 (90%) completed
the study until post-intervention, and 73 (84%)
completed the study until follow-up (Figure 1). 3
patients in the intervention group and 1 in the
control group experienced a recurrent ischaemic
stroke, and there was no significant difference
between the two groups (P=0.56). Those who
completed and withdrew from the study showed
similar baseline characteristics.
Loss-to-follow-up factors in the intervention
group were recurrence of ischaemic stroke in 2
patients, hospitalization for other diseases in 2
Ashizawa et al. 5
patients, and disagreement after participation in the
study in 2 patients. In the control group,
loss-to-follow-up were due to recurrence of ischae-
mic stroke in 1 patient, disagreement after partici-
pation in the study in 4 patients, and insufficient
time to wear the accelerometer in 2 patients.
The characteristics of the 86 patients, which
were similar between the two groups, are shown
in Table 1. The baseline results were similar
between the two groups (Table 2).
Table 2 shows baseline values, changes from base-
line in post-intervention and follow-up assessments,
and results of between-group comparisons. In the post-
intervention assessment, the intervention group
showed significantly greater reductions in sedentary
behaviour and screen time than the control group (sed-
entary behaviour: intervention group −22.7%, control
group −14.9%, P=0.013, 95% Confidence interval–
13.88ー−1.65，effect size =0.58; screen time: inter-
vention group −261.3 min/week, control group
343.1 min/week, P=0.003, 95% Confidence interval
−995.95ー−212.82 ,effect size =0.70), with signifi-
cantly greater increases in moderate-to-vigorous-
intensity physical activity (moderate-to-vigorous-
intensity physical activity: intervention group 8.3%,
control group 5.1%, P=0.028, 95% Confidence inter-
val 0.36ー6.09, effect size =0.52). In the follow-up
assessment, the intervention group showed signifi-
cantly greater reductions in sedentary behaviour and
screen time than the control group (sedentary
behaviour: intervention group −20.4%, control
group −13.6%, P=0.025, 95% Confidence inter-
val–12.67ー−0.88, effect size =0.54; screen time:
intervention group −300.9 min/week, control group
251.4 min/week, P=0.047, 95% Confidence interval
−1097.95ー−6.51, effect size =0.48),with signifi-
cantly greater increases in light-intensity physical
activity（light-intensity physical activity: interven-
tion group13.9%,control group 9.2%, P=0.048,
95% Confidence interval 0.03ー9.49, effect size =
0.47). Both results were positive for the intervention
group.
Table 1. Characteristics of the participants in the intervention and control groups.
Characteristics of the participants All(n =86)
Intervention
(n =43) Control(n =43)
p
value
Sex, % Male:67.4,
Female:32.6
Male:67.4,
Female:32.6
Male:67.4,
Female:32.6
1.000
Age, y 71.6 ±8.0 72.0 ±8.4 71.8 ±7.6 0.686
Body Mass Index，kg/m
2
23.5 ±3.2 23.0 ±2.6 24.1 ±3.6 0.102
Marital status,% 94.2 97.7 90.1 0.167
Number of people living with the patient,n 2.9 ±1.6 3.1 ±1.7 2.7 ±1.6 0.322
Employment status before admission, % 52.3 51.2 53.5 0.829
Alcohol consumption before admission,% 44.2 46.5 41.9 0.664
Smoking status before admission,% 16.3 14 18.6 0.559
History of falls in the past year,% 23.3 16.3 30.2 0.126
Driving time before admission, minute/
week
449.8 ±496.4 442.1 ±432.5 457.6 ±558.1 0.886
Dog breeding before admission, % 14.0 16.3 11.6 0.534
National Institutes of Health Stroke
Scale，point
0.9 ±1.1 1.0 ±1.3 0.9 ±1.0 0.639
Mini Mental State Examination, point 28.4 ±1.9 28.3 ±1.9 28.5 ±1.9 0.655
6-min walking distance,m 485.9 ±97.2 490.8 ±97.9 481.0 ±97.5 0.644
10-meter maximum walking speed,m/sec 1.4 ±0.3 1.5 ±0.3 1.4 ±0.3 0.114
30-s chair stand ,times 16.5 ±4.8 16.8 ±4.4 16.1 ±5.2 0.477
Length of hospitalization, day 12.4 ±5.1 12.1 ±5.3 12.7 ±5.0 0.568
Avarage ±SD.
6Clinical Rehabilitation 0(0)
Table 2. Change from baseline in post-inter vention and follow-up assessments
Item
Intervention Control
Group comparison
Baseline
Post-intervention －
Baseline
Follow-up －
Baseline
Baseline
(n=43)
Post-
intervension －
Baseline
(n=38)
Follow-up －
Baseline
(n=37)
Baseline
(n=43)
Post-
intervension －
Baseline
(n=40)
Follow-up －
Baseline
(n=36)
p
value
95%
Confidence
intervals
Effect
size
p
value
95%
Confidence
intervals
Effect
size
Sedentary
behaviour, %
71.1±7.6 −22.7±11.1 −20.4±11.7 72.6±7.4 −14.9±15.3 −13.6±13.4 0.378 0.013 −13.88ーー1.65 0.58 0.025 ー12.67ーー
0.88
0.54
Light-intensity
physical activity
level, %
24.0±5.9 14.3±7.8 13.9±8.8 22.7±4.8 9.8±12.7 9.2±11.2 0.311 0.067 −0.32ー9.28 0.42 0.048 0.03ー9.49 0.47
Moderate-to-
vigorous
physical activity
level, %
5.0±3.1 8.3±6.7 6.3±6.1 5.6±3.4 5.1±5.8 4.6±5.4 0.768 0.028 0.36ー6.09 0.52 0.197 ー0.94ー4.47 0.31
Step count, step 3593.2±1559.2 3949.1±3445.2 2746.7±3550.7 3357.0±2075.4 2471.4±3787.6 2063.9±3659.5 0.565 0.079 −177.25ー3132.71 0.41 0.421 ー999.91ー
2365.41
0.19
Accelerometer
wearing time，
minutes/day
785.4±147.2 −60.9±149.3 −51.5±177.6 742.2±126.4 −8.1±147.1 −9.3±139.5 0.173 0.127 −121.00ー15.40 ー0.268 ー117.61ー
33.13
ー
Screen time,
minute/week
1977.2±769.2 −261.3±891.6 −300.9±1044.2 2001.6±995.4 343.1±832.9 251.4±1241.6 0.899 0.003 −995.95ーー
212.82
0.70 0.047 ー
1097.95ーー
6.51
0.48
Self-Efficacy
Physical
Activity scale
49.7±23.7 10.6±22.7 9.9±21.3 51.4±27.3 11.5±35.0 7.8±37.6 0.762 0.891 −14.27ー12.43 0.03 0.773 ー12.24ー
16.04
0.07
Depression
symptoms,% *
27.9 15.8 21.6 25.6 22.5 22.2 0.808 0.452 ーー0.951 ーー
Sleep disorders,% * 53.5 36.8 29.7 46.5 37.5 38.9 0.518 0.883 ーー0.410 ーー
Average–SD
*Compares prevalence at 3 months and 6 months after discharge
Ashizawa et al. 7
Discussion
The main findings of this study were that our inter-
vention reduced sedentary behaviour compared to
the control group’s reduction in sedentary behaviour,
both immediately after the intervention and at
follow-up. The secondary results showed that the
intervention group had significantly greater changes
in moderate-to-vigorous-intensity physical activity
and screen time after the intervention compared
with the control group, and had significantly
greater changes in light-intensity physical activity
Figure 1. Flowchart of the study (CONSORT).
8Clinical Rehabilitation 0(0)
and screen time at follow-up than that had by the
control group.
The results of this study support previous studies
in healthy older adults and the working popula-
tion.
4,5,38
The results of this study were similar to
those of our previous study,
8
even with a sufficient
sample size, suggesting that an approach that pro-
motes the reduction of sedentary behaviour is
effective. In the intervention group, education,
goal setting, self-monitoring, and feedback regard-
ing the reduction of sedentary behaviour were pro-
vided from the time of hospitalisation to 3 months
after discharge, which may have increased aware-
ness of reducing sedentary behaviour and, there-
fore, reduced sedentary behaviour.
The intervention group also showed a greater
reduction in sedentary behaviour at follow-up than
that shown by the control group, suggesting that
the effect of the approach to reduce sedentary behav-
iour continued up to follow-up. While outdoor phys-
ical activities are affected by weather conditions,
39
sedentary behaviour can be reduced indoors at
home and may be less affected by weather condi-
tions. In addition, since reducing sedentary behaviour
is considered to be less physically demanding than
increasing moderate-to-vigorous-intensity physical
activity,
40
it may be easier to establish sedentary
behaviour in the daily lives of patients with minor
ischaemic stroke. To ensure long-term behavioural
change, it is necessary for the individuals to recog-
nise the increased health benefits.
41
Therefore, the
reduction in sedentary behaviour could be sustained
until follow-up because the participants were aware
of the health benefits of reducing sedentary behav-
iour because of the ongoing approach of education,
goal setting, feedback and telephone prompts regard-
ing the reduction of sedentary behaviour in the study.
The use of digital devices, measured as screen time,
is one of the most typical sedentary behaviours.
42
The
behaviour of reducing screen time could have contin-
ued not only after the intervention but also until
follow-up, which may have led to the reduction in sed-
entary behaviour. A previous study
43
found similar
results to that of this study, suggesting that decreasing
screen time can easily be continual. In contrast,
moderate-to-vigorous-intensity physical activity was
significantly different between the two groups after
the intervention but not at follow-up. A previous
study
44
reported that moderate-to-vigorous-intensity
physical activity increases with reducing sedentary
behaviour, which is similar to the results in this study.
However, given the low moderate-to-vigorous-inten-
sity physical activity in patients with minor ischaemic
stroke,
45
it may be difficult to continue increasing mod-
erate-to-vigorous-intensity physical activity until after
follow-up. Sedentary behaviour and light-intensity
physical activity are highly correlated
46
and it has
also been reported that reducing sedentary behaviour
increases light-intensity physical activity.
47
Therefore,
after follow-up,light-intensity physical activity may
have been increased to reduce sedentary behaviour.
This is the first study to determine the effect of an
approach to reduce sedentary behaviour in patients
with minor ischaemic stroke until follow-up
assessment. Previous studies
10
investigating the
follow-up effects of interventions to increase physical
activity have reported smaller effects of increased
physical activity in the post-intervention follow-up.
Therefore, sedentary behaviour may also be less
likely to continue to decrease after discharge from hos-
pital due to the loss of reinforcing stimuli. However,
this study suggests that the effect of the approach to
promote reduction of sedentary behaviour in patients
with minor ischaemic stroke may continue up to the
follow-up period. As a reduction in sedentary behav-
iour may contribute to the prevention of recurrent
stroke,
3
the results of this study may provide a basis
for recurrence prevention measures.
There are three limitations to this study. First,
the follow-up period of this study is short and the
long-term results are unknown. For specific recur-
rence prevention, it is important to evaluate
whether long-term behavioural changes are
related to sedentary behaviour reduction; therefore,
long-term follow-up is necessary. Second, the time
for wearing the accelerometer was not defined. In
this study, the wearing time differed from patient
to patient, and it is possible that daily activity was
not accurately evaluated. It is necessary to specify
the wearing time to accurately assess daily activity.
In addition, referring to previous studies,
19,48
we
acquired data with accelerometers worn for more
than 10 h, but it has been reported that 10 h is not
sufficient,
49
which is one of the limitations. Third,
Ashizawa et al. 9
there is the issue of screen time assessment. Screen
time was assessed at baseline by interview and at 3
and 6 months after discharge by questionnaire, both
using a recall method, which may not be accurate.
In conclusion, the intervention group showed a
greater reduction in sedentary behaviour post-
intervention and at follow-up than those shown
by the control group. This suggests that approaches
that promote the reduction of sedentary behaviour,
such as education, goal setting, self-monitoring,
and feedback for patients with minor ischeamic
stroke, effectively reduces sedentary behaviour
after the intervention and sustains this effect until
follow-up.
Clinical messages
•Approaches that promote reduction of sed-
entary behaviour including education, goal
setting, self-monitoring and feedback in
patients with minor ischaemic stroke are
effective in reducing sedentary behaviour
•The approaches taken both during hospital-
ization and post-discharge are effective in
reducing sedentary behaviour for up to 6
months post-discharge.
Acknowledgments
We would like to show our appreciation to Daido Life
Welfare Foundation for supporting this study. We
would alsolike to thank Editage (www.editage.com) for
English language editing.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publica-
tion of this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
This study was partly funded by Daido Life Welfare
Foundation.
ORCID iD
Ryota Ashizawa https://orcid.org/0000-0002-0662-5226
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Appendix
Appendix: Screen Time Questionnaire
Please answer the following questions:
Please indicate the total time you spent on the com-
puter or internet, watching TV, playing computer
games, watching videos, and DVDs in the parentheses
below during the last week. Please include as much
detail as possible.
Total hours per week (hour)
12 Clinical Rehabilitation 0(0)
