Moderate-vigorous multimodal circuit training to boost steps and reduce seated time in post- stroke survivors: Protocol for a randomized clinical trial

Moderate-vigorous multimodal circuit training to boost steps and reduce seated time in post- stroke survivors: Protocol for a randomized clinical trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Study protocol Moderate-vigorous multimodal circuit training to boost steps and reduce seated time in post- stroke survivors: Protocol for a randomized clinical trial Ana Flavia Silveira, Nicoly Ribeiro Uliam, Marluci Castagna Feltrin, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5040428/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Post-stroke survivors commonly display troubling levels of physical inactivity, resulting in diminished daily step counts. Guidelines advocate for multimodal circuit training (GTCir) with intensity set on moderate-vigorous intensity to bolster their mobility. Nevertheless, the efficacy of GTCir, particularly when executed at moderate-vigorous heart rate intensities, in augmenting real-world walking capacity post-stroke remains uncertain. Objective: To assess the effectiveness of a moderate-vigorous intensity GTCir protocol in increasing the number of steps and reducing seated time in post-stroke survivors. Methodology: It is a randomized clinical trial protocol involving 78 individuals capable of independent walking at least six months post-stroke. Participants will be randomly assigned to either a GTCir group with moderate-vigorous intensity (heart rate target 70-84% of heart rate maximum ), or a control group undergoing light-intensity balance training (heart rate target <64% heart rate maximum ). Both groups will engage in supervised sessions three times weekly over 12 weeks, with assessments conducted pre- and post-intervention, along with a follow-up at 6 weeks. The primary outcome will be the number of steps/day and sedentary behavior, with secondary outcomes including mobility, balance, lower limbs and global strengths, self-reported use of the paretic lower extremity, gait speed and endurance, functional and physical activity level, sensorimotor impairment, and quality of life. Statistical analysis will be performed using RStudio software. Generalized Least Squares models, will be utilized to estimate the effect of GTCir on various clinical outcomes, with a significance level set at 5%. Discussion: Moderate-vigorous GTCir holds promise as a rehabilitation strategy for post-stroke survivors. Clinical trial registration: https://ensaiosclinicos.gov.br/rg/RBR-2gf7h77 Cerebrovascular Disorders Exercise Circuit-Based Exercise Figures Figure 1 Figure 2 Background Despite the World Health Organization's recommendation regarding physical activity and the importance of increasing the daily number of steps ( 1 , 2 ) post-stroke survivors have demonstrated a concerning pattern of physical inactivity ( 3 ). Regardless of the post-stroke phase, the number of steps/day can be 2.903 less than that of healthy survivors of a similar age ( 4 ). Additionally, wearable activity monitors showed that post-stroke survivors spend 80% of their awake time in sedentary behavior. The sedentary behavior is characterized by low-level activities such as sitting or lying down ( 5 ). Aerobic exercise is considered the golden standard for enhancing physical fitness among post-stroke survivors ( 6 – 8 ). Current literature recommends 20–60 minutes of aerobic exercise, accompanied by 5–10 minutes of warm-up and cool-down sessions each, performed 3–5 times per week for at least eight weeks. The initiation of exercise should begin at a light intensity level, defined as maintaining a heart rate below 64% of the maximum heart rate or less than 40% of the heart rate reserve. The exercise regimen should commence at a light intensity level, defined as maintaining a heart rate below 64% of the maximum heart rate or less than 40% of the heart rate reserve. Gradual progression to moderate intensity is recommended, ranging from 64–76% of the maximum heart rate or 40–60% of the heart rate reserve ( 7 ). High-intensity exercises have been associated with increased brain-derived neurotrophic factors, enhanced corticospinal tract excitability, and improved functional performance in post-stroke survivors. Studies have demonstrated improvements in maximal oxygen uptake, quality of life, endurance, walking speed, and daily step count when training at moderate to vigorous intensity. However, aerobic exercise protocols often involve using treadmills, which can pose challenges in community centers or public facilities, especially in developing countries ( 9 – 11 ). Multimodal circuit training presents a promising alternative for achieving higher levels of exercise intensity. This approach integrates various components, including balance, strength, and cardiovascular fitness, through repetitive exercises utilizing simple equipment ( 12 – 14 ). Eng (2010) ( 12 ) introduced the FAME protocol, advocating for one physiotherapist to oversee five people per session. Conducting group sessions facilitates accommodating more participants per session, reducing waiting times in public services, and fostering social interaction among post-stroke survivors. Empirical evidence suggests that multimodal circuit training conducted at moderate to vigorous intensity enhances mobility and promotes exercise engagement among post-stroke survivors ( 13 , 14 ). Nevertheless, the specific impact of this training regimen on increasing daily step counts and decreasing sedentary behaviors, such as seated time, remains to be conclusively established. Method The aim, design and setting of the study The aim of this study is to describe a protocol for a randomized clinical trial investigating whether moderate to vigorous intensity multimodal circuit training for post-stroke survivors effectively increases the daily number of steps and reduces sedentary behavior in post-stroke survivors. The secondary objectives are to evaluate the efficacy of this training in improving mobility, balance, speed, endurance, functional and physical activity level, sensorimotor impairment, and quality of life. Our main hypothesis is that a moderate to vigorous intensity multimodal circuit training will effectively enhance mobility, reduce sedentary behaviors, and improve the quality of life in individuals who have had a stroke. We anticipate increases in step count, reductions in sitting time, improvements in gait speed and endurance, enhancements in sensorimotor function and balance following circuit training. Moreover, we expect that improvements in mobility will correlate with enhancements in quality of life. This is a parallel-group, intention-to-treat, single-blind protocol for a randomized clinical trial involving 78 post-stroke survivors in the chronic phase that will follow the CONSORT statement. The research will be conducted at the Federal University of Sao Carlos - Physiotherapy Department. The interventions will be carried out around Sao Carlos/SP, Brazil. The protocol is described based on the standard protocol items: Recommendations for Interventional Trials 2013 checklist (SPIRIT) (Supplemental material A.1), end the Template for Intervention Description and Replication (TIDieR) (Supplemental material B.1). The study will adhere to the guidelines outlined by the Consolidated Standards of Reporting Trials (CONSORT). Ethical aspects, consent, confidentiality, and data management This study will follow the government resolution n° 466/2012 of the National Health Board. The trial was approved by the Ethical Committee of the Federal University of Sao Carlos/SP, Brazil (CAAE 68581123.7.0000.5504) on August 10, 2023. The volunteers must sign the informed consent before any procedure. Potential volunteers and enrolled volunteers will be interviewed and examined. Study data will be collected and managed using Research Electronic Data Capture (RedCap) tools hosted at the Brazilian Hospital Services Company (EBSERH). RedCap is a secure, web-based software platform designed to support data capture for research studies, providing 1) an intuitive interface for validated data capture; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to standard statistical packages; and 4) procedures for data integration and interoperability with external sources ( 15 , 16 ). Randomization, allocation, masking, and sample size determination Randomization will be conducted using Randomizer.org and subsequently integrated into a spreadsheet within the RedCap system. Upon the randomization of a participant, a blinded researcher will access the randomization module, validate the stratification data, and execute the randomization process within the RedCap platform. All patients enrolled in the protocol will be randomly divided into two groups: 1) experimental group - moderate to vigorous Multimodal circuit training (GTCir), and 2) control group - balance training group (CG). The participants will be stratified according to the number of steps and age. The following combinations will be possible: 1) Until 2.499 steps/day and age ≤ 60 years old; 2) ≥ 2.500 steps/day and age ≤ 60 years old; 3) Until 2.499 steps/day and age > 60 years old; and 4) ≥ 2.500 steps and age > 60 years old. A trained physiotherapist researcher, who will be blind for intervention group allocation, will perform the baseline, post-intervention, and follow-up assessments (Fig. 1). Two trained physical therapists, who will be blind to volunteer assessments (except for information about functional ambulation classification and maximum heart rate), will conduct both intervention groups. Due to the characterization of this trial, volunteers and physical therapists will not be blinded about group allocation. However, they will be asked to keep information about allocation settings private. Different groups will be scheduled at different times to prevent them from meeting each other, thereby reducing group bias. Sample Table 1 describes the inclusion and exclusion criteria. Table 1 Inclusion and exclusion criteria INCLUSION Written informed consent was assigned Able to walk even that with supervision or assistive walking devices Age: 40–80 years old Diagnosis of unilateral stroke (≥ 6 months ≤ 5 years) Medical allowance to perform moderate to vigorous exercise Memory and cognition preserved (considering the Mini-Mental State Examination scored by age and scholar level) (17) Be physically inactive (< 7.500 steps per day) (18) At least 2 doses of COVID-19 vaccines Do not attend to another rehabilitation program No health issues that can cause symptoms and risks for the patients during the evaluations/training protocol (< 1-month acute myocardial infarct/cardiac surgery or pulmonary obstructive/restrictive diseases) No other neurological diseases than stroke No orthopedic disease that impossibility to walk EXCLUSION Withdraw the consente Present any severe symptoms during the assessments or intervention, such as prior cardiac surgery and/or acute myocardial infarction within one month, pacemaker utilization, obstructive or restrictive pulmonary diseases. Those not meeting all eligibility criteria will receive a folder with recommendations and explanations about the importance of exercise performance and changing life behavior. The Mini-Mental State Examination scored by age and scholar level and the number of step to be considered physically activity are based on Bertolucci 1994 ( 17 ) and Fulk 2017 ( 18 ), respectively. The sample size calculation was derived from the methodologies outlined in Thompson, Pohlig, McCartney, Hornby, Kasner, Raser-Schramm, Miller, Henderson, Wright, Wright, Reisman (2023) ( 19 ) and Wright, Wright, Pohlig, Kasner, Raser-Schramm, Reisman. (2018) ( 20 ), utilizing the R Studio software+-- tailored for Longitudinal Studies ( 21 ). The first study is a randomized controlled trial, while the second outlines the protocol for it. Both studies identified daily step count as their primary outcome. A clinically significant median increase of 1,700 steps per day was considered meaningful, with a statistical power of at least 80%.These computations are predicated on several assumptions: equal group sizes, a moderate correlation (r = 0.5) among repeated measures, and a standard deviation of 2,500 steps per day for daily step counts ( 20 ). Additionally, we accounted for a 15% sample loss, resulting in 78 volunteers (39 per group). Procedures As shown in the Spirit flowchart (Fig. 1) and Spirit figure (Fig. 2), all the assessments will occur over ten days on two different days. Outcomes Our primary outcome is the daily number of steps. Secondary outcomes are sedentary behavior, mobility, balance, lower limbs and global strengths, self-reported use of the paretic lower extremity, gait speed, gait endurance, functional and physical activity level, sensorimotor impairment, and quality of life. Table 2 describes all information about the domain used to evaluate the intervention, the measurement variable or specific measurement used to achieve the domain (e.g., ActivPAL to evaluate the daily number of steps), the specific metric (time of the event to analysis, e.g., change from baseline), the method of variable aggregation, such as type of variable, and the time point of each variable (time of the outcome obtained and analyzed). Table 2 Outcome description Domain Measurement variable or specific measurement Specific metric Method of aggregation Time point Descriptive name If applicable, the total score or the subscales that will be analyzed Participant level unit of measurement (e.g., change from baseline, final value, or a value at a time point, time to event) for analysis If the outcome will be treated as a continuous, categorical, or time-to-event variable For continuous variables, a measure of central tendency (e.g., mean value); for categorical and time-to-event data variables, proportion with an event and, if relevant, the specific cutoff values or categories compared When outcome measurements will be obtained Which of the outcome measurements will be analyzed Daily number of steps ActivPAL 3™ NA Change from baseline Continuous variable Mean value Baseline; 15 weeks and 21 weeks after randomization 15 weeks and 21 weeks after randomization Upright Time(m) Standing Time(m) Total Stepping Time(m) Sitting Time(m) Seated Transport Time(m) Primary Lying Time(m) Secondary Lying Time(m) Number Sit To Stand Transitions Activity Score(MET.h) Number Sitting Bouts > 30m Number Sitting Bouts > 60m Time Spent In Sitting Bouts > 30m Time Spent In Sitting Bouts > 60m Stepping Time(m) (duration 1m 5m 10m 20m) Number Steps (duration 1m 5m 10m 20m) Stepping Time(m) (Cadence>:75) Stepping Time(m) (Cadence>:75, duration > 1m) Number Steps (Cadence>:75) Num Steps (Cadence>:75, duration > 1m) Stepping Time(m) (Cadence>:100) Stepping Time(m) (Cadence>:100, duration > 1m) Number Steps (Cadence>:100) Num Steps (Cadence>:100, duration > 1m) Balance TUG - ABS NA Change from baseline Continuous variable Mean value Cutoff: >14,5s Baseline; 15 weeks and 21 weeks after randomization 15 weeks and 21 weeks after randomization DGI Score: 0–24 Mean value Cutoff: ≤ 19 Lower limbs strengths 5X Sit-To-stand NA Change from baseline Continuous variable Mean value Cutoff: >12,2s Baseline; 15 weeks and 21 weeks after randomization 15 weeks and 21 weeks after randomization Global strengths Hand grip NA Change from baseline Continuous variable Mean value Baseline; 15 weeks and 21 weeks after randomization 15 weeks and 21 weeks after randomization Self-reported use of the paretic lower extremity LE-MAL Score: Assistance: 0–205 Functional ability: 0–140 Confidence scores: 0–140 Activity: 0–162 Change from baseline Continuous variable Mean value Baseline; 15 weeks and 21 weeks after randomization 15 weeks and 21 weeks after randomization Gait Speed 10MWT NA Change from baseline Continuous and Categorical variable Mean value Cutoff: 0,8 m/s Unlimited community ambulator Baseline; 15 weeks and 21 weeks after randomization 15 weeks and 21 weeks after randomization Gait endurance 6MWT MSD: 54.1m Change from baseline Continuous variable Mean value Baseline; 15 weeks and 21 weeks after randomization 15 weeks and 21 weeks after randomization Functional and physical activity levels HAP Score: MAS 0–94 AAS : 0–94 LEC : 2–36 Change from baseline Continuous variable Mean value Baseline; 15 weeks and 21 weeks after randomization 15 weeks and 21 weeks after randomization Motor impairment Fugl-Meyer Scale Score: 0–226 Change from baseline Categorical Cutoff: <50% severe; 50–84% marked; 85–95 moderate; 96–99% slight; 100% no impairment Baseline; 15 weeks and 21 weeks after randomization 15 weeks and 21 weeks after randomization Quality of Life SSQOL Score: 49–245 Change from baseline Categorical Mean value Baseline; 15 weeks and 21 weeks after randomization 15 weeks and 21 weeks after randomization Waist circumference Tape measure NA Change from baseline Continuous variable Mean value Baseline; 15 weeks and 21 weeks after randomization 15 weeks and 21 weeks after randomization Movement repetition during exercise HRV - HR monitor H10 NA Value at a time point Continuous variable Mean value 1st, 2nd, 4th, 8th, and 12th training week 1st, 2nd, 4th, 8th, and 12th training week Steps and transferences during training week ActivPAL 3TM NA Value at a time point Continuous variable Mean value 1st, 2nd, 4th, 8th, and 12th training week 1st, 2nd, 4th, 8th, and 12th training week Legend: SS-QOL: Stroke-Specific Quality of Life; TUG ABS: Timed Up and Go Assessment of Biomechanical Strategies; DGI: Dynamic Gait Index; HAP: Human Activity Profile; MAS: Maximal Activity Score; AAS: Adjusted Activity Score; LEC: Lifestyle Energy Consumption; LE-MAL: Lower-Extremity Motor Activity Log; 6MWT: 6 Minutes Walk Test; MSD: Minimal Significative Difference. [Table 2] All assessments will be performed by a physical therapist on the research team. We will briefly describe the assessments below. Number of steps and sedentary behavior monitoring The daily number of steps and sedentary behavior will be assessed by ActivPAL 4 ™. The ActivPAL has been described as reliable for counting daily steps in post-stroke survivors. Additionally, it is the gold standard for measuring sedentary behavior ( 22 , 23 ). The sensor is a continuous, waterproof wearable device. The volunteers will wear it for 7 to 10 consecutive days; however, only six valid days will be used for analysis. The sensor must be worn on the anterior aspect of the thigh of the less affected lower limb. The volunteers will be requested not to take the sensor off or engage in diving activities. Balance and mobility assessments To assess the balance and mobility of post-stroke volunteers, the following tests will be performed: Time Up and Go Assessment of Biomechanical Strategies (TUG-ABS) The TUG-ABS is reliable for evaluating balance, mobility, fall risk, and biomechanical task performance strategies. The TUG test will be repeated three times, and the mean value will be obtained. For ABS analysis, the TUG will be recorded during the second trial ( 24 ). Dynamic Gait Index (DGI) The DGI is a quantitative scale that assesses the balance required to perform daily activities. The score categorizes the quality of the movement as “normal,” “moderate impairment,” or “severe impairment” ( 25 , 26 ). Lower limb strength To assess lower limb strength, the 5x sit-to-stand test will be performed. A chair with no arm support will be used. The volunteers must sit and stand as fast as they can. The time will be chronometer by chronometer advice ( 27 ). Lower Extremity Motor Activity Log (LE-MAL) The Lower Extremity Motor Activity Log (LE-MAL) will be used to assess the self-reported use of the paretic lower extremity. This scale measures the volunteer's self-perception of the level of assistance, performance quality, and confidence in a real-world daily life context ( 28 , 29 ). Gait speed and endurance The 10-meter Walk Test (10MWT) will assess gait speed. It will be repeated three times to obtain a mean value of self-selected and fast gait speed ( 30 ). The 6-minute Walk Test (6MWT) is a reliable and safe test to assess gait endurance and submaximal capacity. The test will follow American Thoracic Society recommendations ( 31 , 32 ). Functional and physical activity level The Human Activity Profile (HAP) is a scale used to measure physical activity levels in post-stroke survivors. The primary outcomes of the HAP are the maximum activity score (MAS) and the adjusted activity score (AAS), which indicate the highest level of energy expenditure that the volunteers can still perform ( 33 – 35 ). Sensorimotor impairment The sensorimotor impairment of post-stroke survivors will be measured using the Fugl-Meyer scale ( 36 , 37 ). Quality of life The stroke-specific quality of life (SSQOL) will measure the quality of life ( 38 , 39 ). Maximum heart rate determination Maximal effort treadmill test The study will employ an incremental effort test to ascertain participants' maximum heart rate. The volunteers' heart rate, blood pressure, and perceived exertion will be monitored throughout the test. Established recommendations and contraindications for conducting the test will be adhered to ( 40 , 41 ). During the incremental effort test ( 41 ), participants will begin on the treadmill at a 1.5 KM/h velocity for 1.5 minutes. Subsequently, the velocity will be systematically increased at 30-second intervals until reaching the maximum velocity previously determined by the 6-minute walking test, maintaining this pace until the fourth minute of the test. Following this phase, the treadmill's incline will increase by 2° per minute until the participant reaches their performance limit. The test will be conducted by a qualified cardiologist, ensuring impartiality by restricting access to other variables, assessments, or the allocation of volunteers. Groups exercises protocol Two groups will be conducted on different schedules simultaneously at medical outpatient clinics or community centers: the experimental group - moderate-vigorous intensity multimodal circuit training and the control group - balance training. Both protocols were developed using the main guidelines for post-stroke survivors ( 7 , 12 , 42 ). Both protocols will be implemented on alternate days over 12 weeks, with sessions occurring three times per week (every other day). The duration of each protocol session will range from 30 to 60 minutes. The experimental group will progressively increase intensity, whereas the control CG will maintain a light intensity throughout. Table 3 summarizes the entire time and intensity progression protocol for both groups. Table 3: Duration and intensity description of experimental and control group Week Warm-up (time) Exercise Repetition Total training time Intensity Cool-down Total session time GTCir protocol 1 st - 2 nd 5 minutes 5 stations 2 X 1min + 1min resting 20 minutes <64% HR maximum RPE <5 Light 5 minutes 30 minutes 3 rd - 4 th 5 minutes 5 stations 2 X 2min + 1min resting 30 minutes ≥64 HR maximum ≤76% RPE 4 - 5 Moderate 5 minutes 40 minutes 5 th - 12 th 5 minutes 5 stations 2 X 3min + 3min resting 50 minutes ≥70 HR maximum ≤84% RPE 5 - 7 Moderate - Vigorous 5 minutes 60 minutes Balance training - CG 1 st - 2 nd 5 minutes 5 stations 2 X 1min + 1min resting 20 minutes <64% HR maximum RPE <5 Light 5 minutes 30 minutes 3 rd - 4 th 5 minutes 5 stations 2 X 2min + 1min resting 30 minutes <64% HR maximum RPE <5 Light 5 minutes 40 minutes 5 th - 12 th 5 minutes 5 stations 2 X 3min + 1min resting 40 minutes <64% HR maximum RPE <5 Light 5 minutes 50 minutes Legend: GTCir: Multimodal Circuit Training; CG: Control Group; HR: Heart Rate; RPE: Rating of Perceived Exertion. [Table 3 ] All groups will be formed by one physiotherapist and one assistant (physiotherapy student or another physiotherapist) for five volunteers. For those volunteers with more ambulation compromising (functional ambulation classification = 3), the caregiver will be invited to participate to guarantee their security. Before the protocol begins for both groups, a familiarization week (3 days) will be performed for approximately 60 minutes. Over familiarization, three talking circles will be conducted for about 25 minutes each. The reunion will be divided over three days to discuss stroke, modifiable risk factors for stroke recurrence, impairments, and the importance of decreasing sedentary behavior and increasing physical activity to improve health. Explanation of signals and symptoms of dyspnea, fatigue, angina, seizure, and swoon will also be delivered this week to identify any red flag signal quickly. A practical class will be given about perceived exercise exertion and how to identify and report on the perceived exertion scale rating from 0–10 (RPE). The other 35 minutes of familiarization day will be to explain the protocol and determine the capacity of each volunteer to perform each exercise. For instance, specific volunteers may require a chair with an elevated seat to facilitate the sit-to-stand exercise. In contrast, others may be able to initiate the exercise with or without additional support, thereby necessitating individualized approaches to accommodate varying needs. The adaptations will provide the correct level of assistance/difficulty to perform all protocol levels. At the beginning of each session, all volunteers will have a heart rate (HR) monitor polar H10 attached to their chest. The HR will be recorded in real-time during the session to guarantee the correct HR zone. The HR monitor will be connected to the polar team (used on iOs Apple). This application allows all HR zone monitoring at the same time. Plus, data storage is possible in % of the time in each HR zone. Vital signs (HR, arterial pressure, respiratory rate, and oxygen saturation) and an RPE rating from 0 to 10 will be reported before and after each session. The session will follow a 5-minute warm-up, 20 to 50 minutes of multimodal circuit or balance training, and a 5-minute cool-down. Other signals and symptoms will be evaluated according to the necessity. Following the primary guidelines about physical activity ( 8 , 43 , 44 ), the protocol will be interrupted whether volunteers report fatigue beyond the expected exercise level. Even as pain, angina, seizure, and/or swoon. If volunteers reach a heart rate surpassing 85% of their maximum, they will be instructed to reduce exercise intensity or cease the activity altogether. All researchers involved will receive emergency training to act in emergencies. A portable automatic defibrillator will be available in every training protocol room. All circuits will be monitored in the first, fourth, eighth, and twelfth weeks. Tracking the session aims to evaluate the volunteers' progression and count their repetitions. Furthermore, the ActivPAL 4™, positioned as described above, will record the number of steps taken and transitions made during the session. Reasons for missing sessions will be recorded. All data from intervention groups will be recorded on RedCap. All volunteers will be asked to stop any other training/rehabilitation activities they may have been participating in. Moderate-vigorous intensity multimodal circuit training - Experimental group The recommendations for physical activity and exercise for stroke survivors recommend that healthcare professionals incorporate low-vigorous intensity exercises and muscle-strengthening exercises. Additionally, circuit training (combining balance, strength, and aerobic exercises) has shown promise in enhancing walking speed and distance among individuals with chronic brain injury. In alignment with these recommendations, we devised a multimodal circuit training regimen featuring moderate to vigorous intensity levels. The full protocol involves three different exercise combinations performed on alternating days: Circuit A, B, and C. All three will consist of strength, balance, flexibility, and aerobic exercises. Supplementary material C.1 describe details about each day and exercise. Progressions/adaptations will be made during the protocol to maintain the exercise performance and challenge. All progressions are based on the recommendations of the American College of Sports Medicine for health and post-stroke survivors ( 7 , 12 , 45 ). The HR target will be based on HR maximum as explained ( 45 ). As detailed in Table 2 , exercise duration and intensity will increase from light to moderate to vigorous intensity during the weeks. Although the protocol is performed in groups, the adaptations/evolution of each exercise are individualized. Individualization is necessary because each individual has their own HR target . Besides, each of them has different abilities and limitations. These adaptations and evolutions will be based on increased heights, velocity, loads, targets, and surfaces. Suggestions of possible adaptations/modifications are described in Supplementary Materials C.2. There will be flexibility for alterations within the session, making it more or less challenging based on real-time data from HR target and reported effort perception. Balance training - Control group Since balance training has a high level of evidence to increase mobility after stroke ( 6 ), it will be used as our control group. The control group will occur on alternating days with different balance training exercises (supplementary material D.1). As this group focuses on functional balance, the exercise intensity will be maintained at light levels, with a greater emphasis on the quality of task performance. Heart rate will be monitored during all sessions. Progression will occur by increasing disturbances to the center of gravity and sensory inputs ( 6 ). The increase in exercise time will follow the same pattern as in the GTCir. For more details about adaptations/modifications for the control group, see supplementary material D.2. Statistical analysis The data will be tabulated in spreadsheets using Microsoft Office Excel, exported from RedCap software, and exported to RStudio software, an integrated development environment for utilizing the R programming language. All analyses will be conducted using the R language (R Core Team, 2023) with appropriate packages and functions. The data will be analyzed according to the intention-to-treat principle. For hypothesis testing, a significance level of 5% will be adopted. Given that this study involves repeated measures, wherein the same individuals will be evaluated at different time points (T0, T1, and T2) to estimate the effect of multimodal circuit training on various clinical outcomes, Generalized Least Squares Models will be used with restricted maximum likelihood estimation. A model will be constructed for each clinical outcome, with all models having the following structure: OutcomeT1, T2 = OutcomeT0 + Group + Time + GroupTime + Age + Gender + Time since Stroke Outcome T0, Age, Gender, and Time since Stroke will be included in the models to enhance the precision of the aerobic training effect estimates, as they are potential outcome predictors. The overall intervention effect will be tested using a partial Wald test (with 2 degrees of freedom) applied to the 'Group' term in the model. The homogeneity of the intervention effect, i.e., whether this effect varies from T1 to T2, will be tested using a partial Wald test (with 1 degree of freedom) applied to the model's Group x Time' term. If an intervention effect is identified, contrasts will be calculated to compare the two groups at times T1 and T2, thereby estimating the mean difference between the groups at these times. Finally, to quantify the uncertainty of these mean difference estimates between the groups, nonparametric 95% percentile bootstrap confidence intervals will be utilized. Discussion The present protocol follows known guidelines regarding moderate-to-vigorous exercise for post-stroke survivors, recognizing the established benefits such as increased walking distance and speed. The use of wearable devices offers insights into how the gains observed in clinical settings transfer to the real-world environment of post-stroke survivors. Additionally, the multimodal circuit format facilitates group performance, which is important for reducing waiting times and enhancing quality of life. The effectiveness of moderate-vigorous multimodal circuit training as a rehabilitation modality for post-stroke survivors is a topic of increasing interest. One aspect under examination is the potential to augment the daily step count, contributing to improved mobility and overall functional independence. Wearable activity monitors present a promising avenue for complementing traditional outcome measures by providing insights into the physical activity levels and social participation of post-stroke survivors in real-world settings. Post-stroke survivors have demonstrated a favorable response to circuit training, regarded as a safe and reliable intervention within this population. Even individuals with multiple comorbidities have shown tolerance to moderate-vigorous multimodal circuit training ( 46 ). Studies have indicated that circuit training can enhance gait speed and endurance when performed at higher intensities. However, maintaining these gains, particularly in daily step count, remains challenging, underscoring the importance of sustained exercise engagement ( 47 ). In addition to its impact on physical outcomes, circuit training has been associated with improved psychosocial domains among post-stroke survivors. Evidence suggests that it can mitigate the fear of falling, enhance activities of daily living, improve balance and cadence, and promote overall psychosocial well-being ( 48 , 49 ). Task-specific circuit training, in particular, has shown promise in improving the quality of life, highlighting the multidimensional benefits of exercise interventions post-stroke ( 50 ). Despite the evidence supporting the efficacy of circuit training for mobility in post-stroke survivors, there is still a significant gap in understanding how these improvements translate into real-world functioning. Addressing this gap necessitates tailoring exercise interventions to individual needs and maintaining them long-term. Conclusion In conclusion, moderate-vigorous multimodal circuit training holds promise as a rehabilitation strategy for post-stroke survivors. It offers multifaceted benefits encompassing physical, psychological, and social dimensions. Our protocol research is warranted to optimize the implementation of these protocols and their long-term efficacy in enhancing mobility and overall quality of life in this population. Abbreviations 10MWT - 10-meter Walk Test 6MWT - 6-minute Walk Test CG - Control group - balance training group CONSORT - Consolidated Standards of Reporting Trials DGI - Dynamic Gait Index EBSERH - Brazilian Hospital Services Company GTCir - Multimodal circuit training HAP - Human Activity Profile HR - Heart rate LE-MAL - Lower Extremity Motor Activity Log REBEC - Brazilian Clinical Trials Registry RedCap - Research Electronic Data Capture RPE - Report on the perceived exertion scale SPIRIT - Recommendations for Interventional Trials 2013 checklist SSQOL - Stroke-specific quality of life TIDieR - Template for Intervention Description and Replication TUG-ABS - Time Up and Go Assessment of Biomechanical Strategies Declarations Name and contact information for the trial sponsor: No trial sponsor is supporting this study. Role of the study sponsor and funders: This study received exclusive support from public research agencies. The Sao Paulo Research Foundation (FAPESP) provided research grants (grant numbers: 2023/04712-7) as well as scholarships (grant numbers: 2023/00506-3; 2023/04797-2; and 2024/05286-4). The National Council for Scientific and Technological Development (CNPq) (grant numbers: 310798/2020-5; 141311/2023-1) and the Coordination for the Improvement of Higher Education Personnel (CAPES) (grant number: 001) supported scholarships. The Brazilian Company of Hospital Services (EBSERH) also provided clinical staff and diagnostic infrastructure. Ethics approval and consent to participate This study will follow the government resolution n° 466/2012 of the National Health Board. The trial was approved by the Ethical Committee of the Federal University of Sao Carlos/SP, Brazil (CAAE 68581123.7.0000.5504) on August 10, 2023. Consent for publication All consent for publication were obtained Availability of data and materials/Data monitoring and access to data. All researchers involved in this protocol will be responsible for data monitoring and following all protocols established and approved by the ethical committee. The Physical Therapy Department—Postgraduate Program of UFSCar will supervise the integrity of the data. All information about the protocol can be found in the Brazilian Registry of Clinical Trials or by contacting the authors. The underlying research materials related to this paper, including data, samples, and models, are available upon request. Interested parties should contact the corresponding author to obtain access to these materials. We encourage and welcome inquiries to facilitate the replication and extension of our research findings. All authors will have access to all the data as soon as the protocol archives the sample size. The trial will be closed when the sample size is completed. Meanwhile, the researchers who collect the outcomes will only access them, and the physical therapist who promotes the intervention will only have access to intervention data. Funding: This work was supported by the Sao Paulo Research Foundation (FAPESP) (grant number 2023/04712-7, 2023/00506-3, 2023/04797-2, and 2024/05286-4); National Council for Scientific and Technological Development (CNPq) (310798/2020-5, 141311/2023-1); Coordination for the Improvement of Higher Education Personnel (CAPES) (grant 001); and Brazilian Company of Hospital Services (EBSERH). Authors' contributions AFS, NRU, MCF, PNA, MGR, ACMT, CDCMF, RSS, MCL, and TLR were involved in the protocol conception, construction of the outcome and intervention assessments and protocol description; NRU and PNA will be responsible for outcome assessments; AFS and MCF will be accountable for intervention; LBF and TAO will assist during assessments; AQB, SRSJ, and PBF will assist during intervention protocol; ACMT and CDCMF will provide technical and theoretical support to perform the assessments; RFS will collect exercise test and provide theoretical support; TLR will supervise all the research activities. All authors have read and approved the final protocol manuscript and agree to be accountable for all aspects of the work designed. Declaration of Generative AI and AI-assisted technologies in the writing process During the preparation of this work the author(s) used Chatgpt in order to improve readability and language. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the publication. The authors recognize the limitations of language models in the manuscript, including the potential for bias, errors, and gaps in knowledge due to the use of generative AI and AI-assisted technologies. Declaration of interest The authors declare no conflict of interest. Harms Whether there may be any adverse events, they will be collected after the individuals have provided consent and enrolled in the study. All harms will be reported at RedCap and categorized into arterial hypertension, HR >85% HR maximum , fatigue beyond the expected, vertigo, fell, pain, and others. All of the harms will be reported at the publication with the final results of this trial. The volunteers participating in this trial can rest assured that the principal author and the Physical Therapy Department will fully support any injury resulting from the intervention. The materials provided for participation document this assurance, ensuring the safety and well-being of all involved. Auditing Under the guidance of the study coordinator, the authors will conduct regular checks on trial procedures and ensure quality assurance measures are implemented. They will meticulously verify the security of all protected health information documents, ensuring strict alignment with the procedures outlined in the protocol. Protocol amendments Any necessary protocol modifications will lead to a modification in this protocol, which will be described when the main article is published. The primary author will supervise any changes, and the ethical committee and REBEC will be notified to receive approval to follow the study. Ancillary, post-trial care, and dissemination policy This research is part of doctorate thesis. The results obtained will be disseminated through the scientific network by publishing articles and abstracts related to the topic. After the follow-up period, the results will be made available to the general community by delivering support materials explaining the reasons, based on the findings, for the importance of self-managed perception of effort for physical exercise. Additionally, volunteers will have guaranteed access to the results of their assessments and clinical examinations. Whether any harm occurs during or after the procedures and interventions, the volunteer will be guaranteed the right to immediate and free treatment by the Unified Health System (SUS), without excluding the possibility of compensation as determined by law if the harm results from the research. Finally, the researchers have committed to training professionals within the network on the proposed training model, provided that its results prove superior to balance training. This will allow the protocol to be recognized as a valuable resource in the primary care of São Carlos/SP, Brazil. References Bull FC, Al-Ansari SS, Biddle S, Borodulin K, Buman MP, Cardon G, et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med. 2020 Dec 1;54(24):1451–62. Tudor-Locke C, Hatano Y, Pangrazi RP, Kang M. Revisiting “how many steps are enough?” Med Sci Sports Exerc [Internet]. 2008 [cited 2022 Sep 22];40(7 Suppl). Available from: https://pubmed.ncbi.nlm.nih.gov/18562971/ Martin Ginis KA, van der Ploeg HP, Foster C, Lai B, McBride CB, Ng K, et al. Participation of people living with disabilities in physical activity: a global perspective [Internet]. Vol. 398, The Lancet. Lancet; 2021 [cited 2023 Jan 16]. p. 443–55. 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Available from: https://pubmed.ncbi.nlm.nih.gov/36115574/ Martins JC, Nadeau S, Aguiar LT, Scianni AA, Teixeira-Salmela LF, De Morais Faria CDC. Efficacy of task-specific circuit training on physical activity levels and mobility of stroke patients: A randomized controlled trial. NeuroRehabilitation [Internet]. 2020 [cited 2024 Feb 29];47(4):451–62. Available from: https://pubmed.ncbi.nlm.nih.gov/33136078/ Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterial.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5040428","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Study protocol","associatedPublications":[],"authors":[{"id":352991437,"identity":"1eae9765-a8c9-4672-80b6-997b62c3b0ca","order_by":0,"name":"Ana Flavia Silveira","email":"data:image/png;base64,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","orcid":"","institution":"Federal University of São Carlos","correspondingAuthor":true,"prefix":"","firstName":"Ana","middleName":"Flavia","lastName":"Silveira","suffix":""},{"id":352991438,"identity":"b361fd22-a7c6-4d28-afa6-c9ab116a2cdf","order_by":1,"name":"Nicoly Ribeiro Uliam","email":"","orcid":"","institution":"Federal University of São Carlos","correspondingAuthor":false,"prefix":"","firstName":"Nicoly","middleName":"Ribeiro","lastName":"Uliam","suffix":""},{"id":352991439,"identity":"6a418b46-1352-4eb7-9fa4-248f01fbf877","order_by":2,"name":"Marluci Castagna Feltrin","email":"","orcid":"","institution":"Federal University of São Carlos","correspondingAuthor":false,"prefix":"","firstName":"Marluci","middleName":"Castagna","lastName":"Feltrin","suffix":""},{"id":352991440,"identity":"3cd8ceee-d9c7-46eb-b4fe-4a1b1dee25ac","order_by":3,"name":"Paloma Nepomuceno Araujo","email":"","orcid":"","institution":"Federal University of São Carlos","correspondingAuthor":false,"prefix":"","firstName":"Paloma","middleName":"Nepomuceno","lastName":"Araujo","suffix":""},{"id":352991441,"identity":"5c58f975-56b2-4e43-8f9e-5f71ca9e30d5","order_by":4,"name":"Meliza Goi Roscani","email":"","orcid":"","institution":"Federal University of São Carlos","correspondingAuthor":false,"prefix":"","firstName":"Meliza","middleName":"Goi","lastName":"Roscani","suffix":""},{"id":352991442,"identity":"f840fd2e-494f-4418-88c2-183193030021","order_by":5,"name":"Anielle Christine M. Takahashi","email":"","orcid":"","institution":"Federal University of São Carlos","correspondingAuthor":false,"prefix":"","firstName":"Anielle","middleName":"Christine M.","lastName":"Takahashi","suffix":""},{"id":352991443,"identity":"5bdcb384-0072-44d2-b6a6-55c2f04b42d4","order_by":6,"name":"Christina Danielli Coelho Morais Faria","email":"","orcid":"","institution":"Universidade Federal de Minas Gerais","correspondingAuthor":false,"prefix":"","firstName":"Christina","middleName":"Danielli Coelho Morais","lastName":"Faria","suffix":""},{"id":352991444,"identity":"7d8fb171-b829-455b-9c00-d829e8e0705d","order_by":7,"name":"Rafaelle Silva Santos","email":"","orcid":"","institution":"Federal University of São Carlos","correspondingAuthor":false,"prefix":"","firstName":"Rafaelle","middleName":"Silva","lastName":"Santos","suffix":""},{"id":352991445,"identity":"9ffe8e6e-7e74-487b-86dc-98de656defa2","order_by":8,"name":"Milena Carvalho Libardi","email":"","orcid":"","institution":"Federal University of São Carlos","correspondingAuthor":false,"prefix":"","firstName":"Milena","middleName":"Carvalho","lastName":"Libardi","suffix":""},{"id":352991446,"identity":"d42b79d1-58f3-4903-82ae-1c267f1218fc","order_by":9,"name":"Thiago Luiz Russo","email":"","orcid":"","institution":"Federal University of São Carlos","correspondingAuthor":false,"prefix":"","firstName":"Thiago","middleName":"Luiz","lastName":"Russo","suffix":""}],"badges":[],"createdAt":"2024-09-05 21:09:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5040428/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5040428/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":67197077,"identity":"eacf7ca3-4cc0-4d2a-a144-fdab8f2cad94","added_by":"auto","created_at":"2024-10-22 09:15:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":83514,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of recruitment\u003c/p\u003e\n\u003cp\u003eLegend: IC: Informed Consent; MMSE: Mini-Mental State Examination; SSQOL: Stroke Specific Quality of Life Scale; TUG-ABS: Timed up and Go Assessment of Biomechanical Strategies; DGI: Dynamic Gait Index; 10MWT: 10 meter Walk Test; HAP: Human Activity Profile; LE-MAL: Lower-Extremity Motor Activity Log; 6MWT: 6 Minutes Walk Test; FMD\u003csub\u003eBA\u003c/sub\u003e: Flow Mediated Dilation \u003csub\u003eBracherial Artery\u003c/sub\u003e; GTCir: Multimodal Circuit Training; CG: Control Group.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5040428/v1/d61b1edc08672f4d75d5f89f.png"},{"id":67195434,"identity":"2b372e9b-689b-4ffa-b07b-e7ee7eae45f7","added_by":"auto","created_at":"2024-10-22 09:07:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":69746,"visible":true,"origin":"","legend":"\u003cp\u003eSpirit-Figure\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5040428/v1/4f9ad29e47d7e4969b299828.png"},{"id":97670538,"identity":"6e1429a5-56c8-455a-9e8d-a4f6b8bd071b","added_by":"auto","created_at":"2025-12-08 09:30:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1638225,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5040428/v1/7588590e-411b-4112-bb64-e44f51590170.pdf"},{"id":67195436,"identity":"cefacc9a-6b12-42f8-a184-5e73c218d859","added_by":"auto","created_at":"2024-10-22 09:07:52","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":5954576,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-5040428/v1/2966643b098b4d8072c6fa48.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Moderate-vigorous multimodal circuit training to boost steps and reduce seated time in post- stroke survivors: Protocol for a randomized clinical trial","fulltext":[{"header":"Background","content":"\u003cp\u003eDespite the World Health Organization's recommendation regarding physical activity and the importance of increasing the daily number of steps (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) post-stroke survivors have demonstrated a concerning pattern of physical inactivity (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Regardless of the post-stroke phase, the number of steps/day can be 2.903 less than that of healthy survivors of a similar age (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Additionally, wearable activity monitors showed that post-stroke survivors spend 80% of their awake time in sedentary behavior. The sedentary behavior is characterized by low-level activities such as sitting or lying down (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAerobic exercise is considered the golden standard for enhancing physical fitness among post-stroke survivors (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Current literature recommends 20\u0026ndash;60 minutes of aerobic exercise, accompanied by 5\u0026ndash;10 minutes of warm-up and cool-down sessions each, performed 3\u0026ndash;5 times per week for at least eight weeks. The initiation of exercise should begin at a light intensity level, defined as maintaining a heart rate below 64% of the maximum heart rate or less than 40% of the heart rate reserve. The exercise regimen should commence at a light intensity level, defined as maintaining a heart rate below 64% of the maximum heart rate or less than 40% of the heart rate reserve. Gradual progression to moderate intensity is recommended, ranging from 64\u0026ndash;76% of the maximum heart rate or 40\u0026ndash;60% of the heart rate reserve (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHigh-intensity exercises have been associated with increased brain-derived neurotrophic factors, enhanced corticospinal tract excitability, and improved functional performance in post-stroke survivors. Studies have demonstrated improvements in maximal oxygen uptake, quality of life, endurance, walking speed, and daily step count when training at moderate to vigorous intensity. However, aerobic exercise protocols often involve using treadmills, which can pose challenges in community centers or public facilities, especially in developing countries (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMultimodal circuit training presents a promising alternative for achieving higher levels of exercise intensity. This approach integrates various components, including balance, strength, and cardiovascular fitness, through repetitive exercises utilizing simple equipment (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Eng (2010) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) introduced the FAME protocol, advocating for one physiotherapist to oversee five people per session. Conducting group sessions facilitates accommodating more participants per session, reducing waiting times in public services, and fostering social interaction among post-stroke survivors. Empirical evidence suggests that multimodal circuit training conducted at moderate to vigorous intensity enhances mobility and promotes exercise engagement among post-stroke survivors (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Nevertheless, the specific impact of this training regimen on increasing daily step counts and decreasing sedentary behaviors, such as seated time, remains to be conclusively established.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eThe aim, design and setting of the study\u003c/h2\u003e \u003cp\u003eThe aim of this study is to describe a protocol for a randomized clinical trial investigating whether moderate to vigorous intensity multimodal circuit training for post-stroke survivors effectively increases the daily number of steps and reduces sedentary behavior in post-stroke survivors. The secondary objectives are to evaluate the efficacy of this training in improving mobility, balance, speed, endurance, functional and physical activity level, sensorimotor impairment, and quality of life. Our main hypothesis is that a moderate to vigorous intensity multimodal circuit training will effectively enhance mobility, reduce sedentary behaviors, and improve the quality of life in individuals who have had a stroke. We anticipate increases in step count, reductions in sitting time, improvements in gait speed and endurance, enhancements in sensorimotor function and balance following circuit training. Moreover, we expect that improvements in mobility will correlate with enhancements in quality of life.\u003c/p\u003e \u003cp\u003eThis is a parallel-group, intention-to-treat, single-blind protocol for a randomized clinical trial involving 78 post-stroke survivors in the chronic phase that will follow the CONSORT statement. The research will be conducted at the Federal University of Sao Carlos - Physiotherapy Department. The interventions will be carried out around Sao Carlos/SP, Brazil. The protocol is described based on the standard protocol items: Recommendations for Interventional Trials 2013 checklist (SPIRIT) (Supplemental material A.1), end the Template for Intervention Description and Replication (TIDieR) (Supplemental material B.1). The study will adhere to the guidelines outlined by the Consolidated Standards of Reporting Trials (CONSORT).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical aspects, consent, confidentiality, and data management\u003c/h3\u003e\n\u003cp\u003e This study will follow the government resolution n\u0026deg; 466/2012 of the National Health Board. The trial was approved by the Ethical Committee of the Federal University of Sao Carlos/SP, Brazil (CAAE 68581123.7.0000.5504) on August 10, 2023.\u003c/p\u003e \u003cp\u003e The volunteers must sign the informed consent before any procedure.\u003c/p\u003e \u003cp\u003ePotential volunteers and enrolled volunteers will be interviewed and examined. Study data will be collected and managed using Research Electronic Data Capture (RedCap) tools hosted at the Brazilian Hospital Services Company (EBSERH). RedCap is a secure, web-based software platform designed to support data capture for research studies, providing 1) an intuitive interface for validated data capture; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to standard statistical packages; and 4) procedures for data integration and interoperability with external sources (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eRandomization, allocation, masking, and sample size determination\u003c/h3\u003e\n\u003cp\u003eRandomization will be conducted using Randomizer.org and subsequently integrated into a spreadsheet within the RedCap system. Upon the randomization of a participant, a blinded researcher will access the randomization module, validate the stratification data, and execute the randomization process within the RedCap platform.\u003c/p\u003e \u003cp\u003eAll patients enrolled in the protocol will be randomly divided into two groups: 1) experimental group - moderate to vigorous Multimodal circuit training (GTCir), and 2) control group - balance training group (CG). The participants will be stratified according to the number of steps and age. The following combinations will be possible: 1) Until 2.499 steps/day and age\u0026thinsp;\u0026le;\u0026thinsp;60 years old; 2)\u0026thinsp;\u0026ge;\u0026thinsp;2.500 steps/day and age\u0026thinsp;\u0026le;\u0026thinsp;60 years old; 3) Until 2.499 steps/day and age\u0026thinsp;\u0026gt;\u0026thinsp;60 years old; and 4)\u0026thinsp;\u0026ge;\u0026thinsp;2.500 steps and age\u0026thinsp;\u0026gt;\u0026thinsp;60 years old.\u003c/p\u003e \u003cp\u003eA trained physiotherapist researcher, who will be blind for intervention group allocation, will perform the baseline, post-intervention, and follow-up assessments (Fig.\u0026nbsp;1). Two trained physical therapists, who will be blind to volunteer assessments (except for information about functional ambulation classification and maximum heart rate), will conduct both intervention groups. Due to the characterization of this trial, volunteers and physical therapists will not be blinded about group allocation. However, they will be asked to keep information about allocation settings private. Different groups will be scheduled at different times to prevent them from meeting each other, thereby reducing group bias.\u003c/p\u003e\n\u003ch3\u003eSample\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e describes the inclusion and exclusion criteria.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInclusion and exclusion criteria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eINCLUSION\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWritten informed consent was assigned\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAble to walk even that with supervision or assistive walking devices\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge: 40\u0026ndash;80 years old\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnosis of unilateral stroke (\u0026ge;\u0026thinsp;6 months\u0026thinsp;\u0026le;\u0026thinsp;5 years)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical allowance to perform moderate to vigorous exercise\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMemory and cognition preserved (considering the Mini-Mental State Examination scored by age and scholar level) (17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBe physically inactive (\u0026lt;\u0026thinsp;7.500 steps per day) (18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt least 2 doses of COVID-19 vaccines\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo not attend to another rehabilitation program\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo health issues that can cause symptoms and risks for the patients during the evaluations/training protocol (\u0026lt;\u0026thinsp;1-month acute myocardial infarct/cardiac surgery or\u0026nbsp; pulmonary obstructive/restrictive diseases)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo other neurological diseases than stroke\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo orthopedic disease that impossibility to walk\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEXCLUSION\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithdraw the consente\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresent any severe symptoms during the assessments or intervention, such as prior cardiac surgery and/or acute myocardial infarction within one month, pacemaker utilization, obstructive or restrictive pulmonary diseases.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThose not meeting all eligibility criteria will receive a folder with recommendations and explanations about the importance of exercise performance and changing life behavior. The Mini-Mental State Examination scored by age and scholar level and the number of step to be considered physically activity are based on Bertolucci 1994 (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) and Fulk 2017 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), respectively.\u003c/p\u003e \u003cp\u003eThe sample size calculation was derived from the methodologies outlined in Thompson, Pohlig, McCartney, Hornby, Kasner, Raser-Schramm, Miller, Henderson, Wright, Wright, Reisman (2023) (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) and Wright, Wright, Pohlig, Kasner, Raser-Schramm, Reisman. (2018) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), utilizing the R Studio software+-- tailored for Longitudinal Studies (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The first study is a randomized controlled trial, while the second outlines the protocol for it. Both studies identified daily step count as their primary outcome. A clinically significant median increase of 1,700 steps per day was considered meaningful, with a statistical power of at least 80%.These computations are predicated on several assumptions: equal group sizes, a moderate correlation (r\u0026thinsp;=\u0026thinsp;0.5) among repeated measures, and a standard deviation of 2,500 steps per day for daily step counts (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Additionally, we accounted for a 15% sample loss, resulting in 78 volunteers (39 per group).\u003c/p\u003e\n\u003ch3\u003eProcedures\u003c/h3\u003e\n\u003cp\u003eAs shown in the Spirit flowchart (Fig.\u0026nbsp;1) and Spirit figure (Fig.\u0026nbsp;2), all the assessments will occur over ten days on two different days.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes\u003c/h2\u003e \u003cp\u003eOur primary outcome is the daily number of steps. Secondary outcomes are sedentary behavior, mobility, balance, lower limbs and global strengths, self-reported use of the paretic lower extremity, gait speed, gait endurance, functional and physical activity level, sensorimotor impairment, and quality of life.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e describes all information about the domain used to evaluate the intervention, the measurement variable or specific measurement used to achieve the domain (e.g., ActivPAL to evaluate the daily number of steps), the specific metric (time of the event to analysis, e.g., change from baseline), the method of variable aggregation, such as type of variable, and the time point of each variable (time of the outcome obtained and analyzed).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOutcome description\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMeasurement variable or\u003c/p\u003e \u003cp\u003especific measurement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSpecific metric\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eMethod of aggregation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eTime point\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescriptive name\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf applicable, the total score or\u003c/p\u003e \u003cp\u003ethe subscales that will be\u003c/p\u003e \u003cp\u003eanalyzed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eParticipant\u003c/p\u003e \u003cp\u003elevel unit of\u003c/p\u003e \u003cp\u003emeasurement (e.g., change from\u003c/p\u003e \u003cp\u003ebaseline, final value, or a value at a\u003c/p\u003e \u003cp\u003etime point, time to event) for\u003c/p\u003e \u003cp\u003eanalysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIf the outcome will be treated as\u003c/p\u003e \u003cp\u003ea continuous, categorical, or\u003c/p\u003e \u003cp\u003etime-to-event variable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFor continuous variables, a\u003c/p\u003e \u003cp\u003emeasure of central tendency\u003c/p\u003e \u003cp\u003e(e.g., mean value); for\u003c/p\u003e \u003cp\u003ecategorical and time-to-event\u003c/p\u003e \u003cp\u003edata variables, proportion with\u003c/p\u003e \u003cp\u003ean event and, if relevant, the\u003c/p\u003e \u003cp\u003especific cutoff values or\u003c/p\u003e \u003cp\u003ecategories compared\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWhen outcome measurements\u003c/p\u003e \u003cp\u003ewill be obtained\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eWhich of the outcome\u003c/p\u003e \u003cp\u003emeasurements will be analyzed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily number of steps\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"31\" rowspan=\"32\"\u003e \u003cp\u003eActivPAL 3\u0026trade;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"31\" rowspan=\"32\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"31\" rowspan=\"32\"\u003e \u003cp\u003eChange from baseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"31\" rowspan=\"32\"\u003e \u003cp\u003eContinuous variable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"31\" rowspan=\"32\"\u003e \u003cp\u003eMean value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"31\" rowspan=\"32\"\u003e \u003cp\u003eBaseline; 15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"31\" rowspan=\"32\"\u003e \u003cp\u003e15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUpright Time(m)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStanding Time(m)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Stepping Time(m)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSitting Time(m)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeated Transport Time(m)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary Lying Time(m)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary Lying Time(m)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber Sit To Stand Transitions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActivity Score(MET.h)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber Sitting Bouts\u0026thinsp;\u0026gt;\u0026thinsp;30m\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber Sitting Bouts\u0026thinsp;\u0026gt;\u0026thinsp;60m\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime Spent In Sitting Bouts\u0026thinsp;\u0026gt;\u0026thinsp;30m\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime Spent In Sitting Bouts\u0026thinsp;\u0026gt;\u0026thinsp;60m\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStepping Time(m) (duration\u0026thinsp;\u0026lt;\u0026thinsp;1m)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStepping Time(m)\u003c/p\u003e \u003cp\u003e(duration\u0026thinsp;\u0026gt;\u0026thinsp;1m \u0026lt;:5m)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStepping Time(m) (duration\u0026thinsp;\u0026gt;\u0026thinsp;5m \u0026lt;:10m)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStepping Time(m) (duration\u0026thinsp;\u0026gt;\u0026thinsp;10m \u0026lt;:20m)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStepping Time(m) (duration\u0026thinsp;\u0026gt;\u0026thinsp;20m)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber Steps\u003c/p\u003e \u003cp\u003e(duration \u0026lt;:1m)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber Steps\u003c/p\u003e \u003cp\u003e(duration\u0026thinsp;\u0026gt;\u0026thinsp;1m \u0026lt;:5m)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNum Steps\u003c/p\u003e \u003cp\u003e(duration\u0026thinsp;\u0026gt;\u0026thinsp;5m \u0026lt;:10m)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber Steps\u003c/p\u003e \u003cp\u003e(duration\u0026thinsp;\u0026gt;\u0026thinsp;10m \u0026lt;:20m)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNum Steps\u003c/p\u003e \u003cp\u003e(duration\u0026thinsp;\u0026gt;\u0026thinsp;20m)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStepping Time(m) (Cadence\u0026gt;:75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStepping Time(m) (Cadence\u0026gt;:75, duration\u0026thinsp;\u0026gt;\u0026thinsp;1m)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber Steps (Cadence\u0026gt;:75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNum Steps (Cadence\u0026gt;:75, duration\u0026thinsp;\u0026gt;\u0026thinsp;1m)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStepping Time(m) (Cadence\u0026gt;:100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStepping Time(m) (Cadence\u0026gt;:100, duration\u0026thinsp;\u0026gt;\u0026thinsp;1m)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber Steps (Cadence\u0026gt;:100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNum Steps (Cadence\u0026gt;:100, duration\u0026thinsp;\u0026gt;\u0026thinsp;1m)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBalance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTUG - ABS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eChange from baseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eContinuous variable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean value\u003c/p\u003e \u003cp\u003eCutoff: \u0026gt;14,5s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBaseline; 15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDGI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eScore: 0\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean value\u003c/p\u003e \u003cp\u003eCutoff:\u0026nbsp; \u0026le; 19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower limbs strengths\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5X Sit-To-stand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChange from baseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eContinuous variable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean value\u003c/p\u003e \u003cp\u003eCutoff:\u0026nbsp; \u0026gt;12,2s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBaseline; 15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlobal strengths\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHand grip\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChange from baseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eContinuous variable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBaseline; 15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-reported use of the paretic lower extremity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLE-MAL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eScore:\u003c/p\u003e \u003cp\u003eAssistance: 0\u0026ndash;205\u003c/p\u003e \u003cp\u003eFunctional ability: 0\u0026ndash;140\u003c/p\u003e \u003cp\u003eConfidence scores: 0\u0026ndash;140\u003c/p\u003e \u003cp\u003eActivity: 0\u0026ndash;162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChange from baseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eContinuous variable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBaseline; 15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGait Speed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10MWT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChange from baseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eContinuous and Categorical variable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean value\u003c/p\u003e \u003cp\u003eCutoff:\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,4 m/s Household\u003c/p\u003e \u003cp\u003eambulator;\u003c/p\u003e \u003cp\u003e0,4\u0026thinsp;\u0026minus;\u0026thinsp;0,8 m/s Limited\u003c/p\u003e \u003cp\u003ecommunity ambulator;\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0,8 m/s Unlimited\u003c/p\u003e \u003cp\u003ecommunity\u003c/p\u003e \u003cp\u003eambulator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBaseline; 15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGait endurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6MWT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMSD: 54.1m\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChange from baseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eContinuous variable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBaseline; 15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunctional and physical activity levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eScore:\u003c/p\u003e \u003cp\u003eMAS 0\u0026ndash;94\u003c/p\u003e \u003cp\u003eAAS : 0\u0026ndash;94\u003c/p\u003e \u003cp\u003eLEC : 2\u0026ndash;36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChange from baseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eContinuous variable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBaseline; 15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotor impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFugl-Meyer Scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eScore:\u003c/p\u003e \u003cp\u003e0\u0026ndash;226\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChange from baseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCategorical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCutoff:\u003c/p\u003e \u003cp\u003e\u0026lt;50% severe;\u003c/p\u003e \u003cp\u003e50\u0026ndash;84% marked;\u003c/p\u003e \u003cp\u003e85\u0026ndash;95 moderate; 96\u0026ndash;99% slight; 100% no impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBaseline; 15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuality of Life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSSQOL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eScore:\u003c/p\u003e \u003cp\u003e49\u0026ndash;245\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChange from baseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCategorical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBaseline; 15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWaist circumference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTape measure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChange from baseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eContinuous variable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBaseline; 15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15 weeks and 21 weeks after randomization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMovement repetition during exercise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHRV - HR monitor H10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eValue at a\u003c/p\u003e \u003cp\u003etime point\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eContinuous variable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1st, 2nd, 4th, 8th, and 12th training week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1st, 2nd, 4th, 8th, and 12th training week\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSteps and transferences during training week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActivPAL 3TM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eValue at a\u003c/p\u003e \u003cp\u003etime point\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eContinuous variable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1st, 2nd, 4th, 8th, and 12th training week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1st, 2nd, 4th, 8th, and 12th training week\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eLegend: SS-QOL: Stroke-Specific Quality of Life; TUG ABS: Timed Up and Go Assessment of Biomechanical Strategies; DGI: Dynamic Gait Index; HAP: Human Activity Profile; MAS: Maximal Activity Score; AAS: Adjusted Activity Score; LEC: Lifestyle Energy Consumption; LE-MAL: Lower-Extremity Motor Activity Log; 6MWT: 6 Minutes Walk Test; MSD: Minimal Significative Difference.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e[Table 2]\u003c/h3\u003e\n\u003cp\u003eAll assessments will be performed by a physical therapist on the research team. We will briefly describe the assessments below.\u003c/p\u003e\n\u003ch3\u003eNumber of steps and sedentary behavior monitoring\u003c/h3\u003e\n\u003cp\u003eThe daily number of steps and sedentary behavior will be assessed by ActivPAL 4 \u0026trade;. The ActivPAL has been described as reliable for counting daily steps in post-stroke survivors. Additionally, it is the gold standard for measuring sedentary behavior (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The sensor is a continuous, waterproof wearable device. The volunteers will wear it for 7 to 10 consecutive days; however, only six valid days will be used for analysis. The sensor must be worn on the anterior aspect of the thigh of the less affected lower limb. The volunteers will be requested not to take the sensor off or engage in diving activities.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eBalance and mobility assessments\u003c/h2\u003e \u003cp\u003eTo assess the balance and mobility of post-stroke volunteers, the following tests will be performed:\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTime Up and Go Assessment of Biomechanical Strategies (TUG-ABS)\u003c/h2\u003e \u003cp\u003eThe TUG-ABS is reliable for evaluating balance, mobility, fall risk, and biomechanical task performance strategies. The TUG test will be repeated three times, and the mean value will be obtained. For ABS analysis, the TUG will be recorded during the second trial (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eDynamic Gait Index (DGI)\u003c/h2\u003e \u003cp\u003eThe DGI is a quantitative scale that assesses the balance required to perform daily activities. The score categorizes the quality of the movement as \u0026ldquo;normal,\u0026rdquo; \u0026ldquo;moderate impairment,\u0026rdquo; or \u0026ldquo;severe impairment\u0026rdquo; (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLower limb strength\u003c/h2\u003e \u003cp\u003eTo assess lower limb strength, the 5x sit-to-stand test will be performed.\u003c/p\u003e \u003cp\u003eA chair with no arm support will be used. The volunteers must sit and stand as fast as they can. The time will be chronometer by chronometer advice (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLower Extremity Motor Activity Log (LE-MAL)\u003c/h2\u003e \u003cp\u003eThe Lower Extremity Motor Activity Log (LE-MAL) will be used to assess the self-reported use of the paretic lower extremity. This scale measures the volunteer's self-perception of the level of assistance, performance quality, and confidence in a real-world daily life context (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eGait speed and endurance\u003c/h2\u003e \u003cp\u003eThe 10-meter Walk Test (10MWT) will assess gait speed. It will be repeated three times to obtain a mean value of self-selected and fast gait speed (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe 6-minute Walk Test (6MWT) is a reliable and safe test to assess gait endurance and submaximal capacity. The test will follow American Thoracic Society recommendations (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eFunctional and physical activity level\u003c/h2\u003e \u003cp\u003eThe Human Activity Profile (HAP) is a scale used to measure physical activity levels in post-stroke survivors. The primary outcomes of the HAP are the maximum activity score (MAS) and the adjusted activity score (AAS), which indicate the highest level of energy expenditure that the volunteers can still perform (\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSensorimotor impairment\u003c/h2\u003e \u003cp\u003eThe sensorimotor impairment of post-stroke survivors will be measured using the Fugl-Meyer scale (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eQuality of life\u003c/h2\u003e \u003cp\u003eThe stroke-specific quality of life (SSQOL) will measure the quality of life (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eMaximum heart rate determination\u003c/h2\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003eMaximal effort treadmill test\u003c/h2\u003e \u003cp\u003eThe study will employ an incremental effort test to ascertain participants' maximum heart rate. The volunteers' heart rate, blood pressure, and perceived exertion will be monitored throughout the test. Established recommendations and contraindications for conducting the test will be adhered to (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDuring the incremental effort test (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e), participants will begin on the treadmill at a 1.5 KM/h velocity for 1.5 minutes. Subsequently, the velocity will be systematically increased at 30-second intervals until reaching the maximum velocity previously determined by the 6-minute walking test, maintaining this pace until the fourth minute of the test. Following this phase, the treadmill's incline will increase by 2\u0026deg; per minute until the participant reaches their performance limit. The test will be conducted by a qualified cardiologist, ensuring impartiality by restricting access to other variables, assessments, or the allocation of volunteers.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eGroups exercises protocol\u003c/h2\u003e \u003cp\u003eTwo groups will be conducted on different schedules simultaneously at medical outpatient clinics or community centers: the experimental group - moderate-vigorous intensity multimodal circuit training and the control group - balance training. Both protocols were developed using the main guidelines for post-stroke survivors (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBoth protocols will be implemented on alternate days over 12 weeks, with sessions occurring three times per week (every other day). The duration of each protocol session will range from 30 to 60 minutes. The experimental group will progressively increase intensity, whereas the control CG will maintain a light intensity throughout. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes the entire time and intensity progression protocol for both groups.\u003c/p\u003e \u003cp\u003eTable 3: Duration and intensity description of experimental and control group\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"948\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6176%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 7.5%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeek\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.8529%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWarm-up (time)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.4118%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExercise\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.5294%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRepetition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.8824%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal training time\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.7941%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntensity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.9706%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCool-down\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.4412%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal session time\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 11.6176%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGTCir protocol\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.5%;\"\u003e\n \u003cp\u003e1\u003csup\u003est\u003c/sup\u003e - 2\u003csup\u003end\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.8529%;\"\u003e\n \u003cp\u003e5 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.4118%;\"\u003e\n \u003cp\u003e5 stations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.5294%;\"\u003e\n \u003cp\u003e2 X 1min + 1min resting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.8824%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003cp\u003eminutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.7941%;\"\u003e\n \u003cp\u003e\u0026lt;64% HR\u003csub\u003emaximum\u003c/sub\u003e\u003c/p\u003e\n \u003cp\u003eRPE \u0026lt;5\u003c/p\u003e\n \u003cp\u003eLight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.9706%;\"\u003e\n \u003cp\u003e5 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.4412%;\"\u003e\n \u003cp\u003e30 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 7.5%;\"\u003e\n \u003cp\u003e3\u003csup\u003erd\u003c/sup\u003e - 4\u003csup\u003eth\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.8529%;\"\u003e\n \u003cp\u003e5 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.4118%;\"\u003e\n \u003cp\u003e5 stations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.5294%;\"\u003e\n \u003cp\u003e2 X 2min +\u003c/p\u003e\n \u003cp\u003e1min resting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.8824%;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003cp\u003eminutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.7941%;\"\u003e\n \u003cp\u003e\u0026ge;64 HR\u003csub\u003emaximum\u003c/sub\u003e\u0026le;76%\u003c/p\u003e\n \u003cp\u003eRPE 4 - 5\u003c/p\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.9706%;\"\u003e\n \u003cp\u003e5 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.4412%;\"\u003e\n \u003cp\u003e40 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 7.5%;\"\u003e\n \u003cp\u003e5\u003csup\u003eth\u003c/sup\u003e - 12\u003csup\u003eth\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.8529%;\"\u003e\n \u003cp\u003e5 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.4118%;\"\u003e\n \u003cp\u003e5 stations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.5294%;\"\u003e\n \u003cp\u003e2 X 3min +\u003c/p\u003e\n \u003cp\u003e3min resting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.8824%;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003cp\u003eminutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.7941%;\"\u003e\n \u003cp\u003e\u0026ge;70 HR\u003csub\u003emaximum\u003c/sub\u003e\u0026le;84%\u003c/p\u003e\n \u003cp\u003eRPE 5 - 7\u003c/p\u003e\n \u003cp\u003eModerate - Vigorous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.9706%;\"\u003e\n \u003cp\u003e5 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.4412%;\"\u003e\n \u003cp\u003e60 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 11.6176%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBalance training - CG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.5%;\"\u003e\n \u003cp\u003e1\u003csup\u003est\u003c/sup\u003e - 2\u003csup\u003end\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.8529%;\"\u003e\n \u003cp\u003e5 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.4118%;\"\u003e\n \u003cp\u003e5 stations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.5294%;\"\u003e\n \u003cp\u003e2 X 1min + 1min resting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.8824%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003cp\u003eminutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.7941%;\"\u003e\n \u003cp\u003e\u0026lt;64% HR\u003csub\u003emaximum\u003c/sub\u003e\u003c/p\u003e\n \u003cp\u003eRPE \u0026lt;5\u003c/p\u003e\n \u003cp\u003eLight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.9706%;\"\u003e\n \u003cp\u003e5 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.4412%;\"\u003e\n \u003cp\u003e30 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 7.5%;\"\u003e\n \u003cp\u003e3\u003csup\u003erd\u003c/sup\u003e - 4\u003csup\u003eth\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.8529%;\"\u003e\n \u003cp\u003e5 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.4118%;\"\u003e\n \u003cp\u003e5 stations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.5294%;\"\u003e\n \u003cp\u003e2 X 2min +\u003c/p\u003e\n \u003cp\u003e1min resting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.8824%;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003cp\u003eminutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.7941%;\"\u003e\n \u003cp\u003e\u0026lt;64% HR\u003csub\u003emaximum\u003c/sub\u003e\u003c/p\u003e\n \u003cp\u003eRPE \u0026lt;5\u003c/p\u003e\n \u003cp\u003eLight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.9706%;\"\u003e\n \u003cp\u003e5 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.4412%;\"\u003e\n \u003cp\u003e40 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 7.5%;\"\u003e\n \u003cp\u003e5\u003csup\u003eth\u003c/sup\u003e - 12\u003csup\u003eth\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.8529%;\"\u003e\n \u003cp\u003e5 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.4118%;\"\u003e\n \u003cp\u003e5 stations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.5294%;\"\u003e\n \u003cp\u003e2 X 3min +\u003c/p\u003e\n \u003cp\u003e1min resting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.8824%;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003cp\u003eminutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.7941%;\"\u003e\n \u003cp\u003e\u0026lt;64% HR\u003csub\u003emaximum\u003c/sub\u003e\u003c/p\u003e\n \u003cp\u003eRPE \u0026lt;5\u003c/p\u003e\n \u003cp\u003eLight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.9706%;\"\u003e\n \u003cp\u003e5 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.4412%;\"\u003e\n \u003cp\u003e50 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eLegend: GTCir: Multimodal Circuit Training; CG: Control Group; HR: Heart Rate; RPE: Rating of Perceived Exertion.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003e[Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e]\u003c/h2\u003e \u003cp\u003eAll groups will be formed by one physiotherapist and one assistant (physiotherapy student or another physiotherapist) for five volunteers. For those volunteers with more ambulation compromising (functional ambulation classification\u0026thinsp;=\u0026thinsp;3), the caregiver will be invited to participate to guarantee their security.\u003c/p\u003e \u003cp\u003eBefore the protocol begins for both groups, a familiarization week (3 days) will be performed for approximately 60 minutes. Over familiarization, three talking circles will be conducted for about 25 minutes each. The reunion will be divided over three days to discuss stroke, modifiable risk factors for stroke recurrence, impairments, and the importance of decreasing sedentary behavior and increasing physical activity to improve health. Explanation of signals and symptoms of dyspnea, fatigue, angina, seizure, and swoon will also be delivered this week to identify any red flag signal quickly. A practical class will be given about perceived exercise exertion and how to identify and report on the perceived exertion scale rating from 0\u0026ndash;10 (RPE). The other 35 minutes of familiarization day will be to explain the protocol and determine the capacity of each volunteer to perform each exercise. For instance, specific volunteers may require a chair with an elevated seat to facilitate the sit-to-stand exercise. In contrast, others may be able to initiate the exercise with or without additional support, thereby necessitating individualized approaches to accommodate varying needs. The adaptations will provide the correct level of assistance/difficulty to perform all protocol levels.\u003c/p\u003e \u003cp\u003eAt the beginning of each session, all volunteers will have a heart rate (HR) monitor polar H10 attached to their chest. The HR will be recorded in real-time during the session to guarantee the correct HR zone. The HR monitor will be connected to the polar team (used on iOs Apple). This application allows all HR zone monitoring at the same time. Plus, data storage is possible in % of the time in each HR zone.\u003c/p\u003e \u003cp\u003eVital signs (HR, arterial pressure, respiratory rate, and oxygen saturation) and an RPE rating from 0 to 10 will be reported before and after each session. The session will follow a 5-minute warm-up, 20 to 50 minutes of multimodal circuit or balance training, and a 5-minute cool-down.\u003c/p\u003e \u003cp\u003eOther signals and symptoms will be evaluated according to the necessity. Following the primary guidelines about physical activity (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e), the protocol will be interrupted whether volunteers report fatigue beyond the expected exercise level. Even as pain, angina, seizure, and/or swoon. If volunteers reach a heart rate surpassing 85% of their maximum, they will be instructed to reduce exercise intensity or cease the activity altogether. All researchers involved will receive emergency training to act in emergencies. A portable automatic defibrillator will be available in every training protocol room.\u003c/p\u003e \u003cp\u003eAll circuits will be monitored in the first, fourth, eighth, and twelfth weeks. Tracking the session aims to evaluate the volunteers' progression and count their repetitions. Furthermore, the ActivPAL 4\u0026trade;, positioned as described above, will record the number of steps taken and transitions made during the session.\u003c/p\u003e \u003cp\u003eReasons for missing sessions will be recorded. All data from intervention groups will be recorded on RedCap. All volunteers will be asked to stop any other training/rehabilitation activities they may have been participating in.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eModerate-vigorous intensity multimodal circuit training - Experimental group\u003c/h2\u003e \u003cp\u003eThe recommendations for physical activity and exercise for stroke survivors recommend that healthcare professionals incorporate low-vigorous intensity exercises and muscle-strengthening exercises. Additionally, circuit training (combining balance, strength, and aerobic exercises) has shown promise in enhancing walking speed and distance among individuals with chronic brain injury. In alignment with these recommendations, we devised a multimodal circuit training regimen featuring moderate to vigorous intensity levels.\u003c/p\u003e \u003cp\u003eThe full protocol involves three different exercise combinations performed on alternating days: Circuit A, B, and C. All three will consist of strength, balance, flexibility, and aerobic exercises. Supplementary material C.1 describe details about each day and exercise.\u003c/p\u003e \u003cp\u003eProgressions/adaptations will be made during the protocol to maintain the exercise performance and challenge. All progressions are based on the recommendations of the American College of Sports Medicine for health and post-stroke survivors (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). The HR\u003csub\u003etarget\u003c/sub\u003e will be based on HR\u003csub\u003emaximum\u003c/sub\u003e as explained (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). As detailed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, exercise duration and intensity will increase from light to moderate to vigorous intensity during the weeks.\u003c/p\u003e \u003cp\u003eAlthough the protocol is performed in groups, the adaptations/evolution of each exercise are individualized. Individualization is necessary because each individual has their own HR\u003csub\u003etarget\u003c/sub\u003e. Besides, each of them has different abilities and limitations. These adaptations and evolutions will be based on increased heights, velocity, loads, targets, and surfaces. Suggestions of possible adaptations/modifications are described in Supplementary Materials C.2. There will be flexibility for alterations within the session, making it more or less challenging based on real-time data from HR\u003csub\u003etarget\u003c/sub\u003e and reported effort perception.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eBalance training - Control group\u003c/h2\u003e \u003cp\u003eSince balance training has a high level of evidence to increase mobility after stroke (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), it will be used as our control group. The control group will occur on alternating days with different balance training exercises (supplementary material D.1). As this group focuses on functional balance, the exercise intensity will be maintained at light levels, with a greater emphasis on the quality of task performance.\u003c/p\u003e \u003cp\u003eHeart rate will be monitored during all sessions. Progression will occur by increasing disturbances to the center of gravity and sensory inputs (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The increase in exercise time will follow the same pattern as in the GTCir. For more details about adaptations/modifications for the control group, see supplementary material D.2.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe data will be tabulated in spreadsheets using Microsoft Office Excel, exported from RedCap software, and exported to RStudio software, an integrated development environment for utilizing the R programming language. All analyses will be conducted using the R language (R Core Team, 2023) with appropriate packages and functions. The data will be analyzed according to the intention-to-treat principle. For hypothesis testing, a significance level of 5% will be adopted.\u003c/p\u003e \u003cp\u003eGiven that this study involves repeated measures, wherein the same individuals will be evaluated at different time points (T0, T1, and T2) to estimate the effect of multimodal circuit training on various clinical outcomes, Generalized Least Squares Models will be used with restricted maximum likelihood estimation. A model will be constructed for each clinical outcome, with all models having the following structure:\u003c/p\u003e \u003cp\u003eOutcomeT1, T2\u0026thinsp;=\u0026thinsp;OutcomeT0\u0026thinsp;+\u0026thinsp;Group\u0026thinsp;+\u0026thinsp;Time\u0026thinsp;+\u0026thinsp;GroupTime\u0026thinsp;+\u0026thinsp;Age\u0026thinsp;+\u0026thinsp;Gender\u0026thinsp;+\u0026thinsp;Time since Stroke\u003c/p\u003e \u003cp\u003eOutcome T0, Age, Gender, and Time since Stroke will be included in the models to enhance the precision of the aerobic training effect estimates, as they are potential outcome predictors.\u003c/p\u003e \u003cp\u003eThe overall intervention effect will be tested using a partial Wald test (with 2 degrees of freedom) applied to the 'Group' term in the model. The homogeneity of the intervention effect, i.e., whether this effect varies from T1 to T2, will be tested using a partial Wald test (with 1 degree of freedom) applied to the model's Group x Time' term. If an intervention effect is identified, contrasts will be calculated to compare the two groups at times T1 and T2, thereby estimating the mean difference between the groups at these times. Finally, to quantify the uncertainty of these mean difference estimates between the groups, nonparametric 95% percentile bootstrap confidence intervals will be utilized.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e The present protocol follows known guidelines regarding moderate-to-vigorous exercise for post-stroke survivors, recognizing the established benefits such as increased walking distance and speed. The use of wearable devices offers insights into how the gains observed in clinical settings transfer to the real-world environment of post-stroke survivors. Additionally, the multimodal circuit format facilitates group performance, which is important for reducing waiting times and enhancing quality of life.\u003c/p\u003e \u003cp\u003eThe effectiveness of moderate-vigorous multimodal circuit training as a rehabilitation modality for post-stroke survivors is a topic of increasing interest. One aspect under examination is the potential to augment the daily step count, contributing to improved mobility and overall functional independence. Wearable activity monitors present a promising avenue for complementing traditional outcome measures by providing insights into the physical activity levels and social participation of post-stroke survivors in real-world settings.\u003c/p\u003e \u003cp\u003ePost-stroke survivors have demonstrated a favorable response to circuit training, regarded as a safe and reliable intervention within this population. Even individuals with multiple comorbidities have shown tolerance to moderate-vigorous multimodal circuit training (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Studies have indicated that circuit training can enhance gait speed and endurance when performed at higher intensities. However, maintaining these gains, particularly in daily step count, remains challenging, underscoring the importance of sustained exercise engagement (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn addition to its impact on physical outcomes, circuit training has been associated with improved psychosocial domains among post-stroke survivors. Evidence suggests that it can mitigate the fear of falling, enhance activities of daily living, improve balance and cadence, and promote overall psychosocial well-being (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Task-specific circuit training, in particular, has shown promise in improving the quality of life, highlighting the multidimensional benefits of exercise interventions post-stroke (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite the evidence supporting the efficacy of circuit training for mobility in post-stroke survivors, there is still a significant gap in understanding how these improvements translate into real-world functioning. Addressing this gap necessitates tailoring exercise interventions to individual needs and maintaining them long-term.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, moderate-vigorous multimodal circuit training holds promise as a rehabilitation strategy for post-stroke survivors. It offers multifaceted benefits encompassing physical, psychological, and social dimensions. Our protocol research is warranted to optimize the implementation of these protocols and their long-term efficacy in enhancing mobility and overall quality of life in this population.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e10MWT - 10-meter Walk Test\u003c/p\u003e\n\u003cp\u003e6MWT - 6-minute Walk Test\u003c/p\u003e\n\u003cp\u003eCG - Control group - balance training group\u003c/p\u003e\n\u003cp\u003eCONSORT - Consolidated Standards of Reporting Trials\u003c/p\u003e\n\u003cp\u003eDGI - Dynamic Gait Index\u003c/p\u003e\n\u003cp\u003eEBSERH - Brazilian Hospital Services Company\u003c/p\u003e\n\u003cp\u003eGTCir - Multimodal circuit training\u003c/p\u003e\n\u003cp\u003eHAP - Human Activity Profile\u003c/p\u003e\n\u003cp\u003eHR - Heart rate\u003c/p\u003e\n\u003cp\u003eLE-MAL - Lower Extremity Motor Activity Log \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eREBEC - Brazilian Clinical Trials Registry\u003c/p\u003e\n\u003cp\u003eRedCap - Research Electronic Data Capture\u003c/p\u003e\n\u003cp\u003eRPE - Report on the perceived exertion scale\u003c/p\u003e\n\u003cp\u003eSPIRIT - Recommendations for Interventional Trials 2013 checklist\u003c/p\u003e\n\u003cp\u003eSSQOL - Stroke-specific quality of life\u003c/p\u003e\n\u003cp\u003eTIDieR - Template for Intervention Description and Replication\u003c/p\u003e\n\u003cp\u003eTUG-ABS - Time Up and Go Assessment of Biomechanical Strategies\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eName and contact information for the trial sponsor:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo trial sponsor is supporting this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRole of the study sponsor and funders:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received exclusive support from public research agencies. The Sao Paulo Research Foundation (FAPESP) provided research grants (grant numbers: 2023/04712-7) as well as scholarships (grant numbers: 2023/00506-3; 2023/04797-2; and 2024/05286-4). The National Council for Scientific and Technological Development (CNPq) (grant numbers: 310798/2020-5; 141311/2023-1) and the Coordination for the Improvement of Higher Education Personnel (CAPES) (grant number: 001) supported scholarships. The Brazilian Company of Hospital Services (EBSERH) also provided clinical staff and diagnostic infrastructure.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study will follow the government resolution n\u0026deg; 466/2012 of the National Health Board. The trial was approved by the Ethical Committee of the Federal University of Sao Carlos/SP, Brazil (CAAE 68581123.7.0000.5504) on August 10, 2023.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll consent for publication were obtained\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials/Data monitoring and access to data.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll researchers involved in this protocol will be responsible for data monitoring and following all protocols established and approved by the ethical committee. The Physical Therapy Department\u0026mdash;Postgraduate Program of UFSCar will supervise the integrity of the data. All information about the protocol can be found in the Brazilian Registry of Clinical Trials or by contacting the authors. The underlying research materials related to this paper, including data, samples, and models, are available upon request. Interested parties should contact the corresponding author to obtain access to these materials. We encourage and welcome inquiries to facilitate the replication and extension of our research findings.\u003c/p\u003e\n\u003cp\u003eAll authors will have access to all the data as soon as the protocol archives the sample size. The trial will be closed when the sample size is completed. Meanwhile, the researchers who collect the outcomes will only access them, and the physical therapist who promotes the intervention will only have access to intervention data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Sao Paulo Research Foundation (FAPESP) (grant number 2023/04712-7, 2023/00506-3, 2023/04797-2, and 2024/05286-4); National Council for Scientific and Technological Development (CNPq) (310798/2020-5, 141311/2023-1); Coordination for the Improvement of Higher Education Personnel (CAPES) (grant 001); and Brazilian Company of Hospital Services (EBSERH).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAFS, NRU, MCF, PNA, \u0026nbsp;MGR, ACMT, CDCMF, RSS, MCL,\u003csup\u003e\u0026nbsp;\u003c/sup\u003eand TLR were involved in the protocol conception, construction of the outcome and intervention assessments and protocol description; NRU and PNA will be responsible for outcome assessments; AFS and MCF will be accountable for intervention; LBF and TAO will assist during assessments; AQB, SRSJ, and PBF will assist during intervention protocol; ACMT and CDCMF will provide technical and theoretical support to perform the assessments; RFS \u0026nbsp;will collect exercise test and provide theoretical support; TLR will supervise all the research activities. All authors have read and approved the final protocol manuscript and agree to be accountable for all aspects of the work designed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Generative AI and AI-assisted technologies in the writing process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the preparation of this work the author(s) used Chatgpt in order to improve readability and language. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the publication. The authors recognize the limitations of language models in the manuscript, including the potential for bias, errors, and gaps in knowledge due to the use of generative AI and AI-assisted technologies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHarms\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhether there may be any adverse events, they will be collected after the individuals have provided consent and enrolled in the study. All harms will be reported at RedCap and categorized into arterial hypertension, HR \u0026gt;85% HR\u003csub\u003emaximum\u003c/sub\u003e, fatigue beyond the expected, vertigo, fell, pain, and others. All of the harms will be reported at the publication with the final results of this trial.\u003c/p\u003e\n\u003cp\u003eThe volunteers participating in this trial can rest assured that the principal author and the Physical Therapy Department will fully support any injury resulting from the intervention. The materials provided for participation document this assurance, ensuring the safety and well-being of all involved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuditing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnder the guidance of the study coordinator, the authors will conduct regular checks on trial procedures and ensure quality assurance measures are implemented. They will meticulously verify the security of all protected health information documents, ensuring strict alignment with the procedures outlined in the protocol.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProtocol amendments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAny necessary protocol modifications will lead to a modification in this protocol, which will be described when the main article is published. The primary author will supervise any changes, and the ethical committee and REBEC will be notified to receive approval to follow the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAncillary, post-trial care, and dissemination policy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research is part of doctorate thesis. The results obtained will be disseminated through the scientific network by publishing articles and abstracts related to the topic. After the follow-up period, the results will be made available to the general community by delivering support materials explaining the reasons, based on the findings, for the importance of self-managed perception of effort for physical exercise. Additionally, volunteers will have guaranteed access to the results of their assessments and clinical examinations.\u003c/p\u003e\n\u003cp\u003eWhether any harm occurs during or after the procedures and interventions, the volunteer will be guaranteed the right to immediate and free treatment by the Unified Health System (SUS), without excluding the possibility of compensation as determined by law if the harm results from the research.\u003c/p\u003e\n\u003cp\u003eFinally, the researchers have committed to training professionals within the network on the proposed training model, provided that its results prove superior to balance training. This will allow the protocol to be recognized as a valuable resource in the primary care of S\u0026atilde;o Carlos/SP, Brazil.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBull FC, Al-Ansari SS, Biddle S, Borodulin K, Buman MP, Cardon G, et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med. 2020 Dec 1;54(24):1451\u0026ndash;62. \u003c/li\u003e\n\u003cli\u003eTudor-Locke C, Hatano Y, Pangrazi RP, Kang M. Revisiting \u0026ldquo;how many steps are enough?\u0026rdquo; Med Sci Sports Exerc [Internet]. 2008 [cited 2022 Sep 22];40(7 Suppl). Available from: https://pubmed.ncbi.nlm.nih.gov/18562971/\u003c/li\u003e\n\u003cli\u003eMartin Ginis KA, van der Ploeg HP, Foster C, Lai B, McBride CB, Ng K, et al. Participation of people living with disabilities in physical activity: a global perspective [Internet]. Vol. 398, The Lancet. Lancet; 2021 [cited 2023 Jan 16]. p. 443\u0026ndash;55. 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Arq Neuropsiquiatr [Internet]. 1994 [cited 2021 Oct 10];52(1):01\u0026ndash;7. Available from: http://www.scielo.br/scielo.php?script=sci_arttext\u0026amp;nrm=iso\u0026amp;lng=pt\u0026amp;tlng=pt\u0026amp;pid=S0004-282X1994000100001\u003c/li\u003e\n\u003cli\u003eFulk GD, He Y, Boyne P, Dunning K. Predicting Home and Community Walking Activity Poststroke. Stroke [Internet]. 2017 Feb 1 [cited 2022 Jun 14];48(2):406\u0026ndash;11. Available from: https://pubmed.ncbi.nlm.nih.gov/28057807/\u003c/li\u003e\n\u003cli\u003eThompson ED, Pohlig RT, McCartney KM, Hornby TG, Kasner SE, Raser-Schramm J, et al. Increasing Activity After Stroke: A Randomized Controlled Trial of High-Intensity Walking and Step Activity Intervention. Stroke [Internet]. 2024 Jan 1 [cited 2024 May 16];55(1):5\u0026ndash;13. Available from: https://pubmed.ncbi.nlm.nih.gov/38134254/\u003c/li\u003e\n\u003cli\u003eWright H, Wright T, Pohlig RT, Kasner SE, Raser-Schramm J, Reisman D. 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Self-reported use of the paretic lower extremity of people with stroke: A reliability and validity study of the Lower-Extremity Motor Activity Log (LE-MAL) - Brazil. Physiother Theory Pract [Internet]. 2022 [cited 2022 Dec 17]; Available from: https://pubmed.ncbi.nlm.nih.gov/35320022/\u003c/li\u003e\n\u003cli\u003eNascimento LR, Caetano LCG, Freitas DCMA, Morais TM, Polese JC, Teixeira-Salmela LF. Diferentes instru\u0026ccedil;\u0026otilde;es durante teste de velocidade de marcha determinam aumento significativo na velocidade m\u0026aacute;xima de indiv\u0026iacute;duos com hemiparesia cr\u0026ocirc;nica. Brazilian J Phys Ther [Internet]. 2012 [cited 2022 Jun 21];16(2):122\u0026ndash;7. Available from: http://www.scielo.br/j/rbfis/a/xmRbLZ5y7z7hjV5bdj8JWDp/abstract/?lang=pt\u003c/li\u003e\n\u003cli\u003eCrapo RO, Casaburi R, Coates AL, Enright PL, MacIntyre NR, McKay RT, et al. ATS statement: Guidelines for the six-minute walk test [Internet]. Vol. 166, American Journal of Respiratory and Critical Care Medicine. Am J Respir Crit Care Med; 2002 [cited 2021 Oct 10]. p. 111\u0026ndash;7. Available from: https://pubmed.ncbi.nlm.nih.gov/12091180/\u003c/li\u003e\n\u003cli\u003eGiannitsi S, Bougiakli M, Bechlioulis A, Kotsia A, Michalis LK, Naka KK. 6-minute walking test: a useful tool in the management of heart failure patients. Ther Adv Cardiovasc Dis [Internet]. 2019 [cited 2024 May 1];13:1\u0026ndash;10. Available from: https://pubmed.ncbi.nlm.nih.gov/31441375/\u003c/li\u003e\n\u003cli\u003eSouza AC, Magalh\u0026atilde;es LDC, Teixeira-Salmela LF. [Cross-cultural adaptation and analysis of the psychometric properties in the Brazilian version of the Human Activity Profile]. Cad Saude Publica [Internet]. 2006 [cited 2024 May 1];22(12):2623\u0026ndash;36. Available from: https://pubmed.ncbi.nlm.nih.gov/17096041/\u003c/li\u003e\n\u003cli\u003eTeixeira-Salmela LF, Devaraj R, Olney SJ. Validation of the human activity profile in stroke: a comparison of observed, proxy and self-reported scores. Disabil Rehabil [Internet]. 2007 Oct [cited 2023 Jun 20];29(19):1518\u0026ndash;24. Available from: https://pubmed.ncbi.nlm.nih.gov/17852225/\u003c/li\u003e\n\u003cli\u003eBrito SAF de, Aguiar LT, Quintino LF, Ribeiro-Samora GA, Britto RR, Faria CDC de M. Assessment of V̇o2peak and Exercise Capacity After Stroke: A Validity Study of the Human Activity Profile Questionnaire. Arch Phys Med Rehabil [Internet]. 2022 Sep 1 [cited 2024 May 1];103(9):1771\u0026ndash;6. Available from: https://pubmed.ncbi.nlm.nih.gov/35101389/\u003c/li\u003e\n\u003cli\u003eFugl-Meyer AR, J\u0026auml;\u0026auml;sk\u0026ouml; L, Olsson S, Steglind S. The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance - PubMed. Scand J Rehabil Med [Internet]. 1975 [cited 2022 Sep 28];13\u0026ndash;31. Available from: https://pubmed.ncbi.nlm.nih.gov/1135616/\u003c/li\u003e\n\u003cli\u003eMaki T, Quagliato E, Cacho E, Paz L, Nascimento N, Inoue M, et al. Estudo de confiabilidade da aplica\u0026ccedil;\u0026atilde;o da escala de Fugl-Meyer no Brasil. Rev Bras Fisioter [Internet]. 2006 [cited 2022 May 30];10(2):177\u0026ndash;83. Available from: http://www.scielo.br/j/rbfis/a/kYcjCHRWD7x839FvtVjVctj/?lang=pt\u003c/li\u003e\n\u003cli\u003eWilliams LS, Weinberger M, Harris LE, Clark DO, Biller J. Development of a stroke-specific quality of life scale. Stroke [Internet]. 1999 [cited 2022 Jun 21];30(7):1362\u0026ndash;9. Available from: https://pubmed.ncbi.nlm.nih.gov/10390308/\u003c/li\u003e\n\u003cli\u003eLima R, Teixeira-Salmela L, Magalh\u0026atilde;es L, Gomes-Neto M. Propriedades psicom\u0026eacute;tricas da vers\u0026atilde;o brasileira da escala de qualidade de vida espec\u0026iacute;fica para acidente vascular encef\u0026aacute;lico: aplica\u0026ccedil;\u0026atilde;o do modelo Rasch. Rev Bras Fisioter [Internet]. 2008 Apr [cited 2022 Jun 21];12(2):149\u0026ndash;56. Available from: http://www.scielo.br/j/rbfis/a/L68NZSypsDwSknmjFWjWMJB/?lang=pt\u003c/li\u003e\n\u003cli\u003eRiebe D, Franklin BA, Thompson PD, Garber CE, Whitfield GP, Magal M, et al. Updating ACSM\u0026rsquo;s recommendations for exercise preparticipation health screening. Vol. 47, Medicine and Science in Sports and Exercise. Lippincott Williams and Wilkins; 2015. 2473\u0026ndash;2479 p. \u003c/li\u003e\n\u003cli\u003eNeves LMT, Karsten M, Neves VR, Beltrame T, Borghi-Silva A, Catai AM. Relationship between inspiratory muscle capacity and peak exercise tolerance in patients post-myocardial infarction. Heart Lung [Internet]. 2012 Mar [cited 2024 May 9];41(2):137\u0026ndash;45. Available from: https://pubmed.ncbi.nlm.nih.gov/22177761/\u003c/li\u003e\n\u003cli\u003ePang MYC, Eng JJ, Dawson AS, McKay HA, Harris JE. A community-based fitness and mobility exercise program for older adults with chronic stroke: a randomized, controlled trial. J Am Geriatr Soc [Internet]. 2005 Oct [cited 2022 Apr 25];53(10):1667\u0026ndash;74. Available from: https://pubmed.ncbi.nlm.nih.gov/16181164/\u003c/li\u003e\n\u003cli\u003eAmerican Thoracic Society; American College of Chest Physicians. ATS/ACCP Statement on cardiopulmonary exercise testing. [Internet]. Vol. 167, American journal of respiratory and critical care medicine. New York: Am J Respir Crit Care Med; 2003 [cited 2022 Apr 18]. p. 211\u0026ndash;77. Available from: https://pubmed.ncbi.nlm.nih.gov/12524257/\u003c/li\u003e\n\u003cli\u003eMiller A, Reisman DS, Billinger SA, Dunning K, Doren S, Ward J, et al. 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Available from: https://pubmed.ncbi.nlm.nih.gov/33136078/\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cerebrovascular Disorders, Exercise, Circuit-Based Exercise","lastPublishedDoi":"10.21203/rs.3.rs-5040428/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5040428/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Post-stroke survivors commonly display troubling levels of physical inactivity, resulting in diminished daily step counts. Guidelines advocate for multimodal circuit training (GTCir) with intensity set on moderate-vigorous intensity to bolster their mobility. Nevertheless, the efficacy of GTCir, particularly when executed at moderate-vigorous heart rate intensities, in augmenting real-world walking capacity post-stroke remains uncertain. Objective: To assess the effectiveness of a moderate-vigorous intensity GTCir protocol in increasing the number of steps and reducing seated time in post-stroke survivors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology:\u003c/strong\u003e It is a randomized clinical trial protocol involving 78 individuals capable of independent walking at least six months post-stroke. Participants will be randomly assigned to either a GTCir group with moderate-vigorous intensity (heart rate\u003csub\u003etarget\u003c/sub\u003e\u0026nbsp; 70-84% of heart rate\u003csub\u003emaximum\u003c/sub\u003e), or a control group undergoing light-intensity balance training (heart rate\u003csub\u003etarget\u003c/sub\u003e \u0026lt;64% heart rate\u003csub\u003emaximum\u003c/sub\u003e). Both groups will engage in supervised sessions three times weekly over 12 weeks, with assessments conducted pre- and post-intervention, along with a follow-up at 6 weeks. The primary outcome will be the number of steps/day and sedentary behavior, with secondary outcomes including mobility, balance, lower limbs and global strengths, self-reported use of the paretic lower extremity, gait speed and endurance, functional and physical activity level, sensorimotor impairment, and quality of life. Statistical analysis will be performed using RStudio software. Generalized Least Squares models, will be utilized to estimate the effect of GTCir on various clinical outcomes, with a significance level set at 5%.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion:\u003c/strong\u003e Moderate-vigorous GTCir holds promise as a rehabilitation strategy for post-stroke survivors.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial registration:\u003c/strong\u003e https://ensaiosclinicos.gov.br/rg/RBR-2gf7h77\u003c/p\u003e","manuscriptTitle":"Moderate-vigorous multimodal circuit training to boost steps and reduce seated time in post- stroke survivors: Protocol for a randomized clinical trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-22 09:07:47","doi":"10.21203/rs.3.rs-5040428/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cab39038-0143-4d81-91bf-b6362eb7ab3b","owner":[],"postedDate":"October 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-05T03:23:44+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-22 09:07:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5040428","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5040428","identity":"rs-5040428","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}