Relationships Among Environmental Variables, Physical Capacity, Balance Self-Efficacy, and Real-World Walking Activity Post-Stroke

Background: Social and physical environmental factors affect real-world walking activity in individuals with stroke. However, environmental factors are often non-modifiable, presenting a challenge for clinicians working with individuals with stroke whose real-world walking is limited due to environmental barriers. Objective: The purpose of this work was to test a model hypothesizing the relationships among environmental factors (specifically, living situation and area deprivation), modifiable factors, and real-world walking activity to understand opportunities for intervention. We hypothesized that balance self-efficacy would mediate the relationship between the environment and real-world walking and that physical capacity would moderate this mediation. Methods: This was a cross-sectional study of 282 individuals with chronic (>= 6 months) stroke. We tested the indirect effect to determine if mediation was present. Multiple group structural equation modeling was used to test if physical capacity moderated this mediation. A chi(2) difference test was used to compare the moderation model against the null (no moderation) model. Results: Balance self-efficacy mediated the relationship between area deprivation and real-world walking (indirect effect: beta = -0.04, P = .04). Both the moderation and null models fit the data equally well statistically (chi(2)(5) = 6.9, P = .23). We therefore accepted the simpler (null) model and concluded that the mediation was not moderated. Conclusions: Targeting balance self-efficacy may be an effective approach to improving real-world walking in persons with stroke who experience barriers within the physical environment. A stroke survivor's physical capacity may not impact this approach. Future work should consider utilizing more specific measures of the social and physical environment to better understand their influences on real-world walking activity in individuals with stroke. However, the results of this work provide excellent targets for future longitudinal studies targeting real-world walking activity in stroke.