## 4 Discussion  
The goal of this study was to objectively measure the activity of post-stroke patients hospitalized in the acute hospital stroke department over time and to characterize their activity pattern as a function of activity type and distribution throughout two working shifts. The study findings join an evolving body of knowledge about the activity of patients after stroke in acute hospital settings and add to the current knowledge on the topic by providing an objective quantification of various aspects of patients' activity patterns in a stroke department. This study also frames the findings on activity distribution within a clinical context of work shifts and in regard to the association with functional ability. We found that the overall amount of activity was low, although activity increased over time. Analyzing activity by shift showed that sitting and overall upright time increased over time only during morning shifts, while number of steps increased over time in both the morning and the evening shifts. The findings also demonstrated that the duration of out-of-bed sitting periods was relatively long, especially during morning shifts (median of longest sitting period ranged from 59.24 to 109 min in morning shifts and from 8.4 to 44.91 min in afternoon shifts). Thus, it seems that activity recommendations are mainly implemented in the morning by means of long periods of sitting. This pattern may reflect the challenges of implementing short and frequent periods of activity, a practice that requires significant personnel resources and changes in routine practices. Several studies have described the temporal pattern of out-of-bed activity and showed that patients in inpatient rehabilitation were less active during the weekend [30], and that patients in acute care settings performed most of the activity in the early morning and were inactive later in the day [17]. Our findings similarly point to a lack of activity in afternoon and evening hours. Taken together, these findings suggest that a better use of evening shifts may help to achieve more activity overall. Furthermore, evening shifts may have some advantages for the implementation of activity recommendations, as less time is typically spent on medical exams and more time is devoted to family support. The development of a structured strategy to facilitate activity during the evening is warranted. The present study revealed poor to fair correlations between functional levels and actual levels of activity. The first finding was that greater grip strength of the hemiparetic upper limb was positively correlated with the number of steps counted during the evening shift. In the evening shift, less help is available from health-related and nursing staff. Therefore, if a stroke patient's mobility depends on their ability to hold onto an assistive device such as a walker, a stronger grip may allow them to walk independently or with family supervision. A second finding shows that less mobile patients were engaged in longer periods of sitting. This finding may reflect more acute patients' dependence on departmental routines, which includes taking patients out of bed to chair in the morning and returning them at noon. This finding is consistent with a report on the association between increased duration of sitting periods, higher age, and higher stroke severity [31]. Contrary to the abovementioned correlations, no correlation was found between stroke severity, measured by the NIHSS, and the actual level of activity. This finding is consistent with previous studies [14; 15; 32] and may reflect the limited information that a global severity score offers with respect to very specific aspects of functioning, such as physical activity, including sitting and mobility. It should be noted, however, that the correlation analyses were somewhat limited since we included only patients with mild to moderate stroke severity.