The effects of an aerobic and resistance exercise training program on cognition following stroke

A systematic review and meta-analysis of the effects of cardiac rehabilitation interventions on cognitive impairment following stroke

PURPOSE

The cardiac rehabilitation model has potential as an approach to providing rehabilitation following stroke. This review aims to identify evidence for the participation of stroke patients in cardiac/cardiovascular rehabilitation programs internationally, whether or not such programs offer a cognitive intervention as part of treatment, and the impact of rehabilitation on post-stroke cognitive function.

METHOD

Five electronic databases were searched from inception to 1 May 2019, namely: MEDLINE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Central Register of Controlled Trials, and the Web of Science. Eligible studies included both randomized and non-randomized studies of cardiac rehabilitation-type interventions which measured cognitive function in patients with transient ischemic attack (TIA) or stroke.

RESULTS

Of 14,153 records reviewed, nine studies which delivered cardiac rehabilitation-type interventions to stroke patients were finally included. Only three of these studies delivered cognitive rehabilitation as part of the intervention. Cardiac rehabilitation had no statistically significant effect on cognitive function in five randomized controlled trials (standardized mean difference= 0.28, 95% CI= -0.16 to 0.73) or in three one group pre-post studies (standardized mean difference= 0.15, 95% CI= -0.03 to 0.33).

CONCLUSIONS

This review highlights that there are very few studies of delivery of cardiac rehabilitation to stroke patients and that the inclusion of cognitive interventions is even less common, despite the high prevalence of post-stroke cognitive impairment.IMPLICATIONS FOR REHABILITATIONThe cardiac rehabilitation model has the potential to be expanded to include patients post-stroke given the commonality of secondary prevention needs, thereby becoming a cardiovascular rehabilitation model.Up to half of patients experience cognitive impairment after stroke; suggesting that a post-stroke cardiovascular rehabilitation model should incorporate specific cognitive strategies for patients.This systematic review identified three cardiovascular rehabilitation programmes which delivered cognitive rehabilitation as part of treatment; however, evidence for efficacy is weak.

Functional and/or structural brain changes in response to resistance exercises and resistance training lead to cognitive improvements - a systematic review

BACKGROUND

During the aging process, physical capabilities (e.g., muscular strength) and cognitive functions (e.g., memory) gradually decrease. Regarding cognitive functions, substantial functional (e.g., compensatory brain activity) and structural changes (e.g., shrinking of the hippocampus) in the brain cause this decline. Notably, growing evidence points towards a relationship between cognition and measures of muscular strength and muscle mass. Based on this emerging evidence, resistance exercises and/or resistance training, which contributes to the preservation and augmentation of muscular strength and muscle mass, may trigger beneficial neurobiological processes and could be crucial for healthy aging that includes preservation of the brain and cognition. Compared with the multitude of studies that have investigated the influence of endurance exercises and/or endurance training on cognitive performance and brain structure, considerably less work has focused on the effects of resistance exercises and/or resistance training. While the available evidence regarding resistance exercise-induced changes in cognitive functions is pooled, the underlying neurobiological processes, such as functional and structural brain changes, have yet to be summarized. Hence, the purpose of this systematic review is to provide an overview of resistance exercise-induced functional and/or structural brain changes that are related to cognitive functions.

METHODS AND RESULTS

A systematic literature search was conducted by two independent researchers across six electronic databases; 5957 records were returned, of which 18 were considered relevant and were analyzed.

SHORT CONCLUSION

Based on our analyses, resistance exercises and resistance training evoked substantial functional brain changes, especially in the frontal lobe, which were accompanied by improvements in executive functions. Furthermore, resistance training led to lower white matter atrophy and smaller white matter lesion volumes. However, based on the relatively small number of studies available, the findings should be interpreted cautiously. Hence, future studies are required to investigate the underlying neurobiological mechanisms and to verify whether the positive findings can be confirmed and transferred to other needy cohorts, such as older adults with dementia, sarcopenia and/or dynapenia.

Effect of a novel designed intensive patient care program on cognitive impairment, anxiety, depression as well as relapse free survival in acute ischemic stroke patients: a randomized controlled study

Objective: We aimed to evaluate the influence of a novel designed intensive patient care program (IPCP) on cognitive impairment, anxiety, depression and relapse-free survival (RFS) in acute ischemic stroke (AIS) patients. Methods: Two hundred forty-two AIS patients were consecutively recruited in this randomized controlled study and randomly allocated to IPCP group or control group as 1:1 ratio. Patients received IPCP and conventional treatment in IPCP group, while received usual education, cognitive rehabilitation training and conventional treatment in control group for 12-month intervention. Cognitive impairment, anxiety and depression were assessed by Mini-Mental State Examination (MMSE), Hospital Anxiety and Depression Scale (HADS) anxiety (HADS-A), and HADS depression (HADS-D) at baseline (M0), month (M)3, M6 and M12. After intervention, patients were followed up until 2018/7/30 and RFS was calculated. Results: IPCP increased MMSE score at M12 and change of MMSE score (M12-M0), while decreased cognitive impairment rate at M12. For anxiety, decreased change of HADS-A score (M12-M0) and lower anxiety rate at M12 were observed in IPCP group compared to control group. For depression, decreased HADS-D score at M6 and M12, reduced change of HADS-D score (M12-M0) and lower depression rate at M12 were shown in IPCP group compared to control group. Besides, RFS was numerically longer in IPCP group compared to control group, but without statistical significance. Conclusions: IPCP presents with a positive influence on improving cognitive impairment and decreasing anxiety as well as depression, while a less effect on improving RFS in AIS patients. Abbreviation: IPCP: intensive patient care program; RFS: relapse free survival; AIS: acute ischemic stroke; MRA: magnetic resonance angiography; ITT: intention-to-treat; LOCF: last observation carried forward.

A systematic review of existing peripheral biomarkers of cognitive aging: Is there enough evidence for biomarker proxies in behavioral modification interventions?: An initiative in association with the nutrition, exercise and lifestyle team of the Canadian Consortium on Neurodegeneration in Aging

Peripheral biomarkers have shown significant value in predicting brain health and may serve as a useful proxy measurement in the assessment of evidence-based lifestyle behavior modification programs, including physical activity and nutrition programs, that aim to maintain cognitive function in late life. The aim of this systematic review was to elucidate which peripheral biomarkers are robustly associated with cognitive function among relatively healthy non-demented older adults. Following the standards for systematic reviews (PICO, PRIMSA), and employing MEDLINE and Scopus search engines, 222 articles were included in the review. Based on the review of biomarker proxies of cognitive health, it is recommended that a comprehensive biomarker panel, or biomarker signature, be developed as a clinical end point for behavior modification trials aimed at enhancing cognitive function in late life. The biomarker signature should take a multisystemic approach, including lipid, immune/inflammatory, and metabolic biomarkers in the biological signature index of cognitive health.

The Effectiveness of Exercise on Cognitive Performance in Individuals with Known Vascular Disease: A Systematic Review

Patients with known vascular disease are at increased risk for cognitive impairments. Exercise has been shown to improve cognition in healthy elderly populations and those with mild cognitive impairments. We explored the literature to understand exercise as a modality to improve cognition in those with vascular disease, focusing on dose-responses. A systematic review was conducted through 2017 using Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Ovid Embase, and Ovid MEDLINE databases. Eligible studies examined effects of exercise on memory and cognition in cardiovascular (CVD) or cerebrovascular disease (CBVD). Data extracted included group characteristics, exercise dosage and outcomes measures employed. Twenty-two studies (12 CVD, 10 CBVD) met the inclusion criteria. Interventions included aerobic, resistance, or mixed training, with neuropsychological test batteries assessing cognition. In CVD populations, five studies demonstrated improved cardiovascular fitness and cognition with aerobic training, and another seven studies suggested a dose-response. In CBVD trials, four studies reported improved cognition, with no effects observed in the fifth study. Another study found enhanced cognition with resistance training and four demonstrated a positive association between functional capacity and cognition following combined aerobic and resistance training. Exercise is able to positively affect cognitive performance in those with known vascular disease. There is evidence to suggest a dose–response relationship. Further research is required to optimize prescription.

Synergistic Benefits of Combined Aerobic and Cognitive Training on Fluid Intelligence and the Role of IGF-1 in Chronic Stroke

BACKGROUND

Paired exercise and cognitive training have the potential to enhance cognition by "priming" the brain and upregulating neurotrophins.

METHODS

Two-site randomized controlled trial. Fifty-two patients >6 months poststroke with concerns about cognitive impairment trained 50 to 70 minutes, 3× week for 10 weeks with 12-week follow-up. Participants were randomized to 1 of 2 physical interventions: Aerobic (>60% VO_2peak using <10% body weight-supported treadmill) or Activity (range of movement and functional tasks). Exercise was paired with 1 of 2 cognitive interventions (computerized dual working memory training [COG] or control computer games [Games]). The primary outcome for the 4 groups (Aerobic + COG, Aerobic + Games, Activity + COG, and Activity + Games) was fluid intelligence measured using Raven's Progressive Matrices Test administered at baseline, posttraining, and 3-month follow-up. Serum neurotrophins collected at one site (N = 30) included brain-derived neurotrophic factor (BDNF) at rest (BDNF_resting) and after a graded exercise test (BDNF_response) and insulin-like growth factor-1 at the same timepoints (IGF-1_rest, IGF-1_response).

RESULTS

At follow-up, fluid intelligence scores significantly improved compared to baseline in the Aerobic + COG and Activity + COG groups; however, only the Aerobic + COG group was significantly different (+47.8%) from control (Activity + Games -8.5%). Greater IGF-1_response at baseline predicted 40% of the variance in cognitive improvement. There was no effect of the interventions on BDNF_resting or BDNF_response; nor was BDNF predictive of the outcome.

CONCLUSIONS

Aerobic exercise combined with cognitive training improved fluid intelligence by almost 50% in patients >6 months poststroke. Participants with more robust improvements in cognition were able to upregulate higher levels of serum IGF-1 suggesting that this neurotrophin may be involved in behaviorally induced plasticity.

The Active Ingredient of Cognitive Restoration: A Multicenter Randomized Controlled Trial of Sequential Combination of Aerobic Exercise and Computer-Based Cognitive Training in Stroke Survivors With Cognitive Decline

OBJECTIVE

To investigate the efficacy of a sequential combination of aerobic exercise and cognitive training on cognitive function and other health-related outcomes in stroke survivors with cognitive decline.

DESIGN

Intervention study and randomized controlled trial.

SETTING

Hospital-based rehabilitation units.

PARTICIPANTS

Survivors of stroke with cognitive decline (N=30) were randomized to sequential combination training (SEQ) (n=15) or an active control (n=15) group.

INTERVENTIONS

The SEQ group received 30 minutes of aerobic exercise, followed by 30 minutes of computerized cognitive training. The control group received 30 minutes of nonaerobic physical exercise, followed by 30 minutes of unstructured mental activities.

MAIN OUTCOME MEASURES

The primary outcome measure was cognitive function. Secondary outcome measures included physical function, social participation, and quality of life.

RESULTS

Compared with the control group, the SEQ group had significantly improved Montreal Cognitive Assessment scores (P=.03) and Wechsler Memory Scale span scores (P=.012) after training. The endurance and mobility level measured by the 6-minute walk test (P=.25) was also enhanced in the SEQ group relative to the control group. However, the transfer of sequential training to social participation (Community Integration Questionnaire) and quality of life (EuroQoL questionnaire) was limited (P>.05 for both).

CONCLUSIONS

Aerobic exercise combined with computerized cognitive training has better effects on the cognitive functional status of survivors of stroke than an active control. The cognitive functional status of stroke survivors was better after participation in aerobic exercise combined with computerized training than after active control therapy, demonstrating the clinical significance of this combination therapy.

Aerobic exercise program with or without motor complexity as an add-on to the pharmacological treatment of depression - study protocol for a randomized controlled trial

BACKGROUND

Patients with major depression disorder presents increased rates of cognitive decline, reduced hippocampal volume, poor sleep quality, hypertension, obesity, suicidal ideation and behavior, and decreased functionality. Although continuous aerobic exercise (CAE) improves some of the aforementioned symptoms, comorbidities, and conditions, recent studies have suggested that performing aerobic exercise with motor complexity (AEMC) may be more beneficial for cognitive decline, hippocampal volume, and functionality. Therefore, this randomized controlled trial will compare the effects of CAE and AEMC on depression score, cognitive function, hippocampal volume, brain-derived neurotrophic factor expression, sleep parameters, cardiovascular risk parameters, suicidal behavior, functionality, and treatment costs in patients with depression.

METHODS/DESIGN

Seventy-five medicated patients with depression will be recruited from a Basic Healthcare Unit to participate in this prospective, parallel group, single blinded, superiority, randomized controlled trial. Patients with depression according to DSM-V criteria will be balanced and randomly assigned (based on depression scores and number of depressive episodes) to a non-exercising control (C), CAE, and AEMC groups. The CAE and AEMC groups will exercise for 60 min, twice a week for 24 weeks (on non-consecutive days). Exercise intensity will be maintained between 12 and 14 points of the rating of perceived exertion scale (~ 70-80% of the maximum heart rate). The CAE group will perform a continuous aerobic exercise while the AEMC group will perform exercises with progressively increased motor complexity. Blinded raters will assess patients before and after the intervention period. The primary outcome measure will be the change in depression score measured by the Montgomery-Asberg Depression Rating Scale. Secondary outcomes will include measures of cognitive function, hippocampal volume, brain-derived neurotrophic factor expression, sleep parameters, cardiovascular risk parameters, suicidal behavior, functionality, and treatment costs.

DISCUSSION

This study was selected in the call of public policy programs for the Brazilian Unified National Health System - "PPSUS 2015". To our knowledge, this is the first pragmatic trial to test the effect of adding AEMC to the pharmacological treatment of patients with depression and to evaluate the possible reductions in depression symptoms and healthcare costs.

TRIAL REGISTRATION

Brazilian Clinical Trials Registry (ReBec) - RBR-9zgxzd - Registered on 4 Jan. 2017.

Integrating Individuals With Stroke Into Cardiac Rehabilitation Following Traditional Stroke Rehabilitation: Promoting a Continuum of Care

Following stroke, people are at high risk for repeat strokes and for complications related to coronary artery disease (CAD). Indeed, stroke and CAD share many of the same risk factors. Unfortunately, patients become sedentary after stroke, which leads to cardiorespiratory deconditioning as well as muscle atrophy and weakness that in turn leads to deterioration in metabolic, cardiorespiratory, and functional health. Access to intensive secondary prevention programs with structured exercise components that include both aerobic and resistance training can help to prevent and reverse these health hazards. Traditional stroke rehabilitation programs face many barriers to providing exercise programming early post-stroke, such as lack of available therapy time and short length of stay, lack of equipment for exercise and assessments, and concerns for patient safety related to cardiac status. Building a partnership between traditional stroke rehabilitation programs and cardiac rehabilitation by operationalizing an automatic referral process has the potential to affect secondary prevention of stroke and cardiovascular risk significantly. It could also mitigate the tremendous burden on patients and their family members. This is an easily identified group that can achieve significant gains over multiple domains of recovery with the targeted exercise and risk-factor modification components offered by comprehensive cardiac rehabilitation programs.

Change in Cognition and Other Non-Motor Symptoms With Obstructive Sleep Apnea Treatment in Parkinson Disease

STUDY OBJECTIVES

Parkinson disease (PD) non-motor symptoms are associated with sleep disorders and impair quality of life. Our objective was to assess the effect of obstructive sleep apnea (OSA) treatment using continuous positive airway pressure (CPAP) on PD non-motor symptoms.

METHODS

In this prospective observational study, 67 patients with idiopathic PD underwent polysomnography. Those with moderate-severe OSA were offered CPAP therapy. Subjects were divided into those without OSA (OSA-), and those with OSA (OSA+). Analyses were conducted for 6 and 12 months' follow-up data. At 6 months, those who had used CPAP at home for at least 1 month were considered CPAP users (OSA+CPAP+), whereas those who did not try it, or declined further treatment following a short trial were considered non-users (OSA+CPAP-). For the 12-month analysis, only those still actively using CPAP at 12 months were included in the OSA+CPAP+ group. Non-motor symptom measurements were: Epworth Sleepiness Scale, Montreal Cognitive Assessment (MoCA), Unified Parkinson's Disease Rating Scale part 1 (UPDRS1), Parkinson's Disease Sleep Scale (PDSS), Fatigue Severity Scale, Apathy Scale, Beck Depression Inventory, and Hospital Anxiety and Depression Scale (HADS).

RESULTS

Sixty-five participants were re-assessed at least once. At 6 months, 30 participants were categorized as OSA+CPAP+, 11 OSA+CPAP-, and 18 OSA-. At 12 months, 21 were categorized as OSA+CPAP+, 21 OSA+CPAP-, and 17 OSA-. The UPDRS1 and PDSS improved from baseline in OSA+CPAP+ at 6 months (-2.7, standard deviation [SD] 4.0, P = .001, and 7.9, SD 19.0, P = .03, respectively) and 12 months (-4.1, SD 5.4, P = .002, and 11.4, SD 24.4, P = .04, respectively), but not in other groups. The MoCA and HADS-A improved in OSA+CPAP+ at 12 months (1.7, SD 3.5, P = .04, and -2.1, SD 3.8, P = .02, respectively). The MoCA improved in those with low baseline MoCA and those with REM sleep behavior disorder. Mean CPAP use in users at 12 months was 3 hours 36 minutes per night.

CONCLUSIONS

CPAP treatment of OSA in PD is associated with improved overall non-motor symptoms, sleep quality, anxiety, and global cognitive function over a 12-month period.

Aerobic With Resistance Training or Aerobic Training Alone Poststroke: A Secondary Analysis From a Randomized Clinical Trial

BACKGROUND

Stroke is associated with muscle atrophy and weakness, mobility deficits, and cardiorespiratory deconditioning. Aerobic and resistance training (AT and RT) each have the potential to improve deficits, yet there is limited evidence on the utility of combined training.

OBJECTIVE

To examine the effects of AT+RT versus AT on physiological outcomes in chronic stroke with motor impairments.

METHODS

Participants (n = 73) were randomized to 6 months of AT (5 d/wk) or AT+RT (3 and 2 d/wk, respectively). Outcomes included those related to body composition by dual-energy X-ray absorptiometry, mobility (6-minute walk distance [6MWD], sit-to-stand, and stair climb performance), cardiorespiratory fitness (VO_2peak, oxygen uptake at the ventilatory threshold [VO_2VT]), and muscular strength.

RESULTS

A total of 68 (93.2%) participants (age, mean ± SD = 63.7 ± 11.9) completed the study. AT+RT and AT yielded similar and significant improvements in 6MWD (39.9 ± 55.6 vs 36.5 ± 63.7 m, P = .8), VO_2peak (16.4% ± 43.8% vs 15.2% ± 24.7%, P = .9), sit-to-stand time (-2.3 ± 5.1 vs 1.02 ± 9.5 s, P = .05), and stair climb performance (8.2% ± 19.6% vs 7.5% ± 23%, P = .97), respectively. AT+RT produced greater improvements than AT alone for total body lean mass (1.23 ± 2.3 vs 0.27 ± 1.6 kg, P = .039), predominantly trunk ( P = .02) and affected-side limbs ( P = .04), VO_2VT (19.1% ± 26.8% vs 10.5% ± 28.9%, P = .046), and upper- and lower-limb muscular strength ( P < .03, all except affected-side leg).

CONCLUSION

Despite being prescribed 40% less AT, AT+RT resulted in similar and significant improvement in mobility and VO_2peak, superior improvements in VO_2VT and muscular strength, and an almost 5-fold greater increase in lean mass compared with AT. RT is the most neglected exercise component following stroke but should be prescribed with AT for metabolic, cardiorespiratory, and strength recovery.

Study protocol for Vitality: a proof-of-concept randomised controlled trial of exercise training or complex mental and social activities to promote cognition in adults with chronic stroke

INTRODUCTION

Cerebrovascular disease-such as stroke-is the second most common cause of dementia (ie, vascular dementia). Specifically, a stroke increases one's risk for dementia by a factor of two. Thus, stroke survivors represent a target population in need of intervention strategies to promote cognitive function and prevent dementia. The current standard of care in stroke rehabilitation does not adequately address the significant cognitive consequences of stroke, especially for those who are in the chronic phase (ie, >12 months since an index stroke). Two potential intervention strategies are: (1) exercise training and (2) cognitive and social enrichment activities.

METHODS AND ANALYSIS

The aim of this proof-of-concept randomised controlled trial is to determine whether a 6-month targeted exercise training programme or a 6-month cognitive and social enrichment programme can efficaciously and efficiently improve cognitive function in older adults with chronic stroke compared with a 6-month stretch and tone programme (ie, control). The primary measurement periods will be baseline, month 6 (postintervention) and month 12 (6-month follow-up). The primary outcome measure will be performance on the Alzheimer's Disease Assessment Scale-Cognitive-Plus (ADAS-Cog-Plus), a global measure of cognitive performance using multidimensional item response theory to summarise scores from the 13-item ADAS-Cog and other standard cognitive assessments. The primary analysis will compare changes in ADAS-Cog-Plus performance from baseline to month 6. Proof-of-concept outcomes relating to intervention feasibility will be analysed descriptively. The economic evaluation will examine the incremental costs and health outcome benefits generated by both interventions versus the control.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the University of British Columbia's Clinical Research Ethics Board (H13-00715, 26 July 2013). Any modifications to the protocol will require a formal amendment to the protocol and approval by the Research Ethics Board. Outcomes of this randomised controlled trial and the statistical code to generate those outcomes will be disseminated through publication in peer-reviewed journals as well as conference presentations.

TRIAL REGISTRATION NUMBER

NCT01916486.

Balance and fear of falling in subjects with Parkinson's disease is improved after exercises with motor complexity

Resistance training with instability (RTI) uses exercises with high motor complexity that impose high postural control and cognitive demands that may be important for improving postural instability and fear of falling in subjects with Parkinson's disease (PD). Here, we hypothesized that: 1) RTI will be more effective than resistance training (RT) in improving balance (Balance Evaluation Systems Test [BESTest] and overall stability index [Biodex Balance System^®]) and fear of falling (Falls Efficacy Scale-International [FES-I] score) of subjects with Parkinson's disease (PD); and 2) changes in BESTest and FES-I after RTI will be associated with changes in cognitive function (Montreal Cognitive Assessment [MoCA] score - previously published) induced by RTI. Thirty-nine subjects with moderate PD were randomly assigned to a nonexercising control, RT, and RTI groups. While RT and RTI groups performed progressive RT twice a week for 12 weeks, the RTI group added progressive unstable devices to increase motor complexity of the resistance exercises. There were significant group × time interactions for BESTest, overall stability index, and FES-I scores (P < 0.05). Only RTI improved BESTest, overall stability index and FES-I scores, and RTI was more effective than RT in improving biomechanical constraints and stability in gait (BESTest sections) at post-training (P < 0.05). There were strong correlations between relative changes in BESTest and MoCA (r = 0.72, P = 0.005), and FES-I and MoCA (r = -0.75, P = 0.003) after RTI. Due to the increased motor complexity in RTI, RTI is recommended for improving balance and fear of falling, which are associated with improvement in cognitive function of PD.

Resistance exercise and episodic memory function: a systematic review

OBJECTIVE

Emerging research demonstrates that aerobic-based physical activity is favourably associated with episodic memory function. Despite resistance exercises being associated with a multitude of health outcomes, independent of aerobic physical activity, less research has examined the effects of resistance exercise on episodic memory function. The purpose of this study was to conduct a systematic review to examine the extent to which resistance exercise may be associated with episodic memory function.

METHODS

Computerized searches were performed in PubMed, PsychInfo and Sports Discuss. Studies were included if they employed an experimental, cross-sectional or prospective study design, and included acute or chronic resistance exercise as the independent variable, with episodic memory function as the outcome variable.

RESULTS

Eight experimental (one acute and seven chronic training studies) studies met the study inclusionary criteria. Seven of these studies were published in the last 5 years, highlighting the infancy of this line of research. Only three of the eight evaluated studies provided evidence of a positive effect of resistance exercise on memory function; within each of these three studies, there was also some indication of null (or unfavourable) effects.

CONCLUSION

The findings of this systematic review do not provide compelling evidence for a beneficial effect of acute or chronic resistance exercise on episodic memory function. Additional research in this under-investigated field is warranted.

Oxygen uptake at aerobic threshold is inversely associated with fatal cardiovascular and all-cause mortality events

PURPOSE

We aimed to assess the associations of oxygen uptake at aerobic threshold (VO₂ at AT) with cardiovascular and all-cause mortality.

DESIGN

VO₂ at AT was assessed in 1663 middle-aged men in a cohort study. Hazard ratios (HRs) were calculated for sudden cardiac death (SCD), fatal coronary heart disease (CHD) and cardiovascular disease (CVD) and all-cause mortality.

RESULTS

During a median follow-up of 25.6 years, 138 SCDs, 209 fatal CHDs, 333 fatal CVDs and 719 all-cause mortality events occurred. On adjustment for established risk factors, the HRs (95% CIs) for SCD, fatal CHD, fatal CVD and all-cause mortality were 0.48 (0.28-0.82), 0.48 (0.31-0.74), 0.57 (0.41-0.79) and 0.66 (0.53-0.82), respectively comparing extreme quartiles of VO₂ at AT. On further adjustment for peak VO₂, the HRs were 0.87 (0.48-1.56), 0.83 (0.52-1.34), 0.91 (0.63-1.30) and 0.88 (0.69-1.12), respectively. Addition of VO₂ at AT to a standard CVD mortality risk prediction model was associated with a C-index change of 0.0085 (95% CI: -0.0002-0.0172; p = .05) at 25 years.

CONCLUSIONS

VO₂ at AT is inversely associated with cardiovascular and all-cause mortality events, but the associations are partly dependent on peak VO₂. VO₂ at AT may improve the prediction of the long-term risk for CVD mortality. KEY MESSAGES Oxygen uptake at aerobic threshold (VO₂ at AT), a cardiopulmonary exercise testing parameter, may be a useful prognostic tool for adverse clinical outcomes in the general population. In a population-based prospective cohort study of men, VO₂ at AT was inversely associated with cardiovascular and all-cause mortality events and improved the prediction of cardiovascular mortality. In populations who cannot achieve maximal VO₂, VO₂ at AT may serve as a useful prognostic tool; however, further studies are warranted.

Resistance Training with Instability for Patients with Parkinson's Disease

PURPOSE

This randomized controlled trial compared the effects of resistance training (RT) and RT with instability (RTI) on the timed up and go test (TUG), on-medication Unified Parkinson's Disease Rating Scale part III motor subscale score (UPDRS-III), Montreal Cognitive Assessment (MoCA) score, Parkinson's Disease Questionnaire (PDQ-39) score, and muscle strength in the leg press exercise (one-repetition maximum) of patients with Parkinson's disease (PD).

METHODS

Thirty-nine patients with moderate to severe PD were randomly assigned to a nonexercising control group (C), RT group, and RTI group. The RT and RTI groups performed progressive RT twice a week for 12 wk. However, only the RTI group used high motor complexity exercises (i.e., progressive RT with unstable devices), for example, half squat exercise on the BOSU® device. The primary outcome was mobility (TUG). The secondary outcomes were on-medication motor signs (UPDRS-III), cognitive impairment (MoCA), quality of life (PDQ-39), and muscle strength (one-repetition maximum).

RESULTS

There were no differences between RTI and RT groups for any of the outcomes at posttraining (P > 0.05). However, there were differences between RTI and C groups in the TUG, MoCA, and muscle strength values at posttraining (P < 0.05). Only the RTI group improved the TUG (-1.9 s), UPDRS-III score (-4.5 score), MoCA score (6.0 score), and PDQ-39 score (-5.2 score) from pre- to posttraining (P < 0.001). Muscle strength improved for both training groups (P < 0.001). No adverse events were reported during the trial.

CONCLUSIONS

Both training protocols improved muscle strength, but only RTI improved the mobility, motor signs, cognitive impairment, and quality of life, likely because of the usage of high motor complexity exercises. Thus, RTI may be recommended as an innovative adjunct therapeutic intervention for patients with PD.

Advances in neurocognitive rehabilitation research from 1992 to 2017: The ascension of neural plasticity

OBJECTIVE

The last 25 years have seen profound changes in neurocognitive rehabilitation that continue to motivate its evolution. Although the concept of nervous system plasticity was discussed by William James (1890), the foundation for experience-based plasticity had not reached the critical empirical mass to seriously impact rehabilitation research until after 1992. The objective of this review is to describe how the emergence of neural plasticity has changed neurocognitive rehabilitation research.

METHOD

The important developments included (a) introduction of a widely available tool that could measure brain plasticity (i.e., functional MRI); (b) development of new structural imaging techniques that could define limits of and opportunities for neural plasticity; (c) deployment of noninvasive brain stimulation to leverage neural plasticity for rehabilitation; (d) growth of a literature indicating that exercise has positively impacts neural plasticity, especially for older persons; and (e) enhancement of neural plasticity by creating interventions that generalize beyond the boundaries of treatment activities. Given the massive literature, each of these areas is developed by example.

RESULTS

The expanding influence of neural plasticity has provided new models and tools for neurocognitive rehabilitation in neural injuries and disorders, as well as methods for measuring neural plasticity and predicting its limits and opportunities. Early clinical trials have provided very encouraging results.

CONCLUSION

Now that neural plasticity has gained a firm foothold, it will continue to influence the evolution of neurocognitive rehabilitation research for the next 25 years and advance rehabilitation for neural injuries and disease. (PsycINFO Database Record

A systematic review of the effect of physical exercise on cognition in stroke and traumatic brain injury patients

OBJECTIVE

To determine whether physical exercise enhances cognition following TBI or stroke.

DATA SOURCES

Studies were identified through searches of PubMed, ScienceDirect and the reference lists of papers that were included for full-text evaluation. Medical subject headings from three concepts, i.e. brain injury, physical exercise and cognition, were used to incorporate related search terms.

STUDY SELECTION

Included were all trials published in English that assessed cognition before and after an exercise intervention in human adults with TBI or stroke. Nine randomized and two non-randomized controlled trials, as well as three single group pre-post studies were included.

DATA EXTRACTION

Relevant data concerning the methods and results of the included studies were extracted. Methodological quality of the RCT's was evaluated using the PEDro scale. Non-randomized trials were assessed using the Downs and Black checklist.

DATA SYNTHESIS

The included trials were generally of medium methodological quality, though often plagued with issues of internal and external validity. The studies exhibited great heterogeneity, rendering a meta-analysis infeasible.

CONCLUSIONS

Though well-designed studies are still needed, the preponderance of evidence suggests a positive effect of physical exercise on global cognitive functioning, especially in the chronic stages of a brain injury. Time after injury as well as the duration of the exercise program are mediating factors.

Exercise as a Positive Modulator of Brain Function

Various forms of exercise have been shown to prevent, restore, or ameliorate a variety of brain disorders including dementias, Parkinson's disease, chronic stress, thyroid disorders, and sleep deprivation, some of which are discussed here. In this review, the effects on brain function of various forms of exercise and exercise mimetics in humans and animal experiments are compared and discussed. Possible mechanisms of the beneficial effects of exercise including the role of neurotrophic factors and others are also discussed.

Cardiorespiratory fitness and cognitive functioning following short-term interventions in chronic stroke survivors with cognitive impairment: a pilot study

This study, a quasi-experimental, one-group pretest-post-test design, evaluated the effects on cognitive functioning and cardiorespiratory fitness of 8-week interventions (aerobic exercise alone and aerobic exercise and cognitive training combined) in patients with chronic stroke and cognitive impairment living in the community (participants: n=14, 61.93±9.90 years old, 51.50±38.22 months after stroke, n=7 per intervention group). Cognitive functions and cardiorespiratory fitness were evaluated before and after intervention, and at a 3-month follow-up visit (episodic memory: revised-Hopkins Verbal Learning Test; working memory: Brown-Peterson paradigm; attention omission and commission errors: Continuous Performance Test; cardiorespiratory fitness: peak oxygen uptake during a symptom-limited, graded exercise test performed on a semirecumbent ergometer). Friedman's two-way analysis of variance by ranks evaluated differences in score distributions related to time (for the two groups combined). Post-hoc testing was adjusted for multiple comparisons. Compared with before the intervention, there was a significant reduction in attention errors immediately following the intervention (omission errors: 14.6±21.5 vs. 8±13.9, P=0.01; commission errors: 16.4±6.3 vs. 10.9±7.2, P=0.04), and in part at follow-up (omission errors on follow-up: 3.4±4.3, P=0.03; commission errors on follow-up: 13.2±7.6, P=0.42). These results suggest that attention may improve in chronic stroke survivors with cognitive impairment following short-term training that includes an aerobic component, without a change in cardiorespiratory fitness. Randomized-controlled studies are required to confirm these findings.

Post-stroke dementia - a comprehensive review

Post-stroke dementia (PSD) or post-stroke cognitive impairment (PSCI) may affect up to one third of stroke survivors. Various definitions of PSCI and PSD have been described. We propose PSD as a label for any dementia following stroke in temporal relation. Various tools are available to screen and assess cognition, with few PSD-specific instruments. Choice will depend on purpose of assessment, with differing instruments needed for brief screening (e.g., Montreal Cognitive Assessment) or diagnostic formulation (e.g., NINDS VCI battery). A comprehensive evaluation should include assessment of pre-stroke cognition (e.g., using Informant Questionnaire for Cognitive Decline in the Elderly), mood (e.g., using Hospital Anxiety and Depression Scale), and functional consequences of cognitive impairments (e.g., using modified Rankin Scale). A large number of biomarkers for PSD, including indicators for genetic polymorphisms, biomarkers in the cerebrospinal fluid and in the serum, inflammatory mediators, and peripheral microRNA profiles have been proposed. Currently, no specific biomarkers have been proven to robustly discriminate vulnerable patients ('at risk brains') from those with better prognosis or to discriminate Alzheimer's disease dementia from PSD. Further, neuroimaging is an important diagnostic tool in PSD. The role of computerized tomography is limited to demonstrating type and location of the underlying primary lesion and indicating atrophy and severe white matter changes. Magnetic resonance imaging is the key neuroimaging modality and has high sensitivity and specificity for detecting pathological changes, including small vessel disease. Advanced multi-modal imaging includes diffusion tensor imaging for fiber tracking, by which changes in networks can be detected. Quantitative imaging of cerebral blood flow and metabolism by positron emission tomography can differentiate between vascular dementia and degenerative dementia and show the interaction between vascular and metabolic changes. Additionally, inflammatory changes after ischemia in the brain can be detected, which may play a role together with amyloid deposition in the development of PSD. Prevention of PSD can be achieved by prevention of stroke. As treatment strategies to inhibit the development and mitigate the course of PSD, lowering of blood pressure, statins, neuroprotective drugs, and anti-inflammatory agents have all been studied without convincing evidence of efficacy. Lifestyle interventions, physical activity, and cognitive training have been recently tested, but large controlled trials are still missing.

Enhancing Neuroplasticity to Augment Cognitive Remediation in Schizophrenia

There is a burgeoning need for innovative treatment strategies to improve the cognitive deficits in schizophrenia. Cognitive remediation (CR) is effective at the group level, but the variability in treatment response is large. Given that CR may depend on intact neuroplasticity to produce cognitive gains, it is reasonable to combine it with strategies that harness patients' neuroplastic potential. In this review, we discuss two non-pharmacological approaches that can enhance neuroplasticity and possibly augment the effects of CR in schizophrenia: physical exercise and transcranial direct current stimulation (tDCS). Substantial body of evidence supports the beneficial effect of physical exercise on cognition, and a handful of studies in schizophrenia have shown that physical exercise in conjunction with CR has a larger impact on cognition than CR alone. Physical exercise is thought to stimulate neuroplasticity through the regulation of central growth factors, and current evidence points to brain-derived neurotrophic factor as the potential underlying mechanism through which physical exercise might enhance the effectiveness of CR. tDCS has emerged as a potential tool for cognitive enhancement and seems to affect the cellular mechanisms involved in long-term potentiation (LTP). A few reports have demonstrated the feasibility of integrating tDCS with CR in schizophrenia, but there are insufficient data to determine if this multimodal approach leads to incremental performance gain in patients. Larger randomized controlled trials are necessary to understand the mechanisms of the combined tDCS-CR intervention. Future research should take advantage of new developments in neuroplasticity paradigms to examine the effects of these interventions on LTP.

Clinical Evidence of Exercise Benefits for Stroke

Even though stroke is the third, not the first, most common cause of disability-adjusted life years in developed countries, it is one of the most expensive to treat. Part of the expense is due to secondary problems in the post-stroke period including: cognition, memory, attention span, pain, sensation loss, psychological issues, and problems with mobility and balance. Research has identified that exercise has both positive physical and psychosocial effects for post-stroke patients. Therefore, this scientific statement provides an overview on exercise rehabilitation for post-stroke patients.We will use systematic literature reviews, clinical and epidemiology reports, published morbidity and mortality studies, clinical and public health guidelines, patient files, and authoritative statements to support this overview.Evidence clearly supports the use of various kinds of exercise training (e.g., aerobic, strength, flexibility, neuromuscular, and traditional Chinese exercise) for stroke survivors. Aerobic exercise, the main form of cardiac rehabilitation, may play an important role in improving aerobic fitness, cardiovascular fitness, cognitive abilities, walking speed and endurance, balance, quality of life, mobility, and other health outcomes among stroke patients. Strength exercise, included in national stroke guidelines and recommended for general health promotion for stroke survivors, can lead to improvements in functionality, psychosocial aspects, and quality of life for post-stroke patients. Flexibility exercises can relieve muscle spasticity problems, improve motor function, range of motion, and prevent contractures. Stretching exercises can also prevent joint contractures, muscle shortening, decrease spasticity, reduce joint stiffness and improve a post-stroke patient's overall function. Neuromuscular exercises can improve activities of daily living (ADL) through coordination and balance activities. Traditional Chinese exercises are used to improve walking and balance ability as well as increase muscle strength, which is important for post-stroke patients.The present evidence strongly supports the power of exercise for post-stroke patients, which in this study combined aerobic exercises, strength training, flexibility exercises, neuromuscular exercises, and traditional Chinese exercises. This research can encourage post-stroke survivors to consider the importance of exercise in the rehabilitation process.

The effects of aerobic exercise on cognition in schizophrenia: A 3-month follow-up study

Aerobic exercise (AE) has been shown to improve cognition in patients with schizophrenia. However, it remains unclear whether these exercise-induced cognitive benefits persist beyond the training period. Accordingly, the present study sought to examine the immediate and maintenance effects of AE on a wide range of cognitive functions in 75 schizophrenia patients randomized to 12 weeks of either moderate-intensity treadmill exercise or stretching and toning exercise that served as a control. Participants completed assessments of neurocognition and cardiovascular fitness at pretest, posttest, and 3-month follow-up. The results showed that the AE group outperformed the controls on processing speed and attention at the end of intervention. The two groups did not differ significantly in any cognitive outcome measured at follow-up; however, improvement over time was noted in certain cognitive domains in AE group. The average effect sizes at follow-up were 0.53 and 0.35 for AE and control groups, respectively. There were no significant between-group differences in aerobic fitness at posttest and follow-up, and that fitness level was not related to changes in cognitive performance. These findings provide preliminary evidence for a trend towards beneficial effects of physical activity on cognition over a short follow-up period in favor of AE.

High-Intensity Interval Training and Moderate-Intensity Continuous Training in Ambulatory Chronic Stroke: Feasibility Study

BACKGROUND

Poststroke guidelines recommend moderate-intensity, continuous aerobic training (MCT) to improve aerobic capacity and mobility after stroke. High-intensity interval training (HIT) has been shown to be more effective than MCT among healthy adults and people with heart disease. However, HIT and MCT have not been compared previously among people with stroke.

OBJECTIVE

The purpose of this study was to assess the feasibility and justification for a definitive randomized controlled trial (RCT) comparing HIT and MCT in people with chronic stroke.

DESIGN

A preliminary RCT was conducted.

SETTING

The study was conducted in a cardiovascular stress laboratory and a rehabilitation research laboratory.

PATIENTS

Ambulatory people at least 6 months poststroke participated.

INTERVENTION

Both groups trained 25 minutes, 3 times per week, for 4 weeks. The HIT strategy involved 30-second bursts at maximum-tolerated treadmill speed alternated with 30- to 60-second rest periods. The MCT strategy involved continuous treadmill walking at 45% to 50% of heart rate reserve.

MEASUREMENTS

Measurements included recruitment and attendance statistics, qualitative HIT acceptability, adverse events, and the following blinded outcome variables: peak oxygen uptake, ventilatory threshold, metabolic cost of gait, fractional utilization, fastest treadmill speed, 10-Meter Walk Test, and Six-Minute Walk Test.

RESULTS

During the 8-month recruitment period, 26 participants consented to participate. Eighteen participants were enrolled and randomly assigned to either the HIT group (n=13) or the MCT group (n=5). Eleven out of the 13 HIT group participants attended all sessions. Participants reported that HIT was acceptable and no serious adverse events occurred. Standardized effect size estimates between groups were moderate to very large for most outcome measures. Only 30% of treadmill speed gains in the HIT group translated into overground gait speed improvement.

LIMITATIONS

The study was not designed to definitively test safety or efficacy.

CONCLUSIONS

Although further protocol optimization is needed to improve overground translation of treadmill gains, a definitive RCT comparing HIT and MCT appears to be feasible and warranted.

Exercise in the Early Stage after Stroke Enhances Hippocampal Brain-Derived Neurotrophic Factor Expression and Memory Function Recovery

BACKGROUND

Exercise in the early stage after stroke onset has been shown to facilitate the recovery from physical dysfunction. However, the mechanism of recovery has not been clarified. In this study, the effect of exercise on spatial memory function recovery in the early stage was shown, and the mechanism of recovery was discussed using a rat model of brain embolism.

METHODS

Intra-arterial microsphere (MS) injection induced small emboli in the rat brain. Treadmill exercise was started at 24 hours (early group) or 8 days (late group) after MS injection. The non-exercise (NE) and sham-operated groups were included as controls. Memory function was evaluated by the Morris water maze test, and hippocampal levels of brain-derived neurotrophic factor (BDNF) were measured by enzyme-linked immunosorbent assays. To further investigate the effect of BDNF on memory function, BDNF was continuously infused into the hippocampus via implantable osmotic pumps in the early or late stage after stroke.

RESULTS

Memory function significantly improved only in the early group compared with the late and the NE groups, although hippocampal BDNF concentrations were temporarily elevated after exercise in both the early and the late groups. Rats infused with BDNF in the early stage exhibited significant memory function recovery; however, rats that received BDNF infusion in the late stage showed no improvement.

CONCLUSION

Exercise elevates hippocampal BDNF levels in the early stage after cerebral embolism, and this event facilitates memory function recovery.

Independent, Community-Based Aerobic Exercise Training for People With Moderate-to-Severe Traumatic Brain Injury

OBJECTIVE

To determine whether people with moderate-to-severe traumatic brain injury (TBI) can adhere to a minimally supervised, community-based, vigorous aerobic exercise program.

DESIGN

Prospective trial.

SETTING

Young Men's Christian Association (YMCA) facilities.

PARTICIPANTS

Community-dwelling volunteers (N=10; 8 men, 2 women; age range, 22-49y) 6 to 15 months after moderate-to-severe TBI.

INTERVENTION

Participants received memberships to local YMCAs and brief orientations to exercise. They were then asked to independently complete ≥12 weeks of ≥3 training sessions per week, performed at 65% to 85% of maximum heart rate for ≥30 minutes per session. Participants could self-select exercise modality, provided they met intensity and duration targets. Programmable heart rate monitors captured session intensity and duration.

MAIN OUTCOME MEASURES

Independence with equipment and facility use and compliance with training goals (session frequency, duration, intensity, total weeks of training).

RESULTS

All participants achieved independence with equipment and facility use. All met at least 2 of 4 training goals; half met all 4 goals. Participants averaged (±SD) 3.3±0.7 sessions per week for 13 weeks (range, 6-24). Average ± SD session duration was 62±23 minutes, of which 51±22 minutes occurred at or above individuals' heart rate training targets.

CONCLUSIONS

People in recovery from moderate-to-severe TBI can, with minimal guidance, perform vigorous, community-based exercise. This suggests that decentralized exercise may be logistically and economically sustainable after TBI, expanding its potential therapeutic utility and rendering longer-duration exercise studies more feasible.

Physiotherapists' perspectives on aerobic exercise early after stroke: A preliminary study

Aerobic exercise is recognized as part of comprehensive stroke rehabilitation in best-practice and clinical guidelines, yet many individuals remain physically inactive during their hospitalization. The purpose of this study was to identify the perspectives of physiotherapists on aerobic exercise prescription and implementation at in-patient stroke rehabilitation centers with and without a structured aerobic exercise program. A survey was conducted at three Canadian rehabilitation centers to evaluate physiotherapist perceptions of individuals recovering from stroke, the practice environment, and their training on aerobic exercise in stroke. Physiotherapists at centers without a structured aerobic exercise program (n = 10) reported the lack of necessary resources and therapeutic support staff and the individuals' physical impairment as the greatest barriers. In contrast, physiotherapists at the center with a structured aerobic exercise program (n = 6) reported therapy selection (insufficient time in a single physiotherapy session) and concern for the individuals' cardiovascular risk and cognitive impairment as the greatest barriers. Both groups of physiotherapists indicated that fatigue was a barrier. Only physiotherapists at the center with a structured aerobic exercise program had received continuing education on aerobic exercise in stroke. The lack of resources at rehabilitation centers without a structured aerobic exercise program needs to be addressed. There remains a need for continuing education on aerobic training in stroke, specifically on assessment and prescription using a standardized approach.

Ventilatory threshold may be a more specific measure of aerobic capacity than peak oxygen consumption rate in persons with stroke

BACKGROUND

After stroke, aerobic deconditioning can have a profound impact on daily activities. This is usually measured by the peak oxygen consumption rate achieved during exercise testing (VO2-peak). However, VO2-peak may be distorted by motor function. The oxygen uptake efficiency slope (OUES) and VO2 at the ventilatory threshold (VO2-VT) could more specifically assess aerobic capacity after stroke, but this has not been tested.

OBJECTIVES

To assess the differential influence of motor function on three measures of aerobic capacity (VO2-peak, OUES, and VO2-VT) and to evaluate the inter-rater reliability of VO2-VT determination post-stroke.

METHODS

Among 59 persons with chronic stroke, cross-sectional correlations with motor function (comfortable gait speed [CGS] and lower extremity Fugl-Meyer [LEFM]) were compared between the different aerobic capacity measures, after adjustment for covariates, in order to isolate any distorting effect of motor function. Reliability of VO2-VT determination between three raters was assessed with intra-class correlation (ICC).

RESULTS

CGS was moderately correlated with VO2-peak (r = 0.52, p < 0.0001) and weakly correlated with OUES (r = 0.41, p = 0.002) and VO2-VT (r = 0.37, p = 0.01). LEFM was weakly correlated with VO2-peak (r = 0.26, p = 0.055) and very weakly correlated with OUES (r = 0.19, p = 0.17) and VO2-VT (r = 0.14, p = 0.31). Compared to VO2-peak, VO2-VT was significantly less correlated with CGS (r difference = -0.16, p = 0.02). Inter-rater reliability of VO2-VT determination was high (ICC: 0.93, 95% CI: 0.89-0.96).

CONCLUSIONS

Motor dysfunction appears to artificially lower measured aerobic capacity. VO2-VT seemed to be less distorted than VO2-peak and had good inter-rater reliability, so it may provide more specific assessment of aerobic capacity post-stroke.

Effect of Aerobic Exercise Interventions on Mobility among Stroke Patients: A Systematic Review

OBJECTIVE

The purpose of this systematic review was to examine studies that examined the effectiveness of aerobic exercise interventions on mobility in long-term stroke survivors.

DESIGN

The authors searched electronic databases for randomized control trials between January 1995 and December 2014 investigating aerobic exercise interventions and mobility in stroke survivors after the subacute phase (>6 mos). Mobility was measured using objective functional fitness tests: 6-minute walk, 10-meter walk, and up-n-go.

RESULTS

Nine randomized control trials that compared aerobic exercise with a control group among stroke survivors (mean age, 56.95-68 yrs) were identified. Aerobic interventions lasted between 2 and 6 mos and primarily involved walking. Using the Comprehensive Meta-analysis software, it was found that two of the three mobility outcomes showed small to moderate effect sizes favoring the aerobic exercise group: 6-minute walk (g = 0.366, P < 0.001) and 10-meter walk (g = 0.411, P = 0.002), while the up-n-go test was not significant (g = -0.150, P = 0.330).

CONCLUSION

These findings demonstrate that stroke survivors may continue to benefit from aerobic exercise after the subacute phase. Future research needs to examine the precise dose and recommendation for aerobic exercise, test other exercise modalities, and use larger samples to thoroughly determine long-term exercise effects on mobility in this population.

Influence of Aerobic Training and Combinations of Interventions on Cognition and Neuroplasticity after Stroke

Stroke often aggravated age-related cognitive impairments that strongly affect several aspects of quality of life. However, few studies are, to date, focused on rehabilitation strategies that could improve cognition. Among possible interventions, aerobic training is well known to enhance cardiovascular and motor functions but may also induce beneficial effects on cognitive functions. To assess the effectiveness of aerobic training on cognition, it seems necessary to know whether training promotes the neuroplasticity in brain areas involved in cognitive functions. In the present review, we first explore in both human and animal how aerobic training could improve cognition after stroke by highlighting the neuroplasticity mechanisms. Then, we address the potential effect of combinations between aerobic training with other interventions, including resistance exercises and pharmacological treatments. In addition, we postulate that classic recommendations for aerobic training need to be reconsidered to target both cognition and motor recovery because the current guidelines are only focused on cardiovascular and motor recovery. Finally, methodological limitations of training programs and cognitive function assessment are also developed in this review to clarify their effectiveness in stroke patients.

The Impact of Falls on Motor and Cognitive Recovery after Discharge from In-Patient Stroke Rehabilitation

BACKGROUND

Falls are common among community-dwelling stroke survivors. The aims of this study were (1) to compare motor and cognitive outcomes between individuals who fell in the 6 months' postdischarge from in-patient stroke rehabilitation and those who did not fall, and (2) to explore potential mechanisms underlying the relationship between falls and recovery of motor and cognitive function.

METHODS

Secondary analysis of a prospective cohort study of individuals discharged home from in-patient rehabilitation was conducted. Participants were recruited at discharge and completed a 6-month falls monitoring period using postcards with follow-up. Nonfallers and fallers were compared at the 6-month follow-up assessment on the Berg Balance Scale (BBS), the Chedoke-McMaster Stroke Assessment (CMSA), gait speed, and the Montreal Cognitive Assessment (MoCA). Measures of balance confidence and physical activity were also assessed.

RESULTS

Twenty-three fallers were matched to 23 nonfallers on age and functional balance scores at discharge. A total of 43 falls were reported during the study period (8 participants fell more than once). At follow-up, BBS scores (P = .0066) and CMSA foot scores (P = .0033) were significantly lower for fallers than for nonfallers. The 2 groups did not differ on CMSA leg scores (P = .049), gait speed (P = .47), or MoCA score (P = .23). There was no significant association between change in balance confidence scores and change in physical activity levels among all participants from the first and third questionnaire (r = .27, P = .08).

CONCLUSIONS

Performance in balance and motor recovery of the foot were compromised in fallers when compared to nonfallers at 6 months post discharge from in-patient stroke rehabilitation.

Muscle, functional and cognitive adaptations after flywheel resistance training in stroke patients: a pilot randomized controlled trial

BACKGROUND

Resistance exercise (RE) improves neuromuscular function and physical performance after stroke. Yet, the effects of RE emphasizing eccentric (ECC; lengthening) actions on muscle hypertrophy and cognitive function in stroke patients are currently unknown. Thus, this study explored the effects of ECC-overload RE training on skeletal muscle size and function, and cognitive performance in individuals with stroke.

METHODS

Thirty-two individuals with chronic stroke (≥6 months post-stroke) were randomly assigned into a training group (TG; n = 16) performing ECC-overload flywheel RE of the more-affected lower limb (12 weeks, 2 times/week; 4 sets of 7 maximal closed-chain knee extensions; <2 min of contractile activity per session) or a control group (CG; n = 16), maintaining daily routines. Before and after the intervention, quadriceps femoris volume, maximal force and power for each leg were assessed, and functional and dual task performance, and cognitive functions were measured.

RESULTS

Quadriceps femoris volume of the more-affected leg increased by 9.4 % in TG. Muscle power of the more-affected, trained (48.2 %), and the less-affected, untrained limb (28.1 %) increased after training. TG showed enhanced balance (8.9 %), gait performance (10.6 %), dual-task performance, executive functions (working memory, verbal fluency tasks), attention, and speed of information processing. CG showed no changes.

CONCLUSION

ECC-overload flywheel resistance exercise comprising 4 min of contractile activity per week offers a powerful aid to regain muscle mass and function, and functional performance in individuals with stroke. While the current intervention improved cognitive functions, the cause-effect relationship, if any, with the concomitant neuromuscular adaptations remains to be explored.

TRIAL REGISTRATION

Clinical Trials NCT02120846.

Exercise and Environmental Enrichment as Enablers of Task-Specific Neuroplasticity and Stroke Recovery

Improved stroke care has resulted in greater survival, but >50% of patients have chronic disabilities and 33% are institutionalized. While stroke rehabilitation is helpful, recovery is limited and the most significant gains occur in the first 2-3 months. Stroke triggers an early wave of gene and protein changes, many of which are potentially beneficial for recovery. It is likely that these molecular changes are what subserve spontaneous recovery. Two interventions, aerobic exercise and environmental enrichment, have pleiotropic actions that influence many of the same molecular changes associated with stroke injury and subsequent spontaneous recovery. Enrichment paradigms have been used for decades in adult and neonatal animal models of brain injury and are now being adapted for use in the clinic. Aerobic exercise enhances motor recovery and helps reduce depression after stroke. While exercise attenuates many of the signs associated with normal aging (e.g., hippocampal atrophy), its ability to reverse cognitive impairments subsequent to stroke is less evident. It may be that stroke, like other diseases such as cancer, needs to use multimodal treatments that augment complimentary neurorestorative processes.

The Effect of Aerobic Exercise on Neuroplasticity within the Motor Cortex following Stroke

Background

Aerobic exercise is associated with enhanced plasticity in the motor cortex of healthy individuals, but the effect of aerobic exercise on neuroplasticity following a stroke is unknown.

Objective

The aim of this study was to compare corticomotoneuronal excitability and neuroplasticity in the upper limb cortical representation following a single session of low intensity lower limb cycling, or a rest control condition.

Methods

We recruited chronic stroke survivors to take part in three experimental conditions in a randomised, cross-over design. Corticomotoneuronal excitability was examined using transcranial magnetic stimulation to elicit motor evoked potentials in the affected first dorsal interosseus muscle. Following baseline measures, participants either cycled on a stationary bike at a low exercise intensity for 30 minutes, or remained resting in a seated position for 30 minutes. Neuroplasticity within the motor cortex was then examined using an intermittent theta burst stimulation (iTBS) paradigm. During the third experimental condition, participants cycled for the 30 minutes but did not receive any iTBS.

Results

Twelve participants completed the study. We found no significant effect of aerobic exercise on corticomotoneuronal excitability when compared to the no exercise condition (P > 0.05 for all group and time comparisons). The use of iTBS did not induce a neuroplastic-like response in the motor cortex with or without the addition of aerobic exercise.

Conclusions

Our results suggest that following a stroke, the brain may be less responsive to non-invasive brain stimulation paradigms that aim to induce short-term reorganisation, and aerobic exercise was unable to induce or improve this response.

Physical fitness training for stroke patients

BACKGROUND

Levels of physical fitness are low after stroke. It is unknown whether improving physical fitness after stroke reduces disability.

OBJECTIVES

To determine whether fitness training after stroke reduces death, dependence, and disability and to assess the effects of training with regard to adverse events, risk factors, physical fitness, mobility, physical function, quality of life, mood, and cognitive function. Interventions to improve cognitive function have attracted increased attention after being identified as the highest rated research priority for life after stroke. Therefore we have added this class of outcomes to this updated review.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched February 2015), the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 1: searched February 2015), MEDLINE (1966 to February 2015), EMBASE (1980 to February 2015), CINAHL (1982 to February 2015), SPORTDiscus (1949 to February 2015), and five additional databases (February 2015). We also searched ongoing trials registers, handsearched relevant journals and conference proceedings, screened reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised trials comparing either cardiorespiratory training or resistance training, or both (mixed training), with usual care, no intervention, or a non-exercise intervention in stroke survivors.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed quality and risk of bias, and extracted data. We analysed data using random-effects meta-analyses. Diverse outcome measures limited the intended analyses.

MAIN RESULTS

We included 58 trials, involving 2797 participants, which comprised cardiorespiratory interventions (28 trials, 1408 participants), resistance interventions (13 trials, 432 participants), and mixed training interventions (17 trials, 957 participants). Thirteen deaths occurred before the end of the intervention and a further nine before the end of follow-up. No dependence data were reported. Diverse outcome measures restricted pooling of data. Global indices of disability show moderate improvement after cardiorespiratory training (standardised mean difference (SMD) 0.52, 95% confidence interval (CI) 0.19 to 0.84; P value = 0.002) and by a small amount after mixed training (SMD 0.26, 95% CI 0.04 to 0.49; P value = 0.02); benefits at follow-up (i.e. after training had stopped) were unclear. There were too few data to assess the effects of resistance training.Cardiorespiratory training involving walking improved maximum walking speed (mean difference (MD) 6.71 metres per minute, 95% CI 2.73 to 10.69), preferred gait speed (MD 4.28 metres per minute, 95% CI 1.71 to 6.84), and walking capacity (MD 30.29 metres in six minutes, 95% CI 16.19 to 44.39) at the end of the intervention. Mixed training, involving walking, increased preferred walking speed (MD 4.54 metres per minute, 95% CI 0.95 to 8.14), and walking capacity (MD 41.60 metres per six minutes, 95% CI 25.25 to 57.95). Balance scores improved slightly after mixed training (SMD 0.27, 95% CI 0.07 to 0.47). Some mobility benefits also persisted at the end of follow-up. The variability, quality of the included trials, and lack of data prevents conclusions about other outcomes and limits generalisability of the observed results.

AUTHORS' CONCLUSIONS

Cardiorespiratory training and, to a lesser extent, mixed training reduce disability during or after usual stroke care; this could be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programmes to improve the speed and tolerance of walking; some improvement in balance could also occur. There is insufficient evidence to support the use of resistance training. The effects of training on death and dependence after stroke are still unclear but these outcomes are rarely observed in physical fitness training trials. Cognitive function is under-investigated despite being a key outcome of interest for patients. Further well-designed randomised trials are needed to determine the optimal exercise prescription and identify long-term benefits.

Defining Optimal Aerobic Exercise Parameters to Affect Complex Motor and Cognitive Outcomes after Stroke: A Systematic Review and Synthesis

Although poststroke aerobic exercise (AE) increases markers of neuroplasticity and protects perilesional tissue, the degree to which it enhances complex motor or cognitive outcomes is unknown. Previous research suggests that timing and dosage of exercise may be important. We synthesized data from clinical and animal studies in order to determine optimal AE training parameters and recovery outcomes for future research. Using predefined criteria, we included clinical trials of stroke of any type or duration and animal studies employing any established models of stroke. Of the 5,259 titles returned, 52 articles met our criteria, measuring the effects of AE on balance, lower extremity coordination, upper limb motor skills, learning, processing speed, memory, and executive function. We found that early-initiated low-to-moderate intensity AE improved locomotor coordination in rodents. In clinical trials, AE improved balance and lower limb coordination irrespective of intervention modality or parameter. In contrast, fine upper limb recovery was relatively resistant to AE. In terms of cognitive outcomes, poststroke AE in animals improved memory and learning, except when training was too intense. However, in clinical trials, combined training protocols more consistently improved cognition. We noted a paucity of studies examining the benefits of AE on recovery beyond cessation of the intervention.

[Effectiveness of acupuncture in spasticity of the post-stroke patient. Systematic review]

OBJECTIVE

To determine the effectiveness of acupuncture for reducing spasticity in post-stroke patients.

DESIGN

Literature review.

DATA SOURCE

The literature search was performed using scientific databases from January 2000 to January 2013.

SELECTION OF STUDIES

Out of the 110 studies that were found, nine random and controlled trials were included. Inclusion criteria were based on clinical trials in which participants were over 18 years old, who were suffering with post-stroke spasticity, and one of the experimental groups was treated with acupuncture.

DATA EXTRACTION

The variables were the passive resistance to stretching of the affected limb, and the degree of personal dependence. The variables were assessed by the Modified Ashworth Scale and Barthel Index.

METHODS

The search was performed in the PUBMED, COCHRANE Library, PEDro, Dialnet, CSIC, CINAHL, databases. Search terms included the combination of keywords "acupuncture"; "muscle spasticity"; "stroke".

RESULTS

Passive resistance to stretching, the degree of personal dependence, and motor function of the affected limb showed statistically significant improvements in at least one study included; however, these improvements are not clinically relevant changes. Passive resistance improved in the elbow, ankle, knee, and wrist. An increased joint range was observed, except for the elbow, forearm, and thumb. Improved of the patient dependency was also observed.

CONCLUSIONS

Although improvements relative to the reduction of spasticity are shown, the results have failed to demonstrate the effectiveness of the technique for this ailment. It would take a greater number of studies to calculate the size of the reported effects with homogeneous procedures in the design as well as in the duration, frequency, and measurement tools.

Spatial cognitive rehabilitation and motor recovery after stroke

PURPOSE OF REVIEW

Stroke rehabilitation needs to take major steps forward to reduce functional disability for survivors. In this article, we suggest that spatial retraining might greatly increase the efficiency and efficacy of motor rehabilitation, directly addressing the burden and cost of paralysis after stroke.

RECENT FINDINGS

Combining motor and cognitive treatment may be practical, as well as addressing the needs after moderate-to-severe stroke. Spatial neglect could suppress motor recovery and reduce motor learning, even when patients receive appropriate rehabilitation to build strength, dexterity, and endurance. Spatial neglect rehabilitation acts to promote motor as well as visual-perceptual recovery. These findings, and the previous underemphasized studies, make a strong case for combining spatial neglect treatment with traditional exercise training. Spatial neglect therapies might also provide motor stimulation if people cannot participate in intensive movement therapies because of limited strength and endurance after stroke.

SUMMARY

Spatial retraining, currently used selectively after right-brain stroke, may be broadly useful after stroke to promote rapid motor recovery.

The effects of golf training in patients with stroke: a pilot study

BACKGROUND

Stroke is the most common neurological disease and the primary cause of lifelong disability in industrialized countries. Because of this it is important to investigate any kind of successful therapy.

METHODS

From the 24 recruited stroke patients who were between 23 and 72 years old, 14 patients were separated either in a golf training group (EG), or a social communication meeting (CG). Both groups met for one hour sessions, twice a week, for ten weeks. All participants completed assessment tests before and after the experimental period: cognitive tests measuring attention (Go/No-Go task), visual-spatial memory (Block-Tapping test) and mental rotation performance (MRT); a balance test (Berg Balance Scale), and an emotional well-being test (CES-D-Scale).

RESULTS

The results show that both groups improved in the CES Scale, the block-tapping test and the balance test. In addition, stroke patients who received a golf training showed a significant improvement in the MRT comparing to the control group (CG).

CONCLUSION

It is indicated that golf training can improve visual imagery ability in stroke patients, even late after stroke.