Heart disease in patients with stroke: incidence, impact, and implications for rehabilitation. Part 1: Classification and prevalence

Cardiorespiratory fitness and walking ability in subacute stroke patients11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVES

To evaluate the cardiorespiratory fitness of subacute stroke patients and to determine whether reduced fitness is associated with gait performance.

DESIGN

Descriptive, cross-sectional study.

SETTING

Rehabilitation hospital.

PARTICIPANTS

Seventeen patients in an inpatient rehabilitation unit who had mild to moderate gait impairments after a recent (< or =7wk) stroke. All subjects could walk at least 3m alone or with an aid but with no standby assistance.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Peak and submaximal cardiorespiratory responses were measured during semirecumbent leg cycling exercise. Walking velocity and endurance were assessed with 10-m and 6-minute walk tests, respectively.

RESULTS

Peak oxygen uptake (Vo(2)peak) was 1.15+/-0.36L/min, which was only 50% of the Vo(2)peak reported in the literature for a healthy, age-matched group. Maximal walking velocity (1.02+/-0.28m/s) and endurance (294.1+/-120.2m) were also approximately 50% of an aged-matched healthy group. Pearson product-moment correlations revealed that 6-minute walking endurance was strongly associated with self-selected walking velocity (R=.91) and measures of peak cardiorespiratory fitness (R=.84).

CONCLUSIONS

Cardiorespiratory fitness was markedly impaired within 7 weeks after a stroke. Although muscle weakness and loss of coordination are the primary impairments that affect gait after a stroke, impaired cardiorespiratory fitness may secondarily affect gait performance by limiting walking endurance. To address this secondary impairment, current rehabilitation interventions can incorporate assessment of cardiorespiratory fitness status and aerobic exercise training for persons after stroke.

A systematic review of exercise trials post stroke

OBJECTIVE

To perform a systematic review of exercise trials post stroke.

DESIGN

A systematic review of controlled clinical trials.

SEARCH STRATEGY

MEDLINE, EMBASE, CINAHL, Amed, Sports Discus, Cochrane controlled trials register and PEDro were searched for relevant trials.

INCLUSION CRITERIA

Studies--randomized or quasi-randomized controlled clinical trials. Participants--Adults of any age with a clinical diagnosis of stroke. Interventions--Any cardiovascular exercise intervention aimed at improving cardiovascular fitness and/or function.

OUTCOMES

Impairment: gait speed, strength, endurance, balance, flexibility, tonus and exercise capacity. Disability: global dependency, functional independence. Extended activities of daily living. Quality of life. Death.

DATA COLLECTION AND ANALYSIS

Two independent reviewers categorized selected trials, documented the methodological quality and extracted the relevant data. Comparisons of cardiovascular exercise interventions versus no cardiovascular intervention were made. Statistical comparisons were carried out using a random effects model to calculate standardized mean differences.

RESULTS

We identified three eligible trials. Small numbers and heterogeneous outcomes limited the analyses and comparisons. Based on the limited data available, we found that cardiovascular exercise post stroke was no better than no exercise with respect to disability, impairment, extended activities of daily living, quality of life and death.

CONCLUSION

Insufficient evidence was identified to establish if cardiovascular exercise has a positive effect on disability, impairment, extended activities of daily living, quality of life and case fatality post stroke.

Exercise capacity early after stroke

OBJECTIVE

To evaluate exercise capacity of patients with a poststroke interval of less than 1 month.

DESIGN

Prospective, cohort, observational study.

SETTING

Exercise testing laboratory in a tertiary care hospital.

PARTICIPANTS

Twenty-nine patients (mean age +/- standard deviation, 64.9+/-13.5 y) with a poststroke interval of 26.0+/-8.8 days.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Peak exercise capacity (VO(2)peak) was measured by open-circuit spirometry during maximal effort treadmill walking with 15% body-weight support.

RESULTS

Mean VO(2)peak was 14.4+/-5.1 mL. kg(-1). min(-1) or 60%+/-16% of age- and sex-related normative values for sedentary healthy adults.

CONCLUSIONS

Exercise capacity approximately 1 month after stroke was compromised. Further research is needed to elucidate the physiologic basis of this low capacity.

Evaluation of autonomic nervous system functions in post-stroke patients

OBJECTIVE

In this study, we aimed to investigate whether there is a sympathetic and parasympathetic system dysfunction in hemiplegic or hemiparetic patients after a cerebrovascular accident.

DESIGN

Sympathetic skin response and R-R interval variation were evaluated in a total of 65 subjects: 37 hemiparetic or hemiplegic patients due to a cerebrovascular accident, seven acute (<30 days) and 30 chronic, with a mean age of 59.16 yr (32-76 yr), and 28 healthy subjects with a mean age of 57.07 yr (45-75 yr). Disease duration was 6.89 mo (1-32 mo) in the patient group. Bilateral sympathetic skin responses were recorded with stimulation of median nerves in both affected and unaffected sides. R-R interval variation was evaluated at rest (R%) and during deep breathing (DB%) at six times per minute.

RESULTS

Although there was no significant difference between sympathetic skin response latencies of the patient and the control groups, the amplitude values of sympathetic skin response in patients were significantly lower than those in controls (P < 0.05). Both R% and DB% in patients significantly increased as compared with controls (P < 0.001 and P < 0.05, respectively).

CONCLUSION

In conclusion, our results suggest that both sympathetic and parasympathetic functions in post-stroke survivors were partially inhibited, and this finding may be useful in the prediction of possible complications during rehabilitation.

Exercise training in a predominantly African-American group of stroke survivors

PURPOSE

The purpose of this study was to determine the effects of a 12-wk exercise training program in a predominantly African-American group of stroke survivors with multiple comorbidities.

METHODS

A lag-control group design was employed to provide training to all participants (N = 35). Two 12-wk training iterations were arranged. Participants trained 3 d x wk(-1) for 60 min x d(-1) (cardiovascular, 30 min; strength, 20 min; flexibility, 10 min). Outcome measures included peak VO2 (mL x min(-1), mL x kg(-1) x min(-1), maximal workload (MW), time to exhaustion (TTE), 10 RM on two LifeFitness strength machines, grip strength (GS), body weight (BW), total skinfolds (TS), waist to hip ratio (WHR), hamstring/low back flexibility (HLBF), and shoulder flexibility (SF).

RESULTS

Compared with controls, the exercise group showed significant gains in peak VO2 (P < 0.01), strength (P < 0.01), HLBF (P < 0.01), and body composition (BW and BMI, P < 0.05; TS, P < 0.01). There was no significant difference between exercise and controls on WHR, SF, and GS.

DISCUSSION

A supervised exercise training program for stroke survivors with multiple comorbidities was highly effective in improving overall fitness, potentially reducing the risk of further disease and disability. Greater effort must be made on the part of the public health community to increase access to community-based physical activity programs for persons with stroke.

Oxygen consumption during treadmill walking with and without body weight support in patients with hemiparesis after stroke and in healthy subjects

OBJECTIVE

To compare oxygen consumption during walking with body weight support (BWS) with oxygen consumption during unsupported treadmill walking.

DESIGN

Patient and reference group. Comparisons between two walking conditions within each group.

SETTING

Research laboratory of a university hospital.

PARTICIPANTS

Nonrandom convenience sample of 9 hemiparetic and 9 healthy subjects, mean age of 56 and 57 years, respectively.

INTERVENTIONS

The subjects walked on a treadmill with 0% and 30% BWS at their self-selected and maximum walking speeds. The trials were performed twice.

MAIN OUTCOME MEASURES

Ventilatory oxygen uptake (VO2) and heart rate were measured by computerized breath-by-breath analysis and electrocardiography.

RESULTS

VO2 was lower during walking with 30% BWS than during unsupported walking. At self-selected speed the Wilcoxon's signed rank p values were <.01 for both patients and reference group; at maximum velocity, p values were p < .02 for the patients and p < .05 for the reference group. Patients' heart rates were lower when they walked with 30% BWS than at 0% BWS, at both self-selected and maximum walking speeds (p < .05 and p < .02, respectively).

CONCLUSIONS

The 30% body weight supported condition requires less oxygen consumption than full weight bearing. Treadmill training with BWS can be tolerated by patients with cardiovascular problems.

Stroke rehabilitation. 2. Co-morbidities and complications

This self-directed learning module highlights new advances in the understanding of co-morbid conditions and medical complications of stroke. It is part of the chapter on stroke rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article covers co-morbid conditions of stroke patients, including cardiovascular disease, diabetes, and sleep apnea. It reviews recent information on complications of stroke, including deep venous thrombosis, dysphagia and aspiration, hospital-acquired infections, depression, falls, spasticity, shoulder pain, and seizures. Treatment advances in diabetes, depression, and spasticity are highlighted. Recent information is presented regarding exercise guidelines for the stroke patient with cardiovascular disease, the relationship between stroke and sleep apnea, prophylaxis of deep venous thrombosis, the changing spectrum of hospital-acquired infections, malnutrition in stroke patients, the problem of falls during rehabilitation, the evaluation and management of poststroke shoulder pain, and the risk of seizures after stroke.

A randomized, controlled pilot study of a home-based exercise program for individuals with mild and moderate stroke

BACKGROUND AND PURPOSE

Many stroke survivors have minimal to moderate neurological deficits but are physically deconditioned and have a high prevalence of cardiovascular problems; all of these are potentially modifiable with exercise. The purposes of this randomized, controlled pilot study were (1) to develop a home-based balance, strength, and endurance program; (2) to evaluate the ability to recruit and retain stroke subjects; and (3) to assess the effects of the interventions used.

METHODS

Twenty minimally and moderately impaired stroke patients who had completed inpatient rehabilitation and who were 30 to 90 days after stroke onset were randomized to a control group or to an experimental group that received a therapist-supervised, 8-week, 3-times-per-week, home-based exercise program. The control group received usual care as prescribed by the patients' physicians. Baseline and postintervention assessments included the Fugl-Meyer Motor Assessment, the Barthel Index of Activities of Daily Living (ADL), the Lawton Scale of Instrumental ADL, and the Medical Outcomes Study-36 Health Status Measurement. Functional assessments of balance and gait included a 10-m walk, 6-Minute Walk, and the Berg Balance Scale. Upper extremity function was evaluated by the Jebsen Test of Hand Function.

RESULTS

Of 22 patients who met study criteria, 20 completed the study and 2 refused to participate. The experimental group tended to improve more than the control group in motor function (Fugl-Meyer Upper Extremity: mean change in score, 8. 4 versus 2.2; Fugl-Meyer Lower Extremity: 4.7 versus -0.9; gait velocity: median change, 0.25 versus .09 m/s; 6-Minute Walk: 195 versus 114 ft; Berg Balance Score: 7.8 versus 5; and Medical Outcomes Study-36 Health Status Measurement of Physical Function: 15. 5 versus 9). There were no trends in differences in change scores by the Jebsen Test of Hand Function, Barthel Index, and Lawton Instrumental ADL Scale.

CONCLUSIONS

This study demonstrated that a randomized, controlled clinical trial of a poststroke exercise program is feasible. Measures of neurological impairments and lower extremity function showed the most benefit. Effects of the intervention on upper extremity dexterity and functional health status were equivocal. The lasting effects of the intervention were not assessed.

Tailoring therapy to a stroke patient's potential

Stroke survivors can be plagued by numerous medical complications, including aspiration pneumonia, heart disease, depression, and venous thromboembolism. Given the impairment already caused by stroke itself, these patients require careful management by a comprehensive rehabilitation team. Dr Harvey discusses common stroke syndromes, possible complications, and appropriate rehabilitation options covering a variety of circumstances.

Low-velocity graded treadmill stress testing in hemiparetic stroke patients

BACKGROUND AND PURPOSE

Coronary artery disease is prevalent in stroke patients and is an important factor affecting rehabilitation and health outcomes. However, the presence of neurological deficits in gait and balance has discouraged systematic application of exercise testing and prescription in the stroke population. We evaluated a novel graded treadmill stress test in paretic stroke patients and tested floor walking as a predictor of adequate neurological function to perform the treadmill test.

METHODS

Patients (n = 31) with residual paretic gait deficits after ischemic stroke were evaluated with graded treadmill at gait velocities individualized to functional mobility observed during an initial zero-incline treadmill tolerance test.

RESULTS

Most patients (30/31) tolerated testing, achieving mean heart rates of 129 +/- 14 beats per minute (mean +/- SD), representing 84 +/- 10% of maximal age-predicted heart rate. Evidence for asymptomatic myocardial ischemia was found in 29% of those without known coronary artery disease. Exercise termination was more often due to generalized fatigue than cardiopulmonary intolerance (23/31 versus 4/31; P < .0001) or hemiparetic leg fatigue (1/31; P < .0001). Floor walking across a wide range of velocities (0.25 to 2.5 mph) demonstrated a strong linear relation with treadmill velocities (n = 24; r = 80; P < .0001); all patients floor walking at > or = 0.5 mph had adequate neuromotor function to perform the exercise test.

CONCLUSIONS

These findings suggest that graded treadmill exercise testing, with proper safety precautions, can be used to assess cardiopulmonary function in paretic stroke patients. A simple floor-walking test predicts adequate neurological function to perform the exercise test. Exercise capacity is most limited by generalized fatigue and not by the paretic limb, supporting a rationale for endurance training in this population.

Treadmill aerobic exercise training reduces the energy expenditure and cardiovascular demands of hemiparetic gait in chronic stroke patients. A preliminary report

BACKGROUND AND PURPOSE

Elevated energy costs of hemiparetic gait contribute to functional disability after stroke, particularly in physically deconditioned older patients. We investigated the effects of 6 months of treadmill aerobic exercise training on the energy expenditure and cardiovascular demands of submaximal effort ambulation in stroke patients with chronic hemiparetic gait.

METHODS

Nine older stroke patients with chronic hemiparetic gait were enrolled in a 6-month program of low-intensity aerobic exercise using a graded treadmill. Repeated measures of energy expenditure based on steady state oxygen consumption during a standardized 1-mph submaximal effort treadmill walking task were performed before and after training.

RESULTS

Six months of exercise training produced significant reductions in energy expenditure (n = 9; 3.40 +/- 0.27 versus 2.72 +/- 0.25 kcal/min [mean +/- SEM]; P < .005) during a given submaximal effort treadmill walking task. Repeated measures analysis in the subset of patients (n = 8) tested at baseline and after 3 and 6 months revealed that reductions in energy expenditure were progressive (F = 11.1; P < .02) and that exercise-mediated declines in both oxygen consumption (F = 9.7; P < .02) and respiratory exchange ratio (F = 13.4; P < .01) occurred in a strong linear pattern. These stroke patients could perform the same standardized submaximal exercise task at progressively lower heart rates after 3 months (96 +/- 4 versus 87 +/- 4 beats per minute) and 6 months of training (82 +/- 4 beats per minute; F = 35.4; P < .002).

CONCLUSIONS

Six months of low-intensity treadmill endurance training produces substantial and progressive reductions in the energy expenditure and cardiovascular demands of walking in older patients with chronic hemiparetic stroke. This suggests that task-oriented aerobic exercise may improve functional mobility and the cardiovascular fitness profile in this population.

Post-stroke autonomic nervous system function: palmar sympathetic skin responses thirty or more days after cerebrovascular accident

We studied sympathetic nervous system (SNS) function after cerebrovascular accident (CVA) by measuring hypothenar sympathetic skin responses (SSR) to normal or hemiplegic arm electrical stimulation. We anticipated SNS function after CVA to be asymmetric and selected null hypotheses of bilaterally symmetric SSR latencies and amplitudes irrespective of side of stimulation and/or recording. Thirteen patients between ages 44 and 77 years (median 59) were tested between 1 and 72 months (median 15) after CVA. Hypothenar recording and dorsal reference surface electrodes were used. Amplifier bandwidth was set from 0.5 to 100 Hz. Gain was adjusted to allow adequate recognition of the waveforms. Sweep speed was set to 500ms/div. Stimulus width was set to 0.2 ms and intensity was increased stepwise from 10mA initially until optimum responses were obtained. Nonparametric statistics were used to analyze the data. SSRs were present in all patients on both the normal and the hemiplegic sides irrespective of the side of stimulation. Median SSR latency recorded homolaterally to the stimulus site was found to be 80ms shorter than median SSR latency recorded heterolaterally. Median SSR latency in left hemiplegics was found to be 16% longer than in right hemiplegics. Otherwise, neither side of hemiplegia, side of stimulation, side of recording nor any paired combination thereof were found to be significant. Our finding of bilaterally obtainable SSRs after CVA diverges from that of Uncini and colleagues but presumably only reflects the difference in poststroke chronology between the respective samples.