Physical Activity and Exercise Recommendations for Stroke Survivors

Medicare spending and outcomes after postacute care for stroke and hip fracture

BACKGROUND

Elderly patients who leave an acute care hospital after a stroke or a hip fracture may be discharged home, or undergo postacute rehabilitative care in an inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF). Because 15% of Medicare expenditures are for these types of postacute care, it is important to understand their relative costs and the health outcomes they produce.

OBJECTIVE

To assess Medicare payments for and outcomes of patients discharged from acute care to an IRF, a SNF, or home after an inpatient diagnosis of stroke or hip fracture between January 2002 and June 2003.

RESEARCH DESIGN

This is an observational study based on Medicare administrative data. We adjust for observable differences in patient severity across postacute care sites, and we use instrumental variables estimation to account for unobserved patient selection.

STUDY OUTCOMES

Mortality, return to community residence, and total Medicare postacute payments by 120 days after acute care discharge.

RESULTS

Relative to discharge home, IRFs improve health outcomes for hip fracture patients. SNFs reduce mortality for hip fracture patients, but increase rates of institutionalization for stroke patients. Both sites of care are far more expensive than discharge to home.

CONCLUSIONS

When there is a choice between IRF and SNF care for stroke and hip fracture patients, the marginal patient is better off going to an IRF for postacute care. However, given the marginal cost of an IRF stay compared with returning home, the gains to these patients should be considered in light of the additional costs.

Effects of a high-intensity task-oriented training on gait performance early after stroke: a pilot study

OBJECTIVE

To investigate the feasibility and the effects on gait of a high intensity task-oriented training, incorporating a high cardiovascular workload and large number of repetitions, in patients with subacute stroke, when compared to a low intensity physiotherapy-programme.

DESIGN AND SUBJECTS

Randomized controlled clinical trial: Forty-four patients with stroke were recruited at 2 to 8 weeks after stroke onset.

MEASURES

Maximal gait speed assessed with the 10-metre timed walking test (10MTWT), walking capacity assessed with the six-minute walk test (6MWT). Control of standing balance assessed with the Berg Balance Scale and the Functional Reach test. Group differences were analysed using a Mann-Whitney U-test.

RESULTS

Between-group analysis showed a statistically significant difference in favour of the high intensity task-oriented training in performance on the 10MTWT (Z = -2.13, P = 0.03) and the 6MWT (Z = -2.26, P = 0.02). No between-group difference were found for the Berg Balance Scale (Z = -0.07, P = 0.45) and the Functional Reach test (Z = -0.21, P = 0.84).

CONCLUSION

A high-intensity task-oriented training programme designed to improve hemiplegic gait and physical fitness was feasible in the present study and the effectiveness exceeds a low intensity physiotherapy-programme in terms of gait speed and walking capacity in patients with subacute stroke. In a future study, it seems appropriate to additionally use measures to evaluate physical fitness and energy expenditure while walking.

Feasibility and effects of adapted cardiac rehabilitation after stroke: a prospective trial

Background

Despite the cardiovascular etiology of stroke, exercise and risk factor modification programs akin to cardiac rehabilitation (CR) are not available. This study aimed to establish the feasibility of adapting a CR model for individuals with mild to moderate stroke disability. A secondary objective was to determine the program's effects on aerobic and walking capacity, and stroke risk factors.

Methods

A repeated measures design was used with a 3-month baseline period and 6-month adapted CR intervention (n = 43, mean ± SD age 65 ± 12 years, 30 ± 28 months post stroke). Feasibility was determined by the number of participants who completed the study, occurrence of adverse events and frequency, duration and intensity of exercise performed. To determine effectiveness of the program, outcomes measured included aerobic capacity (VO₂peak, ventilatory threshold), 6-Minute Walk Test (6MWT) distance, and risk factors. Descriptive statistics characterized the classes attended and number and intensity of exercise sessions. Paired t-tests, one-factor repeated measures analyses of variance contrasts and chi-square analyses were used to compare changes over time.

Results

Two participants withdrew during the baseline period. Of the remaining 41 participants who commenced the program, 38 (93%) completed all aspects. No serious adverse effects occurred. Post-intervention, VO₂peak improved relative to the stable baseline period (P = 0.046) and the increase in ventilatory threshold approached significance (P = 0.062).

Conclusions

CR is feasible after stroke and may be adapted to accommodate for those with a range of post-stroke disability. It is effective in increasing aerobic capacity. CR may be an untapped opportunity for stroke survivors to access programs of exercise and risk factor modification to lower future event risk.

Trial registration

ClinicalTrials.gov registration number: NCT01067495

Physical exercise and cognitive recovery in acquired brain injury: a review of the literature

OBJECTIVE

Physical exercise has been shown to play an ever-broadening role in the maintenance of overall health and has been implicated in the preservation of cognitive function in both healthy elderly and demented populations. Animal and human studies of acquired brain injury (ABI) from trauma or vascular causes also suggest a possible role for physical exercise in enhancing cognitive recovery.

DATA SOURCES

A review of the literature was conducted to explore the current understanding of how physical exercise impacts the molecular, functional, and neuroanatomic status of both intact and brain-injured animals and humans.

STUDY SELECTION

Searches of the MEDLINE, CINHAL, and PsychInfo databases yielded an extensive collection of animal studies of physical exercise in ABI. Animal studies strongly tie physical exercise to the upregulation of multiple neural growth factor pathways in brain-injured animals, resulting in both hippocampal neurogenesis and functional improvements in memory.

DATA EXTRACTION

A search of the same databases for publications involving physical exercise in human subjects with ABI yielded 24 prospective and retrospective studies.

DATA SYNTHESIS

Four of these evaluated cognitive outcomes in persons with ABI who were involved in physical exercise. Three studies cited a positive association between exercise and improvements in cognitive function, whereas one observed no effect. Human exercise interventions varied greatly in duration, intensity, and level of subject supervision, and tools for assessing neurocognitive changes were inconsistent.

CONCLUSIONS

There is strong evidence in animal ABI models that physical exercise facilitates neurocognitive recovery. Physical exercise interventions are safe in the subacute and rehabilitative phases of recovery for humans with ABI. In light of strong evidence of positive effects in animal studies, more controlled, prospective human interventions are warranted to better explore the neurocognitive effects of physical exercise on persons with ABI.

Cost-effectiveness of a structured progressive task-oriented circuit class training programme to enhance walking competency after stroke: the protocol of the FIT-Stroke trial

Background

Most patients who suffer a stroke experience reduced walking competency and health-related quality of life (HRQoL). A key factor in effective stroke rehabilitation is intensive, task-specific training. Recent studies suggest that intensive, patient-tailored training can be organized as a circuit with a series of task-oriented workstations.

Primary aim of the FIT-Stroke trial is to evaluate the effects and cost-effectiveness of a structured, progressive task-oriented circuit class training (CCT) programme, compared to usual physiotherapeutic care during outpatient rehabilitation in a rehabilitation centre. The task-oriented CCT will be applied in groups of 4 to 6 patients. Outcome will be defined in terms of gait and gait-related ADLs after stroke. The trial will also investigate the generalizability of treatment effects of task-oriented CCT in terms of perceived fatigue, anxiety, depression and perceived HRQoL.

Methods/design

The multicentre single-blinded randomized trial will include 220 stroke patients discharged to the community from inpatient rehabilitation, who are able to communicate and walk at least 10 m without physical, hands-on assistance. After discharge from inpatient rehabilitation, patients in the experimental group will receive task-oriented CCT two times a week for 12 weeks at the physiotherapy department of the rehabilitation centre. Control group patients will receive usual individual, face-to-face, physiotherapy. Costs will be evaluated by having each patient keep a cost diary for the first 24 weeks after randomisation. Primary outcomes are the mobility part of the Stroke Impact Scale (SIS-3.0) and the EuroQol. Secondary outcomes are the other domains of SIS-3.0, lower limb muscle strength, walking endurance, gait speed, balance, confidence not to fall, instrumental ADL, fatigue, anxiety, depression and HRQoL.

Discussion

Based on assumptions about the effect of intensity of practice and specificity of treatment effects, FIT-Stroke will address two key aims. The first aim is to investigate the effects of task-oriented CCT on walking competency and HRQoL compared to usual face-to-face physiotherapy. The second aim is to reveal the cost-effectiveness of task-oriented CCT in the first 6 months post stroke. Both aims were recently recommended as priorities by the American Hearth Association and Stroke Council.

Trial registration

This study is registered in the Dutch Trial Register as NTR1534.

Immediate and long-term functional impact of repetitive locomotor training as an adjunct to conventional physiotherapy for non-ambulatory patients after stroke

PURPOSE

The aim of the present study was to assess the heart rate intensity during gait training and to evaluate the relationship between heart rate intensity during gait training and walking ability of patients after stroke.

METHODS

We included non-ambulatory patients within six weeks after first stroke. Over four weeks patients were trained five times a week, with either 20 minutes of repetitive locomotor training and 25 min of physiotherapy (RLT-PT), or 45 min of PT alone. We assessed the heart rate intensity during training period. Additionally we assessed walking ability (Functional Ambulation Categories) and the rate of independent ability to perform activities of daily life (Barthel Index) at the end of study and six months and three years later on.

RESULTS

We included 30 patients in each group. Patients in RLT-PT group exercised longer in the HR target zone than in the PT group (16.1+/-11.8 min vs. 5.3+/-5.6 min, p<0.001). Higher heart rates were associated with independent walking at the end of study, at six months and at three years after the end of study (Fishers exact test, p=0.014, p=0.012 and p=0.017, respectively).

CONCLUSIONS

Higher heart rate intensities during gait-training of non-ambulatory post-stroke patients may improve walking function.

Reduction of disability after stroke is a more informative predictor of long-time survival than initial disability status

PURPOSE

Few studies have evaluated the roles of reducing disability after stroke in predicting survival. This study aimed to investigate the effects of improvement in the Barthel Index (BI) and other prognostic factors on survival in patients with first-time noncardioembolic ischemic stroke.

METHOD

BI effectiveness was defined as the improvement of BI between initial stroke (within 3 days) and 2 months after stroke. Cox regression analysis and Kaplan-Meier methods were used to evaluate the predictive roles of various prognostic factors.

RESULTS

A total of 111 patients were enrolled. Mean age at the time of stroke was 68 (+ or - 11.2) years. Median follow-up time was 77.4 months. Mean initial BI was 36.1 (+ or - 28.5) and mean BI effectiveness was 46.9 + or - 29.0. Overall, 55 deaths (49.5%) of the cohort were ascertained. The BI effectiveness had significant effects on long-time survival while initial BI was not a significant predictor. Higher BI effectiveness led to lower risk of mortality (hazard ratio = 0.44, 95% CI 0.24 - 0.80, p = 0.007). Elder age was correlated with poor survival (overall p = 0.006). Subjects in the eldest age group (> or = 70 years) showed a significant elevated risk for death (hazard ratio = 3.42, 95% CI 1.18 - 9.92). There was a trend indicating that the smaller the lesion size, the more favourable the prognosis (overall p = 0.057).

CONCLUSIONS

BI effectiveness in the first 2 months after first-time noncardioembolic stroke was more informative than initial disability status for predicting long-time mortality. It highlights the potential benefit in maximizing functional performance in patients with stroke.

Cardiac rehabilitation after stroke-need and opportunity

PURPOSE

In North America, established long-term rehabilitation programs are commonly available for individuals following a cardiac event but are largely unavailable for stroke survivors. The purpose of this study was to determine (1) the availability of cardiac rehabilitation (CR) for individuals poststroke (survey of all programs in Ontario, Canada) and (2) the effects of CR, comparing individuals with primary and secondary diagnoses of stroke versus those with cardiac diagnoses only (retrospective review of a large outpatient North American program).

METHODS

An Ontario-wide survey was disseminated to CR programs to determine barriers to enrollment of stroke participants. Additionally, a retrospective analysis of data from 9,173 participants in 1 CR program in Toronto, Ontario, compared 3 subgroups (n = 19 each): (1) primary diagnosis of stroke or transient ischemic attack (TIA), (2) primary cardiac diagnosis and occurrence of stroke or TIA, and (3) cardiac diagnoses only.

RESULTS

Twenty-four of 40 (60%) programs surveyed included stroke participants, although the proportion was small (<5% of total enrollment). Barriers to enrollment included issues around primary diagnosis and degree of stroke-related disability. While those with a history of stroke or TIA had a lower baseline peak oxygen uptake, all 3 groups showed comparable postprogram improvements in peak oxygen uptake and anaerobic threshold (time effect, P < .001). There were no group-time interaction effects.

CONCLUSIONS

Despite the common cardiovascular etiology of stroke and heart disease, individuals with stroke are not routinely included in CR in Ontario. However, individuals with stroke demonstrated similar training-related improvements in exercise capacity compared with nonstroke participants.

Task-oriented training in rehabilitation after stroke: systematic review

AIM

This paper is a report of a review conducted to provide an overview of the evidence in the literature on task-oriented training of stroke survivors and its relevance in daily nursing practice.

BACKGROUND

Stroke is the second leading cause of death and one of the leading causes of adult disability in the Western world. The use of neurodevelopmental treatment in the daily nursing care of stroke survivors does not improve clinical outcomes. Nurses are therefore exploring other forms of rehabilitation intervention, including task-oriented rehabilitation. Despite the growing number of studies showing evidence on task-oriented interventions, recommendations for daily nursing practice are lacking.

DATA SOURCES

A range of databases was searched to identify papers addressing task-oriented training in stroke rehabilitation, including Medline, CINAHL, Embase and the Cochrane Library of systematic reviews. Papers published in English between January 1996 and September 2007 were included. There were 42 papers in the final dataset, including nine systematic reviews.

REVIEW METHODS

The selected randomized controlled trials and systematic reviews were assessed for quality. Important characteristics and outcomes were extracted and summarized.

RESULTS

Studies of task-related training showed benefits for functional outcome compared with traditional therapies. Active use of task-oriented training with stroke survivors will lead to improvements in functional outcomes and overall health-related quality of life.

CONCLUSION

Generally, task-oriented rehabilitation proved to be more effective. Many interventions are feasible for nurses and can be performed in a ward or at home. Nurses can and should play an important role in creating opportunities to practise meaningful functional tasks outside of regular therapy sessions.

Optimising long-term participation in physical activities after stroke: exploring new ways of working for physiotherapists

There is now good empirical evidence of physical and functional benefits for individuals with stroke from long-term engagement in a range of physical activities. However, long-term participation of stroke survivors in physical activity after rehabilitation is low, and maximum benefits are not being achieved. This article reviews relevant literature and evidence, and suggests that physiotherapists are ideally placed to support patients in long-term participation in activity as they prepare patients for the end of physical rehabilitation. However, this requires the development, testing and application of stroke-specific evidence-based behavioural and motivational interventions that are feasible in clinical practice, take account of the role of carers, and seek to address the barriers to activity faced by stroke survivors at the end of rehabilitation. It also requires physiotherapists to take a leading role in developing appropriate policies and strategies with other exercise professionals and services to address the transition from rehabilitation to an active lifestyle following stroke.

Technology-assisted training of arm-hand skills in stroke: concepts on reacquisition of motor control and therapist guidelines for rehabilitation technology design

Background

It is the purpose of this article to identify and review criteria that rehabilitation technology should meet in order to offer arm-hand training to stroke patients, based on recent principles of motor learning.

Methods

A literature search was conducted in PubMed, MEDLINE, CINAHL, and EMBASE (1997–2007).

Results

One hundred and eighty seven scientific papers/book references were identified as being relevant. Rehabilitation approaches for upper limb training after stroke show to have shifted in the last decade from being analytical towards being focussed on environmentally contextual skill training (task-oriented training). Training programmes for enhancing motor skills use patient and goal-tailored exercise schedules and individual feedback on exercise performance. Therapist criteria for upper limb rehabilitation technology are suggested which are used to evaluate the strengths and weaknesses of a number of current technological systems.

Conclusion

This review shows that technology for supporting upper limb training after stroke needs to align with the evolution in rehabilitation training approaches of the last decade. A major challenge for related technological developments is to provide engaging patient-tailored task oriented arm-hand training in natural environments with patient-tailored feedback to support (re) learning of motor skills.

Ambulatory activity of stroke survivors: measurement options for dose, intensity, and variability of activity

BACKGROUND AND PURPOSE

Walking activity is an important part of exercise prescription for stroke survivors. The purpose of this study was to: (1) compare ambulatory activity parameters in subacute stroke survivors over three time periods; and (2) discuss options for measurement of ambulatory activity data with respect to absolute activity, intensity of activity, and variability and pattern of activity.

METHODS

Ten subacute stroke survivors participated (mean+/-SD; age: 66+/-15 years; time from stroke to discharge: 75+/-31 days). Data collection was completed across three time periods, predischarge, 2 weeks postdischarge, and 6 weeks postdischarge. The Step Activity Monitor (Cyma Corporation) was used to measure daily activity parameters. Parameters representing dose, intensity, and variability/pattern of activity were determined using MatLab.

RESULTS

Minutes of activity and length of activity bouts significantly increased from predischarge to 6 weeks postdischarge (P=0.030).

CONCLUSIONS

The measurement of a variety of ambulatory activity parameters may aid clinicians and stroke survivors to determine whether exercise recommendations are being met with daily activity.

Gait training with the newly developed 'LokoHelp'-system is feasible for non-ambulatory patients after stroke, spinal cord and brain injury. A feasibility study

PRIMARY OBJECTIVE

To evaluate the feasibility of using a newly developed electromechanical gait device (LokoHelp) for locomotion training in neurological patients with impaired walking ability with respect to training effects and patients' and therapists' efforts and discomfort.

METHODS AND PROCEDURES

design: Case series. setting: A neurological rehabilitation centre for children, adolescents and young adults. subjects: Six patients with impaired walking function: two after stroke, two after spinal cord injury and two after brain injury.

INTERVENTION

Twenty additional training sessions on a treadmill fitted with a newly developed electromechanical gait device and body weight support (BWS), performed over a study-period of 6 weeks.

MAIN OUTCOMES AND RESULTS

Patients' progress was assessed with the following instruments: the Functional Ambulation Category FAC (walking ability), the 10-metre walk test (gait velocity), the Motricity Index (lower limb strength), the Berg Balance Scale (postural capacity), the modified Ashworth Scale (spasticity) and the Rivermead Mobility Index (activity). After each therapy session, therapists completed a form, thereby indicating whether manual assistance was necessary and, if so, how much physical effort was expended and how much discomfort was experienced during the therapy session. The therapists also indicated on the form information about the patient's effort and discomfort. No severe adverse events were observed during the locomotion training with the LokoHelp device. Patients improved with regard to Functional Ambulation Category (FAC) (from mean 0.7, SD = 1.6, to mean 2.5, SD = 2.1, p = 0.048), Motricity Index (from mean 94 points, SD = 50, to mean 111, SD = 52, p = 0.086), Berg Balance Scale (BBS) (from mean 20 points, SD = 23 to mean 25, SD = 23, p = 0.168) and Rivermead Mobility Index (RMI) (from mean 5 points, SD = 4, to mean 7, SD = 5, p = 0.033). Therapists required a low level of effort to carry out the training and seldom experienced discomfort. Patients described their effort during training as being low-to-exhausting. They rarely experienced discomfort, which was mostly related to difficulties with the BWS-System. Training intensity had to be adjusted in one patient who complained of knee pain.

CONCLUSIONS

Locomotion training with the newly developed 'LokoHelp'-system is feasible in severely affected patients after brain injury, stroke and spinal cord injury. In addition, our results indicate that the described alternative method of gait training may decrease the exertion needed by therapists to carry out the training.

Successful Aging: The Role of Physical Activity

Although no amount of physical activity can stop the aging process, a moderate amount of regular exercise can minimize the physiological effects of an otherwise sedentary lifestyle and increase active life expectancy by limiting the development and progression of chronic disease and disabling conditions. Ideally, exercise prescription for older adults should include aerobic, muscle strengthening, and flexibility exercises. In addition, individuals at risk for falling or mobility impairment should also perform specific exercises to improve balance. The intensity and duration of physical activity should be low at the outset for those who are highly deconditioned, are functionally limited, or have chronic conditions affecting their ability to perform physical tasks. Furthermore, the progression of activities should be individualized and tailored to tolerance and preference. Incorporating principles of behavioral change into the design and application of exercise and physical activity programs will increase the likelihood of an individual initiating and maintaining a regular program of exercise and/ or physical activity. Strategies for maintaining physical function and improving overall health of older adults with chronic conditions and disability are discussed. All older adults with and without disabilities should be encouraged to develop a personalized physical activity plan that meets their needs and personal preferences.

Benefits of Physical Fitness Training in Healthy Aging and Neurogenic Patient Populations

Purpose: In recent years, research has identified a positive connection between physical fitness and exercise, and cognitive performance in healthy aging (e.g., Colcombe & Kramer, 2003) as well as a number of patient populations (e.g., Mostert & Kesselring, 2002). To increase awareness of the benefits of exercise on cognitive and communicative health, this paper reviews the literature pertaining to the cognitive effects of exercise in healthy individuals, as well as preliminary findings regarding the role of exercise in disordered populations including those with stroke, dementia, traumatic brain injury, and multiple sclerosis. It presents a treatment program combining low-intensity fitness training with speech-language therapy that was developed for an individual with traumatic brain injury, stroke, multiple sclerosis, and poor physical fitness.

Method: A review of the literature was conducted to summarize and synthesize previously published research in the area of exercise and cognition in healthy and patient populations.

Results and Conclusions: There is a growing understanding of the relationship between exercise and cognition in both healthy and aging patient populations. Research with various patient populations reveals positive outcomes and suggests the need to further this line of research in individuals with neurogenic cognitive-communicative disorders.

Guidelines for management of ischaemic stroke and transient ischaemic attack 2008

This article represents the update of the European Stroke Initiative Recommendations for Stroke Management. These guidelines cover both ischaemic stroke and transient ischaemic attacks, which are now considered to be a single entity. The article covers referral and emergency management, Stroke Unit service, diagnostics, primary and secondary prevention, general stroke treatment, specific treatment including acute management, management of complications, and rehabilitation.

Intensity, but not duration, of physical activities is related to cognitive function

BACKGROUND

Physical activity is thought to facilitate cognitive performance and to slow down the rate of age-related cognitive decline. This study aimed to investigate the association between the time spent on physical activity as well as the average intensity of these activities and cognitive function.

DESIGN

Cross-sectional analysis.

METHODS

Our study population comprised of 1927 healthy men and women aged 45-70 years in the Netherlands, examined from 1995 until 2000. Physical activity was assessed with an extensive questionnaire, and cognitive function by a neuropsychological test battery.

RESULTS

Multivariate linear regression analysis showed that intensity of weekly physical activities is significantly positively associated with processing speed, memory, mental flexibility and overall cognitive function. No significant associations were observed between the time spent weekly on physical activities and the various cognitive domains. At the same time, variation in activities was significantly positively associated with speed, memory, mental flexibility and overall cognitive function.

CONCLUSIONS

Average intensity of weekly physical activities and variation in activities are positively and significantly associated with cognitive performance on processing speed, memory and mental flexibility as well as performance on overall cognitive function.

Effects of Exercise Training Programs on Walking Competency After Stroke

To determine the effectiveness of training programs that focus on lower-limb strengthening, cardiorespiratory fitness, or gait-oriented tasks in improving gait, gait-related activities, and health-related quality of life after stroke. Randomized controlled trials (RCTs) were searched for in the databases of Pubmed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, DARE, Physiotherapy Evidence Database (PEDro), EMBASE, Database of the Dutch Institute of Allied Health Care, and CINAHL. Databases were systematically searched by two independent researchers. The following inclusion criteria were applied: (1) participants were people with stroke, older than 18 yrs; (2) one of the outcomes focused on gait-related activities; (3) the studies evaluated the effectiveness of therapy programs focusing on lower-limb strengthening, cardiorespiratory fitness, or gait-oriented training; and (4) the study was published in English, German, or Dutch. Studies were collected up to November 2005, and their methodological quality was assessed using the PEDro scale. Studies were pooled and summarized effect sizes were calculated. Best-evidence synthesis was applied if pooling was impossible. Twenty-one RCTs were included, of which five focused on lower-limb strengthening, two on cardiorespiratory fitness training (e.g., cycling exercises), and 14 on gait-oriented training. Median PEDro score was 7. Meta-analysis showed a significant medium effect of gait-oriented training interventions on both gait speed and walking distance, whereas a small, nonsignificant effect size was found on balance. Cardiorespiratory fitness programs had a nonsignificant medium effect size on gait speed. No significant effects were found for programs targeting lower-limb strengthening. In the best-evidence synthesis, strong evidence was found to support cardiorespiratory training for stair-climbing performance. Although functional mobility was positively affected, no evidence was found that activities of daily living, instrumental activities of daily living, or health-related quality of life were significantly affected by gait-oriented training. This review shows that gait-oriented training is effective in improving walking competency after stroke.

Ambulatory monitoring of activity levels of individuals in the sub-acute stage following stroke: a case series

Background

There is an important need to better understand the activities of individual patients with stroke outside of structured therapy since this activity is likely to have a profound influence on recovery. A case-study approach was used to examine the activity levels and associated physiological load of patients with stroke throughout a day.

Methods

Activities and physiologic measures were recorded during a continuous 8 hour period from 4 individuals in the sub-acute stage following stroke (ranging from 49 to 80 years old; 4 to 8 weeks post-stroke) in an in-patient rehabilitation hospital.

Results

Both heart rate (p = 0.0207) and ventilation rate (p < 0.0001) increased as intensity of activity increased. Results revealed individual differences in physiological response to daily activities, and large ranges in physiological response measures during 'moderately' and 'highly' therapeutic activities.

Conclusion

Activity levels of individuals with stroke during the day were generally low, though task-related changes in physiologic measures were observed. Large variability in the physiological response to even the activities deemed to be greatest intensity suggests that inclusion of such extended measurement of physiologic measures may improve understanding of physiological profile that could guide elements of the physical therapy prescription.

[Issues involved with supply of medical and hygienic materials to home care patients]

Questionnaires were mailed to doctors and nurses who are involved in home care to survey their observations on medical and hygienic materials and its supply to home care patients. Some of the survey items, such as problems encountered frequently, areas where an improvement was needed most and concerns that are often raised in suppling of medical and hygienic materials for home care patients, were analyzed by the Berelson's content analysis method to observe problems in suppling adequate medical and hygienic materials. As a result, 5 categories and 17 subcategories were formed. The recognized future issues were: policies concerning support extended to medical organizations and disseminate information of the system, which medical and hygienic materials supplied to home care patients.

Low intensity strength training for ambulatory stroke patients

PURPOSE

To investigate feasibility and effectiveness of an individually-directed, group strength-training programme on knee muscle strength after stroke.

METHOD

Ten volunteers (62 +/- 11 years, mean +/- SD), 6 - 12 months after first-ever unilateral stroke, walking independently with or without aids were recruited. Using an A1-B-A2 design, 3 sets of baseline measures were taken at 2 weekly intervals; volunteers then attended twice weekly sessions of low intensity progressive strengthening exercises and were assessed after each series of 8 sessions to a maximum of 24 sessions; post training, measures were repeated after 4 - 6 weeks. Measures included isometric and concentric knee extensor muscle strength and 10 m walking velocity.

RESULTS

Strength of knee extensor muscles was improved after training (ANOVA, p < 0.05). On cessation of training, isometric strength increased by 58 +/- 19% and concentric strength at 30 degrees /s by 51 +/- 14%; walking velocity quickened from 0.47 +/- 0.06 m x s-1 to 0.57 +/- 0.08 m x s-1 (t = -3.31, p < 0.01). These gains were maintained 4 - 6 weeks after completion of training.

CONCLUSIONS

These findings support the use of low intensity strength training after stroke and confirm published evidence. It was feasible for one therapist to deliver the training programmes for 4 - 6 participants at a time; an important feature when resources are limited.

Prevention of vascular events in patients with cerebrovascular disease: efficacy and appropriate duration of antiplatelet therapy

Antiplatelet therapy has shown consistent benefit in the prevention of secondary stroke. The paucity of head-to-head studies of different antiplatelet regimens, assessment of comparative efficacy, and optimal treatment duration requires evaluation and comparison of clinical studies that vary extensively in design and follow-up. Evidence for aspirin benefit in secondary stroke prevention is strong, but existing studies provide little guidance with regard to treatment duration. The efficacy of clopidogrel in secondary event prevention is significantly greater than that of aspirin for patients with a history of peripheral artery disease, but does not differ from that of aspirin for patients with a history of stroke or myocardial infarction. Relative to clopidogrel alone, the addition of aspirin to clopidogrel results in increased risk for life-threatening bleeding episodes similar in absolute magnitude to the reduction of secondary event risk in patients with stroke. Benefits associated with clopidogrel occur early in the course of therapy; few data support clopidogrel use for longer than 1 year after stroke. Monotherapy with extended-release dipyridamole (ER-DP) provides reduction in secondary stroke risk similar to aspirin; however, the combination of aspirin plus ER-DP significantly reduces risk relative to either agent alone. Compared with placebo and monotherapy with either agent, risk reduction for the aspirin plus ER-DP combination continued through 24 months, with no concomitant increase in bleeding risk. Additional clinical studies should provide needed comparisons of efficacy and guidance with regard to optimal duration of therapy.

Maximal Exercise Test Results in Subacute Stroke

OBJECTIVES

To establish the feasibility and reliability of graded maximal exercise testing, suitability of standard indexes of maximum oxygen consumption (Vo(2)max), and evidence of trial-to-trial practice effects in subacute stroke.

DESIGN

Descriptive, cross-sectional study.

SETTING

Rehabilitation hospital.

PARTICIPANTS

Consecutive sample of 35 participants (mean age, 65.7+/-2.6 y; mean days poststroke, 17.6+/-2.2 d).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Graded maximal exercise test using semirecumbent cycle ergometry. A subset (n=20) performed repeated tests to determine test-retest reliability and presence of practice effects.

RESULTS

Thirty-one (89%) participants completed the exercise test without symptomatic responses (mean peak level of oxygen consumed [Vo(2)peak], 10.7 mL.kg(-1).min(-1); peak work rate, 39 W). Twelve (34%), 15 (44%), and 3 (9%) participants achieved oxygen consumption per unit time (Vo(2)) plateau, respiratory exchange ratio, and heart rate criteria, respectively. Although test-retest correlations were high (intraclass correlation coefficient range, .67-.87), higher Vo(2)peak (1.0 mL.kg(-1).min(-1), P=.04) and work rate (7.3 W, P=.01) were observed with repeated testing, with no associated increase in reaching standard criteria for Vo(2)max.

CONCLUSIONS

This work has important implications for developing guidelines for measuring aerobic capacity early after stroke. Although maximal exercise testing using semirecumbent cycle ergometry is feasible, standard Vo(2)max criteria are not consistently appropriate. At least 1 practice trial is recommended before the actual evaluation is performed.

Alterspolitik und Gesundheit

Proceeding from a comprehensive definition of health which differentiates between personal and environmental aspects and which is explicitly not restricted to the absence of disease, age-related changes in functional capacity and characteristic diseases are discussed. To maintain or re-establish independency is said to be much more important than in the case of younger age groups because of the high prevalence of chronic diseases in old age. Discussing the development of costs in the health care system it is demonstrated that a considerable amount of the increasing costs for treatment in higher age groups is due to the higher portion of those who will die in the following years. As a consequence, an explosion of health care costs might be a too pessimistic scenario. The hypothesis of a compression of morbidity is discussed as a more optimistic perspective on cost development. Three additional parts deal with problems of German nursing care insurance, propositions for an integrative concept of preventive and rehabilitative care, and tasks and challenges of palliative care. The final part of this contribution inquires into priorities of future political action on the societal level, the level of public supplies, the personal level, and the family level.

Relationship Between Maximal Exercise Capacity and Walking Capacity in Adult Hemiplegic Stroke Patients

OBJECTIVE

To evaluate the relationship between maximal exercise capacity and walking capacity in hemiplegic stroke patients.

DESIGN

An uncontrolled observational study was conducted in the physical medicine and rehabilitation unit in an academic hospital. Participants were 21 hemiplegic stroke patients (18 men, 3 women; age, 18-70 yrs) whose stroke occurred >3 mos before the study and who could walk independently with or without walking aids. Main outcome measures were peak oxygen uptake, workload, walking capacity, and motor impairment.

RESULTS

There was a significant correlation between walking capacity (6-min-walk test) and both peak oxygen uptake (r=0.602, P=0.0032) and maximal power output (r=0.867, P<0.0001).

CONCLUSIONS

Aerobic capacity and walking capacity are decreased in hemiplegic stroke patients and are correlated with each other. These results underscore the need for future studies, to confirm the role of fitness in relation to walking capacity, and to evaluate the benefit of integrating aerobic training into more traditional rehabilitation programs after stroke.

[Physical exercise in old age]

For the prevention of diseases and especially functional deficits in old age, physical activity is a simple, practicable and successful method. With increasing age and frailty or in rehabilitation training, these activities have to be more and more individualized and medically supervised. The paper defines from today's viewpoint suitable activities and the amount of training necessary. Finally, the need for research about physical training in geriatric medicine is pointed out.

Planning to win: Health and lifestyles associated with physical activity amongst 15,423 adults

STUDY OBJECTIVE

To assess levels of physical activity in the general population and amongst the 'healthy', and to identify factors associated with this important health behaviour.

DESIGN

Population-based cross-sectional study.

SETTING

North-west England.

PARTICIPANTS

Adults (aged at least 18 years) registered with a general practitioner with a residential address within two local administrative districts (local authorities).

MAIN RESULTS

Less than one-third of adults performed adequate amounts of physical activity for health protection, and this differed little when analyses were restricted to 'healthy' people. Lower levels of physical activity were observed amongst women, older people, ethnic groups, those with obesity and in each increased quintile of social deprivation. Current smokers, but not previous smokers, were less likely to be physically active, as were those not eating at least five portions of fruit and vegetables per day. Lack of physical activity was associated with poor general health and a history of, or current, chronic disease.

CONCLUSIONS

Concerted efforts are required by the Government, society and individuals to overturn our predominantly physically inactive adult population. Interventions may be needed which specifically target certain groups, especially the most socially deprived, and that consider individuals and societal barriers to becoming physically active. Evidence of the effectiveness of individual and population-based interventions remains scant and this needs to be addressed urgently.

Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack

The aim of this new statement is to provide comprehensive and timely evidence-based recommendations on the prevention of ischemic stroke among survivors of ischemic stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches for atherosclerotic disease, antithrombotic treatments for cardioembolism, and the use of antiplatelet agents for noncardioembolic stroke. Further recommendations are provided for the prevention of recurrent stroke in a variety of other specific circumstances, including arterial dissections; patent foramen ovale; hyperhomocysteinemia; hypercoagulable states; sickle cell disease; cerebral venous sinus thrombosis; stroke among women, particularly with regard to pregnancy and the use of postmenopausal hormones; the use of anticoagulation after cerebral hemorrhage; and special approaches for the implementation of guidelines and their use in high-risk populations.

A randomized controlled trial of supervised versus unsupervised exercise programs for ambulatory stroke survivors

BACKGROUND AND PURPOSE

Little is known about the relative efficacy of supervised versus unsupervised community exercise programs for stroke survivors. This study compared the effectiveness of a 10-week supervised strengthening and conditioning program (supervised) with a 1-week supervised instruction program followed by a 9-week unsupervised home program (unsupervised) and evaluated retention of changes at 6 months and 1 year after program completion.

METHODS

Seventy-two subjects retained at baseline (27 women, 45 men; mean+/-SD age, 64.6+/-11.8 years) were randomly allocated to receive the supervised or unsupervised program. The primary outcome was walking speed over 6 minutes, and secondary outcome measures were Human Activity Profile, Medical Outcome Study 36-Item Short-Form survey (SF-36), Physiological Cost Index, and lower extremity muscle strength.

RESULTS

The 6-minute walking speed increased significantly in both groups and remained significantly improved by 1 year. The Human Activity Profile demonstrated an increasing trend only in the supervised group that was significant by 1 year. The SF-36 Physical Component summary score increased significantly in the supervised group and remained improved by 1 year; the unsupervised group showed significant improvement at 1 year. Women made greater gains in supervised programs, but men made greater gains in unsupervised programs.

CONCLUSIONS

Supervised exercise programs and unsupervised programs after initial supervised instruction were both associated with physical benefits that were retained for 1 year, although supervised programs showed trends to greater improvements in self-reported gains. Gender differences require further research.

A "poly-portfolio" for secondary prevention: a strategy to reduce subsequent events by up to 97% over five years

A "polypill" for the primary prevention of cardiovascular disease has been proposed. We estimated the projected benefit of a secondary prevention "poly-portfolio" strategy, including pharmacologic and lifestyle approaches for those with coronary heart disease (CHD) or stroke. Based on recent clinical trial results and clinical guidelines, combinations of a high-dose statin, low to standard doses of antihypertensive therapy, aspirin, omega-3 fish oil, cardiac rehabilitation, and diet were evaluated. Patients with CHD, post-myocardial infarction (MI), or stroke were projected to experience 84%, 91%, and 77% reductions, respectively, in CHD events from a pharmacologic approach. Numbers of those needed to treat (NNT) for 5 years were 9 to 11 to prevent 1 CHD event, and 21 to prevent 1 stroke. Post-MI patients were projected to experience a 93% reduction in the risk of CHD death (NNT 16) from a pharmacologic approach and a 97% reduction in the risk of CHD death (NNT 15) with the addition of lifestyle changes. A secondary prevention polyportfolio holds great promise for reducing the burden of cardiovascular disease in the highest risk patients.