Longitudinal changes in exercise capacity after stroke

High-intensity interval training is feasible, credible and clinically effective in the early subacute stroke stage in the low-income country of Benin

High-intensity interval training (HIIT) has been shown to benefit stroke patients when implemented three months post-stroke. This study examined HIIT's feasibility and clinical effectiveness in the early post-stroke stage in Benin. This was a prospective interventional study comprising an HIIT programme executed on a recumbent bike, three times/week, 20-30 min/session for 6 weeks, added to a conventional physiotherapy. The primary outcomes were feasibility, credibility and expectancy assessed with credibility and expectancy questionnaire. A maximal exercise test, 6-min walking test (6MWT), 10-m walking test (10mWT), Berg balance scale (BBS) and five repetitions sit-to-stand test (5 R-STS) were performed before and after the training programme. Ten outpatients, with a median age [P25-P75]: 63.5[56.7-71.2] years; time since stroke: 15.0[9.7-21.0] days, started and completed all training sessions without serious adverse events. High scores were observed on the Credibility subscale at admission (27.0[25.7-27.0]), which remained so after intervention (26.5[25.7-27.0]). Expectancy subscale scores were high at admission (25.5[24.0-27.0]) and post-training (25.5[24.5-27.0]). Peak workload (p < 0.001), BBS (p < 0.001), 6MWT (p < 0.001), 10mWT (p < 0.001) and 5 R-STS (p = 0.004) were all improved. HIIT is feasible and safe in the early subacute post-stroke stage and is perceived by patients as highly credible, meeting their expectations of recovery.

An 8-week Forced-rate Aerobic Cycling Program Improves Cardiorespiratory Fitness in Persons With Chronic Stroke: A Randomized Controlled Trial

OBJECTIVE

To examine the cardiorespiratory effects of a forced-rate aerobic exercise (FE) intervention among individuals with chronic stroke compared with an upper extremity repetitive task practice (UE RTP) control group.

DESIGN

Secondary analysis of data from a randomized controlled trial.

SETTING

Research laboratory.

PARTICIPANTS

Individuals with chronic stroke (N=60).

INTERVENTIONS

Participants completed 24 sessions of FE followed by RTP (FE+RTP, N=30) or time matched RTP alone (N=30). The FE+RTP group was prescribed exercise at 60%-80% of heart rate reserve on a motorized stationary cycle ergometer for 45 minutes followed by 45 minutes of RTP. The control group completed 90 minutes of RTP.

MAIN OUTCOME MEASURES

Metabolic exercise stress tests on a cycle ergometer were conducted at baseline and post-intervention. Outcomes included peak oxygen consumption (peak V̇o2) and anaerobic threshold (AT).

RESULTS

Fifty participants completed the study intervention and pre/post stress tests. The FE+RTP group demonstrated significantly greater improvements in peak V̇o2 from 16.4±5.7 to 18.3±6.4 mL/min/kg compared with the RTP group (17.0±5.6 to 17.2±5.6 mL/min/kg, P=.020) and significantly greater improvements in AT from 10.3±2.8 to 11.5±3.6 mL/min/kg compared with the RTP group (10.8±3.9 to 10.4±3.2 mL/min/kg, P=.020). In analyzing predictors of post-intervention peak V̇o2, the multivariable linear regression model did not reveal a significant effect of age, sex, body mass index, or beta blocker usage. Similarly, bivariate linear regression models for the FE group only did not find any exercise variables (aerobic intensity, power, or cycling cadence) to be significant predictors of peak V̇o2.

CONCLUSIONS

While the aerobic exercise intervention was integrated into rehabilitation to improve UE motor recovery, it was also effective in eliciting significant and meaningful improvements in cardiorespiratory fitness. This novel rehabilitation model may be an effective approach to improve motor and cardiorespiratory function in persons recovering from stroke.

Effectiveness of hospital-based low intensity and inspected aerobic training on functionality and cardiorespiratory fitness in unconditioned stroke patients: Importance of submaximal aerobic fitness markers

INTRODUCTION

The purpose of our study was to evaluate the effectiveness of low-to moderate intensity aerobic training on cardiorespiratory functions in chronic unconditioned stroke patients. The oxygen uptake efficiency slope (OUES) and the ventilatory threshold (VO2-VT) could represent the aerobic capacity in submaximal test. Our study examined the application of the submaximal parameters for evaluating aerobic capacity of chronic stroke patients.

MATERIALS AND METHODS

In our assessor-blinded controlled pilot study 37 patients were randomized into 2 groups named: intervention group (IG, n: 21) and control group (CG, n:16), respectively. Cardiorespiratory functions were evaluated by ergospirometer before and after the 4-week (20 days) program. Both groups participated in daily occupational therapy (30 minutes) and conventional, customized physiotherapy CG (60 minutes), IG (30 minutes). Only IG performed aerobic training by bicycles (30 minutes) aiming to reach low-to moderate training intensity. Outcome measures included peak oxygen uptake (VO2 peak), OUES, VO2-VT, functional exercise capacity 6-Minute Walking Test (6MWT) and Functional Independence Measure.

RESULTS

Thirty-five subjects completed the study. The VO2 peak uptake was very low in both groups (IG: 11.9 mL/kg/min, CG: 12.45 mL/kg/min) and did not improve after the program, but submaximal parameters such as VO2-VT (P < .01) and OUES (P < .001) have shown significant improvement, but only in IG regardless of insufficient impact on VO2 peak. Each participant in both groups was unable to permanently reach the moderate intensity zone. Functional Independence Measure changed for the better in both groups, but 6MWT only in the IG.

DISCUSSION AND CONCLUSIONS

Four-week exercise training even at low intensity by lower limb cycle ergometer may provide benefit on aerobic and functional capacity without improvement of VO2 peak on unconditioned chronic stroke patients.

Factors That Influence the Clinical Implementation of Aerobic Exercise in Stroke Rehabilitation: A Theory-Informed Qualitative Study

OBJECTIVE

Best practice guidelines recommend that aerobic exercise (AEx) be implemented as early as possible poststroke, yet the prescription of AEx remains limited in stroke rehabilitation settings. This study used theoretical frameworks to obtain an in-depth understanding of barriers and enablers to AEx implementation in the stroke rehabilitation setting.

METHODS

A qualitative, descriptive study was conducted. Participants were recruited from 4 stroke rehabilitation settings in Ontario, Canada, that have participated in an implementation study to provide structured AEx programming as part of standard care. Six clinician focus groups (with 19 physical therapists and 5 rehabilitation assistants) and one-to-one interviews with 7 managers and 1 physician were conducted to explore barriers and enablers to AEx implementation. The Theoretical Domains Framework and Consolidated Framework for Implementation Research informed content analysis for clinician and manager perspectives, respectively.

RESULTS

Barriers specific to resource constraints and health care system pressures, combined with patient goals, led to interventions to improve function being prioritized over AEx. Successful implementation was enabled through an interprofessional approach and team engagement in the planning and implementation process. Health care providers described concerns about patient safety, but confidence and capability for implementing AEx were enabled by education, skill development, use of exercise tests, and consultation with individuals with content expertise. Participants described the development of supportive processes that enabled AEx implementation within team workflows and shared resources.

CONCLUSION

Strategies to support implementation of AEx in stroke rehabilitation should incorporate knowledge and skills, the provision of clinical decision-making tools, access to expert consultation, the roles and social influence of the interprofessional team and formal and informal leaders, and supportive processes adapted to the local context.

IMPACT

Results from this study will inform the development of a clinical implementation toolkit to support clinical uptake of AEx in the stroke rehabilitation setting.

Normobaric Hypoxia Exposure During Treadmill Aerobic Exercise After Stroke: A Safety and Feasibility Study

Objective

To evaluate the safety and feasibility of performing treadmill aerobic exercise in moderate normobaric hypoxia among chronic hemiparetic stroke survivors.

Design

Observational study using convenience sampling.

Setting

Research laboratory in a tertiary rehabilitation hospital.

Participants

Chronic hemiparetic stroke survivors who could walk at least 10-m with or without assistance and had no absolute contraindications to exercise testing.

Intervention

Participants (three male and four female) were asked to complete three normobaric hypoxia exposure protocols within a single session. First, they were passively exposed to normobaric hypoxia through gradual reductions in the fraction of inspired oxygen (F_IO₂ = 20.9, 17.0, and 15.0%) while seated (5-min at each level of F_IO₂). Participants were then exposed to the same reductions in F_IO₂ during constant-load exercise performed on a treadmill at 40% of heart rate reserve. Finally, participants completed 20-min of exercise while intermittently exposed to moderate normobaric hypoxia (5 × 2-min at F_IO₂ = 15.0%) interspaced with 2-min normoxia intervals (F_IO₂ = 20.9%).

Outcome Measures

The primary outcome was occurrence of adverse events, which included standardized criteria for terminating exercise testing, blood oxygen saturation (SpO₂) <80%, or acute mountain sickness score >2. The increased cardiovascular strain imposed by normobaric hypoxia exposure at rest and during exercise was evaluated by changes in SpO₂, heart rate (HR), blood pressure, and rating of perceived exertion (RPE).

Results

One participant reported mild symptoms of nausea during exercise in normobaric hypoxia and discontinued participation. No other adverse events were recorded. Intermittent normobaric hypoxia exposure was associated with reduced SpO₂ (MD = −7.4%, CI: −9.8 to −5.0) and increased HR (MD = 8.2, CI: 4.6 to 11.7) compared to intervals while breathing typical room air throughout the 20-min constant-load exercise period. The increase in HR was associated with a 10% increase in relative effort. However, reducing F_IO₂ had little effect on blood pressure and RPE measurements.

Conclusion

Moderate normobaric hypoxia appeared to be a safe and feasible method to increase the cardiovascular strain of submaximal exercise in chronic hemiparetic stroke survivors. Future studies evaluating the effects of pairing normobaric hypoxia exposure with existing therapies on secondary prevention and functional recovery are warranted.

Hemodynamic responses to In-Bed Cycle Exercise in the acute phase after moderate to severe stroke: A randomized controlled trial

Hemodynamic responses to exercise in the acute phase after moderate to severe stroke have remained poorly investigated. The aim of this randomized controlled study, in which 52 (32 women) patients with moderate to severe stroke were randomized to three weeks of 20 minutes in-bed cycle exercise 5 days per week or to usual care, was to explore the systolic blood pressure (SBP) response to exercise and to evaluate the impact of the intervention on the resting and post-test systolic and diastolic blood pressures and heart rate, and on the systolic blood pressure response to exercise. We found that resting SBP decreased from baseline to post-intervention in both the intervention group (147.7 ± 18.1 mmHg to 125.3 ± 17.1 mmHg, P < .001) and in the control group (147.8 ± 23.7 mmHg to 131.4 ± 14.8 mmHg, P < .001) without a significant difference between the groups (interaction P = .308). However, there was a significant difference (interaction P = .010) regarding how Δ SBP (change in SBP from pre-test to post-test) changed from baseline to post-intervention. In the intervention group, Δ SBP increased from -1.0 ± 15.0 mmHg to 8.5 ± 9.4 mmHg, P = .009, whereas in the control group, Δ SBP decreased from 7.1 + 10.9 mmHg to 4.5 + 11.8 mmHg, P = .395. We conclude that patients randomized to in-bed cycle exercise seemed to normalize their blood pressure response to exercise to a larger extent than patients in the control group.

Pilot Study to Characterize Middle Cerebral Artery Dynamic Response to an Acute Bout of Moderate Intensity Exercise at 3- and 6-Months Poststroke

Background The primary aim of this study was to characterize the middle cerebral artery blood velocity (MCAv) dynamic response to an acute bout of exercise in humans at 3- and 6-months poststroke. As a secondary objective, we grouped individuals according to the MCAv dynamic response to the exercise bout as responder or nonresponder. We tested whether physical activity, aerobic fitness, and exercise mean arterial blood pressure differed between groups. Methods and Results Transcranial Doppler ultrasound measured MCAv during a 90-second baseline followed by a 6-minute moderate intensity exercise bout. Heart rate, mean arterial blood pressure, and end-tidal CO2 were additional variables of interest. The MCAv dynamic response variables included the following: baseline, time delay, amplitude, and time constant. Linear mixed model revealed no significant differences in our selected outcomes between 3- and 6-months poststroke. Individuals characterized as responders demonstrated a faster time delay, higher amplitude, and reported higher levels of physical activity and aerobic fitness when compared with the nonresponders. No between-group differences were identified for baseline, time constant, or exercise mean arterial blood pressure. In the nonresponders, we observed an immediate rise in MCAv following exercise onset followed by an immediate decline to near baseline values, while the responders showed an exponential rise until steady state was reached. Conclusions The MCAv dynamic response profile has the potential to provide valuable information during an acute exercise bout following stroke. Individuals with a greater MCAv response to the exercise stimulus reported statin use and regular participation in exercise.

Integrating Survivors of Stroke Into Exercise-Based Cardiac Rehabilitation Improves Endurance and Functional Strength

Background

Cardiac rehabilitation (CR) is a structured exercise program prevalent in the United States for people with cardiovascular disease that has been shown to increase cardiovascular endurance and improve quality of life. Despite similar cardiovascular risk factors, stroke is not among the covered diagnoses for CR. The purpose of this study was to examine the participant impact of integrating survivors of stroke into the exercise portion of an existing hospital‐based CR program through measures of physical function and other health impacts and through qualitative evaluation of participant perception.

Methods and Results

Subacute and chronic survivors of stroke were integrated into a standard 12‐week, 3 sessions per week, exercise‐based CR program. A total of 29 began the program, 24 completed the program, and 18 were available for 6‐month follow‐up. Quantitative measures were compared preprogram with postprogram with t‐test or equivalent, and preprogram with postprogram to 6‐month follow‐up with ANOVA or equivalent. Semistructured interviews were completed with 11 participants postprogram. Exercise‐based CR had significant impacts on cardiovascular endurance preprogram to postprogram, with maintenance at 6‐month follow‐up. The participants improved on the 6‐minute walk test on average by 61.92 m(95% CI, 33.99–89.84 m), and maximum metabolic equivalents improved by a median of 3.6 (interquartile range, 2.35). Five times sit to stand (functional strength) improved preprogram to postprogram by a median of 2.85 s (interquartile range, 4.03 s). Qualitative findings highlight additional health improvements. Most participants (83% [15/18]) reported continued exercise at follow‐up.

Conclusions

Exercise‐based CR has the potential to improve cardiovascular endurance, health status, and quality of life for survivors of stroke.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03706105.

Combining transcranial direct current stimulation with aerobic exercise to optimize cortical priming in stroke

Aerobic exercise (AE) and transcranial direct current stimulation (tDCS) are priming techniques that have been studied for their potential neuromodulatory effects on corticomotor excitability (CME); however, the synergistic effects of AE and tDCS are not explored in stroke. Here we investigated the synergistic effects of AE and tDCS on CME, intracortical and transcallosal inhibition, and motor control for the lower limb in stroke. Twenty-six stroke survivors participated in 3 sessions: tDCS, AE, and AE+tDCS. AE included moderate-intensity exercise and tDCS included 1 mA of anodal tDCS to the lower limb motor cortex with or without AE. Outcomes included measures of CME, short-interval intracortical inhibition (SICI), ipsilateral silent period (iSP) (an index of transcallosal inhibition) for the tibialis anterior, and ankle reaction time. Ipsilesional CME significantly decreased for AE compared with AE+tDCS and tDCS. No differences were noted in SICI, iSP measures, or reaction time between all 3 sessions. Our findings suggest that a combination of exercise and tDCS, and tDCS demonstrate greater excitability of the ipsilesional hemisphere compared with exercise only; however, these effects were specific to the descending corticomotor pathways. No additive priming effects of exercise and tDCS over tDCS was observed. Novelty: An exercise and tDCS paradigm upregulated the descending motor pathways from the ipsilesional lower limb primary motor cortex compared with exercise. Exercise or tDCS administered alone or in combination did not affect intracortical or transcallosal inhibition or reaction time.

Effect of brain-computer interface training based on non-invasive electroencephalography using motor imagery on functional recovery after stroke - a systematic review and meta-analysis

Background

Training with brain-computer interface (BCI) technology in the rehabilitation of patients after a stroke is rapidly developing. Numerous RCT investigated the effects of BCI training (BCIT) on recovery of motor and brain function in patients after stroke.

Methods

A systematic literature search was performed in Medline, IEEE Xplore Digital Library, Cochrane library, and Embase in July 2018 and was repeated in March 2019. RCT or controlled clinical trials that included BCIT for improving motor and brain recovery in patients after a stroke were identified. Data were meta-analysed using the random-effects model. Standardized mean difference (SMD) with 95% confidence (95%CI) and 95% prediction interval (95%PI) were calculated. A meta-regression was performed to evaluate the effects of covariates on the pooled effect-size.

Results

In total, 14 studies, including 362 patients after ischemic and hemorrhagic stroke (cortical, subcortical, 121 females; mean age 53.0+/− 5.8; mean time since stroke onset 15.7+/− 18.2 months) were included. Main motor recovery outcome measure used was the Fugl-Meyer Assessment. Quantitative analysis showed that a BCI training compared to conventional therapy alone in patients after stroke was effective with an SMD of 0.39 (95%CI: 0.17 to 0.62; 95%PI of 0.13 to 0.66) for motor function recovery of the upper extremity. An SMD of 0.41 (95%CI: − 0.29 to 1.12) for motor function recovery of the lower extremity was found. BCI training enhanced brain function recovery with an SMD of 1.11 (95%CI: 0.64 to 1.59; 95%PI ranging from 0.33 to 1.89). Covariates such as training duration, impairment level of the upper extremity, and the combination of both did not show significant effects on the overall pooled estimate.

Conclusion

This meta-analysis showed evidence that BCI training added to conventional therapy may enhance motor functioning of the upper extremity and brain function recovery in patients after a stroke. We recommend a standardised evaluation of motor imagery ability of included patients and the assessment of brain function recovery should consider neuropsychological aspects (attention, concentration). Further influencing factors on motor recovery due to BCI technology might consider factors such as age, lesion type and location, quality of performance of motor imagery, or neuropsychological aspects.

Trial Registration

PROSPERO registration: CRD42018105832.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12883-020-01960-5.

Energy Cost During the 6-Minute Walk Test and Its Relationship to Real-World Walking After Stroke: A Correlational, Cross-Sectional Pilot Study

BACKGROUND

After experiencing stroke, individuals expend more energy walking than people who are healthy. However, among individuals who have experienced stroke, the correlation between the energy cost of walking, as measured by validated tests (such as the 6-minute walk test), and participation in walking, as measured by more sensitive tools (such as an ambulatory activity monitor), remains unknown.

OBJECTIVE

The main objective of this study was to determine whether the energy cost of walking is correlated with participation in walking.

DESIGN

This study was a correlational, cross-sectional pilot study.

METHODS

Data from 23 participants who had experienced chronic stroke were analyzed. On the first day, data on oxygen uptake were collected using a portable metabolic system while participants walked during the 6-minute walk test. Then, the ambulatory activity monitor was placed on the participants' nonparetic ankle and removed 9 days later. The energy cost of walking was calculated by dividing the mean oxygen uptake recorded during the steady state by the walking speed.

RESULTS

The energy cost of walking was correlated with the following: the number of steps (Spearman rank correlation coefficient [rs] = -0.59); the percentage of time spent in inactivity (rs = 0.48), low cadence (rs = 0.67), medium cadence (rs = -0.56), high cadence (rs = -0.65), and the percentages of steps taken at low cadence (rs = 0.65) and high cadence (rs = -0.64).

LIMITATIONS

Individuals who were physically inactive, convenience sampling, and a small sample size were used in this study.

CONCLUSIONS

Higher energy costs of walking were associated with fewer steps per day and lower cadence in real-world walking in individuals who had experienced stroke.

Trajectories of self-reported physical activity and predictors during the transition to old age: a 20-year cohort study of British men

BACKGROUND

Maintenance of physical activity (PA) during later life is associated with optimal health; however, the long-term trajectories of PA into old age and their predictors have not been extensively researched using latent class methods. This study aimed to identify trajectories of self-reported PA and their predictors in men transitioning from midlife to old age.

METHODS

7735 men (aged 40-59 years) recruited in 1978-80 were followed up after 12, 16 and 20 years, reporting PA, health status, lifestyle behaviours and socio-demographic characteristics. Group-based trajectory modelling identified the trajectories of PA and associations with time-stable and time-varying covariates. We considered a range of sociodemographic and health and lifestyle factors as potential covariates.

RESULTS

4952 men (mean baseline age 49.1 ± 5.6 years) providing PA data at ≥3 time points were included in analyses. Three distinct 20-year trajectories were identified: low decreasing (24.6%, n = 1218), light stable (51.1%, n = 2530) and moderate increasing (24.3%, n = 1204). Being older, having a manual occupation, having never married or had children, residing in the midlands or North of England, suffering from a range of health conditions, being a smoker/ex-smoker and never consuming breakfast cereal or alcohol were independently associated with reduced odds of belonging to the moderate increasing trajectory group compared to the low decreasing group. Of the time-varying covariates considered, leaving employment was associated with a decrease in PA in the low decreasing group (β -0.306, p < 0.001) but an increase in the light stable (β 0.324, p < 0.001) and moderate increasing groups (β 0.847, p < 0.001). Developing cardiovascular-related conditions was associated with a decrease in PA in the low decreasing (β -0.408, p < 0.001) and light stable groups (β -0.118, p < 0.001) but no association was observed in the moderate increasing group (β -0.060, p = 0.313).

CONCLUSIONS

Three distinct trajectories of PA were identified in men transitioning from midlife to old age, of which nearly a quarter had persistently low levels of PA. Promotion efforts may need to focus attention prior to middle age and consider a number of sociodemographic, health and lifestyle factors to sustain PA into old age. The effects of retirement and development of cardiovascular disease may vary according to PA trajectories.

Influence of pilates training on the quality of life of chronic stroke patients

[Purpose] This study was to observe the influence of Pilates training on the quality of life in chronic stoke patients. [Subjects and Methods] Forty chronic stroke patients participated in this study. They were divided into same number of experimental group (EG) and control group (CG). EG participated in a 60-min Pilates training program, twice a week for 12 weeks, while the CG did not participate in any exercise-related activities for the duration and participating in general occupational therapy without any exercise-related activities. Then the MMSE-K was performed before and after Pilates training to observe the influence of Pilates training on the quality of life in chronic stroke patients. [Results] Statistically significant improvement in the physical, social, and psychological domains was found in EG after the training. No statistically significant difference was found in all three quality of life domains for the CG. EG experienced a statistically significant improvement in all quality of life domains compared with that of CG. [Conclusion] Therefore, participation in Pilates training was found to effectively improve the quality of life in stroke patients. Pilates training involves low and intermediate intensity resistance and repetition that match the patient’s physical ability and can be a remedial exercise program that can improve physical ability and influence quality of life.

Cardiorespiratory Responses to Pool Floor Walking in People Poststroke

OBJECTIVE

To compare cardiorespiratory responses between pool floor walking and overground walking (OW) in people poststroke.

DESIGN

Cross-sectional study.

SETTING

University-based therapeutic exercise facility.

PARTICIPANTS

Participants (N=28) were comprised of 14 community-dwelling individuals poststroke (5.57±3.57y poststroke) and 14 age- and sex-matched healthy adults (mean age, 58.00±15.51y; male/female ratio, 9:5).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

A telemetric metabolic system was used to collect cardiorespiratory variables, including oxygen consumption (V˙o₂), energy expenditure (EE), and expired volume per unit time (V˙e), during 6-minute walking sessions in chest-depth water and on land at a matched speed, determined by average of maximum walking speed in water.

RESULTS

Individuals poststroke elicited no significant differences in cardiorespiratory responses between pool floor walking and OW. However, healthy controls showed significant increases in mean V˙o₂ values by 94%, EE values by 109%, and V˙e values by 94% (all P<.05) during pool floor walking compared with OW. A 2×2 mixed model analysis of variance revealed a significant group × condition interaction in V˙o₂, in which the control group increased V˙o₂ from OW to pool floor walking, whereas the stroke group did not.

CONCLUSIONS

Our results indicate that people poststroke, unlike healthy adults, do not increase EE while walking in water compared with on land. Unlike stationary walking on an aquatic treadmill, forward locomotion during pool floor walking at faster speeds may have increased drag force, which requires greater EE from healthy adults. Without demanding excessive EE, walking in water may offer a naturally supportive environment for gait training in the early stages of rehabilitation.

The effects of Pilates exercise on cardiopulmonary function in the chronic stroke patients: a randomized controlled trials

[Purpose] The purpose of this study was to examine the effect of modified Pilates exercise on cardiopulmonary function in chronic stroke patients. [Subjects and Methods] Twenty participants (age, 62.7 ± 7.3 years; height, 163.3 ± 8.5 cm; weight, 68.8 ± 10.3 kg) were recruited for this study, and randomly allocated to the modified Pilates exercise group (n=10) or the control group (n=10). Graded submaximal treadmill exercise test was used to examine the status of patients' cardiopulmonary function, based on maximal oxygen intake, at the end of a patient's exercise tolerance limit. [Results] The resting heart rates, maximal oxygen intake, and maximal oxygen intake per kilogram were significantly different after 8 weeks of modified Pilates exercise. In addition, these variables were also significantly different between the Pilates and control groups after 8 weeks. [Conclusion] This study has demonstrated that 8 weeks of modified Pilates exercise program can have a positive influence on patients with chronic stroke, potentially by enhancing the cardiopulmonary function, which may have positive implications for increasing their functional ability.

Secondary prevention lifestyle interventions initiated within 90 days after TIA or 'minor' stroke: a systematic review and meta-analysis of rehabilitation programmes

Background

Strokes are often preceded by a transient ischaemic attack (TIA) or ‘minor’ stroke. The immediate period after a TIA/minor stroke is a crucial time to initiate secondary prevention. However, the optimal approach to prevention, including non-pharmacological measures, after TIA is not clear.

Aim

To systematically review evidence about the effectiveness of delivering secondary prevention, with lifestyle interventions, in comprehensive rehabilitation programmes, initiated within 90 days of a TIA/minor stroke. Also, to categorise the specific behaviour change techniques used.

Design and setting

The review identified randomised controlled trials by searching the Cochrane Library, Ovid MEDLINE, Ovid EMBASE, Web of Science, EBSCO CINAHL and Ovid PsycINFO.

Method

Two review authors independently screened titles and abstracts for eligibility (programmes initiated within 90 days of event; outcomes reported for TIA/minor stroke) and extracted relevant data from appraised studies; a meta-analysis was used to synthesise the results.

Results

A total of 31 potentially eligible papers were identified and four studies, comprising 774 patients post-TIA or minor stroke, met the inclusion criteria; two had poor methodological quality. Individual studies reported increased aerobic capacity but meta-analysis found no significant change in resting and peak systolic blood pressure, resting heart rate, aerobic capacity, falls, or mortality. The main behaviour change techniques were goal setting and instructions about how to perform given behaviours.

Conclusion

There is limited evidence of the effectiveness of early post-TIA rehabilitation programmes with preventive lifestyle interventions. Further robust randomised controlled trials of comprehensive rehabilitation programmes that promote secondary prevention and lifestyle modification immediately after a TIA are needed.

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.

Efficacy of Feedback-Controlled Robotics-Assisted Treadmill Exercise to Improve Cardiovascular Fitness Early After Stroke: A Randomized Controlled Pilot Trial

BACKGROUND AND PURPOSE

Cardiovascular fitness is greatly reduced after stroke. Although individuals with mild to moderate impairments benefit from conventional cardiovascular exercise interventions, there is a lack of effective approaches for persons with severely impaired physical function. This randomized controlled pilot trial investigated efficacy and feasibility of feedback-controlled robotics-assisted treadmill exercise (FC-RATE) for cardiovascular rehabilitation in persons with severe impairments early after stroke.

METHODS

Twenty individuals (age 61 ± 11 years; 52 ± 31 days poststroke) with severe motor limitations (Functional Ambulation Classification 0-2) were recruited for FC-RATE or conventional robotics-assisted treadmill exercise (RATE) (4 weeks, 3 × 30-minute sessions/wk). Outcome measures focused on peak cardiopulmonary performance parameters, training intensity, and feasibility, with examiners blinded to allocation.

RESULTS

All 14 allocated participants (70% of recruited) completed the intervention (7/group, withdrawals unrelated to intervention), without serious adverse events occurring. Cardiovascular fitness increased significantly in both groups, with peak oxygen uptake increasing from 14.6 to 17.7 mL · kg · min (+17.8%) after 4 weeks (45.8%-55.7% of predicted maximal aerobic capacity; time effect P = 0.01; no group-time interaction). Training intensity (% heart rate reserve) was significantly higher for FC-RATE (40% ± 3%) than for conventional RATE (14% ± 2%) (P = 0.001).

DISCUSSION AND CONCLUSIONS

Substantive overall increases in the main cardiopulmonary performance parameters were observed, but there were no significant between-group differences when comparing FC-RATE and conventional RATE. Feedback-controlled robotics-assisted treadmill exercise significantly increased exercise intensity, but recommended intensity levels for cardiovascular training were not consistently achieved. Future research should focus on appropriate algorithms within advanced robotic systems to promote optimal cardiovascular stress.Video abstract available for more insights from the authors (Supplemental Digital Content 1, http://links.lww.com/JNPT/A107).

Forced Aerobic Exercise Enhances Motor Recovery After Stroke: A Case Report

OBJECTIVE

Previously, we demonstrated that forced aerobic exercise (FE) increases the pattern of neural activation in Parkinson's disease. We sought to evaluate whether FE, when coupled with repetitive task practice, could promote motor recovery poststroke.

METHOD

A 46-yr-old man with ischemic stroke exhibited chronic residual upper-extremity deficits, scoring 35/66 on the Fugl-Meyer Assessment (FMA) at baseline. He completed 24 training sessions comprising 45 min of FE on a motorized stationary bicycle followed by 45 min of upper-extremity repetitive task practice.

RESULTS

From baseline to end of treatment, the FMA score improved by 20 points, perceived level of recovery on the Stroke Impact Scale increased by 20 percentage points, and cardiovascular function measured by peak oxygen uptake improved 30%. These improvements persisted 4 wk after the intervention ceased.

CONCLUSION

FE may be a safe and feasible rehabilitation approach to augment recovery of motor and nonmotor function while improving aerobic fitness in people with chronic stroke.

Cardiopulmonary exercise testing early after stroke using feedback-controlled robotics-assisted treadmill exercise: test-retest reliability and repeatability

BACKGROUND

Exercise capacity is seriously reduced after stroke. While cardiopulmonary assessment and intervention strategies have been validated for the mildly and moderately impaired populations post-stroke, there is a lack of effective concepts for stroke survivors suffering from severe motor limitations. This study investigated the test-retest reliability and repeatability of cardiopulmonary exercise testing (CPET) using feedback-controlled robotics-assisted treadmill exercise (FC-RATE) in severely motor impaired individuals early after stroke.

METHODS

20 subjects (age 44-84 years, <6 month post-stroke) with severe motor limitations (Functional Ambulatory Classification 0-2) were selected for consecutive constant load testing (CLT) and incremental exercise testing (IET) within a powered exoskeleton, synchronised with a treadmill and a body weight support system. A manual human-in-the-loop feedback system was used to guide individual work rate levels. Outcome variables focussed on standard cardiopulmonary performance parameters. Relative and absolute test-retest reliability were assessed by intraclass correlation coefficients (ICC), standard error of the measurement (SEM), and minimal detectable change (MDC). Mean difference, limits of agreement, and coefficient of variation (CoV) were estimated to assess repeatability.

RESULTS

Peak performance parameters during IET yielded good to excellent relative reliability: absolute peak oxygen uptake (ICC =0.82), relative peak oxygen uptake (ICC =0.72), peak work rate (ICC =0.91), peak heart rate (ICC =0.80), absolute gas exchange threshold (ICC =0.91), relative gas exchange threshold (ICC =0.88), oxygen cost of work (ICC =0.87), oxygen pulse at peak oxygen uptake (ICC =0.92), ventilation rate versus carbon dioxide output slope (ICC =0.78). For these variables, SEM was 4-13%, MDC 12-36%, and CoV 0.10-0.36. CLT revealed high mean differences and insufficient test-retest reliability for all variables studied.

CONCLUSIONS

This study presents first evidence on reliability and repeatability for CPET in severely motor impaired individuals early after stroke using a feedback-controlled robotics-assisted treadmill. The results demonstrate good to excellent test-retest reliability and appropriate repeatability for the most important peak cardiopulmonary performance parameters. These findings have important implications for the design and implementation of cardiovascular exercise interventions in severely impaired populations. Future research needs to develop advanced control strategies to enable the true limit of functional exercise capacity to be reached and to further assess test-retest reliability and repeatability in larger samples.

Feasibility of virtual reality augmented cycling for health promotion of people poststroke

BACKGROUND AND PURPOSE

A virtual reality (VR) augmented cycling kit (VRACK) was developed to address motor control and fitness deficits of individuals with chronic stroke. In this article, we report on the safety, feasibility, and efficacy of using the VR augmented cycling kit to improve cardiorespiratory (CR) fitness of individuals in the chronic phase poststroke.

METHODS

Four individuals with chronic stroke (47-65 years old and ≥3 years poststroke), with residual lower extremity impairments (Fugl-Meyer 24-26/34), who were limited community ambulators (gait speed range 0.56-1.1 m/s) participated in this study. Safety was defined as the absence of adverse events. Feasibility was measured using attendance, total exercise time, and "involvement" measured with the presence questionnaire (PQ). Efficacy of CR fitness was evaluated using a submaximal bicycle ergometer test before and after an 8-week training program.

RESULTS

The intervention was safe and feasible with participants having 1 adverse event, 100% adherence, achieving between 90 and 125 minutes of cycling each week, and a mean PQ score of 39 (SD 3.3). There was a statistically significant (13%; P = 0.035) improvement in peak VO(2), with a range of 6% to 24.5%.

DISCUSSION AND CONCLUSION

For these individuals, poststroke, VR augmented cycling, using their heart rate to set their avatar's speed, fostered training of sufficient duration and intensity to promote CR fitness. In addition, there was a transfer of training from the bicycle to walking endurance. VR augmented cycling may be an addition to the therapist's tools for concurrent training of mobility and health promotion of individuals poststroke.

Physiotherapy needs assessment of people with stroke following discharge from hospital, stratified by acute functional independence measure score

PURPOSE

To determine the physiotherapy-related needs of people with stroke at discharge, 6 months after discharge, and 1 year after discharge from hospital, and to examine the results stratified by participants' acute Functional Independence Measure (FIM) scores.

METHODS

A total of 241 adults with recent stroke were recruited into this longitudinal cohort study. As well as participating in a semi-structured interview that included questions about mobility needs and barriers, participants were asked to complete and return a closed-ended needs-assessment survey.

RESULTS

During the interview, participants reported needs and barriers related to motor control, walking, stairs, fatigue, prevention of falls, and access to physiotherapy services. The survey identified many more needs, including transfers, wheelchair use, higher-level balance and mobility skills, and access to physiotherapy and suitable exercise facilities. Frequencies of needs and barriers tended to be lower among participants with higher acute FIM scores. There was no consistent trend for needs and barriers to decrease over time.

CONCLUSIONS

Over the first year after discharge from hospital, people with stroke report a large and varied number of persistent mobility-related needs. Physiotherapists have a role to play in advocating for adequate follow-up services and informing health policy with respect to the needs of their patients with stroke.

Cardiorespiratory Responses During the 6-Minute Walk and Ramp Cycle Ergometer Tests and Their Relationship to Physical Activity in Stroke

Background and objectives. The 6-minute walk test (6MWT) is used to measure exercise capacity after stroke. We sought to compare cardiorespiratory responses during the 6MWT with responses to a ramp cycle ergometer test (CET) in community-dwelling individuals with stroke. A secondary objective was to determine the relationship between cardiorespiratory responses during each test and daily physical activity. Methods. Participants completed 3 evaluation sessions. The CET and 6MWT were conducted in 2 separate sessions at least 72 hours apart. Participants wore a portable gas analysis unit (Cosmed K4b2), which also measured heart rate (HR) during the 6MWT. A uniaxial accelerometer (activPAL) was used to measure time spent upright (standing and stepping) over 5 days as an estimate of daily physical activity. Results. Complete CET and 6MWT data were obtained for 16 participants (14 men), a mean ± standard deviation of 2.0 ± 1.1 years after stroke and 71.1 ± 9.7 years of age. Compared with the 6MWT, the CET elicited a higher VO2peak ( P = .032), VCO2peak ( P = .005), respiratory exchange ratio ( P = .015), and self-reported perceived breathing ( P < .0001) and leg heaviness ( P < .0001) at test completion and a lower HRpeak ( P = .029). Except for the first minute, VO2 during the 6MWT was, on average, 80% to 85% of VO2peak from the CET. Among 15 participants, average time spent upright per day was not significantly associated with 6MWT distance ( r = 0.447, P = .096) or VO2peak from the CET ( r = 0.388, P = .153). Conclusions. Exercise intensity achieved during the 6MWT appeared sufficiently high for aerobic training, assuming CET VO2peak accurately reflects aerobic capacity. The 6MWT may be useful for prescribing aerobic exercise poststroke.

Comparative analysis of speed's impact on muscle demands during partial body weight support motor-assisted elliptical training

Individuals with walking limitations often experience challenges engaging in functionally relevant exercise. An adapted elliptical trainer (motor to assist pedal movement, integrated body weight harness, ramps/stairs, and grab rails) has been developed to help individuals with physical disabilities and chronic conditions regain/retain walking capacity and fitness. However, limited published studies are available to guide therapeutic interventions. This repeated measures study examined the influence of motor-assisted elliptical training speed on lower extremity muscle demands at four body weight support (BWS) levels commonly used therapeutically for walking. Electromyography (EMG) and pedal trajectory data were recorded as ten individuals without known disability used the motor-assisted elliptical trainer at three speeds [20,40, 60 revolutions per minute (RPM)] during each BWS level (0%, 20%, 40%, 60%). Overall, the EMG activity (peak, mean, duration) in key stabilizer muscles (i.e., gluteus medius, gluteus maximus, vastus lateralis, medial gastrocnemius and soleus) recorded at 60 RPM exceeded those at 40 RPM, which were higher than values at 20 RPM in all but three situations (gluteus medius mean at 0% BWS, vastus lateralis mean at 20% BWS, soleus duration at 40% BWS); however, these differences did not always achieve statistical significance. Slower motor-assisted speeds can be used to accommodate weakness of gluteus medius, gluteus maximus, vastus lateralis, medial gastrocnemius and soleus. As strength improves, training at faster motor-assisted speeds may provide a means to progressively challenge key lower extremity stabilizers.

Vascular elasticity and grip strength are associated with bone health of the hemiparetic radius in people with chronic stroke: implications for rehabilitation

BACKGROUND

People with stroke often have increased bone loss and fracture rate. Increasing evidence has demonstrated a link between cardiovascular health and bone loss in other patient populations.

OBJECTIVE

The study objectives were: (1) to compare the bone density and geometry of the radius diaphysis on the left and right sides in people with chronic stroke and people who were matched for age (control participants) and (2) to examine the relationship between the bone strength index at the hemiparetic radius diaphysis and vascular health in people with chronic stroke.

DESIGN

This was a case-control study.

METHODS

The radius diaphysis on both sides was scanned with peripheral quantitative computed tomography in 65 participants with chronic stroke and 34 control participants. Large-artery and small-artery elasticity indexes were evaluated with a cardiovascular profiling system.

RESULTS

The paretic radius diaphysis had significantly lower values for cortical bone mineral density, cortical thickness, cortical area, and the bone strength index but a larger marrow cavity area than the nonparetic radius diaphysis in participants with chronic stroke, whereas no bone measurement showed a significant side-to-side difference in control participants. Multiple regression analyses showed that the large-artery elasticity index and grip strength remained significantly associated with the bone strength index at the hemiparetic radius diaphysis after controlling for age, sex, time since stroke diagnosis, body mass index, and physical activity (R(2)=.790).

LIMITATIONS

This study was cross-sectional and could not establish causality. The radius diaphysis is not the most common site of fracture after stroke.

CONCLUSIONS

Both the integrity of the vasculature and muscle strength were significantly associated with the bone strength index at the hemiparetic radius diaphysis in participants with chronic stroke. The results may be useful in guiding rehabilitative programs for enhancing bone health in the paretic arm after stroke.

Aerobic exercise in subacute stroke improves cardiovascular health and physical performance

BACKGROUND AND PURPOSE

Cardiovascular health is often impaired after stroke. Reduced exercise capacity ((Equation is included in full-text article.)VO(2peak)) and changes in the vascular system in the stroke-affected limb may impact performance of physical activities such as walking. There is little information regarding the role of prescribed moderate- to high-intensity exercise in subacute stroke. The purpose of this study was to examine whether an 8-week aerobic exercise intervention would improve cardiovascular health and physical performance in participants with subacute stroke.

METHODS

Ten subjects were enrolled in the study and 9 of them completed the intervention. Participants were aged 61.2 ± 4.7 years old, were 66.7 ± 41.5 days poststroke, and had minor motor performance deficits (Fugl-Meyer score, 100.3 ± 29.3). Outcome measures were taken at baseline, postintervention, and at 1-month follow-up. Brachial artery vasomotor reactivity (flow-mediated dilation [FMD]) of both arms was used to assess vascular health, and a peak exercise test was used to assess exercise capacity. The 6-minute walk test (6MWT) was used to assess physical performance. Participants exercised on a recumbent stepper 3 times per week for 8 weeks at a prescribed heart rate intensity.

RESULTS

At baseline, we identified between-limb differences in brachial artery FMD and low (Equation is included in full-text article.)VO(2peak) values. After the intervention, significant improvements were observed in the FMD in both arms, resting systolic blood pressure, and the 6MWT. Although we also observed improvements in the resting diastolic blood pressure, heart rate, and (Equation is included in full-text article.)VO(2peak) values, these changes were not significantly different.

DISCUSSION AND CONCLUSION

Aerobic exercise in participants with subacute stroke was beneficial for improving cardiovascular health, reducing cardiac risk, and improving physical performance (6MWT).

Dual effects of body-weight supported treadmill training on cardiovascular fitness and walking ability early after stroke: a randomized controlled trial

BACKGROUND

Body-weight-supported treadmill training (BWSTT) to train both fitness and ambulation has not been investigated.

OBJECTIVE

To compare the effectiveness of BWSTT to dose-equivalent usual care (UC) in improving cardiovascular fitness and walking early after stroke.

METHODS

Participants were randomly assigned to 1 of 2 interventions: BWSTT + UC or UC. All individuals participated in 60-minute physiotherapy sessions 5 times weekly as inpatients for 6 weeks and 3 times weekly as outpatients for another 6 weeks. Baseline, posttraining, 6-, and 12-month follow-up outcome measures were as follows: primary, fitness (peak oxygen consumption, VO2peak) and walking ability (6-Minute Walk Test [6MWT] and 10-m walk); secondary, Berg Balance Scale (BBS) and motor impairment (Chedoke-McMaster Stages of Recovery [CMSR] Leg and Foot).

RESULTS

In all, 50 individuals (mean age, 60 ± 14 years; mean event-to-randomization, 23 ± 5 days; 29 men) participated. No adverse events occurred. BWSTT improved VO2peak by 30%, which was significantly greater than the 8% improvement observed for UC (P = .004 between groups). Similarly, there were significant Time × Group interactions for 6MWT and CMSR Foot, with BWSTT outperforming UC for gains in distance (P = .15; 48% vs. 19%, respectively) and stage (P = .01; 1.0 vs. 0.3, respectively). No group effect was seen for 10-m walk speed, BBS, or CMSR Leg, with both groups demonstrating significant gains. In general, gains observed were preserved for 12 months.

CONCLUSIONS

BWSTT elicits greater improvements in cardiovascular fitness and walking endurance than UC in the subacute poststroke period. These gains are largely sustained for 1 year.

Relative impact of neuromuscular and cardiovascular factors on bone strength index of the hemiparetic distal radius epiphysis among individuals with chronic stroke

The objective of this study was to examine the associations of neuromuscular and cardiovascular impairments with the bone strength index of the hemiparetic distal radius epiphysis in chronic stroke survivors. The results showed that grip strength is the most predominant predictor of the bone strength index.

INTRODUCTION

The purpose of the study was to examine the associations of neuromuscular and cardiovascular impairments with the bone strength index of the hemiparetic distal radius epiphysis in chronic stroke survivors.

METHODS

Sixty-five chronic stroke survivors and 34 healthy control subjects underwent scanning of the distal radius epiphyseal site on both sides using peripheral quantitative computed tomography to measure trabecular volumetric bone mineral density (vBMD) (mg/cm(3)), total vBMD (mg/cm(3)), total area (mm(2)), and compressive bone strength index (cBSI) (g(2)/cm(4)). Various indicators of neuromuscular (grip strength, spasticity) and cardiovascular function (vascular elasticity, oxygen consumption during 6-min walk test) were evaluated.

RESULTS

Analysis of variance revealed a significant main effect of side (p < 0.001) and group × side interaction (p < 0.05) for total BMC, total vBMD, trabecular vBMD, and cBSI (p < 0.05), with the stroke group showing greater side-to-side difference in these variables. However, no significant side-to-side difference in total area was detected in either group (p > 0.05). Sex-specific analysis yielded similar results. Multiple regression analyses revealed that the cBSI of the hemiparetic distal radius epiphysis had a stronger association with neuromuscular factors than cardiovascular factors. Overall, grip strength was the strongest determinant of the cBSI of the hemiparetic distal radius epiphysis (p < 0.01).

CONCLUSIONS

Muscle weakness is the most predominant determinant of cBSI in the hemiparetic distal radius epiphysis among chronic stroke patients. Future studies should investigate the efficacy of different muscle-strengthening strategies in enhancing bone strength of this skeletal site in the chronic stroke population.

Effects of cardiovascular exercise early after stroke: systematic review and meta-analysis

BACKGROUND

Previous studies have shown the beneficial effects of aerobic exercise in chronic stroke. Most motor and functional recovery occurs in the first months after stroke. Improving cardiovascular capacity may have potential to precipitate recovery during early stroke rehabilitation. Currently, little is known about the effects of early cardiovascular exercise in stroke survivors. The aim of this systematic review was to evaluate the effectiveness of cardiovascular exercise early after stroke.

METHODS

A systematic literature search was performed. For this review, randomized and non-randomized prospective controlled cohort studies using a cardiovascular, cardiopulmonary or aerobic training intervention starting within 6 months post stroke were considered. The PEDro scale was used to detect risk of bias in individual studies. Inter-rater agreement was calculated (kappa). Meta-analysis was performed using a random-effects model.

RESULTS

A total of 11 trials were identified for inclusion. Inter-rater agreement was considered to be "very good" (Kappa: 0.81, Standard Error: 0.06, CI95%: 0.70-0.92), and the methodological quality was "good" (7 studies) to "fair" (4 studies). Peak oxygen uptake data were available for 155 participants. Pooled analysis yielded homogenous effects favouring the intervention group (standardised mean difference (SMD) = 0.83, CI95% = 0.50-1.16, Z = 4.93, P < 0.01). Walking endurance assessed with the 6 Minute Walk Test comprised 278 participants. Pooled analysis revealed homogenous effects favouring the cardiovascular training intervention group (SMD = 0.69, CI95% = 0.45-0.94, Z = 5.58, P < 0.01). Gait speed, measured in 243 participants, did not show significant results (SMD = 0.51, CI95% = -0.25-1.26, Z = 1.31, P = 0.19) in favour of early cardiovascular exercise.

CONCLUSION

This meta-analysis shows that stroke survivors may benefit from cardiovascular exercise during sub-acute stages to improve peak oxygen uptake and walking distance. Thus, cardiovascular exercise should be considered in sub-acute stroke rehabilitation. However, concepts to influence and evaluate aerobic capacity in severely affected individuals with sub-acute stroke, as well as in the very early period after stroke, are lacking.Further research is needed to develop appropriate methods for cardiovascular rehabilitation early after stroke and to evaluate long-term effects of cardiovascular exercise on aerobic capacity, physical functioning, and quality-of-life.

Cardiorespiratory Fitness after Stroke: A Systematic Review

Cardiorespiratory fitness programs are increasingly used in stroke rehabilitation. Maximal oxygen uptake is the gold standard measurement of cardiorespiratory fitness; however, no recent publications have collated evidence about maximal oxygen uptake levels following stroke. We therefore performed a systematic review of maximal oxygen uptake in stroke survivors, aiming to observe changes in levels over time, and associations with severity of stroke. We searched Medline and Embase until April 2011, and included cross-sectional studies, longitudinal studies, and baseline data from intervention trials. Studies had to recruit at least 10 stroke survivors, and report direct measurement of maximal/peak oxygen uptake. We then compared maximal oxygen uptake with published data from age and gender-matched controls. The search identified 3357 articles. Seventy-two full texts were retrieved, of which 41 met the inclusion criteria. Time since stroke ranged from 10 days to over seven-years. Peak oxygen uptake ranged from 8 to 22 ml/kg/min, which was 26–87% of that of healthy age- and gender-matched individuals. Stroke severity was mild in most studies. Three studies reported longitudinal changes; there was no clear evidence of change in peak oxygen uptake over time. Most studies recruited participants with mild stroke, and it is possible that cardiorespiratory fitness is even more impaired after severe stroke. Maximal oxygen uptake might have been overestimated, as less healthy and older stroke survivors may not tolerate maximal exercise testing. More studies are needed describing mechanisms of impaired cardiorespiratory fitness and longitudinal changes over time to inform the optimal ‘prescription’ of cardiorespiratory fitness programs for stroke survivors.

Evolution of cardiorespiratory fitness after stroke: a 1-year follow-up study. Influence of prestroke patients' characteristics and stroke-related factors

OBJECTIVES

To examine changes in cardiorespiratory fitness over the first year poststroke and explore the effect of prestroke patients' characteristics and stroke-related factors on this evolution.

DESIGN

Descriptive, longitudinal study with repeated measures of exercise capacity at 3, 6, and 12 months poststroke.

SETTING

Rehabilitation center and exercise testing laboratory.

PARTICIPANTS

Consecutive sample of patients with stroke (N=33; mean age ± SD, 59.0±11.3 y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Peak oxygen consumption (VO(2)peak) and oxygen uptake efficiency slope (OUES) were determined during a symptom-limited graded cycle ergometer test at 3, 6, and 12 months poststroke. Age, sex, premorbid physical activity level, clinical history (smoking, diabetes mellitus, chronic pulmonary diseases, cardiovascular diseases, overweight, and hypertension), stroke type and area, side of lesion, and assessments of stroke severity were evaluated at intake.

RESULTS

Mean VO(2)peak ± SD was 18.1±6.6 mL·kg(-1)·min(-1), 19.8±8.0 mL·kg(-1)·min(-1), and 19.7±8.4 mL·kg(-1)·min(-1) at 3, 6, and 12 months poststroke. Values for OUES were 1575.3±638.3, 1710.7±710.3, and 1687.2±777.5, respectively. Mixed models showed no significant difference over time for VO(2)peak (P=.10), nor for the logarithm of OUES (P=.09). Stroke survivors at risk of deconditioning were premorbidly less active at work or in sport activities, diabetic, or initially more severely impaired. Combination of factors revealed that older patients with stroke and diabetes were less likely to improve on VO(2)peak and that older, women, diabetic nonsmokers improved less on log OUES.

CONCLUSIONS

Cardiorespiratory fitness was reduced from 3 to 12 months poststroke and on average did not significantly change over time. Further studies should elucidate methods of increasing cardiorespiratory fitness during stay in the rehabilitation center and how community-based aerobic exercise training postrehabilitation can be organized.

Chronic Stroke Survivors Benefit From High-Intensity Aerobic Treadmill Exercise

Background and objective. Ambulatory subjects after stroke may benefit from gait-oriented cardiovascular fitness training, but trials to date have not primarily assessed older persons. Methods. Thirty-eight subjects (age >60 years) with residual hemiparetic gait were enrolled >6 months after stroke. Participants were randomized to receive 3 months (3×/week) progressive graded, high-intensity aerobic treadmill exercise (TAEX) or conventional care physiotherapy. Primary outcome measures were peak exercise capacity (Vo2peak) and sustained walking capacity in 6-minute walks (6MW). Secondary measures were gait velocity in 10-m walks, Berg Balance Scale, functional leg strength (5 chair-rise), self-rated mobility (Rivermead Mobility Index), and quality of life (SF-12). Results. Thirty-six participants completed the study (18 TAEX, 18 controls). TAEX but not conventional care improved Vo2peak (difference 6.4 mL/kg/min, P < .001) and 6MW (53 m, P < .001). Likewise, maximum walking speed (0.13 m/s, P = .01), balance ( P < .05), and the mental subscore of the SF-12 ( P < .01) improved more after TAEX. Gains in Vo2peak correlated with the degree at which training intensity could be progressed in the individual participant ( P < .01). Better walking was related to progression in treadmill velocity and training duration ( P < .001). Vo2peak and 6MW performances were still higher 1 year after the end of training when compared with the baseline, although endurance walking (6MW) at 1 year was lower than immediately after training ( P < .01). Conclusion. This trial demonstrates that TAEX effectively improves cardiovascular fitness and gait in persons with chronic stroke.

Relation between physical exertion and postural stability in hemiparetic participants secondary to stroke

INTRODUCTION

Chronic hemiparetic stroke individuals are at a higher risk of falling. This may be due to balance impairments, cardiovascular deconditioning, and muscle weakness associated with stroke effects. Postural instability associated with fatigue would likely be attained more rapidly for stroke individuals than for healthy individuals.

OBJECTIVE

To determine the effects of physical exertion induced by walking on postural stability in hemiparetic stroke participants.

METHODS

Twelve hemiparetic participants and 12 control participants walked over-ground for a duration of 6 min and 18 min at their comfortable speed. Postural stability was assessed using centre of pressure related parameters during double-legged stance and tasks before the walk, immediately after the walk, 15 min post-walk, and 30 min post-walk. Measures of physical exertion during walking were also obtained from cardiorespiratory parameters, time-distance parameters, and subjective scales. Variables on postural stability and on physical exertion were analyzed using two-way repeated measures ANOVA and Generalized Estimating Equations.

RESULTS

Physical exertion measures significantly increased when the duration of walk was increased from 6 min to 18 min in both control and hemiparetic participants. For postural stability measures, increasing the duration of walking led to a significant increase of postural sway in double-legged stance and sit-to-stand for the hemiparetic participants only. This effect on balance of hemiparetic participants was observed immediately after the end of the walk.

CONCLUSION

This study demonstrated that physical exertion can increase postural sway in hemiparetic participants which could possibly lead to an increased risk of falling in these individuals.

Program of rehabilitative exercise and education to avert vascular events after non-disabling stroke or transient ischemic attack (PREVENT Trial): a multi-centred, randomised controlled trial

BACKGROUND

Despite lack of outward signs, most individuals after non-disabling stroke (NDS) and transient ischemic attack (TIA) have significant cardiovascular and cerebrovascular disease and are at high risk of a major stroke, hospitalization for other vascular events, or death. Most have multiple modifiable risk factors (e.g., hypertension, physical inactivity, hyperlipidaemia, diabetes, tobacco consumption, psychological stress). In addition, accelerated rates of depression, cognitive decline, and poor quality of sleep have been reported following TIA, which correlate with poor functional outcomes and reduced quality of life. Thus, NSD and TIA are important warning signs that should not be overlooked. The challenge is not unlike that facing other 'silent' conditions - to identify a model of care that is effective in changing people's current behaviors in order to avert further morbidity.

METHODS/DESIGN

A single blind, randomized controlled trial will be conducted at two sites to compare the effectiveness of a program of rehabilitative exercise and education versus usual care in modifying vascular risk factors in adults after NDS/TIA. 250 adults within 90 days of being diagnosed with NDS/TIA will be randomly allocated to a 12-week program of exercise and education (PREVENT) or to an outpatient clinic assessment and discussion of secondary prevention recommendations with return clinic visits as indicated (USUAL CARE). Primary outcome measures will include blood pressure, waist circumference, 12-hour fasting lipid profile, and 12-hour fasting glucose/hemoglobin A1c. Secondary measures will include exercise capacity, walking endurance, physical activity, cognitive function, depression, goal attainment and health-related quality of life. Outcome assessment will be conducted at baseline, post-intervention, and 6- and 12-month follow-ups. Direct health care costs incurred over one year by PREVENT versus USUAL CARE participants will also be compared. Ethical approval for the trial has been obtained from the relevant Human Research Ethics Boards.

DISCUSSION

Whether timely delivery of an adapted cardiac rehabilitation model is effective in attaining and maintaining vascular risk reduction targets in adults after NDS/TIA is not yet known. We anticipate that the findings of this trial will make a meaningful contribution to the knowledge base regarding secondary stroke prevention.