A Home- and Community-Based Physical Activity Program Can Improve the Cardiorespiratory Fitness and Walking Capacity of Stroke Survivors

Exercise referral schemes increase Patients' cardiorespiratory Endurance: A systematic review and Meta-Analysis

Introduction

The efficacy of exercise referral schemes (ERS) involving primary care providers to an exercise specialist on patients' physical activity is uncertain and primarily based on self-report outcomes. Cardiorespiratory endurance carries clinically relevant information and is an objective outcome measure that has been used to evaluate ERS, but this literature has not been amalgamated. We determined the effectiveness of ERS involving qualified exercise professionals (QEPs) on patients' cardiorespiratory endurance.

Methods

A systematic review with between-group and within-group meta-analyses was performed to examine the effects of ERS on cardiorespiratory endurance. We searched Scopus, EMBASE, MEDLINE, CINAHL, and Academic Search Premier databases from their inception to February 2023 to find ERS interventions (randomized/non-randomized, controlled/non-controlled). To be included, studies required an adult patient referral from a primary care provider to a QEP.

Results

Twenty-nine articles comprising 6326 (3684 females) unique patients were included. Patients were primarily older (62 ± 9 years; range: 48-82) and overweight (body mass index: 28.9 ± 7.5 kg/m2; range: 22.5-37.1). Improvements in patients' cardiorespiratory endurance were observed in 20 of the 29 studies. Among controlled studies (n = 14), the meta-analysis exhibited a favorable effect on cardiorespiratory endurance between the intervention and the comparator groups (Hedge's g: 0.31, 95 % CI: 0.09 to 0.52). The ERS interventions also improved cardiorespiratory endurance when comparing pre- and post-intervention effects (all studies, Cohen's d: 0.57, 95 % CI: 0.45 to 0.69).

Conclusion

ERS that incorporate a QEP lead to improvements in patients' cardiorespiratory endurance, providing support for the creation of these programs to help patients lead healthier lifestyles.

The Interplay of Sports and Nutrition in Neurological Health and Recovery

This comprehensive review explores the dynamic relationship between sports, nutrition, and neurological health. Focusing on recent clinical advancements, it examines how physical activity and dietary practices influence the prevention, treatment, and rehabilitation of various neurological conditions. The review highlights the role of neuroimaging in understanding these interactions, discusses emerging technologies in neurotherapeutic interventions, and evaluates the efficacy of sports and nutritional strategies in enhancing neurological recovery. This synthesis of current knowledge aims to provide a deeper understanding of how lifestyle factors can be integrated into clinical practices to improve neurological outcomes.

Feasibility of an Application-Based Outpatient Rehabilitation Program for Stroke Survivors: Acceptability and Preliminary Results for Patient-Reported Outcomes

BACKGROUND

The majority of stroke survivors experience long-term impairments. Regular physical activity and other lifestyle modifications play an important role in rehabilitation. Outpatient rehabilitation using telemedicine might be suitable to improve functional ability and long-term secondary prevention. The Strokecoach Intervention Program (SIP, Strokecoach GmbH, Cologne, Germany) comprises training, coaching and monitoring with the aim of improving or at least maintaining functional independence and preventing further stroke through more targeted physical activity. The SIP is provided as blended care, which refers to the integrated and coordinated delivery of healthcare services that combines traditional in-person interactions with technology-mediated interventions, optimizing the use of both face-to-face and virtual modalities to enhance patient outcomes.

OBJECTIVE

The aim of this study was to evaluate the acceptance of the SIP by the participants and its practical application, as well as to obtain initial indications of effects of the SIP on the basis of patient-related outcome measures, blood pressure measurements and recording of physical activity in parallel with the intervention.

METHODS

Data from individuals with stroke participating in the SIP were analyzed retrospectively. Within the SIP, participants received an application-based training program, were instructed to measure their blood pressure daily and to wear an activity tracker (pedometer). During the intervention period of either 6 or 12 weeks, the participants were supported and motivated by a personal coach via a messenger application. The primary outcomes of the analysis were recruitment, acceptance of and satisfaction with the SIP. Secondary outcomes included functional measures, mobility and health-related quality of life.

RESULTS

A total of 122 individuals with stroke could be recruited for the SIP. A total of 96 out of 122 were able to start the program (54% female, mean age 54.8 (SD = 13.1), 6.1 (SD = 6.6) years after stroke onset) and 88 completed the SIP. Participants wore the activity tracker on 66% and tracked their blood pressure on 72% of their intervention days. A further analyzed subgroup of 38 participants showed small improvements in patient-reported outcomes such as health-related quality of life (SF-36) with an increase of 12 points in the subdomain mental health, vitality (12.6) and physical functioning (9.1). However, no statistically significant improvements were found in other performance-based measures (Timed Up and Go test, gait speed).

CONCLUSIONS

This study showed that a blended therapy approach for stroke survivors with mild to moderate impairments in the chronic phase is feasible and was highly accepted by participants, who benefitted from the additional coaching.

Adverse Events During Submaximal Aerobic Exercise Testing in People With Subacute Stroke: A Scoping Review

BACKGROUND AND PURPOSE

Concern for adverse cardiovascular events and limited guidance regarding how to conduct aerobic exercise (AEx) testing for individuals poststroke are key barriers to implementation by physical therapists in stroke rehabilitation. This study aimed to describe the nature and safety of submaximal AEx testing protocols for people with subacute stroke (PwSS) and the nature of comorbidity of PwSS who underwent submaximal AEx testing.

METHODS

We conducted a scoping review and searched MEDLINE, EMBASE, PsycINFO, CINAHL, and SPORTDiscus from inception to October 29, 2020. Studies involving submaximal AEx testing with PwSS, reporting on participant comorbidity and on adverse events during testing, were eligible. Two reviewers independently conducted title and abstract and full-text screening. One reviewer extracted data; a second reviewer verified data.

RESULTS

Thirteen studies involving 452 participants and 19 submaximal AEx testing protocols (10 field test, 7 incremental, and 2 constant load) were included. Hypertension (41%), diabetes (31%), and dyslipidemia (27%) were the most common comorbidities reported. No protocols resulted in a serious adverse event. The most common test termination criterion was a heart rate (HR) limit (9 protocols); a limit of 85% age-predicted maximal HR (APM-HR) most frequently reported. Average APM-HR achieved, computed using mean age and mean peak HR, ranged from 59% to 88% across 13 protocols.

DISCUSSION AND CONCLUSION

Diverse submaximal AEx testing protocols with conservative test termination criteria can be safely implemented with PwSS. Results can inform clinical practice guidelines and address physical therapists' concerns with the occurrence of serious adverse events during submaximal AEx testing.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A430 ).

How little is enough? The feasibility of conducting a dose-escalation study for exercise training in people with stroke

QUESTION

Is it feasible and safe to conduct an exercise dose-finding study in people with stroke? Is it possible to determine a minimal dose of exercise required to see clinically meaningful improvements in cardiorespiratory fitness?

METHODS

Dose-escalation study. Twenty people with stroke (n=5 per cohort) who were able to walk independently participated in home-based, telehealth-supervised aerobic exercise sessions 3 d/week at moderate-vigorous intensity for 8 weeks. Dose parameters of frequency (3 d/week), intensity (55-85% of heart rate peak) and program length (8 weeks) were kept constant. The duration of exercise sessions was increased by 5 min per session from Dose 1 (10 min/session) to Dose 4 (25 min/session). Doses were escalated if safe and tolerable (< 33% of a cohort reaching a dose-limiting threshold). Doses were efficacious if ≥ 67% of a cohort increased peak oxygen consumption ≥ 2mL/kg/min.

RESULTS

Target exercise doses were well adhered to, and the intervention was safe (480 exercise sessions delivered; one fall resulting in minor laceration) and tolerable (no participants met the dose-limiting threshold). None of the exercise doses met our criterion for efficacy.

CONCLUSIONS

It is possible to conduct a dose-escalation trial for people with stroke. The small cohort sizes may have limited the ability to determine an efficacious minimum dose of exercise. Providing supervised exercise session at these prescribed doses via telehealth was safe.

REGISTRATION

The study was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12617000460303).

Effects of whole body vibration on functional capacity and respiratory functions in individuals with stroke: A randomized controlled study

BACKGROUND

Management of respiratory-related functional problems using sensory rehabilitation strategies has been poorly researched in patients with stroke.

OBJECTIVE

This study aimed to investigate whether whole body vibration (WBV) training has an effect on functional capacity and respiratory functions in patients with stroke.

METHODS

In the randomized-controlled study, 28 participants were randomized into two groups: one receiving neurodevelopmental treatment (NDT; n = 13) and one receiving both NDT and WBV (NDT + WBV; n = 15). The primary outcome measures were 6-minute walking test (6MWT) and pulmonary function test which evaluate functional and respiratory capacity. Secondary outcome included the chest circumference measurement to evaluate the thoracic expansion ability.

RESULTS

Both groups showed positive significant changes in walking distance and maximum oxygen consumption volume (VO2max), inspiratory capacity, vital capacity and chest circumference measurement scores (p <  0.05). While the NDT +WBV group showed a significantly greater increase in walking distance and VO2max levels than the NDT group (p <  0.05), there were no significant group differences in respiratory function flow and volume parameters, and chest circumference measurement.

CONCLUSION

The addition of WBV training to the treatment program has some incremental benefits on increasing functional capacity and thoracic expansion, and rehabilitating respiratory dysfunction.

Physical Activity Level, Barriers, and Facilitators for Exercise Engagement for Chronic Community-Dwelling Stroke Survivors in Low-Income Settings: A Cross-Sectional Study in Benin

After a stroke incident, physical inactivity is common. People with stroke may perceive several barriers to performing physical activity (PA). This study aimed to document the PA level and understand the barriers and facilitators to engaging in PA for community-dwelling stroke survivors in Benin, a lower middle-income country. A cross-sectional study was conducted in three hospitals in Benin. Levels of PA were recorded by means of the Benin version of the International Physical Activity Questionnaire long form (IPAQ-LF-Benin), which is validated for stroke survivors in Benin. The perceived exercise facilitators and barriers were assessed by the Stroke Exercise Preference Inventory-13 (SEPI-13). A descriptive analysis and associations were performed with a Confidence Interval of 95% and <0.05 level of significance. A total of 87 participants (52 men, mean age of 53 ± 10 years, mean time after a stroke of 11 (IQR: 15) months and an average of 264.5 ± 178.9 m as distance on the 6 min walking test (6MWT) were included. Overall, stroke survivors in Benin reached a total PA of 985.5 (IQR: 2520) metabolic equivalent (METs)-minutes per week and were least active at work, domestic, and leisure domains with 0 MET-minutes per week. The overview of PA level showed that 52.9% of participants performed low PA intensity. However, 41.4% performed moderate PA or walking per day for at least five days per week. Important perceived barriers were lack of information (45.3%), hard-to-start exercise (39.5%), and travelling to places to exercise (29.9%). The preference for exercise was with family or friends, outdoors, for relaxation or enjoyment (90.2%), and receiving feedback (78.3%). Several socio-demographic, clinical, and community factors were significantly associated with moderate or intense PA (p < 0.05) in stroke survivors in this study. Our findings show that the PA level among chronic stroke survivors in Benin is overall too low relative to their walking capacity. Cultural factors in terms of the overprotection of the patients by their entourage and/or the low health literacy of populations to understand the effect of PA on their health may play a role. There is a need for new approaches that consider the individual barriers and facilitators to exercise.

Effects of a multidisciplinary intervention to promote physical activity in patients with stroke undergoing rehabilitation: study protocol for the ActivePAS pilot randomised controlled trial

Introduction

Physical activity after stroke is related to functional recovery and outcomes. To optimise physical activity adapted to a patient's walking ability and characteristics, multidisciplinary support and interventions are required. The Activate Physical Activity for Stroke pilot randomised controlled trial aims to assess the safety and feasibility of a multidisciplinary intervention that promotes physical activity in patients who had a stroke undergoing rehabilitation.

Methods and analysis

This single-centre, randomised controlled trial will enrol 32 patients who had a stroke undergoing rehabilitation. Patients who had a stroke with the ability to walk 50 m with at least hand assistance, regardless of the use of braces or walking aids, and aged≥20 years will be randomly allocated to a multidisciplinary intervention group or control group. Patients in the intervention group will receive instructions for the self-monitoring of hospitalised physical activity and support to promote physical activity by multidisciplinary staff. The primary outcome of the present study is the safety (adverse events) and feasibility (retention and completion rates) of the multidisciplinary intervention. We assess physical activity using a triaxial accelerometer (UW-204NFC, A&D Company) as one of the secondary outcomes.

Ethics and dissemination

The present study has been approved by the Research Ethics Committee of Konan Women's University and the Ethics Committee of Nishi-Kinen Port Island Rehabilitation Hospital. We will disseminate the results of the present study through a peer-reviewed manuscript and presentations at international conferences.

Trial registration number

UMIN000046731.

Feasibility of a home-based physiotherapy intervention to promote post-stroke mobility: A randomized controlled pilot study

Objectives

Home-based physiotherapy interventions to improve post-stroke mobility are successful in high-income countries. These programs require less resources compared to center-based programs. However, feasibility of such an intervention in a low and middle-income setting remains unknown. Therefore, the SunRISe (Stroke Rehabilitation In Suriname) study aimed to assess feasibility and preliminary effectiveness of a home-based semi-supervised physiotherapy intervention to promote post-stroke mobility in a low resource setting.

Design

Prospective randomized controlled trial.

Methods

Chronic stroke patients were recruited and randomized into either an intervention group (IG (N = 20)) or a control group (CG (N = 10)). The IG received a 3-days-a-week home-based physiotherapy program that was supervised in the first 4 weeks and tele-supervised during the second 4 weeks. The physiotherapy program consisted of walking as well as functional and mobilization exercises. The CG received usual care. Feasibility outcome measures included adherence, patient satisfaction and safety. Efficacy measures included functional exercise tolerance (six-minute walking test (6MWT), functional balance (Berg Balance Score (BBS), upper extremity (UE) function (Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire), and UE strength ((non-)paretic handgrip (HG) strength). Two-way analysis of variance was used for data analysis.

Results

Thirty participants (61.8 ± 9.2 years old, 13 men) were enrolled in the study. The intervention was completed by 14 participants (70%). Adherence was affected by rainy season associated infrastructural problems (n = 2), the medical status of participants (n = 3) and insufficient motivation to continue the program without direct supervision (n = 1). No adverse events were noted and participants were satisfied with the program. Functional exercise tolerance (57.2 ± 67.3m, p = 0.02) and UE function (-9.8 ± 15.2, p = 0.04) improved in the IG compared to no change in the CG. HG strength was unaltered and a ceiling effect occurred for BBS.

Conclusion

Our home-based semi-supervised physiotherapy intervention seems safe, associated with moderate to high levels of engagement and patient satisfaction and results in functional improvements.

Exploring Alternative Measurements of Cardiorespiratory Fitness in Patients With Mild Ischemic Stroke at Acute Phase

Background

While emerging studies have suggested an association of cardiorespiratory fitness (CRF) with stroke risk and overall health outcomes, little is known regarding the optimum methods of CRF measurement in patients with mild acute ischemic stroke.

Objective

The aim of this study was to explore the association between the 6-min walk distance (6MWD) and other measurements related to CRF in patients with mild ischemic stroke at the acute stage.

Methods

A total of 30 patients with stroke and 71 healthy subjects matched for age and grip strength (GS) were prospectively recruited. All patients were within 14 days after stroke onset and presented mild motor impairment (with a full score of Fugl-Meyer Motor Assessment). Demographic data of both groups and clinical information of the stroke group were documented, and the CRF comparison between the two groups was conducted. Each participant underwent a one-time assessment of 6MWD and a series of measurements related to CRF, including GS, 10-m walk test (10mWT), five-times sit-to-stand time (FTSST), functional reaching test (FRT), Berg Balance Scale (BBS), and waistline. Pearson's product-moment correlation coefficient test and multiple linear regression were performed to explore the indicators of CRF.

Results

Significant moderate correlations (0.3 < r <0.6) were found between 6MWD and GS of left hand (GS-left) (r = 0.573, p = 0.001), GS of right hand (GS-right) (r = 0.524, p = 0.003), FTSST (r = −0.551, p = 0.002), 10mWT (r = 0.554, p = 0.001), and FRT (r = 0.449, p = 0.021) in the patient group. While 6MWD displayed significant moderate correlations with waistline (r = 0.364, p = 0.002), 10mWT (r = 0.512, p < 0.001), FTSST (r = −0.573, p < 0.001), and FRT (r = 0.550, p < 0.001) in the healthy group. All these dependent variables were entered into a stepwise multiple linear regression analysis to evaluate their values in estimating CRF as measured by 6MWD in each group. Analyses suggested that GS-left (p = 0.002) and FTSST (p = 0.003) were the indicators of CRF in the patient group with stroke and explained 51.4% of the variance of 6MWD (R² = 0.514); FTSST (p < 0.001), 10mWT (p < 0.001), and FRT (p = 0.021) were the indicators of CRF in the healthy group and explained 58.9% of variance of 6MWD (R² = 0.589).

Conclusions

Our data confirmed that CRF is impaired in patients with mild ischemic stroke at the acute phase. Moreover, GS-left may be an optional indicator of CRF in patients with mild acute ischemic stroke, but not in healthy people.

Clinical Trial Registration

www.chictr.org.cn, identifier: ChiCTR2000031379.

Many inpatients may not be physically prepared for community ambulation on discharge from a publicly funded rehabilitation centre: a cross-sectional cohort study

PURPOSE

We assessed the ability of patients discharging home from inpatient rehabilitation to meet criteria for community ambulation.

METHODS

Cross-sectional observational study design. Participants were assessed, within 48-hours of discharge on their ability to: ascend/descend three steps, walk at a speed of 0.44 m/s, ascend/descend a slope, ascend/descend a kerb, and walk 315 m continuously. Demographic data were collected from medical records. Multiple logistic regression determined factors predictive of meeting criteria.

RESULTS

Of 200 participants (mean 73 years, 66% women, mixed diagnosis), 64 (32%) met all criteria. The least commonly met criteria were walking 315 m continuously (37%) and ascending/descending steps (70%). Participants who were female (OR: 0.27, 95%CI: 0.12-0.61), with a high comorbidity index (OR: 0.71, 95%CI: 0.56-0.91) or a traumatic orthopaedic diagnosis (OR: 0.22, 95%CI: 0.05-0.96) were less likely to meet all criteria. Participants with a higher admission functional independence walk item score (OR: 1.37, 95%CI: 1.05-1.78) or higher ambulatory self-confidence (OR: 1.02, 95%CI: 1.01-1.04) were more likely to meet all criteria.

CONCLUSIONS

Approximately, one-third of inpatients discharged home from a publicly funded rehabilitation centre met the community ambulation criteria, suggesting many may not be physically prepared to participate in their community.Implications for RehabilitationOnly about one in three inpatients discharging home from a publicly funded rehabilitation centre met physical criteria for community ambulation.Patients discharging home from inpatient rehabilitation have most difficulty walking long distances (≥315 m) compared to other criteria required for community ambulation (i.e., walking at a speed of 0.44 m/s, stepping up/down a kerb, ascending/descending a slope and ascending/descending three steps) and rehabilitation during this phase may require an increased focus on improving walking endurance/physical activity.Women with a high co-morbidity index, traumatic orthopaedic diagnosis, low self-confidence with ambulation on discharge and who require more assistance with walking on admission are least likely to meet the physical criteria for community ambulation at discharge, and therefore may require additional rehabilitation or supports.

Speech-Language Pathologists' Practice Patterns When Designing Home Practice Programs for Persons With Aphasia: A Survey

Purpose We aimed to describe the current practices of speech-language pathologists regarding the creation and implementation of home practice programs for persons with poststroke aphasia. Method Survey participants were American Speech-Language-Hearing Association-certified speech-language pathologists, had 30% of their caseload include persons with aphasia, and had recently created at least two home programs for persons with aphasia. Respondents completed a web-based survey on home program creation, training, technology, and methods for tracking adherence with closed and open-ended questions. Results We analyzed 80 complete surveys. Most of the participants (n = 56) created home programs for greater than 75% of their caseload. Common interventions in home programs addressed functional practice and spoken expression. Participants describe instructional techniques including building skill practice in daily routines and guided practice. Applications of technology and formal mechanisms to monitor adherence were less frequently reported. Various factors were identified as facilitators and barriers to home program creation with environmental support from others and client factors (i.e., motivation, impairments) most evident. Conclusions This study provides insight into speech-language pathologists' home program creation and implementation. Results can be used to consider mechanisms to improve use of and adherence to home programs to further support recovery. Supplemental Material https://doi.org/10.23641/asha.16840204.

Task-Oriented Circuit Training as an Alternative to Ergometer-Type Aerobic Exercise Training after Stroke

Moderate-intensity aerobic exercise training is an important treatment strategy to enhance functional recovery and decrease cardiometabolic risk factors after stroke. However, stroke related impairments limit access to ergometer-type exercise. The aims of the current study were (1) to evaluate whether our task-oriented circuit training protocol (intermittent functional training; IFT) could be used to sustain moderate-intensity aerobic workloads over a 10-week intervention period, and (2) to investigate its preliminary effects on cardiorespiratory fitness and metabolic profiles compared to constant-load ergometer-type exercise (CET). Forty chronic hemiparetic stroke survivors were randomized to receive 30 sessions of IFT or CET over ten weeks. Similar proportions of participants were randomized to IFT (7/19) and CET (9/18) sustained workloads associated with moderate-intensity aerobic exercise over the study period (p = 0.515). However, CET was associated with more substantial changes in maximal oxygen uptake (MD = 2.79 mL min⁻¹ kg⁻¹ CI: 0.84 to 4.74) compared to IFT (MD = 0.62 mL min⁻¹ kg⁻¹ CI: −0.38 to 1.62). Pre to post changes in C-reactive protein (−0.9 mg/L; p =0.017), short-term glycemia (+14.7 µmol/L; p = 0.026), and resting whole-body carbohydrate oxidation (+24.2 mg min⁻¹; p = 0.046) were observed when considering both groups together. Accordingly, IFT can replicate the aerobic intensities sustained during traditional ergometer-type exercise training. More work is needed to evaluate the dose–response effects of such task-oriented circuit training protocols on secondary prevention targets across the continuum of stroke recovery.

Feasibility and adherence to moderate intensity cardiovascular fitness training following stroke: a pilot randomized controlled trial

BACKGROUND

Stroke is a leading cause of disability worldwide and the cardiovascular fitness levels of stroke survivors are diminished to an extent that impairs functioning and activities of daily living performance. While cardiovascular training seems an empirically appropriate intervention, the optimal dosage and intensity of cardiovascular training in stroke survivors remains unclear. The aim was to determine the safety and feasibility of moderate-intensity cardiovascular training following stroke, including measurement of adherence to training.

METHODS

A pilot, prospective, patient- and assessor-blinded randomised controlled trial conducted in a tertiary, metropolitan hospital-based community rehabilitation centre. Eligibility criteria included ambulant (> 100 m), 6 weeks-12 months post stroke. Moderate-intensity fitness training or control (low-intensity) exercise was offered biweekly for 12 weeks. Outcome measures included adverse events, peak oxygen uptake (VO₂), functional exercise capacity (6-Minute Walk Test, 10-m Walk Test) and health-related quality of life (Short Form-36) and mood (Patient Health Questionnaire, PHQ9).

RESULTS

Feasibility: Seventy-one (50%) of 141 screened participants were eligible (29% did not agree to participate). Twenty participants (10 intervention, 10 control) were recruited. The median (%; IQR) supervised sessions was 19.5 (81%; 12, 20); and 20 (83%; 19, 22) in the intervention and control groups, respectively. Progression of duration and intensity was limited; mean of 10 sessions to achieve target duration (30 min). There were no adverse events. Baseline peak oxygen uptake (VO₂) levels were low (15.94 ml/kg/min). Significant improvements in VO₂ peak in both groups were observed (p < 0.05). Although there were no significant between-group differences, this feasibility trial was not powered to detect change.

CONCLUSIONS

Moderate-intensity fitness training was safe but achievement of target duration and intensity was challenging for stroke survivors. A definitive adequately-powered randomised trial is required. Alternative fitness training protocols may need to be explored.

TRIAL REGISTRATION

The trial protocol was prospectively registered on the Australian New Zealand Clinical Trials Registry ( ACTRN 12613000822785 ) on 25/07/2013.

Tree-Based Machine Learning to Identify and Understand Major Determinants for Stroke at the Neighborhood Level

Background

Stroke is a major cardiovascular disease that causes significant health and economic burden in the United States. Neighborhood community‐based interventions have been shown to be both effective and cost‐effective in preventing cardiovascular disease. There is a dearth of robust studies identifying the key determinants of cardiovascular disease and the underlying effect mechanisms at the neighborhood level. We aim to contribute to the evidence base for neighborhood cardiovascular health research.

Methods and Results

We created a new neighborhood health data set at the census tract level by integrating 4 types of potential predictors, including unhealthy behaviors, prevention measures, sociodemographic factors, and environmental measures from multiple data sources. We used 4 tree‐based machine learning techniques to identify the most critical neighborhood‐level factors in predicting the neighborhood‐level prevalence of stroke, and compared their predictive performance for variable selection. We further quantified the effects of the identified determinants on stroke prevalence using a Bayesian linear regression model. Of the 5 most important predictors identified by our method, higher prevalence of low physical activity, larger share of older adults, higher percentage of non‐Hispanic Black people, and higher ozone levels were associated with higher prevalence of stroke at the neighborhood level. Higher median household income was linked to lower prevalence. The most important interaction term showed an exacerbated adverse effect of aging and low physical activity on the neighborhood‐level prevalence of stroke.

Conclusions

Tree‐based machine learning provides insights into underlying drivers of neighborhood cardiovascular health by discovering the most important determinants from a wide range of factors in an agnostic, data‐driven, and reproducible way. The identified major determinants and the interactive mechanism can be used to prioritize and allocate resources to optimize community‐level interventions for stroke prevention.

Impact of mHealth technology on adherence to healthy PA after stroke: a randomized study

BACKGROUND

Physical activity (PA) is a key health behavior in people with stroke including risk reduction of recurrent stroke. Despite the beneficial effects of PA, many community-dwelling stroke survivors are physically inactive. Information and communication technologies are emerging as a possible method to promote adherence to PA.

OBJECTIVE

The aim of this study is to investigate the effectiveness of a mobile-health (mHealth) App in improving levels of PA.

METHODS

Forty-one chronic stroke survivors were randomized into an intervention group (IG) n=24 and a control group (CG) n=17. Participants in the IG were engaged in the Multimodal Rehabilitation Program (MMRP) that consisted on supervising adherence to PA through a mHealth app, participating in an 8-week rehabilitation program that included: aerobic, task-oriented, balance and stretching exercises. Participants also performed an ambulation program at home. The CG received a conventional rehabilitation program. Outcome variables were: adherence to PA, (walking and sitting time/day), walking speed (10MWT); walking endurance (6MWT); risk of falling (TUG); ADLs (Barthel); QoL (Eq-5D5L) and participant's satisfaction.

RESULTS

At the end of the intervention, community ambulation increased more in IG (38.95 min; SD: 20.37) than in the CG (9.47 min; SD: 12.11) (p≤.05). Sitting time was reduced by 2.96 (SD 2.0) hours/day in the IG and by 0.53 (SD 0.24) hours in the CG (p≤.05).

CONCLUSIONS

The results suggest that mHealth technology provides a novel way to promote adherence to home exercise programs post stroke. However, frequent support and guidance of caregiver is required to ensure the use of mobile devices.

Aerobic Exercise Recommendations to Optimize Best Practices in Care After Stroke: AEROBICS 2019 Update

Most stroke survivors have very low levels of cardiovascular fitness, which limits mobility and leads to further physical deconditioning, increased sedentary behavior, and heightened risk of recurrent stroke. Although clinical guidelines recommend that aerobic exercise be a part of routine stroke rehabilitation, clinical uptake has been suboptimal. In 2013, an international group of stroke rehabilitation experts developed a user-friendly set of recommendations to guide screening and prescription-the Aerobic Exercise Recommendations to Optimize Best Practices in Care after Stroke (AEROBICS 2013). The objective of this project was to update AEROBICS 2013 using the highest quality of evidence currently available. The first step was to conduct a comprehensive review of literature from 2012 to 2018 related to aerobic exercise poststroke. A working group of the original consensus panel members drafted revisions based on synthesis. An iterative process was used to achieve agreement among all panel members. Final revisions included: (1) addition of 115 new references to replace or augment those in the original AEROBICS document, (2) rewording of the original recommendations and supporting material, and (3) addition of 2 new recommendations regarding prescription. The quality of evidence from which these recommendations were derived ranged from low to high. The AEROBICS 2019 Update should make it easier for clinicians to screen for, and prescribe, aerobic exercise in stroke rehabilitation. Clinical implementation will not only help to narrow the gap between evidence and practice but also reduce current variability and uncertainty regarding the role of aerobic exercise in recovery after stroke.

Guided Self-rehabilitation Contract vs conventional therapy in chronic stroke-induced hemiparesis: NEURORESTORE, a multicenter randomized controlled trial

Background

After discharge from hospital following a stroke, prescriptions of community-based rehabilitation are often downgraded to “maintenance” rehabilitation or discontinued. This classic therapeutic behavior stems from persistent confusion between lesion-induced plasticity, which lasts for the first 6 months essentially, and behavior-induced plasticity, of indefinite duration, through which intense rehabilitation might remain effective. This prospective, randomized, multicenter, single-blind study in subjects with chronic stroke-induced hemiparesis evaluates changes in active function with a Guided Self-rehabilitation Contract vs conventional therapy alone, pursued for a year.

Methods

One hundred and twenty four adult subjects with chronic hemiparesis (> 1 year since first stroke) will be included in six tertiary rehabilitation centers. For each patient, two treatments will be compared over a 1-year period, preceded and followed by an observational 6-month phase of conventional rehabilitation. In the experimental group, the therapist will implement the diary-based and antagonist-targeting Guided Self-rehabilitation Contract method using two monthly home visits. The method involves: i) prescribing a daily antagonist-targeting self-rehabilitation program, ii) teaching the techniques involved in the program, iii) motivating and guiding the patient over time, by requesting a diary of the work achieved to be brought back by the patient at each visit. In the control group, participants will benefit from conventional therapy only, as per their physician’s prescription.

The two co-primary outcome measures are the maximal ambulation speed barefoot over 10 m for the lower limb, and the Modified Frenchay Scale for the upper limb. Secondary outcome measures include total cost of care from the medical insurance point of view, physiological cost index in the 2-min walking test, quality of life (SF 36) and measures of the psychological impact of the two treatment modalities. Participants will be evaluated every 6 months (D1/M6/M12/M18/M24) by a blinded investigator, the experimental period being between M6 and M18. Each patient will be allowed to receive any medications deemed necessary to their attending physician, including botulinum toxin injections.

Discussion

This study will increase the level of knowledge on the effects of Guided Self-rehabilitation Contracts in patients with chronic stroke-induced hemiparesis.

Trial registration

ClinicalTrials.gov: NCT02202954, July 29, 2014.

Prevalence of dyspnea after stroke: a telephone-based survey

OBJECTIVE

Dyspnea is a relevant outcome to be taken into consideration during stroke rehabilitation. Prevalence, severity, and effects of this condition on individuals with stroke remain uncertain. This study investigated the prevalence and severity of dyspnea after a stroke, as well the associations between dyspnea, activity limitations, and participation restrictions.

METHODS

A telephone-based survey was conducted with 285 individuals with stroke. The survey included information regarding the onset and severity of the dyspnea, activity limitations, and participation restrictions. Prevalence of dyspnea was reported as percentage of individuals who had the symptom. Chi-square tests were used to investigate the associations between dyspnea, activity limitations, and participation restrictions. Relative risks and respective 95% confidence intervals were calculated.

RESULTS

Out of the 285 participants, 124 (44%) reported having dyspnea after stroke. Severe symptoms were reported by 51% of the participants with dyspnea. In addition, dyspnea limited activity and restricted social participation in 85% and 49% of the participants, respectively. Dyspnea was significantly correlated with activity limitations (r=0.87; 95% CI 0.82-0.92; p<0.01) and participation restrictions (r=0.53; 95% CI 0.46-0.62; p<0.01). The analyses indicated that individuals with dyspnea were more likely to report that it limited their activities (RR: 6.5; 95% CI 4.3-9.9) and restricted social participation (RR: 1.7; 95% CI 1.5-2.0).

CONCLUSIONS

Dyspnea is an important symptom after stroke and showed to be associated with activity limitations and restrictions in community participation. Earlier detection of dyspnea in people with stroke, followed by appropriate management, is strongly recommended and has the potential to improve activity and social participation.

Effectiveness of a multimodal exercise rehabilitation program on walking capacity and functionality after a stroke

The aim of this study was to determine the effectiveness of a 12-week multimodal exercise rehabilitation program on walking speed, walking ability and activities of daily living (ADLs) among people who had suffered a stroke. Thirty-one stroke survivors who had completed a conventional rehabilitation program voluntarily participated in the study. Twenty-six participants completed the multimodal exercise rehabilitation program (2 days/wk, 1 hr/session). Physical outcome measures were: walking speed (10-m walking test), walking ability (6-min walking test and functional ambulation classification) and ADLs (Barthel Index). The program consisted on: aerobic exercise; task oriented exercises; balance and postural tonic activities; and stretching. Participants also followed a program of progressive ambulation at home. They were evaluated at baseline, postintervention and at the end of a 6-month follow-up period. After the intervention there were significant improvements in all outcomes measures that were maintained 6 months later. Comfortable and fast walking speed increased an average of 0.16 and 0.40 m/sec, respectively. The walking distance in the 6-min walking test increased an average of 59.8 m. At the end of the intervention, participants had achieved independent ambulation both indoors and outdoors. In ADLs, 40% were independent at baseline vs. 64% at the end of the intervention. Our study demonstrates that a multimodal exercise rehabilitation program adapted to stroke survivors has benefits on walking speed, walking ability and independence in ADLs.

Cardiorespiratory fitness and walking endurance improvements after 12 months of an individualised home and community-based exercise programme for people after stroke

OBJECTIVE

To evaluate the immediate and longer-term effects of an individually tailored, home- and community-based exercise programme with ongoing remote support in people with stroke on cardiorespiratory fitness (CRF), ambulation and health-related quality of life (HRQoL).

METHODS

Twenty people 5.3 ± 3.5 months post stroke completed the 12-week HowFITSS? exercise programme aimed at increasing CRF and daily physical activity. Support was provided by phone and email, which decreased in frequency over time. Participants were assessed at baseline, then at 3, 6 and 12 months after initiation of the intervention. CRF (VO_2peak) was evaluated using a portable metabolic system during the 6-minute walk test (6MWT), the Shuttle Walk Test (SWT) and the cycle graded exercise test (cGXT). Walking speed, balance, body composition, fatigue, depression and HRQoL were also measured.

RESULTS

CRF improved significantly from pre-intervention to 12-month follow-up on the 6MWT (Effect Size, ES = 0.87; p = 0.002) and cGXT (ES = 0.60; p < 0.001), with more modest improvements on the SWT (ES = 0.52; p = 0.251). From baseline to 12 months, significant within-participant improvements were found for self-selected walking speed, balance and HRQoL. Performances on the remaining tests were maintained over the post-intervention period.

CONCLUSION

There may be health benefits of providing people with stroke an exercise intervention with long-term support that encourages increased regular physical activity.

Circuit class therapy for improving mobility after stroke

BACKGROUND

Circuit class therapy (CCT) offers a supervised group forum for people after stroke to practise tasks, enabling increased practice time without increasing staffing. This is an update of the original review published in 2010.

OBJECTIVES

To examine the effectiveness and safety of CCT on mobility in adults with stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched January 2017), CENTRAL (the Cochrane Library, Issue 12, 2016), MEDLINE (1950 to January 2017), Embase (1980 to January 2017), CINAHL (1982 to January 2017), and 14 other electronic databases (to January 2017). We also searched proceedings from relevant conferences, reference lists, and unpublished theses; contacted authors of published trials and other experts in the field; and searched relevant clinical trials and research registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) including people over 18 years old, diagnosed with stroke of any severity, at any stage, or in any setting, receiving CCT.

DATA COLLECTION AND ANALYSIS

Review authors independently selected trials for inclusion, assessed risk of bias in all included studies, and extracted data.

MAIN RESULTS

We included 17 RCTs involving 1297 participants. Participants were stroke survivors living in the community or receiving inpatient rehabilitation. Most could walk 10 metres without assistance. Ten studies (835 participants) measured walking capacity (measuring how far the participant could walk in six minutes) demonstrating that CCT was superior to the comparison intervention (Six-Minute Walk Test: mean difference (MD), fixed-effect, 60.86 m, 95% confidence interval (CI) 44.55 to 77.17, GRADE: moderate). Eight studies (744 participants) measured gait speed, again finding in favour of CCT compared with other interventions (MD 0.15 m/s, 95% CI 0.10 to 0.19, GRADE: moderate). Both of these effects are considered clinically meaningful. We were able to pool other measures to demonstrate the superior effects of CCT for aspects of walking and balance (Timed Up and Go: five studies, 488 participants, MD -3.62 seconds, 95% CI -6.09 to -1.16; Activities of Balance Confidence scale: two studies, 103 participants, MD 7.76, 95% CI 0.66 to 14.87). Two other pooled balance measures failed to demonstrate superior effects (Berg Blance Scale and Step Test). Independent mobility, as measured by the Stroke Impact Scale, Functional Ambulation Classification and the Rivermead Mobility Index, also improved more in CCT interventions compared with others. Length of stay showed a non-significant effect in favour of CCT (two trials, 217 participants, MD -16.35, 95% CI -37.69 to 4.99). Eight trials (815 participants) measured adverse events (falls during therapy): there was a non-significant effect of greater risk of falls in the CCT groups (RD 0.03, 95% CI -0.02 to 0.08, GRADE: very low). Time after stroke did not make a difference to the positive outcomes, nor did the quality or size of the trials. Heterogeneity was generally low; risk of bias was variable across the studies with poor reporting of study conduct in several of the trials.

AUTHORS' CONCLUSIONS

There is moderate evidence that CCT is effective in improving mobility for people after stroke - they may be able to walk further, faster, with more independence and confidence in their balance. The effects may be greater later after the stroke, and are of clinical significance. Further high-quality research is required, investigating quality of life, participation and cost-benefits, that compares CCT with standard care and that also investigates the influence of factors such as stroke severity and age. The potential risk of increased falls during CCT needs to be monitored.

Interval circuit training for cardiorespiratory fitness is feasible for people after stroke

Aims:

To determine if community-dwelling stroke survivors can achieve exercise intensities sufficient to improve cardiorespiratory fitness during a single session of circuit training using an interval training approach.

Methods:

Thirteen independently ambulant participants within 1 year of stroke were included in this observational study (females=54%; median age=65.6 years; interquartile range=23.9). Exercise intensities were assessed throughout an individually tailored circuit of up to seven 5-minute workstations from a selection of nine functional (e.g. walking, stairs, balance) and three ergometer (upright cycle, rower, treadmill) workstations. The interval durations ranged from 5–60 seconds. Oxygen consumption (VO2) was recorded continuously using a portable metabolic system. The average VO2 during each 30-second epoch was determined. VO2≥10.5 mL/kg/min was categorised as ≥moderate intensity.

Findings:

Participants exercised at VO2≥10.5 mL/kg/min for the majority of the time on the workstations [functional: 369/472 epochs (78%), ergometer: 170/204 epochs (83%)]. Most (69%) participants exercised for ≥30 minutes. No serious adverse events occurred.

Conclusions:

Applying interval training principles to a circuit of functional and ergometer workstations enabled ambulant participants to exercise at an intensity and for a duration that can improve cardiorespiratory fitness. The training approach appears feasible, safe and a promising way to incorporate both cardiorespiratory fitness and functional training into post-stroke management.

Independently ambulant, community-dwelling stroke survivors have reduced cardiorespiratory fitness, mobility and knee strength compared to an age- and gender-matched cohort

BACKGROUND

Most exercise interventions for stroke survivors are designed for those who have substantial motor and functional disabilities. There remains a group of well-recovered stroke survivors who have yet to be investigated in terms of their physical capacity and fitness levels.

OBJECTIVE

To assess and compare the physical capacities of independently ambulant, community-dwelling stroke survivors to age- and gender-matched comparison participants.

METHODS

Data were obtained from 17 stroke survivors participating in the How FITSS? Trial, all with functional ambulatory category of ≥4 and a self-selected walking speed ≥0.8 m s^-1. An additional 17 healthy control participants were recruited. Cardiorespiratory fitness (CRF) was measured using oxygen consumption (VO_2peak), and additional measures of walking speed (m s^-1), leg strength and body composition were also assessed. Differences between groups were assessed by matched pairs t-tests. Effect sizes were calculated using Cohen's d.

RESULTS

There were no significant differences in age, BMI, muscle mass or body fat between groups (p > 0.05). Peak VO₂ was lower in the stroke group for the shuttle walk test (p = 0.037) and progressive cycle test (p = 0.019), as were all CRF test performance measures (p < 0.05). Stroke survivors walked significantly (p < 0.001) slower at both self-selected and fast speeds. Effect sizes of group differences for all leg strength variables were medium to large, with peak torque lower in the stroke group for all trials.

CONCLUSIONS

Despite being independently ambulant and community dwelling, the CRF, walking speed and leg strength of this group were reduced compared to non-stroke comparison participants. These patients may benefit from undertaking targeted exercise programmes.