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

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 ).

Title: Assessment of VO2peak and Exercise Capacity after Stroke: a Validity Study of the Human Activity Profile Questionnaire

OBJECTIVE

to investigate, in individuals after stroke, the concurrent validity of the Human Activity Profile (HAP) to provide the VO_2peak and the construct validity of the HAP to assess exercise capacity; and to provide equations based upon the HAP outcomes to estimate the distance covered in the Incremental Shuttle Walking Test (ISWT).

DESIGN

Cross-sectional study.

SETTING

University laboratory.

PARTICIPANTS

Fifty-seven individuals (54±11 years) after stroke.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Agreement between the VO_2peak provided by the HAP (lifestyle energy consumption (LEC) outcome, in mL.kg^-1.min^-1) and the gold standard measure of the VO_2peak (mL.kg^-1.min^-1), obtained through the symptom-limited Cardiopulmonary Exercise Test (CPET). Correlation between the HAP outcomes (LEC; the maximum activity score (MAS) and the adjusted activity score (AAS)) and the construct measure: the distance covered (in meters) in the ISWT. An equation to estimate the distance covered in the ISWT was determined.

RESULTS

High magnitude agreement was found between the VO_2peak, in mL.kg^-1.min^-1, obtained by the symptom-limited CPET and the value of VO_2peak, in mL.kg^-1.min^-1, provided by the HAP (LEC) (ICC=0.75;p<0.001). Low to moderate magnitude correlations were found between the distance covered in the ISWT and the HAP (LEC/MAS/AAS) (0.34≤rho≤0.58). The equation to estimate the distance covered in the ISWT explained 31% of the variability of the ISWT (ISWT_estimated=-361.91+(9.646xAAS)).

CONCLUSION

The HAP questionnaire is a clinically applicable way to provide a valid value of VO_2peak (in mL.kg^-1.min^-1) and to assess the exercise capacity of individuals after stroke. Furthermore, an equation to estimate the distance covered in the submaximal field exercise test (ISWT) based on the result of the AAS (in points) was provided.

Functional capacity and walking speed reserve in individuals with chronic stroke: A cross-sectional study

INTRODUCTION

Individuals with stroke experience residual walking disabilities, as the inability to increase walking speed (walking speed reserve - WSR), and frequently present decreasing in functional capacity. The relation between functional capacity and walking ability may contribute to more specific functional management of stroke.

OBJECTIVE

To investigate the association between WSR and functional capacity in individuals with chronic stroke and compare functional capacity between individuals who can increase walking speed or not.

METHODS

Cross-sectional study, where functional capacity was assessed with the Duke Activity Status Index (DASI), in metabolic equivalent (METS). WSR was assessed through the difference between fast and self-selected speed (in m/s). The individuals were assigned into two groups: able (WSR ≥ 0.2 m/s) and unable (WSR<0.2 m/s) to increase speed. Pearson's correlation and t test were used for analysis.

RESULTS

Fifty-five individuals (functional capacity 23 ± 13 METS and WSR 0.3 ± 0.2 m/s) were included. The association between functional capacity and WSR was positive and statistically significant, with moderate magnitude (r = 0.56) (p < .001). Individuals who were unable to increase their walking speed have less functional capacity (17.5 versus 31.3) (p = .003).

CONCLUSION

Functional capacity has a positive association with WSR in individuals with chronic stroke. The individuals who are unable to increase walking speed present lower functional capacity.

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.

Significance of Cycle Ergometer as a Measure of Peak Aerobic Capacity in the Disabled

BACKGROUND

To compare different physiological responses between treadmill and cycle ergometer in stroke patients in regard to community ambulation, and to determine strong predictors of equipment-dependent VO_2peak and its related factors among physical fitness parameters and finally to establish the significance of cycle ergometer as a measure of VO_2peak in the disabled according to gait function.

METHODS

Sixty-three stroke survivors were enrolled in this study and were grouped according to the gait speed (32 non-community ambulators <0.8 m/s:31 community ambulators ≥0.8 m/s). All participants performed exercise stress test (EST) with treadmill and cycle ergometer and rehabilitation function tests.

RESULTS

Community ambulators achieved higher VO_2peak by treadmill, but non-community ambulators showed similar VO_2peak between treadmill and cycle ergometer due to gait problems. The gait speed and endurance were strong predictors of difference of peak aerobic capacity between treadmill and cycle ergometer (multiple regression analysis, adjusted R²=0.458).

CONCLUSION

Cycle ergometer might be more appropriate for non-community ambulatory stroke patients to assess the peak aerobic capacity. Gait speed and gait distance could affect equipment-dependent cardiopulmonary performance significantly in the disabled. Therefore, the careful consideration of comprehensive and objective physical function including gait endurance, and speed and prescription of appropriate exercise intensity and equipment depending on the severity should be needed to improve the cardiopulmonary fitness and physical function adequately in stroke rehabilitation.

Reliability and validity of the incremental shuttle walking test in individuals after stroke

BACKGROUND

There are limitations to perform the cardiopulmonary exercise test (CPET) and the six-minute walking test (6MWT) in clinical settings. The incremental shuttle walking test (ISWT) might be an alternative assessment of exercise capacity and an estimation of cardiopulmonary fitness after stroke.

OBJECTIVES

To investigate the test-retest and inter-rater reliabilities, the standard error of measurement (SEM) and the minimal detectable change (MDC) of the ISWT, its construct validity to assess exercise capacity and its concurrent validity to estimate cardiopulmonary fitness after stroke.

METHODS

Prospective diagnostic accuracy study. Fifty-one individuals (54 ± 11 years) at the chronic phase (65 ± 73 months after stroke) were included. The distance walked, in meters, during the 12-stage-ISWT and the 6MWT and the peak oxygen uptake (VO_2peak, ml.kg^-1.min^-1) in the CPET (gold standard) were assessed.

RESULTS

Significant and high to very high magnitude test-retest and inter-rater reliabilities (0.88≤ICC≤0.93) of the ISWT was found. The SEM for both reliabilities was small (-23.35 m≤ SEM≤41.47 m). The MDC for test-retest and inter-rater reliabilities were 114.63 m and 64.53 m, respectively. For construct validity, a significant and high magnitude correlation between the ISWT and the 6MWT was found (ICC = 0.82). For the concurrent validity, a significant, but low magnitude correlation was found between the ISWT and the VO_2peak (rho = 0.42).

CONCLUSIONS

The ISWT demonstrated adequate reliabilities and construct validity for exercise capacity assessment. However, the concurrent validity of the ISWT as an estimation of cardiopulmonary fitness still requires further research.

Guidelines for the Evaluation of Cardiorespiratory Physiotherapy in Stroke Patients

Evaluation of stroke patients is prioritized over therapeutic interventions to restore cardiorespiratory capacity. This study aimed to develop a clinically applicable guideline to evaluate cardiorespiratory physiotherapy in stroke patients based on a literature review and a modified Delphi survey. The literature search included 13,498 articles in PubMed, EMBASE, CINAHL, and Cochrane Library electronic databases. We surveyed previous articles between January 2010 and June 2019. After the option elimination process, a total of 27 documents were selected and analyzed (draft: 18, modified Delphi survey: 9). The results of this research are roughly divided into two categories. First, 31 draft items were extracted, and a modified Delphi survey questionnaire was created from a literature review. Second, an expert was asked to make two modified Delphi surveys and to modify, delete, and supplement the entries in the statistical analysis at each level to finalize the steps to 20 items. The guidelines developed in this study reflect the selective use of cardiorespiratory physiotherapy evaluation methods in the clinical setting, based on the health status of individual patients. Moreover, the guidelines may help physiotherapists make informed decisions based on expert knowledge, thereby playing a crucial role in the patient-centered treatment planning process.

Cardiorespiratory factors related to the increase in oxygen consumption during exercise in individuals with stroke

BACKGROUND

Understanding the cardiorespiratory factors related to the increase in oxygen consumption ([Formula: see text]) during exercise is essential for improving cardiorespiratory fitness in individuals with stroke. However, cardiorespiratory factors related to the increase in [Formula: see text] during exercise in these individuals have not been examined using multivariate analysis. This study aimed to identify cardiorespiratory factors related to the increase in [Formula: see text] during a graded exercise in terms of respiratory function, cardiac function, and the ability of skeletal muscles to extract oxygen.

METHODS

Eighteen individuals with stroke (aged 60.1 ± 9.4 years, 67.1 ± 30.8 days poststroke) underwent a graded exercise test for the assessment of cardiorespiratory response to exercise. The increases in [Formula: see text] from rest to first threshold and that from rest to peak exercise were measured as a dependent variable. The increases in respiratory rate, tidal volume, minute ventilation, heart rate, stroke volume, cardiac output, and arterial-venous oxygen difference from rest to first threshold and those from rest to peak exercise were measured as the independent variables.

RESULTS

From rest to first threshold, the increases in arterial-venous oxygen difference (β = 0.711) and cardiac output (β = 0.572) were significant independent variables for the increase in [Formula: see text] (adjusted R2 = 0.877 p < 0.001). Similarly, from rest to peak exercise, the increases in arterial-venous oxygen difference (β = 0.665) and cardiac output (β = 0.636) were significant factors related to the increase in [Formula: see text] (adjusted R2 = 0.923, p < 0.001).

CONCLUSION

Our results suggest that the ability of skeletal muscle to extract oxygen is a major cardiorespiratory factor related to the increase in [Formula: see text] during exercise testing in individuals with stroke. For improved cardiorespiratory fitness in individuals with stroke, the amount of functional muscle mass during exercise may need to be increased.

People With Aneurysmal Subarachnoid Hemorrhage Have Low Physical Fitness and Can Be Predisposed to Inactive and Sedentary Lifestyles

BACKGROUND

Physical inactivity, sedentary lifestyles, and low functional outcome are thought to impact the level of physical fitness in patients with aneurysmal subarachnoid hemorrhage (a-SAH). However, changes in fitness over time and associated factors have not been studied in a-SAH.

OBJECTIVE

The objective was to evaluate the level of physical fitness in the first year after a-SAH and explore longitudinal relations with physical activity, sedentary behavior, and functional outcome. Additionally, we evaluated whether physical fitness could be predicted by disease-related characteristics (ie, severity of a-SAH, location of the aneurysm, treatment procedure, pituitary dysfunction, and complications).

DESIGN

This was a prospective 1-year follow-up study.

METHODS

Fifty-two participants performed exercise testing at 6 and 12 months after a-SAH. Cardiopulmonary exercise testing and isokinetic dynamometry were applied to determine the peak oxygen uptake $({\rm{\dot{V}}}{{\rm{o}}_{2{\rm{peak}}}})$ and the peak torque of the knee extensors (PText) and flexors (PTflex). In addition, physical activity and sedentary behavior were evaluated by accelerometer-based activity monitoring. The functional outcome was assessed by the Functional Independence Measure and Functional Assessment Measure. Disease-related characteristics were collected at hospital intake.

RESULTS

At both 6 and 12 months, all fitness parameters were lower compared with predicted values (ranging from 18% to 28%). Physical activity is related to both ${\rm{\dot{V}}}{{\rm{o}}_{{\rm{2peak}}}}$ and PTflex. The Functional Independence Measure and Functional Assessment Measure scores was related to PText and PTflex. Further, participants who underwent surgical clipping had lower ${\rm{\dot{V}}}{{\rm{o}}_{{\rm{2peak}}}}$ and PTflex.

LIMITATIONS

Longitudinal observations cannot confirm causality.

CONCLUSIONS

Levels of physical fitness remain low over the first year after a-SAH. Participants who were physically more active had higher levels of physical fitness, whereas participants with impaired functional outcome or who were treated with surgical clipping were at risk of low physical fitness. Exercise interventions are warranted and should focus on the promotion of physical activity and target patients with impaired functional outcome or those who have been treated with surgical clipping.

Senior fitness test; a useful tool to measure physical fitness in persons with acquired brain injury

OBJECTIVES

To evaluate the feasibility and usability of the senior fitness test (SFT) in persons with acquired brain injury (ABI).

METHODS

A pilot cohort design with a convenience sample of persons with ABI was used.

RESULTS

Persons with ABIs (n = 47) were younger than their healthy counterparts (n = 172) were but performed significantly worse on sit to stand, 6-min walk test (6MWT) and 2.45-m up and go. This difference was accentuated in the age groups >60 years of age. Persons with ABIs, divided into subgroups traumatic brain injury (TBI; n = 12) and cerebral insult (CI; n = 35), showed significant differences in leg strength, upper extremity flexibility and walking capacity. Persons with CI were weaker, less flexible in upper and lower extremities, walked shorter distance and were less mobile. CI but not TBI performed significantly worse when compared to healthy elderly persons.

CONCLUSION

This study indicates that SFT is feasible, safe and useful tool for persons with ABI, to evaluate physical capacity, endurance, strength and flexibility. The submaximal test was well tolerated and could be performed by all participants irrespective of age or diagnosis. The distribution of test scores indicates responsiveness to change and no ceiling or floor effects.

Strength of the lower limb and trunk muscles is associated with gait speed in individuals with sub-acute stroke: a cross-sectional study

OBJECTIVES

To investigate the association between measures of strength of the lower limb and trunk muscles and gait speed and to identify the muscle group that would best predict gait speed in individuals with sub-acute stroke.

METHODS

Using a cross-sectional observational study design, forty-four individuals with sub-acute stroke (62 years, SD=14; 4 months, SD=1 post-stroke) were assessed. The evaluations were performed at a university laboratory, participants' homes, or community-based settings. Bilateral maximum isometric strength (hip, knee, and ankle flexors/extensors, hip abductors, trunk flexors/extensors, and trunk lateral flexors and rotators) was measured using a portable dynamometer. Comfortable and maximum gait speeds were measured using the 10-m walk test.

RESULTS

Weak to moderate associations were found between measures of strength of the lower limb muscles and comfortable (0.36≤r≤0.53; p<0.05) and maximum (0.37≤r≤0.59; p<0.05) gait speeds, except for the non-paretic knee flexors and comfortable gait speed (p=0.06). Weak to moderate associations were also found between measures of strength of the trunk muscles and comfortable (0.39≤r≤0.50; p<0.05) and maximum (0.39≤r≤0.61; p<0.05) gait speeds. Stepwise multiple regression analyses revealed that the non-paretic dorsiflexors and the left lateral trunk flexors explained 29% and 42% of the variance in the maximum and comfortable gait speeds, respectively.

CONCLUSIONS

The strength of the lower limb and trunk muscles was positively associated with comfortable and maximum gait speeds. The muscle strength of the non-paretic dorsiflexors and the left lateral trunk flexors might have a role to play in determining comfortable and maximum gait speeds of individuals with sub-acute stroke.

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.

Unilateral Arm Crank Exercise Test for Assessing Cardiorespiratory Fitness in Individuals with Hemiparetic Stroke

Cardiorespiratory fitness assessment with leg cycle exercise testing may be influenced by motor impairments in the paretic lower extremity. Hence, this study examined the usefulness of a unilateral arm crank exercise test to assess cardiorespiratory fitness in individuals with stroke, including sixteen individuals with hemiparetic stroke (mean ± SD age, 56.4 ± 7.5 years) and 12 age- and sex-matched healthy controls. Participants performed the unilateral arm crank and leg cycle exercise tests to measure oxygen consumption ([Formula: see text]O2) and heart rate at peak exercise. The [Formula: see text]O2 at peak exercise during the unilateral arm crank exercise test was significantly lower in the stroke group than in the control group (p < 0.001). In the stroke group, the heart rate at peak exercise during the unilateral arm crank exercise test did not significantly correlate with the Brunnstrom recovery stages of the lower extremity (p = 0.137), whereas there was a significant correlation during the leg cycle exercise test (rho = 0.775, p < 0.001). The unilateral arm crank exercise test can detect the deterioration of cardiorespiratory fitness independently of lower extremity motor impairment severity in individuals with hemiparetic stroke. This study is registered with UMIN000014733.