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Goncalves S, Le Bourvellec M, Duclos NC, Mandigout S. Recommended moderate to vigorous physical activity levels for people in the chronic phase of stroke can be achieved in outpatient physiotherapy: a multicentre observational study. Top Stroke Rehabil 2024:1-10. [PMID: 39172127 DOI: 10.1080/10749357.2024.2392447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 08/10/2024] [Indexed: 08/23/2024]
Abstract
BACKGROUND Rehabilitation in the chronic phase of stroke should include 20 minutes of moderate to vigorous physical activity (MVPA). However, the level of compliance with MVPA guidelines in outpatient physiotherapy is unknown. OBJECTIVES To investigate (1) whether people in the chronic phase of stroke perform the recommended 20 minutes of MVPA during outpatient physiotherapy sessions in France, (2) whether the person's clinical characteristics influence MVPA time and (3) which interventions contribute to achievement of recommended MVPA time. METHODS This was a multicentre, cross-sectional observational study of routine outpatient physiotherapy sessions in France in people in the chronic phase of stroke. The main measures included MVPA time (determined using a heart rate monitor), clinical tests and types of physiotherapy interventions (recorded by external investigator during 2 sessions for each participant). RESULTS 84 people in the chronic phase of stroke and 152 outpatient physiotherapy sessions in 29 outpatient clinics were included (2021-2022). Median (interquartile range) MVPA time was 25 (7-45) minutes across all sessions. Fifty-nine percent of the sessions fulfilled MVPA guidelines. Among clinical tests, only the Mini-Mental Scale Examination was significantly associated with MVPA time. Endurance, balance, and functional lower limb training were associated with the achievement of MVPA guidelines. CONCLUSION Outpatient physiotherapy sessions have the potential to meet the MVPA guidelines. Further research is needed to understand the variability of compliance with MVPA guidelines and to develop strategies to increase the integration of MVPA into outpatient physiotherapy sessions.
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Affiliation(s)
- Stéphanie Goncalves
- Physical Activity and Sport Sciences, Limoges University, HAVAE, UR 20217, Limoges, France
| | - Morgane Le Bourvellec
- Physical Activity and Sport Sciences, Poitiers University, MOVE UR 20296, Poitiers, France
| | - Noémie C Duclos
- University Institute of Rehabilitation Science, INSERM, BPH ACTIVE U1219, Bordeaux University, Bordeaux, France
| | - Stéphane Mandigout
- Physical Activity and Sport Sciences, Limoges University, HAVAE, UR 20217, Limoges, France
- ILFOMER, Limoges University, HAVAE, UR 20217, Limoges, France
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2
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Du X, Brooks D, Oh P, Marzolini S. Sex Differences in Depressive Symptoms in 1308 Patients Post-Stroke at Entry to Cardiac Rehabilitation. J Cardiopulm Rehabil Prev 2024; 44:202-211. [PMID: 38300273 DOI: 10.1097/hcr.0000000000000848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
PURPOSE The objective of this study was to determine whether a sex difference exists in the prevalence of post-stroke depressive symptoms (PSDS) at entry to cardiac rehabilitation (CR) and to determine the correlates of PSDS in all patients, and in women and men separately. METHODS People post-stroke at entry to CR from database records (2006-2017) were included. Bivariate analyses identified PSDS correlates (≥16 on the Center for Epidemiologic Studies Depression Scale) in all patients and women and men separately. RESULTS Patients (n = 1308, 28.9% women), mean age of 63.9 ± 12.9 yr, were 24.2 ± 9.9 mo post-stroke at CR entry. Among all patients, 30.0% had PSDS. A greater proportion of women than men had PSDS (38.6 vs 26.6%; P < .001). Correlates of PSDS in all patients were sex (women) (OR = 1.6: 95% CI, 1.14-2.12), being unemployed, ≤60 yr old, prescribed antidepressant medication, having lower cardiorespiratory fitness (peak oxygen uptake [V̇ o2peak ]), chronic obstructive pulmonary disease (COPD), higher body mass index (BMI), no transient ischemic attack, and longer time from stroke to CR entry (>12 mo). Correlates in women were being obese (BMI ≥ 30), 51-70 yr old, prescribed antidepressant medication, and not married. Correlates in men were being ≤60 yr old, unemployed, prescribed antidepressant medication, having lower V̇ o2peak , sleep apnea, COPD, and no hypertension. CONCLUSION Women were disproportionately affected by PSDS at entry to CR in bivariate and multivariable analyses. Women and men had mostly unique correlates of PSDS, indicating tailored strategies to address PSDS are required. PSDS disproportionately affected patients with longer delay to CR entry, suggesting efforts should target timely referral to facilitate earlier and repeated assessments and management.
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Affiliation(s)
- XiaoWei Du
- Author Affiliations: Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (Ms Du and Drs Brooks, Oh, and Marzolini); Toronto Rehabilitation Institute (KITE), University Health Network, Toronto, Ontario, Canada (Ms Du and Drs Oh and Marzolini); School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada (Dr Brooks); and Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, Ontario, Canada (Drs Oh and Marzolini)
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Davidson S, Bischof-Bockbrader A, Zimmerman E, Rosenfeldt AB, Alberts JL, Linder SM. Characterizing Heart Rate Response During Upper Extremity Repetitive Task Practice in Chronic Stroke. Am J Occup Ther 2024; 78:7802180240. [PMID: 38466612 PMCID: PMC11017740 DOI: 10.5014/ajot.2024.050478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024] Open
Abstract
IMPORTANCE Although the cardiopulmonary benefits of aerobic exercise poststroke are well-established, typical stroke rehabilitation does not elicit an aerobic response. OBJECTIVE To characterize heart rate response during upper extremity repetitive task practice (RTP) and determine factors that predict a higher aerobic intensity during RTP. DESIGN Secondary analysis of a subset of data from a randomized clinical trial. SETTING Research laboratory in a large academic medical center. PARTICIPANTS Patients with chronic stroke (N = 19). INTERVENTION Participants received 90 min of RTP for 24 sessions across 8 wk. OUTCOMES AND MEASURES Aerobic intensity as measured by heart rate reserve (HRR) during RTP. RESULTS A total of 2,968 tasks were included in the analysis. Of the tasks performed, approximately 79.5% elicited a very light aerobic response (<30% HRR), 10.2% elicited a light aerobic response (30%-39% HRR), and 10.3% elicited a moderate to vigorous intensity aerobic response (≥40% HRR). Of the tasks that elicited a moderate to vigorous intensity aerobic response, 54.1% were performed in standing, 79.7% were gross motor in nature, and 27.9% had targets at or above shoulder height. Standing position, targets at or above shoulder height, and gross motor tasks predicted higher HRR (all ps < .001). CONCLUSIONS AND RELEVANCE To maximize aerobic intensity during poststroke RTP, therapists should include gross motor tasks trained in standing with targets at or above shoulder height. Plain-Language Summary: The study characterizes heart rate response in stroke rehabilitation and identifies factors that predict a higher aerobic intensity during upper extremity repetitive task practice. Certain task characteristics were more likely to produce an aerobic response, including gross motor, targets at or above the shoulder, and a standing position. Occupational therapists should include gross motor tasks trained in standing with targets at or above shoulder height to maximize aerobic intensity during poststroke repetitive task practice. Monitoring heart rate may improve awareness of aerobic response to training.
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Affiliation(s)
- Sara Davidson
- Sara Davidson, PTA, BSAS, is Administrative Program Coordinator, Concussion Center, Cleveland Clinic, Cleveland, OH;
| | - Andrea Bischof-Bockbrader
- Andrea Bischof-Bockbrader, PTA, BA, is Physical Therapist Assistant, Physical Medicine and Rehabilitation, Cleveland Clinic, Cleveland, OH
| | - Eric Zimmerman
- Eric Zimmerman, MS, is Statistical Programmer, Concussion Center, Cleveland Clinic, Cleveland, OH
| | - Anson B Rosenfeldt
- Anson B. Rosenfeldt, PT, DPT, is Senior Physical Therapist, Biomedical Engineering, Cleveland Clinic, Cleveland, OH
| | - Jay L Alberts
- Jay L. Alberts, PhD, is Staff, Biomedical Engineering, and Staff, Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH
| | - Susan M Linder
- Susan M. Linder, PT, DPT, PhD, is Assistant Staff, Physical Medicine and Rehabilitation, and Assistant Staff, Biomedical Engineering Cleveland Clinic, Cleveland, OH;
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Ogasawara T, Mukaino M, Matsunaga K, Wada Y, Suzuki T, Aoshima Y, Furuzawa S, Kono Y, Saitoh E, Yamaguchi M, Otaka Y, Tsukada S. Prediction of stroke patients' bedroom-stay duration: machine-learning approach using wearable sensor data. Front Bioeng Biotechnol 2024; 11:1285945. [PMID: 38234303 PMCID: PMC10791943 DOI: 10.3389/fbioe.2023.1285945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/11/2023] [Indexed: 01/19/2024] Open
Abstract
Background: The importance of being physically active and avoiding staying in bed has been recognized in stroke rehabilitation. However, studies have pointed out that stroke patients admitted to rehabilitation units often spend most of their day immobile and inactive, with limited opportunities for activity outside their bedrooms. To address this issue, it is necessary to record the duration of stroke patients staying in their bedrooms, but it is impractical for medical providers to do this manually during their daily work of providing care. Although an automated approach using wearable devices and access points is more practical, implementing these access points into medical facilities is costly. However, when combined with machine learning, predicting the duration of stroke patients staying in their bedrooms is possible with reduced cost. We assessed using machine learning to estimate bedroom-stay duration using activity data recorded with wearable devices. Method: We recruited 99 stroke hemiparesis inpatients and conducted 343 measurements. Data on electrocardiograms and chest acceleration were measured using a wearable device, and the location name of the access point that detected the signal of the device was recorded. We first investigated the correlation between bedroom-stay duration measured from the access point as the objective variable and activity data measured with a wearable device and demographic information as explanatory variables. To evaluate the duration predictability, we then compared machine-learning models commonly used in medical studies. Results: We conducted 228 measurements that surpassed a 90% data-acquisition rate using Bluetooth Low Energy. Among the explanatory variables, the period spent reclining and sitting/standing were correlated with bedroom-stay duration (Spearman's rank correlation coefficient (R) of 0.56 and -0.52, p < 0.001). Interestingly, the sum of the motor and cognitive categories of the functional independence measure, clinical indicators of the abilities of stroke patients, lacked correlation. The correlation between the actual bedroom-stay duration and predicted one using machine-learning models resulted in an R of 0.72 and p < 0.001, suggesting the possibility of predicting bedroom-stay duration from activity data and demographics. Conclusion: Wearable devices, coupled with machine learning, can predict the duration of patients staying in their bedrooms. Once trained, the machine-learning model can predict without continuously tracking the actual location, enabling more cost-effective and privacy-centric future measurements.
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Affiliation(s)
- Takayuki Ogasawara
- NTT Basic Research Laboratories and Bio-Medical Informatics Research Center, NTT Corporation, Atsugi, Japan
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Japan
| | - Masahiko Mukaino
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Japan
- Department of Rehabilitation Medicine, Hokkaido University Hospital, Sapporo, Japan
| | | | - Yoshitaka Wada
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Japan
| | - Takuya Suzuki
- Department of Rehabilitation Medicine, Fujita Health University Hospital, Toyoake, Japan
| | - Yasushi Aoshima
- Department of Rehabilitation Medicine, Fujita Health University Hospital, Toyoake, Japan
| | - Shotaro Furuzawa
- Department of Rehabilitation Medicine, Fujita Health University Hospital, Toyoake, Japan
| | - Yuji Kono
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Japan
- Department of Rehabilitation Medicine, Fujita Health University Hospital, Toyoake, Japan
| | - Eiichi Saitoh
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Japan
| | - Masumi Yamaguchi
- NTT Basic Research Laboratories and Bio-Medical Informatics Research Center, NTT Corporation, Atsugi, Japan
| | - Yohei Otaka
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Japan
| | - Shingo Tsukada
- NTT Basic Research Laboratories and Bio-Medical Informatics Research Center, NTT Corporation, Atsugi, Japan
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Legasto-Mulvale JM, Inness EL, Thompson AN, Chandran N, Mathur S, Salbach NM. Adverse Events During Submaximal Aerobic Exercise Testing in People With Subacute Stroke: A Scoping Review. J Neurol Phys Ther 2024; 48:27-37. [PMID: 37184472 DOI: 10.1097/npt.0000000000000445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
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 ).
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Affiliation(s)
- Jean Michelle Legasto-Mulvale
- Rehabilitation Sciences Institute (J.M.L.M., E.L.I., A.N.T., N.C., S.M., N.M.S.) and Department of Physical Therapy (J.M.L.M., E.L.I., S.M., N.M.S), Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; The KITE Research Institute, Toronto Rehabilitation Institute (E.L.I., N.M.S), University Health Network, Toronto, Ontario, Canada; and School of Rehabilitation Therapy (S.M.), Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
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Marzolini S, da Silva JN, Capone A, Barry-Hickey D, Pikula A, MacDonald SL, Munce S, Mastrangelo D, Oh P. Sex differences and predictors of completion of a 6-month exercise-based cardiac rehabilitation program in 1,536 people following stroke. J Stroke Cerebrovasc Dis 2023; 32:107129. [PMID: 37087771 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107129] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 04/25/2023] Open
Abstract
OBJECTIVE To retrospectively examine sex-differences and predictors of completion in consecutively-referred patients to a 6-month exercise-based cardiac rehabilitation program (CRP) from 2006 to 2017. MATERIALS/METHODS People with hemiplegic gait participated in stroke-adapted-CRP; otherwise, traditional-CRP. Reasons for non-completion were ascertained by interview. Regression-analyses were conducted to determine non-completion in all patients and women and men separately. RESULTS There were 1536 patients (30.3% women), mean age 64.5 ± 12.5 with 23% initiating the stroke-adapted-CRP. Overall, 75.1% completed the CRP (87.3% stroke-adapted-CRP vs 71.5% traditional-CRP; p < .001). There was no difference in completion between women and men (74.5% vs 75.4%; p=0.7), or in attendance to pre-scheduled sessions (p=0.6) or reasons for non-completion (p > .05, all). The only sex difference in completion by age (decade) occurred in those <41 years (59% women vs 85% men; p=.02). Baseline predictors of non-completion among all patients included not being enrolled in the stroke-adapted-CRP, lower V̇O2peak, smoking, diabetes (prescribed insulin) and depression but not sex (p=.5) or age (p=.15). Unique predictors in women vs men were younger age, lower V̇O2peak, smoking, diabetes (prescribed insulin), depression, and cancer diagnoses. Unique to men was having >1 stroke and diabetes (any anti-diabetes medication). The strongest predictor of non-completion among all models was not being enrolled in stroke-adapted-CRP. CONCLUSIONS While there were no sex-differences in adherence to the CRP, women and men have mostly unique predictors of non-completion. Younger women are at greatest risk for non-completion. Practitioners should provide sex-specific, tailored strategies for enhancing completion with a focus on younger women and offering a stroke-adapted-CRP with close attention to those with diabetes.
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Affiliation(s)
- Susan Marzolini
- KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada; Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Exercise Sciences, Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada.
| | - Juliana Nunes da Silva
- KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada; Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Alessia Capone
- Department of Exercise Sciences, Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Danielle Barry-Hickey
- KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada
| | - Aleksandra Pikula
- Department of Medicine, Division of Neurology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Neurovascular Unit, University Health Network Toronto Western Hospital, Toronto, ON, Canada; Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Shannon L MacDonald
- KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada; Department of Medicine, Division of Neurology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Sinai Health, Toronto, ON, Canada
| | - Sarah Munce
- KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada; Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada
| | - David Mastrangelo
- KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada
| | - Paul Oh
- KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada; Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Exercise Sciences, Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
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7
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Zhang Y, Qiu X, Jin Q, Ji C, Yuan P, Cui M, Zhang J, Chen L. Influencing factors of home exercise adherence in elderly patients with stroke: A multiperspective qualitative study. Front Psychiatry 2023; 14:1157106. [PMID: 37091695 PMCID: PMC10113471 DOI: 10.3389/fpsyt.2023.1157106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/06/2023] [Indexed: 04/25/2023] Open
Abstract
Introduction Evidence has shown that stroke exercise rehabilitation is the most effective way to improve disease prognosis, but home exercise adherence in elderly patients with stroke is low due to they are more likely to have movement disorders, cognitive disorders, mental disorders, etc. Currently, most studies on exercise adherence in elderly patients with stroke are quantitative, and there is a lack of qualitative studies from the perspective of patients, caregivers, and medical staff. Considering the importance of home exercise adherence in elderly patients with stroke, the present study aimed to explore the influencing factors of home exercise adherence in them and summarize the potential ways to improve it. Methods From October to December 2022, 9 medical staff, 12 elderly patients with stroke and 7 caregivers from a level A tertiary hospital and community health service center in Nanjing, Jiangsu Province were selected by the purposive sampling and were interviewed in a face-to-face semi-structured way. The data were analyzed and summarized by the phenomenological analysis of Colaizzi's method. Results The influencing factors of home exercise adherence in elderly patients with stroke can be summarized into 3 themes and 8 subthemes. These were individual factors (physical impairment, exercise self-efficacy, and depression), family factors (caregiving ability and emotional support); and stroke rehabilitation environment (exercise prescription, monitoring and feedback, and organizational policy). Conclusion Home exercise adherence in elderly patients with stroke was influenced by many factors. Medical staff should assess the patient's physical function and depression, establish a multi-support system, formulate personalized exercise prescription, pay attention to the monitoring and feedback of home-based exercise rehabilitation, and improve the home-based rehabilitation model for stroke, so as to improve the home exercise adherence in elderly patients with stroke and promote the best rehabilitation effect.
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Affiliation(s)
- Yuanxing Zhang
- Department of Neurosurgery, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Xichenhui Qiu
- Health Science Center, Shenzhen University, Shenzhen, China
| | - Qiansheng Jin
- Department of Neurosurgery, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Cuiling Ji
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Ping Yuan
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Mengjiao Cui
- Department of Neurosurgery, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Juanjuan Zhang
- Department of Dermatology, Liuyang Hospital of Traditional Chinese Medicine, The Second Affiliated Hospital of Integrated Traditional Chinese and Western Medicine of Hunan University of Chinese Medicine, Changsha, Hunan, China
- *Correspondence: Juanjuan Zhang,
| | - Lu Chen
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
- Lu Chen,
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Inness EL, Jagroop D, Andreoli A, Bayley M, Biasin L, Danells C, Hall J, Mansfield A, McDonald A, Nishri D, Salbach NM, Taylor D, Wong K, Tang A. Factors That Influence the Clinical Implementation of Aerobic Exercise in Stroke Rehabilitation: A Theory-Informed Qualitative Study. Phys Ther 2022; 102:6534400. [PMID: 35194641 DOI: 10.1093/ptj/pzac014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 10/14/2021] [Accepted: 02/04/2022] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Elizabeth L Inness
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - David Jagroop
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Angie Andreoli
- Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Mark Bayley
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Division of Physical Medicine and Rehabilitation, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Louis Biasin
- Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Cynthia Danells
- Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Jayne Hall
- Regional Rehabilitation Outpatient Services, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Avril Mansfield
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Evaluative Clinical Sciences, Hurvtiz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Alison McDonald
- Nova Scotia Rehabilitation & Arthritis Centre, Halifax, NS, Canada
| | - Diane Nishri
- Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Nancy M Salbach
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Denise Taylor
- St Joseph's Care Group, Thunder Bay, ON, Canada.,Northern Ontario School of Medicine, Thunder Bay, ON, Canada
| | - Karl Wong
- Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Ada Tang
- McMaster University, School of Rehabilitation, Hamilton ON, Canada
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Marzolini S, Wu C, Hussein R, Xiong LY, Kangatharan S, Peni A, Cooper CR, Lau KS, Nzodjou Makhdoom G, Pakosh M, Zaban SA, Nguyen MM, Banihashemi MA, Swardfager W. Associations Between Time After Stroke and Exercise Training Outcomes: A Meta-Regression Analysis. J Am Heart Assoc 2021; 10:e022588. [PMID: 34913357 PMCID: PMC9075264 DOI: 10.1161/jaha.121.022588] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Knowledge gaps exist regarding the effect of time elapsed after stroke on the effectiveness of exercise training interventions, offering incomplete guidance to clinicians. Methods and Results To determine the associations between time after stroke and 6-minute walk distance, 10-meter walk time, cardiorespiratory fitness and balance (Berg Balance Scale score [BBS]) in exercise training interventions, relevant studies in post-stroke populations were identified by systematic review. Time after stroke as continuous or dichotomized (≤3 months versus >3 months, and ≤6 months versus >6 months) variables and weighted mean differences in postintervention outcomes were examined in meta-regression analyses adjusted for study baseline mean values (pre-post comparisons) or baseline mean values and baseline control-intervention differences (controlled comparisons). Secondary models were adjusted additionally for mean age, sex, and aerobic exercise intensity, dose, and modality. We included 148 studies. Earlier exercise training initiation was associated with larger pre-post differences in mobility; studies initiated ≤3 months versus >3 months after stroke were associated with larger differences (weighted mean differences [95% confidence interval]) in 6-minute walk distance (36.3 meters; 95% CI, 14.2-58.5), comfortable 10-meter walk time (0.13 m/s; 95% CI, 0.06-0.19) and fast 10-meter walk time (0.16 m/s; 95% CI, 0.03-0.3), in fully adjusted models. Initiation ≤3 months versus >3 months was not associated with cardiorespiratory fitness but was associated with a higher but not clinically important Berg Balance Scale score difference (2.9 points; 95% CI, 0.41-5.5). In exercise training versus control studies, initiation ≤3 months was associated with a greater difference in only postintervention 6-minute walk distance (baseline-adjusted 27.3 meters; 95% CI, 6.1-48.5; fully adjusted, 24.9 meters; 95% CI, 0.82-49.1; a similar association was seen for ≤6 months versus >6 months after stroke (fully adjusted, 26.6 meters; 95% CI, 2.6-50.6). Conclusions There may be a clinically meaningful benefit to mobility outcomes when exercise is initiated within 3 months and up to 6 months after stroke.
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Affiliation(s)
- Susan Marzolini
- KITE Research Institute, Toronto Rehabilitation Institute ‐ University Health NetworkTorontoONCanada
- Healthy Living for Pandemic Event Protection (HL–PIVOT) NetworkTorontoONCanada
- Rehabilitation Sciences InstituteUniversity of TorontoONCanada
- Faculty of Kinesiology and Physical EducationUniversity of TorontoONCanada
| | - Che‐Yuan Wu
- Department of Pharmacology and ToxicologyUniversity of TorontoONCanada
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
| | | | - Lisa Y. Xiong
- Department of Pharmacology and ToxicologyUniversity of TorontoONCanada
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
| | - Suban Kangatharan
- KITE Research Institute, Toronto Rehabilitation Institute ‐ University Health NetworkTorontoONCanada
| | - Ardit Peni
- KITE Research Institute, Toronto Rehabilitation Institute ‐ University Health NetworkTorontoONCanada
| | | | - Kylie S.K. Lau
- Department of Human BiologyUniversity of TorontoONCanada
| | | | - Maureen Pakosh
- Library & Information ServicesUniversity Health NetworkToronto Rehabilitation InstituteTorontoONCanada
| | - Stephanie A. Zaban
- Faculty of Kinesiology and Physical EducationUniversity of TorontoONCanada
| | - Michelle M. Nguyen
- Department of Pharmacology and ToxicologyUniversity of TorontoONCanada
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
| | - Mohammad Amin Banihashemi
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
- Institute of Medical ScienceUniversity of TorontoTorontoONCanada
| | - Walter Swardfager
- KITE Research Institute, Toronto Rehabilitation Institute ‐ University Health NetworkTorontoONCanada
- Department of Pharmacology and ToxicologyUniversity of TorontoONCanada
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
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10
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Sharpe A, Boyes V, Lee C, Murtha C, Mah J, Yoshida K, Marzolini S, Inness EL. Cardiopulmonary Exercise Testing in Stroke Rehabilitation: Benefits and Clinical Utility Perceived by Physiotherapists and Individuals with Stroke. Physiother Can 2021; 73:110-117. [PMID: 34456420 DOI: 10.3138/ptc-2019-0070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Purpose: The purpose of this study was to understand the perceived benefits and clinical utility of cardiopulmonary exercise testing (CPET) from the perspectives of physiotherapists and patients and to explore the factors that influence adopting CPET in a stroke rehabilitation setting. Method: A qualitative descriptive study was conducted. Physiotherapists (n = 6) participated in a focus group to discuss the use of CPET in practice. Patients (n = 8) who had completed CPET during stroke rehabilitation participated in a semi-structured interview to explore their experiences. Thematic analysis was performed. Results: CPET increased the physiotherapists' confidence in prescribing exercise, especially for medically complex patients. Ongoing medical management early post-stroke was a barrier to referral. Physiotherapists expressed decreased confidence in interpreting test results. Consultation with local experts facilitated the use of CPET. Patients described how CPET increased their confidence to participate in exercise. They desired more information before and after CPET to better understand the purpose and results and their relation to their rehabilitation goals. Conclusions: Both physiotherapists and patients described the benefit of having CPET available to support them as they participated in exercise in a stroke rehabilitation setting. Physiotherapists would benefit from having educational tools to support their interpretation and application of test results, and patients would benefit from improved communication and education to support their understanding of the relevance of CPET to their rehabilitation goals. Future research should explore these findings in other stroke rehabilitation settings.
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Affiliation(s)
| | - Valerie Boyes
- Department of Physical Therapy, University of Toronto
| | - Calvin Lee
- Department of Physical Therapy, University of Toronto
| | | | - Justin Mah
- Department of Physical Therapy, University of Toronto
| | - Karen Yoshida
- Department of Physical Therapy, University of Toronto
| | - Susan Marzolini
- Department of Physical Therapy, University of Toronto.,Cardiovascular Prevention and Rehabilitation Program.,The KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, Ont
| | - Elizabeth L Inness
- Department of Physical Therapy, University of Toronto.,Brain & Spinal Cord Rehabilitation Program.,The KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, Ont
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11
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Ogasawara T, Mukaino M, Otaka Y, Matsuura H, Aoshima Y, Suzuki T, Togo H, Nakashima H, Yamaguchi M, Tsukada S, Saitoh E. Validation of Data Imputation by Ensemble Averaging to Quantify 24-h Behavior Using Heart Rate of Stroke Rehabilitation Inpatients. J Med Biol Eng 2021. [DOI: 10.1007/s40846-021-00622-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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12
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Kelly LP, Devasahayam AJ, Chaves AR, Curtis ME, Randell EW, McCarthy J, Basset FA, Ploughman M. Task-Oriented Circuit Training as an Alternative to Ergometer-Type Aerobic Exercise Training after Stroke. J Clin Med 2021; 10:jcm10112423. [PMID: 34070731 PMCID: PMC8198652 DOI: 10.3390/jcm10112423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/25/2021] [Accepted: 05/26/2021] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Liam P. Kelly
- Recovery and Performance Laboratory, L.A. Miller Centre, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, NL A1K 5A1, Canada; (A.J.D.); (A.R.C.); (M.E.C.); (J.M.)
- School of Human Kinetics and Recreation, Memorial University of Newfoundland, St. John’s, NL A1C 5S7, Canada;
- Correspondence: (L.P.K.); (M.P.); Tel.: +1-709-777-2099 (M.P.)
| | - Augustine J. Devasahayam
- Recovery and Performance Laboratory, L.A. Miller Centre, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, NL A1K 5A1, Canada; (A.J.D.); (A.R.C.); (M.E.C.); (J.M.)
| | - Arthur R. Chaves
- Recovery and Performance Laboratory, L.A. Miller Centre, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, NL A1K 5A1, Canada; (A.J.D.); (A.R.C.); (M.E.C.); (J.M.)
| | - Marie E. Curtis
- Recovery and Performance Laboratory, L.A. Miller Centre, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, NL A1K 5A1, Canada; (A.J.D.); (A.R.C.); (M.E.C.); (J.M.)
| | - Edward W. Randell
- Discipline of Laboratory Medicine, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, NL A1B 3V6, Canada;
| | - Jason McCarthy
- Recovery and Performance Laboratory, L.A. Miller Centre, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, NL A1K 5A1, Canada; (A.J.D.); (A.R.C.); (M.E.C.); (J.M.)
| | - Fabien A. Basset
- School of Human Kinetics and Recreation, Memorial University of Newfoundland, St. John’s, NL A1C 5S7, Canada;
| | - Michelle Ploughman
- Recovery and Performance Laboratory, L.A. Miller Centre, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, NL A1K 5A1, Canada; (A.J.D.); (A.R.C.); (M.E.C.); (J.M.)
- Correspondence: (L.P.K.); (M.P.); Tel.: +1-709-777-2099 (M.P.)
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13
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Salbach NM, MacKay-Lyons M, Solomon P, Howe JA, McDonald A, Bayley MT, Veitch S, Sivarajah L, Cacoilo J, Mihailidis A. The role of theory to develop and evaluate a toolkit to increase clinical measurement and interpretation of walking speed and distance in adults post-stroke. Disabil Rehabil 2021; 44:3719-3735. [PMID: 33459080 DOI: 10.1080/09638288.2020.1867653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE The iWalk study showed that 10-meter walk test (10mWT) and 6-minute walk test (6MWT) administration post-stroke increased among physical therapists (PTs) following introduction of a toolkit comprising an educational guide, mobile app, and video. We describe the use of theory guiding toolkit development and a process evaluation. MATERIALS AND METHODS We used the knowledge-to-action framework to identify research steps; and a guideline implementability framework, self-efficacy theory, and the transtheoretical model to design and evaluate the toolkit and implementation process (three learning sessions). In a before-and-after study, 37 of the 49 participating PTs completed online questionnaires to evaluate engagement with learning sessions, and rate self-efficacy to perform recommended practices pre- and post-intervention. Thirty-three PTs and 7 professional leaders participated in post-intervention focus groups and interviews, respectively. RESULTS All sites conducted learning sessions; attendance was 50-78%. Self-efficacy ratings for recommended practices increased and were significant for the 10mWT (p ≤ 0.004). Qualitative findings highlighted that theory-based toolkit features and implementation strategies likely facilitated engagement with toolkit components, contributing to observed improvements in PTs' knowledge, attitudes, skill, self-efficacy, and clinical practice. CONCLUSIONS The approach may help to inform toolkit development to advance other rehabilitation practices of similar complexity.Implications for RehabilitationToolkits are an emerging knowledge translation intervention used to support widespread implementation of clinical practice guideline recommendations.Although experts recommend using theory to inform the development of knowledge translation interventions, there is little guidance on a suitable approach.This study describes an approach to using theories, models and frameworks to design a toolkit and implementation strategy, and a process evaluation of toolkit implementation.Theory-based features of the toolkit and implementation strategy may have facilitated toolkit implementation and practice change to increase clinical measurement and interpretation of walking speed and distance in adults post-stroke.
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Affiliation(s)
- Nancy M Salbach
- Department of Physical Therapy, University of Toronto, Toronto, Canada.,Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | | | - Patricia Solomon
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | - Jo-Anne Howe
- Department of Physical Therapy, University of Toronto, Toronto, Canada.,Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | | | - Mark T Bayley
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Surabhi Veitch
- Department of Physical Therapy, University of Toronto, Toronto, Canada
| | - Lavan Sivarajah
- Department of Physical Therapy, University of Toronto, Toronto, Canada
| | - Joseph Cacoilo
- Department of Physical Therapy, University of Toronto, Toronto, Canada
| | - Alex Mihailidis
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada
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14
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Atwi S, Sweeny M, Cohen E, Robertson AD, Marzolini S, Swardfager W, Swartz RH, Oh PI, MacIntosh BJ. Cerebrovascular assessments to help understand brain-related changes associated with aerobic exercise after stroke. Appl Physiol Nutr Metab 2021; 46:412-415. [PMID: 33400620 DOI: 10.1139/apnm-2020-0228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Evidence suggests exercise is "good medicine" after stroke, yet consensus is lacking on the time to initiate, type, exertion level, and duration per session. It remains a challenge to identify outcome measures for stroke-exercise trials that are sufficiently sensitive to intervention parameters. Cerebrovascular assessments, namely cerebral blood flow and intracranial pulsatility, are herein discussed as examples of quantitative brain-specific measures that may be useful to monitor exercise-related brain changes and help to guide stroke rehabilitation interventions. Novelty: Cerebral blood flow and arterial stiffness are potential vascular targets for stroke exercise trials.
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Affiliation(s)
- Sarah Atwi
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Research Institute, University of Toronto, Toronto, ON M4N 3M5, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Michelle Sweeny
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Research Institute, University of Toronto, Toronto, ON M4N 3M5, Canada.,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Ellen Cohen
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Research Institute, University of Toronto, Toronto, ON M4N 3M5, Canada.,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Andrew D Robertson
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Research Institute, University of Toronto, Toronto, ON M4N 3M5, Canada.,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Susan Marzolini
- KITE Research Institute, Toronto Rehab-University Health Network, Toronto, ON M4G 2V6, Canada
| | - Walter Swardfager
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Research Institute, University of Toronto, Toronto, ON M4N 3M5, Canada.,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Richard H Swartz
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Research Institute, University of Toronto, Toronto, ON M4N 3M5, Canada.,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada.,Department of Medicine (Neurology), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Paul I Oh
- KITE Research Institute, Toronto Rehab-University Health Network, Toronto, ON M4G 2V6, Canada
| | - Bradley J MacIntosh
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Research Institute, University of Toronto, Toronto, ON M4N 3M5, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada.,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
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15
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Jung C, Ye DH, Lee SH. Integrating Cardiac Rehabilitation with Neurorehabilitation in a Patient with Ischemic Stroke after Cardiac Surgery: a Case Report. BRAIN & NEUROREHABILITATION 2020; 14:e2. [PMID: 36742109 PMCID: PMC9879410 DOI: 10.12786/bn.2021.14.e2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 11/01/2020] [Accepted: 11/03/2020] [Indexed: 11/08/2022] Open
Abstract
Stroke and cardiac disorders are difficult to approach separately. Stroke survivors commonly have cardiovascular comorbidities and vice versa. These patients often need both neurorehabilitation and cardiac rehabilitation; therefore, this is an important issue in the rehabilitation process. However, no consensus has been reached on the integration of cardiac rehabilitation and neurorehabilitation. We report the case of a 52-year-old male patient who had ischemic stroke after mitral valvuloplasty. The patient underwent 3 weeks of inpatient neurorehabilitation, and then transited to 6 weeks of outpatient cardiac rehabilitation and occupational therapy. After 9 weeks of well-integrated rehabilitation, the patient experienced neurologic recovery and improvement in his cardiopulmonary fitness. Like this case, successful integrated rehabilitation will contribute to enhancing patients' functional recovery.
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Affiliation(s)
- Chul Jung
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Hyun Ye
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Hak Lee
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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16
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Girard V, Bellavance-Tremblay H, Gaudet-Drouin G, Lessard G, Dupont M, Gagnon MA, Ngueleu AM, Mandigout S, Batcho CS. Cardiorespiratory strain during stroke rehabilitation: Are patients trained enough? A systematic review. Ann Phys Rehabil Med 2020; 64:101443. [PMID: 33080374 DOI: 10.1016/j.rehab.2020.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 09/14/2020] [Accepted: 09/18/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Rehabilitation is a mandatory component of stroke management, aiming to recover functional capacity and independence. To that end, physical therapy sessions must involve adequate intensity in terms of cardiopulmonary stress to meet the physiological demands of independent living. OBJECTIVE The aim of this systematic review was to determine the current level of cardiopulmonary strain during rehabilitation sessions in stroke patients. METHODS Three electronic databases (PubMed, CINAHL and Embase. com) were searched to identify observational studies that documented cardiopulmonary strain during rehabilitation sessions in post-stroke patients (last search performed in February 2019). A manual cross-referencing search was also performed. To be included, articles needed to report data related to both cardiopulmonary strain (heart rate, oxygen consumption or energy expenditure) and active therapy time. The methodological quality of each study was assessed with the Evidence-Based Librarianship Critical Appraisal Tool. Data related to both cardiorespiratory strain and active therapy time were extracted from selected articles. RESULTS Four of 43 full-text articles assessed for eligibility met the inclusion criteria. Results extracted from these articles suggested that the intensity of rehabilitation sessions was insufficient to induce a cardiopulmonary training effect in a post-stroke context as measured by metabolic stress. Patients were inactive from 21% to 80% of the therapy time. The Evidence-Based Librarianship tool scores ranged from 65% (15/23) to 91% (21/23), which indicates questionable to good quality. CONCLUSION The current literature on cardiopulmonary solicitation during stroke rehabilitation sessions is poor in terms of both the number of studies available and their methodological quality. Summarized results tend to support previous claims that rehabilitation sessions offered to stroke patients are of suboptimal cardiopulmonary strain, which can interfere with their capacity to regain functional independence.
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Affiliation(s)
- Vicky Girard
- Department of rehabilitation, Laval University, 1050, avenue de la Médecine, QC, G1V0A6 Quebec, Canada
| | | | - Gabrielle Gaudet-Drouin
- Department of rehabilitation, Laval University, 1050, avenue de la Médecine, QC, G1V0A6 Quebec, Canada
| | - Geneviève Lessard
- Centre for Interdisciplinary Research in Rehabilitation and Social Integration, 525, boulevard Wilfrid-Hamel, QC, G1M 2S8 Quebec City, Canada
| | - Myriam Dupont
- Laval University Library, 2345, allée des Bibliothèques, QC, G1V0A6, Quebec, Canada
| | - Marie-Andrée Gagnon
- Centre for Interdisciplinary Research in Rehabilitation and Social Integration, 525, boulevard Wilfrid-Hamel, QC, G1M 2S8 Quebec City, Canada
| | - Armelle M Ngueleu
- Centre for Interdisciplinary Research in Rehabilitation and Social Integration, 525, boulevard Wilfrid-Hamel, QC, G1M 2S8 Quebec City, Canada
| | - Stéphane Mandigout
- Laboratory HAVAE EA-6310, University of Limoges, 123, avenue Albert Thomas, 87060 Limoges, France
| | - Charles Sebiyo Batcho
- Department of rehabilitation, Laval University, 1050, avenue de la Médecine, QC, G1V0A6 Quebec, Canada; Centre for Interdisciplinary Research in Rehabilitation and Social Integration, 525, boulevard Wilfrid-Hamel, QC, G1M 2S8 Quebec City, Canada.
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17
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Abstract
More than 13 million cases of stroke are occurring annually worldwide. Approximately a quarter of these strokes are recurrent strokes, and there is compelling evidence of the benefit of supervised exercise and risk factor modification programming in the secondary prevention of these strokes. However, there is insufficient time in inpatient and outpatient stroke rehabilitation for focused exercise interventions. General lifestyle interventions on their own, without guidance and supervision, are insufficient for improving physical activity levels. Cardiac rehabilitation (CR) is a setting where cardiac patients, and increasingly stroke patients, receive comprehensive secondary prevention programming, including structured exercise. Unfortunately, not all CR programs accept referrals for people following a stroke and for those that do, only a few patients participate. Therefore, the purpose of this review is to report the barriers and facilitators to improving linkage between health services, with a focus on increasing access to CR. In the next two decades, it is projected that there will be a marked increase in stroke prevalence globally. Therefore, there is an urgent need to create cross-program collaborations between hospitals, outpatient stroke rehabilitation, CR, and community programs. Improving access and removing disparities in access to evidence-based exercise treatments would positively affect the lives of millions of people recovering from stroke.
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18
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Inness EL, Aqui A, Foster E, Fraser J, Danells CJ, Biasin L, Brunton K, Howe JA, Poon V, Tang A, Mansfield A, Marzolini S, Oh P, Bayley M. Determining Safe Participation in Aerobic Exercise Early After Stroke Through a Graded Submaximal Exercise Test. Phys Ther 2020; 100:1434-1443. [PMID: 32494824 PMCID: PMC7462052 DOI: 10.1093/ptj/pzaa103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 03/01/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVE The benefits of aerobic exercise early after stroke are well known, but concerns about cardiovascular risk are a barrier to clinical implementation. Symptom-limited exercise testing with electrocardiography (ECG) is recommended but not always feasible. The purpose of this study was to determine the frequency of and corresponding exercise intensities at which ECG abnormalities occurred during submaximal exercise testing that would limit safe exercise prescription beyond those intensities. METHODS This study was a retrospective analysis of ECGs from 195 patients who completed submaximal exercise testing during stroke rehabilitation. A graded submaximal exercise test was conducted with a 5- or 12-lead ECG and was terminated on the basis of predetermined endpoint criteria (heart rate, perceived exertion, signs, or symptoms). ECGs were retrospectively reviewed for exercise-induced abnormalities and their associated heart rates. RESULTS The peak heart rate achieved was 65.4% (SD = 10.5%) of the predicted maximum heart rate or 29.1% (SD = 15.5%) of the heart rate reserve (adjusted for beta-blocker medications). The test was terminated more often because of perceived exertion (93/195) than because of heart rate limits (60/195). Four patients (2.1%) exhibited exercise-induced horizontal or downsloping ST segment depression of ≥1 mm. Except for 1 patient, the heart rate at test termination was comparable with the heart rate associated with the onset of the ECG abnormality. CONCLUSION A graded submaximal exercise test without ECG but with symptom monitoring and conservative heart rate and perceived exertion endpoints may facilitate safe exercise intensities early after stroke. Symptom-limited exercise testing with ECG is still recommended when progressing to higher intensity exercise. IMPACT Concerns about cardiovascular risk are a barrier to physical therapists implementing aerobic exercise in stroke rehabilitation. This study showed that, in the absence of access to exercise testing with ECG, submaximal testing with conservative heart rate and perceived exertion endpoints and symptom monitoring can support physical therapists in the safe prescription of aerobic exercise early after stroke. LAY SUMMARY It is recommended that people with stroke participate in aerobic exercise as early as possible during their rehabilitation. A submaximal exercise test with monitoring of heart rate, perceived exertion, blood pressure, and symptoms can support physical therapists in safely prescribing that exercise.
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Affiliation(s)
| | - Anthony Aqui
- Toronto Rehabilitation Institute, University Health Network–KITE Research Institute
| | - Evan Foster
- Toronto Rehabilitation Institute, University Health Network–KITE Research Institute
| | - Julia Fraser
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - Cynthia J Danells
- Toronto Rehabilitation Institute, University Health Network–KITE Research Institute; and Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Louis Biasin
- Toronto Rehabilitation Institute, University Health Network–Brain and Spinal Cord Rehab Program; and Department of Physical Therapy, University of Toronto
| | - Karen Brunton
- Toronto Rehabilitation Institute, University Health Network–Education; and Department of Physical Therapy, University of Toronto
| | - Jo-Anne Howe
- Toronto Rehabilitation Institute, University Health Network–Education
| | - Vivien Poon
- Toronto Rehabilitation Institute, University Health Network–Brain and Spinal Cord Rehab Program; and Department of Physical Therapy, University of Toronto
| | - Ada Tang
- School of Rehabilitation Science, Institute of Applied Health Science, McMaster University, Hamilton, Ontario, Canada
| | - Avril Mansfield
- Toronto Rehabilitation Institute, University Health Network–KITE Research Institute; Department of Physical Therapy, University of Toronto; and Sunnybrook Research Institute–Evaluative Clinical Sciences, Hurvitz Brain Sciences Research Program, Toronto, Ontario, Canada
| | - Susan Marzolini
- Toronto Rehabilitation Institute, University Health Network–KITE Research Institute and Cardiovascular Prevention and Rehabilitation Program; and Department of Exercise Sciences, Faculty of Kinesiology and Physical Education, University of Toronto
| | - Paul Oh
- Toronto Rehabilitation Institute, University Health Network–KITE Research Institute and Cardiovascular Prevention and Rehabilitation Program
| | - Mark Bayley
- Toronto Rehabilitation Institute, University Health Network–KITE Research Institute; and Faculty of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto
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19
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Barriers and Facilitators to Aerobic Exercise Implementation in Stroke Rehabilitation: A Scoping Review. J Neurol Phys Ther 2020; 44:179-187. [DOI: 10.1097/npt.0000000000000318] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Stone JE, Dukelow S, Stone JA. Stroke Rehabilitation and Cardiac Rehabilitation: Siblings or Strangers? CJC Open 2020; 2:189-191. [PMID: 32697199 PMCID: PMC7365825 DOI: 10.1016/j.cjco.2020.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
| | - Sean Dukelow
- Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - James A. Stone
- Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Toma J, Hammond B, Chan V, Peacocke A, Salehi B, Jhingan P, Brooks D, Hébert AA, Marzolini S. Inclusion of People Poststroke in Cardiac Rehabilitation Programs in Canada: A Missed Opportunity for Referral. CJC Open 2020; 2:195-206. [PMID: 32695969 PMCID: PMC7365786 DOI: 10.1016/j.cjco.2020.01.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 01/29/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Evidence supports establishing a continuum of care from stroke rehabilitation (SR) to cardiac rehabilitation programs (CRPs). It is not known to what extent people poststroke are being integrated. This study aimed to determine the proportion of CRPs that accept referrals poststroke, barriers/facilitators, and eligibility criteria. METHODS A web-based questionnaire was sent to CRPs across Canada. RESULTS Of 160 questionnaires sent, 114 representatives (71%) of 130 CRPs responded. Of respondents, 65% (n = 74) reported accepting people with a diagnosis of stroke and doing so for a median of 11 years, 11 offering stroke-specific classes and an additional 6 planning inclusion. However, 62.5% of CRPs reported that < 11 patients participated in the last calendar year despite 88.5% reporting no limit to the number they could enroll. Among CRPs, 25% accepted only patients with concurrent cardiac diagnoses, living in the community (47.8%), and without severe mobility (70.1%), communication (80.6%), or cognitive (85.1%) deficits. The 2 most influential barriers and facilitators among all CRPs were funding and staffing. The fourth greatest barrier was lack of poststroke referrals, and third to sixth facilitators were SR/CRP collaboration to ensure appropriate referrals (third) and to increase referrals (sixth), toolkits for prescribing resistance (fourth), and aerobic training (fifth). CRP characteristics associated with accepting stroke were a hybrid program model, a medium program size, and having a falls prevention component. CONCLUSIONS Most CRPs accept patients poststroke, but few participate. Therefore, establishing SR/CRP partnerships to increase appropriate referrals, using a toolkit to help operationalize exercise components, and allocating funding/resources to CRPs may significantly increase access to secondary prevention strategies.
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Affiliation(s)
- Jelena Toma
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Brittany Hammond
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Vito Chan
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Alex Peacocke
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Baharak Salehi
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Prateek Jhingan
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Dina Brooks
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
- KITE Research Institute, Toronto Rehab-University Health Network, Toronto, Ontario, Canada
- Heart and Stroke Foundation, Canadian Partnership for Stroke Recovery, Ottawa, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
| | | | - Susan Marzolini
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
- KITE Research Institute, Toronto Rehab-University Health Network, Toronto, Ontario, Canada
- Heart and Stroke Foundation, Canadian Partnership for Stroke Recovery, Ottawa, Ontario, Canada
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22
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The Effect of Stroke on Middle Cerebral Artery Blood Flow Velocity Dynamics During Exercise. J Neurol Phys Ther 2020; 43:212-219. [PMID: 31449179 PMCID: PMC6744289 DOI: 10.1097/npt.0000000000000289] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Previous work demonstrates that older adults have a lower response in the middle cerebral artery velocity (MCAv) to an acute bout of moderate-intensity exercise when compared with young adults. However, no information exists regarding MCAv response to exercise after stroke. We tested whether MCAv response to an acute bout of moderate-intensity exercise differed between participants 3 months after stroke and an age- and sex-matched control group of older adults (CON). A secondary objective was to compare MCAv response between the stroke- and non-stroke-affected MCAv. METHODS Using transcranial Doppler ultrasound, we recorded MCAv during a 90-second baseline (BL) followed by a 6-minute moderate-intensity exercise bout using a recumbent stepper. Heart rate (HR), end-tidal CO2 (PETCO2), and beat-to-beat mean arterial blood pressure (MAP) were additional variables of interest. The MCAv response measures included BL, peak response amplitude (Amp), time delay (TD), and time constant (τ). RESULTS The Amp was significantly lower in the stroke-affected MCAv compared with CON (P < 0.01) and in the nonaffected MCAv compared with CON (P = 0.03). No between-group differences were found between TD and τ. No significant differences were found during exercise for PETCO2 and MAP while HR was lower in participants with stroke (P < 0.01). Within the group of participants with stroke, no differences were found between the stroke-affected and non-stroke-affected sides for any measures. DISCUSSION AND CONCLUSIONS Resolution of the dynamic response profile has the potential to increase our understanding of the cerebrovascular control mechanisms and test cerebrovascular response to physical therapy-driven interventions such as exercise.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A284).
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Oxygen Consumption While Walking With Multijoint Neuromuscular Electrical Stimulation After Stroke. Am J Phys Med Rehabil 2020; 99:e138-e141. [PMID: 32149817 DOI: 10.1097/phm.0000000000001416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This case study evaluated the effect of implanted multijoint neuromuscular electrical stimulation gait assistance on oxygen consumption relative to walking without neuromuscular electrical stimulation after stroke. The participant walked slowly with an asymmetric gait pattern after stroke. He completed repeated 6-min walk tests at a self-selected walking speed with and without hip, knee, and ankle stimulation assistance. His walking speed with neuromuscular electrical stimulation more than doubled from 0.28 ± 0.01 m/sec to 0.58 ± 0.04 m/sec, whereas average step length and cadence increased by 0.12 m and 24 steps/min, respectively. As a result, energy cost of walking with neuromuscular electrical stimulation decreased by 0.19 ml O2/kg per meter as compared with walking without stimulation while oxygen consumption increased by 1.1 metabolic equivalent of tasks (3.9 ml O2/kg per minute). These metabolic demands are similar to those reported for stroke survivors capable of walking at equivalent speeds without stimulation, suggesting the increase in oxygen consumption and decreased energy cost result from improved efficiency of faster walking facilitated by neuromuscular electrical stimulation. Although the effect of neuromuscular electrical stimulation on gait economy has implications for community walking within the user's metabolic reserves, this case study's results should be interpreted with caution and the hypothesis that multijoint neuromuscular electrical stimulation improves metabolic efficiency should be tested in a wide population of stroke survivors with varied deficits.
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Marzolini S, Fong K, Jagroop D, Neirinckx J, Liu J, Reyes R, Grace SL, Oh P, Colella TJF. Eligibility, Enrollment, and Completion of Exercise-Based Cardiac Rehabilitation Following Stroke Rehabilitation: What Are the Barriers? Phys Ther 2020; 100:44-56. [PMID: 31588512 DOI: 10.1093/ptj/pzz149] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 03/09/2019] [Accepted: 06/09/2019] [Indexed: 11/13/2022]
Abstract
BACKGROUND People after stroke benefit from comprehensive secondary prevention programs including cardiac rehabilitation (CR), yet there is little understanding of eligibility for exercise and barriers to use. OBJECTIVE The aim of this study was to examine eligibility for CR; enrollment, adherence, and completion; and factors affecting use. DESIGN This was a prospective study of 116 consecutive people enrolled in a single outpatient stroke rehabilitation (OSR) program located in Toronto, Ontario, Canada. METHODS Questionnaires were completed by treating physical therapists for consecutive participants receiving OSR and included reasons for CR ineligibility, reasons for declining participation, demographics, and functional level. CR eligibility criteria included the ability to walk ≥100 m (no time restriction) and the ability to exercise at home independently or with assistance. People with or without hemiplegic gait were eligible for adapted or traditional CR, respectively. Logistic regression analyses were used to examine factors associated with use indicators. RESULTS Of 116 participants receiving OSR, 82 (70.7%) were eligible for CR; 2 became eligible later. Sixty (71.4%) enrolled in CR and 49 (81.7%) completed CR, attending 87.1% (SD = 16.6%) of prescribed sessions. The primary reasons for ineligibility included being nonambulatory or having poor ambulation (52.9%; 18/34 patients) and having severe cognitive deficits and no home exercise support (20.6%; 7/34). Frequently cited reasons for declining CR were moving or travel out of country (17.2%; 5/29 reasons), lack of interest (13.8%; 4/29), transportation issues (10.3%; 3/29), and desiring a break from therapy (10.3%; 3/29). In a multivariate analysis, people who declined CR were more likely to be women, have poorer attendance at OSR, and not diabetic. Compared with traditional CR, stroke-adapted CR resulted in superior attendance (66.1% [SD = 22.9%] vs 87.1% [SD = 16.6%], respectively) and completion (66.7% vs 89.7%, respectively). The primary reasons for dropping out were medical (45%) and moving (27%). LIMITATIONS Generalizability to other programs is limited, and other, unmeasured factors may have affected outcomes. CONCLUSIONS An OSR-CR partnership provided an effective continuum of care, with approximately 75% of eligible people participating and more than 80% completing. However, just over 1 of 4 eligible people declined participation; therefore, strategies should target lack of interest, transportation, women, and people without diabetes. An alternative program model is needed for people who have severe ambulatory or cognitive deficits and no home exercise support.
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Affiliation(s)
- Susan Marzolini
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada; Canadian Partnership for Stroke Recovery, Toronto, Ontario, Canada; University of Toronto, Ontario, Canada; and York University, Toronto, Ontario, Canada
| | - Karen Fong
- Toronto Rehabilitation Institute, University Health Network
| | - David Jagroop
- Toronto Rehabilitation Institute, University Health Network
| | | | - Jean Liu
- Toronto Rehabilitation Institute, University Health Network
| | - Rina Reyes
- Toronto Rehabilitation Institute, University Health Network
| | - Sherry L Grace
- Toronto Rehabilitation Institute, University Health Network; and York University
| | - Paul Oh
- Toronto Rehabilitation Institute, University Health Network; and Canadian Partnership for Stroke Recovery
| | - Tracey J F Colella
- Toronto Rehabilitation Institute, University Health Network; and University of Toronto
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Marzolini S, Robertson AD, Oh P, Goodman JM, Corbett D, Du X, MacIntosh BJ. Aerobic Training and Mobilization Early Post-stroke: Cautions and Considerations. Front Neurol 2019; 10:1187. [PMID: 31803129 PMCID: PMC6872678 DOI: 10.3389/fneur.2019.01187] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 10/25/2019] [Indexed: 12/14/2022] Open
Abstract
Knowledge gaps exist in how we implement aerobic exercise programs during the early phases post-stroke. Therefore, the objective of this review was to provide evidence-based guidelines for pre-participation screening, mobilization, and aerobic exercise training in the hyper-acute and acute phases post-stroke. In reviewing the literature to determine safe timelines of when to initiate exercise and mobilization we considered the following factors: arterial blood pressure dysregulation, cardiac complications, blood-brain barrier disruption, hemorrhagic stroke transformation, and ischemic penumbra viability. These stroke-related impairments could intensify with inappropriate mobilization/aerobic exercise, hence we deemed the integrity of cerebral autoregulation to be an essential physiological consideration to protect the brain when progressing exercise intensity. Pre-participation screening criteria are proposed and countermeasures to protect the brain from potentially adverse circulatory effects before, during, and following mobilization/exercise sessions are introduced. For example, prolonged periods of standing and static postures before and after mobilization/aerobic exercise may elicit blood pooling and/or trigger coagulation cascades and/or cerebral hypoperfusion. Countermeasures such as avoiding prolonged standing or incorporating periodic lower limb movement to activate the venous muscle pump could counteract blood pooling after an exercise session, minimize activation of the coagulation cascade, and mitigate potential cerebral hypoperfusion. We discuss patient safety in light of the complex nature of stroke presentations (i.e., type, severity, and etiology), medical history, comorbidities such as diabetes, cardiac manifestations, medications, and complications such as anemia and dehydration. The guidelines are easily incorporated into the care model, are low-risk, and use minimal resources. These and other strategies represent opportunities for improving the safety of the activity regimen offered to those in the early phases post-stroke. The timeline for initiating and progressing exercise/mobilization parameters are contingent on recovery stages both from neurobiological and cardiovascular perspectives, which to this point have not been specifically considered in practice. This review includes tailored exercise and mobilization prescription strategies and precautions that are not resource intensive and prioritize safety in stroke recovery.
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Affiliation(s)
- Susan Marzolini
- KITE, Toronto Rehab-University Health Network, Toronto, ON, Canada
- Department of Exercise Sciences, Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- Canadian Partnership for Stroke Recovery, Toronto, ON, Canada
| | - Andrew D. Robertson
- Schlegel-University of Waterloo Research Institute for Aging, University of Waterloo, Waterloo, ON, Canada
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada
| | - Paul Oh
- KITE, Toronto Rehab-University Health Network, Toronto, ON, Canada
- Department of Exercise Sciences, Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- Canadian Partnership for Stroke Recovery, Toronto, ON, Canada
| | - Jack M. Goodman
- KITE, Toronto Rehab-University Health Network, Toronto, ON, Canada
- Department of Exercise Sciences, Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Dale Corbett
- Canadian Partnership for Stroke Recovery, Toronto, ON, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Xiaowei Du
- KITE, Toronto Rehab-University Health Network, Toronto, ON, Canada
- School of Kinesiology and Health Studies, Queen's University, Kingston, ON, Canada
| | - Bradley J. MacIntosh
- Canadian Partnership for Stroke Recovery, Toronto, ON, Canada
- Sunnybrook Health Sciences Center, Toronto, ON, Canada
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