Aerobic exercise in subacute stroke improves cardiovascular health and physical performance

Cardiorespiratory Fitness Benefits of High-Intensity Interval Training After Stroke: A Randomized Controlled Trial

BACKGROUND

Limited evidence supports the effects of short-interval high-intensity interval training (HIIT) for improving cardiorespiratory fitness (V̇O2peak) after stroke. We aimed to compare the effects of 12 weeks of short-interval HIIT versus moderate-intensity continuous training (MICT) on V̇O2peak, cardiovascular risk factors, and mobility outcomes among individuals ≥6 months poststroke.

METHODS

This study was a multi-site, 12-week randomized controlled trial (NCT03614585) with an 8-week follow-up. Participants were randomized into 3 d/wk of HIIT (10×1 minute 80%-100% heart rate reserve interspersed with 1 minute 30% heart rate reserve [19 minutes]) or MICT (20-30 minutes 40%-60% heart rate reserve). Secondary outcomes of the trial, including V̇O2peak, cardiovascular risk factors (carotid-femoral pulse wave velocity, blood pressure, and waist-hip ratio), and mobility (6-minute walk test, 10 m gait speed), were reported. Linear mixed model analyses with a group×study time point interaction evaluated between-group differences.

RESULTS

Of the 305 potential participants, 82 consented (mean [SD] age 64.9 [9.3] years, 32 females [39%], 1.8 [1.2] years poststroke) and were randomized to HIIT (n=42, mean [SD] baseline V̇O2peak 17.3 [5.9] mL/kg·min) or MICT (n=40, mean [SD] baseline V̇O2peak 17.2 [6.0] mL/kg·min). Participants attended 82% of visits (n=2417/2952). No adverse events occurred during the study period. A significant group×study time point interaction was found (χ2=8.46; P=0.015) for V̇O2peak at 12 weeks (mean difference, 1.81 [95% CI, 0.58-3.04]; P=0.004) whereby the HIIT group had greater gains in V̇O2peak (∆3.52 mL/kg·min [95% CI, 2.47-4.57]; P<0.001) compared with the MICT group (∆1.71 mL/kg·min [95% CI, 0.55-2.86]; P=0.001). There was no between-group difference in V̇O2peak (mean difference, 1.08 [95% CI, -0.26 to 2.42]; P=0.11) at 8-week follow-up. No group×study time point interactions were found for cardiovascular risk factors or mobility outcomes.

CONCLUSIONS

Short-interval HIIT may be an effective alternative to MICT for improving V̇O2peak at 12 weeks postintervention.

REGISTRATION

URL: https://clinicaltrials.gov; Unique identifier: NCT03614585.

Feasibility of a Recumbent Stepper for Short-Interval, Low-Volume High-Intensity Interval Exercise in Stroke

BACKGROUND AND PURPOSE

Studies investigating high-intensity interval exercise (HIIE) in stroke typically emphasize treadmill training. However, a literature review suggested that seated devices such as a recumbent stepper or cycle offer a promising alternative for HIIE since exercise can be prescribed using peak power output (PPO). Therefore, this would give health care professionals the ability to monitor and adapt power output for the target heart rate range. The purpose of this secondary analysis was to examine the feasibility of prescribing short-interval, low-volume HIIE using PPO in chronic stroke.

METHODS

We used several methods to test feasibility: (1)Acceptability: Measured by the percentage of participants who completed the entire HIIE protocol; (2) Implementation was assessed by the number of reported cardiac or serious adverse events during submaximal exercise testing and HIIE and the average percentage of participants reaching vigorous intensity, defined by the American College of Sports Medicine as at least 77% of age-predicted maximal heart rate (HR max ).

RESULTS

Data were available for 28 participants who were 32.2 (17.2) months post-stroke and 61.4 (11.9) years of age. Twenty-eight participants completed HIIE per protocol. No cardiac or serious adverse events occurred during the submaximal exercise test or during HIIE. The rapid switching between HIIE and recovery showed no evidence of blood pressure reaching unsafe thresholds. Average intensity during HIIE reached 76.8% HR max , which is slightly below the target of 77.0%.

DISCUSSION AND CONCLUSIONS

A single bout of short-interval, low-volume HIIE, prescribed using PPO, was feasible in chronic stroke.

Video Abstract : Available for more insights from the authors (Supplemental Digital Content, Video, available at: http://links.lww.com/JNPT/A474 ).

Mechanisms and benefits of cardiac rehabilitation in individuals with stroke: emerging role of its impact on improving cardiovascular and neurovascular health

Human and animal studies have demonstrated the mechanisms and benefits of aerobic exercise for both cardiovascular and neurovascular health. Aerobic exercise induces neuroplasticity and neurophysiologic reorganization of brain networks, improves cerebral blood flow, and increases whole-body VO2peak (peak oxygen consumption). The effectiveness of a structured cardiac rehabilitation (CR) program is well established and a vital part of the continuum of care for people with cardiovascular disease. Individuals post stroke exhibit decreased cardiovascular capacity which impacts their neurologic recovery and extends disability. Stroke survivors share the same risk factors as patients with cardiac disease and can therefore benefit significantly from a comprehensive CR program in addition to neurorehabilitation to address their cardiovascular health. The inclusion of individuals with stroke into a CR program, with appropriate adaptations, can significantly improve their cardiovascular health, promote functional recovery, and reduce future cardiovascular and cerebrovascular events thereby reducing the economic burden of stroke.

Peripheral vascular function in stroke: systematic review and meta-analysis

Peripheral vascular dysfunction, measured as flow-mediated dilation (FMD), is present across all phases of stroke recovery and elevates the risk for recurrent cardiovascular events. The objective of this systematic review and meta-analysis was to characterize baseline FMD in individuals' poststroke, with consideration for each phase of stroke recovery. Three databases (PubMed, CINAHL, and Embase) were searched between January 1, 2000 and October 12, 2023 for studies that examined baseline FMD in stroke. Three reviewers conducted abstract and full-text screening, data extraction, and quality assessment. A random effects model was used to estimate FMD across studies. Meta-regression was used to examine the impact of age and time since stroke (acute, subacute, chronic) on FMD. Twenty-eight studies with ischemic and hemorrhagic stroke were included. Descriptive statistics for the demographics and FMD values of each study are presented. For the meta-analysis, average estimate FMD was 3.9% (95% CI: 2.5-5.3%). We report a large amount of heterogeneity (Cochrane's Q P value <0.001, and I2 = 99.6%). Differences in average age and the time poststroke between studies were not significantly associated with differences in FMD values. Despite the large heterogeneity for FMD values across studies, our primary finding suggests that FMD remains impaired across all phases of stroke.NEW & NOTEWORTHY This systematic review and meta-analysis offers invaluable insight into poststroke vascular function. Despite the inherent heterogeneity among the 28 studies analyzed, we report that peripheral vascular dysfunction, as quantified by flow-mediated dilation, exists across all stages of stroke recovery. This finding underscores the importance for interventions that focus on improving vascular health and secondary stroke prevention.

Lower middle cerebral artery blood velocity during low-volume high-intensity interval exercise in chronic stroke

High-intensity interval training (HIIE) may present unique challenges to the cerebrovascular system in individuals post-stroke. We hypothesized lower middle cerebral artery blood velocity (MCAv) in individuals post-stroke: 1) during 10 minutes of HIIE, 2) immediately following HIIE, and 3) 30 minutes after HIIE, compared to age- and sex-matched controls (CON). We used a recumbent stepper submaximal exercise test to determine workloads for high-intensity and active recovery. Our low volume HIIE protocol consisted of 1-minute intervals for 10 minutes. During HIIE, we measured MCAv, mean arterial pressure (MAP), heart rate (HR), and end tidal carbon dioxide (PETCO2). We assessed carotid-femoral pulse wave velocity as a measure of arterial stiffness. Fifty participants completed the study (25 post-stroke, 76% ischemic, 32% moderate disability). Individuals post-stroke had lower MCAv during HIIE compared to CON (p = 0.03), which remained 30 minutes after HIIE. Individuals post-stroke had greater arterial stiffness (p = 0.01) which was moderately associated with a smaller MCAv responsiveness during HIIE (r = -0.44). No differences were found for MAP, HR, and PETCO2. This study suggests individuals post-stroke had a lower MCAv during HIIE compared to their peers, which remained during recovery up to 30 minutes. Arterial stiffness may contribute to the lower cerebrovascular responsiveness post-stroke.

Integrating Cardiac Rehabilitation in Stroke Recovery

Stroke remains a top contributor to long-term disability in the United States and substantially limits a person's physical activity. Decreased cardiovascular capacity is a major contributing factor to activity limitations and is a significant health concern. Addressing the cardiovascular capacity of stroke survivors as part of poststroke management results in significant improvements in their endurance, functional recovery, and medical outcomes such as all-cause rehospitalization and mortality. Incorporation of a structured approach similar to the cardiac rehabilitation program, including aerobic exercise and risk factor education, can lead to improved cardiovascular function, health benefits, and quality of life in stroke survivors.

Financial Cost Analysis Associated with a Locomotor Exercise Randomized Controlled Trial in Chronic Stroke

Background

Post-stroke recovery trials pose distinct recruitment and retention challenges, and understanding the financial requirements of conducting randomized controlled trials is crucial to ensure sufficient resources for successful study execution. The purpose of this analysis was to quantify the costs at a single site with a large catchment area of the Moderate-Intensity Exercise Versus High-Intensity Interval Training to Recover Walking Post-Stroke, HIT Stroke Trial.

Methods

To determine cost, study expense reports were gathered and divided into four categories: oversight, recruitment, retention, and outcome assessments. Categories were then further divided into chronological order for initial contact and prescreening, consenting, initial screening, and baseline testing. The 12-week intervention was divided into 4-week blocks: intervention block 1, post 4-week outcome testing, intervention block 2, post 8-week outcome testing, intervention block 3, and post 12-week outcome testing.

Results

Total direct cost for site execution was $539,768 with cost per participant approximated as $35,984. Oversight costs accounted for 65.8% of the budget at $355,661. To achieve goals related to inclusive participant recruitment ($21,923) and retention ($28,009), our site costs totaled $49,932. Direct study-related costs included screening assessments ($5,905), baseline assessments ($15,028), intervention ($76,952), and outcome assessments ($36,288).

Conclusion

Clinical trials on walking rehabilitation and exercise, especially those involving multiple assessment visits, require intensive oversight. This cost analysis provides important and critical insight into the expenses required to successfully execute an exercise-based walking rehabilitation trial in the United States.

Effects of 2-Year-Long Maintenance Training and Detraining on 558 Subacute Ischemic Stroke Patients' Clinical-Motor Symptoms

PURPOSE

This study aimed to determine the effects of a 2-yr-long maintenance training (MT) exergaming and detraining (DT) on clinical-motor symptoms in subacute ischemic patients with stroke (PwST). The hypothesis was that MT motor rehabilitation program would further increase the effects of the initial rehabilitation.

METHODS

After high-intensity and high-frequency exergaming twice or once a day, 5 times per week for 5 wk (EX2: 50 sessions; EX1: 25 sessions, results reported previously), 558 PwST were randomized to EX2-MT, EX2-DT, EX1-MT, and EX1-DT. MT exergaming consisted of once a day, 3 times per week for 2 yr, and DT did not train. Outcomes were measured at 6, 12, 18, and 24 months. The data were analyzed using longitudinal linear mixed-effects models and general linear hypotheses testing.

RESULTS

Modified Rankin Score (primary outcome), body mass, Mini-Mental State Examination score, Beck Depression Inventory, measures of quality of life, Berg Balance Scale, 6-min walk test, and four measures of center of pressure path tended to retain the initial rehabilitation-induced gains in the MT patients in selected outcomes (especially walking capacity). The scores tended to mildly worsen after DT, partially supporting the hypothesis.

CONCLUSIONS

MT successfully maintained, but only in selected variables did it further increase the initial exergaming rehabilitation-induced robust improvements. DT modestly reduced the initial exergaming rehabilitation-induced improvements. MT programs might be needed after initial stroke rehabilitation to reduce subsequent losses of quality of life and further improve clinical-motor symptoms.

A Systematic Review on the Effects of Acute Aerobic Exercise on Neurophysiological, Molecular, and Behavioral Measures in Chronic Stroke

BACKGROUND

A single bout of aerobic exercise (AE) can produce changes in neurophysiological and behavioral measures in healthy individuals and those with stroke. However, the effects of AE-priming effects on neuroplasticity markers and behavioral measures are unclear.

OBJECTIVES

This systematic review aimed to examine the effects of AE on neuroplasticity measures, such as corticomotor excitability (CME), molecular markers, cortical activation, motor learning, and performance in stroke.

METHODS

A literature search was performed in MEDLINE, CINAHL, Scopus, and PsycINFO databases. Randomized and non-randomized studies incorporating acute AE in stroke were selected. Two reviewers independently assessed the risk of bias and methodological rigor of the studies and extracted data on participant characteristics, exercise interventions, and neuroplasticity related outcomes. The quality of transcranial magnetic stimulation reported methods was assessed using a standardized checklist.

RESULTS

A total of 16 studies were found suitable for inclusion. Our findings suggest mixed evidence for the effects of AE on CME, limited to no effects on intracortical inhibition and facilitation and some evidence for modulating brain derived neurotrophic factor levels, motor learning, and cortical activation. Exercise intensities in the moderate to vigorous range showed a trend towards better effects on neuroplasticity measures.

CONCLUSION

It appears that choosing a moderate to vigorous exercise paradigm for at least 20 to 30 minutes may induce changes in some neuroplasticity parameters in stroke. However, these findings necessitate prudent consideration as the studies were diverse and had moderate methodological quality. There is a need for a consensus on an exercise priming paradigm and for good-quality, larger controlled studies.

Addition of high-intensity interval training to a moderate intensity continuous training cardiovascular rehabilitation program after ischemic cerebrovascular disease: A randomized controlled trial

Introduction

Moderate intensity continuous training (MICT) is usually recommended for stroke or transient ischemic attack (TIA) patients. High intensity interval training (HIIT) has emerged as a potentially effective method for increasing cardiorespiratory fitness (CRF) among clinical populations. Its effectiveness remains to be demonstrated after stroke. A combined program of HIIT and MICT was designed to create a realistic exercise program implemented for a clinical setting to help patients become more active.

Purpose

This study aimed to compare the effects of a 6-month exercise program with either MICT only or a combination of HIIT and MICT and a control group in terms of CRF, cardiovascular risk factors, functionality, cognitive function (Montreal Cognitive Assessment) and depression markers (Hospital Anxiety and Depression Scale).

Methods

This randomized controlled trial started with 52 participants (33 men and 19 women, mean age: 69.2 ± 10.7) divided into three groups: HIIT + MICT combined, MICT, and control. Both exercise groups consisted of 4 weekly sessions including supervised and at-home exercise. Outcomes were assessed at T0 (baseline measure), T6 (end of exercise protocols), and T12 (follow-up), 40 participants having completed the 12-month follow-up.

Results

At T6, both HIIT+MICT and MICT programs provided a similar increase of CRF (3 ml·min-1·kg-1) from baseline (p < 0.01), while the control group showed a global slight decrease. Despite some decrease of CRF at T12 compared to T6, improvement persisted 6 months post-intervention (HIIT + MICT: p < 0.01 and MICT: p < 0.05). The control group decreased compared with baseline (p < 0.05). The two exercise programs induced a comparable increase in self-reported physical activity and a decrease in anxiety and depression markers. Participants in HIIT + MICT and MICT programs declared a good degree of acceptability assessed by the Acceptability and Preferences Questionnaire.

Conclusion

A 6-month HIIT + MICT combined program and a standard MICT program induced similar improvements in CRF, self-reported physical activity and anxiety and depression markers among patients with prior ischemic stroke or TIA compared with a control group. These effects appear to persist over time. Addition of HIIT was safe and considered acceptable by participants. Our results do not support any superiority of the combination HIIT + MICT nor disadvantage vs. MICT in this population.

Quantification of Tissue Oxygen Saturation in the Vastus Lateralis Muscle of Chronic Stroke Survivors during a Graded Exercise Test

Purpose

This study examined tissue oxygen saturation (StO2) of the vastus lateralis (VL) muscles of chronic stroke survivors during a graded exercise test (GXT). We hypothesized the reduction in StO2 will be blunted in the paretic vs. non-paretic VL during a maximum-effort GXT.

Methods

Chronic stroke survivors performed a GXT and StO2 of the VL in each leg was measured using near infrared spectroscopy. Twenty-six stroke survivors performed a GXT.

Results

At rest, there was no difference in StO2 between the paretic and non-paretic VL (65±9% vs. 68±7%, respectively, p=0.32). The maximum change in StO2 from rest during the GXT was greater in the non-paretic vs. the paretic VL (-16±14% vs. -9±10%, respectively, p<0.001). The magnitude of the oxygen resaturation response was also greater in the non-paretic vs. the paretic VL (29±23% vs. 18±15%, respectively, p<0.001). VO2 Peak was associated with the magnitude of the VL StO2 change during (r2=0.54, p<0.0001) and after (r2=0.56, p<0.001) the GXT.

Conclusions

During a GXT there is a blunted oxygen desaturation response in the paretic vs. the non-paretic VL of chronic stroke survivors. In the paretic VL there was a positive correlation between the oxygen desaturation response during the GXT and VO2 Peak.

Effect of modified Total Body Recumbent Stepper training on exercise capacity and thioredoxin in COPD: a randomized clinical trial

Exercise intolerance is one of the major symptoms of chronic obstructive pulmonary disease (COPD). Exercise training can benefit COPD patients, but the underlying mechanism remains unclear. The modified Total Body Recumbent Stepper (TBRS, Nustep-T4) can benefit patients with stroke, spinal cord injury and amyotrophic lateral sclerosis. Nevertheless, the effect of TBRS training alone on pulmonary rehabilitation (PR) in COPD patients remains largely unknown. We aimed to explore the effect of TBRS training on exercise capacity and the thioredoxin system (TRXS) in COPD patients to provide a novel rehabilitation modality and new theoretical basis for PR of COPD patients. Ninety stable COPD patients were randomly divided into a control group (NC group) and a TBRS training group (TBRS group), with 45 cases in each group. Subjects in the TBRS training group were scheduled to undergo TBRS endurance training triweekly for 12 weeks under the guidance of a rehabilitation therapist. We assessed the primary outcome: exercise capacity (6-min walking distance, 6MWD); and secondary outcomes: perception of dyspnoea (mMRC, Borg), the COPD assessment test (CAT), the BODE index, pulmonary function, the number of acute exacerbations of COPD and oxidative stress (TRXS) at one-year follow-up. Compared with before the intervention and the control group, after the intervention, the TBRS training group, exhibited an increase in the 6MWD (from 366.92 ± 85.81 to 484.10 ± 71.90, 484.10 ± 71.90 vs 370.63 ± 79.87, P < 0.01), while the scores on the BORG, mMRC, BODE index, CAT, and the number of acute exacerbations of COPD were reduced, and the protein and mRNA expression levels of TRXS was significantly increased (P < 0.01). However, no differences were found in PF parameters in the comparison with before the intervention or between groups. TBRS training can effectively increase exercise capacity, while there are indications that it can alleviate COPD-related dyspnoea and reduce the number of acute exacerbations of COPD. Interestingly, long-term regular TBRS training may reduce oxidative stress associated with COPD to increase exercise capacity.

What are the effects of acute exercise and exercise training on cerebrovascular hemodynamics following stroke? A systematic review and meta-analysis

INTRODUCTION

Limited data exist regarding the effects of acute exercise and exercise training on cerebrovascular hemodynamic variables post-stroke.

PURPOSE

This systematic review and meta-analysis 1) examined the effects of acute exercise and exercise training on cerebrovascular hemodynamic variables reported in the stroke exercise literature; and 2) synthesized the peak middle cerebral artery blood velocity (MCAv) achieved during an acute bout of moderate-intensity exercise in individuals post-stroke.

METHODS

Six databases (MEDLINE, EMBASE, Web of Science, CINAHL, PsycINFO, AMED) were searched from inception to December 1^st 2021, for studies that examined the effect of acute exercise or exercise training on cerebrovascular hemodynamics in adults post-stroke. Two reviewers conducted title and abstract screening, full-text evaluation, data extraction, and quality appraisal. Random effects models were used in meta-analysis.

RESULTS

Nine studies, including 4 acute exercise (n=61) and 5 exercise training studies (n=193), were included. Meta-analyses were not statistically feasible for several cerebrovascular hemodynamic variables. Descriptive analysis reveals that exercise training may increase cerebral blood flow and cerebrovascular reactivity to carbon dioxide among individuals post-stroke. Meta-analysis of three acute exercise studies revealed no significant changes in MCAv during acute moderate intensity exercise (n=48 participants, mean difference = 5.2 cm/s, 95% CI [-0.6, 11.0], P=0.08) compared to resting MCAv values.

CONCLUSION

This review suggests that individuals post-stroke may have attenuated cerebrovascular hemodynamics as measured by the MCAv during acute moderate-intensity exercise. Higher quality research utilizing agreed upon hemodynamic variables are needed to synthesize the effects of exercise training on cerebrovascular hemodynamics post-stroke.

Total body recumbent stepping vs treadmill walking in supervised exercise therapy: A pilot study

Background: Treadmill walking is the most commonly recommended exercise modality in supervised exercise therapy (SET) for peripheral artery disease (PAD); however, other modalities may be equally effective and more tolerable for patients. The primary aim of this single-blind, randomized pilot study was to compare the feasibility, safety, and preliminary efficacy of a treadmill walking (TM) versus a total body recumbent stepping (TBRS) exercise program for treatment of PAD. Methods: Participants (n = 19) enrolled in a 12-week SET program and were randomized to either a TM (n = 9) or TBRS (n = 10) exercise group that followed current SET exercise guidelines. Feasibility, safety, and efficacy outcomes were assessed. Results: SET attendance was 86% and 71%, respectively, for TBRS and TM groups (p = 0.07). Session exercise dose (metabolic equivalents of task [MET] minutes) (mean [SD]) for TM was 117.6 [27.4] compared to 144.7 [28.7] in the TBRS group (p = 0.08). Study-related adverse events were nine in 236 training hours and three in 180 training hours for the TBRS and TM groups, respectively. There were no significant differences between groups for improvement in 6-minute walk distance (mean [SD]) (TM: 133.2 ft [53.5] vs TBRS: 154.8 ft [49.8]; p = 0.77) after adjusting for baseline 6-minute walk distance. Conclusion: This is the first randomized study comparing TBRS to TM exercise in SET using current SET guidelines. This pilot study showed that TBRS is a feasible and safe exercise modality in SET. This study provides preliminary efficacy of the use of TBRS exercise in SET programs following current guidelines. Larger studies should be conducted to confirm these findings.

Muscle Oxygenation of the Paretic and Nonparetic Legs During and After Arterial Occlusion in Chronic Stroke

Oxygen delivery and demand are reduced in the paretic leg post-stroke, reflecting decreased vascular function and reduced muscle quantity and quality. However, it is unknown how muscle oxygenation, the balance between muscle oxygen delivery and utilization, is altered in chronic stroke during and after occlusion-induced ischemia.

OBJECTIVES

The objective was to determine muscle oxygen consumption rate, microvascular responsiveness and reactive hyperemia in the paretic and nonparetic legs during and after arterial occlusion post-stroke.

MATERIALS AND METHODS

Muscle oxygen saturation was measured with near-infrared spectroscopy on the vastus lateralis of each leg during 3-minute arterial occlusion and recovery (3 min). Muscle oxygen consumption was derived from the desaturation slope during ischemia, microvascular responsiveness was derived from the resaturation slope after ischemia and reactive hyperemia was derived from the area under the curve above baseline after ischemia.

RESULTS

Eleven subjects (91% male; 32.2±6.1 months post-stroke; age 62.9±13.6 years) with a hemiparetic gait pattern participated. There was no significant between-leg muscle oxygenation difference at rest (paretic: 64.9±16.6%; nonparetic: 70.6±15.6%, p = 0.13). Muscle oxygen consumption in the paretic leg (-0.53±0.24%/s) was significantly reduced compared to the nonparetic leg (-0.70±0.36%/s; p = 0.03). Microvascular responsiveness was significantly reduced in the paretic leg compared to the nonparetic leg (paretic: 4.6±1.8%/s; nonparetic: 5.7±1.6%/s, p = 0.04). Reactive hyperemia was not significantly different between legs (paretic:4384±2341%·s; nonparetic: 3040±2216%·s, p = 0.07).

CONCLUSION

Muscle oxygen consumption and microvascular responsiveness are impaired in the paretic compared to the nonparetic leg, suggesting both reduced skeletal muscle aerobic function and reduced ability to maximally perfuse muscle tissue.

Cardiorespiratory responses to exercise related to post-stroke fatigue severity

Physical deconditioning after stroke may induce post-stroke fatigue. However, research on this association is limited. Our primary objective was to investigate the associations of post-stroke fatigue severity with oxygen uptake ([Formula: see text]O₂) at peak exercise and the time constant of [Formula: see text]O₂ kinetics (τ[Formula: see text]O₂) at exercise onset. The secondary objective was to examine the associations between fatigue and cardiorespiratory variables potentially affecting [Formula: see text]O₂ during exercise. Twenty-three inpatients from a subacute rehabilitation ward were enrolled in this study. The median (interquartile range) Fatigue Severity Scale (FSS) score, as a measure of fatigue, was 32 (range 27-42) points. The FSS score was not associated with [Formula: see text]O₂ at peak exercise during a symptom-limited graded exercise test (rho = - 0.264; p = 0.224), whereas it was significantly associated with τ[Formula: see text]O₂ during a submaximal constant-load exercise test (rho = 0.530; p = 0.009). A higher FSS score also significantly correlated with a longer time constant of cardiac output (CO) kinetics (rho = 0.476; p = 0.022). Our findings suggest that severe post-stroke fatigue is associated with delayed increases in [Formula: see text]O₂ and CO at the onset of exercise. Our findings can contribute to the development of an appropriate rehabilitation programme for individuals with post-stroke fatigue.

Ambulatory activity in stroke survivors associated with functional outcome and quality of life: an observational cohort study

BACKGROUND

Physical activity is beneficial in stroke prevention and recovery. Understanding activity dynamics and its effect on outcome after stroke is important to improve recommendations and develop interventions.

OBJECTIVES

We examined serial changes in daily ambulatory activity (AA) averaged over 1 week in people with subacute to chronic stroke and its association with functional outcome (modified Rankin scale [mRS]) and quality of life (EQ-5D-3L).

METHODS

This observational study examined AA in stroke survivors with no to moderate disability (US National Institute of Stroke Scale [NIHSS] score) who were mostly community dwelling and had cryptogenic stroke based on data from the Continuous Cardiac Monitoring to Assess Atrial Fibrillation After Cryptogenic Stroke study. The participants underwent long-term AA monitoring by accelerometric activity data obtained from an insertable cardiac monitor without receiving any specific encouragement regarding physical activity. We analysed AA changes and assessed the association between baseline AA and mRS/EQ-5D-3L scores. A small group of participants had follow-up data for 2 years, which allowed for analysing long-term serial changes.

RESULTS

We included 186 participants (mean [SD] age 61.3 [11.2] years, 67% male, mean 39 [28] days after stroke). AA increased during the subacute phase in individuals with mild (NIHSS score 1-4, p<0.001) and moderate (NIHSS score 5-10, p=0.013) disability but not in the non-impaired group. Baseline AA was inversely associated with NIHSS score (p<0.001) and was associated with mRS score (p=0.001) and weakly correlated with EQ-5D-3L score at 6 months (p=0.032, r=0.22). For the 45 participants with follow-up data (mean age 64.5 [9.7] years, 80% male, mean 34 [21] days after stroke), AA remained stable.

CONCLUSION

AA increased in stroke survivors with impairments but remained stable in those whose symptoms had resolved. AA during the early subacute period was associated with mRS and EQ-5D-3L scores at 6 months. Insertable cardiac monitoring offers a feasible method for monitoring activity over prolonged periods in people after stroke. Its increased use may offer an opportunity to overcome the limited reliability and validity of many existing measures.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT00924638).

Safety and effectiveness of early cardiac rehabilitation in a stroke patient with heart failure and atrial fibrillation

Stroke patients have reduced aerobic capacity. Therefore, intensive structured exercise programs are needed. We report the case of a patient with stroke and cardiac disease who underwent early inpatient cardiac rehabilitation (CR). A 38-year-old male patient with atrial fibrillation, heart failure, and cerebral infarction underwent a symptom-limited exercise tolerance test (ETT) without any problems on day 45 after admission. He completed a 2-week inpatient program and an 8-week home-based CR program. Follow-up ETT showed increased exercise capacity. The present case might be the first to report a safely performed CR program in a patient with stroke and cardiac comorbidity in Korea. Systematic guidance is needed for post-stroke patients to receive safe and effective CR for the secondary prevention of stroke and cardiovascular risk.

Effects of Visual Feedback During Recumbent Stepping in Individuals With Chronic Stroke

Objective

To investigate the effects of intermittent visual feedback (using the Balanced Power program on the NuStep Transitt) during recumbent stepping on strength, balance, and functional mobility in individuals with chronic stroke.

Design

Quasi-experimental 1-group pretest-posttest study.

Setting

Human performance research laboratory.

Participants

Adults (N=11; 7 female; mean age, 58.7±13.6y), >6 months post stroke.

Interventions

Eight 45-minute training sessions on the NuStep Transitt (visits 2-9) twice a week (5-minute warm-up and cooldown with 35 minutes of training [5min with and then without visual feedback regarding left/right lower extremity percentage effort]). Visits 1 and 10: pre- and post assessment.

Main Outcome Measures

Self-selected and fast gait speeds; maximum voluntary contractions (MVCs) of knee extension and flexion and ankle dorsiflexion and plantarflexion; and 5 times sit-to-stand (5TSTS).

Results

Significant improvements in 5TSTS (14.2s, P=.007) and fast gait (hemi: 4.9 cm [P=.024], nonhemi: 4.5cm (P=.019) stride length; nonhemi step length 2.3 cm (P=.024]). MVC and self-selected gait parameters showed no significant changes.

Conclusions

The NuStep Transitt is a valuable tool that provides real-time feedback about percentage of use of the hemiparetic leg. This intervention study has demonstrated that the addition of visual feedback about left/right percentage effort while exercising on the Transitt has significant and clinically relevant effects on the functional mobility of individuals with chronic stroke.

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

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

Optimizing Recruitment Strategies and Physician Engagement for Stroke Recovery Research

BACKGROUND AND PURPOSE

A major challenge for stroke rehabilitation and recovery research is the recruitment and retention of participants. Our prior challenges and successes have influenced our team to rethink our approach and the potential for large-scale stroke recruitment.

SUMMARY OF KEY POINTS

In this special interest article, we highlight how the adoption and implementation of recruitment strategies such as physician engagement and a streamlined "customer service" approach helped us improve our enrollment and maximize efficiency. Another positive outcome of enrollment was increased representation of those who identify as underrepresented minority or live in rural areas.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Rethinking our recruitment processes and infrastructure allowed for greater interprofessional interactions, minimal burden for our stroke physician team members, and maximized enrollment into our stroke studies.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A324).

Two weeks of remote ischemic conditioning improves brachial artery flow mediated dilation in chronic stroke survivors

Many stroke survivors have reduced cardiorespiratory fitness as a result of their stroke. Ischemic conditioning (IC) is a noninvasive, cost-effective, easy-to-administer intervention that can be performed at home and has been shown to improve both motor function in stroke survivors and vascular endothelial function in healthy individuals. In this study, we examined the effects of 2 wk of remote IC (RIC) on brachial artery flow mediated dilation (FMD) in chronic stroke survivors. We hypothesized that FMD would be improved following RIC compared with a sham RIC control group. This was a prospective, randomized, double-blinded, controlled study. Twenty-four chronic stroke survivors (>6 mo after stroke) were enrolled and randomized to receive either RIC or sham RIC on their affected thigh every other day for 2 wk. For the RIC group, a blood pressure cuff was inflated to 225 mmHg for 5 min, followed by 5 min of recovery, and repeated a total of five times per session. For the sham RIC group, the inflation pressure was 10 mmHg. Brachial artery FMD was assessed on the nonaffected arm at study enrollment and following the 2-wk intervention period. Nine men and fourteen women completed all study procedures. Brachial artery FMD increased from 5.4 ± 4.8 to 7.8 ± 4.4% (P = 0.030; n = 12) in the RIC group, while no significant change was observed in the sham RIC group (3.5 ± 3.9% pretreatment versus 2.4 ± 3.1% posttreatment; P = 0.281, n = 11). Two weeks of RIC increases brachial artery FMD in chronic stroke survivors.NEW & NOTEWORTHY In this study, we report that 2 wk of remote ischemic conditioning (RIC) improves brachial artery flow-mediated dilation in chronic stroke survivors. Because poor cardiovascular health puts stroke survivors at a heightened risk for recurrent stroke and other cardiovascular events, an intervention that is simple, cost-effective, and easy to perform like RIC holds promise as a means to improve cardiovascular health in this at-risk population.

Determining Maximal Tolerable Aerobic Training Intensity in the Acute Phase after Stroke: a Novel Dose Ranging Trial Protocol

INTRODUCTION

There is strong evidence that cardiorespiratory fitness (CRF) training improves fitness and mobility after stroke. Despite the large number of studies, the most efficacious dose is yet to be determined. Furthermore, the safety of early post-stroke training, while theoretically beneficial, remains uncertain. The aim of this study is to determine the maximum safe and tolerable intensity of CRF training early post-stroke.

METHODS

This is a stratified (low to moderate exercise capacity), Phase I, 5+5 dose ranging trial protocol. Participants will be recruited within one month post-stroke and stratified by their exercise-capacity (i.e. low and moderate capacity). Cohorts of five participants will perform 12 interval-based training sessions for four-weeks at a pre-determined target-intensity. The intensity will increase in each consecutive cohort, in each stratum according to pre-defined rules until the maximum safe and tolerable intensity is reached, as determined by the occurrence of dose-limiting events and occurrence of adverse events. Dose-limiting events are defined as symptoms indicative of over-training including pain and inability to perform usual activities.

STUDY OUTCOME

Maximum safe and tolerable intensity of CRF training in stroke survivors with low and moderate exercise capacity.

DISCUSSION

This study is a first step in the systematic development of a CRF training intervention. We believe similar dose ranging designs may be useful for development of other rehabilitation interventions in different study populations.

Vascular Health is Associated with Amyloid-β in Cognitively Normal Older Adults

Background:

Vascular health is closely related to Alzheimer’s disease (AD). Vascular function measured by flow mediated dilation (FMD) or pulsatility index (PI) can be used as marker of peripheral and central vascular health but is poorly characterized in those at risk for AD.

Objective:

To assess the relationship of peripheral and central vascular function with amyloid-β (Aβ) and white matter lesion burden among cognitively normal older adults.

Methods:

We enrolled participants 65 years of age and older. Using Doppler ultrasound, we assessed brachial artery FMD, and middle cerebral artery (PI). Global Aβ burden, quantified using [18F] Florbetapir PET imaging, and white matter lesion volume (WML) were used as measures of AD pathology and vascular brain injury.

Results:

After adjusting for age and cardiovascular risk factors, the data (n = 83) showed a negative association between FMD and Aβ burden (β= –0.03, p < 0.001). FMD at a cut-off of 4.45% had 88% specificity and 75% sensitivity to elevated Aβ (AUC = 0.86, 95% CI: 0.77–0.95). FMD was not related to WML volume (p = 0.8), and PI was unrelated to Aβ burden or WML volume (0 > 0.4).

Conclusions:

Among cognitively normal older adults, blunted peripheral vascular function, as measured by brachial artery FMD, is associated with Aβ burden. These findings provide support for further exploration into the pathophysiological relationship of vascular health and AD risk as measured by Aβ.

The effect of stem cell therapy and comprehensive physical therapy in motor and non-motor symptoms in patients with multiple sclerosis: A comparative study

INTRODUCTION

People with multiple sclerosis (PwMS) experience a wide range of disabilities which negatively impact their quality of life (QOL). Several interventions have been used in PwMS such as medication, physical therapy exercises and stem cell therapy to improve their QOL. However, there is a limited evidence on the benefits of combining interventions. The purpose of this study is to explore the effect of combining physical therapy exercises (PTE) and Wharton Jelly mesenchymal stem cell (WJ-MSCs) injections on motor and non-motor symptoms versus each intervention alone in PwMS.

METHODS

Sixty PwMS will be allocated to either PTE, WJ-MSCs, or a combined group, followed up for 12 months and examined using a comprehensive battery of measures. Participants in the PTE group will receive 2 sessions per week of a supervised exercise program for 6 months followed by a home exercise program for another 6 months. The WJ-MSCs group will receive 3 WJ-MSCs injections in the first 6 months then they will be encouraged to follow an active life style. The third group will receive both interventions.

DISCUSSION

This study will aid in a better understanding of the combined effect of physical therapy and mesenchymal stem cell therapy. The results from this proposed study may reduce disability, improve QOL in PwMS, and consequently, reduce the cost associated with the life-time care of these individuals worldwide.

TRIAL REGISTRATION NUMBER

NCT03326505.

Reaction of the Organisms of Young Football Players to City Smog in the Sports Training

The essence of a sports training includes not only developing the skills necessary in a chosen sport but also particular care about athlete’s health. This issue should be taken into account especially in case of children and youth engaged in sporting activities. In the paper there are issues connected to the control of physical effort abilities in the sports training of young football players and the assessment of the reaction of the body to physical exercise in city smog conditions (the environment of the city of Kraków) and clean air conditions (the environment of the town of Głuchołazy). This paper shows that, when assessing physical effort, one can consider not nly the results of physical tests but also the reaction of the body to a given physical load. One should remember that physical load depends not only on the methods used and the range of intensity, but also on the environmental conditions, like the quality of the air. Determining the reaction of the body to physical load (performance tests), taking into account the conditions in which the training takes place, prevents overloading and sets directions for rational sports training. The analysis of the results of the study leads to three main conclusions: (1) The planning of sports training has to consider not only the methods and means of the training but also environmental factors (air pollution); (2) Physical effort in smog conditions should be done with the use of antismog face masks; (3) The arrangement of sports training (particularly for youth) should strictly take into account the environment in which the training takes place.

The Effect of Stroke on Middle Cerebral Artery Blood Flow Velocity Dynamics During Exercise

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).

Augmented Performance Feedback during Robotic Gait Therapy Results in Moderate Intensity Cardiovascular Exercise in Subacute Stroke

BACKGROUND

Low cardiovascular fitness is common poststroke. Conventional subacute stroke rehabilitation does not meet Australian National Stroke Guidelines for cardiovascular exercise, particularly in mobility-dependent patients. Walking robotics can potentially achieve recommended cardiovascular exercise with these patients.

AIM

The primary aim was to determine whether sustained moderate intensity cardiovascular exercise can be achieved using 3 Lokomat Augmented Performance Feedback activities in mobility-dependent adults with subacute stroke. Secondary aims were to assess if cardiovascular workload was influenced by the activity completed, participants motivation or enjoyment, or changes in Lokomat settings.

METHODS

Ten patients with subacute stroke (mean (SD) age: 63.4 (13) years) participated in 6x20-minute Lokomat study sessions. Each study session involved a warm-up and 3x5-minute APF activities presented in a random order. Metabolic data were collected using the COSMED-K5. Participants rated their perceived exertion on the BORG CR10 scale and Lokomat settings of body-weight support, guidance force, and speed were recorded.

RESULTS

Moderate intensity cardiovascular exercise was achieved and maintained over the 15 minutes of exercise, objectively demonstrated by a mean (SD) Metabolic Equivalent Task of 3.1 (1.3), and mean (SD) oxygen consumption of 8.0 (3.8) ml/kg/min, estimated as 52% VO₂max. This was subjectively confirmed by exertion scores between 3 and 5. The cardiovascular workload was not affected by which activity was completed, participant motivation or enjoyment, or significant progression of Lokomat settings between study sessions.

CONCLUSIONS

Mobility-dependent patients with subacute stroke can achieve sustained moderate intensity cardiovascular exercise on the Lokomat when using APF activities.

Implementation of home-based health promotion program to improve flow-mediated dilation among patients with subacute stroke

INTRODUCTION

Stroke causes physiologic functional changes such as vascular resistance and arterial remodeling. This study aimed to explore the effects of 3-month regular home-based exercise rehabilitation on brachial flow-mediated dilation (FMD), daily physical activity, and upper and lower extremity sensorimotor of the acute ischemic stroke patients.

MATERIALS AND METHODS

This randomized control trial was done from August 2017 to September 2018. Patients with unilateral ischemic stroke were recruited from inpatient wards at an educational hospital. Patients were randomly assigned to the home-based rehabilitation program (intervention group) or usual care (control group). Fugl-Meyer upper and lower extremity sensorimotor score and Barthel score were evaluated in both the groups before and 3 months after baseline assessment. Furthermore, brachial artery vasomotor reactivity (FMD) hemiparetic arm assessed vascular health. The intervention group received home-based rehabilitation exercise program for 3 months. The control group did not receive home-based rehabilitation program and incentive telephone call. All data were collected and analyzed by SPSS software (version 20) and appropriate statistical tests.

RESULTS

Forty ischemic stroke patients (twenty in the intervention group and twenty in the control group) were examined. Results showed that Barthel score and Fugl-Meyer upper and lower extremity score and FMD in the intervention group were significantly higher than the control group after 3-month home-based exercise rehabilitation (P < 0/001).

CONCLUSION

Twelve-week regular home-based exercise training was well tolerated by the intervention group. After this period, improvements were reported in brachial FMD as well as daily physical activity and upper and lower extremity functional capacity.

Safety of Performing a Graded Exercise Test Early after Stroke and Transient Ischemic Attack

BACKGROUND

Low cardiorespiratory fitness (CRF) is a predictor of stroke risk and poor outcome poststroke. Fitness levels are rarely assessed in the acute phase and it is unclear if it is safe for stroke survivors and people with transient ischemic attack (TIA) to perform a graded exercise test to assess fitness.

OBJECTIVE

To determine if people within 14 days post stroke can safely perform a graded exercise test.

DESIGN

Observational study.

SETTING

Research institute.

PARTICIPANTS

People with stroke or TIA admitted to an acute stroke unit.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Safety of performing a graded exercise test early post stroke. Safety outcomes were (1) occurrence of an adverse event or (2) <85% blood oxygen saturation (SpO₂ ). Participants performed a graded exercise test on a recumbent stepper at a research institute <2 weeks postevent. CRF was determined by measuring peak volume of oxygen uptake (VO_2peak ) using a metabolic cart.

RESULTS

Twenty-nine participants were enrolled in the study (median age 69 years; interquartile range 58-75). Sixteen were diagnosed with TIA and 13 with a mild stroke. Twenty-eight participants completed the test; one participant was unable to perform the test due to back pain. The test was terminated due to standardized stopping criteria in 26 cases (5 = volitional fatigue, 6 = unable to keep required cadence, 15 = reaching 85% HR_max ), one due to safety (ie, SpO₂  < 85%), and one was inadvertently terminated before stopping criteria were reached. Average CRF determined by the exercise test was low; mean VO_2peak of 16.2 ± 4.5 mL/kg/min for men (n = 20) and 12.4 ± 3.6 mL/kg/min for women (n = 8).

CONCLUSIONS

Determining exercise capacity early post stroke and TIA using a graded exercise test appears to be safe in patients with mild deficits. This information should be useful to plan tailored exercise programs. Further research should focus on determining safety of exercise testing in more severely affected stroke survivors.

The six-minute walk test as a fall risk screening tool in community programs for persons with stroke: a cross-sectional analysis

Background and Purpose: Persons with stroke have increased risk for recurrent stroke. Group exercise programs like cardiac rehabilitation might reduce this risk. These programs commonly use the six-minute walk test to measure aerobic capacity. However, failure to assess fall risk may compromise safety for persons with stroke. The study aim was to determine the association between the six-minute walk test and fall risk in persons with stroke.Methods: Cross-sectional analysis measured the association between the six-minute walk test and fall risk in 66 persons with stroke with a mean age of 66 years (SD 12) and median stroke chronicity of 60.9 months (range 6.0-272.1). The six-minute walk test was evaluated using logistic regression. The best fit model was used in Receiver Operating Characteristic analysis. Likelihood ratios and post-test probabilities were calculated.Results: Lower six-minute walk test distance was associated with increased fall risk in logistic regression (p = .002). The area under the curve for the univariate six-minute walk test model (best fit) was 0.701 (p = .006). The cutoff for increased fall risk was six-minute walk test <331.65 m. The post-test probability of fall risk increased to 74.3% from a pre-test probability of 59.1%.Discussion: The moderate association between fall risk and six-minute walk test suggests that in addition to assessing capacity, the six-minute walk test provides insight into fall risk/balance confidence.Conclusion: Using the six-minute walk test cutoff to screen fall risk in community exercise programs may enhance safety for persons with stroke without additional testing required.

Effect of high-intensity exercise on cardiorespiratory fitness in stroke survivors: A systematic review and meta-analysis

BACKGROUND

Knowledge of the optimal protocol and safety of particularly high-intensity exercise applied to individuals with stroke is lacking.

OBJECTIVE

This systematic review and meta-analysis aimed to investigate the effect of high-intensity exercise on cardiorespiratory fitness in stroke survivors.

METHODS

We performed a systematic electronic search for articles in MedLine via PubMed, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials, CINAHL, and SPORTSDiscus up to April 1, 2019. Peak oxygen consumption (VO₂peak), 6-min walk test (6MWT), fastest 10-m walk test (10MWT), and adverse events were assessed. The standardized mean difference (SMD), weighted mean difference (WMD), and odds ratios (ORs) were used to compute the effect size, and subgroup analysis was conducted to test the consistency of results as well as sensitivity analysis to assess the robustness of the results. The quality of evidence was assessed with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

We included 17 studies (PEDro score≥4) in the meta-analysis. Post-intervention, high-intensity exercise had a significant effect on peak oxygen uptake (VO₂peak; SMD=0.56, P<0.01, I²=8%; WMD=2.53mL/kg/min; high quality of evidence) and 6MWT (SMD=0.26, P<0.01, I²=40%; WMD=17.08m; moderate quality of evidence) but not fastest 10MWT (SMD=0.33, P=0.27, I²=77%; WMD=0.05m/s; low quality of evidence). Subgroup analysis showed better effects of higher-intensity treadmill training (≥70% heart rate reserve/VO₂peak) for a longer duration (≥12 weeks) on VO₂peak and 6MWT in sub-acute or chronic stroke survivors. The high-intensity exercise and control groups did not differ in adverse events including falls [odds ratio (OR) 1.40, P=0.35, I²=11%; low quality of evidence], pain (OR 3.34, P=0.09, I²=0%; moderate quality of evidence), or skin injuries (OR 1.08, P=0.90, I²=0%; low quality of evidence).

CONCLUSIONS

Our meta-analysis suggests that high-intensity exercise is beneficial for cardiorespiratory fitness in stroke survivors and might be safe as a novel intervention in cardiopulmonary rehabilitation after stroke.

Are Aerobic Programs Similar in Design to Cardiac Rehabilitation Beneficial for Survivors of Stroke? A Systematic Review and Meta-Analysis

Background Survivors of stroke face movement disability and increased cardiovascular disease and stroke risk. Treatment includes rehabilitation focused on functional movement with less emphasis on aerobic capacity. After rehabilitation, survivors of stroke must self-manage activity with limited appropriate community programs. Lack of structured activity contributes to sedentary behavior. The objective of this systematic review and meta-analysis is to review aerobic programs for stroke survivors similar in activity and dosage to cardiac rehabilitation programs to determine their efficacy for improving aerobic and walking capacity. Methods and Results Preferred Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to review 5 databases. Group interventions for survivors of stroke with a primary aerobic component and dosage from 18 to 36 visits over 8 to 18 weeks (matching cardiac rehabilitation requirements in the United States) were included. The 6-minute walk test, maximal oxygen consumption (VO2) peak, and walking speed were included as measures of aerobic capacity. Summary effect sizes and outcome measure mean differences were calculated for preintervention to postintervention, and summary effect sizes were calculated for preintervention to follow-up. Activity type and initial 6-minute walk test moderator analyses were performed. Nineteen studies with 23 eligible groups were selected. Survivors of stroke improved their composite aerobic capacity with an effect size of 0.38 (95% CI, 0.27-0.49). Studies including 6-minute walk test demonstrated a pooled difference in means of 53.3 m (95% CI, 36.8-69.8 m). Follow-up data were inconclusive. Conclusions Survivors of stroke benefit from aerobic programs with similar dosing to cardiac rehabilitation in the United States. The potential integration into existing programs could expand the community exercise options.

Development and Evaluation of MOVit: An Exercise-Enabling Interface for Driving a Powered Wheelchair

Powered wheelchair users can experience negative health effects from reduced physical activity. If a user could exercise by driving the chair, it might improve fitness. This paper presents the development of MOVit, an exercise-enabling, wheelchair driving interface. The design goal of MOVit was that users cyclically move their arms to drive the chair, thereby providing a light level of exercise while driving. MOVit supports this arm movement with custom mobile arm supports that also serve as the sensors that provide controller inputs. Here, we first quantified how increasing the frequency and amplitude of arm movement increase oxygen consumption and heart rate. Then, we evaluated two novel control methods for driving by moving the arm supports. Participants without impairment ( N = 24 ) were randomized to one of the two methods, or conventional joystick control, and performed driving tests over two days on a simulator and test course. Our results indicate that driving speed and accuracy were significantly lowered with the exercise-enabling methods compared to joystick control (ANOVA, ), but the decreases were small (speed was ~0.1 m/s less and course tracking error ~1 cm greater). These results show, for the first time, the feasibility of exercising while driving a powered wheelchair.

A Bout of High Intensity Interval Training Lengthened Nerve Conduction Latency to the Non-exercised Affected Limb in Chronic Stroke

Objective: Evaluate intensity-dependent effects of a single bout of high intensity interval training (HIIT) compared to moderate intensity constant-load exercise (MICE) on corticospinal excitability (CSE) and effects on upper limb performance in chronic stroke.

Design: Randomized cross-over trial.

Setting: Research laboratory in a tertiary rehabilitation hospital.

Participants: Convenience sample of 12 chronic stroke survivors.

Outcome measures: Bilateral CSE measures of intracortical inhibition and facilitation, motor thresholds, and motor evoked potential (MEP) latency using transcranial magnetic stimulation. Upper limb functional measures of dexterity (Box and Blocks Test) and strength (pinch and grip strength).

Results: Twelve (10 males; 62.50 ± 9.0 years old) chronic stroke (26.70 ± 23.0 months) survivors with moderate level of residual impairment participated. MEP latency from the ipsilesional hemisphere was lengthened after HIIT (pre: 24.27 ± 1.8 ms, and post: 25.04 ± 1.8 ms, p = 0.01) but not MICE (pre: 25.49 ± 1.10 ms, and post: 25.28 ± 1.0 ms, p = 0.44). There were no significant changes in motor thresholds, intracortical inhibition or facilitation. Pinch strength of the affected hand decreased after MICE (pre: 8.96 ± 1.9 kg vs. post: 8.40 ± 2.0 kg, p = 0.02) but not after HIIT (pre: 8.83 ± 2.0 kg vs. post: 8.65 ± 2.2 kg, p = 0.29). Regardless of type of aerobic exercise, higher total energy expenditure was associated with greater increases in pinch strength in the affected hand after exercise (R² = 0.31, p = 0.04) and decreases in pinch strength of the less affected hand (R² = 0.26 p = 0.02).

Conclusion: A single bout of HIIT resulted in lengthened nerve conduction latency in the affected hand that was not engaged in the exercise. Longer latency could be related to the cross-over effects of fatiguing exercise or to reduced hand spasticity. Somewhat counterintuitively, pinch strength of the affected hand decreased after MICE but not HIIT. Regardless of the structure of exercise, higher energy expended was associated with pinch strength gains in the affected hand and strength losses in the less affected hand. Since aerobic exercise has acute effects on MEP latency and hand strength, it could be paired with upper limb training to potentiate beneficial effects.

High-Intensity Interval Training After Stroke: An Opportunity to Promote Functional Recovery, Cardiovascular Health, and Neuroplasticity

INTRODUCTION

Stroke is the leading cause of adult disability. Individuals poststroke possess less than half of the cardiorespiratory fitness (CRF) as their nonstroke counterparts, leading to inactivity, deconditioning, and an increased risk of cardiovascular events. Preserving cardiovascular health is critical to lower stroke risk; however, stroke rehabilitation typically provides limited opportunity for cardiovascular exercise. Optimal cardiovascular training parameters to maximize recovery in stroke survivors also remains unknown. While stroke rehabilitation recommendations suggest the use of moderate-intensity continuous exercise (MICE) to improve CRF, neither is it routinely implemented in clinical practice, nor is the intensity always sufficient to elicit a training effect. High-intensity interval training (HIIT) has emerged as a potentially effective alternative that encompasses brief high-intensity bursts of exercise interspersed with bouts of recovery, aiming to maximize cardiovascular exercise intensity in a time-efficient manner. HIIT may provide an alternative exercise intervention and invoke more pronounced benefits poststroke.

OBJECTIVES

To provide an updated review of HIIT poststroke through ( a) synthesizing current evidence; ( b) proposing preliminary considerations of HIIT parameters to optimize benefit; ( c) discussing potential mechanisms underlying changes in function, cardiovascular health, and neuroplasticity following HIIT; and ( d) discussing clinical implications and directions for future research.

RESULTS

Preliminary evidence from 10 studies report HIIT-associated improvements in functional, cardiovascular, and neuroplastic outcomes poststroke; however, optimal HIIT parameters remain unknown.

CONCLUSION

Larger randomized controlled trials are necessary to establish ( a) effectiveness, safety, and optimal training parameters within more heterogeneous poststroke populations; (b) potential mechanisms of HIIT-associated improvements; and ( c) adherence and psychosocial outcomes.

Validity of Multisensor Array for Measuring Energy Expenditure of an Activity Bout in Early Stroke Survivors

Introduction. Stroke survivors use more energy than healthy people during activities such as walking, which has consequences for the way exercise is prescribed for stroke survivors. There is a need for wearable device that can validly measure energy expenditure (EE) of activity to inform exercise prescription early after stroke. We aimed to determine the validity and reliability of the SenseWear-Armband (SWA) to measure EE and step-counts during activity <1 month after stroke. Materials and Methods. EE was measured using the SWA and metabolic cart and steps-counts were measured using the SWA and direct observation. Based on walking ability, participants performed 2x six-minute walks or repeated sit-to-stands. Concurrent validity and test-retest reliability were determined by calculating intraclass and concordance correlation coefficients. Results and Discussion. Thirteen participants walked; nine performed sit-to-stands. Validity of the SWA measuring EE for both activities was poor (ICC/CCC < 0.40). The SWA overestimates EE during walking and underestimated EE during sit-to-stands. Test-retest agreement showed an ICC/CCC of <0.40 and >0.75 for walking and sit-to-stand, respectively. However, agreement levels changed with increasing EE levels (i.e., proportional bias). The SWA did not accurately measure step-counts. Conclusion. The SWA should be used with caution to measure EE of activity of mild to moderate stroke survivors <1 month after stroke.

Preliminary Evidence for the Impact of Combat Experiences on Gray Matter Volume of the Posterior Insula

Background: Combat-exposed veteran populations are at an increased risk for developing cardiovascular disease. The anterior cingulate cortex (ACC) and insula have been implicated in both autonomic arousal to emotional stressors and homeostatic processes, which may contribute to cardiovascular dysfunction in combat veteran populations. The aim of the present study was to explore the intersecting relationships of combat experiences, rostral ACC and posterior insula volume, and cardiovascular health in a sample of combat veterans.

Method: Twenty-four male combat veterans completed clinical assessment of combat experiences and posttraumatic stress symptoms. Subjects completed a magnetic resonance imaging scan and autosegmentation using FreeSurfer was used to estimate regional gray matter volume (controlling for total gray matter volume) of the rostral ACC and posterior insula. Flow-mediated dilation (FMD) was conducted to assess cardiovascular health. Theil-sen robust regressions and Welch's analysis of variance were used to examine relationships of combat experiences and PTSD symptomology with (1) FMD and (2) regional gray matter volume.

Results: Increased combat experiences, deployment duration, and multiple deployments were related to smaller posterior insula volume. Combat experiences were marginally associated with poorer cardiovascular health. However, cardiovascular health was not related to rostral ACC or posterior insula volume.

Conclusion: The present study provides initial evidence for the relationships of combat experiences, deployment duration, and multiple deployments with smaller posterior insula volume. Results may suggest that veterans with increased combat experiences may exhibit more dysfunction regulating the autonomic nervous system, a key function of the posterior insula. However, the relationship between combat and cardiovascular health was not mediated by regional brain volume. Future research is warranted to further clarify the cardiovascular or functional impact of smaller posterior insula volume in combat veterans.

Four birds with one stone? Reparative, neuroplastic, cardiorespiratory, and metabolic benefits of aerobic exercise poststroke

PURPOSE OF REVIEW

Converging evidence from animal models of stroke and clinical trials suggests that aerobic exercise has effects across multiple targets.

RECENT FINDINGS

The subacute phase is characterized by a period of heightened neuroplasticity when aerobic exercise has the potential to optimize recovery. In animals, low intensity aerobic exercise shrinks lesion size and reduces cell death and inflammation, beginning 24 h poststroke. Also in animals, aerobic exercise upregulates brain-derived neurotrophic factor near the lesion and improves learning. In terms of neuroplastic effects, clinical trial results are less convincing and have only examined effects in chronic stroke. Stroke patients demonstrate cardiorespiratory fitness levels below the threshold required to carry out daily activities. This may contribute to a 'neurorehabilitation ceiling' that limits capacity to practice at a high enough frequency and intensity to promote recovery. Aerobic exercise when delivered 2-5 days per week at moderate to high intensity beginning as early as 5 days poststroke improves cardiorespiratory fitness, dyslipidemia, and glucose tolerance.

SUMMARY

Based on the evidence discussed and applying principles of periodization commonly used to prepare athletes for competition, we have created a model of aerobic training in subacute stroke in which training is delivered in density blocks (duration × intensity) matched to recovery phases.

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.

Is there influence of the load addition during treadmill training on cardiovascular parameters and gait performance in patients with stroke? A randomized clinical trial

BACKGROUND

Although exercises involving both lower limbs are indicated for aerobic training, stroke patients have shown expressive asymmetry between the paretic and non-paretic lower limb (NPLL). Performing activities that stimulate the paretic limb during aerobic exercise may optimize training results.

OBJECTIVE

To evaluate if there is influence of load addition on NPLL during treadmill training on cardiovascular parameters and gait performance of subacute stroke patients.

METHODS

Thirty-eight stroke subjects with gait deficits were randomized into experimental group, which underwent treadmill training with a mass attached on NPLL, and control group, which underwent only treadmill training. Interventions lasted 2 weeks (9 sessions). Main outcomes were heart rate, arterial blood pressure, gait speed and distance covered. Assessments occurred at rest, 10th and 20th minutes of the session and immediately after each session.

RESULTS

There was improvement in speed and walking distance in both groups. All cardiovascular parameters had showed no changes compared to 1st and 9th sessions and there were no differences between groups within each session.

CONCLUSIONS

Load addition on NPLL did not alter cardiovascular parameters and gait training provide better gait performance of subacute stroke patients, which indicates this therapy can be considered useful and safe for these patients.

The Effects of Exercise Training on Brachial Artery Flow-Mediated Dilation: A Meta-analysis

PURPOSE

Flow-mediated dilation, a barometer of cardiovascular (CV) health, is reported to increase with exercise training (ET); however, the potential moderating factors of ET are not clear to date. The purpose of this study was to determine the effect of ET assessed by brachial artery flow-mediated dilation (BAFMD).

METHODS

Authors searched PubMed between January 1999 and December 2013, bibliographies, and reviews to identify studies examining ET and BAFMD. Two independent reviewers extracted quality, descriptive, exercise, and outcome data of eligible studies. Data were presented as weighted effect sizes (ESs) and 95% confidence limits.

RESULTS

Analysis included 66 studies reporting BAFMD data (1865 ET and 635 control subjects). Overall, ET had significant improvements in BAFMD compared with controls (P < .0001). Exercise training at higher ET intensities resulted in a greater increase in BAFMD (9.29; 95% CI, 5.09-13.47) than lower ET intensities (3.63; 95% CI, -0.56 to 7.83) or control (-0.42; 95% CI, -2.06 to 1.21). Subjects whose ET duration was ≥150 min/wk (11.33; 95% CI, 7.15-15.51) had a significant improvement in BAFMD compared with those with <150 min/wk (4.79; 95% CI, 3.08-6.51) or control (-0.30; 95% CI, -1.99 to 1.39). Age (P = .11) and baseline artery diameter (P = .31) did not modify the BAFMD response to ET.

CONCLUSION

Exercise training contributes to a significant increase in BAFMD. These results provide indirect evidence that ET alters a well-known factor associated with the primary and secondary prevention of CV diseases. Exercise training interventions, including greater intensity and duration, may optimize the increase in BAFMD.