Defining Optimal Aerobic Exercise Parameters to Affect Complex Motor and Cognitive Outcomes after Stroke: A Systematic Review and Synthesis

Effects of exercise dose based on the ACSM recommendations on patients with post-stroke cognitive impairment: a systematic review and meta-analyses

Purpose

This review aimed to assess the impact of different exercise dosages on cognitive function in individuals with post-stroke cognitive impairment (PSCI).

Methods

Four electronic databases-Embase, PubMed, Web of Science, and Cochrane Library-were systematically searched from inception to 01 January 2024, focusing on the impact of exercise therapy on cognitive function in individuals with PSCI. Only randomized controlled trials meeting the criteria were included. The exercise therapy dose and adherence were evaluated following the American College of Sports Medicine (ACSM) guidelines, categorized into a high compliance group with ACSM recommendations and a low or uncertain compliance group. A random-effects model compared the effect of ACSM compliance on cognitive function in individuals with PSCI, with the effect size represented by the standardized mean difference (SMD) and a 95% confidence interval (CI).

Results

In total, 18 studies meeting the criteria were included, with data from 1,742 participants. The findings suggested a beneficial effect of exercise on cognitive function in individuals with PSCI [SMD = 0.42, 95% CI (0.20, 0.65)]. Ten studies were categorized as the "high adherence group" and eight in the "low or uncertain adherence group" based on the ACSM recommendations. The subgroup analysis revealed that the SMD of the high compliance group was 0.46 (95% CI: 0.10, 0.82) (p = 0.01), while the SMD of the low or uncertain compliance group was 0.38 (95% CI: 0.07, 0.70) (p = 0.02).

Conclusion

Our study indicates the beneficial impact of exercise for patients with PSCI over no exercise. Furthermore, high adherence to the exercise dose recommended by ACSM guidelines demonstrated a more substantial improvement in cognitive function than low or uncertain adherence in patients with PSCI. Systematic Review Registration: https:// www.crd.york.ac.uk/prospero/#myprospero, identifier CRD42023487915.

Potential effect of physical exercise on the downregulation of BDNF mRNA expression in rat hippocampus following intracerebral hemorrhage

OBJECTIVES

Physical exercise is known to induce expression of the neuroprotective brain derived neurotrophic factor (BDNF) in the hippocampus. This study examined the effects of physical exercise on hippocampal BDNF expression and the potential benefits for preventing remote secondary hippocampal damage and neurological impairment following intracerebral hemorrhage (ICH).

MATERIALS AND METHODS

Wistar rats were randomly assigned to sham-operated, ICH, and ICH followed by exercise (ICH/Ex) groups. The two ICH groups were injected with type IV collagenase into the left basal ganglia, while sham animals were injected with equal-volume saline. The ICH/Ex group rats ran on a treadmill at 11 m/min for 30 min/day from day 3 to 16 post-ICH. All animals were examined for neurological function on day 2 pretreatment and from day 3 to 15 posttreatment, for spontaneous motor activity in the open field on day 15, and for cognitive ability using the object location test on day 16. Animals were then euthanized and bilateral hippocampi collected for gene expression analyses.

RESULTS

Experimental ICH induced neurological deficits that were not reversed by exercise. In contrast, ICH did not alter spontaneous activity or object location ability. Expression of BDNF mRNA of the ICH group was significantly downregulated in the ipsilateral hippocampus compared to the SHAM group, but this downregulation was not shown in the ICH/Ex group. The ICH/Ex group showed the downregulation of caspase-3 mRNA expression in the contralateral hippocampus compared to the SHAM group, while neither ICH nor exercise influenced toll-like receptor 4 mRNA expression.

CONCLUSIONS

ICH induced the secondary BDNF downregulation in the hippocampus remote from the lesion, whereas physical exercise might partially mitigate the downregulation.

Effects of Hand Motor Interventions on Cognitive Outcomes Post-stroke: A Systematic Review and Bayesian Network Meta-analysis

OBJECTIVE

To synthetize the evidence on the effects of hand rehabilitation (RHB) interventions on cognition post-stroke and compare their efficacy.

DATA SOURCES

PubMed, Embase, Cochrane, Scopus, Web of Science, and CINAHL were searched from inception to November 2022.

DATA SELECTION

Randomized controlled trials conducted in adults with stroke where the effects of hand motor interventions on any cognitive domains were assessed.

DATA EXTRACTION

Data were extracted by 2 independent reviewers. A Bayesian Network Meta-analysis (NMA) was applied for measures with enough studies and comparisons. Risk of bias was assessed with the Cochrane Risk of Bias tool.

DATA SYNTHESIS

Fifteen studies were included in qualitative synthesis, and 11 in NMA. Virtual reality (VR) (n=7), robot-assisted (n=5), or handgrip strength (n=3) training were the experimental interventions and conventional RHB (n=14) control intervention. Two separate NMA were performed with MoCA (n=480 participants) and MMSE (n=350 participants) as outcome measures. Both coincided that the most probable best interventions were robot-assisted and strength training, according to SUCRA and rankogram, followed by conventional RHB and VR training. No significant differences between any of the treatments were found in the MoCA network, but in the MMSE, robot-assisted and strength training were significantly better than conventional RHB and VR. No significant differences between robot-assisted and strength training were found nor between conventional RHB and VR.

CONCLUSIONS

Motor interventions can improve MoCA/MMSE scores post-stroke. Most probable best interventions were robot-assisted and strength training. Limited literature assessing domain-specific cognitive effects was found.

The Critical Period After Stroke Study (CPASS) Upper Extremity Treatment Protocol

Objective

To present the development of a novel upper extremity (UE) treatment and assess how it was delivered in the Critical Periods After Stroke Study (CPASS), a phase II randomized controlled trial (RCT).

Design

Secondary analysis of data from the RCT.

Setting

Inpatient and outpatient settings the first year after stroke.

Participants

Of the 72 participants enrolled in CPASS (N=72), 53 were in the study groups eligible to receive the treatment initiated at ≤30 days (acute), 2-3 months (subacute), or ≥6 months (chronic) poststroke. Individuals were 65.1±10.5 years of age, 55% were women, and had mild to moderate UE motor capacity (Action Research Arm Test=17.2±14.3) at baseline.

Intervention

The additional 20 hours of treatment began using the Activity Card Sort (ACS), a standardized assessment of activities and participation after stroke, to identify UE treatment goals selected by the participants that were meaningful to them. Treatment activities were broken down into smaller components from a standardized protocol and process that operationalized the treatments essential elements.

Main Outcome Measures

Feasibility of performing the treatment in a variety of clinical settings in an RCT and contextual factors that influenced adherence.

Results

A total of 49/53 participants fully adhered to the CPASS treatment. The duration and location of the treatment sessions and the UE activities practiced during therapy are presented for the total sample (n=49) and per study group as an assessment of feasibility and the contextual factors that influenced adherence.

Conclusions

The CPASS treatment and therapy goals were explicitly based on the meaningful activities identified by the participants using the ACS as a treatment planning tool. This approach provided flexibility to customize UE motor therapy without sacrificing standardization or quantification of the data regardless of the location and UE impairments of participants within the first year poststroke.

Defining, quantifying, and reporting intensity, dose, and dosage of neurorehabilitative interventions focusing on motor outcomes

Introduction

Determining the minimal amount of therapy needed for positive neurorehabilitative outcomes is important for optimizing active treatment interventions to improve motor outcomes. However, there are various challenges when quantifying these relationships: first, several consensuses on the definition and usage of the terms intensity, dose, and dosage of motor interventions have been proposed, but there seems to be no agreement, and the terms are still used inconsistently. Second, randomized controlled trials frequently underreport items relevant to determining the intensity, dose, and dosage of the interventions. Third, there is no universal measure to quantify therapy intensity accurately. This "perspectives" paper aims to increase awareness of these topics among neurorehabilitation specialists.

Defining quantifying and reporting

We searched the literature for definitions of intensity, dose, and dosage and adapted the ones we considered the most appropriate to fit the needs of neurorehabilitative interventions. Furthermore, we suggest refining the template for intervention description and replication (TIDieR) to enhance the reporting of randomized controlled trials. Finally, we performed a systematic literature search to provide a list of intensity measures and complemented these with some novel candidate measures.

Discussion

The proposed definitions of intensity, dose, and dosage could improve the communication between neurorehabilitation specialists and the reporting of dose and dosage in interventional studies. Quantifying intensity is necessary to improve our understanding of the minimal intensity, dose, and dosage of therapy needed to improve motor outcomes in neurorehabilitation. We consider the lack of appropriate intensity measures a significant gap in knowledge requiring future research.

The effects of exercise intervention on cognition and motor function in stroke survivors: a systematic review and meta-analysis

BACKGROUND

Cognitive impairment was a common sequela among stroke survivors, and exercise intervention was a promising non-pharmacological treatment modality for it.

PURPOSE

To explore the effects of exercise intervention programs on cognitive and motor function in patients with cognitive impairment after stroke.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Seven online databases (PubMed, Embase, Cochrane Library, Web of Science, Scopus, PsycInfo, and SPORTDiscus) were searched from their inception to 10 February 2022. Randomised controlled trials (RCTs) comparing the effects of exercise with non-exercise rehabilitation, using the Montreal Cognitive Assessment, Addenbrooke's Cognitive Examination, Mini-Mental State Examination, Trial Making Test, Upper and Lower Extremity Fugl-Meyer Assessment, Berg Balance Scale, and Barthel Index, were selected. Calculations for each assessment were performed for the overall effect and the therapy of interest, taking into account the effect of stroke severity or stimulus parameters.

RESULTS

Twelve RCTs involving 975 participants and investigating nine different types of exercise interventions were included. The results were not affected by participant characteristics or reactive balance outcomes. Our results emphasise the importance of lightweight and operable aerobic exercises. Exercise itself had a high potential to improve cognitive impairment and motor function after stroke.

CONCLUSIONS

Exercise had significant positive effects on alleviating cognitive and motor impairments after stroke.

Effects of moderate-intensity aerobic exercise on serum BDNF and motor learning in the upper-limb in patients after chronic-stroke: A randomized, controlled feasibility study with embedded health economic evaluation

BACKGROUND

Brain-derived neurotrophic factor (BDNF) promotes activity-dependent neuroplasticity and is released following aerobic-exercise.

OBJECTIVE

Feasibility and efficacy of 1.Moderate-Intensity Cycle-Ergometer-Training (MI-ET) and 2.Low-Intensity Circuit-Training (LI-CT) on BDNF-serum-concentration in chronic-stroke and consequently efficacy of motor-learning in varying BDNF-concentrations (neuroplasticity being the substrate for motor-learning) via upper-limb robotic-training (RT) in both groups.

METHODS

Randomised-control feasibility-study. 12-week, 3x/week intervention, 17 chronic-stroke-survivors randomized into: (1) MI-ET&RT or (2) LI-CT&RT. Both groups completed 40 mins MI-ET or LI-CT followed by 40 mins RT. Feasibility outcomes: (1) screening and enrollment-rates, (2) retention-rates, (3) adherence: (i) attendance-rates, (ii) training-duration, (4) adverse events. Primary clinical outcomes: 1. serum-BDNF changes pre-post training (immediate) and pre-training basal-levels over 12-weeks (long-term). 2.upper-limb performance with Action-Research-Arm-Test (ARAT). Additionally, feasibility of an embedded health economic evaluation (HEE) to evaluate health-costs and cost-effectiveness.

OUTCOMES

cost-questionnaire return-rates, cost-of-illness (COI) and Health-Utitility-Index (HUI).

RESULTS

21.5% of eligible and contactable enrolled. 10 randomized to MI-ET and 7 to LI-CT. 85% of training-sessions were completed in MI-ET (306/360) and 76.3% in LI-CT-group (165/216). 12-weeks: Drop-outs MI-ET-10%, LI-CT-43%.

CLINICAL OUTCOMES

No significant changes in immediate or long-term serum-BDNF in either group. Moderate-intensity aerobic-training did not increase serum-BDNF post-stroke. Individual but no group clinically-relevant changes in ARAT-scores. HEE outcomes at 12-weeks: 100% cost-questionnaires returned. Group-costs baseline and after treatment, consistently favouring MI-ET group. COI: (1-year-time-frame): MI-ET 67382 SD (43107) Swiss-Francs and LI-CT 95701(29473) Swiss-Francs.

CONCLUSION

The study is feasible with modifications. Future studies should compare high-intensity versus moderate-intensity aerobic-exercise combined with higher dosage arm-training.

Effects of Exercise Programs on Functional Capacity and Quality of Life in People With Acquired Brain Injury: A Systematic Review and Meta-Analysis

OBJECTIVE

The aims of this systematic review and meta-analyses were to evaluate the effects of exercise on the functional capacity and quality of life (QoL) of people with acquired brain injury (ABI) and to analyze the influence of training variables.

METHODS

Five electronic databases (MEDLINE, Cochrane Library, CINAHL, SportDiscus, and Web of Science) were searched until October 2021 for clinical trials or experimental studies examining the effects of exercise on the functional capacity and QoL in adults with ABI and comparing exercise interventions with non-exercise (usual care).

RESULTS

Thirty-eight studies were evaluated. A total sample of 2219 people with ABI (exercise, n = 1572; control, n = 647) were included in the quantitative analysis. A greater improvement was observed in walking endurance (z score = 2.84), gait speed (z score = 2.01), QoL physical subscale (z score = 3.42), and QoL mental subscale (z score = 3.00) was observed in the experimental group than in the control group. In addition, an improvement was also observed in the experimental group in the "Timed Up and Go" Test scores and balance without differences from the control group. Significant interactions were also observed between the rehabilitation phases, type, frequency and volume of training, and overall effects.

CONCLUSION

The results suggest that exercise improves functional capacity and QoL regardless of model training, highlighting the effectiveness of long-term exercise that includes short sessions with components such as strength, balance, and aerobic exercise.

IMPACT

The results shown in this systematic review with meta-analysis will allow physical therapists to better understand the effects of training on people with ABI.

Comparison of the Effects of Constraint-Induced Movement Therapy and Unconstraint Exercise on Oxidative Stress and Limb Function-A Study on Human Patients and Rats with Cerebral Infarction

Most conventional post-stroke rehabilitation treatments do not involve imposed constraints of the unaffected limb. In contrast, Constraint-Induced Movement Therapy (CIMT) is comprised of massed task practice with the affected limb and constraint of the unaffected limb. CIMT is a promising rehabilitation technique used for motor recovery of affected limbs after stroke, but its effectiveness and mechanism are not fully understood. We compared the effects of the two exercise modes on limb function post-stroke in animal models and human subjects, and investigated whether oxidative stress response was involved in regulating the effects. We first conducted a randomized controlled trial (RCT), in which 84 subjects with cerebral infarction were assigned to dose-matched constraint-induced movement therapy (CIMT), or unconstraint exercise (UE), or conventional rehabilitation treatment. Motor functions of the limb are primary outcomes of the RCT measured using Brief Fugl-Meyer upper extremity score (FMA-UE), Ashworth score, and Barthel scale. Psychological influence of CIMT and UE was also examined using Self-Rating Depression Scale (SDS). Next, we investigated the effects of CIMT and UE in rats undergoing middle cerebral artery occlusion and reperfusion (MCAO/R). Motor function, infarct volume, and pathohistological changes were investigated by mNSS, MRI, and histological studies. The role of Keap1-Nrf2-ARE was investigated using qRT-PCR, Western blot, immunochemistry, immunofluorescence, and ELISA experiments. In RCT, patients taking CIMT had a higher score in FMA-UE, Barthel index, and SDS, and a lower score in modified Ashworth, compared to those taking UE. In rats receiving CIMT, motor function was increased, and infarct volume was decreased compared to those receiving UE. The expression of Keap1 protein and mRNA in the peri-infarct tissue was decreased, and Nrf2 and ARE protein and mRNA were increased in rats receiving CIMT compared with UE. Nrf2 agonist t-BHQ increased the benefits of CIMT. In conclusion, CIMT is more effective than UE in improving upper limb motor function, reducing muscle spasm in patients with cerebral infarction compared to UE, but patients receiving CIMT may feel depressed. Moreover, both CIMT and UE are beneficial to limb function recovery and limit the infarct expansion in MCAO/R rats, but CIMT was more effective than UE. Oxidative stress reaction has an essential role in regulating the CIMT induced benefits.

The Stroke Recovery in Motion Implementation Planner: Mixed Methods User Evaluation

Background

As more people are surviving stroke, there is a growing need for services and programs that support the long-term needs of people living with the effects of stroke. Exercise has many benefits; however, most people with stroke do not have access to specialized exercise programs that meet their needs in their communities. To catalyze the implementation of these programs, our team developed the Stroke Recovery in Motion Implementation Planner, an evidence-informed implementation guide for teams planning a community-based exercise program for people with stroke.

Objective

This study aimed to conduct a user evaluation to elicit user perceptions of the usefulness and acceptability of the Planner to inform revisions.

Methods

This mixed methods study used a concurrent triangulation design. We used purposive sampling to enroll a diverse sample of end users (program managers and coordinators, rehabilitation health partners, and fitness professionals) from three main groups: those who are currently planning a program, those who intend to plan a program in the future, and those who had previously planned a program. Participants reviewed the Planner and completed a questionnaire and interviews to identify positive features, areas of improvement, value, and feasibility. We used descriptive statistics for quantitative data and content analysis for qualitative data. We triangulated the data sources to identify Planner modifications.

Results

A total of 39 people participated in this study. Overall, the feedback was positive, highlighting the value of the Planner’s comprehensiveness, tools and templates, and real-world examples. The identified areas for improvement included clarifying the need for specific steps, refining navigation, and creating more action-oriented content. Most participants reported an increase in knowledge and confidence after reading the Planner and reported that using the resource would improve their planning approach.

Conclusions

We used a rigorous and user-centered process to develop and evaluate the Planner. End users indicated that it is a valuable resource and identified specific changes for improvement. The Planner was subsequently updated and is now publicly available for community planning teams to use in the planning and delivery of evidence-informed, sustainable, community-based exercise programs for people with stroke.

The Effect of Endurance Training on Serum BDNF Levels in the Chronic Post-Stroke Phase: Current Evidence and Qualitative Systematic Review

Research in modern neurorehabilitation focusses on cognitive and motor recovery programmes tailored to each stroke patient, with particular emphasis on physiological parameters. The objectives of this review were to determine whether a single bout of endurance activity or long-term endurance activity regulates exercise-dependent serum brain-derived neurotrophic factor (BDNF) levels and to evaluate the methodological quality of the studies. To assess the effectiveness of endurance exercise among patients in the chronic post-stroke phase, a systematic review was performed, including searching EBSCOhost, PEDro, PubMed, and Scopus for articles published up to the end of October 2021. The PRISMA 2020 outline was used, and this review was registered on PROSPERO. Of the 180 papers identified, seven intervention studies (comprising 200 patients) met the inclusion criteria. The methodological quality of these studies was evaluated by using the Physiotherapy Evidence Database (PEDro) criteria. The effect of exercise was evaluated in four studies with a single bout of endurance activity, two studies with long-term endurance activity, and one study with a single bout of endurance activity as well as long-term endurance activity. The results of our systematic review provide evidence that endurance exercise might augment the peripheral BDNF concentration in post-stroke individuals.

Can exercise shape your brain? A review of aerobic exercise effects on cognitive function and neuro-physiological underpinning mechanisms

It is widely accepted that physical exercise can be used as a tool for the prevention and treatment of various diseases or disorders. In addition, in the recent years, exercise has also been successfully used to enhance people's cognition. There is a large amount of research that has supported the benefits of physical exercise on human cognition, both in children and adults. Among these studies, some have focused on the acute or transitory effects of exercise on cognition, while others have focused on the effects of regular physical exercise. However, the relation between exercise and cognition is complex and we still have limited knowledge about the moderators and mechanisms underlying this relation. Most of human studies have focused on the behavioral aspects of exercise-effects on cognition, while animal studies have deepened in its possible neuro-physiological mechanisms. Even so, thanks to advances in neuroimaging techniques, there is a growing body of evidence that provides valuable information regarding these mechanisms in the human population. This review aims to analyze the effects of regular and acute aerobic exercise on cognition. The exercise-cognition relationship will be reviewed both from the behavioral perspective and from the neurophysiological mechanisms. The effects of exercise on animals, adult humans, and infant humans will be analyzed separately. Finally, physical exercise intervention programs aiming to increase cognitive performance in scholar and workplace environments will be reviewed.

Use of artificial intelligence as an instrument of evaluation after stroke: a scoping review based on international classification of functioning, disability and health concept

Introduction: To understand the current practices in stroke evaluation, the main clinical decision support system and artificial intelligence (AI) technologies need to be understood to assist the therapist in obtaining better insights about impairments and level of activity and participation in persons with stroke during rehabilitation. Methods: This scoping review maps the use of AI for the functional evaluation of persons with stroke; the context involves any setting of rehabilitation. Data were extracted from CENTRAL, MEDLINE, EMBASE, LILACS, CINAHL, PEDRO Web of Science, IEEE Xplore, AAAI Publications, ACM Digital Library, MathSciNet, and arXiv up to January 2021. The data obtained from the literature review were summarized in a single dataset in which each reference paper was considered as an instance, and the study characteristics were considered as attributes. The attributes used for the multiple correspondence analysis were publication year, study type, sample size, age, stroke phase, stroke type, functional status, AI type, and AI function. Results: Forty-four studies were included. The analysis showed that spasticity analysis based on ML techniques was used for the cases of stroke with moderate functional status. The techniques of deep learning and pressure sensors were used for gait analysis. Machine learning techniques and algorithms were used for upper limb and reaching analyses. The inertial measurement unit technique was applied in studies where the functional status was between mild and severe. The fuzzy logic technique was used for activity classifiers. Conclusion: The prevailing research themes demonstrated the growing utility of AI algorithms for stroke evaluation.

Examining the Role of Physical Activity on Word Learning in School-Aged Children

Purpose Previous studies show that there is increased brain activity after exercise, leading to improved word recall in adults. The aim of this study was to examine whether different types of exercise (i.e., aerobic vs. anaerobic) may also lead to improved performance during vocabulary learning in children. Method A total of 48 participants (24 in Experiment 1 and 24 in Experiment 2) between the ages of 6 and 12 years completed a word learning task. Training of words took place in a resting and in an exercise condition using a within-subject design. In the resting measure, children were taught names of novel objects and then colored for 3 min before being tested on their ability to recognize the words. In the exercise condition, the same steps were followed, but instead of coloring, children engaged in 3 min of either aerobic exercise (i.e., swimming in Experiment 1) or anaerobic exercise (i.e., a CrossFit-like workout in Experiment 2). Results In Experiment 1, accuracy of word recognition was significantly higher for words that were trained in the aerobic exercise compared to the resting condition. In Experiment 2, there was no significant difference in performance between the anaerobic exercise and resting conditions. Conclusions These findings suggest that previously identified benefits of exercise on language abilities in adults also extend to school-aged children. However, not all types of physical activity lead to this boost in performance, as only aerobic (but not anaerobic) exercise improved children's ability to acquire new word-object relations. Supplemental Material https://doi.org/10.23641/asha.14462187.

Physical Activity and Sport for Acquired Brain Injury (PASABI): A Non-Randomized Controlled Trial

Background and objectives: Acquired brain injury (ABI) is the first cause of disability and physical activity (PA) is a key element in functional recovery and health-related quality of life (HRQoL) during the subacute and chronic phases. However, it is necessary to develop PA programs that respond to the heterogeneity and needs of this population. The aim of this study was to assess the effectiveness of a PA program on the HRQoL in this population. Materials and Methods: With regard to recruitment, after baseline evaluations, participants were assigned to either the intervention group (IG, n = 38) or the control group (CG, n = 35). Functional capacity, mood, quality of life and depression were measured pre- and post-intervention. The IG underwent the “Physical Activity and Sport for Acquired Brain Injury” (PASABI) program, which was designed to improve HRQoL (1-h sessions, two to four sessions/week for 18 weeks). The CG underwent a standard rehabilitation program without PA. Results: Results for the IG indicated significant differences and large effect sizes for the physical and mental dimensions of quality of life, as well as mood and functional capacity, indicating an increase in HRQoL. No significant differences were found for the CG across any variables. Conclusions: The PASABI program was feasible and beneficial for improving physiological and functionality variables in the IG. The wide range of the activities of the PASABI program allow its application to a large number of people with ABI, promoting health through PA, especially in the chronic phase.

Cerebrovascular assessments to help understand brain-related changes associated with aerobic exercise after stroke

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.

The Effect of Exercise Training on Gait, Balance, and Physical Fitness Asymmetries in Persons With Chronic Neurological Conditions: A Systematic Review of Randomized Controlled Trials

Background: Persons with chronic neurological conditions (CNCs) often present with asymmetrical impairments, creating significant differences between contralateral limbs in body functions. These asymmetries have been associated with reduced mobility and balance, and are often targeted for reduction during rehabilitation. Exercise training has established benefits for persons with CNCs, and may have positive effects on asymmetry outcomes.

Objectives: The purpose of this review was to summarize the current evidence for the effects exercise training on gait, balance, and physical fitness asymmetry in randomized control trials (RCTs) of persons with CNCs.

Methods: A search of four electronic databases (EMBASE, CINAHL, SPORTdiscus, and ovidMEDLINE) was conducted following the structured Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results: The search retrieved 3,493 articles, with 465 articles assessed for eligibly, and nine articles meeting the criteria for inclusion. Of the included articles, five incorporated resistance exercise, three incorporated aerobic exercise, and one incorporated combined exercise (i.e., resistance and aerobic exercise). Gait asymmetry improved significantly in four studies after resistance, aerobic, and combined exercise. Significant improvements in weight bearing asymmetry were reported in three studies after resistance exercise. One study reported significant improvements in both gait and balance asymmetry after resistance exercise.

Conclusions: Preliminary evidence suggests that exercise training, as a component of rehabilitation, may have positive effects on gait and balance asymmetry in persons with CNCs. Several limitations of the current literature were noted, including a limited number of studies, combination of exercise with other rehabilitation modalities, a lack of reporting on exercise prescriptions (e.g., number of repetitions, intensity), and variability in the calculation of asymmetry outcomes. These limitations prevent definitive conclusions on the effects of exercise training on asymmetry outcomes. Future trials are needed to determine the potential of exercise training for reducing asymmetry in persons with CNCs.

Effect of Baduanjin exercise on cognitive function in patients with post-stroke cognitive impairment: a randomized controlled trial

OBJECTIVE

To investigate the effectiveness and safety of Baduanjin training on the cognitive function in stroke survivors with cognitive impairment.

DESIGN

A randomized, two-arm parallel controlled trial with allocation concealment and assessors blinding.

SETTING

Community centre of Fuzhou city, China.

SUBJECTS

A total of 48 participants were recruited and randomly allocated into the Baduanjin exercise intervention or control group.

INTERVENTIONS

The control group maintained original medication and rehabilitation treatment. The Baduanjin training group received 24-week Baduanjin training with a frequency of three days a week and 40 minutes a day based on original medication and rehabilitation treatment.

MAIN OUTCOME MEASURES

The primary outcome was global cognitive function. Secondary outcome measures included the specific domains of cognition (i.e. memory, processing speed, execution, attention and visuospatial ability) and activities daily living.

RESULTS

In total, 41 (Baduanjin n = 22, control n = 19) participants completed 24-week treatment and data collection. Mean differences between groups at 24-week treatment were statistically significant for global cognitive function (MoCA: 2.54 (0.91 to 4.16)), execution (TMT-A: -42.4 (-75.0 to -9.8); TMT-B: -71.3 (-130.6 to -12.1)), memory (immediate recall: 2.11 (0.49 to 3.73); short-term delayed recognition: 2.47 (0.58 to 4.35) and long-term delayed recognition: 1.68(0.18 to 3.17)), attention (response time of alertness: -245.5 (-387 to -104)) and activities of daily living (modified Barthel Index).

CONCLUSION

Regular Baduanjin training is associated with less loss of cognitive function in patients after stroke.

Effect of Community Exercise for Patients with Stroke: A Systematic Review and Meta-analysis

Background Community exercise might be beneficial to stroke recovery. However, the results remained controversial. We conducted a systematic review and meta-analysis to explore the effect of community exercise on stroke patients.

Methods PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials (RCTs) assessing the effect of community exercise vs. usual care on stroke were included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. The primary outcome were 6-Minute walk test and walking speed. Metaanalysis was performed using random-effect model.

Results Four RCTs involving 497 patients were included in the metaanalysis. Overall, compared with control intervention, community exercise intervention was found to significantly improve 6-Minute walk distance (Std. mean difference=0.48; 95% CI=0.22 to 0.74; P=0.0003), and walking speed (Std. mean difference=0.40; 95% CI=0.10 to 0.70; P=0.009) in stroke patients, but resulted in no influence on Berg Balance Scale (Std. mean difference=0.39; 95% CI=−0.29 to 1.07; P=0.26), muscle strength (Std. mean difference=0.05; 95% CI=-0.34 to 0.43; P=0.82) and mental quality of life (Std. mean difference=0.04; 95% CI=−0.25 to 0.34; P=0.77).

Conclusions Compared to control intervention, community exercise was found to significantly increase 6-Minute walk test, walking speed and Berg Balance Scale, but showed no influence on Berg Balance Scale, muscle strength and mental quality of life.

Physical fitness training for stroke patients

BACKGROUND

Levels of physical activity and physical fitness are low after stroke. Interventions to increase physical fitness could reduce mortality and reduce disability through increased function.

OBJECTIVES

The primary objectives of this updated review were to determine whether fitness training after stroke reduces death, death or dependence, and disability. The secondary objectives were to determine the effects of training on adverse events, risk factors, physical fitness, mobility, physical function, health status and quality of life, mood, and cognitive function.

SEARCH METHODS

In July 2018 we searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, SPORTDiscus, PsycINFO, and four additional databases. We also searched ongoing trials registers and conference proceedings, screened reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised trials comparing either cardiorespiratory training or resistance training, or both (mixed training), with usual care, no intervention, or a non-exercise intervention in stroke survivors.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed quality and risk of bias, and extracted data. We analysed data using random-effects meta-analyses and assessed the quality of the evidence using the GRADE approach. Diverse outcome measures limited the intended analyses.

MAIN RESULTS

We included 75 studies, involving 3017 mostly ambulatory participants, which comprised cardiorespiratory (32 studies, 1631 participants), resistance (20 studies, 779 participants), and mixed training interventions (23 studies, 1207 participants). Death was not influenced by any intervention; risk differences were all 0.00 (low-certainty evidence). There were few deaths overall (19/3017 at end of intervention and 19/1469 at end of follow-up). None of the studies assessed death or dependence as a composite outcome. Disability scores were improved at end of intervention by cardiorespiratory training (standardised mean difference (SMD) 0.52, 95% CI 0.19 to 0.84; 8 studies, 462 participants; P = 0.002; moderate-certainty evidence) and mixed training (SMD 0.23, 95% CI 0.03 to 0.42; 9 studies, 604 participants; P = 0.02; low-certainty evidence). There were too few data to assess the effects of resistance training on disability. Secondary outcomes showed multiple benefits for physical fitness (VO2 peak and strength), mobility (walking speed) and physical function (balance). These physical effects tended to be intervention-specific with the evidence mostly low or moderate certainty. Risk factor data were limited or showed no effects apart from cardiorespiratory fitness (VO2 peak), which increased after cardiorespiratory training (mean difference (MD) 3.40 mL/kg/min, 95% CI 2.98 to 3.83; 9 studies, 438 participants; moderate-certainty evidence). There was no evidence of any serious adverse events. Lack of data prevents conclusions about effects of training on mood, quality of life, and cognition. Lack of data also meant benefits at follow-up (i.e. after training had stopped) were unclear but some mobility benefits did persist. Risk of bias varied across studies but imbalanced amounts of exposure in control and intervention groups was a common issue affecting many comparisons.

AUTHORS' CONCLUSIONS

Few deaths overall suggest exercise is a safe intervention but means we cannot determine whether exercise reduces mortality or the chance of death or dependency. Cardiorespiratory training and, to a lesser extent mixed training, reduce disability during or after usual stroke care; this could be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programmes to improve fitness, balance and the speed and capacity of walking. The magnitude of VO2 peak increase after cardiorespiratory training has been suggested to reduce risk of stroke hospitalisation by ˜7%. Cognitive function is under-investigated despite being a key outcome of interest for patients. Further well-designed randomised trials are needed to determine the optimal exercise prescription, the range of benefits and any long-term benefits.

Effects of Exercise Intensity on Acute Circulating Molecular Responses Poststroke

Background. Exercise intensity can influence functional recovery after stroke, but the mechanisms remain poorly understood. Objective. In chronic stroke, an intensity-dependent increase in circulating brain-derived neurotrophic factor (BDNF) was previously found during vigorous exercise. Using the same serum samples, this study tested acute effects of exercise intensity on other circulating molecules related to neuroplasticity, including vascular-endothelial growth factor (VEGF), insulin-like growth factor-1 (IGF1), and cortisol, with some updated analyses involving BDNF. Methods. Using a repeated-measures design, 16 participants with chronic stroke performed 3 exercise protocols in random order: treadmill high-intensity interval training (HIT-treadmill), seated-stepper HIT (HIT-stepper), and treadmill moderate-intensity continuous exercise (MCT-treadmill). Serum molecular changes were compared between protocols. Mediation and effect modification analyses were also performed. Results. VEGF significantly increased during HIT-treadmill, IGF1 increased during both HIT protocols and cortisol nonsignificantly decreased during each protocol. VEGF response was significantly greater for HIT-treadmill versus MCT-treadmill when controlling for baseline. Blood lactate positively mediated the effect of HIT on BDNF and cortisol. Peak treadmill speed positively mediated effects on BDNF and VEGF. Participants with comfortable gait speed ≥0.4 m/s had significantly lower VEGF and higher IGF1 responses, with a lower cortisol response during MCT-treadmill. Conclusions. BDNF and VEGF are promising serum molecules to include in future studies testing intensity-dependent mechanisms of exercise on neurologic recovery. Fast training speed and anaerobic intensity appear to be critical ingredients for eliciting these molecular responses. Serum molecular response differences between gait speed subgroups provide a possible biologic basis for previously observed differences in training responsiveness.

Principles of Neurorehabilitation After Stroke Based on Motor Learning and Brain Plasticity Mechanisms

What are the principles underlying effective neurorehabilitation? The aim of neurorehabilitation is to exploit interventions based on human and animal studies about learning and adaptation, as well as to show that the activation of experience-dependent neuronal plasticity augments functional recovery after stroke. Instead of teaching compensatory strategies that do not reduce impairment but allow the patient to return home as soon as possible, functional recovery might be more sustainable as it ensures a long-term reduction in impairment and an improvement in quality of life. At the same time, neurorehabilitation permits the scientific community to collect valuable data, which allows inferring about the principles of brain organization. Hence neuroscience sheds light on the mechanisms of learning new functions or relearning lost ones. However, current rehabilitation methods lack the exact operationalization of evidence gained from skill learning literature, leading to an urgent need to bridge motor learning theory and present clinical work in order to identify a set of ingredients and practical applications that could guide future interventions. This work aims to unify the neuroscientific literature relevant to the recovery process and rehabilitation practice in order to provide a synthesis of the principles that constitute an effective neurorehabilitation approach. Previous attempts to achieve this goal either focused on a subset of principles or did not link clinical application to the principles of motor learning and recovery. We identified 15 principles of motor learning based on existing literature: massed practice, spaced practice, dosage, task-specific practice, goal-oriented practice, variable practice, increasing difficulty, multisensory stimulation, rhythmic cueing, explicit feedback/knowledge of results, implicit feedback/knowledge of performance, modulate effector selection, action observation/embodied practice, motor imagery, and social interaction. We comment on trials that successfully implemented these principles and report evidence from experiments with healthy individuals as well as clinical work.

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.

Aerobic Training and Mobilization Early Post-stroke: Cautions and Considerations

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.

Effect of aerobic exercise prior to modified constraint-induced movement therapy outcomes in individuals with chronic hemiparesis: a study protocol for a randomized clinical trial

BACKGROUND

Recovery of upper limb function in individuals after a stroke remains challenging. Modified constraint-induced movement therapy (m-CIMT) has strong evidence for increasing the use and recovery of sensorimotor function of the paretic upper limb. Recent studies have shown that priming with aerobic exercise prior to task-specific training potentiates upper limb recovery in individuals with stroke. This protocol describes a randomized clinical trial designed to determine whether priming with moderate-high intensity aerobic exercise prior to m-CIMT will improve the manual dexterity of the paretic upper limb in individuals with chronic hemiparesis.

METHODS

Sixty-two individuals with chronic hemiparesis will be randomized into two groups: Aerobic exercise + m-CIMT or Stretching + m-CIMT. m-CIMT includes 1) restraint of the nonparetic upper limb for 90% of waking hours, 2) intensive task-oriented training of the paretic upper limb for 3 h/day for 10 days and 3) behavior interventions for improving treatment adherence. Aerobic exercise will be conducted on a stationary bicycle at intervals of moderate to high intensity. Participants will be evaluated at baseline, 3, 30, and 90 days postintervention by the following instruments: Motor Activity Log, Nottingham Sensory Assessment, Wolf Motor Function Test, Box and Block Test, Nine-Hole Peg Test, Stroke Specific Quality of Life Scale and three-dimensional kinematics. The data will be tested for normality and homogeneity. Parametric data will be analyzed by two-way ANOVA with repeated measures and Bonferroni's adjustment. For nonparametric data, the Friedman test followed by the Wilcoxon test with Bonferroni's adjustment will be used to compare the ratings for each group. To compare the groups in each assessment, the Mann-Whitney test will be used.

DISCUSSION

This study will provide valuable information about the effect of motor priming for fine upper limb skill improvement in people with chronic poststroke hemiparesis, bringing new evidence about the association of two therapies commonly used in clinical practice.

TRIAL REGISTRATION

This trial was retrospectively registered (registration number RBR-83pwm3 ) on 07 May 2018.

Influence of Post-Stroke Depression on Functional Independence in Activities of Daily Living

Background

Little attention has been paid to screening of depression among stroke survivors in outpatient physiotherapy clinics. Post-stroke depression is reported to have a negative impact on functional recovery. However, the exact influence on the outcome of rehabilitation such as level of functional independence remains controversial. This study aims at ascertaining the influence of post-stroke depression on functional independence in activities of daily living.

Methods

The study is a cross sectional survey of stroke survivors attending outpatient physiotherapy clinics of the University of Nigeria Teaching Hospital (UNTH) Enugu, and the Enugu State University Teaching Hospital (ESUTH). Participants were evaluated for socio-demographic characteristics. Post-stroke depression and level of functional recovery in Activities of Daily Living were assessed using the Hamilton Depression Rating Scale and the Barthel Index respectively. Data was analyzed using SPSS version 23, with α set at 0.01.

Results

A total of 66 participants, 42 females and 24 males, were purposively recruited into the study. Over 80% (56) of the participant had depression, with over 50% (32) being severely depressed. Post-stroke depression was associated with less functional independence in activities of daily living (p=0.000). A significant difference was found in the level of functional independence between participants with and without depression (p=0.00).

Conclusion

Participants with post-stroke depression have less independence in activities of daily living. A longitudinal study with a larger sample size is, however, recommended so as to improve the external validity. In the mean time, outpatient rehabilitation of depressed stroke survivors should include pharmacological and psychological components.

A Short Bout of Exercise Prior to Stroke Improves Functional Outcomes by Enhancing Angiogenesis

Stroke remains a significant unmet clinical need with limited therapeutic options. The peculiar feature of ischemic stroke is the interruption in brain circulation, resulting in a cascade of detrimental cerebrovasculature alterations. Treatment strategies designed to maintain potency of the cerebrovasculature may protect against stroke. The present study assessed the effects of short bouts of exercise prior to stroke induction and characterized cerebral blood flow and motor functions in vivo. Adult Sprague-Dawley rats were exposed to a single short bout of exercise (30-min or 60-min forced running wheel) then subjected to transient middle cerebral artery occlusion (MCAO). Non-exercise stroke rats served as controls while non-stroke rats represented shams. Cerebral blood flow (CBF) was evaluated by laser Doppler at baseline (prior to MCAO), during MCAO, and during reperfusion. Behavioral tests using the elevated body swing test was conducted at baseline, day 0 (day of stroke), and at days 1 and 3 after stroke. Animals that received exercise displayed typical alterations in CBF after stroke, but exhibited improved motor performance compared to non-exercise rats. Exercised stroke rats showed a reduction in infarct size and an increased number of surviving cells in the peri-infarct area, with a trend towards prolonged duration of the exercise. Immunofluorescence staining and Western blot analysis of the peri-infarct area revealed increased levels of endothelial markers/angiogenesis markers, VEGF, VEGFR-2, and Ang-2, and endothelial progenitor cell marker CD34+ in exercise groups compared with the controls. These results demonstrated that prophylactic exercise affords neuroprotection possibly by improving cerebrovascular potency.

The Effectiveness of Exercise on Cognitive Performance in Individuals with Known Vascular Disease: A Systematic Review

Patients with known vascular disease are at increased risk for cognitive impairments. Exercise has been shown to improve cognition in healthy elderly populations and those with mild cognitive impairments. We explored the literature to understand exercise as a modality to improve cognition in those with vascular disease, focusing on dose-responses. A systematic review was conducted through 2017 using Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Ovid Embase, and Ovid MEDLINE databases. Eligible studies examined effects of exercise on memory and cognition in cardiovascular (CVD) or cerebrovascular disease (CBVD). Data extracted included group characteristics, exercise dosage and outcomes measures employed. Twenty-two studies (12 CVD, 10 CBVD) met the inclusion criteria. Interventions included aerobic, resistance, or mixed training, with neuropsychological test batteries assessing cognition. In CVD populations, five studies demonstrated improved cardiovascular fitness and cognition with aerobic training, and another seven studies suggested a dose-response. In CBVD trials, four studies reported improved cognition, with no effects observed in the fifth study. Another study found enhanced cognition with resistance training and four demonstrated a positive association between functional capacity and cognition following combined aerobic and resistance training. Exercise is able to positively affect cognitive performance in those with known vascular disease. There is evidence to suggest a dose–response relationship. Further research is required to optimize prescription.

Synergistic Benefits of Combined Aerobic and Cognitive Training on Fluid Intelligence and the Role of IGF-1 in Chronic Stroke

BACKGROUND

Paired exercise and cognitive training have the potential to enhance cognition by "priming" the brain and upregulating neurotrophins.

METHODS

Two-site randomized controlled trial. Fifty-two patients >6 months poststroke with concerns about cognitive impairment trained 50 to 70 minutes, 3× week for 10 weeks with 12-week follow-up. Participants were randomized to 1 of 2 physical interventions: Aerobic (>60% VO_2peak using <10% body weight-supported treadmill) or Activity (range of movement and functional tasks). Exercise was paired with 1 of 2 cognitive interventions (computerized dual working memory training [COG] or control computer games [Games]). The primary outcome for the 4 groups (Aerobic + COG, Aerobic + Games, Activity + COG, and Activity + Games) was fluid intelligence measured using Raven's Progressive Matrices Test administered at baseline, posttraining, and 3-month follow-up. Serum neurotrophins collected at one site (N = 30) included brain-derived neurotrophic factor (BDNF) at rest (BDNF_resting) and after a graded exercise test (BDNF_response) and insulin-like growth factor-1 at the same timepoints (IGF-1_rest, IGF-1_response).

RESULTS

At follow-up, fluid intelligence scores significantly improved compared to baseline in the Aerobic + COG and Activity + COG groups; however, only the Aerobic + COG group was significantly different (+47.8%) from control (Activity + Games -8.5%). Greater IGF-1_response at baseline predicted 40% of the variance in cognitive improvement. There was no effect of the interventions on BDNF_resting or BDNF_response; nor was BDNF predictive of the outcome.

CONCLUSIONS

Aerobic exercise combined with cognitive training improved fluid intelligence by almost 50% in patients >6 months poststroke. Participants with more robust improvements in cognition were able to upregulate higher levels of serum IGF-1 suggesting that this neurotrophin may be involved in behaviorally induced plasticity.

The Past, Present, and Future of Neurorehabilitation: From NUSTEP Through IV STEP and Beyond

PURPOSES

To present the history and aims of the STEP conferences; describe the interdependence of prevention, prediction, plasticity, and participation; reflect on where we stand today regarding those 4 Ps; and discuss how future neurorehabilitation should look for individuals with movement disorders.

KEY POINTS

Physical therapists have focused primarily on tertiary prevention, emphasizing primary/secondary prevention far less. Predicting optimal response to intervention is essential for primary prevention. Research examining neurorehabilitation effects mediated by brain plasticity is evolving from an emphasis on impairment outcomes toward examination of participation outcomes. CLINICAL PRACTICE RECOMMENDATIONS:: (1) Capitalize on primary and secondary prevention. (2) Administer simple, environmentally relevant predictive measures. (3) Partner with researchers to examine exercise-induced brain plasticity effects via neuroimaging. (4) Encourage physical activity to promote secondary prevention of lifestyle-related diseases and enhance participation. (5) Integrate psychological/social sciences with physiological sciences to move forward with advances in mindful health and patient-centered practices.

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.

The effect of combined therapies on recovery after acquired brain injury: Systematic review of preclinical studies combining enriched environment, exercise, or task-specific training with other therapies

BACKGROUND

Acquired brain injuries (ABI) have devastating effects for the affected individual as well as society. Many studies have investigated the effect of different monotherapies. However, functional recovery is typically only partial. One possible strategy to promote a greater degree of recovery is to apply monotherapies in combination with one or more treatments.

OBJECTIVE

The objective of this systematic review is to investigate if approaches combining enriched environment (EE), exercise, or task-specific training with other monotherapies, further enhance the degree of recovery after ABI.

METHOD

Scopus, PsychINFO, and PubMed databases were searched in March 2016 with the following search strings: exercise (or) enriched environment (or) environmental enrichment (or) rehabilitation (and) traumatic brain injury (or) ischemia (or) stroke (and) rat (or) rodent. Studies were included if they (1) were in English, (2) used adult animals subjected to brain injury, (3) included EE, and/or exercise, and/or task-specific training as post-injury treatment strategies, (4) included at least one group receiving another monotherapy. Out of 2.168 hits, 29 studies fulfilled the inclusion criteria.

RESULTS

Despite several trends for enhanced recovery after combined therapies, this systematic review of 29 studies does not indicate that combined therapies confer consistent combined effects on motor, cognitive, or cerebral recovery according to present criteria for combined effect.

CONCLUSION

Combined treatments continue to provide hope for enhanced recovery after ABI, however, the research area is in its infancy. This systematic review does not provide conclusive evidence. This is likely due to sparse knowledge regarding optimal treatment parameters. Combined treatments, however, hold the best promise regarding treatment of the complex changes induced by ABI.

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.

Biological effects of dosing aerobic exercise and neuromuscular electrical stimulation in rats

Aerobic exercise (AE) and non-aerobic neuromuscular electric stimulation (NMES) are common interventions used in physical therapy. We explored the dose-dependency (low, medium, high) of these interventions on biochemical factors, such as brain derived neurotrophic growth factor (BDNF), vascular endothelial growth factor-A (VEGF-A), insulin-like growth factor-1 (IGF-1) and Klotho, in the blood and brain of normal rats, as well as a treadmill-based maximum capacity test (MCT). A medium dose of AE produced the most improvement in MCT with dose-dependent changes in Klotho in the blood. A dose-dependent increase of BDNF was evident following completion of an NMES protocol, but there was no improvement in MCT performance. Gene expression in the hippocampus was increased after both AE and NMES, with IGF-1 being a signaling molecule that correlated with MCT performance in the AE conditions, but also highly correlated with VEGF-A and Klotho. Blood Klotho levels can serve as a biomarker of therapeutic dosing of AE, whereas IGF-1 is a key molecule coupled to gene expression of other molecules in the hippocampus. This approach provides a translatable paradigm to investigate the mode and mechanism of action of interventions employed in physical therapy that can improve our understanding of how these factors change under pathological conditions.

Prescribing Exercise to Individuals with Disabilities: What Are the Concerns?

It is well known that individuals with disabilities, constituting 15% to 20% of the adult population, experience a disproportionate risk of cardiometabolic disease and are more likely to live sedentary lifestyles when compared with their able-bodied peers. Although many complex factors likely lead to these disparities, targeted exercise programs can be influential in improving the health outcomes of this population. Additionally, it is important to keep several factors in mind when tailoring the exercise prescription for individuals with varied types of disability, given unique factors related to medical history, mobility, and community barriers. By safely engaging individuals with disabilities in exercise programs, clinicians can promote inclusion while making a significant contribution to health outcomes, ensuring that the principles of "Exercise is Medicine" are accessible to individuals of all abilities.

The Past, Present, and Future of Neurorehabilitation: From NUSTEP Through IV STEP and Beyond

PURPOSES

To present the history and aims of the STEP conferences; describe the interdependence of prevention, prediction, plasticity, and participation; reflect on where we stand today regarding those 4 Ps; and discuss how future neurorehabilitation should look for individuals with movement disorders.

KEY POINTS

Physical therapists have focused primarily on tertiary prevention, emphasizing primary/secondary prevention far less. Predicting optimal response to intervention is essential for primary prevention. Research examining neurorehabilitation effects mediated by brain plasticity is evolving from an emphasis on impairment outcomes toward examination of participation outcomes. CLINICAL PRACTICE RECOMMENDATIONS:: (1) Capitalize on primary and secondary prevention. (2) Administer simple, environmentally relevant predictive measures. (3) Partner with researchers to examine exercise-induced brain plasticity effects via neuroimaging. (4) Encourage physical activity to promote secondary prevention of lifestyle-related diseases and enhance participation. (5) Integrate psychological/social sciences with physiological sciences to move forward with advances in mindful health and patient-centered practices.